ESC: Cardiac evaluation, follow-up critical in athletic participants with CVD
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A new European Society of Cardiology guideline on sports cardiology and exercise in patients with CVD emphases the importance of regular exercise and sports participation for the general population.
The general population also includes patients with CAD, especially after proper cardiac evaluation and follow-up to potentially prevent adverse events.
“The reason for writing the guidelines for sports cardiology is to fill the gap in the knowledge of the cardiologist regarding the modality to evaluate the patient with a broad spectrum of cardiovascular conditions, what kind of testing is appropriate in a single disease how to read the results and eventually how to advise the type of sport and modality to participate in,” Antonio Pelliccia, MD, chief of cardiology at the Institute of Sports Medicine and Science in Rome and chairperson of the guideline task force, said during the presentation of the guideline at the ESC Congress.
One topic addressed in the guideline is exercise and sports in healthy individuals, who should perform at least 150 minutes of moderate intensity exercise per week or 75 minutes of vigorous intensity aerobic exercise per week or a combination of both. This can be gradually increased to 300 minutes of moderate exercise per week or 150 minutes of vigorous intensity aerobic intensity per week to obtain additional benefits. Healthy patients should be regularly assessed and counseled to promote adherence.
Patients with obesity and hypertension are recommended to participate in resistance training three or more times per week with moderate or vigorous aerobic exercise 5 to 7 days per week to reduce CVD risk. High-intensity exercise is not recommended for patients with uncontrolled hypertension but can be considered once BP has been controlled.
Moderate-intensity aerobic exercise for at least 150 minutes per week is recommended for patients 65 years and older who are fit and without health conditions that limit mobility. Strength training at least 2 days per week is recommended to improve balance and coordination.
“Exercise is important and should be performed in the global population, whether they are healthy, do have risk factors and even in the elderly up to end of life,” Martin Halle, MD, professor in the department of prevention and sports medicine at the European Association of Preventive Cardiology-accredited Center for Sports Cardiology at the Technical University of Munich and member of the task force, said during the presentation.
Asymptomatic patients who are diagnosed with CAD at screening or for those at risk for CAD can participate in all types of exercise based on individual assessment, the authors wrote.
A class IIa recommendation was given for participation in competitive or leisure sports in patients with CAD who are at low risk for exercise-induced events. Patients with CAD and a high risk for exercise-induced adverse events may better participate in leisure-time exercise, although they should not partake in competitive sports, according to the guideline.
“In patients with CAD, we are not talking anymore about only rehabilitation or just leisure-time activity, but we are also opening the border for entering in competitive sports in selected patients when you have evidence that there is a low risk for disease and for adverse events during exercise,” Pelliccia said during the presentation.
Stable patients with HF with reduced or mid-range ejection fraction may participate in low-to-moderate intensity recreational sporting activity and structured exercise programs. Low-risk patients may be considered even for high-intensity interval training if they want to return to participate in mixed endurance and high-intensity aerobic sports.
Preliminary optimization of HF risk factor control and therapy is recommended for patients with HF who wish to participate in sports. Patients who are stable, asymptomatic and optimally treated for HF with mid-range EF can also be considered for noncompetitive endurance sports. Selected patients with stable, asymptomatic and optimally treated HF with mid-range EF can also be considered for high-intensity recreational sports when adapted to the patient’s capabilities. Although patients with HF with reduced EF may be considered for noncompetitive recreational skill-related sports, they are not recommended to participate in high-intensity power and endurance sports regardless of severity of symptoms.
Moderate endurance and resistance exercise are recommended for patients with HF with preserved EF. Competitive sports may be considered for certain patients without abnormalities on maximal exercise testing.
Several key messages are addressed in the guideline with regards to patients with valvular heart disease, as all patients with this disease are recommended to do some exercise. The type of exercise a patient with valvular heart disease participates in depends on symptoms, as those with mild aortic regurgitation have no exercise restriction while patients with severe aortic stenosis cannot participate in intensive exercise.
Regular physical activity is recommended for AF prevention. For those with AF, participation in sports and exercise is dependent on efficacy of treatment and symptoms.
Patients with long QT syndrome and previous symptoms should be on a targeted dose of beta-blockers when exercising. These patients should also avoid QT-prolonging drugs and an imbalance in electrolytes. High-intensity recreational and competitive sports are not recommended in these patients while on beta-blockers. Competitive sports are not recommended for patients with long QT syndrome and prior arrhythmic syncope or cardiac arrest.
Clinical evaluation is important in the patient groups discussed during the presentation and in those detailed throughout the guideline. This can aid in shared decision making with regards to the intensity of exercise a patient should participate in. Regular follow-up is also important while a patient partakes in an exercise program.
The guideline was simultaneously published in the European Heart Journal.
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Perspective
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Michael S. Emery, MD, MS, FACC
Medical science and knowledge continue to advance. Every so often, it takes a body like ESC or the American College of Cardiology to coalesce these various studies into something practical and usable for the everyday clinician.
Sports and exercise is a topic that does not have many publications on a day-to-day basis, particularly in major journals and in the media, so a lot of this information is new to clinicians who may only peripherally care for athletic individuals.
It is important to realize that this guideline is not just about athletes. Yes, sports cardiology is in the title and there is a big portion of it dedicated to athletic participation, but there is also a lot about exercise in general. It is not meant to be like a U.S. Preventive Services Task Force guideline, but it does bring in some recommendations on general exercise in the general population.
This guideline also covers general exercise recommendations for some special groups that are not brought to the level of consciousness in other guidelines, for example, chronic kidney disease, pregnancy, older people, obesity, congestive HF. All of these special populations may not fit in that athletic paradigm, but they certainly do benefit from structured exercise programs.
This document has many distinct pathways and sections within it, and the best way to use this document more than likely is going to be, “I have a specific question; can I use this document to help me answer that specific question and provide guidance to that patient that might be right in front of me in the exam room right now?”
To the credit of the task force, there is a section on knowledge gaps, which I was impressed with and happy to see. It is not up front and placed at the end of the document, but the task force acknowledged our lack of knowledge in a lot of these areas and where things need to go. Most guidelines do not acknowledge that quite as readily as this one.
These guidelines tend to have a very significant impact in clinical practice. We have seen that with, in particular, the last ACC/American Heart Association guidelines about 5 years ago. Those brought forth the introduction of shared decision-making, which is also a big piece of this current document. The document discusses the need to have shared decision-making when talking about how to use these guidelines and how to counsel your athletic patients. There is a pretty drastic shift in the recommendations for participation in sports and athletics with hypertrophic cardiomyopathy, for example, and also continues to mirror the ACC/AHA guidelines about participation with long QT syndrome and implantable cardioverter defibrillators.
A part of the thing that really struck me was acknowledging what we know and what we don’t know. The vast majority of guidelines in this area are level of evidence C, which means this is our expert opinion, and we have very limited or no data to back it up, but we’re extrapolating from other research and studies not directly derived from this specific population. The reader must understand how much of this is expert opinion and how little data we may have on a lot of things. There are probably a little more data now than there were in the previous iteration, which is good because we need to make strides, but we have a lot of strides to make, hence the need for such a strong emphasis on shared decision-making and less of an emphasis on that paternalistic nature of previous guidelines. We have made this drastic shift from paternalism to shared decision-making, and this document reflects that immensely. I am happy to see that.
The ESC guideline’s definition of an athlete is a little different from that in the ACC/AHA guidelines, most notably because it mentioned official participation in competitive sports. The current document, in essence, states that a competitive athlete is someone who signs up with the intent to win something or get an official ranking. It’s not how I tend to define a competitive athlete. I know lots of very athletic individuals who don’t sign up to get a certificate, but they’re competing every day just as hard in their training and “compete” with themselves or their friends at very high levels. Those are athletes that fall within that very competitive side that we need to not marginalize.
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Pellicia A, et al. 2020 ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 1, 2020 (virtual meeting).
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