The American College of Cardiology hosted its 68th Annual Scientific Session and Expo March 16th-18th, 2019, in New Orleans, Louisiana. In the midst of creole shrimp, jazz music and historical landmarks, attendees learned the latest data for transcatheter aortic valve replacement versus surgical replacement, antiplatelet strategies post-percutaneous intervention, antihypertensive strategies and more. In addition, those interested in sports and exercise cardiology were able to explore some hotly debated topics as well as learn from those presenting new data within the field, including how to manage coronary artery disease in an athlete and how to incorporate wearables such as the Apple Watch into cardiology practice. We bring you an overview of what we found to be the top highlights from this energized meeting.

Prevention

Release of the new primary prevention guidelines

The 2019 ACC/American Heart Association Guideline on the Primary Prevention of Cardiovascular Disease was presented by Guideline Co-Chairs Drs. Roger Blumenthal and Donna Arnett.¹ Attendees welcomed this intuitive framework that emphasized lifestyle interventions, such as diet, exercise, and tobacco avoidance, as central to the prevention discussion. Exercise recommendations were congruent with the 2018 physical activity guidelines,² suggesting at least 150 minutes of moderate-intensity or 75 minutes of high-intensity exercise weekly, although the maximum physical activity recommended remains debated.

Obesity and hypertension among high school students

Obesity in the United States adolescent and teen populations is a well-documented epidemic in the pediatric literature. Physical activity guidelines targeting even younger individuals is at play, yet we are still faced with challenges. Dr. Prashant Rao and colleagues described the prevalence of hypertension within a large community cardiac screening program with alarming rates of high blood pressure, especially in obese and overweight individuals as well as ethnic minorities. The findings are striking given that these health conditions are noted within a population of which many are likely already achieving the recommended level of daily physical activity through organized sport. Therefore, we must focus our prevention education and lifestyle efforts even further for this young cohort.

Nutrition

The newly released prevention guidelines endorse consuming a pescatarian, plant-based diet to mitigate the risk of developing cardiovascular disease. Dr. Carl Lavie reminded us that the balance of energy intake and output, specifically increased calories and decreased physical activity, is important in the development of obesity, and highlighted strategies to maintain a healthy weight.³ He expanded our understanding of the "obesity paradox," where those with extra weight have been described to have a better prognosis Further, he explained that fitness is more important than fatness, and especially the ability to sustain fitness over time, when observing short- and long-term cardiovascular outcomes. Moreover, while the importance of nutrition is well-known, further dietary research and recommendations were noticeably absent from this year's session programming.

Cardiovascular health of professional athletes in retirement

Dr. Genevieve Smith and colleagues from Tulane University School of Medicine presented data sampled from a large cohort of former National Football League (NFL) athletes. Hypertension and left ventricular hypertrophy (LVH) was present in 70% and 12.3% of this cohort, respectively. Interestingly, playing position but not detraining time had a significant effect on the presence of LVH. In a recently published study from the Football Players Health Study, Dr. Timothy Churchill and colleagues described the weight gain throughout the career of former NFL players and its independent association with the development of health conditions later in life.⁴ While much of the weight is gained during their early career transition, most maintain their elevated playing weight into retirement. Further studies will need to evaluate if there is a causal relationship between weight and specific health conditions and what other factors contribute. At present, available knowledge suggests that this retired cohort of patients may require further counseling and education about preventative strategies for cardiovascular disease. This also begs the question as to whether other professional and college athletes from different sporting disciplines would have similar outcomes.

Pre-Participation Evaluation

History and physical +/- electrocardiogram

Pre-participation evaluation (PPE) is mandated for athletes competing in organized sport to screen for conditions associated with sudden cardiac death (SCD); however, the approach to evaluation is not standardized in the United States. In a moderated abstract presentation, Dr. Kimberly Harmon reviewed >8,000 athlete records from PAC-12 institutions from 2009-2017 and found that incorporation of ECG in the PPE uncovers eight times the number of conditions associated with SCD, such as hypertrophic cardiomyopathy, compared to those using solely history and physical. This amounted to a prevalence of 1 in 2,500 with history and physical and 1 in 313 when adding ECG, which is more congruent with the currently described prevalence of cardiovascular disorders at risk for SCD. The majority of these athletes were able to return to sport after further evaluation and treatment as indicated. Importantly, at any time when implementing a PPE program, it is important to have the modalities in place to properly evaluate and treat conditions identified.

Pre-Existing Cardiovascular Conditions and Impact on Activity Restriction and/or Management

Competitive sports restriction/return to play debate: arrhythmia, aortopathies

Drs. Rachel Lampert and Jordan Prutkin represented competing sides of a debate on whether those with inherited arrhythmia disorders should be allowed to compete in athletics. We have progressed since the early Bethesda Guidelines, in that we understand some physical activity may be okay for certain cohorts. However, most agree that those with catecholaminergic polymorphic ventricular tachycardia may be too high risk to enter full athletic competition. As with most areas of sports and exercise cardiology, much is based on expert opinion, and so we greatly anticipate results of prospective studies such as LIVE-HCM (Lifestyle and Exercise in Hypertrophic Cardiomyopathy) and LIVE-LQTS (Lifestyle and Exercise in Long QT Syndrome) to help answer some of these hotly debated topics.

Drs. Paul Thompson, Matthew Martinez and Michael Emery shared their clinical pearls regarding aortas and athletics. Aortopathies come in many varieties and not all aortas are the same when it comes to evaluation and management. Most agree that it is very rare for an athlete's aorta to be greater than 40 mm and that additional imaging is required for further evaluation. Those with a dilated aorta should be cautioned against heavy weight-lifting/strain activities and especially if paired with an inherited aortopathy should be cautioned against contact sports. Medical management and routine follow-up imaging are not to be forgotten. Data for aorta and sport are limited, so further research is urged.

The shared decision-making model cannot be emphasized enough in all management and treatment decisions, given that each athlete will have their own value system and treatment goals. This model incorporates the input from the multidisciplinary team, including coaches, athletic trainers, sports medicine physicians and others, and importantly decisions center around the individual athlete.

Coronary artery calcification in athletes and management of coronary artery disease in athletes either stable CAD or post-MI/PCI

Dr. Meagan Wasfy discussed the accruing data that demonstrate a signal for increased coronary artery calcification (CAC) in masters endurance athletes. Studies suggest that veteran endurance athletes have more CAC than an age-matched sedentary cohort. Many athletes are concerned by these data as they expect exercise, regardless of how high the level, to protect them from atherosclerotic disease. However, it is important to acknowledge the lack of longitudinal data demonstrating the clinical significance of calcium scores in athletes and this represents an area for further research. That said, it is clear that even elite athletes are not immune from traditional atherosclerotic heart disease. Dr. Tamanna Singh explained that when assessing CAC it is important to understand the extent of soft versus hard plaque, the presence or absence of symptoms with exertion and other cardiovascular risk factors before determining if further testing is indicated, and whether treatment should consist of aspirin and/or statin therapy.

Intermittent pre-excitation

Wolff-Parkinson-White (WPW) pattern on ECG may not be as benign as we originally thought. Dr. Susan Etheridge and colleagues found that sudden death and aborted sudden death were the first presenting symptom for approximately one third of patients in a studied cohort of patients with previously diagnosed asymptomatic WPW.⁵ She reminded us that asymptomatic WPW can be associated with left ventricular dysfunction as well. Further, not all intermittent pathways are benign, and it is difficult to have 100% confidence that a pathway is more benign based on an invasive electrophysiology study because the conditions of the EP study include factors such as sedation and the supine position, which may hamper the ability to incite the pathway. She implored that, because WPW ablation is so successful and that perhaps we are not as good at assessing pathway risk, ablation should be given more consideration in younger individuals. Continued studies will help elucidate further details for these patients.

Exercise Prescription

Exercise testing in heart failure patients and cardiac rehabilitation

It is clear that exercise therapy is beneficial for most patients with cardiovascular disease, including heart failure. Exercise capacity is often used as an outcome in heart failure clinical trials, but some question whether this is an important outcome measure. Dr. John Teerlink led a discussion emphasizing that while measures of exercise capacity may not always correlate with harder outcomes (e.g., myocardial infarction, stroke, death), exercise capacity is still an important quality of life factor that we should be aiming to improve in our patients. This is an important point to keep in mind as we design future trials. Further, Dr. Ileana Pina reviewed data from the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) trial demonstrating that cardiac rehabilitation is indeed beneficial for our heart failure patients, but the issue is that it is difficult for patients to adhere to prescribed rehabilitation regimens. Drs. Pam Taub and Karen Aspry highlighted ways to overcome these barriers by engaging physicians in the cardiac rehab process from start to finish, considering novel options such as wearable and mHealth-based options. In the meantime, we can improve the overall quality and intensity of the rehab we do offer and make sure not to forget to address mental health.

Technology and Sport

Wearables

The highly anticipated Apple Heart Study presented by Drs. Mintu Turakhia and Marco Perez revealed that while we receive endless data and possibly signals for abnormalities from our devices, they are not always accurate at diagnosing disease. Wearables have empowered patients and physicians alike; for example, heart rate monitors can aid in the personalization of exercise prescriptions while monitoring heart rate data in real time. There are sweat sensors that can signal metabolic abnormalities, devices for determining respirations, heart rate variability, projected cardiorespiratory fitness and others. It can be helpful to calibrate the devices with a treadmill stress test to ensure the accuracy of the device, and even then, many of the algorithms are not 100% reliable. The intersection of technology and medical industries within ongoing and future research studies is of utmost importance if these devices are to be used and trusted on a daily clinical basis.

Caring for the athlete requires a multidisciplinary team and a shared-decision-making approach. The field of sports and exercise cardiology is ripe for discovery, with many questions needing further evaluation so we can better care for our athletic patients.

For those interested in getting involved with the American College of Cardiology's Sports and Exercise Cardiology section, please reach out to Chris Driver at cdriver@acc.org. There are opportunities to foster involvement at the local state level and national level, including meeting planning and participation, sharing cases and knowledge on acc.org and advocating for athlete health. If you are interested in learning more or developing your career, you can access the ACC mentorship program as well. We invite you to watch the FITS on the Go blog video from ACC Sports and Exercise Chair, Matthew Martinez, MD, that highlights key aspects of the section. Further, if you are looking to take a deeper dive and learn more about sports and exercise cardiology, we encourage you to join us in Washington, DC, June 20-22, 2019 at ACC's Care of the Athletic Heart: From Elite to Exercise Enthusiasts meeting, with an option to attend a cardiopulmonary exercise testing "pre-conference" workshop leading up to the conference.

References

1. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019. [Epub ahead of print]
2. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Washington, DC: US Department of Health and Human Services, 2018.
3. Lavie CJ, Laddu D, Arena R, Ortega FB, Alpert MA, Kushner RF. Healthy weight and obesity prevention: JACC Health Promotion Series. J Am Coll Cardiol 2018;72:1506-31.
4. Churchill TW, Krishnan S, Weisskopf M, et al. Weight gain and health affliction among former national football players. Am J Med 2018;131:1491-8.
5. Etheridge SP, Escudero CA, Blaufox AD, et al. Life-threatening event risk in children with Wolff-Parkinson-White syndrome: a multicenter international study. JACC Clin Electrophysiol 2018;4:433-44.

Keywords: ACC Annual Scientific Session, ACC19, Sports, Exercise, Athletes, Algorithms, American Heart Association, Antihypertensive Agents, Aspirin, Aorta, Biomedical Technology, Body Weight, Calcium, Cardiomyopathy, Hypertrophic, Cardiac Rehabilitation, Cardiovascular Diseases, Cohort Studies, Coronary Artery Disease, Death, Sudden, Death, Sudden, Cardiac, Decision Making, Diet, Vegetarian, Diet, Electrocardiography, Electrophysiology, Energy Intake, Exercise Test, Follow-Up Studies, Exercise Therapy, Expert Testimony, Heart Rate, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Hypertrophy, Left Ventricular, Life Style, Long QT Syndrome, Mentors, Myocardial Infarction, Obesity, Outcome Assessment, Health Care, Overweight, Parkinson Disease, Patient Care Team, Percutaneous Coronary Intervention, Physical Exertion, Primary Prevention, Prospective Studies, Quality of Life, Retirement, Sports Medicine, Risk Factors, Stroke, Supine Position, Tachycardia, Ventricular, Telemedicine, Tobacco, Transcatheter Aortic Valve Replacement, Veterans, Ventricular Dysfunction, Left, Weight Gain

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