Interest in sports and exercise cardiology has witnessed a significant rise in recent years. However, there are only a few dedicated sports cardiology programs in the US and limited opportunities for training. It is against this backdrop that the American College of Cardiology (ACC) Care of the Athletic Heart Virtual 2020 held a session entitled 'So You Want to Be a Sports Cardiologist?' The aim of the session was to help trainees and early career cardiologists navigate a career in sports cardiology and provide advice to those interested in building a sports cardiology program. In this article, we outline some of the key questions and answers from this session.

Dr. Jeffrey Hsu (University of California Los Angeles) and Dr. Sheela Krishnan (University of Pennsylvania) moderated an expert panel including:

• Dr. Jonathan Kim (Emory University)
• Dr. Eugene Chung (University of Michigan)
• Dr. Meagan Wasfy (Massachusetts General Hospital)
• Dr. Dermot Phelan (Sanger Heart and Vascular Institute)
• Dr. Matthew Martinez (Atlantic Health, Morristown Medical Center)

What are the essential elements of building a Sports Cardiology program?

The recent growth in the number of competitive athletes and highly active individuals has led to an increase in the need for sports cardiology practices. Sports cardiologists treat a wide range of patients, including young symptomatic athletes, asymptomatic athletes with concerning pre-participation sports evaluations, athletes with inherited cardiac conditions, and older recreational athletes with coronary artery disease and arrhythmias. As a result, the role of the sports cardiologist may vary depending on the type of patient-athlete. In young athletes, for instance, it could be to differentiate pathology from physiological exercise-induced cardiac remodeling, whereas, for older individuals, the objective might be to provide individualized training prescriptions to safely engage cardiac patients in exercise.

Despite the apparent need for more sports cardiology centers, there are few dedicated programs in the US.  There are several challenges and barriers to creating a sports cardiology program. The discussion at the session highlighted a general consensus that building a successful program requires three key components. First, it is important to have the support of the hospital and division leadership. While this may be challenging, inviting well-established sports cardiologists to deliver grand rounds may be helpful, as they would bring the depth of understanding of the complex interplay between intense exercise and cardiovascular disease. Second, the involvement of other cardiac sub-specialties, notably electrophysiologists, cardiac imaging specialists and exercise physiologists, is also critical. For Dr. Wasfy, working alongside an exercise physiologist interested and accustomed to exercise testing in athletes has been crucial to her sports cardiology practice. Finally, generating the patient-athlete volume through fostering excellent relationships with local sports teams, trainers, and physicians is essential to build a successful sports cardiology program. Engagement at the grassroots level and effective communication with athletic trainers and team doctors has been central to the panel's patient-athlete referral base.

How to market yourself as a sports cardiologist

Marketing oneself as a sports cardiologist is not too dissimilar to what would be required for any niche field. Broadly speaking, this involves building a profile, developing a network, and possessing a vision for the program. Attending sports cardiology conferences such as the Care of the Athletic Heart annual meeting (which we hope will return in-person next year), as well as the sports cardiology sessions at the ACC Scientific Sessions can also facilitate networking with leaders in the field. Often these meetings provide the first encounter to demonstrate an interest in the field, which could lead to opportunities to contribute in a more meaningful way. These may include an invitation to write articles for ACC.org, present cases at national meetings, or moderate sports cardiology sessions.

What career pathways can be pursued to become a Sports Cardiologist?

Although a niche field, sports cardiology encompasses most aspects of general cardiology, and therefore a well-rounded training holds a candidate in good stead for a career in sports cardiology. It is important to acknowledge that there are no fixed routes to becoming a sports cardiologist. Among the panel, there were specialists in electrophysiology, cardiac imaging, and hypertrophic cardiomyopathy. This has led to some heterogeneity in the type of sports cardiology clinics in the US. For example, some centers have a greater focus on cardiopulmonary exercise testing (CPET), while others may provide more specialized arrhythmia management. Indeed, collaboration with multiple colleagues and centers across institutions may be needed to provide optimal care for a patient-athlete. That said, a deep understanding of CPET, specialization in electrophysiology, and advanced cardiac imaging training would be immensely helpful in sports cardiology.

It is important to note that for the vast majority of sports cardiologists, clinical duties are not entirely dedicated to treating patient-athletes. For the panel, sports cardiology represents 15-100% of their clinical time. This is influenced, in part, by the volume of patient-athletes at the center, the time of year (increased volume during pre-participation sports evaluations), whether research is a substantial part of overall effort, and choice of sub-specialty (invasive subspecialties may require more time directed towards higher revenue-generating procedures).

What advice do you have for Fellows-In-Training (FIT)?

While some FITs may have the advantage of training at a center with an established sports cardiology program, it is, nevertheless, important to remain resourceful and seek out opportunities to develop an interest in the field. This may involve attending clinics where local athletes are being evaluated, which may often be in non-cardiology practices such as sports or family medicine. In addition, volunteering at race events and working with the team physician or medical director for professional teams provides important exposure to the field. Beyond these efforts, the ACC Sports and Exercise Cardiology Section provides useful resources and professional advice for those interested in pursuing sports cardiology training (contact information is available on the Section's homepage through ACC.org). Presenting sports cardiology papers at journal clubs and contributing interesting cases or articles to ACC.org allows for a deeper understanding of important aspects of sports cardiology. Above all, passion, commitment, and determination are essential characteristics that would enable one to keep pace with developments in the field and comprehend the ongoing challenges of sports cardiology.

Recommended Sports Cardiology Resources

There are numerous sports cardiology resources, including but not limited to those listed below. Local sports medicine and cardiology mentors as well as those through the ACC can serve as an important resource and provide guidance to find other educational opportunities.

Conferences

• ACC Care of the Athletic Heart: annual meeting for all health care professionals interested in sports cardiology. Next conference: June 24-26, 2021. Location: Heart House in DC and/or virtual. 
• A Practicum: Cardiopulmonary Exercise Testing and Interpretation. Includes didactic lectures, small group tutorials and laboratory demonstrations with CPET. Usually 3 practicums held per year, next tentatively scheduled for October 8-10, 2020. 

Textbooks

• Thompson PD, Fernandez AB. Exercise and Sports Cardiology. New York City: McGraw-Hill Companies; 2001.

Literature

• Baggish AL, Battle RW, Beckerman JG, et al. Sports cardiology: core curriculum for providing cardiovascular care to competitive athletes and highly active people. J Am Coll Cardiol 2017;70:1902-18.
• Baggish AL, Battle RW, Beaver TA, et al. Recommendations on the use of multimodality cardiovascular imaging in young adult competitive athletes: a report from the American Society of Echocardiography in collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2020;33:523-49.

Other Online Resources

• ACC.org Sports and Exercise Cardiology Collection webpage with expert reviews and case-based quizzes: https://www.acc.org/clinical-topics/sports-and-exercise-cardiology#sort=%40fcommonsortdate90022%20descending
• ACC.org Sports and Exercise Cardiology Section webpage: https://www.acc.org/membership/sections-and-councils/sports-and-exercise-cardiology-section
• University of Washington online athlete electrocardiogram tutorial: https://uwsportscardiology.org/e-academy/ecg-modules/
• Other helpful articles listed at the ACC Care of the Athletic Heart Virtual 2020 Website: https://virtual.acc.org/ah20/additional-resources/eabstracts

Clinical Topics: Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Sports and Exercise Cardiology, Atherosclerotic Disease (CAD/PAD), Sports and Exercise and ECG and Stress Testing

Keywords: Sports, Athletes, Coronary Artery Disease, Physician Executives, Cardiovascular Diseases, Hospitals, General, Specialization, Teaching Rounds, Consensus, Family Practice, Leadership, Universities, Ventricular Remodeling, Exercise Test

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