Sports Cardiology Research Articles

Semiautomatic Training Load Determination in Endurance Athletes

Background: Despite endurance athletes recording their training data electronically, researchers in sports cardiology rely on questionnaires to quantify training load. This is due to the complexity of quantifying large numbers of training files. We aimed to develop a semiautomatic postprocessing tool to quantify training load in clinical studies. Methods: Training data were collected from two prospective athlete’s heart studies (Master Athlete’s Heart study and Prospective Athlete Heart study). Using in-house developed software, maximal heart rate (MaxHR) and training load were calculated from heart rate monitored during cumulative training sessions. The MaxHR in the lab was compared with the MaxHR in the field. Lucia training impulse score, based on individually based exercise intensity zones, and Edwards training impulse, based on MaxHR in the field, were compared. A questionnaire was used to determine the number of training sessions and training hours per week. Results: Forty-three athletes recorded their training sessions using a chest-worn heart rate monitor and were selected for this analysis. MaxHR in the lab was significantly lower compared with MaxHR in the field (183 ± 12 bpm vs. 188 ± 13 bpm, p < .01), but correlated strongly (r = .81, p < .01) with acceptable limits of agreement (±15.4 bpm). An excellent correlation was found between Lucia training impulse score and Edwards training impulse (r = .92, p < .0001). The quantified number of training sessions and training hours did not correlate with the number of training sessions (r = .20) and training hours (r = −.12) reported by questionnaires. Conclusion: Semiautomatic measurement of training load is feasible in a wide age group. Standard exercise questionnaires are insufficiently accurate in comparison to objective training load quantification.

Interpretation and management of premature ventricular beats in athletes: An expert opinion document of the Italian Society of Sports Cardiology (SICSPORT)

Premature ventricular beats (PVBs) are recorded in a sizeable proportion of athletes during pre-participation screening, especially if the evaluation includes both resting and exercise ECG. While in the majority of cases no underlying heart disease is present, in others PVBs may be the sign of a condition at risk of sudden cardiac death, including cardiomyopathies, congenital, coronary artery, heart valves and ion channels diseases. In this expert opinion document of the Italian Society of Sports Cardiology, we propose a multiparametric interpretation approach to PVBs in athletes and a stepwise diagnostic algorithm. The clinical work-up should include the assessment of the probable site of origin based on the ECG pattern of the ectopic QRS and of the arrhythmia behavior (including the number of different PVB morphologies, complexity, response to exercise and reproducibility), as well as first-line tests such as echocardiography. Based on this initial evaluation, most athletes can be reassured of the benign nature of PVBs and cleared for competition under periodical follow-up. However, when the clinical suspicion is high, further investigations with non-invasive (e.g. cardiac magnetic resonance, cardiac computed tomography, genetic testing) and, in very selected cases, invasive (e.g. endocardial voltage mapping and endomyocardial biopsy) tests should be carried out to rule out a high-risk condition. Importantly, such advanced tests should be performed in centers with a consolidated experience not only in the technique, but also in evaluation of athletes.

Comparative evaluation of an electrocardiogram workflow model for athletic cardiovascular screening: Primary care network versus sports cardiology interpretation

BackgroundElectrocardiogram (ECG) testing in pre-participation screening (PPS) remains controversial due to its cost, resource dependency, and the potential for inaccurate interpretations. At most centres, ECGs are conducted internally by providers trained in athletic ECG interpretation. Outsourcing ECG requisitions to an athlete's primary care network (PCN) may reduce institutional demands. This study compared PCN-conducted athletic ECG interpretation to expert sports cardiology interpretation. MethodsThis was a retrospective, single-centre chart-review study of all athletes who underwent cardiovascular PPS between 2017 and 2021. All athletes submitted an ECG with their screening package, which was conducted and interpreted within their PCN. All ECGs were reinterpreted by a sports cardiologist using the International Criteria (IC) for electrocardiographic interpretation in athletes. Overall, positive, and negative percent agreement were used to compare PCN-conducted ECG interpretation with IC interpretation. ResultsA total of 740 athletes submitted a screening package with a valid ECG (mean age: 18.5 years, 39.6% female). PCN-conducted ECGs were interpreted by 181 unique physicians. Among 41 (5.5%) PCN-conducted ECGs that were initially interpreted as abnormal, only 5 (0.7%) were classified as abnormal according to the IC. All PCN-conducted ECGs reported as normal were also classified as normal according to the IC. The overall agreement between PCN-conducted and IC ECG interpretation was 95.1% (positive percent agreement: 100%, negative percent agreement: 95.1%). ConclusionsNormal PCN-conducted athletic ECGs are interpreted with high agreement to the IC. Majority of PCN-conducted ECGs interpreted as abnormal are indeed normal as per the IC. These findings suggest that a PPS workflow model that outsources ECG requisitions to a PCN may be a reliable approach to PPS, all while reducing screening-related institutional costs and resource requirements.

Evolving spectrum of arrhythmogenic cardiomyopathy: Implications for Sports Cardiology.

Arrhythmogenic cardiomyopathy (ACM) is a genetic heart muscle disease, structurally characterized by progressive fibro-fatty replacement of the normal myocardium and clinically by ventricular arrhythmias (VAs). Predominantly thanks to the use of cardiac magnetic resonance, we have learnt that the spectrum of the disease encompasses not only the classical right ventricular phenotype, but also biventricular and left dominant variants.Sport activity contributes to the phenotypic expression and progression of ACM and may trigger life-threatening VAs and sudden cardiac death (SCD).We conducted a review of the literature about ACM and its implications in Sport Cardiology and summarized the main findings in this topic.Early identification of affected athletes through preparticipation screening (PPS) is fundamental but, while classical right-ventricular or biventricular phenotypes are usually suspected because of electrocardiogram (ECG) and echocardiographic abnormalities, variants with predominant left ventricular involvement are often characterized by normal ECG and unremarkable echocardiography. Usually the only manifestations of such variants are exercise-induced VAs and for this reason exercise testing may empower the diagnostic yield of the PPS.Patients with ACM are not eligible to competitive sports activity, but low-to-moderate intensity physical activity under medical supervision is possible in most cases.

An overview of the electrocardiographic monitoring devices in sports cardiology: Between present and future.

Athletes represent a mainly healthy population, which however could be considered at risk of major arrhythmic events, especially in case of undiagnosed cardiomyopathies. For this reason, the periodical sports medicine examination and the electrocardiography are essential tools in the cardiovascular screening, even though they do not always succeed in identifying rhythm disturbances, particularly when asymptomatic or rarely symptomatic. Prolonged cardiac monitoring often enables clinicians to stratify the arrhythmic risk and reach the diagnosis. The technological progress of the last decades has produced an always-increasing number of heart rhythm monitoring devices, starting from the 24-hourelectrocardiogram Holtermonitoring and ending with the wide world of wearable devices. In the literature, the extreme utility of this equipment in the patients affected by cardiovascular diseases and in the general population is well established. On the contrary, athletes-based randomized trials or large-scale epidemiological studies targeting the frequency of cardiac symptoms and the use of cardiac monitoring are missing, while an ever-growing number of case series and small observational studies are flourishing in recent years. The present review showcases the available electrocardiographic monitoring options, principally in the medical setting, listing their characteristics, their indications, their supporting evidence, and their general pros and cons. The ultimate goal of this review is guiding physicians through the wide variety of heart rhythm monitoring options in the specific subfield of sports cardiology, when an arrhythmia is suspected in an athlete, to tailor the diagnostic process and favor the best diagnostic accuracy.

Correction to: Social Media and Sports Cardiology: Potential Pitfalls and the Importance of Informed Communication.

HomeCirculationVol. 147, No. 23Correction to: Social Media and Sports Cardiology: Potential Pitfalls and the Importance of Informed Communication Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUBCorrection to: Social Media and Sports Cardiology: Potential Pitfalls and the Importance of Informed Communication Originally published5 Jun 2023https://doi.org/10.1161/CIR.0000000000001156Circulation. 2023;147:e719This article corrects the followingSocial Media and Sports Cardiology: Potential Pitfalls and the Importance of Informed CommunicationIn the article by Kim et al, “Social Media and Sports Cardiology: Potential Pitfalls and the Importance of Informed Communication,” which appeared in the May 9, 2023, issue of the journal (Circulation.2023;147:1419–1421. doi: 10.1161/CIRCULATIONAHA.123.064082), a correction is needed.The date in the following sentence, related to Damar Hamlin, was incorrect and was updated to:“Other recent examples of premature and reckless SCA judgments (ie, rendered “guilty” verdicts as to cause and manner of the SCA) include Christian Eriksen (Union of European Football Associations European Football Championship 2020) in 20012 and now Damar Hamlin of the Buffalo Bills (National Football League) on January 2, 2023.3”The article has been updated and the corrected article is available at https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.123.064082.FootnotesCirculation is available at www.ahajournals.org/journal/circ Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesSocial Media and Sports Cardiology: Potential Pitfalls and the Importance of Informed CommunicationJonathan H. Kim, et al. Circulation. 2023;147:1419-1421 June 6, 2023Vol 147, Issue 23 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIR.0000000000001156PMID: 37276256 Originally publishedJune 5, 2023 PDF download Advertisement

Focus on Cardiac Rehabilitation, Exercise and Sport Cardiology.

Focus on Cardiac Rehabilitation, Exercise and Sport Cardiology.

QUANTITATIVE ANALYSES OF THE ESC GUIDELINES ON SPORTS CARDIOLOGY AND EXERCISE

Objective: Exercise and sports are important components of preventing/delaying the development of cardiovascular disease (CVD) as evidenced by reduced all-cause morbidity and mortality. Because of that, the European Society of Cardiology (ESC) published “2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease” (GL-SCE) summarizing recommendations and supporting evidence to ‘prescribe’ various types of exercise and sports regimens that can be used to prevent, delay, or alleviate CVD. Thus we aimed to assess quantitatively the efficacy of the GL-SCE providing help in the sport- /exercise-related treatment decision-making in specific cardiovascular condition Design and method: An analytic study was conducted on the GL-SCE regarding the Classes of Recommendations (CLASS) and the Levels of Evidence (LEVEL) (n = 159). Then LEVEL areas under CLASS were calculated to form a Certainty Index (CI: -1 to +1). Results: The frequency of CLASS I and CLASS III was relatively high in GL-SCE (52.2%) and GL-CS) (in Clinical Settings: 50.7%). Yet, the most frequent LEVEL was C (41.2%–83.8%), indicating only a relatively low quality of scientific evidence in GL-SCE. The GL-SCE showed a relatively high CI (+0.57), 78.4% Certainty, and 21.6% Uncertainty. Conclusions: The GL-SCE provides substantial help in decision-making through the recommendations (CLASS), but the supporting evidence (LEVEL) in most cases is only lower quality, which is well reflected in the newly developed Certainty Index identifying issues that should be clarified and investigated in future studies.

The role of the arrhythmologist in a sports cardiology centre: the devil is in the detail

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The role of the arrhythmologist in a sports cardiology centre (SCC) is to provide comprehensive care to athletes with cardiac arrhythmias. Objective To determine the proportion of athletes with arrhythmias examined at a SCC. To define the differences in care between an athlete with and without arrhythmia. Methods Retrospective analysis of the registry of all athletes of one SCC. Identification of patients=athletes with arrhythmias, description of key differences in access to arrhythmology subunits. Cohort: Between 1/2020-6/2022, a total of 115 cases of athletes, 100 males and 15 females (13%), aged 26 (+/-11 years), were examined and definitively closed at SCC. Twenty-two athletes (19%) received care for cardiac rhythm disorders. Duration of sports activity was at the borderline of statistical significance in demographic parameters (see Table No. 1), with 15 (+/-11) vs 12 (+/-8) years for athletes with non-arrhythmic diagnoses (p=0.085). Results In the statistical comparison of the groups without and with arrhythmias (Table No. 2), we see a statistically significantly higher proportion of athletes presenting because of symptoms and with pathological findings of the pre-participation screening, with a higher proportion of family history of sudden cardiac death, with a higher proportion of coronary CT use and an extraordinary statistical significance of cardiac MRI use. Conversely, there is no statistically significant difference in diagnosis and impact on sports eligibility. The sports cardiologist must be particularly cautious in the diagnosis and treatment of ventricular extrasystoles, which have a different "diagnostic-eligibility" pathway for athletes. Similarly, they must listen to the medical history more than non-athletes and be willing and able to use various sports monitor records. In invasive methods of diagnosing and treating arrhythmias, it is necessary to understand when arrhythmias occur in real life and try to mimic the diagnostic conditions of this situation (e.g., when inducing clinical arrhythmias that an athlete has in real life during the peak moments of a match or race). Last but not least, the sports cardiologist must communicate the potential changes that may occur by ablative treatment of the arrhythmia (e.g., a decrease in maximal heart rate after AVNRT ablation on the so-called slow pathway, or, e.g. a possible increase in resting heart rate after pulmonary vein isolation with radiofrequency or laser energy). Conclusion Athletes with arrhythmias are different in many aspects, and the role of the arrhythmologist in the sports cardiology team is to be prepared to respect these differences in an effort to provide the best possible care for the athlete.

Exercise-induced cardiovascular remodelling in a large cohort of female, elite athletes: towards sex-specific CMR reference ranges

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Amsterdam Movement Sciences (AMS); Dutch National Olympic Committee & National Sports Federation (NOC*NSF); Heart To Handle. Background Differentiating between exercise-induced cardiac remodelling (EICR) and pathology constitutes a central challenge in sports cardiology. To facilitate this differentiation, reference ranges for cardiovascular magnetic resonance imaging (CMR) are needed. However, female athletes, and especially, female elite athletes with potentially the most outspoken adaptation, are severely underrepresented. Moreover, no large studies including CMR data in female, elite athletes are currently available. Purpose To quantify EICR on CMR in a large cohort of female, elite athletes, compared with currently available reference values of the general female, and female athlete population. Methods We performed a cross-sectional CMR analysis in female elite athletes aged ≥16 years, included in the ELITE cohort. We excluded athletes with known cardiovascular disease. The primary outcome was EICR quantification as BSA indexed RV and LV end-diastolic volume (EDVi), LV wall mass (LVMi), LV remodelling index (LVMi/LVEDVi), and LV/RV ratio (LVEDi/RVEDVi). Second, we compared our parameters with reference ranges (1,2). CMR was performed according to a uniform protocol, and included cine-imaging and delayed hyperenhancement, preferentially on 1.5T. A dedicated core-lab analysed all CMRs in Circle Cardiovascular Imaging. Results We included 102 female elite athletes, 97% caucasian, mean age of 26.3 ±5.0, BSA 1.79 ±0.14 m2, and mean professional athlete years of 10.3 ±5. Main athlete disciplines (≥10 hours/week) were field hockey (15%), rowing (13%), road cycling (12%), and European style football (10%). Female elite athletes had marked EICR as compared with general population reference values, with higher LVEDVi (108 ±13.9 vs 69 ±12 ml/m2, p<0.05), RVEDVi (110 ±15.3 vs 76 ±14 ml/m2, p<0.05), and LVMi (49.9 ±11.2 vs 45 ±7 g/m2, p<0.05) (Figure 1). Compared with current female elite athlete references (n=33), our female elite athlete population demonstrated a markedly lower RVEDVi (118 ±17 vs 110 ±15 ml/m2), and a higher upper-limit (95th percentile) of LVMi (66 vs 72.3 g/m2) with comparable LVEDVi. LV remodelling showed a lower LVM/LVEDV ratio (0.46 ±0.08 vs 0.7 ±0.1 ml) compared to the general population, with balanced dilatation (LVEDV/RVEDV=0.98 ±0.05). In general, we observed EICR as increased cardiac volumes in 67% (n=68), increased cardiac volumes and mass in 21% (n=21) lone increase in cardiac mass in 1% (n=1), with 11% (n=11) demonstrating normal geometry (Figure 2). Conclusion EICR on CMR in female, elite athletes is mainly characterised by isolated increased volumes, with a considerable proportion (11%) demonstrating no EICR. Compared with the general population, female athletes have larger cardiac ventricular volumes and wall mass; compared with available elite athlete reference ranges comparable ventricular volumes, but a larger spread in cardiac wall mass. Our results constitute a first step towards sex-specific CMR reference ranges for female athletes.

Are there gender differences in diagnostic and therapeutic sports cardiology care? Data from one sports cardiology centre

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiovascular care of highly active individuals and competitive athletes has become an important topic in the field of sports medicine. The evolving understanding of exercise-induced cardiovascular remodeling in athletes has led to a more thorough characterization of physiological adaptation versus pathological dysfunction, but this distinction is often challenging because of diagnostic commonalities. The current data reflect sport-specific analyses of predominantly male athletes that may not be readily applicable to the female athletic heart. Another aspect of this care may be the different approach to indication, interpretation, and referral between men and women. Objective To determine whether there is a difference between men and women in access to sports cardiac care. Whether there is a difference between the indicated investigations, therapeutic care and recommendations made. Methods Retrospective analysis of the registry of all athletes of the Sports Cardiology Centre (SCC). Statistical comparison of the cohort of women and men in all parameters studied. Cohort: Between 1/2020-6/2022, a total of 115 cases of athletes, 100 men and 15 women (13%), aged 26 (+/-11 years), were examined and definitively closed in the SCC. Demographics in Table No. 1. Results There were no statistically significant differences in indications, symptoms, examination methodologies, percentage of diagnosis or eligibility for sport from a cardiological perspective. The only statistically significant difference seen was in the higher percentage of women taking regular pharmacological medication (hormonal contraception was not included in this category) - namely 40% of women taking regular medication vs. 60% of women without medication vs. 85% of men without regular medication vs. 15% with regular medication (p=0.019). The differences in parameters across categories are summarized in Table No. 2. Conclusion Except for the total number of men and women screened, we do not see a significant difference in indication, screening, diagnosis and eligibility proposal between genders.

Sports cardiology centre - experience to date, data from the 2020-2022 registry and challenges of the third year of operation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): grant IGA_LF_2022_027. Introduction Sports cardiology is a dynamically developing subspecialty of cardiology. There are four Sports Cardiology Centres in the Czech Republic, which were established under the leadership of the Sports Cardiology Working Group thanks to the Czech Society of Cardiology (CSC) and the Czech Society of Sports Medicine. Objective To describe the experience, data from the registry of the Sports Cardiology Centre of our hospital for the period 1.1.2020-15.8.2022. Functioning and file: A) The patient logs into our way by way of the web interface, where the basic information and previous examinations are given. B) These input data will be incorporated by the center coordinator , ensure communication with the client, other necessary information or examination and after consultation with sports cardiologists, determine a plan of care. C) The organisational aspects of the established procedure are ensured by the nurses. D) After the follow-up examination, the client has a final consultation at the centre, where sport recommendations are always given. Between 1/2020 and 8/15/2022, 133 athletes were consulted at our Sports Cardiology Centre. Of these, 18 athletes are not completed and 115 clients with completed examinations were included in the next cohort, where 100 were male(87%) and 25 were female(13%). All were Caucasian, with a mean age of 26 ± 11 years. The youngest athlete was 15 years old and the oldest was 71 years old. The sports the clients participated in were 66.1% mixed, 27.8% endurance, 4.3% strength and 1.7% skill sports according to the European Society of Cardiology(ESC)2020 sport distribution. The average training load was 10 h/week. The minimum training load was 3h/week and the maximum 25h/week. The average duration of sport activity was 12 years per individual. The most frequent request for consultation was without a medical referral and this was in 41.7%, a physical therapist indicated an examination in 36.5%, a cardiologist in 14.8% and a PL in 6.1%. Reasons for referral were most commonly abnormalities in preparticipation screening /PPS/ 40.9%, symptoms 22.6% and Covid infection 13.9%. A final diagnosis was completed in 89 athletes(77.4%), a suspected diagnosis was made in 8 clients(7%). Eligibility for sport and eligibility with condition was received in 90 individuals(78.3%). Ineligibility was issued in 4 athletes(3.5%). The number of athletes who did not complete the investigation/ did not come in for a result was 21(18.3%). Conclusion The established organisational procedure of consultations allows for the least possible staff load on the hospital and speeds up the process of athlete follow-up. In the pursuit of the development of the field and the achievement of a stable quality of care, our centre is potentially able to meet the requirements of the ESC/ European Association of Preventive Cardiology for a sports cardiology unit in terms of methodological/procedural and personnel parameters.

Family history of cardiovascular disease in athletes: 2 sports medicine clinics, 4 systems of preparticipation screening, 7 years of work. Is it time for a change?

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): IGA-internal grant agency Palacky University,Olomouc. Introduction Searching for a positive family history (FH) of cardiovascular disease (CVD) or sudden cardiac death (SCD) is a standard part of preparticipation screening (PPS) of athletes. This is despite the fact that there is no evidence to support either a mortality or cost-effective benefit of this practice. It is generally accepted that the use of a questionnaire method of family history investigation will expedite and refine the process of obtaining adequate responses required for the PPS. There are a number of PPS systems currently in use around the world, of which four standardized PPS systems are very commonly used (AHA; 5thPPE; IOC = Lausanne Questionnaire; FIFA), each with its own questionnaire that is distinct from the other systems. A positive finding of a family history of CVD/SCD in an athlete during PPS is an accepted indication for (sports) cardiology investigation. However, there is no evidence to define the scope of this examination and validate the mortality or cost-effective benefit of this practice. Purpose 1. To determine the number of athletes with positive FH in the entire cohort using questionnaires from the four PPS systems mentioned above. 2. Evaluate differences in frequency analysis of each questionnaire. 3. To identify question wording issues and to highlight overly "soft" criteria in each PPS system. 4. Propose optimization of FH data collection and follow-up. Methods and file Between 2015 and 6/2022, 14083 patients were screened at 2 centers. There were 13879 athletes with traceable FH (3768 females -27.1%), aged 14 (IQR 5) years. Results 180 athletes (1.3%) had positive FH according to at least one PPS system. The IOC system generated the fewest positive responses, followed by the AHA and FIFA, and the 5thPPE system clearly generated the most positive responses (by 80% compared to IOC). See Table 1. Clearly the "softest" question is the query about any heart disease/heart problems/ in 5thPPE, this alone is responsible for the majority of positive responses above the response levels of the other systems. Conclusion Investigating positive FH CVD/SCD is an established part of the athlete's PPS. There is up to 80% variation when using the 4 globally accepted PPS questionnaires. The lack of evidence for their use, as well as the lack of evidence for other cardiac retrospective investigations, coupled with their complexity and difficulty for patients to understand, is a challenge to research in this field.

What makes athletes with extra training volume at a sports cardiology center different

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Athletes have always recognized the importance of training, but in modern times there has been a dramatic increase in the volume and intensity of training that athletes undergo. This has led to concerns about the potential risks associated with such high levels of training. However, there is also evidence to suggest that athletes who train the hardest may actually be at lower risk of developing cardiovascular problems. Objective To determine the proportion of athletes with arrhythmias screened at a sports cardiology center. To define the differences in care between an athlete with and without an arrhythmia. Methodology Retrospective analysis of the registry of all athletes of the one Sports Cardiology Centre. Statistical comparison of the cohort of athletes with weekly training volume above the 95th percentile versus the rest of the cohort. File: Between 1/2020-6/2022, a total of 115 cases of athletes, 100 males and 15 females (13%), aged 26 (+/-11 years) were examined and definitively closed at CSK. Median 95th percentile group training volume was 18 hours, mean 22 (+/3) hours vs 9 (+/- 3) hours (p<0.001), detailed in Table 1. Results The cohort of athletes in the greater than 95th percentile of weekly training volume sides differed statistically significantly from the rest of the cohort only in the type of sport according to ESC (typically endurance athletes, p=0.021) and the percentage of medication used regularly (50% vs 16.9%, p=0.039). Data summarized in Table 2. Conclusion Apart from the statistically significant greater use of regular medication, there was no difference from the rest of the cohort in workflow and sports cardiology centre outcomes in the cohort of those athletes with the highest training volume. The difference in heart dimensions and volumes on echocardiographic and MRI scans will be the subject of further investigation.

A semi-automatic tool to quantify training load in endurance athletes

Abstract Funding Acknowledgements Type of funding sources: None. Background Despite the widespread use of wearables in endurance sports allowing the measurements needed for quantification of the training load (TL), studies in sports cardiology consistently use less reliable questionnaires to assess TL.[1] This scant use of activity trackers to determine TL can be explained by the large workload for data analysis. Purpose We aimed to develop a semi-automated post-processing tool that allows quantifying TL, based on heart rate (HR) monitoring by commercial wearables, for future use in clinical and epidemiological studies. We compared the calculated maximal HR automatically derived from HR monitoring during endurance training with the maximal HR obtained during incremental exercise testing in the lab. We describe TL calculated by our tool in young and older endurances athletes and compare it with the TL obtained via questionnaires. Methods Training data was collected in two multicenter studies. Master@Heart is a cohort study of endurance trained middle-aged men between 45 and 70 years.[2] Pro@Heart is a prospective study in young endurance athletes between 16 and 23 years.[3] For the purpose of this substudy, 44 athletes (38 ± 17 years) that had recorded all their training sessions using a chest-worn HR monitor for one year were included. Using an in-house developed pipeline in R (R core Team, Vienna, Austria), maximal HR and TL were calculated from training data. The maximal HR measured in the field (Tangent MaxHR) was then compared with the lab-measured maximal HR (Lab MaxHR). Both Lucia training impulse (LuTRIMP) and Edwards TRIMP (eTRIMP) were compared as measures of TL based on HR-based intensity zones. LuTRIMP, based on individually based exercise intensity zones, and eTRIMP based on the Tangent MaxHR. Participants filled in a standard exercise questionnaire to determine the amount of training sessions and training hours per week. Results Lab MaxHR was lower than Tangent MaxHR (183 ± 12.2bpm vs. 188.3 ± 13.0bpm; Figure 1 A), but correlated strongly (r=0.81, P<0.01; Figure 1 B) with low mean bias (-5.3bpm, LOA±15.4; Figure 1 C). LuTRIMP and eTRIMP correlated very strong (r=0.93, P<0.01). Pro@Heart athletes performed a higher TL (1730 ± 644 vs. 1190 ± 314 AU/week, P<0.01; Figure 2 A), duration (12.2 ± 4.6 hours per week vs. 7.9 ± 2.4, P<0.01; Figure 2 B) and trained more frequent (5.9 ± 1.7 vs. 4.0 ± 1.0 sessions per week, P<0.01; Figure 2 C) than Master@Heart athletes. Neither the reported training sessions nor the training hours in the questionnaires correlated with the measured training sessions (r=0.20) and training hours respectively (r=0.12). Conclusion Our tool allows to semi-automatically quantify different TL parameters in endurance athletes from a wide age range. The use of questionnaires to determine TL is inaccurate. TL calculated using eTRIMP is comparable to TL calculated using LuTRIMP. Since eTRIMP does not require an exercise test, it is more easily implementable in large studies.

Non-specific myocardial fibrosis in young competitive athletes, predicted by a powerful machine learning-based model

Abstract Funding Acknowledgements Type of funding sources: None. Background Non-specific myocardial fibrosis (NSMF) is a heterogeneous entity with potentially significant clinical implications. We aimed to create a machine-learning (ML) based model for its prediction, based on thorough baseline investigations in a cohort of young competitive athletes with and without NSMF. Methods We analysed data from 328 young athletes referred to our Sports Cardiology service for a variety of reasons. All athletes underwent an evaluation with ECG, Holter, cardiopulmonary exercise test and cardiac magnetic resonance (CMR). We identified 61 athletes with NSMF (80% male, 72% white, 65% endurance sport) and compared them with a matched group of 75 athletes with no fibrosis (controls). Athletes with NSMF were further divided into Group 1 (n=28) with minimal (‘minor’=insertion point) fibrosis and Group 2 (n=33), (all other patterns, ‘major’) fibrosis. Selected baseline athletes’ characteristics including demographics, ECG findings , exercise intensity and type, arrhythmia, echo and CMR findings were tested to train the model. Finally, we tested various machine learning (ML) algorithms to create a model which classifies the individuals under observance into two distinct classes; Class A which contains the control group plus the athletes with ‘minor’ fibrosis, while the second, Class B which contains the athletes with ‘major’ fibrosis. We created 4 different classifiers; a logistic regression classifier, a random forest classifier, a naive Bayes classifier, and a voting classifier which chooses the class predicted by the majority of the previous three. Results Given that ~75% of athletes belonged to either no fibrosis or Group 1 (class A), and ~25% to Group 2, it can be inferred that a dummy classifier who would always predict class A would achieve an accuracy of 75%. We therefore used such a classifier method, which a-priori predicts class A, as a baseline to which we compared the results of our trained classifiers. We split the dataset, trained the model, and measured its accuracy (and the accuracy of the benchmark a-priori classifier) on the test set for each classifier. Machine learning classifiers had the following accuracy classification results; ȃȃA-priori classifier: 75% [74%, 76] ȃȃNaive Bayes: 83% [81%, 85%] <0.001 ȃȃLogistic Regression: 87% [86%, 88%] <0.001 ȃȃVoting classifier: 89% [88%, 90%] <0.001 ȃȃRandom forest: 90% [89%, 91%] <0.001 Testing the models derived by machine learning, all our models significantly outperformed the benchmark method and the best accuracy was achieved by the random forest classifier with 90% mean accuracy. Conclusions This study showed that ECG findings, demographics and comprehensive baseline assessment can be used to develop a powerful ML-based prediction model of NSMF. Testing ML-derived models, they all significantly outperformed the benchmark method and the best accuracy was achieved by the random forest classifier with 90% mean accuracy.

Exercise and prevalence of cardiovascular disease in older female endurance athletes during 10 years follow-up

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): PhD student Kristoffer Johansen is funded by the Northern Norway Regional Health Authority (grant number HNF1568-21). The Birkebeiner Ageing Study has been funded by the Kavli research center for ageing and dementia and the Norwegian ExtraFoundation. Background Although research suggests that the health benefits of endurance sport practice is larger in female compared to male athletes, women are underrepresented in sports cardiology research. Furthermore, previous studies on endurance sport practice in women have mostly included younger to middle aged athletes. Thus, prospective studies addressing endurance sport practice and health among older female endurance athletes is lacking. Purpose The purpose of this study was to characterise how older recreational female cross-country skiers maintained exercise and cardiovascular health during 10-years follow up. Method Forty-six women aged ≥65 years that completed the 54-km Birkebeiner cross country ski race in Norway in 2009/2010 were included. The Birkebeiner race includes about 1000 uphill altitude meters and is considered one of the world's most challenging ski races. Participants answered a questionnaire addressing exercise habits and health issues at baseline in 2009/10 and at follow-up in 2014 and 2020. Thirty-five (76%) participants attended follow-up in 2014 and 36 (78%) participants attended follow-up in 2020. Descriptive statistics are given as mean ± SD for continuous variables and as percentages for categorical variables. Results Skiers (age 67.5 ± 2.2 years at baseline) reported a cumulative exposure to regular endurance exercise of 26 ± 15 years. The proportion reporting moderate- to vigorous exercise during the past year was 86% at baseline and 61% at follow-up in 2020. One woman died during follow up. During 10-years follow-up the cumulative prevalence of atrial fibrillation (AF) was 15.6%, more than twice as high as for other cardiac diseases (7.1%) and stroke (7.1%). Conclusion Most female athletes sustained a physically active and healthy lifestyle with advancing age. Notably, the prevalence of AF was twice as high as for other cardiac diseases and stroke. Thus, although previous literature indicates that the risk of AF in female athletes is reduced, our findings suggest that additional research is needed to draw more firm conclusions. Future studies aiming to further clarify the female athlete and AF association would greatly benefit from including older athletes that has accumulated several decades of endurance sport practice. In conclusion, further research aiming to close the knowledge gap between female and male athletes are highly warranted.

Cardiac screening: physician-led or a score based approach?

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Research innovation and development trust Beating Hearts Malta. Introduction Sudden cardiac death (SCD) is an important cause of morbidity in young individuals. Cardiac screening may help identify high risk subjects and enable physicians to implement various early preventive strategies. However, geographical limitations and physician related expenses hinder the feasibility of widespread screening. Objective The objective of this study was to compare a physician-led assessment with a score-based approach. Methodology Students attending Form 5 (2017/2018 scholastic year) were invited to undergo cardiac screening. The screening protocol consisted of a questionnaire, ECG and an onsite consultation with a physician (Approach 1). The questionnaire included symptomatology, family history and athletic ability. Subjects were referred based on symptoms or red flags in the family history or ECG. Questions from the validated Sports Cardiology British Columbia (SCBC) questionnaire were also included in the questionnaire.[1] The SCBC score was calculated retrospectively and a score ≥7 would have required physician referral. Those with red flags in the family history or ECG would also have been referred (Approach 2). The referral, diagnostic rates and costs were compared for both approaches. Results 2672 students gave consent to undergo cardiac screening (mean 15.0±0.3 years, 50.4% female, 95.85 Caucasian). Patients who were under follow-up for known heart disease were excluded (n=9). 9 subjects were diagnosed with a condition linked to SCD (n=5 WPW, n=2 coronary anomalies, n=1 HCM, n=1 LQTS). A physician led screening method (Approach 1) led to 109 (4.1%) referrals. The commonest reason for referral was an abnormal ECG (n=99, 3.7%) in isolation or in combination with symptoms/family history (Pie Chart). ECG was far more sensitive (88.9% [95% CI, 50.7% to 99.4%]) compared to symptoms (22.2% [95% CI, 3.9% to 59.8%]). Symptoms and ECG had comparable specificity (99.3% [95% CI, 98.9% to 99.5%] vs 96.5% [95% CI 95.7% 97.2%]). Approach 2 would have led to more referrals (14.3% (n=382), p<0.001)) compared to a physician-led approach. 294 (n=11.0%) had a SCBC questionnaire score of ≥7, most (n=277, 10.4%) did not have other red flags (family history or ECG). The sensitivity of this approach was however comparable to ECG (88.9% [95% CI, 50.7% to 99.4%]). Specificity was also high (89.4% [95% CI, 88.2% to 90.5%]). One individual would have been missed, resulting in a lower diagnostic yield (2.2% vs 8.3%, p=0.005). Having a two-tier approach (SCBC and ECG initially) led to a 49.4% cost reduction. The total cost of the screening program would drop to €70,079.95, equivalent to €26.32/individual screened. The cost per cardiac diagnosis linked to SCD would drop to €7,786.66 per cardiac diagnosis. Conclusion A two-tier approach leads to substantial reductions in cost, with no negative impact on sensitivity and specificity. The impact of score-based questionnaires should be evaluated in larger cohorts.

Diagnostic yield in national team football players

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Malta Football Association. Introduction Sudden cardiac death (SCD) is an important cause of morbidity in competitive athletes. Pre-participation evaluation (PPE) is mandatory for most sporting organisations. The ECG plays a very important diagnostic role and is included in most screening algorithms. PPE for athletes ≥14 years registered with the National Football Association is now mandatory. Study objectives: The objective of this study was to assess the diagnostic yield of PPE in a group of elite Maltese football players competing at national level. Methodology Players selected at national level (years 2020-2022) underwent PPE (history, physical examination, and resting ECG). Senior team players also underwent echocardiography (biannually) as per regulations. Data was tabulated and analyzed in Microsoft Excel. Results 300 athletes (69% male) were selected in this timeframe. 10.6% (n=32) required referral for secondary evaluation, equating to 1 in 11 athletes screened. Referrals were more frequent in male vs female athletes (22.1% vs 10.2%, p=0.005). Most referrals were from the men’s senior’s squad (22.5%), followed by the men’s U17 squad (21.7%) and 20% of the men’s U15 team. The ECG was the commonest reason for referral to a sports cardiologist (n=23, 71.8%). The commonest abnormal ECG patterns included anterior TWI (n=9, 3.0%), inferior/lateral TWI (n=6, 2.0%) and WPW (n=2, 0.7%). 108 (36.0%) had echocardiography as a first line screening modality. This was abnormal in a fifth of those referred (n=7, 21.9%), 4 of these had a normal ECG. 3 (1.0%) athletes were diagnosed with a condition linked to SCD (n=2 WPW, n=1 HCM). Another 5 (1.7%) athletes were diagnosed with a cardiac disorder (n=1 left ventricular outflow tract ectopy, n=1 dilated aortic root, n=1 aortic regurgitation, n=1 atrial septal defect, n=1 mitral regurgitation). Echocardiography doubled the diagnostic yield (1.3% vs 2.7%), with 3 athletes having otherwise a normal history, physical examination and ECG. 1 in 38 athletes (2.7%) were given a cardiac diagnosis, 1 in 100 athletes (1.0%) were labelled with a condition linked to SCD. Conclusion The referral rate is comparable to that reported in international screening programs, higher in males. The ECG was the commonest reason for referral. The overall diagnostic yield equates to 2.7%, while 1.0% were given a diagnosis linked to SCD. The higher diagnostic yield in this population highlights the importance of raising awareness about heart disease and PPE in young athletes.

Electroanatomic mapping in athletes: Why and when. An expert opinion paper from the Italian Society of Sports Cardiology

Three-dimensional electroanatomical mapping (EAM) has the potential to identify the pathological substrate underlying ventricular arrhythmias (VAs) in different clinical settings by detecting myocardial areas with abnormally low voltages, which reflect the presence of different cardiomyopathic substrates. In athletes, the added value of EAM may be to enhance the efficacy of third-level diagnostic tests and cardiac magnetic resonance (CMR) in detecting concealed arrhythmogenic cardiomyopathies. Additional benefits of EAM in the athlete include the potential impact on disease risk stratification and the consequent implications for eligibility to competitive sports. This opinion paper of the Italian Society of Sports Cardiology aims to guide general sports medicine physicians and cardiologists on the clinical decision when to eventually perform an EAM study in the athlete, highlighting strengths and weaknesses for each cardiovascular disease at risk of sudden cardiac death during sport. The importance of early (preclinical) diagnosis to prevent the negative effects of exercise on phenotypic expression, disease progression, and worsening of the arrhythmogenic substrate is also addressed.