Exercise-related Sudden Cardiac Death Research Articles

Abstract 15455: Unraveling the Mechanism of Ischemia in Pediatric Patients With R-AAOCA: Fixed and Dynamic Obstruction

Introduction: Although rare, anomalous aortic origin of the right coronary artery (R-AAOCA) is associated with exercise-related sudden cardiac death and dynamic obstruction to coronary flow in the intramural segment has been proposed as the ischemia mechanism. We aim to describe fixed and dynamic obstruction mechanism of ischemia in select group of R-AAOCA patients undergoing invasive transcatheter stress FFR and iFR. Hypothesis: Ischemia in R-AAOCA involves a 2-tier mechanism involving both fixed and dynamic obstruction. Methods: Single institution retrospective study of R-AAOCA patients undergoing cardiac catheterization due to ischemic symptoms and negative perfusion defects on dobutamine stress CMRI. Coronary angiography was performed in all patients. Instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) were performed at baseline and under pharmacologic stress with adenosine (aFFR)/dobutamine (diFR) when the coronary ostium was engaged in a stable manner. Significant fixed obstruction was considered if aFFR<0.80 and dynamic if diFR <0.85. Results: A total of 14/446 (3%) R-AAOCA patients were included. In 10 patients, a Verrata pressure guide wire (Volcano, San Diego, CA) was able to be advanced to perform iFR and FFR. Fixed RCA obstruction was demonstrated in 4/10 patients (40%) and 2 of these (2/10, 20%) also had dynamic RCA obstruction (Table). All 4 patients were referred to surgery: 3 completed, 1 pending. In 4/14 (28%) patients, iFR and FFR were not performed due to inability to engage the RCA ostium, all of which found to be hypoplastic (1-1.5 mm) and slit-like at surgery. There were no procedural complications. Conclusions: In a small cohort of R-AAOCA patients, mechanisms for myocardial ischemia during stress suggest dynamic and fixed components. Our preliminary results provide important insight for risk stratification. Long-term follow-up will be important to validate the performance of iFR/FFR in R-AAOCA

The safety of sports in children with inherited arrhythmia substrates.

Sudden cardiac death (SCD) is a rare and devastating event in children and remains a leading cause of death in young athletes. Channelopathies and cardiomyopathies, in particular long QT syndrome (LQTS), catecholaminergic polymorphic ventricular tachycardia (CPVT), hypertrophic cardiomyopathy (HCM), and arrhythmogenic cardiomyopathy (ACM) are associated with exercise-related SCD. Implantable cardioverter-defibrillators (ICDs) are often placed for secondary prevention for athletes with cardiomyopathy or channelopathy. There remains concern regarding the safety of return to participation with an ICD in place. Guidelines have historically recommended that patients with inherited heart rhythm disorders be restricted from competitive sports participation. Increasing evidence suggests a lower risk of exercise-related cardiac events in young athletes with inherited heart rhythm disorders. In this review, we highlight current knowledge, evolving guidelines, and present a multidisciplinary approach involving shared decision-making and appropriate planning for safe sports participation of children with inherited heart rhythm disorders.

Prevalence of coronary artery anomalies in young sudden cardiac death: insights from a prospective state-wide registry

Abstract Background Coronary artery anomalies (CAAs) have been previously implicated as a major cause of young sudden cardiac death (SCD), particularly in exercise-related SCD with a reported prevalence of up to 33%. Methods A state-wide prospective out-of-hospital cardiac arrest registry identified all patients aged 1–50 years who experienced an SCD and underwent autopsy from April 2019 to April 2021. Rates of normal anatomy, normal variants and CAAs were identified and circumstances and cause of death for patients with CAAs examined. Results Of 1,477 patients who experienced cardiac arrest during the study period, 490 underwent autopsy and were confirmed to have experienced SCD. Of these 490 patients, five (1.0%) had a CAA identified with three having anomalies of coronary origin and two having anomalies of coronary course. In no cases was the CAA deemed responsible for the SCD. In two cases, severe coronary disease and intra-coronary thrombus with histological evidence of acute myocardial infarction were identified, in the third critical coronary disease was found, the fourth had an unrelated thoracic aortic dissection and the fifth had cardiomegaly in the setting of illicit drug use. Of 27 patients who experienced their SCD during exercise, only one had a CAA identified (the patient with thoracic aortic dissection). Conclusion In this prospective cohort of consecutive young patients with SCD who underwent autopsy, CAAs occurred in 1.0% of patients and did not cause any deaths. The role of CAAs in causing young SCD appears to be less significant than previously hypothesised. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): NHMRC, NHF

Sudden cardiac death related to physical exercise in the young: a nationwide cohort study of Australia.

Sudden cardiac death (SCD) during physical exercise is devastating. To evaluate causes and circumstances of exercise-related SCD in the young in Australia. We reviewed the National Coronial Information System database for deaths in Australia relating to cardiovascular disease in cases aged 10-35 years between 2000 and 2016. Cases who had undertaken physical exercise at the time of the event were included. We collected demographics, circumstances of death, type of physical exercise, bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use prior to ambulance arrival. Over a 17-year period, 1925 SCD cases were identified, of which 110 (6%) cases (median age 27 years (interquartile range 21-32 years); 92% male) were related to sports/physical exercise. Thirteen (12%) cases occurred in active athletes. Most common causes were coronary artery disease (CAD; 37%) and sudden arrhythmic death syndrome (SADS; 20%). Among Aboriginal and Torres Strait Islanders (n = 10), all deaths were related to CAD. Australian Rules Football (24%), running/jogging (14%) and soccer (14%) were the most frequent physical exercise activities. Prior symptoms were present in 39% (chest pain 37%, pre-syncope/syncope 26%). Most (87%) were witnessed, with bystander CPR in 70%. AED use prior to ambulance arrival was 8%. The present study demonstrates the high occurrence of CAD and SADS in SCD in the young related to physical exercise. Aboriginal and Torres Strait Islanders were disproportionately affected by CAD. Although events were commonly witnessed, AED was seldom used prior to ambulance arrival and highlights an important opportunity to improve outcomes in the post-arrest chain of survival.

Prevalence of Coronary Artery Anomalies in Young and Middle-Aged Sudden Cardiac Death Victims (from a Prospective State-Wide Registry)

Coronary artery anomalies (CAAs) have been previously implicated as a major cause of young sudden cardiac death (SCD), particularly in exercise-related SCD, with a prevalence of up to 33%. A state-wide prospective out-of-hospital cardiac arrest registry identified all patients aged 1 to 50years who experienced an SCD and underwent autopsy from April 2019 to April 2021. Rates of normal anatomy, normal variants, and CAAs were identified, and circumstances and causes of death for patients with CAAs examined. Of 1,477 patients who experienced cardiac arrest during the study period, 490 underwent autopsy and were confirmed to have experienced SCD. Of these 490 patients, 5 (1%) had a CAA identified, with 3 having anomalies of coronary origin and 2 having anomalies of coronary course. In no cases were the CAA deemed responsible for the SCD. In 2 cases, severe coronary disease and intra-coronary thrombus with histological evidence of acute myocardial infarction were identified. In the third, critical coronary disease was found, the fourth had an unrelated thoracic aortic dissection, and the fifth had cardiomegaly in the setting of illicit drug use. Of 27 patients who experienced their SCD during exercise, only 1 had a CAA identified (the patient with thoracic aortic dissection). In conclusion, in this prospective cohort of consecutive young patients with SCD who underwent autopsy, CAAs occurred in 1% of patients and did not cause any deaths. The role of CAAs in causing young and middle-aged SCD appears to be less significant than previously hypothesized.

The Female Athlete's Heart: Overview and Management of Cardiovascular Diseases.

The number of female athletes taking part in elite and amateur sport is ever increasing. In contrast with male athletes, few studies have focused on cardiovascular adaptations to exercise in women, the effects of lifelong exercise on heart muscle and electrical tissue, the risk of exerciserelated sudden cardiac death and the management of cardiovascular disease. Women have a lower prevalence of large QRS complexes, repolarisation changes including inferior and lateral T-wave inversion, and cardiac dimensions exceeding predicted limits compared with men. The risk of exercise-related sudden cardiac death is significantly lower in women than men. Also, women who have engaged in lifelong exercise do not have a higher prevalence of AF, coronary artery calcification or myocardial fibrosis than their sedentary counterparts. Apart from providing an overview of the existing literature relating to cardiac adaptations, this review explores possible reasons for the sex differences and focuses on the management of cardiovascular disorders that affect female athletes.

Right ventricular assessment of the adolescent footballers heart: impact of ethnicity

Abstract Introduction Athletic training often results in electrical and structural changes that may mimic phenotypical features of pathological cardiomyopathies. These physiological changes are influenced by age, ethnicity and sporting discipline. The presence of such changes that overlap with diseases implicated in exercise related sudden cardiac death may require comprehensive assessment to confirm or refute the presence of disease. One such potential physiological overlap with pathological change in athletes can occur in arrhythmogenic right ventricular dysplasia (ARVD), with features including chamber dilatation and T-wave inversion (TWI). An erroneous interpretation may have profound consequences ranging from false reassurance in a vulnerable athlete to unfair disqualification in a healthy individual. Therefore, it is important for the clinician to distinguish physiology from pathology. Purpose Studies detailing the physiological adaptation to exercise on the right ventricle (RV) of adolescent athletes are fewer compared to the left ventricle, with even fewer reports describing the impact of ethnicity on the RV. We set out to describe the normal dimensions of the RV of academy football players. Results ECG and echocardiographic data of 3000 academy male footballers were analysed, aged between 13 and 18 years old (mean age 16.4±0.5 years), who underwent mandatory cardiac screening. Ethnicity was categorised as white (n=1000), black (African/Caribbean; n=1000) and mixed-race (one parent white and one parent black; n=1000). ARVD major criteria for TWI was seen in 6.3% of the cohort. This was more prevalent in black footballers (3.7%) when compared to mixed race footballers (2%) or white footballers (0.6%), p<0.05. In up to 67% of the overall cohort, RV values exceeded those for normal adult reference ranges. There were no differences in RV dimensions between ethnicities (Tables 1 & 2). If ARVD criteria was applied, 13.2% would fulfil major ARVD criteria for right ventricular outflow tract. This was also demonstrated for RVOT dimensions (6.1% - 23.6%; Figure 1). Overall, 0.2% of the cohort would fulfil diagnosis for “definite” ARVD and 2.2% would fulfil diagnosis for “borderline” ARVD. This was seen more frequently in black footballers (9.9%) than mixed race footballers (3.9%) or white footballer (0.6%), P=0.0005. Among athletes meeting definite or borderline ARVD criteria, no cardiomyopathy was identified after comprehensive clinical assessment. Conclusion This is the largest study to our knowledge that reports RV dimension data among adolescent footballers of different ethnicities. Right heart sizes in excess of standard adult ranges occurred in as many as one in 22 athletes. It is not unusual to observe values that would overlap with criteria for ARVD. As with LV parameters, variations in terms of ethnicity should be accounted for when considering RV dimensions and ECG changes when performing routine cardiac assessments of adolescent athletes. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): National Institute for Health Research

Optical Coherence Tomography for the Diagnosis of Exercise-Related Acute Cardiovascular Events and Inconclusive Coronary Angiography.

Objectives The aim of this study is to assess the utility of optical coherence tomography (OCT) in patients with exercise-related acute coronary syndrome (ACS) presenting with inconclusive angiographic findings. Background Regular physical activity reduces the incidence of cardiovascular events. Nevertheless, the risk of ACS or sudden cardiac death (SCD) increases during sport. In adults older than 35 years, exercise-related ACS or SCD is associated with plaque rupture, but not infrequently patients present ambiguous angiographic findings. Methods Between September 2015 and January 2020, patients admitted for ACS or SCD triggered by physical exertion and with coronary stenosis ≤50% were included in this prospective observational study. OCT was performed on the artery deemed to be responsible of the event. Results Ten patients were enrolled, predominantly men (80%) of middle age (51 years old, IQR 41–63) with low cardiovascular risk burden. Cycling was the most frequent (50%) exercise-related trigger, 8 patients were regular sport practitioners, and 7 had the clinical event during strenuous exertion. Five patients presented with non-ST-elevation ACS, two with ST-elevation ACS, and three with SCD. Angiographic analysis showed nonsignificant stenosis in all patients (42% stenosis, IQR 36–46). OCT identified the etiology of the event in 9 patients (4 plaque erosion, 3 plaque rupture, 1 eruptive calcific nodule, and 1 coronary dissection). Treatment was adjusted according to OCT findings. Conclusions OCT is a valuable technique to identify the etiology of exercise-related ACS or SCD in patients with nonobstructive coronary arteries and, as a result, may lead to a more specific treatment.

Interpretation of T-wave inversion in physiological and pathological conditions: Current state and future perspectives.

The presence of T‐wave inversion (TWI) at 12‐lead electrocardiogram (ECG) in competitive athletes is one of the major diagnostic challenges for sports physicians and consulting cardiologists. Indeed, while the presence of TWI may be associated with some benign conditions and it may be occasionally seen in healthy athletes presenting signs of cardiac remodeling, it may also represent an early sign of an underlying, concealed structural heart disease or life‐threatening arrhythmogenic cardiomyopathies, which may be responsible for exercise‐related sudden cardiac death (SCD). The interpretation of TWI in athletes is complex and the inherent implications for the clinical practice represent a conundrum for physicians. Accordingly, the detection of TWI should be viewed as a potential red flag on the ECG of young and apparently healthy athletes and warrants further investigations because it may represent the initial expression of cardiomyopathies that may not be evident until many years later and that may ultimately be associated with adverse outcomes. The aim of this review is, therefore, to report an update of the literature on TWI in athletes, with a specific focus on the interpretation and management.

Exercise Recommendations for the Athlete With Coronary Artery Disease.

We provide a framework for formulating exercise prescriptions for those with CAD in order to achieve the "optimal" dose of exercise for each individual. Multiple epidemiological studies demonstrate that exercise is inversely associated with atherosclerotic coronary artery disease (CAD), yet the risk of an acute coronary event is transiently elevated during vigorous exercise. In turn, CAD is the most common cause of exercise-related sudden cardiac death (SCD) in older athletes. When prescribing exercise recommendations for athletes with CAD, we should maintain equipoise between the benefits derived from sports participation and the risk of an adverse cardiac event. Athletes are not immune from atherosclerotic CAD, and we should perform risk assessments regardless of physical and athletic prowess. Cardiopulmonary exercise testing may be a useful tool to develop individualized exercise regimens for athletes with CAD.

Exercise related sudden cardiac death (SCD) in the young — Pre-mortal characterization of a Swedish nationwide cohort, showing a decline in SCD among athletes

AimsTo study the frequency, etiology, and premortal abnormalities in exercise-related sudden cardiac death (SCD) in the young in Sweden. MethodsAll subjects with SCD in 10–35-year olds in Sweden during 2000–10, were included (n = 514). Information about each case was retrieved from death certifications, autopsy- and medical records. The number of SCD in athletes was compared to national figures from 1992-99. ResultsExercise-related SCD occurred in 12% (62/514) of the SCD-population, a majority being men (56/62; 90%). Cardiopulmonary resuscitation (CPR) was started in 87% (54/62). In total, 48% (30/62), had a cardiac diagnosis, symptoms, family history and/or ECG-changes, before the fatal event. The most prevalent autopsy diagnosis was sudden arrhythmic death syndrome (15/62; 24%). The frequency of hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC) was significantly higher in exercise-related SCD compared to non-exertional SCD. Exercise-related SCD was more common in athletes (21/29) than in non-athletes (41/485) (P < 0.0001). The total number of SCDs/year in athletes 15–35 years old, are approximately halved in 2000-10 compared to the years 1992–99. ConclusionThe increased risk of exercise-related SCD in HCM and ARVC underlines the importance of early detection and eligibility recommendations. There is a major reduction in deaths among athletes in the 2000s, compared to the previous decade. These results may partly be explained by improved acute preparedness for sudden cardiac arrest (CPR, defibrillation), but as a substantial percentage have preceding risk factors, such as symptoms and ECG-abnormalities, increased cardiac screening and increased general awareness, may also play a role.

Catecholaminergic Polymorphic Ventricular Tachycardia: An Unusual Case of Fright-Induced Prehospital Cardiac Arrest in a Healthy 6-Year-Old Child

Catecholaminergic Polymorphic Ventricular Tachycardia is a rare but often lethal genetic disorder that affects approximately 1 in 10,000 people. It often first manifests as stress or exercise-related syncope or sudden unexplained cardiac death, primarily in the pediatric and young adult population. We present a case of a 6-year-old male who had a sudden unexplained prehospital cardiac arrest after being scared by a domestic animal and who presented in ventricular fibrillation. The patient was subsequently defibrillated with a return of spontaneous circulation. During the course of care, medications with beta-1 and -2 agonist properties were administered, followed by multiple further episodes of polymorphic ventricular tachycardia (PVT)/ventricular fibrillation (VF). Once these medications were discontinued and beta blockers were administered, the patient had no further episodes of PVT/VF and was subsequently discharged from hospital 7 days later, completely neurologically intact. This case suggests the need for caution when considering administering beta agonists in a pediatric cardiac arrest patient with no known history of heart disease who presents in VF or PVT after an incident of extreme stress or strenuous physical activity.

Inherited primary arrhythmia disorders: cardiac channelopathies and sports activity.

Sudden cardiac death (SCD) in an apparently healthy individual is atragedy. It is important to identify the cause of death and to prevent SCD in potentially at-risk family members. Inherited primary arrhythmia disorders are associated with exercise-related SCD. Despite the well-known benefits of exercise, exercise restriction has been ahistorical mainstay of therapy for these conditions. However, since familiarity with inherited arrhythmia conditions has increased and patients are often children and young adults, it is necessary to reassess the treatment guidelines regarding exercise constraints. The aim of this review is to analyze the risk of exercise-induced SCD in patients with inherited cardiac conditions and explore the challenges faced when advising patients about exercise limitations. We searched for publications on cardiac channelopathies in PubMed with the following medical subject headings (MeSH): "long QT syndrome"; "short QT syndrome"; "Brugada syndrome"; and "catecholaminergic polymorphic ventricular tachycardia". The abstracts of these articles were scanned, and articles of relevance, along with pertinent references, were read in full. The analysis was restricted to reports published in English. The findings of this analysis suggest that exercise with low-to-moderate cardiovascular demand may be possible under regular clinical follow-up in inherited primary arrhythmia disorders. Recent data show that patients with inherited primary arrhythmia disorders are at low risk for events once acomprehensive treatment program has been established. Recreational activity is likely safe for these individuals, with personalized management based on individual patient preferences and priorities.

Abstract 21417: Fragmented QRS Complex as a Predictor of Exercise-Related Sudden Cardiac Death

Objective: Our aim was to identify electrocardiographic (ECG) changes related to exercise-induced sudden cardiac death (SCD). Methods and Results: The Finnish Study of Genotype and Phenotype Characteristics of SCD (FinGesture) includes 3,989 consecutive sudden cardiac deaths in northern Finland between 1998 and 2012. Previously recorded ECGs were acquired manually from archives of Oulu University Hospital. A total of 647 SCD had a previously recorded ECG. In 276 of these cases the death was witnessed, and the activity at the time of death could be divided into either rest or physical exercise; in 40 (14%) cases SCD was exercise-related (PE group) and in 236 (86%) cases death took place at rest (R group). A total of 371 (57%) deaths were unwitnessed or the cases did not meet the criteria of either exercise or rest. Fragmented QRS (fQRS) complex in at least 2 consecutive leads within anterior leads (V1-V3) was more common in the exercise-group compared to rest-group (17/40, 43% vs. 51/236, 22%, p=0.005). Pathologic Q wave in anterior leads was somewhat more common in the PE group (9/40, 23% vs. 26/236, 11%; p=0.044). QRS duration, QTc interval or the prevalence of inverted T-waves did not differ significantly between the 2 groups. Conclusions: Fragmented QRS complex in the anterior leads is associated with an increased risk of SCD during physical exercise.

Management of mature athletes with cardiovascular conditions

### Learning objectives Exercise is a potent therapy for the prevention1–4 and rehabilitation5 of cardiovascular disease, including the management of risk factors for atherosclerotic cardiovascular disease.6 It is important to...

Fragmented QRS complex as a predictor of exercise-related sudden cardiac death.

Little is known about the association between electrocardiographic abnormalities and exercise-related sudden cardiac death. Therefore, our aim was to identify possible electrocardiographic findings related to exercise-induced sudden cardiac death. The FinGesture study includes 3,989 consecutive sudden cardiac deaths in northern Finland between 1998 and 2012, out of whom a total of 647 subjects had a previously recorded electrocardiography acquired from the archives of Oulu University Hospital. In 276 of these cases the death was witnessed, and the activity at the time of death was either rest or physical exercise (PE); in 40 (14%) cases sudden cardiac death was exercise-related and in 236 (86%) cases death took place at rest. Fragmented QRS complex in at least two consecutive leads within anterior leads (V1-V3) was more common in the exercise-group compared to rest-group (17 of 40, 43%vs. 51 of 236, 22%, P=0.005). Pathologic Q wave in anterior leads was more common in the PE group (9 of 40, 23%vs. 26 of 236, 11%; P=0.044). Median QRS duration was prolonged in the exercise-group compared to the rest-group (100milliseconds vs. 94milliseconds, P=0.047). QTc interval, the prevalence of inverted T-waves, or other electrocardiographic abnormalities did not differ significantly between the two groups. As a conclusion, fragmented QRS complex in the anterior leads is associated with an increased risk of sudden cardiac death during PE.

Management of young competitive athletes with cardiovascular conditions

### Learning objectives Physical activity has numerous substantial health benefits, including reduction in cardiovascular disease,1 lower incidence of certain cancers,2 ,3 improved healthy ageing4 and all-cause mortality.1 In this regard,...

Tunneled Coronary Artery-A Case Series

Isolated congenital coronary artery anomalies are rare, but well described cause of sudden death. Incidence of this condition is 1–1.5% of general population and only 50% of these cases are symptomatic. The medico legal significance is that it can be associated with exercise related sudden cardiac death in apparently healthy young adults. Tunneled coronary artery is an isolated congenital coronary artery disease in which a portion of a major coronary artery goes intramurally through the myocardium for a variable distance. The present descriptive prospective study was done at department of Forensic Medicine Government Medical College, Thiruvananthapuram. All cases brought for autopsy excluding the other causes of death were studied in detail during a period of one year from July 2009 to August 2010. Out of the 325 cases of sudden death, 120 were due to cardiac diseases and three cases showed features of tunneling of the coronary arteries. These cases were studied in detail and discussed in this case series.

Identifying Coronary Artery Disease in Asymptomatic Middle-Aged Sportsmen: The Additional Value of Pulse Wave Velocity.

BackgroundCardiovascular screening may benefit middle-aged sportsmen, as coronary artery disease (CAD) is the main cause of exercise-related sudden cardiac death. Arterial stiffness, as measured by pulse wave velocity (PWV), may help identify sportsmen with subclinical CAD. We examined the additional value of PWV measurements to traditional CAD risk factors for identifying CAD.MethodsFrom the Measuring Athlete’s Risk of Cardiovascular events (MARC) cohort of asymptomatic, middle-aged sportsmen who underwent low-dose Cardiac CT (CCT) after routine sports medical examination (SME), 193 consecutive sportsmen (aged 55±6.6 years) were included with additional PWV measurements before CCT. Sensitivity, specificity and predictive values of PWV values (>8.3 and >7.5m/s) assessed by Arteriograph were used to identify CAD (coronary artery calcium scoring ≥100 Agatston Units or coronary CT angiography luminal stenosis ≥50%) and to assess the additional diagnostic value of PWV to established cardiovascular risk factors.ResultsForty-seven sportsmen (24%) had CAD on CCT. They were older (58.9 vs. 53.8 years, p<0.001), had more hypertension (17 vs. 4%, p=0.003), higher cholesterol levels (5.7 vs. 5.4mmol/l) p=0.048), and more often were (ever) smokers (55 vs. 34%, p=0.008). Mean PWV was higher in those with CAD (8.9 vs. 8.0 m/s, p=0.017). For PWV >8.3m/s respectively >7.5m/s sensitivity to detect CAD on CT was 43% and 74%, specificity 69% and 45%, positive predictive value 31% and 30%, and negative predictive value 79% and 84%. Adding PWV to traditional risk factor models did not change the area under the curve (from 0.78 (95% CI = 0.709-0.848)) to AUC 0.78 (95% CI 0.710-0.848, p = 0.99)) for prediction of CAD on CCT.ConclusionsLimited additional value was found for PWV on top of established risk factors to identify CAD. PWV might still have a role to identify CAD in middle-aged sportsmen if risk factors such as cholesterol are unknown.

The athletes' ECG and the exercise related sudden cardiac death

Regular physical activity induces structural, electrical and functional cardiac adaptations. The main challenge for the athletes' physician is to distinguish abnormal structural changes of the heart from training-induced adaptations (so-called “athlete's heart”). In athletes with underlying cardiac disease, physical activity may be a trigger, not the cause of exercise-induced tachyarrhythmia's and sudden cardiac death (SCD). To identify athletes with cardiac diseases and increased risk for an SCD, the European society of cardiology (ESC) recommends a pre-participation screening in elite athletes which was adopted by the Swiss society of sports medicine. The screening includes a specific medical history, cardiac auscultation and a resting ECG. Due to the high number of false-positive cases of athletes' ECGs based on traditional criteria, the ESC assessment criteria were adjusted to account for training-related changes of the ECG. The sensitivity and especially the specificity could be improved in the “revised Seattle criteria” in 2014. During the last years main attention has been shifted to the early repolarization pattern: additionally to (endurance-) training there is a clear association with male gender, ethnicity, changes in autonomic nervous system activity and high QRS-voltage criteria