Editor's Note:

Dear Sports and Exercise Cardiology Enthusiasts:

Care of the Athletic Heart 2019 (CAH), directed by Matthew Martinez MD, and Jonathan Kim, MD, convened June 20-22 at the American College of Cardiology's Heart House in Washington, DC. The overflow capacity of attendees and number of live streaming participants exceeded 220 in total. In the next few weeks, we will post summaries of key sessions written by cardiology Fellows-in-Training (FIT). Most of them were presenters at CAH, and all are active in the Sports and Exercise Cardiology Section FIT Interest Group.

The full CAH agenda can be accessed here. Please feel free to contact Chris Driver (cdriver@acc.org) or me (chungeug@umich.edu) with any questions.

Thank you to the FITs for all their hard work. We hope you enjoy the summaries.

Eugene H Chung, MD, FACC
Editorial Team Lead, Sports & Exercise Cardiology Clinical Topic Collection

Background
Saturday morning at the ACC Care of the Athletic Heart conference began with a session dedicated to recreational and everyday athletes. Dr. Meagan Wasfy opened with a discussion on the heart of the female athlete, Dr. Mark Link provided an update on the impact of wearable technology on the everyday athlete and Dr. Ben Levine presented a paradigm for evaluating the extreme and the tactical athlete. The following are key points from this session.

• Training-related ECG patterns differ between males and females. Males are more likely than females to demonstrate voltage criteria for left ventricular hypertrophy, incomplete right bundle branch block and early repolarization patterns on ECG. Females have lower rates of exercise related sudden cardiac death, even after accounting for differences in prevalence of predisposing conditions.
• Differences between genders are also seen in exercise-related cardiac remodeling. Females have smaller un-indexed right ventricles, left atria and left ventricles than males; however, with the exception of left ventricular mass, these differences disappear when indexed to body surface area. Female endurance athletes are also more likely to develop eccentric versus concentric hypertrophy (e.g., wall thickness >12 mm is very rare in females).
• The world of wearable technology in the everyday athlete is rapidly expanding. Concerns about data from wearables are increasing referrals for cardiology consultation. Photoplethysmography based devices are not bad at detecting atrial fibrillation, but any detection must be confirmed by an ECG or ECG monitor.
• For detecting atrial fibrillation and/or assessment of symptoms like palpitations, a single lead smartphone ECG can be useful; the positive predictive value will depend on disease prevalence in the population using the technology.
• In extreme sports (e.g., rock climbing), strains on the heart are fairly minimal and the challenge typically comes from environmental stressors, nutrition and musculoskeletal integrity. Exertion at high altitude leads to a significant drop in VO2 max and comes with an increased risk of sudden cardiac death for which acclimatization may be protective.
• When assessing the tactical athlete, there are more stakeholders than the individual patient (e.g., a firefighter is responsible for him or herself as well as the coworkers and victims). Ideal cardiovascular testing for these athletes should mimic (as much as possible) job specific tasks as each occupation has its own job-specific demands.
• In the athlete with a bicuspid aortic valve, ensure comprehensive evaluation of the aorta. If the aortic root diameter becomes larger than 40 mm, athletes should be advised to avoid activities that increase loading conditions on the aorta (i.e., isometric exercise).
• A diver who develops multiple episodes of decompression sickness should be evaluated with a bubble study echocardiogram to evaluate for a patent foramen ovale (PFO). If a PFO is found, the diver should stop diving or dive more conservatively until the PFO is closed.
• When differentiating between hypertrophic cardiomyopathy and athlete's heart, factors that favor hypertrophic cardiomyopathy include: the presence of red flag symptoms, a family history of hypertrophic cardiomyopathy or sudden cardiac death, major ECG abnormalities, asymmetric pattern of left ventricular hypertrophy, normal or reduced left ventricular end-diastolic diameter, left ventricular outflow obstruction or systolic anterior motion of the mitral valve, diastolic dysfunction and failure to reduce wall thickness with detraining.

Keywords: Sports, Athletes, Aortic Valve, Hypertrophy, Left Ventricular, Heart Ventricles, Decompression Sickness, Body Surface Area, Atrial Fibrillation, Bundle-Branch Block, Foramen Ovale, Patent, Photoplethysmography, Mitral Valve, Physical Exertion, Heart Valve Diseases, Cardiomyopathy, Hypertrophic, Death, Sudden, Cardiac, Electrocardiography, Ventricular Outflow Obstruction, Acclimatization, Referral and Consultation

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