Introduction

The 2023 American College of Cardiology (ACC) Care of the Athletic Heart conference featured presentations and expert panel discussions from world-renowned leaders within the field of sports cardiology. Topics included controversies in preparticipation screening, common mistakes with imaging athletes' hearts, managing the master athlete, and advocacy within the sports cardiology community. High-yield learning points are summarized from several conference sessions.

Can Exercise Harm the Heart?

• Current guidelines for adults recommend 150-300 min/week of moderate-intensity exercise, 75-150 min/week of vigorous-intensity exercise, or an equivalent combination of moderate and vigorous physical activity.¹ Although exercise has health benefits, acute and long-term endurance exercise may cause detrimental cardiac events.
• Running-induced injury to skeletal muscle is repaired by satellite cells, which release cardiac enzymes. Troponin level elevation in this context is not a marker of myocardial involvement/injury.
• Long-term, high-volume endurance exercise is correlated with increased incidence of atrial fibrillation, coronary artery calcification, insertion-point late gadolinium enhancement, and aortic dilatation. Given the complex and unclear mechanisms of injury, individualized risk assessment is required.

Electrocardiography (ECG) Interpretation in Athletes

• Each iteration of the criteria for ECG interpretation in athletes (European Society of Cardiology [ESC] 2010, Seattle 2013, Refined Seattle 2014, and the current International ECG 2017 criteria) has decreased the false-positive rates while maintaining high sensitivity.²
• Although currently considered a normal finding, further investigation of the anterior repolarization pattern in Black athletes may be warranted.
• Future efforts should focus on the female athlete's ECG, as well as clinical implications of race-specific differences and ensuring equitable cardiovascular (CV) care for all athletes.

Controversies of Preparticipation Screening of Competitive Athletes Without Symptoms

• The benefit-to-risk ratio of ECG screening in competitive athletes who are free of symptoms remains an ongoing debate.
• The top causes of sudden cardiac death (SCD) in young athletes in the United States are autopsy-negative sudden unexplained death, hypertrophic cardiomyopathy, and idiopathic left ventricular (LV) hypertrophy/possible cardiomyopathy.³
• Patients with traditional risk factors for coronary artery disease should undergo aggressive risk factor modification regardless of athlete status.
• Although ECG screening has a high sensitivity for identifying conditions that predispose to sudden cardiac arrest/SCD, it is not perfect and athletes will still have cardiac events.

Noncardiac Causes of Dysfunctional Breathing in Athletes

• The Milstein Breathing Pattern Assessment Index (M-BPAI) can be used to assess the degree of tightness in the respiratory muscles during heavy breathing tasks, which can help in evaluation of exercise-induced bronchoconstriction (EIB), exercise-induced laryngeal obstruction (EILO), and breathing pattern disorder (BPD).
• Treatment of EIB, BPD, and/or EILO consists of comorbidity management, environmental trigger minimization, inspiratory muscle training, and surgical treatment in select cases.

How to Evaluate Young Athletes With Symptoms

• High-risk features of chest pain in athletes include exertional dyspnea, diaphoresis or palpitations, abnormal ECG findings, and/or troponin level elevation.
• The use of cardiac magnetic resonance and the Lake Louise Criteria for the evaluation of myocarditis in young athletes should be reserved for cases in which there is a high pretest probability.

Evaluation of Athletes After Sudden Collapse

• Differentiating between neurally mediated syncope and high-risk cardiac structural abnormalities is crucial in the management of athletes after sudden collapse.
• A positive finding on tilt-table testing is often seen in athletes; however, this finding does not exclude more serious underlying pathology. Tilt-table testing does not have much utility in this population.
• Obtaining a video of the collapse can be useful in understanding the mechanism of sudden collapse.

Emergency Action Plans (EAPs) and Advocacy in Sports Cardiology

• Successfully implemented EAPs are effective at improving survival after a cardiac arrest.
• An effective EAP includes a team-based collaboration by training stakeholders in performing cardiopulmonary resuscitation and using automatic external defibrillators (AEDs).
• Rates of response to cardiac emergencies are higher in states with mandated EAP laws.
• Effective ways for sports cardiologists to become involved with advocacy include advocating for AED mandates at the state level and engaging in ACC legislative advocacy.

Shared Decision Making With Athletes With Cardiac Disease

• Cardiologists have a responsibility to practice shared decision making with athletes, with an emphasis on patient autonomy and beneficence.
• Eligibility recommendations should not be based on an athlete's level of engagement with a particular sport but on the patient's values.
• More research is needed to understand the interaction between cardiovascular disease (CVD) and exercise to inform communication strategies and integration of values into decisions.

Common Mistakes in Imaging Athletes' Hearts

• Exercise-induced cardiac remodeling can occur as a result of hemodynamic stress from regular strenuous exercise.
• Normal diastolic findings in athletes include E/A >2 on mitral inflow and D > S on pulmonary vein flow, which is consistent with brisk and active LV relaxation.

Managing Atherosclerotic CVD Risk Factors in Master Athletes

• Exercise is beneficial in those with elevated coronary artery calcium (CAC) scores—a higher aerobic capacity is associated with improved outcomes in athletes compared with those of patients with similar CAC scores who are less active.⁴
• Athletes free of symptoms but with elevated CAC scores should be counseled to remain active.

Arrhythmogenic Cardiomyopathy and Cardiac Arrhythmias in Athletes

• Right ventricular (RV) enlargement can often be a normal finding in elite endurance athletes.
• RV-to-LV size ratio can be greater in athletes than in nonathletes, but an RV-to-LV basal end-diastolic diameter ratio of >1 should be considered abnormal.⁵
• Signs of pathologic RV enlargement include presence of arrhythmias, segmental wall dysfunction, reduced contractile reserve, and scar in both ventricles.

Environmental Considerations for Vocational and Tactical Athletes

• Vocational athletes exercising at extreme altitudes are exposed to hemodynamic shifts that can exacerbate underlying cardiopulmonary conditions.^6-7
• Low-stress diving is generally performed at 3-4 METs. Divers should be able to perform 6 METs at steady state and 12-13 METs at peak exercise to manage unexpected events.^8-9
• Comorbidities should be optimized at sea level and athletes should allow for acclimatization before vigorous exercise to decrease the risk of complications under extreme environmental exposures.
• The expected duration of altitude exposure and intensity of exercise should be known for vocational athletes with a focus on establishing an evacuation plan in the event of a CV event.

References

1. World Health Organization. Global recommendations on physical activity for health (WHO website). 2010. Available at: https://www.who.int/publications/i/item/9789241599979.  Accessed 07/17/2023.
2. Dhutia H, Malhotra A, Finocchiaro G, et al. Impact of the international recommendations for electrocardiographic interpretation on cardiovascular screening in young athletes. J Am Coll Cardiol 2017;70:805-7.
3. Peterson DF, Kucera K, Thomas LC, et al. Aetiology and incidence of sudden cardiac arrest and death in young competitive athletes in the USA: a 4-year prospective study. Br J Sports Med 2021;55:1196-203.
4. DeFina LF, Radford NB, Barlow CE, et al. Association of all-cause and cardiovascular mortality with high levels of physical activity and concurrent coronary artery calcification. JAMA Cardiol 2019;4:174-81.
5. Pelliccia A, Caselli S, Sharma S, et al.; Internal Reviewers for EAPC and EACVI. European Association of Preventive Cardiology (EAPC) and European Association of Cardiovascular Imaging (EACVI) joint position statement: recommendations for the indication and interpretation of cardiovascular imaging in the evaluation of the athlete's heart. Eur Heart J 2018;39:1949-69.
6. Wolfel EE. Exercise at High Altitude. In: Thompson PD, Fernandez AB, eds. Exercise and Sports Cardiology. Hackensack, NJ: World Scientific Publishing Europe Ltd.; 2018.
7. Cornwell WK 3rd, Baggish AL, Bhatta YKD, et al.; American Heart Association Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology, Council on Arteriosclerosis, Thrombosis and Vascular Biology. Clinical implications for exercise at altitude among individuals with cardiovascular disease: a scientific statement from the American Heart Association. J Am Heart Assoc 2021;Oct 5:[ePub ahead of print].
8. Bove AA. Diving medicine. Am J Respir Crit Care Med 2014;189:1479-86.
9. Mitchell SJ, Bove AA. Medical screening of recreational divers for cardiovascular disease: consensus discussion at the Divers Alert Network Fatality Workshop. Undersea Hyperb Med 2011;38:289-96.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Sports and Exercise Cardiology, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Coronary Artery Disease, Contrast Media, Cardiovascular Diseases, Myocarditis, Troponin, Cicatrix, Calcium, Bronchoconstriction, Decision Making, Shared, Dilatation, Gadolinium, Arrhythmias, Cardiac, Electrocardiography, Risk Factors, Athletes, Syncope, Defibrillators, Cardiopulmonary Resuscitation, Risk Assessment, Respiratory Muscles, Hemodynamics, Muscle, Skeletal, Dyspnea, Comorbidity, Acclimatization, Hypertrophy, Sports, Sports Medicine

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