Sports and Exercise Cardiology: The Summit
I must confess that I am an inveterate runner. I started in high school where the track coach insisted that we participate in cross country in the fall, indoor track in the winter, and outdoor track in the spring. His admonition was to return the following fall in top shape, so many of us gathered 1 or 2 days a week in the summer to run 4 or 5 miles. This year-round commitment to running carried into college, medical school, residency, post-doctoral fellowship, the US Navy, and subsequent life as an academic cardiologist.
So when Dr. Chris Lawless contacted me in 2010 to start an ACC committee on Sports Cardiology, my immediate response was, "Yes but it should be a section and a council." Thus was born the ACC Sports and Exercise Cardiology Council and Section. The first three years of the Council, led by Drs. Chris Lawless and Dick Kovaks was a rapid growth period. The Council leadership was made up of cardiologists who had prior experience in sports and exercise cardiology. The section quickly grew to over 2,000 members who were interested in this area of cardiology. We instituted the Sports Cardiology Summit in 2012 as a result of demand for more education about athletes and others who exercise, and held the Summit for each of the past 3 years. This edition of CardioSource WorldNews features the most recent Summit.
Over 200 cardiologists flocked to Indianapolis this past September to hear the latest from experts in the area of exercise physiology, sports physiology, care of athletes with heart disease, and screening for sudden death in athletes. A persistent topic that pervades any discussion of sports cardiology is the topic of preparticipation screening for sudden cardiac death (SCD) risk. In Italy and Israel, mandatory screening with history, physical and ECG is thought to reduce the risk of sudden death, but in many other countries the risk is so low that there is no evidence of an advantage to ECG screening, and this year the discussion pointed out that the incidence of SCD in the non-athlete population of adolescents and young adults is three to four times higher than in the athlete population, so screeningif it is doneshould also include the general population of young individuals. In the United States, because of the large number of people in this category, cost of screening is high, and the detection of a person at risk is so low as to make screening with an ECG impractical. Indeed, the cost of downstream testing based on an abnormal ECG, and the stigma attached to even a false diagnosis, far exceeds the reduction in SCD risk.
This year, Dr. Ben Levine did his usual excellent job of making the cardiovascular system responses to exercise and exercise training understandable. This knowledge base is essential when dealing with athletes of all ages, particularly when there are important cardiovascular issues that must be considered. Recent data on long-term adaptations to exercise in athletes of all ages demonstrates important adaptations to exercise in the ventricles, and evidence that a delay in age-related changes can be found in individuals who train for many years.
Interesting data on endurance events points out the concern for over-hydration, particularly in slower runners who drink copious amounts of water without a balanced replacement of electrolytes. Severe hyponatremia has been found in a number of marathon runners and triathletes to the point of cerebral dysfunction and coma. The problem is significant enough that instruments for measuring serum sodium are located in emergency tents for these events. Malignant hyperthermia is also a concern in these events, particularly when the ambient temperature on race day is elevated.
Professional athletes continue to attract attention because of their different training programs, body habitus, and cardiac adaptations to their sport. Soccer players appear to be the most aerobically fit athletes and football players the most isometrically trained athletes. Basketball players fall in between.
Several presentations put sudden cardiac death in context with other causes of sudden death in young people. While we concentrate on sports-related SCD, auto accidents, homicides, and suicides far exceed the deaths from sport participation. Even death caused by lightning strikes exceeds sport-related cardiac deaths.
From this summit and the prior two, it has become apparent that special knowledge is needed by cardiologists who want to provide medical care, team support, or screening of athletes. The normal ECG in most athletes is not typical of our usual medical population, cardiac dimensions are usually larger than our usual population, cardiac hypertrophy is still not well defined, left and right ventricular size often exceeds the usual normal values, significant bradycardias are common, and we question the significance of focal areas of late gadolinium enhancement in asymptomatic athletes. An important concern is over-diagnosis that can stigmatize a young athlete for life.
We continue to refine our understanding of the normal athlete and the normal athlete's heart. There is enough to learn that we agreed that a cardiologist who works with athletes, or who wants to work with athletes needs special knowledge in this area. Looking back at this third Summit, it is apparent that the Sports and Exercise Cardiology Council and Section has an important goal to bring improved cardiovascular care to athletes of all ages and all levels of participation. We will continue to promote education, research, and improved care for this interesting area of cardiovascular medicine.
Alfred A. Bove, MD, PhD, is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and former president of the ACC.
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