The ACC Care of the Athletic Heart 2021 Virtual was saturated with high-yield teaching from the world's experts in the cardiovascular care of athletes. Over 20 hours of wisdom distilled to the following pearls summarized here. Full content is still available On-Demand through the ACC until the end of September.

Congenital Cardiology

1. If you must look up the eponym for your patient's anatomy or corrective surgery, you should involve pediatric and adult congenital heart disease (CHD) specialists!
2. Considerations for the athlete with congenital heart disease include the history (age, anomaly, prior intervention and timing, sport), physical exam (blood pressure in both arms), electrocardiogram (ECG), stress testing and imaging.
3. The AHA/ACC Task Force 4 recommendations¹ are an excellent resource that detail return to play and eligibility recommendations for athletes with CHD.
4. Coarctation is never cured: patients are predisposed to hypertension, re-coarctation, aneurysmal disease, an association with bicuspid aortic valves, left sided obstructive lesions and brain aneurysms.
5. Symptoms should prompt an investigation into potential coronary anomalies, but because ECG and exercise stress tests are often normal in these cases, a high pre-test probability deserves further imaging.

The Masters Athlete

1. When applying risk stratification tools, understand whether the athlete was represented in the data used to derive the risk calculators and account for non-traditional risk factors such as performance enhancing substances and Lipoprotein(a).
2. To guide the "worried well": focus on primary prevention i.e., family history (not just the condition but who is the person and what are their risk factors), smoking, hypertension (including exercise blood pressure [BP]) and lipid management.
3. Dr. Aaron Baggish's 7 Common Sense Tricks of the Trade for risk reduction:
   1. Address cardiovascular (CV) risk factors
   2. Discuss health versus performance
   3. Plan for annual periodicity
   4. Prioritize warm-ups/cool-downs
   5. Respect a virus
   6. Listen to warning signs
4. When guiding patients back into sports, take their event into consideration: a single vessel percutaneous coronary intervention (PCI) for stable angina is much different than a coronary artery bypass graft (CABG) with resulting left ventricular dysfunction.
5. For aortic aneurysms: focus less on exact weight-lifting limits and instead avoid maximum weight and recognize that needing a spotter or straining at the end of an exercise is an indication of over-exertion.

Genetic Testing: The Do's and Don'ts

1. Get the clinical phenotype right, pre-test genetic counseling for everyone, recognize the importance of "pre-test" probability and seek out expertise in genetic cardiology.
2. The Achilles' heel of genetic testing is determining pathogenicity. Beware of the variant of uncertain significance!

Dizziness in the Athlete

1. Orthostatic hypotension is uncommon before a race but very common post ultra-endurance event. If syncope occurs after exercising it is more likely a benign cause and can be managed with behavioral modifications, but if the syncope occurs during exercise, then one must suspect a potentially life-threatening problem.
2. History and physical diagnostic pearls in the evaluation of syncope:
   1. Distinguish "syncope" from "collapse"
   2. Post-event state (i.e., postictal/incontinence vs. rapid recovery)
   3. Orthostatic vital signs and measurements in both arms and legs
   4. Timing: during or after exercise
   5. Prodromal symptoms
   6. Body position
   7. Family history of sudden death
   8. Pulses and murmurs
3. Proper vital signs: supine for 10 minutes and then quietly stand for 5-10 minutes. A late fall in BP (after 3 minutes) is more consistent with a neurologic or autonomic cause of syncope, whereas it can be normal for systolic blood pressure (SBP) to fall up to 40 mmHg within 1 minute.

Sudden Death in the Young

1. Either "abnormal autopsy" (cardiomyopathies, myocarditis, coronary disease, arrhythmogenic right ventricular cardiomyopathy, aortic dissection, coronary anomalies) or "unrevealing autopsy" (long QT syndrome, Brugada, catecholaminergic polymorphic ventricular tachycardia, "idiopathic ventricular fibrillation").
2. Evaluation of surviving family members: clinical screening, genetic testing, and prevention.

ECG Screening

1. Complete right bundle branch block is observed in athletes (2.5%) but can be differentiated from Brugada pattern by a broad base R' in Brugada pattern.
2. T-wave inversions in lateral/apical leads are not normal but can be normal in anterior precordial leads in Black athletes, especially with J-point elevation.²

Arrhythmias in Athletes

1. Training can lead to sinus bradycardia at rest, not bradycardia or chronotropic incompetence with exercise. 
2. When implanting a pacemaker in an athlete, set the expectation that it may take several adjustments to fully optimize the settings for athletic performance.
3. Though it is less accurate below 60 bpm and 100 bpm, Bazett's formula is the most common formula to correct the QT interval.

Hypertrophic Cardiomyopathy (HCM)

1. When counseling patients with possible HCM, acknowledge the uncertainty of risk for each individual and recognize that the initial evaluation is not a "one and done" evaluation. Risk should be assessed at least yearly.
2. There are ways to mitigate risk which include: train with others, have an emergency action plan, easy access to an automated external defibrillator, gradual return to play, ample hydration and yearly risk assessment.
3. A modest degree of hypertrophy is not necessarily reassuring with respect to sudden cardiac death (SCD) risk.

Wolff-Parkinson-White (WPW) Syndrome

1. Intermittent pre-excitation is more benign, and routine follow up is acceptable. Persistent pre-excitation should prompt a stress test to look for abrupt loss of pre-excitation which indicates a more benign phenotype.
2. A bicycle stress test with the ECG speed increased to 50 mm/sec is preferred to see the ECG tracings more clearly.

Exercise Testing and Cardiopulmonary Exercise Testing (CPET)

1. Customize the protocol to the athlete's sport and maintain consistency between tests at different times: bikes for cyclists, treadmills for runners, row machine for rowers (if possible). Because a test that does not reproduce the symptoms is unhelpful, push the athlete to volitional fatigue.
2. Many conditioned Masters athletes with long standing multivessel coronary disease undergo ischemic preconditioning and don't manifest ECG changes until the limits of workload.
3. Using a bike instead of a treadmill can lead to a 10-15% decrease in peak VO2.
4. How much variability should be expected between CPETs? Reasonable daily variability is 3-5% but up to 15% through the course of a training season.

COVID-19

1. High sensitivity troponin is almost always elevated in myopericarditis; therefore, one should think critically about labeling a patient based on imaging alone without elevated troponins.
2. Several papers describe athletes with subtly abnormal cardiac imaging findings associated with COVID-19, however, it is unclear if these translate to an increase in adverse clinical events.
3. Recent large, multi-institutional registry data have been reassuring in establishing a very low prevalence of cardiac injury post COVID in college and professional athletes.

Preventive Cardiology and Cardiac Rehabilitation

1. There is a U-shaped curve between activity and coronary calcium, but this has not been associated with increased risk for CV events.
2. The increased risk of atrial fibrillation comes at extreme weekly amounts of exercise (100 MET-hours/week or more than 4,000 hours).
3. Qualifying diagnoses for cardiac rehabilitation include myocardial infarction (MI), PCI, CABG, stable angina, valve repair or replacement, stable chronic heart failure and cardiac transplant. The pillars of cardiac rehabilitation include exercise, nutrition, health psychology and best practices in preventive medical care.

References

1. Van Hare GF, Ackerman MJ, Evangelista JK, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 4: congenital heart disease: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2372-84.
2. Sharma S, Drezner JA, Baggish A, et al. International recommendations for electrocardiographic interpretation in athletes. J Am Coll Cardiol 2017;69:1057-75.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Sports and Exercise Cardiology, Stable Ischemic Heart Disease, Implantable Devices, EP Basic Science, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Advanced Lipid Testing, Lipid Metabolism, Acute Heart Failure, Heart Transplant, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Hypertension, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and ECG and Stress Testing, Chronic Angina

Keywords: Sports, Exercise Test, Performance-Enhancing Substances, Troponin I, Atrial Fibrillation, Cardiac Rehabilitation, Wolff-Parkinson-White Syndrome, Bundle-Branch Block, Arrhythmogenic Right Ventricular Dysplasia, Blood Pressure, Bradycardia, Myocarditis, Lipoprotein(a), Hypotension, Orthostatic, Weight Lifting, Angina, Stable, Percutaneous Coronary Intervention, Genetic Counseling, Dizziness, Autopsy, Behavioral Medicine, Prodromal Symptoms, Prodromal Symptoms, African Americans, Intracranial Aneurysm, Virulence, Physical Exertion, COVID-19, SARS-CoV-2, Parkinson Disease, Heart Defects, Congenital, Electrocardiography, Athletes, Death, Sudden, Cardiac, Syncope, Heart Failure, Athletic Performance, Heart Transplantation, Ventricular Dysfunction, Left, Long QT Syndrome, Pacemaker, Artificial, Coronary Artery Bypass, Myocardial Infarction, Hypertension, Risk Assessment, Aortic Aneurysm, Risk Factors, Cardiomyopathy, Hypertrophic, Coronary Disease, Defibrillators, Risk Reduction Behavior, Primary Prevention, Hypertrophy, Ischemic Preconditioning, Aneurysm, Dissecting, Registries

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