The 69th American College of Cardiology (ACC)/World Congress of Cardiology(WCC) Scientific Sessions played witness to an unprecedented turn of events. For the first time in the history of the College, the Scientific Sessions were canceled in the face of the global SARS-CoV-2 (COVID-19) pandemic. Despite this ongoing public health crisis, the ACC delivered on its commitment to education and advancement of science by conducting an entirely virtual online learning platform from March 28-30, 2020. We will summarize some of the key scientific abstracts and case presentations in sports cardiology and provide take home points.

ATRIAL FIBRILLATION IN UNITED STATES ACTIVE DUTY MILITARY PILOTS IS ASSOCIATED WITH MILITARY RETENTION
Bush K, Keithler A, Wilson A, Yuan A, Sosa J.

Literature describing military personnel with atrial fibrillation (AF) is sparse.¹ In this study, Bush et al (San Antonio Military Medical Center, San Antonio, TX, USA) retrospectively studied 385 active duty (AD) United States military members with AF, treatment strategies employed, and subsequent military retention rates. The mean age of the cohort was 35.1 years; mean body-mass index 28.3 kg/m²; 93% male; 57% Caucasian, and 94% had paroxysmal AF. Almost 25% of the study cohort had hypertension, and 20% had sleep apnea. Mean CHA₂DS₂-VASc scores were low (0.39) relative to the general AF population. The predominant treatment strategy was rate control in 259 subjects (67.2%), followed by rhythm control in 173 (45.0%). Of the subjects, 104 (27.0%) received combination rate and rhythm therapies, and 161 (41.8%) underwent pulmonary vein isolation. Interestingly, almost 67% of AD met military retention standards despite the diagnosis of AF. Military retention rates did not differ between those who received no therapy, rate control, rhythm strategies, or combination therapy (P=0.475).² The authors shed light on the presence of modifiable risk factors, including hypertension and sleep apnea, in an otherwise healthy population. The lack of significant differences in military retention rates should encourage military members to seek adequate treatments to achieve symptom control and better quality of life.

OUTCOMES OF SPORTS PARTICIPATION FOR PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY AND IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS (ICD): DATA FROM THE ICD SPORTS REGISTRY
Maron B, Daimee U, Olshansky B, et al.

Shared-decision-making (SDM) is reasonable for athletes with implantable cardioverter-defibrillators (ICDs) who desire sport participation.³ Hypertrophic cardiomyopathy (HCM) is a common cause of sudden cardiac death; however, outcomes in HCM patients with ICDs have not been described. Maron et al (Tufts Medical Center, Boston, MA, USA) analyzed the ICD Sports Registry database to assess the risks of competitive sports in 68 patients with confirmed HCM. Of the patients, 38% were <20 years old and 26% were female. The majority (74%) had a primary prevention indication for ICD. The median (IQR) septal wall thickness was 1.9 cm (1.5-2.4) and the most prevalent sports represented were basketball, running, and baseball/softball. Over a median follow-up of 48 months, there were no sports-related deaths, arrests, or arrhythmia-related injuries. Nineteen (28%) athletes received shocks. Of these, five athletes (7%) received shocks during competition or practice, of which three (4%) were for ventricular tachycardia (VT) / ventricular fibrillation (VF). The authors concluded that among competitive athletes with HCM, ICD shocks during sports were relatively common, but potentially lethal VT/VF episodes were rare and responded to the initial shock.⁴ While SDM should remain emphasized, these data will help physicians and families further understand the risks of sport participation in the HCM population. Further, device programming strategies to prevent inappropriate shocks should be prioritized in all athletes with ICDs.

ASSOCIATION BETWEEN BIVENTRICULAR MECHANICAL PATTERN AND EXERCISE CAPACITY IN ATHLETES: MACHINE LEARNING BASED PREDICTION OF PEAK OXYGEN UPTAKE
Tokodi M, Lakatos BK, Tősér Z, et al.

Habitual vigorous exercise leads to significant adaptive changes in cardiac structure and function.⁵ Tokodi and colleagues (Semmelweis University, Heart and Vascular Center, Budapest, Hungary) sought to utilize machine learning to explore the relationship between resting left (LV) and right ventricular (RV) dimensions and strain with peak exercise capacity in a large cohort of athletes. The subjects included 396 competitive athletes (15 training hours/week) and 55 sedentary healthy volunteers who underwent 3D echocardiographic evaluation at rest. The 3D global longitudinal (GLS) and circumferential strain (GCS) were measured. Per expectation, athletes had larger chamber dimensions. Athletes also demonstrated lower LV and RV ejection fraction and less negative strain values. Cardiopulmonary exercise testing was performed to calculate peak oxygen consumption (VO₂). VO₂ correlated positively with LV end-diastolic volume index (r=0.49), RV end-diastolic volume index (r=0.49), LV mass index (r=0.41), LV GLS (r=0.28), LV GCS (r=0.21), RV GCS (r=0.18), and negatively with LV ejection fraction (r=-0.23) and RV ejection fraction (r=-0.22, all p<0.001). Random forest regression was applied to predict VO₂ from numerous 3D echocardiographic parameters, and t-distributed Stochastic Neighbor Embedding was used for 2D visualization of high dimensional data. The machine-learning algorithm predicted VO₂ with mean absolute error of 4.49 mL/kg/min and R² of 0.47. The authors propose that their machine learning-based approach was capable of predicting VO₂ based on 3D echocardiographic data.⁶ While this study has promising implications, the pitfalls of artificial intelligence (AI) must be kept in mind. These include, but are not limited to the requirement of massive samples for model accuracy, presence of a "black-box" in AI processing, and the need to include a diverse population for input to the neural networks in order to mitigate bias.⁷

ANABOLIC ANDROGENIC STEROID ABUSE: A POTENTIAL CAUSE OF MYOCARDIAL INFARCTION IN YOUNG PATIENTS
Tan BE-X, Chowdhury M, Hall C, Baibhav B.

Myocardial infarction (MI) related to anabolic-androgenic steroid (AAS) use is rare, and most cases occur with pre-existing coronary artery disease (CAD). Tan et al (Rochester General Hospital, Rochester, NY, USA) presented a fascinating case of AAS-related STEMI in the absence of CAD. The patient, a 25-year-old male recreational bodybuilder, presented with new chest pain and diffuse ST elevation without reciprocal change. Troponin level was 4.76 ng/mL, and echocardiography showed LV ejection fraction of 45% with apical akinesis. Emergent angiogram revealed a large thrombus in the proximal left anterior descending artery (LAD), and a small occlusive thrombus in the apical LAD. The proximal LAD thrombus was treated with aspiration thrombectomy without stent placement. It was later revealed that the patient had been using intramuscular testosterone for three years. He was discharged on aspirin and clopidogrel. Three days later, he presented with abdominal pain found to have an embolic right renal infarct on abdominal computed tomography (CT) angiogram and was started on warfarin. Outpatient thrombophilia workup was negative and free testosterone level was markedly elevated at 102 ng/dL.⁸ The authors urge the community to consider AAS-related MI as a cause of chest pain in athletes on testosterone supplementation. Testosterone associated thrombophilia has been well-described, and while venous thromboembolic events are more common, arterial events have been described.⁹ Concern should be heightened for patients with intracardiac shunts and those with genetic thrombophilia syndromes.

AORTIC ROOT DIMENSIONS IN ADOLESCENT FOOTBALLERS
Yiangou K, Malhotra A, Papadakis M, Esteban MTT, Sharma S.

Routine vigorous exercise stimulates cardiac remodeling that results in structural changes, coined as the 'athlete's heart'. While this may involve left ventricular wall thickening and chamber dilatation, less is known about whether exercise-induced aortic remodeling occurs. Aortic dilatation is frequently encountered in clinical practice among older athletes, but the distribution of aortic size in young athletes is unknown. In this study, Yiangou and colleagues (St George's Hospital, University of London, London, UK) described the aortic root dimensions of >1000, predominantly male elite adolescent soccer players.¹⁰ They developed nomograms from this cohort of healthy athletes, none of whom demonstrated pathologic aortic dilatation, allowing determination of the Z-score for aortic diameters as a function of gender and body surface area (BSA) at the level of the sinuses of Valsalva and ascending aorta. These data contribute to our understanding of normal aortic dimensions in youthful athletes that differentiate from pathologic dilatation.

THE IMPACT OF AMERICAN-STYLE FOOTBALL PARTICIPATION ON VENTRICULAR-ARTERIAL COUPLING
Tso J, Hollowed C, Liu C, et al.

American-style football (ASF) is the most popular team sport in the United States, yet the implications of ASF participation on long-term cardiovascular health are controversial. Although deliberate weight gain is common in ASF, weight gain during collegiate football participation is independently associated with later-life CV morbidity.¹¹ Further, college ASF athletes who gain weight and develop increased systolic blood pressure (SBP) levels are at risk of developing left ventricular hypertrophy, arterial stiffening, and reduced left ventricular diastolic function.¹² Tso et al (Emory University School of Medicine, Atlanta, GA, USA) compared cardiovascular efficiency in high-school senior and collegiate freshman ASF athletes with that of male endurance athletes and male undergraduates.¹³ V-A uncoupling, a measure of cardiovascular inefficiency, was estimated non-invasively by the ratio of arterial elastance (EA) and left ventricular end-systolic elastance (ELV). Among ASF athletes, SBP and EA/ELV increased while Tissue-Doppler E' velocity decreased from pre- to post-season. This directional change in VA-coupling was not observed in endurance athletes or male undergraduates. These results suggest that ASF participation leads to sub-clinical V-A uncoupling after one competitive season. The authors rightly note that longitudinal data are required to understand the true impact of early V-A uncoupling patterns on long-term cardiovascular morbidity and outcomes.

RETURN TO PLAY HIGH SCHOOL FOOTBALL IN PATIENT WITH HYPERTROPHIC CARDIOMYOPATHY
Hammond BH, Phelan D, Saarel E.

Risk stratification of athletes with cardiac disease is often a challenging and nuanced decision-making process. Hammond and colleagues (Cleveland Clinic, Cleveland, OH, USA) present a case report of a 14-year old male athlete with hypertrophic cardiomyopathy (HCM, MYH7 gene mutation).¹⁴ At the time of diagnosis, he reported palpitations and dizziness, and had septal thickness of 21 mm with <15% late gadolinium enhancement. There was no ectopy or decrease in blood pressure during exercise, and stress echocardiography showed the presence of a left ventricular outflow tract obstruction only during exercise (155 mmHg gradient). He was intolerant to beta-blockade. A subcutaneous ICD was placed, and he was restricted from sports participation. The patient developed clinical depression, decrease in academic performance, and requested return to sport participation with a detailed emergency action plan. Using shared decision-making, the authors agreed to support the athlete's return to play. This case highlights two important points pertaining to athletes with HCM. First, according to the 2011 HCM guidelines, there was no clear indication for ICD placement. Second, using shared decision-making, a less restrictive approach to sports participation may be reasonable in select cases of athletes with HCM. According to the recent position statement of the European Association of Preventive Cardiology,¹⁵ adults with mild clinical expression of HCM and no conventional risk factors for sudden cardiac death may participate in competitive sports, with exception of cases where syncope may cause substantial harm or death.

HIGH INCIDENCE OF ELEVATED BLOOD PRESSURE AMONG COLLEGIATE FEMALE ATHLETES AT PRE-PARTICIPATION PHYSICAL EVALUATION
Rambarat C, Reifsteck F, Taha Y, et al.

Identification of cardiovascular risk factors, such as hypertension, has gained increased attention as part of sport pre-participation evaluations. Rambarat and colleagues (University of Florida, Gainesville, FL and University of Georgia, Athens, GA, USA) reviewed records for 329 National Collegiate Athletic Association (NCAA) Division-I female athletes from eight different sports between 2010-2019.¹⁶ They found that 44% of these athletes had at least pre-hypertensive blood pressure (BP, systolic >120 mmHg) at the pre-participation physical evaluation. Most (61%) of these elevations were in the elevated BP (systolic BP 120-129 mmHg) range. Interestingly, there were no elevated BPs in gymnasts (N=14), whereas softball players had the highest percentage of abnormal BP (13/22 with abnormally elevated BP). Whether this sport-specific variation is a manifestation of the different static/dynamic components of each sport remains to be determined, and the long-term consequences of abnormal BP in this population needs further evaluation.

EXERTIONAL SYNCOPE IN COLLEGE VARSITY ATHLETES
Gier C, Shapero K, Arlis-Mayor S, Lampert RJ.

Exertional syncope in competitive athletes appropriately raises concern about possible underlying cardiovascular disease. However, the actual incidence of cardiac disease in this specific clinical scenario is not entirely clear. Gier et al (Yale University, New Haven, CT, USA) reviewed the medical records of college varsity athletes at Yale who had medical encounters associated with the diagnosis of syncope over an 8-year period (2011-2019).¹⁷ The investigators identified 42 patients who were diagnosed with presyncope or syncope. They found the most common activity at the time of a syncopal event was running (37%), while the most common etiology of the presenting event was exercise-associated collapse (37%). In 26% of cases, the etiology was "multifactorial." Stress tests, 12-lead electrocardiography and echocardiography were obtained in 56%, 85%, and 56% of the cases, respectively. Cardiac MRI and coronary CT angiography were only ordered in 19% and 7% of cases, respectively. This study provides interesting information on the 'real world' clinical approach to the athlete with syncope and highlights the critical role an adequate and detailed history still plays in the diagnostic algorithm to reduce unnecessary testing. While the incidence of cardiac disease is uncommon, it remains crucial to key on specific historical features that could indicate underlying cardiovascular disease.

References

1. Bush KNV, Gerasimon GG. The role of catheter ablation in military personnel with atrial fibrillation. Mil Med 2019;184:E379–E382.
2. Bush K, Keithler A, Wilson A, Yuan A, Sosa J. Characteristics of United States military personnel with atrial fibrillation and associated service retention rates. J Am Coll Cardiol 2020;75:395.
3. Zipes DP, Link MS, Ackerman MJ, Kovacs RJ, Myerburg RJ, Estes NAM3rd. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 9: arrhythmias and conduction defects: a statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2412-23.
4. Maron B, Daimee U, Olshansky B, et al. Outcomes of sports participation for patients with hypertrophic cardiomyopathy and implantable cardioverter-defibrillators: data from the ICD Sports Registry. J Am Coll Cardiol 2020;75:305.
5. Kovacs R, Baggish AL. Cardiovascular adaptation in athletes. Trends Cardiovasc Med 2016;26:46–52.
6. Tokodi M, Lakatos BK, Tősér Z, et al. Association between biventricular mechanical pattern and exercise capacity in athletes: machine learning based prediction of peak oxygen uptake. J Am Coll Cardiol 2020;75:1562.
7. Noseworthy PA, Attia ZI, Brewer LC, et al. Assessing and mitigating bias in medical artificial intelligence. Circ Arrhythm Electrophysiol 2020;13:e007988.
8. Tan BE-X, Chowdhury M, Hall C, Baibhav B. Anabolic androgenic steroid abuse: a potential cause of myocardial infarction in young patients. J Am Coll Cardiol 2020;75:2416.
9. Glueck CJ, Prince M, Patel N, et al. Thrombophilia in 67 patients with thrombotic events after starting testosterone therapy. Clin Appl Thromb Hemost 2016;22:548–553.
10. Yiangou K, Malhotra A, Papadakis M, Esteban MTT, Sharma S. Aortic root dimensions in adolescent footballers. J Am Coll Cardiol 2020;75:1614.
11. Churchill TW, Krishnan S, Weisskopf M, et al. Weight gain and health affliction among former national football league players. Am J Med 2018;131:1491–8.
12. Kim JH, Hollowed C, Liu C, et al. Weight gain, hypertension, and the emergence of a maladaptive cardiovascular phenotype among US football players. JAMA Cardiol 2019;4:1221–9.
13. Tso J, Hollowed C, Liu C, et al. The impact of American-style football participation on ventricular-arterial coupling. J Am Coll Cardiol 2020;75:1558.
14. Hammond BH, Phelan D, Saarel E. Return to play high school football in patient with hypertrophic cardiomyopathy. J Am Coll Cardiol 2020;75:2328.
15. Borjesson M, Dellborg M, Niebauer J, et al. Recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: a position statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC). Eur Heart J 2019;40:13–18.
16. Rambarat C, Reifsteck F, Taha Y, et al. High incidence of elevated blood pressure among collegiate female athletes at pre-participation physical evaluation. J Am Coll Cardiol 2020;75:14.
17. Gier C, Shapero K, Arlis-Mayor S, Lampert RJ. Exertional syncope in college varsity athletes. J Am Coll Cardiol 2020;75:393.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Noninvasive Imaging, Sports and Exercise Cardiology, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Echocardiography/Ultrasound, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging, Chronic Angina

Keywords: Sports, acc20, ACC Annual Scientific Session, Blood Pressure, Cardiovascular Diseases, Dizziness, Exercise Test, Incidence, Echocardiography, Stress, Contrast Media, Hypertrophy, Left Ventricular, Dilatation, Pathologic, ST Elevation Myocardial Infarction, Military Personnel, Troponin, Atrial Fibrillation, Warfarin, Body Surface Area, Risk Factors, Universities, Pulmonary Veins, Aspirin, Artificial Intelligence, Retrospective Studies, Coronary Artery Disease, Defibrillators, Implantable, Body Mass Index

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