Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death: Position paper from the EHRA and the EACPR, branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE
Introduction 140 Incidence of sudden cardiac death in athletes 140 Causes of sudden cardiac death in athletes 141 Hypertrophic cardiomyopathy 141 Arrhythmogenic right ventricular cardiomyopathy 144 Coronary congenital abnormalities 144 Ventricular pre-excitation 145 Left ventricle non-compaction 146 Dilated cardiomyopathy 147 Valvulopathies 147 Inherited primary arrhythmia syndromes 148 Long QT syndrome 148 Short QT syndrome 148 Catecholaminergic polymorphic ventricular tachycardia 149 Brugada syndrome 150 Acquired cardiac abnormalities 150 Coronary artery disease 150 Chagas disease 151 Myocarditis 152 Exercise as a promoter of cardiac injury 152 Role of screening techniques 152 Role of electrocardiogram 152 Role of ECG exercise test 154 Role of ambulatory ECG monitoring 154 Role of imaging modalities in screening 155 Echocardiography 155 Cardiac magnetic resonance imaging 155 Computed Tomography […] coronary angiography and coronary artery calcium scoring 155 Existing screening programmes, rationale, and limitations 156 Evidence supporting preparticipation evaluation programmes: impact on cardiovascular mortality 156 Cost-effectiveness considerations 157 Consensus statements 158 Aim and nature of the preparticipation evaluation 159 Protocol of the preparticipation evaluation 159 Implementation of the preparticipation evaluation 159 Future directions 159 References 159 acute myocardial infarction arrhythmogenic right ventricular cardiomyopathy Brugada syndrome coronary artery calcium score coronary artery disease Chagas heart disease cardiac magnetic resonance catecholaminergic polymorphic ventricular tachycardia computed tomography coronary angiography cardiovascular dilated cardiomyopathy European Association for Cardiovascular Prevention and Rehabilitation hypertrophic cardiomyopathy late gadolinium enhancement long QT syndrome left/right ventricle left ventricle hypertrophy non-sustained ventricular tachycardia preparticipation evaluation premature ventricular contractions sudden cardiac arrest/death transthoracic echocardiography ventricular fibrillation ventricular tachycardia Sudden cardiac death (SCD) associated with athletic activity is a rare but devastating event. Victims are usually young and apparently healthy, and while many of these deaths remain unexplained, a substantial number of victims harbour an underlying and potentially detectable cardiovascular (CV) disease.1–4 The vast majority of these events are due to malignant tachyarrhythmias, usually ventricular fibrillation (VF) or ventricular tachycardia (VT) degenerating into ventricular fibrillation (VF), occurring in individuals with arrhythmogenic disorders (e.g. hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, channelopathies). Intensive exercise training and competitive sport participation is a trigger that may favour insurgence of ominous ventricular tachyarrhythmias in predisposed individuals.5 Consequently, there is a great interest in early identification of at-risk individuals for whom appropriate treatment, followed or not by physical activity adjustment, may be implemented to minimize the risk of SCD. However, the role of pre-participation evaluation (PPE) in athletes as a feasible and efficient strategy to identify individuals at risk has remained controversial. There are several points that have been debated in the recent years, including the actual incidence of acute cardiac events in the athlete's population, the diagnostic capability, as well as the specificity and sensitivity of the testing commonly in use to identify the cardiac conditions at-risk (particularly, but not only,6 12-lead ECG), the impact of the screening protocols on the clinical outcome, and finally the cost/efficacy considerations. The target of this document is ‘athletic participants’, here defined as individuals of any age, either amateur or professional, who are engaged in regular exercise training, independent of the competitive status. We acknowledge that not uncommonly athletic participants, regardless of the level of achievement, have the inclination to exert physically up to their limits to improve performance. The purpose of the present position paper promoted by EHRA and EACPR and endorsed by APHRS, HRS, and SOLAECE, is to review the scientific evidence regarding the appropriate diagnostic methods to identify the cardiac conditions at risk in the athletic population, discuss the role of the different tests in the context of PPE and, finally, offer the consensus opinions relative to the most efficient pre-participation screening to improve safe sport participation, according to the current scientific evidence and—if necessary—to update the last recommendations on this topic.7,8 Notably, consequences of PPE such as the most appropriate medical treatment for a certain condition or criteria to be used for disqualification from intensive exercise are discussed elsewhere.7,9–12 Our interest for safe sport participation is dictated by the awareness that exercise and sport activities are already a component of the lifestyle in a large subset of our societies, and are recommended by the current guidelines for maintaining CV health and preventing disease.13 Sports-related SCD is usually defined as sudden and unexpected death occurring during, or shortly after, exercise (with varying time intervals up to 24 h used by different investigators), if witnessed by a bystander and/or in an who to be The incidence of SCD in athletes is to the of to of by The in the of the incidence of SCD in of the many athletes and the large is the in these in an with and of not to be sudden but of sudden cardiac are in the of the and has an impact on the incidence of is to the from a health sudden deaths of athletes and be an to of athletes the of and The most from on of and on regular medical evaluation in of in a in and in the that there is a incidence of in athletes at in not these and a SCD in is not in the of the as a trigger of ventricular and in predisposed The incidence of SCD is in competitive and The incidence is with in in the of are not well The incidence with age, in to and not a of and the from and athletes in the to with athletes and to have a the for these are not be to up of The of on or have been of including of the of death in to and of the exercise level of the this be with a evaluation by and We review the of the most and cardiovascular conditions in SCD. be that the most conditions are on such as and of the of these conditions are in of of SCD and their relative Hypertrophic cardiomyopathy is defined by left ventricular hypertrophy that is not by recent guidelines not a or this in for of young and is of the most conditions in young The of has been at in and evaluation that most individuals who have not uncommonly with an electrocardiogram but imaging diagnostic the of is in the of may remain a long of their may heart and SCD be the disease in clinical risk a sudden death risk be Exercise and sport in most from the is the most of SCD in young individuals engaged in competitive exercise individuals with to an of left ventricle for and ventricular of imaging testing echocardiography or magnetic resonance an with in in or from the is athlete's heart from may of the is in the of the criteria in rare in and of with left in in Left ventricle and (with on are in athletes is in supporting an athlete's heart in athletes with a hypertrophy in the of of in of hypertrophy of in the or and to hypertrophy Cardiac magnetic resonance imaging imaging and in the and and is for is to or with late gadolinium enhancement of myocardial gadolinium in a is in in the of ECG are in to of and may be present in of the of imaging of ECG have been in with but be as the of the However, certain abnormalities (e.g. in left usually the and most disease in such may be in up to of and of athletes in the of diagnostic imaging of such ECG abnormalities evaluation of the the of athletic training, and in the testing to the of exercise and of arrhythmia 24 h ECG), while imaging tests may the in athletes a of testing has been for a of in athletes with However, of an is and the 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