Cardiologists and others involved in athletes’ care need to know how the heart adapts to different sports. But they must also know how to treat and advise athletes with pre-existing cardiovascular conditions, who have an increased risk of fatal arrhythmias and sudden cardiac death during exercise.
A new position statement written on behalf of the Sport Cardiology Section of the European Association of Preventive Cardiology focuses on competitive sport in athletes with myocardial disease. The document provides the most updated recommendations for practicing cardiologists and sport physicians managing athletes with these conditions. It also provides practical medical advice for safe participation in competitive sports activities and/or regular exercise programs.
Recent developments in the field
This paper reflects several developments in sports cardiology since 2005, when the European Society of Cardiology last published its recommendations for sports participation in athletes with cardiovascular disease. For example, new methods have been introduced to differentiate between the physiological adaptions to exercise and the early signs of cardiomyopathy. We now also better understand the clinical features of cardiomyopathies in athletes. In addition, diagnosis and risk stratification has improved thanks to the use of cardiovascular magnetic resonance (CMR) imaging, and new genetic tests are enabling the study of genotype-phenotype relationships in cardiomyopathies.
Despite these recent developments, robust evidence is still lacking in the field, and the authors emphasize that their recommendations mainly reflect expert opinion. Physicians should therefore consider the paper a practical guide for managing athletes with these disorders, rather than as something to be followed strictly to the letter.
Risk depends on disease subtype and sport discipline
The position paper covers four types of cardiomyopathy: hypertrophic cardiomyopathy, dilated cardiomyopathy, left ventricular non-compaction cardiomyopathy, and arrhythmogenic right ventricular cardiomyopathy. It also discusses athletes with isolated ECG abnormalities and those with cardiomyopathies and an implanted cardioverter defibrillator, as well as athletes with the inflammatory conditions myocarditis and pericarditis. The paper provides clear recommendations for diagnosing each heart condition – including the use of ECG, echocardiography and CMR imaging. In terms of risk stratification, the recommendations indicate whether or not sports participation should be restricted, depending on the disease subtype and the sport discipline. For example, if an athlete has a cardiovascular disease which can cause them to lose consciousness, there is a high risk of serious harm or death in sports such as motor racing, scuba diving, and rock climbing. The authors also provide advice on the frequency of periodic clinical assessment, and guidance for leisure time sport.
An individualized approach
While it is clear that high-risk individuals should be identified during pre-participation screening processes, a one-size-fits-all approach does not apply. The authors recommend an individualized approach based on six factors: symptomatic status, risk factors for sudden cardiac death/cardiac arrest, disease history, age, how long they have been an athlete, and the sports discipline. These should all be considered when advising athletes on participation in competitive sport or whether they should be disqualified as a precaution.
Given the additional personal and financial consequences of disqualification, they stress the importance of involving athletes in the decision-making process. This means providing detailed disease information and openly discussing the potential risks associated with ongoing competitive sport and high-intensity exercise programs.
Author: Sally Hill
Original article: Pelliccia et al. Eur Heart J 2019