Dr. Hein Heidbuchel,
Although sudden death in athletes is luckily a rare phenomenon, everyone has experienced personal moments of disbelief when hearing of the sudden demise of an athlete. Why did this happen? Could this have been prevented? A panelist of experts explored what is known and how preventive strategies can be refined.
Prof. F. Carré (Rennes, France) rephrased the official ESC recommendations, also supported by IOC and FIFA, that screening of athletes should include an ECG. An ECG may diagnose many underlying etiologies that cannot be uncovered by a mere history or physical examination. Nevertheless, distinguishing normal from abnormal ECG findings in athletes is confounded by the ECG changes that occur secondarily to sports activity itself. By better recognition of these changes, and taking effects of race, age, type and intensity of sports into account, the false positive prediction of ECGs has been reduced to less than 10%. Recent data have shown a clearly higher prevalence of repolarization abnormalities in athletes of African-Caribbean descent, without prognostic concerns. In some however, further work-up will be required to rule out underlying cardiovascular disease and prevent life-threatening ventricular arrhythmias.
Prof. Lluis Mont (Barcelona, Spain) discussed a less lethal but much more prevalent form of arrhythmia in athletes: atrial fibrillation. There is more and more epidemiological data that defines regular and intensive physical activity as an independent risk factor for the development of this arrhythmia. Often, AF only develops in the forties or later. Therefore, physicians taking care of athletes in their active careers do not see this as a frequent problem. Prof. Mont indicated that there is growing understanding into the pathophysiology of sports as risk factor for AF, which most likely is due to an interaction between atrial dilatation, increased vagal tone, increased atrial ectopy, and maybe even interstitial fibrosis. Indeed, a rat model of endurance training, developed in his lab, showed a progressive increase of fibrogenetic markers in parallel with the development of AF inducibility. Interestingly, there is regression of fibrosis on cessation of endurance training in these rats. In how far these findings translate to humans is still unclear. In any case, the fact that sports may be a risk factor for a related ‘cardiac injury’ does not negate its beneficial effects on cardiovascular health in general.
The finding of ventricular premature beats (VPB) on the ECG or Holter of an athlete is not uncommon. Dr. Steinvil (Tel Aviv, Israel) zoomed in on their relevance and consequences for further screening. Indeed, sudden death in athletes is rare (between 0.4 to 2 per 100.000 and per year, worldwide) and the question is by how far VPB are an incidental finding or require further work-up that can prevent such sudden death. The fact that some studies have shown that there is a regression in VPB frequency after deconditioning and that these athletes have a good prognosis, even on resumption, can be taken as a reassuring fact. However, since most of these arrhythmias come from the RV, it may also suggest that there is a causal relation between sports and these RV arrhythmias, as has been suggested by some authors. The prognosis of athletes with RV arrhythmias is not always benign. Therefore, after some debate at the end of his lecture, the conclusion was that the real significance of VPB is still unclear, but that a cautious approach is recommended to exclude underlying heart disease. This may also include late potentials (often a sensitive test for RV perturbations), MRI with gadolinium (fibrosis being an ominous sign), and even an EP study (which has been shown to confer prognostic information in athletes with suspected underlying morphological abnormalities).
The same difficult work-up applies to athletes with syncope, as Dr. Eckhardt (Münster, Germany) continued. The spectrum of causes is as wide as in the general population, ranging from benign neurocardiogenic syncope to life-threatening ventricular arrhythmias. A syncope during or immediately after sports should be approached with high suspicion, since these syncopes are definitely related to a less favorable outcome. This points back to the first presentation of the session indicating the importance of a full screening, including good personal and family history taking. Of course, any other unusual finding on ECG, physical examination, or during tailored further cardiovascular evaluation, can be an indicator for underlying disease that may impact on prognosis. If an abrupt syncope is reported or when minor changes in the right precordial leads are seen, a challenge with class-1 drugs (like ajmaline) may also be appropriate in the evaluation.
The challenge of arrhythmias in athletes
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