Promoting Cardiovascular Health in Athletes
With the advent of health care reform in the U.S., much attention has been focused recently on achieving the “Triple Aim” – better care, better health and lower costs. In order to achieve the Triple Aim, we must create high-performing health systems dedicated to managing defined populations efficiently and effectively. Increasing awareness of the critical role that interprofessional teams play in these systems is just now beginning to be understood by health professionals and health system reformers.1 Of course those that have been engaged in the care of athletes have long been accustomed to working in interprofessional teams – team physicians, certified athletic trainers, physical therapists, and subspecialists – to optimize the care of athletes for whom they are responsible.
The publication of “Protecting the Heart of the American Athlete: Proceedings of the American College of Cardiology Sports and Exercise Cardiology Think Tank,” which appeared online before print on October 8, 2014 in The Journal of the American College of Cardiology, has underscored how effectively interprofessional teams can function when brought together to improve health care.2 A multidisciplinary group of professionals gathered in Washington, D.C. in 2012 to identify the gaps that existed in optimizing the cardiovascular health of athletes. Their deliberations have resulted in an extensive list and recognized the important role that interdisciplinary cooperation between multiple professional organizations and their respective professionals can play in closing these identified gaps.
At a time when the discussion about cardiovascular health in the athlete heart has disproportionately focused on the debate about how to effectively screen competitive athletes prior to their participation in organized sports,3,4 it is refreshing to read that this group has focused on the current knowledge gaps that exist in our understanding of the interplay between exercise and its influence on the heart and how best to care for those that participate in vigorous physical activity. Several important areas deserve to be underscored.
While it has been known for some time that exercise affects the structure and function of the heart,5,6 much remains to be understood. How do we explain the heterogeneity that exists in those studies that have attempted to further elucidate myocardial function using direct measurement?7 What effect does varying types of exercise have on lusitropy and how does this effect myocardial compliance?8 Can too much exercise have pathological consequences for the heart? Specifically, do the changes that have recently been documented with respect to right ventricular functional remodeling and/or the presence of delayed gadolinium enhancement suggestive of fibrosis within the interventricular septum at the right ventricular insertion have clinical significance?9 The wide variation in the cardiac response to exercise in various racial and ethnic groups begs for a clearer understanding of the genetic influence on cardiac remodeling.10
The electrical changes that occur in the heart in response to exercise training and how these manifest in the electrocardiogram have also been well documented.11 Much work has been done to improve our ability to differentiate these changes from those that are more suggestive of true cardiac disease with the publication of the European Society of Cardiology recommendations in 2010 and the Seattle Criteria in 2013.12,13 While preliminary comparisons of these criteria have been helpful in distinguishing the utility of each,14 additional research is needed to understand the nuanced differences of the two schemas when evaluating the athlete with a cardiac complaint.
Multiple studies have attempted to characterize the frequency and etiology of sudden cardiac arrest and death in exercising individuals, yielding wide estimates in the incidence and prevalence, as well as the etiology, of these phenomena.15,16,17 Most of these differences can be attributed to methodological differences and potential sampling bias. Nevertheless, these differences will not be resolved until agreement is reached on a standardized way for reporting these events and their subsequent confirmation with careful review of the medical records and postmortem findings. The ability to study these phenomena would be greatly enhanced by a national registry given their relatively infrequent occurrence.
A recent Scientific Statement published by the American Heart Association (AHA) and the American College of Cardiology (ACC) has cast considerable doubt on the wisdom of using the electrocardiogram for large scale screening of not only athletes, but also young people in the general population, for potential cardiovascular disease that could result in sudden death.18 However, the debate over the utility of screening in selected populations will not be resolved until a national registry is created. The low frequency of these events makes a randomized controlled trial to study this issue difficult, if not impossible. However, the benefits of using a registry to answer this question can be extrapolated from the important clinical findings that have resulted from clinical data extraction from well-run registries.19 A perfect example of this methodology was demonstrated in the use of the ACC’s National Cardiovascular Data Registry and the Society of Thoracic Surgery Adult Cardiac Surgery Database to study the comparative effectiveness of revascularization strategies in those with coronary artery disease.20
The larger issue that has largely been left unexplored by the proceedings is the influence that participation in athletic activity has on cardiovascular health long after the athlete stops competing. Longstanding evidence demonstrates that athletes are not immune from cardiovascular disease after they finish their careers.21 What strategies are best for optimizing heart health in athletes, particular those that gain considerable weight to participate in their respective sports? How do we help modify those risk factors that place these individuals at risk for hypertension, diabetes, coronary artery disease and stroke?
Most importantly, on a much larger scale, how do we broaden our concern about cardiovascular health to larger populations? Most physicians involved in the care of athletes view all of their patients as potential athletes who can utilize exercise as a powerful tool to promote cardiovascular health. It is accepted that obesity has reached epidemic proportions in the youth of our country. Evidence suggests that obesity in this age group results in subtle but significant subclinical myocardial dysfunction.22 While the long-term effect of these findings are uncertain, how do we encourage regular exercise and heart-healthy behaviors in all for whom we are responsible for providing care? As we move into an era of even greater accountability for population health, these interventions may have the greatest import in achieving the Triple Aim of better care, better health and lower cost.
- Interprofessional Care Coordination: Looking to the Future. New York Academy of Medicine. Policy, Research & Practice. Issue Brief Volume 1:Issue 2, October 2013.
- Lawless CE, Asplund C, Asif IM, et al. Protecting the heart of the athlete: proceedings of the American College of Cardiology Sports and Exercise Cardiology Think Tank. J Am Coll Cardiol 2014 Oct 1. [Epub ahead of print]
- Myerburg RJ, Vetter VL. Electrocardiograms should be included in preparticipation screening of athletes. Circulation 2007;116:2616-26.
- Chaitman BR. An electrocardiogram should not be included in routine preparticipation screening of athletes. Circulation 2007;116:2610-14.
- Deutsch F, Kauf E, Warfield LM (translator). Heart and Athletics. CV Mosby Company. St. Louis, 1927.
- Huston TP, Puffer JC, Rodney WM. The athletic heart syndrome. N Engl J Med 1985;313:24-32.
- Lord RN, George K, Jones H, et al. Reproducibility and feasibility of right ventricular strain and strain rate (SR) as determined by myocardial speckle tracking during high intensity upright exercise: a comparison with tissue Doppler-derived strain and SR in healthy human hearts. Echo Res Pract 2014;1:31-41.
- Levine BD, Lane LD, Buckey JC, et al. Left ventricular pressure-volume and Frank-Starling relations in endurance athletes. Circulation 1991;84:1016-23.
- La Gerche, A. Can intense exercise cause myocardial damage and fibrosis. Curr Sports Med Rep 2013;12:63-9.
- Basavarajaiah S, Boraita A, Whyte G, et al. Ethnic differences in left ventricular remodeling in highly-trained athletes: relevance to differentiating physiologic left ventricular hypertrophy form hypertrophic cardiomyopathy. J Am Coll Cardiol 2008;51:2256-62.
- Pellicia A, Maron BJ, Culasso F, et al. Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 2000;102:278-84.
- Corrado D, Pelliccia A, Heidbuchel H, et al. Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur Heart J 2010;31:243–59.
- Drezner JA, Ackerman MJ, Anderson J, et al. Electrocardiographic interpretation in athletes: the ‘Seattle Criteria.’ Br J Sports Med 2013;47:122–4.
- Sheikh N, Papadakis M, Ghani S, et al. Comparison of electrocardiographic criteria for the detection of cardiac abnormalities in elite black and white athletes. Circulation 2014;129:1637-49.
- Harmon KG, Asif IM, Klossner D, et al. Incidence of sudden cardiac death in national collegiate athletic association athletes. Circulation 2011;123:1594–600.
- Harmon KG, Drezner JA, Maleszewski JJ, et al. Etiologies of sudden cardiac death in National Collegiate Athletic Association athletes Circ Arrhythm Electrophysiol 2014 March 1. [Epub ahead of print]
- Maron BJ, Haas, TS, Murphy CJ, et al. Incidence and causes of sudden death in U.S. college athletes. J Am Coll Cardiol 2014;63:1636-43.
- Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology. J Am Coll Cardiol 2014;64:1479-514.
- Curtis LH, Hammil BG, Eisenstein, EL, et al. Using inverse probability-weighted estimators in comparative effectiveness analyses with observational databases. Med Care 2007;45(suppl 2):s103-7.
- Weintraub WS, Grau-Sepulveda MV, Weiss JM, et al. Comparative effectiveness of revascularization strategies. N Engl J Med 2012;366:1467-76.
- Paffenbarger Jr, RS, Hyde, T, Wing, AL, et al. A natural history of athleticism and cardiovascular health. JAMA 1984;252:491-5.
- Koopman LP, Mertens LL. Impact of childhood obesity on cardiac structure and function. Curr Treat Options Cardio Med 2014;16:345-364.
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