ACC.24 Sports and Exercise Cardiology Highlights

Quick Takes

  • Shared decision-making (SDM) remains a fundamental pillar in sports cardiology, though may vary in application depending on the type of athlete being evaluated (e.g., tactical vs. competitive).
  • Hypertrophic cardiomyopathy (HCM) and aortopathy should no longer be absolute contraindications to involvement in sports; recommendations should be individualized to each athlete.
  • Interventions tailored for an athletic population should be considered, such as percutaneous coronary intervention (PCI) for masters athletes with coronary artery disease (CAD) who do not meet typical fractional flow reserve (FFR) thresholds.

The 2024 American College of Cardiology Scientific Sessions (ACC.24), which took place April 6-8, 2024, in Atlanta, GA, included several important Sports and Exercise Cardiology sessions. Here is a summary of some of the key takeaways for trainees as well as practitioners who are interested or engaged in the care of competitive, recreational, and tactical athletes.

Assessing Tactical Athletes: A Collaborative Approach

Evaluation of tactical athletes — such as firefighters, police officers, emergency medical technicians (EMTs), Special Weapons and Tactics (SWAT) team members, astronauts, and military personnel — requires collaborative decision-making between the individual and key stakeholders. This is because a cardiac event occurring in the line of duty could present significant dangers to the rest of the team and potentially compromise the safety of others and the mission's success. As such, the concept of shared decision making (SDM) in tactical athletes is not equivalent to that of a competitive athlete. SDM in the tactical athlete must consider not only the safety of the athlete but also the possible resulting consequences of a cardiac event in the line of duty.

Cardiologists charged in the care of tactical athletes must understand the varied types of physical demands and risks within specific work environments (e.g., pilots experiencing high g-force during flights, firefighters carrying heavy equipment in active fire situations) as these details can significantly influence physician guidance. For example, a tactical athlete with aortopathy might be able to safely perform tasks that require moderate amounts of dynamic exertion, but not high levels of static strain. A future 'Bethesda-style' classification matrix will aid clinicians in assessing the static and dynamic demands of tactical athletes in different roles.

Coronary Artery Calcium (CAC) Implications in Masters Athletes

Elevated levels of physical activity are associated with lower risk of cardiovascular (CV) disease and mortality. However, male masters endurance athletes who exercise vigorously may have higher CAC scores compared to healthy matches from the general population.1 Although higher CAC confers increased CV risk in the general population,2 individuals having high levels of cardiorespiratory fitness are at reduced risk of adverse CV events compared to more sedentary individuals with a similar CAC score.3 Mechanisms underlying sub-clinical coronary artery disease (CAD),4 including CAC,1,5 are uncertain in presumed lower risk masters athletes.

Cath Lab Interventions in 'Athletic Hearts'

Traditional angiographic functional measurement cutoffs (fractional flow reserve [FFR]≤0.80 / instantaneous wave-free ratio [iFR] ≤0.89) may not be as generalizable in highly athletic populations as these measures were derived in a non-athletic population. Hence, it remains unclear the significance of prolonged ischemia during endurance exercise and how exactly one may define an analogous level of ischemia on either invasive or non-invasive testing. It is also important to acknowledge that studies that tested these thresholds, such as Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) and Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 2 (FAME 2), did not include or control for cardiorespiratory fitness. Decisions regarding evaluation, medical therapy, and/or revascularization need to be individualized, utilizing a SDM approach, for all masters athletes with obstructive CAD.

Strategizing Atrial Fibrillation (AF) Treatment in Masters Athletes

The relative risk of AF in masters endurance athletes, particularly among men, increases in proportion to the intensity of endurance exercise habits and duration of years involved in endurance exercise.6 In this population, beta blockers can be considered as part of the initial management strategy as the masters athlete monitors their heart rate, symptoms, and performance during exercise. Given known side effects with atrioventricular nodal agents, however, many masters athletes may prefer rhythm control to minimize the exercise intolerance.

Pulmonary vein isolation is reasonable for athletes with symptomatic AF. In single center data, athletes who had earlier ablation had freedom from AF at a higher rate than those who had later ablation (>2 years).7

Navigating Hypertrophic Cardiomyopathy (HCM) in Elite Athletes

Universal competitive sports restriction for athletes with HCM should no longer represent the standard of care. SDM must be integrated into this process. Exercise remains an important method to lower overall CV risk within this patient population, and recent data suggest cardiac risks are not prohibitive for vigorous exercise and competitive sports among competitive athletes with HCM.8 For example, in a recent prospective cohort study, individuals with HCM who engaged in vigorous exercise did not have a higher rate of events (including death, cardiac arrest) compared to a nonvigorous exercise group with HCM.8 As such, competitive athletes with HCM may be able to return-to-play after careful evaluation by a sports cardiologist with expertise in the management of HCM that includes appropriate cardiac risk stratification and SDM.9

Balancing Risks: Aortic Enlargement and SDM

Uncertain risks of competitive sports in athletes with known aortic dilation or aneurysm include disease progression, aortic dissection, and sudden cardiac death (SCD). Current guidelines from 2015 addressing competitive sports in athletes with aortopathy are conservative and outdated.10

SCD in athletes due to aortic dissection is much lower than the estimated prevalence of athletes with aortopathy, particularly aortopathy associated with bicuspid aortic valves. SDM and continued longitudinal clinical surveillance are critical in the care of athletes who present with aortic enlargement or aortopathy and continue with competitive sports.

This overview offers a glimpse of the discussions from the ACC.24 Sports and Exercise Cardiology sessions. Those who are interested in learning more about this exciting and dynamic field should attend (in person or virtually) the Care of the Athletic Heart course, which will take place in Washington D.C. June 6-8, 2024. As a fellow in training myself, I am incredibly excited to go and learn from world renowned leaders in the field. Hope to see you there!


  1. Merghani A, Maestrini V, Rosmini S, et al. Prevalence of subclinical coronary artery disease in masters endurance athletes with a low atherosclerotic risk profile. Circulation 2017;136:126-37.
  2. Greenland P, Blaha MJ, Budoff MJ, Erbel R, Watson KE. Coronary calcium score and cardiovascular risk. J Am Coll Cardiol 2018;72:434-47.
  3. Radford NB, DeFina LF, Leonard D, et al. Cardiorespiratory fitness, coronary artery calcium, and cardiovascular disease events in a cohort of generally healthy middle-age men: results from the Cooper Center Longitudinal Study. Circulation 2018;137:1888-95.
  4. De Bosscher R, Dausin C, Claus P, et al. Lifelong endurance exercise and its relation with coronary atherosclerosis. Eur Heart J 2023;44:2388-99.
  5. Aengevaeren VL, Mosterd A, Bakker EA, et al. Exercise volume versus intensity and the progression of coronary atherosclerosis in middle-aged and older athletes: findings from the MARC-2 Study. Circulation 2023;147:993-1003.
  6. Andersen K, Farahmand B, Ahlbom A, et al. Risk of arrhythmias in 52 755 long-distance cross-country skiers: a cohort study. Eur Heart J 2013;34:3624-31.
  7. Mandsager KT, Phelan DM, Diab M, et al. Outcomes of pulmonary vein isolation in athletes. JACC Clin Electrophysiol 2020;6:1265-74.
  8. Lampert R, Ackerman MJ, Marino BS, et al.; on behalf of the LIVE Consortium. Vigorous exercise in patients with hypertrophic cardiomyopathy: results of the prospective, observational, multinational, "Lifestyle and Exercise in HCM" (LIVE-HCM) Study. JAMA Cardiol 2023;8:595-605.
  9. Martinez KA, Bos JM, Baggish AL, et al. Return-to-play for elite athletes with genetic heart diseases predisposing to sudden cardiac death. J Am Coll Cardiol 2023;82:661-70.
  10. 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.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Sports and Exercise Cardiology, Exercise

Keywords: ACC Annual Scientific Session, ACC24, Sports, Sports Medicine, Exercise, Hypertrophic Cardiomyopathy, Cardiomyopathy, Hypertrophic, Decision Making, Shared

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