The sports cardiology team: personalising athlete care through a comprehensive, multidisciplinary approach

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Dutch National Olympic Committee & National Sports Federation (NOC*NSF)Amsterdam Movement Sciences (AMS)

Background/Introduction

Multidisciplinary teams (MDTs) are an integral part of cardiology. In sports cardiology, multidisciplinary expertise is required to differentiate between extraordinary pathophysiological adaption and pathology. In addition, expert consensus-based sports advice should be prescribed with care considering the potential severe impact on (professional) sports careers. A formally organised sports cardiology MDT could potentially improve quality of care; we therefore established a formally organised sports cardiology MDT at the Amsterdam UMC in April 2019, aiming to facilitate the diagnostic process, enhance the process of formulating optimal sports advice, and to maximise safety in sports. However, no studies have reported on the effects of such teams.

Purpose

To systematically investigate and document infrastructure, practices, recommendations, and clinical consequences of a sports cardiology MDT.

Methods

We retrospectively analysed all reviewed athletes of our (online) bimonthly sports cardiology MDT meetings (April 2019 to January 2021). The MDT consisted of a permanent panel of experts in sports cardiology, sports- and exercise medicine, cardio/clinical genetics, paediatric cardiology, cardiovascular imaging, and electrophysiology (Figure 1). Cases were referred (inter)nationally by sports physicians or cardiologists. The primary objective of this study was to investigate the 2 years of experiences of practices, recommendations, and clinical consequences of a formal sports cardiology MDT.

Results

In total 115 athletes underwent MDT review, mean age 32 (SD 16.0) years, 11% women, 65% recreational athletes, and 54% performed 'mixed' type of sports. MDT review led to diagnosis revision of ‘suspected cardiac pathology’ to ‘no cardiac pathology’ in 44/115 (38%) (Figure 2) and increased the number of definitive diagnoses; 77/115 before to 109/115 after MDT review (P<0.05). We observed less ‘total sports restrictions’ (6 to 0 p<0.05) and more tailored sports advice concerning ‘no peak load/specific maximum load’ (10 to 26 p<0.05) (Figure 2). At 14 (± 6) months follow-up, 112 (97%) athletes reported no cardiovascular events, 111 (97%) no (new) cardiac symptoms, 113 (98%) adherence to MDT sports advice, and no diagnoses were revised.

Conclusion

Our experiences with a comprehensive sports cardiology MDT demonstrate that this approach leads to a higher percentage of definitive diagnoses and fewer diagnosis of cardiac pathology, more tailored treatment- and sports advice, high rates of sports advice adherence, and less total sports restrictions. Our findings highlight the added value of dedicated sports cardiology MDTs in care for elite, professional, and recreational athletes and patients who wish to engage in sports and exercise.

The sports cardiology team: personalizing athlete care through a comprehensive, multidisciplinary approach

Background/Introduction

Multidisciplinary teams (MDT) are an integral part of cardiology. In sports cardiology wide area of expertise is required to differentiate between extraordinary pathophysiological adaption and pathology. In Addition, expertise-based sports advice should be prescribed with great care considering the great impact on (professional) sports careers. Specific guidelines for the composition of MDT's for sports cardiology are currently lacking. We established a sports cardiology MDT in April 2020 (Amsterdam UMC), consisting of experts in the fields of sports medicine, cardiogenetics and paediatric cardiology, cardiovascular imaging and electrophysiology, with bi-monthly meetings. Cases were contributed from cardiologists or referred nationally for expertise with patients/athletes varying from recreational to elite-level sports.

Purpose

To describe our infrastructure and utilization of a sports cardiology MDT, and to justify the need for a sports cardiology MDT.

Methods

We retrospectively analysed all MDT reviewed cases (from April 2020 to April 2021), and collected follow-up data 1 year after initial MDT review. Data were classified according to type/level of sports. We compared diagnosis and/or reason for referral and sports advice at initial MDT application and after panel review. In addition we abstracted data on occurrence of cardiac symptoms and/or cardiac events, and adherence to sports advice.

Results

112 cases underwent MDT review, with a mean age of 32 (SD 16.0) years. In total 12% were women, 38% professional athletes, and 30% engaged in high dynamic/low static sports. Reasons for referral were personalised sports advice in 48%, expert opinion in 28%, and abnormal ECG/CMR/CPX in 24%. The diagnosis was revised in 55% (n=61), main groups; 1) suspicion of (non-specified) cardiomyopathy (CMP) to no cardiac pathology in 20% (n=12), and 2) “cardiac abnormalities with no clear diagnosis” to “no cardiac pathology” in 36% (n=22) (Figure 1). Sports advice was revised to more personalized sports advice in 30% (n=34) (Figure 2), main groups; no restriction to no peak load/specific maximum load in 38% (n=13), and no restrictions to no competitive sports in 26% (n=9). At 1 year follow-up, the (sports) advice was adhered in 99,98% (n=111), and cases with no sports restrictions reported no cardiac symptoms in 99% (n=72/73), and no major acute cardiovascular events in 100% (73/73). No further revisions of diagnoses were found to have taken place.

Conclusion

Our experience with a comprehensive, sports cardiology MDT demonstrates that such an approach is feasible, and leads to more personalised treatment- and sports advice in athletes. Medium-term adherence to sports advice given is high. A team-based approach also leads to a higher percentage definitive diagnoses. Our findings serve as a proof-of-concept of the added value of the sports cardiology team in care for athletes and patients who wish to engage in sports and exercise.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Dutch Olympic Committee*Dutch Sports Federation (NOC*NSF)Amsterdam Movement Sciences (AMS) Figure 1. Revised diagnosis before and after panel review (N=61)Figure 2. Revised sports advice before and after panel review (N=34)

Return to sports after COVID-19: a position paper from the Dutch Sports Cardiology Section of the Netherlands Society of Cardiology

The coronavirus disease 2019 (COVID-19) pandemic has led to preventive measures worldwide. With the decline of infection rates, less stringent restrictions for sports and exercise are being implemented. COVID-19 is associated with significant cardiovascular complications; however there are limited data on cardiovascular complications and long-term outcomes in both competitive (elite) athletes and highly active individuals. Based on different categories of disease severity (asymptomatic, regional/systemic symptoms, hospitalisation, myocardial damage, and/or myocarditis), in this point-of-view article we offer the (sports) cardiologist or sports physician in the Netherlands a practical guide to pre-participation screening, and diagnostic and management strategies in all athletes >16 years of age after COVID-19 infection.

Crystal structures of the Streptomyces coelicolor TetR-like protein ActR alone and in complex with actinorhodin or the actinorhodin biosynthetic precursor (S)-DNPA

Actinorhodin, an antibiotic produced by Streptomyces coelicolor, is exported from the cell by the ActA efflux pump. actA is divergently transcribed from actR, which encodes a TetR-like transcriptional repressor. We showed previously that ActR represses transcription by binding to an operator from the actA/actR intergenic region. Importantly, actinorhodin itself or various actinorhodin biosynthetic intermediates can cause ActR to dissociate from its operator, leading to derepression. This suggests that ActR may mediate timely self-resistance to an endogenously produced antibiotic by responding to one of its biosynthetic precursors. Here, we report the structural basis for this precursor-mediated derepression with crystal structures of homodimeric ActR by itself and in complex with either actinorhodin or the actinorhodin biosynthetic intermediate (S)-DNPA [4-dihydro-9-hydroxy-1-methyl-10-oxo-3-H-naphtho-[2,3-c]-pyran-3-(S)-acetic acid]. The ligand-binding tunnel in each ActR monomer has a striking hydrophilic/hydrophobic/hydrophilic arrangement of surface residues that accommodate either one hexacyclic actinorhodin molecule or two back-to-back tricyclic (S)-DNPA molecules. Moreover, our work also reveals the strongest structural evidence to date that TetR-mediated antibiotic resistance may have been acquired from an antibiotic-producer organism.

Initiation of actinorhodin export in Streptomyces coelicolor

Many microorganisms produce molecules having antibiotic activity and expel them into the environment, presumably enhancing their ability to compete with their neighbours. Given that these molecules are often toxic to the producer, mechanisms must exist to ensure that the assembly of the export apparatus accompanies or precedes biosynthesis. Streptomyces coelicolor produces the polyketide antibiotic actinorhodin in a multistep pathway involving enzymes encoded by genes that are clustered together. Embedded within the cluster are genes for actinorhodin export, two of which, actR and actA resemble the classic tetR and tetA repressor/efflux pump-encoding gene pairs that confer resistance to tetracycline. Like TetR, which represses tetA, ActR is a repressor of actA. We have identified several molecules that can relieve repression by ActR. Importantly (S)-DNPA (an intermediate in the actinorhodin biosynthetic pathway) and kalafungin (a molecule related to the intermediate dihydrokalafungin), are especially potent ActR ligands. This suggests that along with the mature antibiotic(s), intermediates in the biosynthetic pathway might activate expression of the export genes thereby coupling export to biosynthesis. We suggest that this could be a common feature in the production of many bioactive natural products.

A hitchhiker's guide to the cullin ubiquitin ligases: SCF and its kin

The SCF (Skp1-Cullin-F-box) E3 ubiquitin ligase family was discovered through genetic requirements for cell cycle progression in budding yeast. In these multisubunit enzymes, an invariant core complex, composed of the Skp1 linker protein, the Cdc53/Cul1 scaffold protein and the Rbx1/Roc1/Hrt1 RING domain protein, engages one of a suite of substrate adaptors called F-box proteins that in turn recruit substrates for ubiquitination by an associated E2 enzyme. The cullin-RING domain-adaptor architecture has diversified through evolution, such that in total many hundreds of distinct SCF and SCF-like complexes enable degradation of myriad substrates. Substrate recognition by adaptors often depends on posttranslational modification of the substrate, which thus places substrate stability under dynamic regulation by intracellular signaling events. SCF complexes control cell proliferation through degradation of critical regulators such as cyclins, CDK inhibitors and transcription factors. A plethora of other processes in development and disease are controlled by other SCF-like complexes, including those based on Cul2-SOCS-box adaptor protein and Cul3-BTB domain adaptor protein combinations. Recent structural insights into SCF-like complexes have begun to illuminate aspects of substrate recognition and catalytic reaction mechanisms.

Systematic identification of protein complexes in Saccharomyces cerevisiae by mass spectrometry

The recent abundance of genome sequence data has brought an urgent need for systematic proteomics to decipher the encoded protein networks that dictate cellular function. To date, generation of large-scale protein-protein interaction maps has relied on the yeast two-hybrid system, which detects binary interactions through activation of reporter gene expression. With the advent of ultrasensitive mass spectrometric protein identification methods, it is feasible to identify directly protein complexes on a proteome-wide scale. Here we report, using the budding yeast Saccharomyces cerevisiae as a test case, an example of this approach, which we term high-throughput mass spectrometric protein complex identification (HMS-PCI). Beginning with 10% of predicted yeast proteins as baits, we detected 3,617 associated proteins covering 25% of the yeast proteome. Numerous protein complexes were identified, including many new interactions in various signalling pathways and in the DNA damage response. Comparison of the HMS-PCI data set with interactions reported in the literature revealed an average threefold higher success rate in detection of known complexes compared with large-scale two-hybrid studies. Given the high degree of connectivity observed in this study, even partial HMS-PCI coverage of complex proteomes, including that of humans, should allow comprehensive identification of cellular networks.

SCF ubiquitin protein ligases and phosphorylation-dependent proteolysis

Many key activators and inhibitors of cell division are targeted for degradation by a recently described family of E3 ubiquitin protein ligases termed Skp1-Cdc53-F-box protein (SCF) complexes. SCF complexes physically link substrate proteins to the E2 ubiquitin-conjugating enzyme Cdc34, which catalyses substrate ubiquitination, leading to subsequent degradation by the 26S proteasome. SCF complexes contain a variable subunit called an F-box protein that confers substrate specificity on an invariant core complex composed of the subunits Cdc34, Skp1 and Cdc53. Here, we review the substrates and pathways regulated by the yeast F-box proteins Cdc4, Grr1 and Met30. The concepts of SCF ubiquitin ligase function are illustrated by analysis of the degradation pathway for the G1 cyclin Cln2. Through mass spectrometric analysis of Cdc53 associated proteins, we have identified three novel F-box proteins that appear to participate in SCF-like complexes. As many F-box proteins can be found in sequence databases, it appears that a host of cellular pathways will be regulated by SCF-dependent proteolysis.

Combinatorial control in ubiquitin-dependent proteolysis: don't Skp the F-box hypothesis

The ubiquitin-dependent proteolytic pathway targets many key regulatory proteins for rapid intracellular degradation. Specificity in protein ubiquitination derives from E3 ubiquitin protein ligases, which recognize substrate proteins. Recently, analysis of the E3s that regulate cell division has revealed common themes in structure and function. One particularly versatile class of E3s, referred to as Skp1p-Cdc53p-F-box protein (SCF) complexes, utilizes substrate-specific adaptor subunits called F-box proteins to recruit various substrates to a core ubiquitination complex. A vast array of F-box proteins have been revealed by genome sequencing projects, and the early returns from genetic analysis in several organisms promise that F-box proteins will participate in the regulation of many processes, including cell division, transcription, signal transduction and development.

Cdc53 is a scaffold protein for multiple Cdc34/Skp1/F-box proteincomplexes that regulate cell division and methionine biosynthesis in yeast

In budding yeast, ubiquitination of the cyclin-dependent kinase (Cdk) inhibitor Sic1 is catalyzed by the E2 ubiquitin conjugating enzyme Cdc34 in conjunction with an E3 ubiquitin ligase complex composed of Skp1, Cdc53 and the F-box protein, Cdc4 (the SCFCdc4 complex). Skp1 binds a motif called the F-box and in turn F-box proteins appear to recruit specific substrates for ubiquitination. We find that Skp1 interacts with Cdc53 in vivo, and that Skp1 bridges Cdc53 to three different F-box proteins, Cdc4, Met30, and Grr1. Cdc53 contains independent binding sites for Cdc34 and Skp1 suggesting it functions as a scaffold protein within an E2/E3 core complex. F-box proteins show remarkable functional specificity in vivo: Cdc4 is specific for degradation of Sic1, Grr1 is specific for degradation of the G1 cyclin Cln2, and Met30 is specific for repression of methionine biosynthesis genes. In contrast, the Cdc34-Cdc53-Skp1 E2/E3 core complex is required for all three functions. Combinatorial control of SCF complexes may provide a basis for the regulation of diverse cellular processes.

Cdc53 targets phosphorylated G1 cyclins for degradation by the ubiquitin proteolytic pathway

In budding yeast, cell division is initiated in late G1 phase once the Cdc28 cyclin-dependent kinase is activated by the G1 cyclins Cln1, Cln2, and Cln3. The extreme instability of the Cln proteins couples environmental signals, which regulate Cln synthesis, to cell division. We isolated Cdc53 as a Cln2-associated protein and show that Cdc53 is required for Cln2 instability and ubiquitination in vivo. The Cln2-Cdc53 interaction, Cln2 ubiquitination, and Cln2 instability all depend on phosphorylation of Cln2. Cdc53 also binds the E2 ubiquitin-conjugating enzyme, Cdc34. These findings suggest that Cdc53 is a component of a ubiquitin-protein ligase complex that targets phosphorylated G1 cyclins for degradation by the ubiquitin-proteasome pathway.

Studies on the transformation of intact yeast cells by the LiAc/SS-DNA/PEG procedure

An improved lithium acetate (LiAc)/single-stranded DNA (SS-DNA)/polyethylene glycol (PEG) protocol which yields > 1 x 10(6) transformants/micrograms plasmid DNA and the original protocol described by Schiestl and Gietz (1989) were used to investigate aspects of the mechanism of LiAc/SS-DNA/PEG transformation. The highest transformation efficiency was observed when 1 x 10(8) cells were transformed with 100 ng plasmid DNA in the presence of 50 micrograms SS carrier DNA. The yield of transformants increased linearly up to 5 micrograms plasmid per transformation. A 20-min heat shock at 42 degrees C was necessary for maximal yields. PEG was found to deposit both carrier DNA and plasmid DNA onto cells. SS carrier DNA bound more effectively to the cells and caused tighter binding of 32P-labelled plasmid DNA than did double-stranded (DS) carrier. The LiAc/SS-DNA/PEG transformation method did not result in cell fusion. DS carrier DNA competed with DS vector DNA in the transformation reaction. SS plasmid DNA transformed cells poorly in combination with both SS and DS carrier DNA. The LiAc/SS-DNA/PEG method was shown to be more effective than other treatments known to make cells transformable. A model for the mechanism of transformation by the LiAc/SS-DNA/PEG method is discussed.

Determinants of prognosis in symptomatic ventricular tachycardia or ventricular fibrillation late after myocardial infarction. The Dutch Ventricular Tachycardia Study Group of the Interuniversity Cardiology Institute of The Netherlands

In a multicenter study, 390 patients with sustained symptomatic ventricular tachycardia or ventricular fibrillation late after acute myocardial infarction were prospectively followed up to assess determinants of mortality and recurrence of arrhythmic events. Patients were given standard antiarrhythmic treatment, which consisted primarily of drug therapy. During a mean follow-up period of 1.9 years, 133 patients (34%) died; arrhythmic events and heart failure were the most common cause of death (41 patients [11%] died suddenly, 31 [8%] died because of recurrent ventricular tachycardia or ventricular fibrillation and 23 [6%] died of heart failure). One hundred ninety-two patients (49%) had at least one recurrent arrhythmic event; 85% of first recurrent arrhythmic events were nonfatal. Multivariate analysis of data from patients who developed the arrhythmia less than 6 weeks after infarction identified five variables as independent determinants of total mortality: 1) age greater than 70 years (risk ratio 4.5); 2) Killip class III or IV in the subacute phase of infarction (risk ratio 3.5); 3) cardiac arrest during the index arrhythmia (risk ratio 1.7); 4) anterior infarction (risk ratio 2.2); and 5) multiple previous infarctions (risk ratio 1.6). Multivariate analysis of data from patients developing the arrhythmia greater than 6 weeks after infarction identified four variables as independently predictive of total mortality: 1) Q wave infarction (risk ratio 2.1); 2) cardiac arrest during the index arrhythmia (risk ratio 1.7); 3) Killip class III or IV in the subacute phase of infarction (risk ratio 1.7); and 4) multiple previous infarctions (risk ratio 1.4). The results of the two multivariate analyses were used in a model for prediction of mortality at 1 year. The average predicted mortality rate varied considerably according to the model: for 243 patients (62%) with the lowest risk, it was 13%, corresponding to an observed mortality rate of 12%; for 92 patients (24%) with intermediate risk, it was 27%, corresponding to an observed rate of 28%; for 55 patients (14%) with the highest risk, it was 64%, corresponding to an observed rate of 54%. This study shows that patients with symptomatic ventricular tachycardia or ventricular fibrillation late after myocardial infarction who are given standard antiarrhythmic treatment have a high mortality rate. The predictive model presented identifies patients at low, intermediate and high risk of death and can be of help in designing the appropriate diagnostic and therapeutic strategy for the individual patient.