The Asian Pacific Society of Cardiology (APSC)
Asia is the largest and most populous continent in the world, with significant participation in international organized sporting events. Moreover, Asia is the origin of several unique sports that are now practiced globally, such as Karate, Taekwondo and Muay Thai. To date, healthcare providers in Asia caring for athletes have referred to combined recommendations from the United States (US) and Europe,^1,2 as sports cardiology is still regarded as a niche field and is relatively nascent in the region. Challenges in managing Asian athletes pertain to the need to extrapolate from recommendations for non-Asian athletes^3,4 who are vastly different in terms of ethnicity, disease epidemiology, and resources available.⁵

To address the paucity of Asia-centric sports cardiology related recommendations, a panel of nineteen APSC cardiologists and sports medicine practitioners from seven Asian countries convened in December 2020 to develop consensus recommendations for pre-participation screening (PPS) in young competitive Asian athletes. This successful initiative will hopefully be the first of many joint efforts to develop the field of sports cardiology in the region.

A Distinctly Asian Perspective
A key aspect of the APSC consensus statement was determining the best modality for classification of sporting disciplines. The Mitchell classification of sport, modified by Levine et al.,⁶ was chosen and further adapted to include many Asian competitive sports being practiced within the region. This classification was chosen because of its emphasis on stratifying the sporting activities depending on increasing dynamic and static component and is informative for the practitioner. We have categorized sports in IB, IIA and IIB as moderate cardiovascular intensity, and IC, IIC, IIIA to IIIC as high cardiovascular intensity, allowing for more refined decision-making. (Figure 1)

Figure 1

Our paper also provides recommendations regarding pre-participation cardiovascular screening of young competitive athletes.⁷ The working group is aware of the differences between the US and European recommendations regarding the conduct of screening.^8,9 In addition, we have taken into consideration the wide variation in medical expertise and available resources within Asia and provide flexibility for a nuanced and practical approach within our five key statements. Each statement has been voted on by all working group members, with ≥80% of votes required to reach consensus.

Statement 1: Young (age <35 years old) competitive athletes participating in moderate to high cardiovascular intensity sports are advised to undergo a standardized history and physical examination as part of PPS, particularly if the screening institution has the capacity for mass screening. A suggested checklist is the 14-element AHA/ACC Cardiovascular Screening Checklist for Congenital and Genetic Heart Disease or equivalent.
Level of agreement: Agree 95%; neutral 5%; disagree 0%
Level of evidence: Low

Statement 2: Young competitive athletes participating in moderate to high cardiovascular intensity sport are recommended to undergo a resting 12-lead electrocardiogram (ECG) as part of PPS, provided that all of the following are fulfilled: (1) the screening institution has the capacity for mass ECG screening; (2) the ECG is performed to an acceptable standard; and (3) the ECG should be interpreted by a trained healthcare professional, with reference to prevailing standards.    
Level of agreement: Agree 100%; neutral 0%; disagree 0%
Level of evidence: Low

Statement 3: Referral to a qualified and relevant healthcare professional/specialist for further evaluation should be considered in the presence of ANY of the following: (1) any positive element(s) in the standardized history questionnaire, or (2) abnormal physical finding(s) on physical examination, or (3) ≥2 borderline, or ≥1 abnormal ECG findings (*based on the International Recommendations 2017).¹⁰
Level of agreement: Agree 95%; neutral 5%; disagree 0%
Level of evidence: Low

Statement 4: Routine pre-participation screening for athletes engaging in low-intensity sport is generally not necessary.
Level of agreement: 85% agree; 15% neutral; 0% disagree
Level of evidence: Low

Statement 5: Competitive athletes with pre-existing cardiovascular disease should be managed according to established eligibility and disqualification recommendations for: (1) cardiomyopathies, myocarditis and pericarditis; (2) coronary artery disease; (3) arrhythmias; (4) channelopathies; (5) COVID-19.
Level of agreement: Agree 100%; neutral 0%; disagree 0%
Level of evidence: Low

Looking Ahead as a Team
While our consensus statements provide recommendations for healthcare practitioners in the Asia Pacific, we acknowledge that uncertainties remain. Specifically, issues such as false positive rates in applying ECG criteria to the Asian population, financial implications, and questions of whether implementation of ECG screening improves outcomes in Asian athletes are important considerations that need good prospective data to be answered. We acknowledge that it remains unknown if ECG screening of athletes improves long-term clinical outcomes and leads to reduced mortality in athletes. These statements are not absolute mandates but provide broad guidance with conditions and room for individualized care.

This APSC initiative highlights a pressing need for more research involving Asian athletes. We acknowledge that this consensus statement skims the surface of sports cardiology in Asia, and hope it will draw attention to other areas with limited evidence-base, for instance epidemiology of sudden cardiac death in Asian athletes as well as physiological cardiac remodeling in Asian athletes. From ethnicity and genetic factors that contribute to unique causes of arrhythmogenic sudden cardiac death (such as Brugada syndrome), to the distinct sociocultural aspects in applying shared decision-making practices in cardiovascular disease management and return to play, the uniqueness of the patient athlete population in Asia has many implications and provide significant opportunities to contribute new data. The working group intends to continue developing guidelines and recommendations specific to Asia while forming mutually beneficial collaborations with our international colleagues to further improve sports cardiology research and practice.

References

1. Baggish AL, Battle RW, Beckerman JG, et al. Sports cardiology: core curriculum for providing cardiovascular care to competitive athletes and highly active people. J Am Coll Cardiol 2017;70:1902-18.
2. Wilson MG, Drezner JA, Sharma S, eds. IOC Manual of Sports Cardiology. Oxford, England: John Wiley & Sons, LTD; 2017.
3. Pelliccia A, Sharma S, Gati S, et al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J 2021;42:17-96.
4. Baggish AL, Ackerman MJ, Putukian M, Lampert R. Shared decision making for athletes with cardiovascular disease: practical considerations. Curr Sports Med Rep 2019;18:76-81.
5. Chan NY. Sudden cardiac death in Asia and China: are we different? J Am Coll Cardiol 2016;67:590-92.
6. Levine BD, Baggish AL, Kovacs RJ, Link MS, Maron MS, Mitchell JH. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 1: classification of sports: dynamic, static, and impact: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2350-55.
7. Wang L, Yeo TJ, Tan B, et al. Asian Pacific Society of Cardiology consensus recommendations for pre-participation screening in young competitive athletes. Eur Cardiol 2021;16:e44.
8. Maron BJ, Levine BD, Washington RL, Baggish AL, Kovacs RJ, Maron MS. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 2: preparticipation screening for cardiovascular disease in competitive athletes: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2356-61.
9. Petek BJ, Baggish AL. Current controversies in pre-participation cardiovascular screening for young competitive athletes. Expert Rev Cardiovasc Ther 2020;18:435-42.
10. 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, Cardiovascular Care Team, COVID-19 Hub, Heart Failure and Cardiomyopathies, Pericardial Disease, Sports and Exercise Cardiology, Atherosclerotic Disease (CAD/PAD), Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias

Keywords: Cardiovascular Diseases, Sports, Athletes, Consensus, Brugada Syndrome, SARS-CoV-2, COVID-19, Channelopathies, Coronary Artery Disease, Ethnic Groups, Myocarditis, Prospective Studies, Return to Sport, Ventricular Remodeling, Death, Sudden, Cardiac, Sports Medicine, Electrocardiography, Physical Examination, Mass Screening, Pericarditis, Delivery of Health Care, Referral and Consultation, Martial Arts, Asian Continental Ancestry Group, Asian Americans, Asia, Oceanic Ancestry Group

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