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Sports and Exercise Cardiology: Highlights From the 2024 American Heart Association Scientific Sessions

Quick Takes

  • The relationship between exercise and cardiovascular (CV) health remains a robust area of investigation, encompassing molecular studies, cohort analyses, and randomized controlled trials.
  • CV assessment of the athlete is an evolving discipline that requires distinguishing between benign exercise-induced adaptations and underlying cardiac pathology, as identified on imaging and electrocardiographic findings.
  • Recent guidelines on return to play in athletes with inherited arrhythmias or genetic cardiac disease have shifted from universal restrictions on competitive sports to an athlete-centered, shared decision-making approach, grounded in a comprehensive evaluation, detailed risk stratification, and disease-specific management.

The 2024 American Heart Association (AHA) Scientific Sessions in Chicago featured programming related to sports cardiology and exercise. Highlights included a dedicated sports cardiology educational session, Cardiac Evaluation in the Athlete: When Should I Worry?, and abstract presentations exploring the relationship between exercise and cardiovascular health.

Cardiac Evaluation in the Athlete: When Should I Worry?

Imaging Interpretation in the Athlete: Distinguishing Athlete's Heart From Pathology (Presenter: Abbas Zaidi)

Athletic training induces structural and functional changes—collectively referred to as exercise-induced cardiac remodeling (EICR)—including left ventricular hypertrophy (LVH), increased cavity dimensions, and enhanced diastolic filling.1 A framework for distinguishing adaptive changes from pathology is crucial to identify athletes with cardiac conditions and avoid unnecessary disqualification of healthy athletes. Imaging findings should be interpreted within the clinical context, including symptoms, electrocardiogram (ECG) changes, family history, and training intensity. EICR is proportional to training intensity and presents as mild, symmetric structural changes (e.g., LVH ≤13-14 mm, mild atrial/ventricular dilation) with normal or supranormal diastolic filling. Disproportionate or extreme remodeling, asymmetric hypertrophy or dilation, abnormal strain, or fibrosis on magnetic resonance imaging suggest underlying cardiomyopathy.

ECG Interpretation in the Athlete: What Is Normal? (Presenter: Victoria Vetter)

The 2017 International Recommendations for ECG Interpretation in Athletes provides guidance on distinguishing normal from abnormal findings.2 Normal ECG findings include sinus bradycardia, sinus arrhythmia, first-degree atrioventricular (AV) block, Mobitz type 1 second-degree AV block, and incomplete right bundle branch block. Isolated increased QRS voltage or early repolarization in the absence of other ECG abnormalities or clinical markers of pathology do not require further evaluation. Abnormal findings such as pre-excitation, prolonged QT, ST-segment depression, or abnormal T-wave inversions always warrant further investigation regardless of training history.

Evaluation of the Syncopal Athlete (Presenter: Susan Etheridge)

Syncope while exercising (i.e., syncope before the finish line) should be considered cardiac until proven otherwise. Although only a fraction of those with exertional syncope will be diagnosed with cardiac disease, a thorough evaluation is warranted due to the high stakes of missing a potentially fatal condition. The 2024 Heart Rhythm Society (HRS) Expert Consensus Statement on Arrhythmias in the Athlete provides an algorithm for evaluating exertional syncope in an athlete.3 ECG, echocardiography, and exercise testing form the basis of the evaluation, with additional studies tailored to individual findings.

What Do I Do With My VUS Patient Who Wants to Play Competitive Sports? (Presenter: Michael Ackerman)

Athletes with inherited arrhythmias were historically barred from competitive sports. Recent guidelines acknowledge return to play (RTP) may be possible for these athletes provided they are comprehensively evaluated, risk-stratified, and appropriately managed. Variants of uncertain significance (VUS) do not independently influence adverse event rates and should not factor into the decision-making process. Six critical considerations in RTP for young athletes are:

  1. Ensure you have sufficient expertise to guide the discussion.
  2. There must be agreement between the athlete and parents.
  3. Inform school officials/trainers.
  4. Require an automated external defibrillator as part of safety gear.
  5. Prepare younger athletes for shifting from shared decision-making (SDM) to their decision-making at the university/professional level, where decisions may be unilateral.
  6. Thoroughly document the SDM process.

When Can I Provide Sports Clearance for My Patient With an Inherited Arrhythmia? (Presenter: Rachel Lampert)

The 2024 HRS expert consensus statement emphasizes how to facilitate safe RTP for patients with inherited arrhythmias rather than if participation is possible.3 This SDM approach does not offer clearance—which implies zero risk—but rather an individualized decision-making process that documents understanding and acceptance of risk by both athlete and clinician. Additionally, Dr. Lampert outlines an approach to SDM when discussing RTP4:

  1. Patient/family education—provide detailed data relevant to the athlete's condition, noting limitations.
  2. Determination of values/preferences—recognize that personal risk tolerance and interpretation varies for each patient and informs individual decisions.
  3. Longitudinal care—shift emphasis away from one-time clearance to ongoing follow-up for optimal safety.

Exercise-Related Abstract Presentations:

Association of Sleep and Exercise With Chronic Disease: Insights From Long-Term Wearable Data Among All of Us Participants (Presenter: Asanish Kalyanasundaram; Senior Author: Prashant Rao)

This study leveraged Fitbit (Fitbit Inc., San Francisco, California) data from 9,399 individuals to examine the relationship between objective measures of moderate-to-vigorous physical activity (MVPA) and total sleep duration (TSD) across the human phenome. MVPA and TSD were independently and inversely associated with several cardiometabolic and noncardiometabolic diseases including obesity, hypertension, and major depressive disorder. Whereas different patterns of association with disease were seen across increasing levels of MVPA and TSD, combined analyses suggest optimal levels of both sleep and exercise achieve the lowest risk of incident chronic disease.

The Multi-Omic, Multi-Tissue Response to Acute Endurance and Resistance Exercise: Results From the Molecular Transducers of Physical Activity Consortium (Presenter: Daniel Katz; Senior Author: Matthew Wheeler)

The Molecular Transducers of Physical Activity Consortium (MoTrPAC) analyzed multiomic data from 175 sedentary individuals randomized to resistance exercise, endurance exercise, or no exercise (control arm). The findings, which provide an early insight into the human MoTrPAC data, highlighted a potentially novel exerkine, cellular communication network factor 1, providing further insight into how tissues coordinate response to exercise.

Legacy Effects of Supervised Exercise Training on Body Composition and Cardiorespiratory Fitness in STRRIDE-Prediabetes (Presenter: Leanna Ross; Senior Author: William Kraus)

The STRRIDE-Prediabetes (Studies of Targeted Risk Reduction Interventions Through Defined Exercise Among Individuals With Prediabetes) examined the legacy benefits of a 6-month aerobic exercise program (with varying intensities and volumes) in adults with prediabetes. All exercise groups demonstrated legacy effects for waist circumference, fat mass, and body mass more than a decade post intervention. However, participants assigned to vigorous-intensity exercise did not maintain cardiorespiratory fitness (CRF) benefits to a greater extent than those in the moderate-intensity group. These findings differed from the STRRIDE I Reunion findings, which showed greater CRF legacy effects in vigorous-intensity participants, possibly because of baseline differences in study populations.

Impact of Lifelong Exercise on Left Ventricular Wall Stress (Presenter: Lexis Will; Senior Author: Satyam Sarma)

This study evaluated the relationship between aerobic exercise and left ventricular wall stress, a marker of ventricular workload. In this retrospective analysis of 57 healthy seniors with varying exercise habits, right heart catheterization and echocardiography with preload manipulation showed significantly reduced wall stress among those who engaged in even modest exercise habits (two to three times per week for ~30 min per session) versus sedentary individuals.

References

  1. Martinez MW, Kim JH, Shah AB, et al. Exercise-induced cardiovascular adaptations and approach to exercise and cardiovascular disease: JACC state-of-the-art review. J Am Coll Cardiol 2021;78:1453-70.
  2. Sharma S, Drezner JA, Baggish A, et al. International recommendations for electrocardiographic interpretation in athletes. J Am Coll Cardiol 2017;69:1057-75.
  3. Lampert R, Chung EH, Ackerman MJ, et al. 2024 HRS expert consensus statement on arrhythmias in the athlete: evaluation, treatment, and return to play. Heart Rhythm 2024;21:e151-e252.
  4. Baggish AL, Ackerman MJ, Putukian M, Lampert R. Shared decision making for athletes with cardiovascular disease: practical considerations. Curr Sports Med Rep 2019;18:76-81.

Resources

Clinical Topics: Sports and Exercise Cardiology

Keywords: Sports, Sports Medicine, AHA24, AHA Annual Scientific Sessions