Sports Cardiology (SC) is a growing subspecialty within cardiology that focuses on competitive athletes and highly active people who have or potentially have cardiovascular (CV) disease. It is a lens through which emphasis can be placed on exercise physiology, prevention through maintenance of a healthy lifestyle, and risk stratification and mitigation.¹ From prevention to promotion, SC is a worthwhile career path for Fellows-in-Training (FIT) and Early Career (EC) physicians interested in making a positive impact in their communities.^1,2

Awareness and interest in SC continue to increase exponentially. From concerns regarding SARS-CoV-2 myocarditis in athletes to high-profile exercise-induced sudden cardiac arrest events, SC is at the forefront of community cardiovascular health.³ Concurrently, the American College of Cardiology (ACC) Sports and Exercise Cardiology Council and the FIT/EC working group have been diligently educating our community about common SC themes. Given the relative 'newness' of the field and limited data in many areas, individualized care, expert consensus, and shared decision-making remain central components of any SC practice.

In September 2022, JACC: Case Reports published its first focused issue on SC. We were honored to collaborate with Editor-in-Chief Julia Grapsa, MD, PhD, FACC and the Editorial Board to create a unique picture of the challenges and common themes for the practicing sports cardiologists. The content highlights the transcendent nature of SC across all aspects of cardiology and the importance of community, commitment, and teamwork. In the sections below, we summarize some of the many key points from the focus issue.

Perseverance and Community

The Husaini et al. piece on the mentor relationship specific to SC was the result of discussions of the FIT/EC working group of the ACC Sports and Exercise Cardiology Leadership Council.² This joint perspective was 3+ years in the making after our first working group meeting. The key lesson here for FIT/ECs is that perseverance, a 'good idea,' and a supportive community will result in tangible benefits. In addition, most of the cases in this issue have a trainee or EC sports cardiologist as a senior or first author – a manifestation of the mentoring and relationship building that went on behind the scenes.

Medical Reasoning at its Best

Medical reasoning is paramount when a case (not exclusive to SC) is challenging with little or no data to support one decision over another. Brush and Krumholz's description of medical decision-making in Braunwald's 11th edition, in our view, describes one of the best parts of SC:⁴

'Medical reasoning is an undeniable advantage for making difficult risk decisions that rely on an amalgamation of clinical pattern recognition and perception of probability as well as clinical acumen and a measure of intuition, which draw on knowledge and experience acquired over years in medical training and practice.'

As the cases in the focus issue illustrate, the sports cardiologist must be flexible and call upon clinical pattern recognition, perception of probability, clinical acumen, and a measure of intuition. As our international call for cases ran its course, four broad themes emerged:

Doctoring at its Best: Integrating History, Physiology, Imaging, and Risk Assessment

1. Petek et al. describe an unusual case of a deep vein thrombosis in a competitive cyclist that was attributed to psoas muscle hypertrophy. They integrated the history of endurance exercise, limitations of various testing modalities, and potential future complications when weighing various management approaches.⁵
2. Hermes-Laufer et al. describe a myocardial bridge becoming ischemic during recreational exercise secondary to supraventricular tachycardia. This case illustrates the importance of identifying clinical scenarios in which myocardial bridges have the potential to induce myocardial ischemia.⁶
3. Lander et al. describe a cardiac arrest initially attributed to commotio cordis. As the history and potential mechanism were not consistent, further evaluation led to the correct diagnosis of anomalous left coronary artery from the pulmonary artery (ALCAPA).⁷

Nuanced Shared Decision-Making

1. Norton et al. describe the workup and subsequent discussion in a recreational athlete with idiopathic ventricular fibrillation (VF) who used exercise as a coping mechanism for stress.⁸
2. Kanwal et al. describe a case of recurrent VF during a return-to-play evaluation in an older patient with coronary artery disease. They emphasize that "although patient-centered shared decision-making is important, the discussion must be realistic and balanced, to provide patients with accurate assessments of their risk."⁹
3. Klein et al. describe a case of recurrent pericarditis in a professional tennis player after cardiac surgery for a bicuspid aortic valve. They describe a complex return-to-play discussion in a professional athlete whose livelihood depends on strenuous exercise.¹⁰
4. Tso et al. describe a case series of various coronary anomalies. They emphasize the importance of ensuring an emergency action plan (EAP) is in place for return-to-play after shared decision-making in a non-high-risk situation.¹¹

Wonderful Physiology: Analyzing Physiologic Testing

1. Rabbini et al. studied serial cardiac magnetic resonance images (MRI) in an ultramarathoner running a 2,469 km event. They demonstrate the limits of short-term cardiovascular adaptations and the consequences of extreme escalation of exercise.¹²
2. Rao et al. utilized tilt table testing, non-invasive cardiopulmonary exercise testing (CPET), and a graduated exercise protocol to describe the overlap between post-acute sequalae of SARS-CoV-2 (PASC) and orthostatic intolerance.¹³
3. Fusi et al. describe a case and evaluation of a young athlete with a markedly prolonged PR interval (400 msec), which in this patient was attributed to a late progressive form of autoimmune atrioventricular (AV) block.¹⁴

Red-Flag and Uncommon Presentations

1. Marcus et al. describe a female competitive collegiate swimmer with multiple episodes of peri-exercise syncope. Her evaluation demonstrated right ventricular outflow tract (RVOT) ventricular arrhythmia consistent with borderline arrhythmogenic RV cardiomyopathy.¹⁵
2. Pabba et al. describe a football player with blunt force chest trauma which resulted in a low-output cardiomyopathy, reduced systolic function, and hypoxemic respiratory failure necessitating mechanical ventilation.¹⁶
3. Barouch brings attention to swimming-induced pulmonary edema by describing a case of a masters triathlete and summarizing the appropriate workup for respiratory symptoms in open water.¹⁷

Overall, each case has unique learning objectives, imaging pearls, and thoughtful analysis from experts across the world. We hope the focus issue will inspire SC enthusiasts by highlighting themes germane to caring for athletes and highly active people.

References

1. Husaini M, Papadakis M, Grapsa J, Chung EH. Sports cardiology: from prevention to promotion. JACC Case Rep 2022;4:1147–49.
2. Husaini M, Kline KP, Chukumerije M, Emery MS, Martinez MW, Chung EH. Sports cardiology: the transition of fellow-in-training to early career physician. JACC Case Rep 2022;4:1143–46.
3. Harris J. Remembering Robert Rowan and cardiac screening with Eriksen and Frank (theathletic.com). 2022. Available at: https://theathletic.com/3303398/2022/05/10/remembering-robert-rowan-and-cardiac-screening-with-eriksen-and-frank/. Accessed 10/02/2022.
4. Brush JE Jr, Krumholz HM. Clinical decision making in cardiology. In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GM, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine (11th Edition). Philadelphia: Elsevier; 2018:25-32.
5. Petek BJ, Soong C, Buckley AJ, et al. Acute deep vein thrombosis in a cyclist with iliac vein compression from psoas muscle hypertrophy. JACC Case Rep 2022;4:1080–85.
6. Hermes-Laufer J, Niederseer D, Karolyi M, Gotschy A, Templin C. Myocardial infarction by a myocardial bridge in the LAD combined with atrioventricular re-entrant supraventricular tachycardia. JACC Case Rep 2022;4:1115–18.
7. Lander BS, Zilinyi RS, Einstein AJ, et al. Cardiac arrest in a softball player following a collision: catching the correct diagnosis. JACC Case Rep 2022;4:1070–73.
8. Norton C, Cooper DH, Ewald G, Husaini M. Idiopathic ventricular fibrillation in a previously healthy recreational athlete. JACC Case Rep 2022;4:1129–33.
9. Kanwal AS, Battle J, Friedman EM. Coronary artery disease, cardiac arrest, and shared decision making in a recreational athlete. JACC Case Rep 2022;4:1110–14.
10. Klein BM, Dugan ES, LaCombe AD, et al. Complex management decisions in a professional athlete with recurrent pericarditis. JACC Case Rep 2022;4:1090–93.
11. Tso JV, Cantu SM, Kim JH. Case series of coronary artery anomalies in athletes: challenges in clinical management and sports eligibility. JACC Case Rep 2022;4:1074–79.
12. Rabbani M, Satriano A, Garcia J, et al. Limits of Cardiovascular adaptation during an extreme ultramarathon: insights from serial multidimensional, multiparametric CMR. JACC Case Rep 2022;4:1104–09.
13. Rao P, Peritz DC, Systrom D, Lewine K, Cornwell WK 3rd, Hsu JJ. Orthostatic and exercise intolerance in recreational and competitive athletes with long COVID. JACC Case Rep 2022;4:1119–23.
14. Fusi C, Lazzerini PE, Cavigli L, et al. Maternal anti-ro/SSA autoantibodies and prolonged PR interval in a competitive athlete: beyond training-induced electrical remodeling. JACC Case Rep 2022;4:1098–1103.
15. Marcus M, Wu R, Link MS, Levine BD. Ventricular flutter and pleomorphic ventricular tachycardia-induced syncope in borderline arrhythmogenic right ventricular cardiomyopathy. JACC Case Rep 2022;4:1134–39.
16. Pabba K, Widmer RJ, Nguyen V, Martinez MW. Cardiac contusion complicated by heart failure in a young athlete. JACC Case Rep 2022;4:1124–28.
17. Barouch LA. Swimming-induced pulmonary edema: an underrecognized cause of triathlon-associated medical emergencies. JACC Case Rep 2022;4:1094–97.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Sports and Exercise Cardiology, Valvular Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Magnetic Resonance Imaging, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging

Keywords: Sports, Athletes, SARS-CoV-2, COVID-19, Exercise Test, Bland White Garland Syndrome, Anomalous Left Coronary Artery, Atrioventricular Block, Bicuspid Aortic Valve Disease, Commotio Cordis, Coronary Artery Disease, Leadership, Mentoring, Mentors, Myocarditis, Orthostatic Intolerance, Psoas Muscles, Pulmonary Artery, Pulmonary Edema, Respiration, Artificial, Return to Sport, Respiratory Insufficiency, Tachycardia, Supraventricular, Magnetic Resonance Imaging, Clinical Decision-Making, Venous Thrombosis, Death, Sudden, Cardiac, Risk Assessment, Healthy Lifestyle, Patient-Centered Care, Cardiac Surgical Procedures, Heart Arrest, Pericarditis, Hypertrophy, Perception, Syncope, Adaptation, Psychological

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