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PREPARTICIPATION CARDIOLOGICAL
SCREENING OF ATHLETES
ASTERIOS DELIGIANNIS
CARDIOLOGIST
PROFESSOR OF SPORTS MEDICINE
ARISTOTLE UNIVERSITY OF THESSALONIKI GREECE
SPORTS MEDICINE LABORATORY
DIRECTOR PROF A DELIGIANNIS
QUESTION 1
The rates of sudden cardiac death by
cardiovascular diseases were 21 in
100000 athletes per year compared with
07 in 100000 non athletes per year
Plaque rupture coronary occlusion ischaemia and in
turn ventricular fibrillation may also occur during
exercise in young competitive athletes but especially in
middle aged or elderly runners or bikers who are not
aware of existing plaques in their coronary arteries
Exercise markedly increases blood flow velocity and
pressure and induces inflammation with expression of
cytokines such as interleukin-6 among others Indeed in
marathon runners excessive levels of these cytokines
comparable to those found in sepsis have been reported
European Heart Journal (2010) 31 1156
RISKS OF EXERCISE
QUESTION 2
WHAT ARE THE COMMON CAUSES OF SCD
IN ATHLETES
Figure Distribution of cardiovascular causes of sudden death in 1435 young competitive athletes
Maron B J et al Circulation 20071151643-1655
Copyright copy American Heart Association
Causes of sudden deaths in athletes (aged lt35 yrs)
in the Veneto region of Italy from 1979 to 1996
Arrhythmogenic RV cardiomyopathy 11 (224)
Atherosclerotic coronary artery
disease 9 (185)
Anomalous origin of coronary artery 6 (122)
Conduction system pathology 4 (82)
Mitral valve prolapse 5 (102)
HCM 1 (2)
Myocarditis 3 (61)
Myocardial bridge 2 (4)
Pulmonary thrombo-embolism 1 (2)
Dissecting aortic aneurysm 1 (2)
Dilated cardiomyopathy 1 (2)
Other 5 (102)
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 2006 13 687-694
Furlanello F et al Eur J Cardiovasc Prev Rehabil 2007 14 487-494
BAD LUCK
QUESTION 3
Organization of
First Aids in
Arena
Identification of
Target Groups
(High Risk Family)
Pre-
participation
Health
Screening
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
QUESTION 1
The rates of sudden cardiac death by
cardiovascular diseases were 21 in
100000 athletes per year compared with
07 in 100000 non athletes per year
Plaque rupture coronary occlusion ischaemia and in
turn ventricular fibrillation may also occur during
exercise in young competitive athletes but especially in
middle aged or elderly runners or bikers who are not
aware of existing plaques in their coronary arteries
Exercise markedly increases blood flow velocity and
pressure and induces inflammation with expression of
cytokines such as interleukin-6 among others Indeed in
marathon runners excessive levels of these cytokines
comparable to those found in sepsis have been reported
European Heart Journal (2010) 31 1156
RISKS OF EXERCISE
QUESTION 2
WHAT ARE THE COMMON CAUSES OF SCD
IN ATHLETES
Figure Distribution of cardiovascular causes of sudden death in 1435 young competitive athletes
Maron B J et al Circulation 20071151643-1655
Copyright copy American Heart Association
Causes of sudden deaths in athletes (aged lt35 yrs)
in the Veneto region of Italy from 1979 to 1996
Arrhythmogenic RV cardiomyopathy 11 (224)
Atherosclerotic coronary artery
disease 9 (185)
Anomalous origin of coronary artery 6 (122)
Conduction system pathology 4 (82)
Mitral valve prolapse 5 (102)
HCM 1 (2)
Myocarditis 3 (61)
Myocardial bridge 2 (4)
Pulmonary thrombo-embolism 1 (2)
Dissecting aortic aneurysm 1 (2)
Dilated cardiomyopathy 1 (2)
Other 5 (102)
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 2006 13 687-694
Furlanello F et al Eur J Cardiovasc Prev Rehabil 2007 14 487-494
BAD LUCK
QUESTION 3
Organization of
First Aids in
Arena
Identification of
Target Groups
(High Risk Family)
Pre-
participation
Health
Screening
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
The rates of sudden cardiac death by
cardiovascular diseases were 21 in
100000 athletes per year compared with
07 in 100000 non athletes per year
Plaque rupture coronary occlusion ischaemia and in
turn ventricular fibrillation may also occur during
exercise in young competitive athletes but especially in
middle aged or elderly runners or bikers who are not
aware of existing plaques in their coronary arteries
Exercise markedly increases blood flow velocity and
pressure and induces inflammation with expression of
cytokines such as interleukin-6 among others Indeed in
marathon runners excessive levels of these cytokines
comparable to those found in sepsis have been reported
European Heart Journal (2010) 31 1156
RISKS OF EXERCISE
QUESTION 2
WHAT ARE THE COMMON CAUSES OF SCD
IN ATHLETES
Figure Distribution of cardiovascular causes of sudden death in 1435 young competitive athletes
Maron B J et al Circulation 20071151643-1655
Copyright copy American Heart Association
Causes of sudden deaths in athletes (aged lt35 yrs)
in the Veneto region of Italy from 1979 to 1996
Arrhythmogenic RV cardiomyopathy 11 (224)
Atherosclerotic coronary artery
disease 9 (185)
Anomalous origin of coronary artery 6 (122)
Conduction system pathology 4 (82)
Mitral valve prolapse 5 (102)
HCM 1 (2)
Myocarditis 3 (61)
Myocardial bridge 2 (4)
Pulmonary thrombo-embolism 1 (2)
Dissecting aortic aneurysm 1 (2)
Dilated cardiomyopathy 1 (2)
Other 5 (102)
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 2006 13 687-694
Furlanello F et al Eur J Cardiovasc Prev Rehabil 2007 14 487-494
BAD LUCK
QUESTION 3
Organization of
First Aids in
Arena
Identification of
Target Groups
(High Risk Family)
Pre-
participation
Health
Screening
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Plaque rupture coronary occlusion ischaemia and in
turn ventricular fibrillation may also occur during
exercise in young competitive athletes but especially in
middle aged or elderly runners or bikers who are not
aware of existing plaques in their coronary arteries
Exercise markedly increases blood flow velocity and
pressure and induces inflammation with expression of
cytokines such as interleukin-6 among others Indeed in
marathon runners excessive levels of these cytokines
comparable to those found in sepsis have been reported
European Heart Journal (2010) 31 1156
RISKS OF EXERCISE
QUESTION 2
WHAT ARE THE COMMON CAUSES OF SCD
IN ATHLETES
Figure Distribution of cardiovascular causes of sudden death in 1435 young competitive athletes
Maron B J et al Circulation 20071151643-1655
Copyright copy American Heart Association
Causes of sudden deaths in athletes (aged lt35 yrs)
in the Veneto region of Italy from 1979 to 1996
Arrhythmogenic RV cardiomyopathy 11 (224)
Atherosclerotic coronary artery
disease 9 (185)
Anomalous origin of coronary artery 6 (122)
Conduction system pathology 4 (82)
Mitral valve prolapse 5 (102)
HCM 1 (2)
Myocarditis 3 (61)
Myocardial bridge 2 (4)
Pulmonary thrombo-embolism 1 (2)
Dissecting aortic aneurysm 1 (2)
Dilated cardiomyopathy 1 (2)
Other 5 (102)
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 2006 13 687-694
Furlanello F et al Eur J Cardiovasc Prev Rehabil 2007 14 487-494
BAD LUCK
QUESTION 3
Organization of
First Aids in
Arena
Identification of
Target Groups
(High Risk Family)
Pre-
participation
Health
Screening
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
QUESTION 2
WHAT ARE THE COMMON CAUSES OF SCD
IN ATHLETES
Figure Distribution of cardiovascular causes of sudden death in 1435 young competitive athletes
Maron B J et al Circulation 20071151643-1655
Copyright copy American Heart Association
Causes of sudden deaths in athletes (aged lt35 yrs)
in the Veneto region of Italy from 1979 to 1996
Arrhythmogenic RV cardiomyopathy 11 (224)
Atherosclerotic coronary artery
disease 9 (185)
Anomalous origin of coronary artery 6 (122)
Conduction system pathology 4 (82)
Mitral valve prolapse 5 (102)
HCM 1 (2)
Myocarditis 3 (61)
Myocardial bridge 2 (4)
Pulmonary thrombo-embolism 1 (2)
Dissecting aortic aneurysm 1 (2)
Dilated cardiomyopathy 1 (2)
Other 5 (102)
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 2006 13 687-694
Furlanello F et al Eur J Cardiovasc Prev Rehabil 2007 14 487-494
BAD LUCK
QUESTION 3
Organization of
First Aids in
Arena
Identification of
Target Groups
(High Risk Family)
Pre-
participation
Health
Screening
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Figure Distribution of cardiovascular causes of sudden death in 1435 young competitive athletes
Maron B J et al Circulation 20071151643-1655
Copyright copy American Heart Association
Causes of sudden deaths in athletes (aged lt35 yrs)
in the Veneto region of Italy from 1979 to 1996
Arrhythmogenic RV cardiomyopathy 11 (224)
Atherosclerotic coronary artery
disease 9 (185)
Anomalous origin of coronary artery 6 (122)
Conduction system pathology 4 (82)
Mitral valve prolapse 5 (102)
HCM 1 (2)
Myocarditis 3 (61)
Myocardial bridge 2 (4)
Pulmonary thrombo-embolism 1 (2)
Dissecting aortic aneurysm 1 (2)
Dilated cardiomyopathy 1 (2)
Other 5 (102)
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 2006 13 687-694
Furlanello F et al Eur J Cardiovasc Prev Rehabil 2007 14 487-494
BAD LUCK
QUESTION 3
Organization of
First Aids in
Arena
Identification of
Target Groups
(High Risk Family)
Pre-
participation
Health
Screening
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Causes of sudden deaths in athletes (aged lt35 yrs)
in the Veneto region of Italy from 1979 to 1996
Arrhythmogenic RV cardiomyopathy 11 (224)
Atherosclerotic coronary artery
disease 9 (185)
Anomalous origin of coronary artery 6 (122)
Conduction system pathology 4 (82)
Mitral valve prolapse 5 (102)
HCM 1 (2)
Myocarditis 3 (61)
Myocardial bridge 2 (4)
Pulmonary thrombo-embolism 1 (2)
Dissecting aortic aneurysm 1 (2)
Dilated cardiomyopathy 1 (2)
Other 5 (102)
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 2006 13 687-694
Furlanello F et al Eur J Cardiovasc Prev Rehabil 2007 14 487-494
BAD LUCK
QUESTION 3
Organization of
First Aids in
Arena
Identification of
Target Groups
(High Risk Family)
Pre-
participation
Health
Screening
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 2006 13 687-694
Furlanello F et al Eur J Cardiovasc Prev Rehabil 2007 14 487-494
BAD LUCK
QUESTION 3
Organization of
First Aids in
Arena
Identification of
Target Groups
(High Risk Family)
Pre-
participation
Health
Screening
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
BAD LUCK
QUESTION 3
Organization of
First Aids in
Arena
Identification of
Target Groups
(High Risk Family)
Pre-
participation
Health
Screening
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
QUESTION 3
Organization of
First Aids in
Arena
Identification of
Target Groups
(High Risk Family)
Pre-
participation
Health
Screening
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Organization of
First Aids in
Arena
Identification of
Target Groups
(High Risk Family)
Pre-
participation
Health
Screening
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
IS PRE-PARTICIPATION SCREENING OF
ATHLETES NECESSARY
QUESTION 4
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Prevention of SCD in athletes The Needle in a Haystack
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Evidence-based medicine does not
support use of cardiovascular
preparticipation screening in the
USAThe heterogeneity of the US
population the lack of highly skilled
screening practitioners and the low
prevalence of cardiovascular
conditions lead to a high frequency of
false-positive results
Eur J Cardiovasc Prev Rehabil 2010 17607
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Corrado D et al EJCPR 2010
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Maron B et al Am J Cardiol 2009 104 276-280
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
INTERRUPTION FREQUENCY OF SPORTS
BECAUSE OF HEALTH DISORDERS
bull 25 (125408 athletes)
Zeppilli et al 1990
bull 18 (33735 athletes)
Corrado et al 1998
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
CARDIOVASCULAR PRE-PARTICIPATION
SCREENING OF 22205 ATHLETES
A NORTHERN GREECE 17 YEARS EXPERIENCE
ARISTOTLE UNIVERSITY OF THESSALONIKI
DEPARTMENT OF PHYSICAL EDUCATION amp SPORTS SCIENCE
LABORATORY OF SPORTS MEDICINE
DIRECTOR PROFESSOR A DELIGIANNIS
Deligiannis et al Eur J Cardiovasc Prev Rehabil
submitted for publication
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
SPORTS ACTIVITY DISQUALIFICATION
DISQUALIFIED ATHLETES FROM ANY COMPETITIVE
SPORT ACTIVITY
1
NO SUDDEN CARDIAC DEATH CASES
DURING 17 YEARS
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
ARE THERE COMMON
RECOMMENDATIONS FOR THE PRE-
PARTICIPATION SCREENING OF
ATHLETES
QUESTION 5
Europe vs USA
Who Wins
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Circulation 2007 116 2610-15
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
European Heart Journal (2005) 26516-524
ESC STUDY GROUP OF SPORTS CARDIOLOGY
RECOMMENDATIONS FOR PREPARTICIPATION
SCREENING OF YOUNG ATHLETES
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
IS ECG USEFUL
QUESTION 6
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Pelliccia A et al Eur Heart J 2007 28 2006-2010
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Pelliccia A et al Circulation 2000
THE VALUE OF ECG IN PREPARTICIPATION
SCREENING
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
ELECTROCARDIOGRAPHIC FINDINGS
OF 22205 GREEK ATHLETES
543
457
NORMAL
ABNORMAL ECG PATTERNS
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
COMMON ECG FINDINGS
168
132121
09
0
4
8
12
16
20
RBBB
Sinus Bradycardia
1st degree AV-Block
Inverted T-Waves in precordial leads
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Pelliccia et al N Engl J Med 2008 3582
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Pelliccia et al N Engl J Med 2008 3582
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
bull Structural cardiac adaptations
bull Lower intrinsic heart rate
bull Increased parasympathetic tone
bull Decreased sympathetic tone
bull Non-homogenous repolarisation of ventricles
bull Electrolytic disturbances
bull Doping
FACTORS FOR ECG ALTERATIONS IN ATHLETES
Deligiannis A et al Eur J Cardiovasc Prev Rehabil 200613687
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Corrado D et al Eur Heart J 201031243-259
Flow diagram illustrating screening work-up according to the
proposed criteria for ECG interpretation in trained athletes
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Fuller C Med Sci Sports Exerc 2000
Cost of Preparticipation Medical
Screening
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
The purpose of this study was to determine if pre-
participation screening of athletes with a strategy including
resting and exercise electrocardiography (ECG) reduces
their risk for sudden deathAn increasing number of
countries mandate pre-participation ECG screening of
athletes for the prevention of sudden death helliphellip The
respective averaged yearly incidence during the decade
before and the decade after the 1997 legislation was 254
and 266 events per 100000 person years respectively (p =
088)The incidence of sudden death of athletes in our study
is within the range reported by others However mandatory
ECG screening of athletes had no apparent effect on their
risk for cardiac arrest
Steinvil A Chundadze T Zeltser D Rogowski O Halkin A Galily YViskin
S Mandatory electrocardiographic screening of athletes to reduce their
risk for sudden death proven fact or wishful thinking [Journal Article]
J Am Coll Cardiol 2011 Mar 15 57(11)1291-6
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
IS ECHO NECESSARY
QUESTION 7
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
ITALIAN NATIONAL PREPARTICIPATION
SCREENING PROGRAMME
Pelliccia A et al Eur Heart J 2006
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Fuller C Med Sci Sports Exerc 2000
COST EFFECTIVENESS OF ECHO
IN PRE-PARTICIPATION SCREENING
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Additional testing as echocardiography
requires enormous financial support and raises
a number of criticisms since it is considered to
have limited diagnostic accuracy and efficiency
in many cardiac disorders and also they are
time-consuming
Maron BJ et al Circulation 2007 1151643-55
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
WHICH IS THE ROLE OF THE
CARDIOLOGISTS
QUESTION 8
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
OrsquoConnor F et al Clin J Sport Med 2005 15 177-179
ROLE OF CARDIOLOGIST
IN PREPARTICIPATION HEALTH SCREENING
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
IS THERE A SCREENING PROTOCOL FOR
ATHLETES WITH CARDIOVASCULAR
DISEASES
QUESTION 9
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
HOCM
Prevalence of the disease is 02 in the general population
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Maron B and Pelliccia A Circulation 20061141633-1644
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
ECG
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
12-Lead ECG
bull The majority (75ndash95) of HCM patients
show abnormal ECGs
bull ECG abnormalities usually precede the
development of LV hypertrophy
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
22 years old male
soccer player
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
T-wave inversion in young and apparently healthy
athletes may represent the initial phenotypic expression
of an underlying cardiomyopathy prior to the
development of morphological changes detectable on
cardiac imaging Thus failure to detect structural
abnormalities on imaging does not exclude underlying
heart muscle disease as this may only become evident
over time but may nonetheless be associated with risk
of sudden cardiac death
T-WAVE INVERSION
Corrado D et al Eur Heart J 201031243-259
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
B Maron and P Spirito 1996
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Lauschke J Maisch B Clin Res Cardiol 2009 98 80-88
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Nojiri A et al J Cardiol 2011 in press
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Genetic analysis
Genetic analysis has the potential to
provide a definitive diagnosis should
any one of the most common mutant
genes be identified
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Lesion Evaluation Risk stratification Recommendations Follow-up
Athletes with definite
diagnosis of HCM
History PE ECG Echo
ET Holter
No SD in the relatives no
symptoms only mild LVH
normal BP response to
exercise no complex
ventricular arrhythmias
No competitive sports with
possible exception of low
dynamic low static sports
(IA) in low-risk patients
Yearly
Athletes genotype-
positive phenotype-
negative
History PE ECG Echo No symptoms no LVH no
ventricular arrhythmias
Only recreational non-
competitive sports activities
Yearly
Recommendation for sport participation in athletes with HCM
Sports Cardiology Study Group of ESC 2006
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Atypical origin of the left coronary
artery from the right aortic sinus
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
A 15-year-old male Italian soccer player with a history of exertional syncope one year before death who died suddenly while running during the second half of a game
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
35 years old male
soccer player
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
REPORTS OF WRONG SINUS CORONARY ARTERY ANOMALIES
IN PERSONS AGED le35 Years
J Am Coll Cardiol 2000 35(6)1493-501
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Copyright copy2000 American College of Cardiology Foundation Restrictions may apply
Basso C et al J Am Coll Cardiol 2000351493-1501
Flow-chart showing clinical data available and findings in the present study group of
athletes who died of wrong aortic sinus coronary artery anomalies
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Myerburg RJ Vetter VL Circulation 2007 116 2616-26
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
23 years old male elite cyclist
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
22 years old male rowing elite athlete
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Only profound sinus bradycardia andor marked sinus
arrhythmia (heart rate less than 30 bpm andor
pauses ge3 s during wake hours) need to be
distinguished from sinus node disease Sino-atrial
node dysfunction can be reasonably excluded by
demonstrating that (i) symptoms such as dizziness or
syncope are absent (ii) heart rate normalizes during
exercise sympathetic manoeuvres or drugs with
preservation of maximal heart rate and (iii)
bradycardia reverses with training reduction or
discontinuation
Pelliccia et alEur Heart J 2005 261422-45
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
18 years old male soccer player
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
In athletes with Type II second-degree
(Mobitz Type II) and third-degree AV block a
careful diagnostic evaluation is mandatory
and pacemaker implantation may be
indicated
Pelliccia et alEur Heart J 2005 261422-45
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
17 years old male
basketball player
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Only when cardiovascular abnormalities can effectively be
excluded when there are no frequent VPBs (lt200024 h)
and no exercise-induced increase of VPB or VBP related
symptoms (without or with treatment) all competitive and
leisure-time sports activity are allowed
RECOMMENDATIONS
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
17 years old male swimmer
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Athletes with a diagnosis of ventricular pre-
excitation should be referred to a specialist
for evaluation by electrophysiological study
(either transesophageal or intracardiac) for
the inducibility of AV re-entrant tachycardia
and refractoriness of the accessory pathway
ASYMPTOMATIC PRE-EXCITATION
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 475
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Eur Heart J 2005 261422-45
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
32 years old male
soccer player
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Competitive and even
moderate leisure-time sports
are formally contraindicated
CATECHOLAMINERGIC POLYMPORPHIC
VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
18 years old male soccer player
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Evaluation should include imaging techniques like
echocardiography (to rule out dilated hypertrophic and
right ventricular cardiomyopathy (ARVC) pulmonary
hypertension or valve disease) nuclear scintigraphy and
coronary angiography (to rule out coronary abnormalities
[18] or premature atherosclerosis) and cardiac magnetic
resonance imaging (to rule out ARVC)
NONSUSTAINED VENTRICULAR TACHYCARDIA
Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 2006 13 676
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Eur Heart J 2005 261422-45
MVP SYNDROME
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
BLOOD PRESSURE IN YOUNG ATHLETES
ltltWHITE COATgtgt PRESSURE 44
TRUE PRESSURE 05
Kouidi et al Am J Hypertens 1999
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
Bethesda Conference 36 and the European Society
of Cardiology Consensus Recommendations Revisited
A PellicciaD ZipesB Maron JACC 2008 521990
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
QUESTION 10
Are there recommendations for the preparticipation screening of aged athletes
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
QUESTION 11
Is it reasonably safe to recommend that an athlete with a specific cardiovascular abnormality be eligible for a particular
competitive sport
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