On June 21-23, 2018, the American College of Cardiology held its annual sports cardiology conference, "Care of the Athletic Heart: Contemporary Concepts, Cases and Controversies." Located in Park City, Utah, the meeting hosted over 150 sports cardiology and sports medicine practitioners. Course directors Drs. Matthew Martinez and Jonathan Kim organized an excellent, well-rounded agenda that stimulated insightful discussions from improving ECG screening in athletes to identifying when advanced treatment options (e.g., atrial fibrillation ablation, ICD implantation) are appropriate for an athlete.

Dr. John Parsons, Director of the NCAA Sports Science Institute, started the meeting with an invigorating keynote lecture that carried the ambitious title "Can Sport Save Society?" He highlighted the strategic priorities for the Sports Science Institute, which in addition to cardiac health, include improving our understanding of concussions and emphasizing mental health in the overall care of the young athlete.

Building upon the meeting's success from previous years, Drs. Martinez and Kim added timely new topics to this year's agenda. These included discussions on managing congenital heart disease and aortopathies in athletes, understanding the demands of a "tactical athlete," and best approaches to shared decision making. Arguably the most fitting portion of the program was a scheduled time to "practice what we preach," during which participants had the opportunity to participate in CrossFit (organized by Dr. Michael Emery) or trail runs/hikes during one of the afternoon sessions.

As a fellow-in-training, Care of the Athletic Heart was the ideal meeting to learn directly from the experts as well as to network with other trainees looking to make an impact in this rapidly emerging field. The meeting provided the unique opportunity to hear thought leaders in sports cardiology discuss differing approaches to challenging clinical scenarios and highlight the important gaps in our collective knowledge. The location and organization of the meeting permitted easy access to the experts and speakers who were more than happy to interact and discuss cases outside of the conference room.

While I still have a tremendous amount to learn about this field, I did my best to reflect and identify the Top 10 Key Questions addressed at the meeting:

1. ECG screening: How can we improve our specificity in identifying true ECG abnormalities in an athlete?
   
   Routine ECG screening of young athletes continues to be a matter of debate, but a cornerstone for sports cardiology practitioners remains the ability to identify truly abnormal ECG findings in athletes. Dr. Aaron Baggish led an expert panel in detailed discussions of challenging ECGs, giving attendees the opportunity to apply the latest international recommendations from 2017.¹ As these criteria will likely continue to evolve to improve specificity and sensitivity, emphasis was placed on interpreting ECGs in the appropriate context, particularly understanding race-based and sport-specific (i.e., endurance vs. non-endurance) patterns.
2. Cardiovascular Imaging in the Athlete: What is "normal"?
   
   Major strides have been made in understanding the "normal" range of cardiovascular chamber sizes in elite athletes. Based on recent studies, including one on over 500 NBA players,² we are learning more about the normal limits for wall thickness in athletes. In a new topic presented this year, Dr. Dermot Phelan discussed the upper limits for aortic sizes, particularly in the taller (e.g., NBA players) and bigger (e.g., NFL players) athletes. As more studies continue to better characterize these parameters, Dr. Baggish reminded everyone of one of the central themes in imaging the athletic heart: "symmetry is key."
3. Extreme endurance exercise: What are the cardiovascular consequences?
   
   While the cardiovascular benefits of moderate exercise are widely accepted, we are learning more about the consequences of habitual intense endurance exercise. Dr. Andre La Gerche presented data from his group suggesting that intensive exercise may recapitulate the phenotype of arrhythmogenic right ventricular cardiomyopathy (ARVC), even without known associated genetic mutations.³ Though these cases may fall under the category of "gene-elusive" ARVC, a better understanding of this pathophysiology will help us better inform our patients. Additional discussion by Dr. Eugene Chung on the associations of atrial fibrillation with intense exercise seen in men further highlighted the relevance of this question.⁴ It was emphasized, however, that these issues still need to be resolved and affect small numbers of people. Epidemiological studies continue to show prognostic benefit for most people even at the extremes of exercise.
4. Hypertrophic cardiomyopathy & long-QT syndrome (LQTS): How much physical activity/exercise can we "prescribe" or safely recommend? Bottom line, we do not have perfectly precise answers. It is clear, however, that regular moderate exercise is safe and beneficial and needs to be actively discussed and encouraged in these patient cohorts. In certain situations, competitive sports may be permissible after consultation with an expert in the field. The nearly fully-enrolled LIVE-HCM and LIVE-LQTS studies (led by meeting faculty Drs. Rachel Lampert and Michael Ackerman) hope to be very informative.
5. Sudden cardiac death on the field: How we can improve our response?
   
   Recent, high-profile, sports-related sudden cardiac death events have emphasized the importance of refining "emergency action plans," as highlighted by Dr. George Chiampas during the meeting. While Dr. Parsons revealed that only 29% of youth coaches in the United States are trained in CPR,⁵ Dr. Richard Kovacs discussed policies that some states have implemented to address these issue (e.g., Maine requires all coaches to be trained in CPR or else lose coaching eligibility).
6. The 'master' athlete: How do we manage cardiovascular issues?
   
   Despite their physically active lifestyles, athletes are not immune from common cardiovascular conditions, such as coronary artery disease (CAD) and atrial fibrillation and managing these issues in active athletes requires a nuanced approach. Dr. Paul Thompson addressed the management of CAD in the master athlete and emphasized the importance of balancing the benefits of statin therapy with the potential adverse effect of myalgias. Additionally, Dr. Chung led a lively discussion on the role of ablation in the athlete with atrial fibrillation.
7. "Tactical athlete": Who are they and what are their cardiorespiratory demands?
   
   From military personnel to police officers and firefighters, tactical athletes represent a group whose occupational demands can impose strenuous physical demands on their bodies. Dr. Ben Levine educated attendees on important considerations in evaluating this population, emphasizing that their cardiorespiratory systems should be able to handle the peak load required. Incapacitation can impact not only the tactical athlete, but can dramatically impact the lives of those around the athlete.
8. Genetic testing: Where does it fit in our evaluation?
   
   As the role of genetic testing in general cardiology practice continues to evolve, Dr. Ackerman shared his five reasons to not order a genetic test in an athlete. He emphasized the importance of identifying not only the right patients to test, but also the need to respect the "dark side" of a test. As we refine the role of genetic testing, he encourages better knowledge of the likely yield of a test in a given patient.
9. Shared decision making: How do we balance our roles as an advocate for athletes' participation versus disqualifying athletes from competition?
   
   While shared decision making is a central tenet in modern medicine, it can frequently be more complex in the management of athletes. For professional and collegiate level athletes, there are often additional stakeholders, such as the university or a professional team, and their input will also weigh heavily in these cases. Helping athletes navigate through these external influences can be challenging, but it is crucial to inform them as well as possible on the known and unknown risks of athletic competition in the presence of cardiovascular disease. Throughout the conference speakers provided their own approach to individual cases which are often very complex and nuanced.
10. The next Care of the Athletic Heart meeting: How can you attend?
    
    If any of the above topics interest you, be sure to check ACC.org throughout the year for more educational content on these and related issues. Stay tuned for details on the next Care of the Athletic Heart meeting, which will take place on June 20-22 in Washington, DC.

References

1. Sharma S, Drezner JA, Baggish A, et al. International recommendations for electrocardiographic interpretation in athletes. Eur Heart J 2018;39:1466-80.
2. Engel DJ, Schwartz A, Homma S. Athletic cardiac remodeling in US professional basketball players. JAMA Cardiol 2016;1:80-7.
3. La Gerhce A, Heidbuchel H. Can intensive exercise harm the heart? You can get too much of a good thing. Circulation 2014;130:992-1002.
4. Mohanty S, Mohanty P, Tamaki M, et al. Differential association of exercise intensity with risk of atrial fibrillation in men and women: evidence from a meta-analysis. J Cardiovasc Electrophysiol 2016;27:1021-9.
5. Aspen Institute. State of Play 2017: Trends and Developments. Available at: https://assets.aspeninstitute.org/content/uploads/2017/12/FINAL-SOP2017-report.pdf. Accessed July 4, 2018.

Keywords: Athletes, Arrhythmogenic Right Ventricular Dysplasia, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Atrial Fibrillation, Myalgia, Coronary Artery Disease, Mentors, Brain Concussion, Death, Sudden, Cardiac, Long QT Syndrome, Cardiomyopathy, Hypertrophic, Electrocardiography, Life Style, Sports Medicine, Sports, Cardiopulmonary Resuscitation, Epidemiologic Studies

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