Sports cardiology roundup from ACC 2024: Return to play, occupational risks among hot topics
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Key takeaways:
- Several presenters recommended an individualistic approach for determining if athletes with heart conditions should return to play.
- Heart-related risks of “tactical athletes” should be carefully considered.
Return-to-play considerations and CVD risks of people who perform under life-threatening conditions were among the key sports cardiology topics at the American College of Cardiology Scientific Session in April in Atlanta.
The sports cardiology sessions ranged from abstract presentations to debates between experts and drew large audiences. In this Sports Cardiology Corner column, four sports cardiology-specific sessions will be discussed.
To compete or to not compete
One session entailed moderated case presentations by fellows in training, centering on the ability to compete or to not compete.
In this session chaired by Bradley Petek, MD, sports cardiologist and director of the sports cardiology program at Oregon Health & Science University, and Jeffrey Hsu, MD, PhD, assistant clinical professor of medicine at University of California, Los Angeles, trainees provided case presentations of athletes with myocarditis, hypertrophic cardiomyopathy, anomalous coronaries, CAD, aortopathy and noncompaction.
Each athlete in the presentations played a different sport and had different training regimens and symptomatology. In the past, athletes with these diseases have been disqualified from return to sport without nuance or discussion.
This session further demonstrated the need for discussion and shared decision-making between the sports cardiologist and all the stakeholders. Ample risk stratification should be complete, and the athlete should be informed of the risk of his or her condition. An individualistic approach should be used with the athlete’s best interests in mind.
Cardiovascular and occupational risks in the tactical athlete
Benjamin D. Levine, MD, professor of internal medicine in the division of cardiology and holder of the Distinguished Professorship in Exercise Sciences at University of Texas Southwestern, led a session titled “Cardiovascular and Occupational Risks in the Tactical Athlete.” A tactical athlete is defined as someone who has a high demand for speed, strength and agility in bursts and is required to perform under life-threatening conditions. Often, tactical athletes are subjected to extreme circumstances (weather, altitude, etc.). Examples of these athletes include firefighters, police, SWAT, emergency medicine technicians (EMTs), military and astronauts. These athletes have a service-based job, rather than participating in sport as with a traditional athlete.
When dealing with tactical athletes with CVD, the cardiologist must understand the full scope of different occupations, including physical, mental and environmental factors. Often, these athletes are relied upon by the rest of their unit, and even brief incapacitation can lead to a disastrous situation. Thus, the concept of shared decision-making, which is applied to athletes, needs to be broadened to include all the stakeholders in the setting of a tactical athlete. The goal of the cardiologist seeing tactical athletes should be to have the ability to simulate the demands of each individual job to safely allow return to work.
Sheela Krishnan, MD, cardiologist and assistant professor of medicine at MaineHealth, then discussed specific CV risk factors for firefighters, who have the highest mortality from CVD compared with other occupations. Sudden cardiac death, largely due to coronary disease, remains the largest cause of mortality in the line of duty. This risk comes as a function of the job itself, likely from the sympathetic activity from emergency duty. The National Fire Protection Association has provided a manual to physicians to provide specific return-to-work guidelines for those with CV conditions.
Eddie Davenport, MD, FACC, FAsMA, a cardiologist at Miami Valley Hospital in Centerville, Ohio, and a flight surgeon with the U.S. Air Force, discussed screening in the tactical athlete. When discussing pilots, both military and commercial, the screening guidelines are simply to perform an ECG. Meanwhile, other branches of the military evaluate ECG in conjunction with echocardiogram and stress testing. Given the large variance in both screening and treatment in tactical athlete populations, further consideration of a comprehensive guideline approach to these athletes needs to be taken.
Parameters of myocardial work
Antonio Carvalho, MD, and colleagues from the Hospital da Luz de Setúbal in Lisbon, Portugal, presented an abstract titled “Myocardial Work in Athletes: A Novel Approach to Differentiate Athletic Heart Adaptations from Cardiomyopathy.” This study aimed to differentiate between exercise-induced cardiac physiologic adaptations and cardiomyopathies using myocardial work. This study compared parameters of myocardial work from the echocardiographic reference ranges for normal noninvasive myocardial work indices (EACVI NORRE study), including global longitudinal strain, global work index, global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) in healthy adults.
Myocardial work is a means to measure left ventricular systolic function incorporating deformation and load, which can be measured via echocardiogram. Work was evaluated from mitral valve closure to opening. Indices of work were defined as follows:
- GCW — work performed during shortening in systole adding negative work during lengthening in isovolumetric relaxation.
- GWW — negative work performed during lengthening in systole adding work performed during shortening in isovolumetric relaxation.
- GWE — constructive work divided by the sum of constructive and wasted work.
The study compared these parameters of healthy adults with 121 professional male soccer players. The athlete population was found to have lower global longitudinal strain, global work index, GCW and GWW. Athletes were found to have an equivalent GWE to healthy adults.
This means the use of GWE on echocardiography may help to differentiate physiologic adaptations of exercise and cardiomyopathies in athletic populations.
Debate on return to play
One session featured debates on return to play between experts in the field. Erika Parisi, MD, a cardiology fellow at University of Michigan, presented a case of HCM in a basketball player. Matthew W. Martinez, MD, director of Atlantic Health System Sports Cardiology at Morristown Medical Center in Morristown, New Jersey, and Ankit B. Shah, MD, MPH, FACC, president of Sports and Performance Cardiology in Chevy Chase, Maryland, debated return to play in this population.
The strategy of return to play for athletes with HCM is highly nuanced and can vary between athlete to athlete. As with any patient with HCM, the athlete should have screening for high-risk features, which may increase chances of sudden cardiac death (late gadolinium enhancement on cardiac MRI, unexplained syncope, ventricular arrhythmias, wall thickness > 30 mm, presence of apical aneurism). A further sports-specific approach can be used with cardiopulmonary exercise testing. In the case of this patient, the peak VO2 (the maximal oxygen uptake during exercise) was 19.3 mL/kg per minute (59% predicted). The benefit of CV fitness vs. the risk for sudden death in this population is paramount. Martinez and Shah debated the LIVE-HCM trial data, which pointed to no increased risk for death or ventricular arrhythmias with exercise. However, the cardiologist must be careful using this data when allowing full return to play for these patients. In this trial, “vigorous” exercise was defined as 6 metabolic equivalents of task (METs) for 90 minutes per week, and the number of elite athletes was low. Finally, there was significant discussion around the use of shared decision-making and expert referral in return to play. An individualized approach to exercise should be used accounting for age, sex, risk factors, symptoms risk tolerance and sport, with an emergency action plan in place.
The final debate of the session deliberated return to play in a Division I collegiate football player with a bicuspid aortic valve and an aortic root of 46 mm. The return-to-play discussion of this athlete took place between Aaron Baggish, MD, founder and emeritus director of the Cardiovascular Performance Program at Massachusetts General Hospital, and Alan Braverman, MD, FACC, the Alumni Endowed Professor in Cardiovascular Diseases and professor of medicine at Washington University School of Medicine in St. Louis. The risk of return to play in this athlete stems from the risk of worsening of aortopathy as well as the risk for aortic rupture (with aortic rupture responsible for 2% to 5% of sudden cardiac death in athletes). However, there is a paucity of true data in these populations and, thus, Baggish mentioned we must consider “the values, preferences and risk tolerance of the athlete.” In this specific case, a sports cardiologist must be aware that a dissection is unlikely, but certainly possible, and sport may accelerate the disease. Given the athlete’s choice to play football, they may be able to accept an inherent risk, and thus the decision of return to play must truly be from the athlete in conjunction with the sports cardiologist.
References:
- Carvalho A, et al. Abstract 1222-114. Presented at: American College of Cardiology Scientific Session; April 6-8, 2024; Atlanta.
- Harmon KG. Clin Sports Med. 2022;doi:10.1016/j.csm.2022.02.002.
- Kim JH, et al. A new era in consideration of competitive sports participation in athletes with heart disease: Let's debate. Presented at: American College of Cardiology Scientific Session; April 6-8, 2024; Atlanta.
- Lampert R, et al. JAMA Cardiol. 2023;doi:10.1001/jamacardio.2023.1042.
- Levine B, et al. Cardiovascular and occupational risks in the tactical athlete: OK For clearance back to work. Presented at: American College of Cardiology Scientific Session; April 6-8, 2024; Atlanta.
- Manganaro R, et al. Eur Heart J Cardiovasc Imaging. 2019;doi:10.1093/ehjci/jey188.
- Petek B, et al. Sports cardiology: To compete or to not compete. Presented at: American College of Cardiology Scientific Session; April 6-8, 2024; Atlanta.
For more information:
Arjun Kanwal, MD, is a cardiovascular disease fellow at New York Medical College/Westchester Medical Center. He can be reached at arjun.kanwal@wmchealth.org; X (Twitter): @arjunkanwalmd.
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