Sports cardiology

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Sports Cardiology
ECGfemaleathlete.jpg
A screening electrocardiogram being performed in a female athlete
System Cardiovascular
Significant diseases Hypertrophic cardiomyopathy, Wolff–Parkinson–White syndrome, Long QT syndrome, Arrhythmogenic cardiomyopathy, Sudden death (sport)
Significant tests electrophysiology study, cardiac imaging, ECG, echocardiograms, stress test
SpecialistSports Cardiologist

Sports cardiology is an emerging subspecialty field of Cardiology. [1] [2] [3] It may also be considered a subspecialty field of Sports medicine (or Sport & Exercise Medicine), or alternatively a hybrid subspecialty that spans cardiology and sports medicine. Emergency medicine is another medical specialty that has some overlap with Sports Cardiology. Sports cardiology is now considered to be a distinct subspecialty in Europe and the USA, with a core curriculum developed in both regions. [4] [5] [6] In Europe it has traditionally been grouped under Preventive Cardiology, but the subspecialty of Sports Cardiology is now considered a distinct field. In the USA, it has developed from being a special interest area to a distinct subspecialty as well.

Contents

Sports cardiology can be roughly divided into two areas itself:

The preventive aspect of Sports Cardiology aligns slightly more with the speciality of Sports Medicine (doctors who look after athletes and exercising people), acute response with Emergency medicine, whereas the management of athletes with known heart disease is more aligned with the Cardiology side of Sports Cardiology. Sports Cardiology as a cardiology subspecialty overlaps with Electrophysiology, Cardiac Stress Testing, Echocardiography and other cardiac imaging, Genetic testing, and Cardiomyopathy.

Formal education for doctors is now available in Sports Cardiology, such as a Masters Degree in Sports Cardiology at St George's, University of London [7] and at the University of Padua, in Italy [8] .

Sudden Cardiac Death in Athletes

Sudden cardiac death (SCD) is a very rare event but particularly tragic affecting apparently healthy young or early middle-aged people. Sudden cardiac death occurs in approximately one per 100,000 young athletes per year, generally in matches or training, but also occasionally at rest. [9]

Common categories of sudden cardiac death causes are: [10]

Cardiomyopathies and conduction diseases are responsible for the majority of sudden cardiac death in young athletes (< 30 years old), whereas Coronary artery disease (often latent in a relatively young person) increases in risk with age and is by far the most common cause of sudden cardiac death in an athlete >35 years old. Commotio cordis is less common but caused by an external force rather than an intrinsic abnormality of the heart. [11]

Prevention of sudden cardiac death in athletes

Classification of sports for risk of sudden cardiac death

Sports have been classified into varying risks for Sudden Cardiac Death for competitive athletes. [12] [13] Sports with high static and dynamic forces are those that present the greatest risk, bearing in mind that for individual athletes playing in these sports the risks are still very small. Rowing, cycling and basketball are amongst the sports with the highest annual risk. [14] Football (soccer) provides the highest number of young athletes who suffer cardiac arrest, being a medium risk sport that is played extensively worldwide. The risk is higher in male athletes than female athletes. [15] [16]

Screening of athletes to prevent sudden cardiac death

Screening of athletes to prevent SCD is a controversial area. Generally, medical screening is considered to be potentially valuable for conditions or diseases that are relatively common and not useful for conditions that are rare, due to the likely high number of false positives. SCD is rare and hence screening necessarily has a high rate of false positives (that is, athletes flagged as being potentially unsafe to participate in high-level sport but who would not die if they did continue to play sport). Nevertheless, because of the fear of SCD and occupational requirement to train and compete at extremely high intensity in professional and elite sport, screening is established as a standard of care in many countries of the world. [17] The country with the most established program of screening for cardiac disease in athletes is Italy, which requires this to be done by law. Over many decades the rate of SCD in Italy has reduced, probably due to nationwide screening. [18] Some experts question whether the rate may have been reduced through other means, and whether the disqualification of many young people from playing vigorous sport annually is worth it. [19]

International guidelines have been agreed to regarding what constitutes a normal and abnormal athletic ECG when screening asymptomatic athletes. [20] [21]

In Europe, the UK and Australia, [22] the standard of care is generally to include an ECG as part of the standard screening program. Whilst ECGs are done for many athletes in the USA, the standard of care is more likely to be an annual history & physical examination, with an ECG only performed if any item of concern with the clinical presentation. [23]

A major charity in the UK is Cardiac Risk in the Young (CRY) which performs regular screenings.

Athletic event management to respond to cardiac arrest

A wall-mounted Automated External Defibrillator (AED) at a sporting venue WallDefib.jpg
A wall-mounted Automated External Defibrillator (AED) at a sporting venue

In theory, cardiac arrest at a sporting event whilst very rare can be predicted and hence the survival rate from arrest should be higher if a good emergency management plan has been implemented. Not all stadia and athletic fields have AEDs present, particularly at amateur level. And not all events have well-trained event staff (doctors, paramedics and staff qualified in basic life support). Finally, even with AEDs and staff present, because of the rarity of cardiac arrest in the community especially in young people, event staff may not be well or recently trained to respond, or may not be concentrating at the time of an arrest. [24]

Event planning is therefore a key component of Sports Cardiology, even though event planning would not normally be a concern of a medical speciality. Making sure that there are sufficiently trained medical, paramedical and other trained staff or volunteers at sporting events, ready availability of AEDs or ambulances or both, and that those qualified people are ready to respond to an arrest, probably leads to a greater lowering of the rates of sudden cardiac death in sport than any other measure. Hence, having an excellent understanding of the parameters of safe event planning is a core subject in Sports Cardiology. [25]

Management of known heart disease in athletes

Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) or HOCM (O = obstructive) is considered the most common cause of sudden cardiac death in young athletes that may be preventable. However, the difficulty is that it overlaps with the more Athlete Heart syndrome and vast majority of discovered cases are mild, making it unclear about whether it is safe to continue playing intense sport. [26]

Arrhythmogenic right ventricular cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is less common than HCM but usually more clearly progressive, associated with intense activity and usually has more clear indication to avoid highly intense sporting activities. It is more common in certain genetic backgrounds. Much of the reduction in deaths in Italy since the advent of nationwide screening has been thought to be due to ARVC reduction. [27]

Long QT syndrome

Long QT syndrome is a familial condition that is uncommon but is a known source of sudden death in young people. It can cause cardiac arrest during athletic activity but also when doing other activities that raise heart rate. [28]

Brugada syndrome

Brugada syndrome is a familial condition that is also very uncommon, and also a known source of sudden death in young people. Many of the deaths occur when inactive and it is less commonly a cause of sudden death playing sport. [29]

Atrial fibrillation in athletes

Atrial fibrillation (AF) is more common in the inactive, elderly population than the inactive young population. There is a reverse J-shaped curve, however, in that elite athletes doing very arduous sport have a higher rate of AF than moderately active people. Whereas the AF that occurs in the inactive elderly population is known to be associated with increased risk of stroke, it is unknown whether athletic AF increases the risk of sudden death or stroke. AF in athletes can be treated with a minimally-invasive procedure known as ablation. [30]

Wolff–Parkinson–White syndrome

Wolff–Parkinson–White syndrome (WPW) syndrome is a known cause of arrhythmia in young people. It causes supraventricular tachycardia during exercise. Most of the time this causes cessation of exercise when the SVT occurs. It can lead to cardiac arrest but generally does not. It can also be successfully treated by a minimally-invasive procedure known as ablation. [31] [32]

Implantable cardioverter-defibrillators in athletes

An Implantable cardioverter-defibrillators (ICD device) can be used in an athlete who has either had a previous cardiac arrest or is known to be at very high risk for cardiac arrest to trigger an internal shock to cardiovert the heart in the event of a fatal rhythm occurring. [33]

Related Research Articles

<span class="mw-page-title-main">Cardiology</span> Branch of medicine dealing with the heart

Cardiology is the study of the heart. Cardiology is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease, and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

<span class="mw-page-title-main">Cardiomyopathy</span> Disease of the heart muscle

Cardiomyopathy is a group of primary diseases of the heart muscle. Early on there may be few or no symptoms. As the disease worsens, shortness of breath, feeling tired, and swelling of the legs may occur, due to the onset of heart failure. An irregular heart beat and fainting may occur. Those affected are at an increased risk of sudden cardiac death.

<span class="mw-page-title-main">Cardiac arrest</span> Sudden stop in effective blood flow due to the failure of the heart to beat

Cardiac arrest, also known as sudden cardiac arrest, is when the heart suddenly and unexpectedly stops beating. As a result, blood cannot properly circulate around the body and there is diminished blood flow to the brain and other organs. When the brain does not receive enough blood, this can cause a person to pass out and become unresponsive. Cardiac arrest is also identified by a lack of central pulses and abnormal or absent breathing.

<span class="mw-page-title-main">Brugada syndrome</span> Heart conduction disease

Brugada syndrome (BrS) is a genetic disorder in which the electrical activity of the heart is abnormal due to channelopathy. It increases the risk of abnormal heart rhythms and sudden cardiac death. Those affected may have episodes of syncope. The abnormal heart rhythms seen in those with Brugada syndrome often occur at rest. They may be triggered by a fever.

<span class="mw-page-title-main">Myocarditis</span> Inflammation of the heart muscle

Myocarditis, also known as inflammatory cardiomyopathy, is an acquired cardiomyopathy due to inflammation of the heart muscle. Symptoms can include shortness of breath, chest pain, decreased ability to exercise, and an irregular heartbeat. The duration of problems can vary from hours to months. Complications may include heart failure due to dilated cardiomyopathy or cardiac arrest.

<span class="mw-page-title-main">Mitral valve prolapse</span> Medical condition

Mitral valve prolapse (MVP) is a valvular heart disease characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. It is the primary form of myxomatous degeneration of the valve. There are various types of MVP, broadly classified as classic and nonclassic. In severe cases of classic MVP, complications include mitral regurgitation, infective endocarditis, congestive heart failure, and, in rare circumstances, cardiac arrest.

<span class="mw-page-title-main">Arrhythmogenic cardiomyopathy</span> Medical condition

Arrhythmogenic cardiomyopathy (ACM), arrhythmogenic right ventricular dysplasia (ARVD), or arrhythmogenic right ventricular cardiomyopathy (ARVC), most commonly is an inherited heart disease.

Hypertrophic cardiomyopathy is a condition in which muscle tissues of the heart become thickened without an obvious cause. The parts of the heart most commonly affected are the interventricular septum and the ventricles. This results in the heart being less able to pump blood effectively and also may cause electrical conduction problems. Specifically, within the bundle branches that conduct impulses through the interventricular septum and into the Purkinje fibers, as these are responsible for the depolarization of contractile cells of both ventricles.

<span class="mw-page-title-main">Dilated cardiomyopathy</span> Medical condition

Dilated cardiomyopathy (DCM) is a condition in which the heart becomes enlarged and cannot pump blood effectively. Symptoms vary from none to feeling tired, leg swelling, and shortness of breath. It may also result in chest pain or fainting. Complications can include heart failure, heart valve disease, or an irregular heartbeat.

<span class="mw-page-title-main">Short QT syndrome</span> Medical condition

Short QT syndrome (SQT) is a very rare genetic disease of the electrical system of the heart, and is associated with an increased risk of abnormal heart rhythms and sudden cardiac death. The syndrome gets its name from a characteristic feature seen on an electrocardiogram (ECG) – a shortening of the QT interval. It is caused by mutations in genes encoding ion channels that shorten the cardiac action potential, and appears to be inherited in an autosomal dominant pattern. The condition is diagnosed using a 12-lead ECG. Short QT syndrome can be treated using an implantable cardioverter-defibrillator or medications including quinidine. Short QT syndrome was first described in 2000, and the first genetic mutation associated with the condition was identified in 2004.

<span class="mw-page-title-main">Athletic heart syndrome</span> Medical condition

Athletic heart syndrome (AHS) is a non-pathological condition commonly seen in sports medicine in which the human heart is enlarged, and the resting heart rate is lower than normal.

<span class="mw-page-title-main">Takotsubo cardiomyopathy</span> Sudden temporary weakening of the heart muscle

Takotsubo cardiomyopathy or takotsubo syndrome (TTS), also known as stress cardiomyopathy, is a type of non-ischemic cardiomyopathy in which there is a sudden temporary weakening of the muscular portion of the heart. It usually appears after a significant stressor, either physical or emotional; when caused by the latter, the condition is sometimes called broken heart syndrome. Examples of physical stressors that can cause TTS are sepsis, shock, subarachnoid hemorrhage, and pheochromocytoma. Emotional stressors include bereavement, divorce, or the loss of a job. Reviews suggest that of patients diagnosed with the condition, about 70–80% recently experienced a major stressor, including 41–50% with a physical stressor and 26–30% with an emotional stressor. TTS can also appear in patients who have not experienced major stressors.

<span class="mw-page-title-main">Cardiac Risk in the Young</span>

Cardiac Risk in the Young (CRY) is a humanitarian charitable organisation helping to raise awareness of young sudden cardiac death, including sudden arrhythmic death syndrome. CRY was established in May 1995 by Alison Cox MBE and is based in the United Kingdom.

The following outline is provided as an overview of and topical guide to cardiology, the branch of medicine dealing with disorders of the human heart. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology. Physicians who specialize in cardiology are called cardiologists.

<span class="mw-page-title-main">Hypertrophic cardiomyopathy screening</span> Procedure for detecting a form of heart disease

Hypertrophic cardiomyopathy screening is an assessment and testing to detect hypertrophic cardiomyopathy (HCM).

A wearable cardioverter defibrillator (WCD) is a non-invasive, external device for patients at risk of sudden cardiac arrest (SCA). It allows physicians time to assess their patient's arrhythmic risk and see if their ejection fraction improves before determining the next steps in patient care. It is a leased device. A summary of the device, its technology and indications was published in 2017 and reviewed by the EHRA Scientific Documents Committee.

<span class="mw-page-title-main">Sudden cardiac death of athletes</span> Natural, unexpected death from cardiac arrest of athletes

It remains a difficult medical challenge to prevent the sudden cardiac death of athletes, typically defined as natural, unexpected death from cardiac arrest within one hour of the onset of collapse symptoms, excluding additional time on mechanical life support. Most causes relate to congenital or acquired cardiovascular disease with no symptoms noted before the fatal event. The prevalence of any single, associated condition is low, probably less than 0.3% of the population in the athletes' age group, and the sensitivity and specificity of common screening tests leave much to be desired. The single most important predictor is fainting or near-fainting during exercise, which should require detailed explanation and investigation. The victims include many well-known names, especially in professional association football, and close relatives are often at risk for similar cardiac problems.

Frank I. Marcus was an American cardiologist and Emeritus Professor of Medicine at the University of Arizona Health Sciences Center, the author of more than 290 publications in peer-reviewed medical journals and of 90 book chapters. He was considered a world expert on arrhythmogenic right ventricular cardiomyopathy (ARVC) and was a member of the Editorial/Scientific Board of 14 Cardiovascular Journals as well as a reviewer for 26 other medical publications.

<span class="mw-page-title-main">Jonathan Drezner</span> American sports medicine physician

Jonathan A. Drezner is an American sport and exercise medicine physician, currently editor in chief of the British Journal of Sports Medicine. In both clinical practice and research he has a strong interest in sports cardiology. He is a first author for the International Guidelines for Electrocardiography (ECG) Interpretation in athletes and was the 19th President of the American Medical Society for Sports Medicine (AMSSM) in 2012.

<span class="mw-page-title-main">Preparticipation physical evaluation</span> Physical examination of athletes in sports medicine

In sports medicine, a preparticipation physical evaluation (PPE) is a physical examination of an athlete. PPEs screen for a variety of conditions, including athletic heart syndrome and risk of sudden cardiac death. PPEs are required for athletic participation according to the laws of some jurisdictions and the rules of many sports governing bodies. PPE is known by a variety of other names, such as preparticipation evaluation, preparticipation physical examination, preparticipation screening, sports physical, sports physical exam, examination for participation in sport, and similar.

References

  1. ↑ Halle, M; Löllgen, H (May 2014). "Sports cardiology: more than caring for athletes". European Journal of Preventive Cardiology. 21 (5): 656–7. doi: 10.1177/2047487313518279 . PMID   24396115. S2CID   206819852.
  2. ↑ Rakhit, D; Marwick, TH; Prior, DL; La Gerche, A (September 2018). "Sports Cardiology - A Bona Fide Sub-Specialty". Heart, Lung & Circulation. 27 (9): 1034–1036. doi:10.1016/j.hlc.2018.04.303. PMID   30029872. S2CID   51704303.
  3. ↑ Lawless, CE (July 2015). "How to Practice Sports Cardiology: A Cardiology Perspective". Clinics in Sports Medicine. 34 (3): 539–49. doi:10.1016/j.csm.2015.03.009. PMID   26100427.
  4. ↑ Heidbuchel, H; Papadakis, M; Panhuyzen-Goedkoop, N; Carré, F; Dugmore, D; Mellwig, KP; Rasmusen, HK; Solberg, EE; Borjesson, M; Corrado, D; Pelliccia, A; Sharma, S; Sports Cardiology Section of European Association for Cardiovascular Prevention and Rehabilitation (EACPR) of European Society of Cardiology, (ESC). (October 2013). "Position paper: proposal for a core curriculum for a European Sports Cardiology qualification". European Journal of Preventive Cardiology. 20 (5): 889–903. doi: 10.1177/2047487312446673 . PMID   22582328. S2CID   41412648.
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  20. ↑ Sharma, S; Drezner, JA; Baggish, A; Papadakis, M; Wilson, MG; Prutkin, JM; La Gerche, A; Ackerman, MJ; Borjesson, M; Salerno, JC; Asif, IM; Owens, DS; Chung, EH; Emery, MS; Froelicher, VF; Heidbuchel, H; Adamuz, C; Asplund, CA; Cohen, G; Harmon, KG; Marek, JC; Molossi, S; Niebauer, J; Pelto, HF; Perez, MV; Riding, NR; Saarel, T; Schmied, CM; Shipon, DM; Stein, R; Vetter, VL; Pelliccia, A; Corrado, D (21 April 2018). "International recommendations for electrocardiographic interpretation in athletes". European Heart Journal. 39 (16): 1466–1480. doi: 10.1093/eurheartj/ehw631 . hdl: 10067/1468710151162165141 . PMID   28329355. S2CID   205037699.
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  27. ↑ Pilichou, Kalliopi; Thiene, Gaetano; Bauce, Barbara; Rigato, Ilaria; Lazzarini, Elisabetta; Migliore, Federico; Perazzolo Marra, Martina; Rizzo, Stefania; Zorzi, Alessandro; Daliento, Luciano; Corrado, Domenico; Basso, Cristina (2 April 2016). "Arrhythmogenic cardiomyopathy". Orphanet Journal of Rare Diseases. 11 (1): 33. doi: 10.1186/s13023-016-0407-1 . PMC   4818879 . PMID   27038780.
  28. ↑ "Long QT syndrome". Genetic and Rare Diseases Information Center (GARD) – an NCATS Program. 2017. Retrieved 2 July 2021.
  29. ↑ Polovina MM, Vukicevic M, Banko B, Lip GY, Potpara TS (October 2017). "Brugada syndrome: A general cardiologist's perspective". European Journal of Internal Medicine. 44: 19–27. doi:10.1016/j.ejim.2017.06.019. PMID   28645806.
  30. ↑ "Atrial Fibrillation". The Lecturio Medical Concept Library. 11 August 2020. Retrieved 2 July 2021.
  31. ↑ Bhatia, A; Sra, J; Akhtar, M (March 2016). "Preexcitation Syndromes". Current Problems in Cardiology. 41 (3): 99–137. doi:10.1016/j.cpcardiol.2015.11.002. PMID   26897561.
  32. ↑ "Wolff-Parkinson-White syndrome". rarediseases.info.nih.gov. 31 December 2012. Archived from the original on 21 April 2017. Retrieved 2 July 2021.
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