Top Takeaways From ACC Care of the Athletic Heart Virtual 2022

Quick Takes

  • Top learning points from ACC Care of the Athletic Heart Virtual 2022 are summarized below.
  • Key sessions covered ECG interpretation in athletes, clinical evaluation of the athlete's heart, management considerations in athletes with cardiac pathology, and current hot topics in sports cardiology.

Care of the Athletic Heart Virtual was 'live' from Heart House in 2022! Sessions included presentations from sports cardiology experts around the world and debates on controversial treatment options. Online access to all sessions is available through September 6, 2022. Some key top take-home points from the sessions are summarized below.

Imaging the Athlete's Heart

  • Cardiac chamber measurements in athletes frequently fall outside normal cut-off values. Athletic remodeling should be interpreted in the context of an athlete's sport type, age, sex, exercise dose, race, and body size.
  • Myocardial fibrosis on cardiac magnetic resonance imaging (CMR) is present in 10-30% of athletes. This includes "minor" fibrosis in the right ventricular (RV) insertion points, RV trabeculae, or papillary muscles and "major" fibrosis indicative of pathology.
  • Minor fibrosis without clinical correlates does not typically mandate sport restriction.
  • In younger athletes, major fibrosis warrants exercise testing and ambulatory rhythm monitoring. In older athletes, major fibrosis should be interpreted in clinical context.

Return to Play in an Athlete with Hypertrophic Cardiomyopathy (HCM) and Sudden Cardiac Arrest

  • High intensity sport increases the risk of lethal arrhythmias in HCM.
  • Disqualified athletes, however, also have decreased quality of life and may experience increased anxiety and adverse mental health behaviors.
  • Return to sport, even with high-risk conditions, may be possible with thorough evaluation and shared decision making with the athlete. Ultimately, the decision to return to competitive play must be supported by the sponsoring institution/team and other stakeholders.

Athlete Gray Zone: Hypertrabeculation versus Left Ventricular Noncompaction (LVNC) Cardiomyopathy

  • A benign LV hypertrabeculation phenotype has been associated with vigorous physical activity and is more common in endurance and Black athletes.
  • It is important to be familiar with the diagnostic criteria by echocardiography and CMR in the evaluation of hypertrabeculation.
  • Hypertrabeculation on imaging should be placed in the context of pre-test probability and clinical presentation to differentiate athletic remodeling from LVNC.

Considerations for the Tactical Athlete

  • Tactical athletes must perform in hazardous environmental conditions and include military members, police, firefighters, and other vocational athletes.
  • Cardiovascular symptoms in tactical athletes warrant aggressive evaluation as incapacitation of the tactical athlete could result in harm to both the patient and team members.

Revascularization in Athletes with Coronary Artery Disease (CAD)

  • While multiple large trials of revascularization for stable CAD have not shown survival benefit, the applicability of these trials to highly athletic populations is questionable.
  • In athletes with anginal chest pain limiting exercise capacity, revascularization may be a reasonable option to improve quality of life.

Athletes with Mitral Valve Prolapse and Arrhythmias

  • Mitral valve prolapse is a common valvular pathology associated with sudden cardiac death. In the absence of ventricular arrhythmias, clinical course is usually benign.
  • High risk echocardiographic findings include mitral annular disjunction, bi-leaflet prolapse, Pickelhaube sign, and greater than moderate mitral regurgitation. These should prompt further investigation with CMR, exercise testing, and ambulatory rhythm monitoring.

Strength Athletes with Aortopathy

  • 1-2% of athletes will have clinically relevant aortic enlargement (>4 cm in men, >3.4 cm in women), but aortas >4.2 cm are rare.
  • High risk genetic abnormalities such as Marfan Syndrome are associated with acute aortic syndromes and aortic enlargement.
  • Bicuspid aortic valve is the most common abnormality associated with aortopathy. While risk of aortic dissection is increased compared to the general population, the absolute risk is still low. 

Disparities in Sports Cardiology

  • Minorities experience barriers including structural racism that increase the risk of poor health outcomes and cardiovascular disease.
  • Black athletes are at increased risk of sudden cardiac death compared to White athletes.
  • Social determinants of health may contribute to race-associated outcomes in athletes. This is an area that warrants further investigation.

Wearables in Sports Cardiology

  • While the use of wearables is rapidly growing, data accuracy remains an important challenge limiting routine clinical use.
  • Evolving technology may soon facilitate performance improvement, potential screening for cardiac conditions, and guidance of safe exercise in athletes with cardiac disease.


  • Young athletes have a low incidence of cardiac involvement and risk of clinic events with COVID-19 infection .
  • CMR is a valuable tool in diagnosing myocarditis but should not be used in screening asymptomatic athletes or those with low pre-test clinical probability of myocarditis.
  • Return to play after COVID-19 infection should be guided by symptoms. Those with cardiopulmonary symptoms or more severe illness warrant cardiac evaluation.1
  • The risk of COVID-19 vaccine associated myocarditis is low but present in young males and highest after the second mRNA vaccine dose. Most patients (~90%) have a benign clinical course.
  • There appears to be a clear benefit to vaccination in avoiding hospitalization and intensive care unit stay among young individuals.2


  1. Gluckman TJ, Bhave NM, Allen LA, et al. 2022 ACC expert consensus decision pathway on cardiovascular sequelae of COVID-19 in adults: myocarditis and other myocardial involvement, post-acute sequelae of SARS-CoV-2 infection, and return to play: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2022;79:1717-56.
  2. Olson SM, Newhams MM, Halasa NB, et al. Effectiveness of BNT162b2 vaccine against critical Covid-19 in adolescents. N Engl J Med 2022;386:713-23.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Valvular Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, 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 VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Exercise, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging, Mitral Regurgitation

Keywords: COVID-19 Vaccines, COVID-19, Quality of Life, Return to Sport, Exercise Test, Cardiovascular Diseases, Bicuspid Aortic Valve Disease, Coronary Artery Disease, Data Accuracy, Decision Making, Shared, Exercise Tolerance, Marfan Syndrome, Mitral Valve Insufficiency, Mitral Valve Prolapse, Myocarditis, Papillary Muscles, Social Determinants of Health, Death, Sudden, Cardiac, Athletes, Arrhythmias, Cardiac, Cardiomyopathy, Hypertrophic, Echocardiography, Exercise, Fibrosis, Magnetic Resonance Imaging, Intensive Care Units, Aneurysm, Dissecting, Health Behavior, Hospitalization, Outcome Assessment, Health Care, Vaccination, Body Size, Chest Pain, Phenotype, Wearable Electronic Devices, Aorta, Prolapse

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