ACC.22 Sports Cardiology Abstracts Highlights

Quick Takes

  • High-intensity endurance exercise following thoracic aorta with or without aortic valvular repair may be safe in certain populations – is it time to re-think the 2015 guidelines?
  • Preparticipation screening may not cause significant psychological distress in young athletes.
  • Among the general population of older male adults with hypertension, fitness level is inversely correlated with incident atrial fibrillation.

The 71st American College of Cardiology (ACC) Scientific Sessions returned to in-person, incorporating a mix of both live and virtual events from April 2-4, 2022. A summary of a few key sports cardiology abstracts and key take home points are provided here.

Endurance Exercise is Low-Risk Following Ascending Aortic Aneurysm Resection in Bicuspid Aortic Valve Aortopathy
Lai A, Watkins D, Boyer L, Braverman AC
Current exercise recommendations for those with bicuspid aortic valve (BAV) aortopathy after ascending aortic surgery are generally restrictive and advise against high-intensity isometric exercise.1,2 Lai et al. (Washington University School of Medicine, Saint Louis, MO, USA) investigated clinical outcomes of motivated athletes, without Marfan or Loeys-Dietz syndrome, who returned to high-intensity exercise after elective aortic repair with or without concurrent valve replacement.3 In the 21 included individuals recruited through the authors' tertiary care center and Ironheart Foundation, no adverse aortic outcomes were reported over a mean follow-up of 8.0 ± 5.2 years. Three athletes required repeat aortic valve replacement for bioprosthetic valvular degeneration after a mean of 8.7 ± 3.7 years. Notably, this study excluded those with genetic aortopathies, which likely represent an increased risk population regardless of surgical repair. This study highlighted that high-intensity exercise may be reasonable to consider in some patients after appropriate shared-decision making.

Echocardiography in Young Athlete Screening: Simon's Heart Experience
Johnson DM, Doshi H, Dikdan SJ, Frankel E, Shipon D
At present, based on recommendations by the American Heart Association, routine preparticipation screening (PPS) in the United States includes a detailed history and physical exam, reserving routine electrocardiograms and echocardiograms for those with concerning findings on the initial screen. However, some argue that a focused echocardiogram, especially in collegiate athletes, may be beneficial and feasible.4,5 Simon's Heart is a non-profit organization that provides adolescent student-athletes complimentary cardiovascular screenings, including a history, physical exam, electrocardiogram, and for individuals with abnormal findings or family history: an echocardiogram. Johnson et al. (Thomas Jefferson University Hospital, Philadelphia, PA, USA) reviewed all echocardiograms performed between October 2012 and December 2020 with the aim of identifying prevalent abnormalities.6 Of the 512 echocardiograms performed on the 15,716 student-athletes screened, 400 (78%) were normal. The most common abnormalities included: aortic regurgitation (5%), patent foramen ovale or atrial septal defect (3%), left ventricular hypertrophy (3%), bicuspid aortic valve (2%), mitral valve prolapse (2%), and greater than mild valvular regurgitation (2%). All remaining abnormalities included: subaortic membrane, abnormal coronary arteries, intracardiac mass, and situs inversus occurred in <1% of screened individuals. Although this study demonstrated a significant prevalence of abnormal echocardiograms, most findings represent those of uncertain significance. Further, there are significant limitations in the consideration of screening echocardiography for athletes. At this time, use of echocardiogram in the PPS continues to be reserved only for those student-athletes with abnormalities on initial screening.

Does Cardiovascular Preparticipation Screening Cause Psychological Distress in Athletes? A Systematic Review
Hill B, Williamson M, Grubic N, Phelan D, Baggish A, Dorian P, Johri AM
Sudden cardiac arrest is the leading cause of death among young athletes; however, PPS guidelines and practices are variable among geographical regions and sport organizations. This Canadian-based review by Hill et al. (Queen's University, Kingston, CA) investigated if discrepant PPS practices imposed a psychological burden on athletes.7 A total of eight studies involving athletes, who participated in cardiovascular PPS, were included that reported psychological outcomes before, during and/or afterwards (median sample size: 479). Athletes had a median age of 20.5 years, 59% were male and all skill levels (recreational, collegiate, and professional) were represented. Most athletes – including those with false-positive results – reported positive or neutral reactions to PPS (88-100%, 5 studies). Negative reactions, including increased psychological stress, were almost exclusively reported among athletes with true-positive screening results, and near-uniformly reported after PPS was completed. Interestingly, even in those athletes for which PPS had a negative psychological impact, there was uniform satisfaction with the process as well as support for continuation of PPS programs. This study found that overall, PPS does not result in undue stress for most athletes. Moreover, the availability of appropriate psychological care and resources are imperative for athletes with psychological distress stemming from PPS.

Exercise Capacity and Atrial Fibrillation Risk in 459,592 Hypertensive US Veterans: A Cohort Study
Pittaras AE, Faselis C, Samuel IBH, Doumas M, Grassos H, Murphy R, Myers JN, Kokkinos P
There are contradictory studies regarding the association of exercise capacity or 'fitness' and atrial fibrillation (AF), with the collective thought that low- and moderate-intensity physical activity lowers one's risk of developing AF; whereas high-dose high-intensity exercise increases one's risk of AF, especially in men. Pittaras et al. (Mediton Medical Center, Athens, Greece and VA & George Washington University Medical Centers, Washington DC, USA) followed 459,592 veterans (mean age of 63 ± 8.6 years, 95% male) with hypertension, a prevalent risk factor for AF, stratified at initial study visit into quintiles based on metabolic equivalents (METs) completed on an exercise stress test.8 Over a follow-up period of 9.8 years, 44,120 (9.6%) veterans developed AF. After adjusting for age, body mass index, gender, smoking, diabetes, hyperlipidemia, cardiovascular medications, and renal disease, exercise capacity was inversely related to incidence of AF, with the overall risk of incident AF 11% lower with each 1-MET exercise capacity. Compared to the 'Least-Fit' quintile, the hazard ratio for incident AF was 0.72 (Low Fit), 0.61 (Mod Fit), 0.52 (Fit), and 0.45 (High Fit). This study suggests that among general population males with hypertension, increased fitness is not associated with incident AF.


  1. Bonow RO, Nishimura RA, Thompson PD, Udelson JE. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 5: valvular heart disease: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2385-92.
  2. Braverman AC, Harris KM, Kovacs RJ, Maron BJ. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 7: aortic diseases, including Marfan syndrome: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2398-2405.
  3. Lai A, Watkins D, Boyer L, Braverman AC. Endurance exercise is low-risk following ascending aortic aneurysm resection in bicuspid aortic valve aortopathy. J Am Coll Cardiol 2022;79:1978.
  4. Modaff DS, Hegde SM, Wyman RA, Rahko PS. Usefulness of focused screening echocardiography for collegiate athletes. Am J Cardiol 2019;123:169-74.
  5. Fischetti CE, Kamyszek RW, Shaheen S, et al. Evaluation of a standardized cardiac athletic screening for National Collegiate Athletic Association (NCAA) athletes. West J Emerg Med 2019:14;20:810-17.
  6. Johnson DM, Doshi H, Dikdan SJ, Frankel E, Shipon DM. Echocardiography in youth athlete screening, Simon's Heart experience. J Am Coll Cardiol 2022;79:1985.
  7. Hill B, Williamson M, Grubic N, et al. Does cardiovascular preparticipation screening cause psychological distress in athletes? a systematic review. J Am Coll Cardiol 2022;79:1982.
  8. Pittaras A, Faselis C, Samuel IBH, et al. Exercise capacity and atrial fibrillation risk in 459,592 hypertensive US veterans: a cohort study. J Am Coll Cardiol 2022;79:1986.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Valvular Heart Disease, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, 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, Exercise, Hypertension, Stress, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging

Keywords: ACC Annual Scientific Session, ACC22, Sports, Atrial Fibrillation, Aortic Valve, Exercise Test, Follow-Up Studies, Bicuspid Aortic Valve Disease, Heart Septal Defects, Atrial, American Heart Association, Aortic Valve Insufficiency, Body Mass Index, Cause of Death, Cohort Studies, Coronary Vessels, Exercise Tolerance, Foramen Ovale, Patent, Hyperlipidemias, Hypertrophy, Left Ventricular, Loeys-Dietz Syndrome, Marfan Syndrome, Metabolic Equivalent, Mitral Valve Prolapse, Personal Satisfaction, Tertiary Care Centers, Exercise, Athletes, Death, Sudden, Cardiac, Echocardiography, Electrocardiography, Risk Factors, Academic Medical Centers, Psychological Distress, Stress, Psychological, Decision Making, Situs Inversus, Hypertension, Diabetes Mellitus

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