Excellent teaching, informative discussion and engaging debates highlighted another excellent conference of the 70th American College of Cardiology (ACC) Virtual Scientific Sessions. The online learning platform allowed for the conference to be streamed to thousands of cardiovascular caregivers around the world. Sports cardiologists played a prominent role over the past year as the SARS-CoV-2 (COVID-19) pandemic raised concern for COVID-19-related myocarditis in our young athletes. While the consensus recommendations for screening after COVID-19 and the contemporaneous debates of screening techniques dominated the sports cardiology literature over the past year, there was a refreshing variety and depth to the sports cardiology abstracts presented. We will attempt to summarize some of the key studies presented.

While authorship varied, there were themes in the science presented this year. We have therefore grouped the reviewed studies into the following categories:

1. Cardiovascular risks in athletes
2. Cardiovascular benefits of exercise
3. Pediatric sports cardiology

I: Cardiovascular Risks in Athletes

THE ASSOCIATION BETWEEN INCREASED BLOOD PRESSURE RESPONSE TO EXERCISE AND AORTIC DILATATION IN MALE MASTER ENDURANCE ATHLETES

Tso J, Turner C, Miller A, et al.

Tso et al. looked at the relationship between the blood pressure response to exercise and aortic root enlargement. They studied 58 male endurance athletes with cardiopulmonary exercise testing and 2-D echocardiography. Of those studied, 12 athletes (21%) had clinically relevant aortic dilatation (aortic root diameter ≥40 mm) and 22 athletes had an exaggerated systolic blood pressure (SBP) response (ΔSBP ≥60 mmHg). An increased blood pressure response to exercise was associated with a larger aortic root diameter (p = 0.03). The authors concluded that longitudinal studies looking at the significance of this finding are warranted.¹

HYPERTENSION AND IMPAIRED LEFT VENTRICULAR SYSTOLIC FUNCTION PREDICT VENTRICULAR-ARTERIAL UNCOUPLING IN AMERICAN-STYLE FOOTBALL ATHLETES

Tso J, Turner C, Liu C, et al.

The effect of elevated blood pressure on athletes' ventricular function was further evaluated by the team from Emory. Ventricular-arterial (VA) coupling is the ratio of arterial elastance (EA) over left ventricular end-systolic elastance (ELV) which represent afterload and contractility, respectively. VA coupling can be disrupted in hypertensive heart disease. American-style football (ASF) athletes have been shown to develop elevated systolic blood pressure in conjunction with their sport. Tso et al. studied 142 collegiate athletes longitudinally over 3 years of ASF participation, using clinical measurements and echocardiography. During the study, the prevalence of hypertension increased from 54% to 77% and in parallel, EA/ELV (VA uncoupling) increased steadily as well. In mixed effects linear regression analysis, increased SBP, and reduced global longitudinal strain were associated with VA uncoupling. The authors concluded that "ASF athletes develop clinically significant hypertension and progressive VA uncoupling over the course of their collegiate careers." This uncoupling was not secondary solely to an increase in EA (hypertension), it was also due to a decrease in LV systolic function (decreased ELV). The authors propose that future studies should evaluate the effect of timely and appropriate hypertension management in these young athletes.²

LEFT VENTRICULAR EJECTION FRACTION IN ATHLETES COMPARED TO THE WORLD ALLIANCE SOCIETIES OF ECHOCARDIOGRAPHY (WASE) NORMAL VALUES

Parizher G, Phelan D, Singh T, et al.

Parizher et al. posited that left ventricular ejection fraction (LVEF) values in athletes would be different for conditioned athletes compared to the general population. They retrospectively reviewed echocardiographic data from 203 athletes evaluated at the Cleveland Clinic Sports Cardiology Center, excluding those with known heart or lung disease (excepting asthma). They noted LVEF ranged from 52-69% in male athletes (mean 61%) and 54-69% in female athletes (mean 62%). There were 46 athletes (22%) who would be reclassified as having abnormally low LVEF when using the normative values from WASE. The authors concluded that the WASE normative values should not apply to athletes and recommended future studies to better define LVEF normative ranges in athletes "so as not to ascribe potential pathological conditions to healthy athletes".³

THE ASSOCIATION BETWEEN RACE AND ACQUIRED LEFT VENTRICULAR HYPERTROPHY IN AMERICAN-STYLE FOOTBALL ATHLETES

Tso J, Turner, C, Liu C, et al.

In recent years, we have become increasingly aware of racial and socioeconomic disparities in health and healthcare. Tso et al. identified an association between race and risk of acquired left ventricular hypertrophy (LVH). Echocardiography was reviewed in 249 freshmen collegiate ASF athletes at the beginning and then at the end of the football season. Athletes identified as White (n=125) or Black (n=124). There were similar increases in SBP and weight and reduction in E' on echo imaging. Progression to concentric LV remodeling and hypertrophy was almost twice as common in Black athletes (n=31, 25%) compared to White athletes (n=17, 13%), which was significant (p = 0.02). The authors identified Black race (OR: 2.35, p = 0.03), increased SBP (OR: 1.04, p = 0.009), decreased Eʹ (OR: 0.84, p = 0.02), and lower family income (OR: 0.73, p = 0.007) as predictive of concentric LV remodeling or hypertrophy. Additional research into the epigenetic and environmental factors behind these findings is needed for better understanding of this disparity.⁴

II: Cardiovascular Benefits of Exercise

LEISURE TIME PHYSICAL ACTIVITY ASSOCIATES FAVORABLY WITH THE BIOACTIVE LIPIDOME AND RISK OF INCIDENT CVD EVENTS/ RESULTS FROM THE VITAMIN D AND OMEGA-3 TRIAL AND JUPITER TRIALS

Hoshi RA, Liu Y, Luttmann-Gibson H, et al.

The effects of physical activity on bioactive lipids were evaluated in a study by Hoshi et al. Samples from the randomized controlled VITAL and JUPITER studies were used to measure the plasma bioactive lipidome (the full lipid complement), specifically measuring >11,000 fatty acids and bioactive lipids. The median age of the studied subjects was 68 years-old. The authors were able to identify 28 novel bioactive lipids which were increased with higher physical activity and were associated with a lower risk of cardiovascular disease. Identification of these bioactive lipids will contribute to a better understanding of the biochemical benefits of physical activity in relation to cardiovascular disease.⁵

EXERCISE LOWERS STRESS-ASSOCIATED NEUROBIOLOGICAL ACTIVITY: POTENTIAL MECHANISM CONTRIBUTING TO CARDIOVASCULAR RISK REDUCTION

Zureigat H, Osborne M, Abohashem S, et al.

In another study out of Boston, Zureigat et al. hypothesized that exercise was associated with decreased stress-related neurobiological activity. This involved PET/CT imaging, measuring a ratio of amygdalar to pre-frontal cortical activity (AmygA) using validated methods, which was then associated with self-reported physical activity (PA). Risk of myocardial infarction was evaluated in a subset of 744 patients with PET/CT imaging to determine the association of AmygA with this outcome. The authors reported PA was associated with a dose-dependent decrease in AmygA (p = 0.036) and MI (p = 0.013).⁶

III: Pediatric Sports Cardiology

A VIDEO ENHANCED, ELECTRONIC MODALITY FOR PRE-PARTICIPATION EXAMINATION (VPPE) OF YOUNG ATHLETES

Parizher G, Phelan D, Ayers C, et al.

Parizher et al. previously published a video-enhanced pre-participation evaluation (PPE) questionnaire (V-PPE) to help screen athletes for risk of sudden cardiac arrest.⁷ They now present outcomes of a prospective evaluation comparing symptom frequencies on the standard PPE versus V-PPE. Out of 5,700 high school athletes, 492 patients filled out the V-PPE with no significant difference in reporting frequency when compared to the entire cohort. Symptoms of palpitations and syncope appeared more likely to be reported on the V-PPE than the PPE. The authors concluded that the educational videos included in V-PPE can improve screening yield and they recommend further research into the predictive value of such an instrument in identifying cardiac pathology.

CARDIOPULMONARY STRESS TEST CHANGES IN CHILDREN WITH PECTUS EXCAVATUM

Devol C, Darwish M, Hyde A, et al.

Pectus excavatum (PE) is a congenital deformity of the chest wall that can cause cardiopulmonary symptoms due to restriction of the intrathoracic cavity. The standard method of determining indication for surgical repair is the Haller index which measures chest wall dimensions. DeVol et al. retrospectively evaluated cardiopulmonary exercise test data on 121 patients with PE between the ages of 10 and 19 years. They divided the patients into two groups by Haller index (mild/moderate 2-3.5, severe >3.5) and demonstrated that an increased Haller index was associated with a decreased ventilator reserve (VR). There was also a decrease in oxygen pulse, a surrogate for stroke volume, from 93% to 88%, but this was not statistically significant. Further analyses demonstrated significant negative correlations between Haller index and heart rate reserve, measures of ventilation (FVC, FEV1, VR), and oxygen pulse. These correlations may have clinical significance and aid decision-making towards corrective surgery.⁸

INTERSECTION OF SPORTS PARTICIPATION AND OBESITY IN BICUSPID AORTIC VALVE

Baleilevuka-Hart M, Khader A, Gonzalez de Alba C, et al.

Baleilevuka-Hart et al. retrospectively studied 110 patients with bicuspid aortic valve. They noted that the majority of patients had hemodynamically insignificant pathology with only 6% having more than mild aortic regurgitation and 8% having more than mild aortic stenosis. Significant aortic dilation was more common, with 21% having more than mild dilation. Applying the 2015 AHA/ACC sports eligibility recommendations, they found that 53 (48%) met criteria for some degree of recommended athletic restriction (contact sports, weight lifting).⁹ Critically, there was a higher rate of obesity (17%) compared to the state reported age-matched data (12.9%). The authors suggest that sports restrictions could be preventing several young congenital heart disease patients from participating in sports, thus promoting obesity in this population of relatively healthy individuals.¹⁰

References

1. Tso J, Turner C, Miller A, et al. The association between increased blood pressure response to exercise and aortic dilatation in male master endurance athletes. J Am Coll Cardiol 2021;77:3201.
2. Tso J, Turner C, Liu C, et al. Hypertension and impaired left ventricular systolic function predict ventricular-arterial uncoupling in American-style football athletes. J Am Coll Cardiol 2021;77:3200.
3. Parizher G, Phelan D, Singh T, Mandsager K, Emery M. Left ventricular ejection fraction in athletes compared to the World Alliance Societies of Echocardiography Normal Values. J Am Coll Cardiol 2021;77:3205.
4. Tso J, Turner C, Liu C, et al. The association between race and acquired left ventricular hypertrophy in American-style football athletes. J Am Coll Cardiol 2021;77:3199.
5. Hoshi RA, Liu Y, Luttmann-Gibson H, et al. Leisure-time physical activity associates favorably with the bioactive lipidome and risk of incident CVD events/ results from the Vitamin D and Omega-3 Trial (Vital) and Jupiter Trials. J Am Coll Cardiol 2021;77:3207.
6. Zureigat H, Osborne M, Abohashem S, et al. Exercise lowers stress-associated neurobiological activity: potential mechanism contributing to cardiovascular risk reduction. J Am Coll Cardiol 2021;77:15.
7. Parizher G, Putzke JD, Lampert R, et al. Web-based multimedia athlete preparticipation questionnaire: introducing the video-PPE (v-PPE). Br J Sports Med 2020;54:67-68.
8. Devol C, Darwish M, Hyde A, Eubanks T, Philip R. Cardiopulmonary stress test changes in children with pectus excavatum. J Am Coll Cardiol 2021;77:3202.
9. Maron BJ, Zipes DP, Kovacs RJ. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: preamble, principles, and general considerations. J Am Coll Cardiol 2015;66:2343-49.
10. Baleilevuka-Hart M, Khader A, De Alba CG, Holmes K, Huang J. Intersection of sports participation and obesity in bicuspid aortic valve. J Am Coll Cardiol 2021;77:3198.

Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Dyslipidemia, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Valvular Heart Disease, SCD/Ventricular Arrhythmias, Lipid Metabolism, Echocardiography/Ultrasound, Exercise, Hypertension, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging

Keywords: Sports, Athletes, ACC21, ACC Annual Scientific Session, Stroke Volume, Exercise Test, Retrospective Studies, Cardiovascular Diseases, Dilatation, Hypertrophy, Left Ventricular, Funnel Chest, Blood Pressure, Vitamin D, Weight Lifting, African Americans, Self Report, Aortic Valve Insufficiency, Thoracic Wall, Reference Values, Heart Rate, Prospective Studies, Ventricular Function, Left, Risk Factors, Exercise, Echocardiography, Echocardiography, Hypertension, Myocardial Infarction, Death, Sudden, Cardiac, Syncope, Obesity, Lung Diseases, Delivery of Health Care, Asthma, Lipids, Socioeconomic Factors, Regression Analysis, Fatty Acids, Plasma, Longitudinal Studies, Aortic Valve Stenosis, Decision Making, Ventilators, Mechanical, Epigenesis, Genetic, Reference Standards, Oxygen

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