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: This was a five-part session on cardiac screening programs, cardiovascular risks of American style football, sports nutrition, race medicine and emergency action plans. The following are the top 10 key points from this session:

Current Cardiac Evaluations: How They Do It
This was a panel discussion, moderated by Dr. Jonathan Kim, covering the state of current cardiac evaluations in the NCAA, the professional sports world and the community. Speakers included Mr. Ron Courson and Drs. Matthew Martinez, David Shipon and Dermot Phelan. The goal of this session was not to debate the merits or risks of screening, but rather to address when screening is undertaken by mandate or by choice, how it is done, and what is important to consider. Each speaker, though involved with different organizations in different capacities, mutually agreed upon a few major themes.

1. All screening programs, regardless of organization, are based upon obtaining a thorough history and physical via a standardized pre-participation evaluation. Screening programs differ in terms of whether on-site ECG and echocardiograms are performed. However, in any cardiac screening program, it is critical to have highly trained and qualified personnel (athletic trainers, coaches, physicians, sonographers, technicians) available to support, conduct, acquire and interpret high quality data, as well as to closely monitor athletes. On the field expertise and standardized processes are essential for success.
2. Having a plan to expedite and quickly investigate borderline or concerning findings is critical. A successful screening program not only makes diagnoses, but also has a plan for how to further investigate concerning findings, to make referrals if necessary, and to communicate concerns with patients/athletes and their families in a timely manner. Rapidly obtained second opinions and consensus decisions among experienced personnel are very valuable.
3. Community engagement, education about health and wellness, and shared decision-making are critical components of a successful screening program. Diagnoses and treatment plans require thoughtful conversations and teamwork amongst highly-qualified and well-trained professionals in order to care for athletes holistically.

Dr. Kim next presented on American Style Football and Cardiovascular Concerns, providing an in-depth review of prior and ongoing research into the unique health and cardiovascular risks of American football.

4. A recent study found that veteran NFL players, regardless of position, have increased cardiovascular morbidity and mortality when compared to retired professional baseball players. Active and veteran NFL players also have a higher incidence of pre-hypertension and hypertension compared to age-matched controls in the general population. Former linemen and/or those with a high BMI, appear to have an increased cardiovascular risk compared to lower weight or non-linemen football-playing peers. Development of early cardiovascular risk and subclinical maladaptive cardiovascular phenotypes (increased blood pressure, arterial stiffening, maladaptive LV remodeling, etc.) starts when athletes are actively playing. Research on the exact mechanisms, environmental factors, and temporal sequences that result in these increased cardiovascular risks in this population is ongoing.
5. Hence, this patient population needs better primary and preventive cardiovascular care. Future areas of investigation include early assessment of cardiovascular risk, appropriate counseling based on player field position and management of risk factors over time.

Dr. Michael Emery presented on Sports Nutrition: Preparation, Supplements, and Steroids – What to Watch For and Hidden Dangers.

6. Performance enhancing drug (PED) use ranks ahead of Type I diabetes and HIV in terms of prevalence in the US population. The majority of PED users are under the age of 50 and are not competitive athletes. Androgenic anabolic steroids represent the highest proportion of PEDs used in oral or injectable form. They are known to have multiple adverse neuroendocrine and organ system effects, including long and short-term cardiac effects, only some of which are reversible with cessation. Some "body-building" powders may contain anabolic steroids, and patients should be warned about them as these products are not FDA-regulated.
7. Energy drinks are a multi-billion dollar industry. They contain many ingredients besides caffeine, many of which are also stimulants. Most have their own "proprietary energy blend," and companies are not required to inform consumers of the quantity of each ingredient. While espresso and a standard cup of coffee have more caffeine than most energy drinks, the quantity of drinks and how they are consumed affect how much caffeine is ultimately ingested. It is not clear whether reported increases in QTc and systolic blood pressure from energy drinks are due to caffeine or the other ingredients.

Dr. Sharma, the medical director of the London Marathon, next gave a talked entitled Introduction to Race Medicine – Hypothermia, Hyperthermia, Hyponatremia. While a majority of deaths that occurred at the London Marathon over a 28-year period were cardiac in nature, non-cardiac causes require vigilance and prompt intervention.

8. Obtaining a core temperature to assess for heatstroke should be done early in symptomatic athletes presenting for evaluation, along with routine assessment of ABCs (airway, breathing, circulation). Hyperthermia may present with many non-specific symptoms including fatigue, shivering (due to volume depletion) and altered mental status. Resources to initiate rapid and therapeutic cooling should be easily accessible on the racecourse.
9. Modest to moderate levels of dehydration are tolerable and pose little risk; however, hyponatremia from excess consumption of hypotonic fluids can be fatal. Participants should be advised to drink according to thirst. It is important to educate the public regarding the dangers of excessive hydration with hypotonic solutions (water, sports drinks) before a race. Serum sodium testing is recommended prior to administration of any IV fluids on the racecourse, and hypertonic saline should also be readily available.

Finally, Mr. Courson addressed Where There is No Debate: Emergency Action Plans for Cardiac Arrest.

10. While the utility of cardiovascular screening for athletes is frequently debated, the development and implementation of Emergency Action Plans (EAPs) at sporting events undoubtedly saves lives. Successful EAPs require advanced planning, including appropriately trained first responders, easy accessibility of AEDs, familiarity with protocol and equipment, early communication with outside emergency personnel and rapid response by police and EMS. It is crucial for administrators, trainers, physicians and other staff to be trained to recognize and evaluate collapse quickly and appropriately and to utilize closed-loop communication. "Medical time outs" should be conducted prior to every sporting event to ensure preparedness. Finally, it is important to remember EAPs are more often required for non-athlete participants or spectators.

Keywords: Sports, Athletes, Blood Pressure, Performance-Enhancing Substances, Energy Drinks, Prehypertension, Football, Dehydration, Risk Factors, Hypothermia, Hypotonic Solutions, Hyponatremia, Cardiovascular Diseases, Body Mass Index, Body Weight, Sports Medicine, Hypertension, Sunstroke, Testosterone Congeners, Heart Arrest, Phenotype, Electrocardiography, Diabetes Mellitus

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