The American College of Cardiology's (ACC) Care of the Athletic Heart is a yearly course focusing on exercise and sports cardiology. The course sessions include management of athletes with cardiovascular (CV) disease, debates on return to play, and discussions on advocacy for cardiac safety in the community. Here, we provide an overview of the 2024 course sessions.

Sports Cardiology – The Dawn of a Great Era

• The field of sports cardiology has evolved from a focus on preventing sudden cardiac death (SCD) to promoting safe participation in exercise. It is rapidly evolving to use promotion of physical activity as a form of prevention.
• Sports cardiology is evolving from a paternalistic approach (i.e., disqualification decisions based on limited data) to a focus on shared decision making (SDM) given the progress in understanding risk phenotypes and the focus on preemptive emergency action planning.
• Given the increasing complexity and individualistic nuances, competency standards in training and certifying sports cardiologists is likely needed.

Electrocardiogram Interpretation in Athletes

• Electrocardiogram (ECG) screening has shown mixed data on decreasing the incidence of SCD. An Italian study showed a significant decreased incidence of SCD after screening¹ while a similar Israeli study showed no change on risk of SCD after screening.²
• ECG screening was found to have a significantly higher sensitivity for echocardiographic abnormalities than history and physical examination alone.³
• Previously, anterior T Wave inversions from V1-V4 have been thought to be limited to Black athletes and thus dubbed the "Black athlete ECG pattern". However, there is emergence that this pattern may exist in athletes of all races, rather than only in Black athletes. More research is needed to better understand this pattern while being careful not to use self-identified race as an impetus for further testing.

CV Care in Masters Athletes

• Runners have been found to have more coronary artery calcium (CAC) when compared to sedentary controls, with CAC increasing proportionally to metabolic equivalents per week.⁴
• Recent data has shown lifelong endurance athletes had more coronary plaques, including more non-calcified plaques in proximal segments, than fit and healthy controls.⁵
• Masters athletes with traditional risk factors for coronary disease should be appropriately counseled on their risk. The cardiologist should consider reluctance to statins in this population, as well as the effect of beta blockers or diuretics for hypertension given their effects on exercise.

Prevention of Sudden Cardiac Arrest in Athletes

• Black athletes have been shown to have a three to seven times higher rate of SCD, decreased rate of survival after SCD, increased false positive ECG screening rate and a higher incidence of left ventricular hypertrophy than non-Black athletes.⁶
• Preparticipation physical examination (PPE) and emergency action planning (EAP) are cornerstones to improving athlete safety. EAPs are fundamental in saving an athlete with SCD.
• The contemporary approach to preparticipation screening enables athletes with a positive screen to undergo diagnosis, risk stratification and management with subsequent, timely SDM on potential return to play based on cardiac risk, and athlete/family values and preferences.
• ECG screening of athletes during PPE remains the subject of discussion. There is consensus that mass screening should not be mandated. Professional, college, and high school leagues all have different screening methodologies.
• The Smart Heart Sports Coalition, of which the ACC is a member, advocates for all 50 states to adopt evidence-based policies that will help prevent fatal outcomes from sudden cardiac arrest (SCA) among high school students.

SDM and Returning to Sport Participation

• The field of sports cardiology continues to evolve with a SDM approach being the hallmark.
• It is the duty of the sports cardiologist to inform the athlete and all stakeholders of the diagnosis and its associated potential risks, both of continued participation and the risk without sport participation. Once all stakeholders understand the potential risks involved as well as their respective likelihoods, the sports cardiologist should aid the athlete in their decision regarding return to play.

Imaging in Athletes Heart

• Athletic adaptations to the heart can vary in athletes depending on sport and position within the sport.
• Right ventricular and left ventricular chamber size are often proportionately enlarged in athletes, however overall ejection fraction typically remains preserved.⁷
• Left ventricular thickness may be increased in athletes. Exercise related remodeling, however, is unlikely to yield >15mm in males and >13mm in females.
• Athletes will often have supra-normal diastolic function with small A waves and increased medial and lateral e' velocities.

CV Care of the Young Athlete

• 1-2% of athletes will have an 'enlarged' aorta, but it is rare for the aorta to be >4.2 cm in this population.
• Sport participation does not seem to accelerate aortic enlargement in those with bicuspid valves.⁸
• Genetic testing in athletes can be important when used in conjunction with clinical screening. If a screening test is positive, genetic testing may help to establish a true diagnosis as well as to risk stratify chances of SCA. However, the implications of a positive test must be considered before the test itself is competed.
• Routine and widespread genetic testing is NOT recommended in athletes.

CV Care for Exercise in the Extremes

• High altitudes can cause a decrease in exercise capacity by 1% for every 100m over 1500m.
• In hypertensive patients, severe hypertension may occur at altitude due to sympathetic activation leading to peripheral vasoconstriction.
• Altitude may exacerbate ischemic heart disease due to a combination of decreased oxygen delivery and vasoconstriction.
• Immersion in cold water can increase myocardial oxygen demand, central venous return, and peripheral vasoconstriction which may lead to immersion pulmonary edema.⁹
• There is no sufficient evidence to screen for or close known patent foramen ovale in asymptomatic individuals partaking in scuba diving.

CV Care in the Tactical Athlete

• Tactical athletes are those whose occupations require a high demand for speed, strength, and agility with a focus on service, rather than competition. Often performance is required under life-threatening conditions and outcomes are based on survival of themselves and others.
• Tactical athletes in various fields experience increased risk of SCD across age groups.
• Contrary to general athletes, the decision of return to service of tactical athletes is often a more paternalistic approach, given the stakes involved.

Arrhythmias in the Athlete

• Endurance exercise is associated with increased risk of developing atrial fibrillation.
• Singular pulmonary vein isolation (PVI) has not been shown to decrease exercise capacity. However, with multiple PVI ablations there may be potential for stiff left atrium syndrome, resulting in decreased exercise capacity via decreased left atrial compliance, and in turn elevated post capillary pulmonary pressures.
• The Heart Rhythm Society recently published a consensus statement on arrhythmias in athletes intended to guide in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction.

References

1. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 2006;296:1593-601.
2. Steinvil A, Chundadze T, Zeltser D, et al. Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death: proven fact or wishful thinking? J Am Coll Cardiol 2011;57:1291-96.
3. Baggish AL, Hutter AM, Wang F, et al. Cardiovascular screening in college athletes with and without electrocardiography: a cross-sectional study. Ann Intern Med 2010;152:269-75.
4. Aengevaeren VL, Hopman MTE, Thompson PD, et al. Exercise-induced cardiac troponin I increase and incident mortality and cardiovascular events. Circulation 2019;140:804-14.
5. De Bosscher R, Dausin C, Claus P, et al. Lifelong endurance exercise and its relation with coronary atherosclerosis. Eur Heart J 2023;44:2388-99.
6. Petek BJ, Churchill TW, Moulson N, et al. Sudden cardiac death in National Collegiate Athletic Association athletes: a 20-year study. Circulation 2024;149:80-90.
7. D'Ascenzi F, Pelliccia A, Solari M, et al. Normative reference values of right heart in competitive athletes: a systematic review and meta-analysis. J Am Soc Echocardiogr 2017;30:845-858.e2.
8. Schreurs BA, Hopman MTE, Bakker CM, et al. Associations of lifelong exercise characteristics with valvular function and aortic diameters in patients with a bicuspid aortic valve. J Am Heart Assoc 2024;13:e031850.
9. Bove AA. Diving medicine. Am J Respir Crit Care Med 2014;189:1479-86.