Editor's Note:

Dear Sports and Exercise Cardiology Enthusiasts:

Care of the Athletic Heart 2019 (CAH), directed by Matthew Martinez MD, and Jonathan Kim, MD, convened June 20-22 at the American College of Cardiology's Heart House in Washington, DC. The overflow capacity of attendees and number of live streaming participants exceeded 220 in total. In the next few weeks, we will post summaries of key sessions written by cardiology Fellows-in-Training (FIT). Most of them were presenters at CAH, and all are active in the Sports and Exercise Cardiology Section FIT Interest Group.

The full CAH agenda can be accessed here. Please feel free to contact Chris Driver (cdriver@acc.org) or me (chungeug@umich.edu) with any questions.

Thank you to the FITs for all their hard work. We hope you enjoy the summaries.

Eugene H Chung, MD, FACC
Editorial Team Lead, Sports & Exercise Cardiology Clinical Topic Collection

Background

The faculty speakers of this session all highlighted the main challenge in the management of athletes who have known aortopathy and/or a history of congenital heart disease: lack of evidence in the literature to support decision-making in this population. The American Heart Association/American College of Cardiology (AHA/ACC) eligibility and disqualification recommendations for competitive athletes with aortic disease and congenital heart disease (CHD) are largely based on expert consensus.^1,2 Evaluation and management of athletes with these conditions should be individualized and integrated into a shared-decision making approach. Key points from this session are described below:

• Know your aortic nomogram: When assessing the aortic size on imaging studies, Dr. Alan Braverman, lead author of the AHA/ACC recommendations for managing athletes with aortic disease,¹ recommends comparing these measurements to published nomograms for the athlete's body size. In addition to determining the Z-score, a helpful rule of thumb is to consider evaluation for an underlying aortopathy in any male or female with an aortic root size >40mm or >34mm, respectively. It should be noted that even in the tallest of athletes (e.g., NBA players), aortic root size rarely exceeds 40mm, and in published data from NBA players, the maximum aortic root size was 42mm.³
• Identify the cause of dilated aortic roots: Dr. Braverman also emphasized the importance of searching for the underlying cause of a dilated aortic root, which should include investigation for conditions such as bicuspid aortic valve, Marfan syndrome, Loeys-Dietz syndrome and hereditary thoracic aortic aneurysm disease. This evaluation should include a careful and expanded physical examination, with recognition of characteristic facial features of Marfan and Loeys-Dietz syndromes, as well as utilization of validated scoring systems for diagnosing these syndromes (such as the revised Ghent nosology).⁴ Further, these assessments will often require genetic evaluation, and integration of a cardiovascular genetics specialist into the sports cardiology team is recommended.
• Recommendations for physical activity after aortic surgery: Dr. Braverman addressed the important question of how we can counsel athletes after they have had aortic surgery. One of the key questions to ask is why the athlete needed the surgery in the first place (i.e., what caused the aneurysm or dissection). If there is a syndromic condition that renders the unrepaired aorta at risk, then extra caution should be taken to prevent injury to that portion of the vasculature and the expert recommendations err on the side of safety. In general, the recommendations are to remain active with aerobic exercise in moderation with non-competitive and dynamic exercises. Contact sports and any activity involving significant isometric maneuvers should be avoided. Individualized exercise prescriptions can be helpful.
• Reconsidering sports restriction in CHD: Dr. Bob Battle reviewed the nuanced decision-making process that needs to occur when deciding whether an athlete with CHD should be restricted from competition. He emphasized that the guidelines for eligibility in CHD are largely expert opinion-based, and any assessment of an athlete with CHD needs to incorporate an understanding of their hemodynamics and how their sport of choice may impact cardiovascular remodeling. Further, he encouraged the audience to consider the potential consequences of restricting sports participation in an athlete with CHD, including psychosocial effects and the potential push towards a sedentary, unhealthy lifestyle.
• How to counsel athletes with "fixed" CHD: Dr. Tess Saarel reviewed issues that affect the growing number of patients we will be seeing with "fixed," or surgically repaired CHD, and how these issues may impact an athlete's ability to participate in competitive sports. Notably, arrhythmias are common in adults with CHD, but exercise appears to be safe in athletes with "fixed" CHD, and the vast majority of them should be counseled to engage in physical activity. Reiterating Dr. Battle's message, individually tailored non-invasive testing (e.g., exercise stress test, ambulatory monitoring) to the level achieved in their chosen sport is an important part of guiding recommendations. And as was the common theme throughout Care of the Athletic Heart, a shared-decision making approach with the athlete and other involved parties is a critical aspect of managing this growing population of athletes, particularly given the unique aspects of their post-surgical hemodynamics.

References

1. Braverman AC, Harris KM, Kovacs RJ, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 7: aortic diseases, including Marfan syndrome: a scientific statement from the American Heart Association and American College of Cardiology. Circulation 2015;132:e303-9.
2. Van Hare GF, Ackerman MJ, Evangelista JK, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 4: congenital heart disease: a scientific statement from the American heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2372-84.
3. Engel DJ, Schwartz A, Homma S. Athletic cardiac remodeling in US professional basketball players. JAMA Cardiol 2016;1:80-7.
4. Loeys BL, Dietz HC, Braverman AC, et al. The revised Ghent nosology for the Marfan syndrome. J Med Genet 2010;47:476-85.

Keywords: Sports, Athletes, Exercise Test, Nomograms, Aortic Aneurysm, Thoracic, American Heart Association, Expert Testimony, Marfan Syndrome, Heart Valve Diseases, Aortic Valve, Exercise, Aorta, Arrhythmias, Cardiac, Hemodynamics, Monitoring, Ambulatory, Body Size, Life Style

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