Using Wet Bulb Globe Temperature and Physiological Equivalent Temperature as Predicative Models of Medical Stress in a Marathon: Analysis of 30 Years of Data From the Twin Cities Marathon.

OBJECTIVES: : Assess the relationships between wet bulb globe temperature (WBGT) and physiologic equivalent temperature (PET) at the start of a northern latitude marathon and their associations with medical stress and transfers to the emergency room (ER) when the race environment is unexpectedly warm, and participants are not acclimatized. DESIGN: : Retrospective review. SETTING: : Twin Cities Marathon from 1990 to 2019. PARTICIPANTS: : Runners competing in the Twin Cities Marathon. INDEPENDENT VARIABLES: : Start WBGT (prospectively collected) and PET (retrospectively calculated). MAIN OUTCOME MEASURES: : Marathon race starters and finishers and race day medical data (eg, medical stress, number of medical encounters, and number of ER visits). RESULTS: : The mean WBGT was 7.4°C (range -1.7°C to 22.2°C), and the meant PET was 5.2°C (range -16.7°C to 25.9°C). PET was not determined to be a significant predictor of medical stress (P = 0.71); however, a significant quadratic association between WBGT and medical stress was found (P = 0.006). WBGT (P = 0.002), but not PET (P = 0.07), was a significant predictor of the number of ER visits. CONCLUSIONS: Start WBGT was a better predictor of medical stress and ER visits than PET at the Twin Cities Marathon over a 30-year period. The start WBGT may be a better tool to predict race day environment medical safety.

Persistent COVID and a Return to Sport.

ABSTRACT: Coronavirus disease (COVID) has become a global pandemic that has widely impacted athletes at all levels of competition. For many athletes infected with COVID, the course is mild or asymptomatic, and most athletes are able to return to play in a matter of weeks. However, 10% to 15% of people infected with COVID will go on to have prolonged COVID symptoms that last for weeks to months and impact their ability to function and exercise. Not much is known about why certain people become "COVID long-haulers," nor are there any predictive tools to predetermine who may have prolonged symptoms. However, many athletes will suffer from prolonged symptoms that may require further evaluation and may prolong their return to exercise, training, and competition. The purpose of this article is to discuss a framework in which sports medicine and primary care physicians can use to evaluate COVID long-haulers and help them return to sport.

Adaptations to Protect Sideline Providers as They Respond to Sudden Cardiac Arrest During Sars-CoV-2.

ABSTRACT: The 2019 severe acute respiratory syndrome coronavirus 2 has dramatically changed the sports landscape, compelling sports medical providers to adapt to evolving scientific discoveries and adopt ever-changing guidelines that protect our athletes, ourselves, and our staff. To best serve our athletes, providers need to be proactive and anticipate potential complications in providing care for athletes as athletic events resume.

Preparticipation Cardiovascular Screening: An Infrastructure Assessment in Collegiate Athletics.

OBJECTIVE: To assess the available infrastructure for secondary testing after preparticipation cardiovascular screening of collegiate athletes. DESIGN: Cross-sectional study. SETTING: National Collegiate Athletic Association (NCAA) athletic programs PARTICIPANTS:: Team physicians. INTERVENTIONS: Online survey distributed by the NCAA and American Medical Society for Sports Medicine. MAIN OUTCOME MEASURES: Availability of secondary cardiovascular diagnostic testing and services. RESULTS: Team physicians from 235 schools completed the assessment, representing 21% of all NCAA schools. Ninety (38.3%) NCAA team physicians reported screening athletes using electrocardiogram (ECG). Division I schools were more likely than Division II and III schools to perform both screening ECG (RR, 2.38, P < 0.0001) and echocardiogram (RR, 2.83, P = 0.01). More than 97% of schools had access to resting echocardiogram, stress ECG/echocardiogram, and Holter monitoring within 25 miles with no significant variability between divisions, regions, or size of undergraduate student body. Cardiac magnetic resonance imaging and electrophysiology studies were available within 25 miles of more than 80% of schools, and genetics testing was available within 25 miles for 64.8%. CONCLUSIONS: Secondary testing for cardiovascular abnormalities seems to be readily available for NCAA athletes, regardless of division, region, or school size.

International recommendations for electrocardiographic interpretation in athletes.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current evidence, knowledge gaps, recommendations and future directions.

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for cardiovascular screening in athletes remains an issue of considerable debate. At the centre of the controversy is the addition of a resting ECG to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation cardiovascular screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcome-based evidence at this time precludes AMSSM from endorsing any single or universal cardiovascular screening strategy for all athletes, including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate cardiovascular screening strategy unique to their athlete population, community needs and resources. The decision to implement a cardiovascular screening programme, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. AMSSM is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

International criteria for electrocardiographic interpretation in athletes: Consensus statement.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

Triathlon Medical Coverage: A Guide for Medical Directors.

Interest and participation in triathlon has grown rapidly over the past 20 yr and with this growth, there has been an increase in the number of new events. To maximize the safety of participation, triathlons require medical directors to plan and oversee medical care associated with event participation. Provision of proper medical care requires knowledge of staffing requirements, common triathlon medical conditions, impact of course design, communication skill, and a familiarity of administrative requirements. These guidelines serve as a tool for triathlon medical and race directors to improve race safety for athletes.

Hypothesised mechanisms of swimming-related death: a systematic review.

BACKGROUND: Recent reports from triathlon and competitive open-water swimming indicate that these events have higher rates of death compared with other forms of endurance sport. The potential causal mechanism for swimming-related death is unclear. OBJECTIVE: To examine available studies on the hypothesised mechanisms of swimming-related death to determine the most likely aetiologies. MATERIAL AND METHODS: MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews (1950 to present) were searched, yielding 1950 potential results, which after title and citation reviews were reduced to 83 possible reports. Studies included discussed mechanisms of death during swimming in humans, and were Level 4 evidence or higher. RESULTS: A total of 17 studies (366 total swimmers) were included for further analysis: 5 investigating hyperthermia/hypothermia, 7 examining cardiac mechanisms and responses, and 5 determining the presence of pulmonary edema. The studies provide inconsistent and limited-quality or disease-oriented evidence that make definitive conclusions difficult. CONCLUSIONS: The available evidence is limited but may suggest that cardiac arrhythmias are the most likely aetiology of swimming-related death. While symptoms of pulmonary edema may occur during swimming, current evidence does not support swimming-induced pulmonary edema as a frequent cause of swimming-related death, nor is there evidence to link hypothermia or hyperthermia as a causal mechanism. Further higher level studies are needed.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations, and Future Directions.

Cardiovascular (CV) screening in young athletes is widely recommended and routinely performed before participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for CV screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation CV screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal CV screening strategy for all athletes including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate CV screening strategy unique to their athlete population, community needs, and resources. The decision to implement a CV screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. American Medical Society for Sports Medicine is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

The Evidence Against Cardiac Screening Using Electrocardiogram in Athletes.

Sudden cardiac death (SCD) in young athletes is publicly remarkable and tragic because of the loss of a seemingly healthy young person. Because many of the potential etiologies may be identified with a preparticipation electrocardiogram (ECG), the possible use of an ECG as a screening tool has received much attention. A good screening test should be cost-effective and should influence a disease or health outcome that has a significant impact on public health. The reality is that the prevalence of SCD is low and no outcome-based data exist to determine whether early detection saves lives. Further, there is insufficient screening infrastructure, and the risk of screening and follow-up may be higher than that of the actual disease. Until outcomes data demonstrate a benefit with regard to SCD, universal screening cannot be recommended.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations and Future Directions.

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for cardiovascular screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation cardiovascular screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal cardiovascular screening strategy for all athletes, including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate cardiovascular screening strategy unique to their athlete population, community needs, and resources. The decision to implement a cardiovascular screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence-base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. AMSSM is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

Cardiac preparticipation screening for the young athlete: why the routine use of ECG is not necessary.

The addition of an electrocardiogram (ECG) to the current United States athlete preparticipation physical evaluation (PPE) as a screening tool has dominated the PPE discussion over the past decade despite the lack of demonstrable outcomes data supporting the routine use of the diagnostic study for reduction of sudden cardiac death (SCD). A good screening test should influence a disease or health outcome that has a significant impact on public health and the population screened must have a high prevalence of the disease to justify the screening intervention. While SCD is publicly remarkable and like any death, tragic, the prevalence of SCD in young athletes is very low and the potential for false positive results is high. While ECG screening appears to have made an impact on SCD in Italian athletes, the strategy has made no impact on Israeli athletes, and the overall impact of ECG screening on American athletes is unclear. Until outcomes studies show substantial SCD reduction benefit, the addition of routine ECG PPE screening in young athletes should not be instituted.

Medical Evaluation for Exposure Extremes: Heat.

Exertional heat illness can be a serious consequence of sports or exercise in hot environments. Participants can possess intrinsic or face extrinsic risk factors that may increase their risk for heat-related illness. Knowledge of the physiology and pathology of heat illness, identification of risk factors, and strategies to combat heat accumulation will aid both the practitioner and the participant in preparing for activities that occur in hot environments. Through preparation and mitigation of risk, safe and enjoyable wilderness adventure can be pursued.

General Medical Considerations for the Wilderness Adventurer: Medical Conditions That May Worsen With or Present Challenges to Coping With Wilderness Exposure.

Participation in wilderness and adventure sports is on the rise, and as such, practitioners will see more athletes seeking clearance to participate in these events. The purpose of this article is to describe specific medical conditions that may worsen or present challenges to the athlete in a wilderness environment.

Medical Evaluation for Exposure Extremes: Heat.

Exertional heat illness can be a serious consequence of sports or exercise in hot environments. Participants can possess intrinsic or face extrinsic risk factors that may increase their risk for heat-related illness. Knowledge of the physiology and pathology of heat illness, identification of risk factors, and strategies to combat heat accumulation will aid both the practitioner and the participant in preparing for activities that occur in hot environments. Through preparation and mitigation of risk, safe and enjoyable wilderness adventure can be pursued.

General Medical Considerations for the Wilderness Adventurer: Medical Conditions That May Worsen With or Present Challenges to Coping With Wilderness Exposure.

Participation in wilderness and adventure sports is on the rise, and as such, practitioners will see more athletes seeking clearance to participate in these events. The purpose of this article is to describe specific medical conditions that may worsen or present challenges to the athlete in a wilderness environment.

Cardiovascular preparticipation screening practices of college team physicians.

OBJECTIVE: Determine the cardiovascular screening practices of college team physicians. DESIGN: Cross-sectional survey. SETTING: Electronic mail with a link to a 9-item survey. PARTICIPANTS: American Medical Society for Sports Medicine college team physicians. INTERVENTIONS: Screening practices survey administered to college team physicians. MAIN OUTCOME MEASURES: Cardiovascular preparticipation screening practices including noninvasive cardiac screening (NICS) such as electrocardiogram (ECG) or echocardiogram. RESULTS: Two hundred twenty-four of 613 AMSSM members identifying themselves as college team physicians (36.5%) responded: National Collegiate Athletic Association Division I: 146, Division II: 41, Division III: 27, National Association of Intercollegiate Athletics: 8, and Junior College: 2. The majority (78%) of schools conducted the American Heart Association (AHA) 12-element history and physical examination. Division I institutions were more likely to add an ECG and/or echocardiogram (30%) to their preparticipation examination (PPE) compared with lower divisions (P < 0.0001). Those Division I schools using NICS were more likely to do so for all athletes (P < 0.001) or revenue generating sports (P < 0.001), whereas other institutions did so only for high-risk subgroups (P < 0.01). Lower division schools would consider adding ECG if it cost less (P = 0.01) or if there were more local expertise in athlete-specific interpretation standards (P = 0.04). CONCLUSIONS: Many National Collegiate Athletic Association Athletes Division I programs already use NICS to screen athletes, whereas a significant portion of lower division schools add ECG for athletes deemed high risk. Increased use of these modalities suggests limitations of traditional PPE screening methods. CLINICAL RELEVANCE: This is the first study to assess cardiac screening practices across all collegiate divisions and broadens our understanding of cardiac screening in high-level athletes.

Effects of excessive endurance activity on the heart.

Regular moderate exercise confers many cardiovascular and health benefits. Because of this, endurance sports events have become very popular with participation increasing tremendously over the past few years. In conjunction with this increase in popularity and participation, people also have increased the amount that they exercise with many training for and competing in ultraendurance events such as ultradistance running events, iron distance triathlons, or multiday races. This excess endurance activity may appear to increase the risk of cardiac abnormalities, which may increase the risk for long-term morbidity or mortality. While it is known that moderate exercise has benefits to cardiovascular health, ultimately, the long-term cardiac effects of excessive endurance activity are unclear. What is clear, however, is that moderate exercise is beneficial, and to date, the evidence does not support recommending against physical activity.

Normal electrocardiographic findings: recognising physiological adaptations in athletes.

Electrocardiographic changes in athletes are common and usually reflect benign structural and electrical remodelling of the heart as a physiological adaptation to regular and sustained physical training (athlete's heart). The ability to identify an abnormality on the 12-lead ECG, suggestive of underlying cardiac disease associated with sudden cardiac death (SCD), is based on a sound working knowledge of the normal ECG characteristics within the athletic population. This document will assist physicians in identifying normal ECG patterns commonly found in athletes. The ECG findings presented as normal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.