Australians are enthusiastic about sports, both as spectators and participants. Most school-aged children participate in organized individual or team sports, many young adults participate in competitive or recreational sports, and middle-aged and older adults are aware of the benefits of exercise. Despite the statistics on increasing rates of overweight and obesity in the community, participation in community endurance exercise events also continues to grow. This includes mass participation cycling, running, triathlon and adventure sport events. In many areas, cycling is the new golf for the corporate business person and Middle-Aged Men In Lycra (MAMILs) on bikes are a frequent sight on our streets. You would think that sports cardiology would be booming and that provision of cardiac care tailored to the needs of the athletic individual would, therefore, be an important part of the cardiology spectrum.

Sports and exercise cardiology is, however, far less organized and developed than in the U.S.¹ and Europe.² Due to the size of the Australian population and the number of practicing cardiologists, most cardiologists will have one or two areas of sub-specialization, and sports and exercise cardiology is not a common area of special interest. To date, athletes with known or suspected cardiac conditions have been largely cared for by general cardiologists or cardiologists with specific interest in the underlying condition or symptom. For example, athletes with syncope or palpitations may be referred to an electrophysiologist, while athletes with cardiac enlargement or a cardiomyopathy will be referred to a heart failure clinic. There is, however, demand for cardiologists with appropriate skills and expertise in cardiac care of the athlete who have a deeper understanding of the specific issues facing athletes. There are also an increasing number of athletes with known cardiac disease who require informed advice about whether and how to continue to exercise. The cardiology community is also interested, with scientific sessions on sports cardiology topics at the Cardiac Society of Australia and New Zealand (CSANZ) Annual Scientific Meeting always very well attended, often resulting in standing room only and a room filled to capacity.

At present, specific training in sports and exercise cardiology is not included in the curriculum for advanced training in adult cardiology in Australia and New Zealand. In fact, sports physicians have a more structured understanding of issues in sports and exercise cardiology than many cardiologists, due to this being a core requirement in their advanced training program. Those cardiologists with interest and expertise in the area have largely developed this through personal or research interests in exercise and its interaction with the heart, and have increased their knowledge through interactions with the U.S. and European sports and exercise cardiology communities. This does appear to be changing, however, with the inaugural meeting of a Sports and Exercise Cardiology Working Group at the CSANZ Annual Scientific Meeting in 2013. One of the aims of forming this group was to identify those with a self-declared interest in the area, something that has been demanded by sports physicians who are often looking for cardiologists with this type of expertise to see athletes around the country.

Australians participate in a number of sports that are not common outside the country, in addition to many other sports with a more global reach. The most commons men's professional sports are Australian Rules Football and Rugby League and the most common women's sport is netball, all sports which are not played globally. Whilst the sports are different, the need for cardiac care remains the same. Soccer, basketball, athletics, triathlon, and cycling are all also common and are more global sports. At a professional level, many of these sports engage in pre-participation screening (PPS) of athletes using history, physical examination and electrocardiogram (ECG) to detect life-threatening cardiac conditions, but this is not consistent, and there is no organized screening of amateur and recreational athletes. As in many countries, there is still debate in Australia about the effectiveness of en-mass PPS with or without ECG, given that there has never been a controlled trial of PPS, and much of our understanding of the potential effect of screening is based on two contradictory observation studies,^3,4 even before the cost effectiveness of such an approach is considered. Whilst it is attractive to think we can save lives through PPS, in general, many sports physicians favour screening resulting in a position statement from the Australasian College of Sports Physicians,⁵ whilst in the cardiology community, there is still reluctance to screen widely due to the limited sensitivity and specificity of screening tests in identifying those with life-threatening cardiac disease. We have shown in Australian athletes that, although the newer Seattle criteria appear to reduce the false-positive rate of ECG screening without reducing sensitivity,⁶ agreement on ECG findings between interpreters is only modest,⁷ and in truly elite athletes, the rate of training unrelated ECG abnormalities remains high.⁸

Although there are episodes of sudden cardiac death (SCD) during sports participation in Australia, most of the evidence for this comes from media reports, as there are currently no reliable systematic data regarding the incidence of these events, making it difficult to know whether Australia has a large or small problem with this rare but devastating event. It is unclear whether Australian rates and causes of SCD are closer to those reported in the United States⁹ or those reported in Italy.¹⁰ It seems clear that the racial and genetic mix in a particular country impacts both the rates and etiologies of SCD during sports participation, with notable differences between the U.S. and Italy in regard to rates of SCD due to hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy. This is relevant for Australia, of which the population has been shaped by waves of immigration over the last 200 years and includes Australians whose families originated in the United Kingdom and Ireland, southern and eastern Europe, Asia, the Middle East, and, more recently, Africa. In addition, Australia has an indigenous population of Aboriginal and Torre Strait Islanders who are highly represented in professional sport, and there is some evidence they may have a higher risk of SCD, largely driven by premature coronary artery disease.¹¹ The unique racial mix throughout Australia makes it likely the country has a unique pattern of SCD risk and makes it imperative that we have local knowledge of the incidence and causes of SCD.

What would I like to see in sports and exercise cardiology "down under" in the future? Firstly, I would like to see this become part of the advanced training curriculum in cardiology so that future cardiologists know what's important in this field, but also to give them a sense of what they don't know and when a true expert in the area is needed. I would like to see a registry for episodes of SCD during sport to empower us to make rational decisions about how to address this problem. Because there is currently no mandatory PPS in Australia, it may be one of the few places in the world where a randomized trial of the process to try and definitively answer the questions that remain about the efficacy of PPS could be conducted. Because of the growth in exercise in middle-aged and older Australians who probably account for the majority of SCD events in sports,¹² the needs of this group that potentially has the most to gain from regular exercise are often neglected and need to be addressed. Finally, sports cardiology in Australia needs to continue to engage with sports and exercise cardiologists globally to increase our collective understanding and improve cardiac care in athletes.

References

1. Lawless CE, Olshansky B, Washington RL, et al. Sports and exercise cardiology in the United States: cardiovascular specialists as members of the athlete healthcare team. J Am Coll Cardiol 2014;63:1461-72.
2. Heidbuchel H, Papadakis M, Panhuyzen-Goedkoop N, et al. Position paper: proposal for a core curriculum for a European Sports Cardiology qualification. Eur J Prev Cardiol 2013;20:889-903.
3. 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.
4. 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;57:1291-6.
5. Physicians ACoS. Pre-participation cardiac evaluation in young athletes. 2013.
6. Brosnan M, La Gerche A, Kalman J, et al. The Seattle Criteria increase the specificity of preparticipation ECG screening among elite athletes. Br J Sports Med 2014;48:1144-50.
7. Brosnan M, La Gerche A, Kalman J, et al. Comparison of frequency of significant electrocardiographic abnormalities in endurance versus nonendurance athletes. Am J Cardiol 2014;113:1567-73.
8. Brosnan M, Gerche AL, Kumar S, Lo W, Kalman J, Prior D. Modest agreement in ECG interpretation limits the application of ECG screening in young athletes. Heart Rhythm 2015;12:130-6.
9. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation 2009;119:1085-92.
10. Corrado D, Pelliccia A, Bjornstad HH, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2005;26:516-24.
11. Young MC, Fricker PA, Thomson NJ, Lee KA. Sudden death due to ischaemic heart disease in young aboriginal sportsmen in the Northern Territory, 1982-1996. Med J Aust 1999;170:425-8.
12. Marijon E, Tafflet M, Celermajer DS, et al. Sports-related sudden death in the general population. Circulation 2011;124:672-81.

Keywords: Adult, Athletes, Arrhythmogenic Right Ventricular Dysplasia, Australia, Basketball, Child, Cardiomyopathy, Hypertrophic, Coronary Artery Disease, Cost-Benefit Analysis, Curriculum, Death, Sudden, Cardiac, Electrocardiography, Emigration and Immigration, Europe, Female, Football, Golf, Heart Failure, Humans, Incidence, Ireland, Male, Middle Aged, New Zealand, Obesity, Overweight, Population Groups, Registries, Running, Soccer, Sports, Syncope, United States

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