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Do elite athletes need a specifically tailored cardiovascular evaluation?

Comment by Luis Serratosa, EAPC Sports Cardiology Section

Sports Cardiology


This retrospective study from the group with probably the longest experience in cardiovascular screening of athletes provides new evidence supporting the efficacy of a periodic and specifically tailored cardiovascular evaluation of elite athletes.

The study included data from the cardiovascular screening programme (history, physical examination, 12-lead and exercise ECG and echocardiography) of 2352 Italian Olympic athletes (age 25±6, 64% men), competing in 31 summer or 15 winter sports, during the 2004-2014 period. Additional tests (24 hour ECG monitoring, cardiac MR, CT scan, coronary angiography) were selectively performed to confirm diagnosis and/or assess risk stratification when indicated.

The main finding of the study is the unexpected prevalence of clinically relevant cardiovascular abnormalities affecting 92 athletes (3.9%) who had already been evaluated within the national preparticipation screening before entering the Olympic programme. Findings included 66 (2.8%) with structural abnormalities (4 cardiomyopathies, 1 coronary artery disease, 4 perimyocarditis, 2 myocardial bridges, 45 valvular and congenital diseases and 10 systemic hypertension) and 26 (1.1%) with primary electrical diseases (2 atrial fibrillation, 14 supraventricular reciprocating tachycardia, 6 non-sustained ventricular tachycardia, 1 bidirectional ventricular tachycardia, 1 Wolff-Parkinson-White and 2 Long QT syndrome).

Primary suspicion for diagnosis was prompted by history and physical examination in 27 (29%), in 52 (56%) by adding the 12-lead ECG, in 69 (75%) by adding exercise-ECG and finally up to all 92 athletes with abnormalities, when echocardiography was performed. No relationship was found between type of sport and prevalence or type of cardiac abnormality.

The vast majority of athletes were allowed to continue with competitive sports participation and those with cardiovascular conditions were managed according to current recommendations. A small but not negligible proportion (0.6%) of athletes were diagnosed with conditions (0.2% with cardiomyopathies and 0.4% with complex ventricular tachyarrhythmias, WPW and long QT syndrome) which are associated to an increased risk for SCD/SCA during sport participation. This proportion is even slightly higher than the one reported in previous studies (1), and could raise concern about the efficacy of the screening protocol based on history, physical examination and resting 12-lead ECG. Apparently, most of the cases were missed in the preparticipation screening because of inconclusive imaging studies or incorrect ECG interpretations, substantiating the difficulty of diagnosis in cardiomyopathies (HCM, ARVC) when morphological changes are mild and suggesting the need for continuous improvement of athlete-specific ECG interpretation criteria and training of physicians performing the preparticipation screening. Over the last decade and based on several studies, ECG interpretation standards have undergone several modifications to improve the accuracy of detecting potentially life threatening cardiac conditions in young athletes while also limiting false-positive results. New echocardiographic technologies have also improved the diagnostic capabilities of this noninvasive imaging technique to better differentiate cardiac pathology from physiological adaptation.
The results of this study might be useful for national and international sports governing bodies considering implementation of periodic and specifically tailored cardiovascular evaluation for the prevention of cardiac events and appropriate medical care of elite athletes.

 

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology

References

1. Comparison of electrocardiographic criteria for the detection of cardiac abnormalities in elite black and white athletes Sheikh N, Papadakis M, Ghani S et al, Circulation. 2014 Apr 22;129(16):1637-49.

2. Are Olympic athletes free from cardiovascular diseases? Systematic investigation in 2352 participants from Athens 2004 to Sochi 2014 , Pelliccia A, Adami PE, Quattrini F et al., Br J Sports Med. 2016 Dec 30. doi: 10.1136/bjsports-2016-096961.