Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis: position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC).

Myocardial diseases are associated with an increased risk of potentially fatal cardiac arrhythmias and sudden cardiac death/cardiac arrest during exercise, including hypertrophic cardiomyopathy, dilated cardiomyopathy, left ventricular non-compaction, arrhythmogenic cardiomyopathy, and myo-pericarditis. Practicing cardiologists and sport physicians are required to identify high-risk individuals harbouring these cardiac diseases in a timely fashion in the setting of preparticipation screening or medical consultation and provide appropriate advice regarding the participation in competitive sport activities and/or regular exercise programmes. Many asymptomatic (or mildly symptomatic) patients with cardiomyopathies aspire to participate in leisure-time and amateur sport activities to take advantage of the multiple benefits of a physically active lifestyle. In 2005, The European Society of Cardiology (ESC) published recommendations for participation in competitive sport in athletes with cardiomyopathies and myo-pericarditis. One decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of cardiomyopathies and myo-pericarditis. The present document, therefore, aims to offer a comprehensive overview of the most updated recommendations for practicing cardiologists and sport physicians managing athletes with cardiomyopathies and myo-pericarditis and provides pragmatic advice for safe participation in competitive sport at professional and amateur level, as well as in a variety of recreational physical activities.

Sudden cardiac arrest in sports: a video analysis.

OBJECTIVES: Information about sudden cardiac arrest (SCA) in sports arises from registries, insurance claims and various reports. Analysing video footage of SCA during sports for scientific purposes has scarcely been done. The objective of this study was to examine videotaped SCA in athletes to better understand the mechanisms of SCA. METHODS: Publicly available online video databases were searched for videos displaying SCA in athletes. RESULTS: Thirty-five online videos (26 from professional and 9 from amateur sport; 34 male victims) were obtained. Twenty-one events resulted in survival and 14 in sudden cardiac death. Level of physical activity prior to SCA was assessable in 28 videos; 19 events occurred during low-intensity, 6 during moderate-intensity and 3 during high-intensity activity. SCA predominately occurred during low-intensity compared with both moderate-intensity and high-intensity activities (p<0.01). In 26/35 videos, it was possible to observe if resuscitation was provided. Resuscitation was carried out in 20 cases; cardiopulmonary resuscitation (CPR) alone (8 cases), CPR+defibrillation (10), cardiac thump (1) or shock from an implantable cardioverter defibrillator (1). Thirteen of the 20 cases with resuscitation received an intervention within 1 min after collapse. Survival was high when intervention occurred within 1 min (12/13) compared with those who received delayed (3/5) or no intervention (1/6). Associated signs of SCA such as agonal respirations and seizure-like movements were observed in 66% of the cases. CONCLUSIONS: SCA during sport most often occurred during low-intensity activity. Prompt intervention within 1 min demonstrated a high survival rate and should be the standard expectation for witnessed SCA in athletes.

Recommendations for participation in competitive sports of athletes with arterial hypertension: a position statement from the sports cardiology section of the European Association of Preventive Cardiology (EAPC).

Current guidelines of the European Society of Cardiology advocate regular physical activity as a Class IA recommendation for the prevention and treatment of cardiovascular disease. Despite its undisputed multitude of beneficial effects, competitive athletes with arterial hypertension may be exposed to an increased risk of cardiovascular events. This document is an update of the 2005 recommendations and will give guidance to physicians who have to decide on the risk of an athlete during sport participation.

Screening for symptoms of depression and anxiety in a cardiology department. / Screening for symptomer på depresjon og angst ved en hjertemedisinsk avdeling.

BACKGROUND: Depression and anxiety are common in patients with cardiac disease and predict a poorer prognosis, increased mortality and reduced compliance with treatment. National and international guidelines recommend procedures for screening, but there is a lack of studies of such practices in Norwegian hospitals. The objective of this study was to implement a simple screening method for symptoms of depression and anxiety in patients with cardiac disease. MATERIAL AND METHOD: Patients in the Department of Cardiology at Diakonhjemmet Hospital who had valvular heart disease, tachyarrhythmia, myocardial infarction or heart failure were screened for symptoms of depression, anxiety and panic attacks with the aid of five questions from the Patient Health Questionnaire-2 (PHQ-2), Generalized Anxiety Disorder Scale-2 (GAD-2) and Patient Health Questionnaire - Somatic, Anxiety, and Depressive Symptom Scales (PHQ-SADS). The patients were recruited from the outpatient clinic or ward at least one month after acute heart disease. RESULTS: A total of 57 of 232 patients reported symptoms of depression or anxiety when screened. The screening method was easy to implement, but time constraints and uncertainty regarding procedures for follow-up and the effect of following up the patients were reported. INTERPRETATION: Good tools and methods are available for screening for symptoms of depression and anxiety and anxiety in patients with cardiac disease. More studies are needed regarding the benefits of screening, at what stage of the disease it should be performed, and whether it should be performed by the primary and/or the specialist health services.

Exercise-induced rhabdomyolysis - a patient series. / Treningsindusert rabdomyolyse ­ en pasientserie.

BACKGROUND: No guidelines are available for the treatment and follow up of exercise-induced rhabdomyolysis. The purpose of this study was to describe the treatment, complications and follow-up of patients with exercise-induced rhabdomyolysis at Diakonhjemmet Hospital. MATERIAL AND METHOD: A retrospective observational study from 2011 up to and including 2015 of patients with exercise-induced rhabdomyolysis ≥ 18 years and with creatine kinase > 5 000 IU/l. RESULTS: We registered a total of 42 patients and obtained informed consent from 31. Twenty were treated as inpatients with a median hospitalisation time of 2.5 (1­6) days. Median creatine kinase was 36 797 (17 172­53 548) IU/l upon admission and 16 051 (11 845­26 505) IU/l at discharge. Median intravenous fluid volume was 6 000 (1 000­27 700) ml. Eleven patients underwent urinary alkalinisation. None developed severe kidney injury or other serious complications such as electrolyte imbalance, compartment syndrome or disseminated intravascular coagulation, either during hospitalisation or in the course of the study period. INTERPRETATION: Healthy persons with exercise-induced rhabdomyolysis have a very low risk of complications. Our patients are treated as outpatients or considered for discharge with creatine kinase < 40 000 IU/l measured at least three days after their workout, and if they have no risk factors or other complications.

Sex differences in heart rate variability: a longitudinal study in international elite cross-country skiers.

PURPOSE: Exercise-related sudden cardiac deaths (SCD) occur with a striking male predominance. A higher sympathetic tone in men has been suggested as risk factor for SCD. Elite athletes have the highest risk for exercise-related SCD. We aimed to analyze the autonomic nervous system of elite cross-country skiers from Norway, Russia and Switzerland in supine position and after orthostatic challenge in various training periods (TP). METHOD: Measurements of heart rate variability (HRV) were performed on a weekly basis over 1 year using an orthostatic challenge test with controlled breathing. Main outcome parameters were the high-frequency power in supine position (HFsupine) as marker of cardiac parasympathetic activity and the low-frequency/high-frequency power ratio after orthostatic challenge (LF/HFstand) as marker of cardiac sympathetic activation. Training intensity and duration were recorded daily and expressed as training strain. The training year was divided into three TPs. An average of weekly HRV measurements was calculated for each TP. RESULT: Female (n = 19, VO2max 62.0 ± 4.6 ml kg(-1) min(-1), age 25.8 ± 4.3 years) and male (n = 16, VO2max 74.3 ± 6.3 ml kg(-1) min(-1), age 24.4 ± 4.2 years) athletes were included. Training strain was comparable between sexes (all p > 0.05) and changed between TPs (all p < 0.05) while no HRV parameters changed over time. There were no sex differences in HFsupine while the LF/HFstand was significantly higher in male athletes in all TPs. CONCLUSION: For a comparable amount of training, male athletes showed constantly higher markers of sympathetic activity after a provocation maneuver. This may explain part of the male predominance in sports-related SCD.

Development of a global health curriculum for family medicine based on ACGME competencies.

BACKGROUND: With the popularity of global health among medical students and residents, family medicine (FM) residencies are developing pathways in global health. Curriculum based on Accreditation Council for Graduate Medical Education (ACGME) competencies adds rigor to the efforts. DESCRIPTION: We describe the adaptation of a comprehensive pediatric global health curriculum based on ACGME competencies for family medicine. The curriculum maps out goals, objectives, curricular elements, and evaluation modalities for each of the six competencies (medical knowledge, patient care, practice-based learning, professionalism, communication, and systems-based practice). A literature review, followed by an iterative process, guided the expansion of the pediatric curriculum and the prioritization of domains for FM. Input was sought from FM global health faculty at our 8 residencies, affiliated community faculty, and international health experts from across the United States who attended our workshop at a national FM global health meeting. The final product includes comprehensive competency-based curriculum, open-source resources, and evaluation modalities. The goals and objectives pertinent to all FM residents, and those specific to global health pathway residents and fellows, are outlined. EVALUATION: The limiting and enabling factors of the curriculum implementation are presented. CONCLUSIONS: This global family medicine curriculum has added structure and rigor to our international electives in the department at the University of Minnesota. The competency-based curriculum is in the early stages of implementation and evaluation. It has already strengthened components of the residency learning experience for all residents. A robust evaluation is needed and requires monitoring pathway graduates and their career choices into the future. The curriculum is available for adoption by other FM residencies.

High ambulatory blood pressure in male professional football players.

BACKGROUND: No data exist on ambulatory blood pressure (ABP) in athletes. OBJECTIVES: To identify ABP and examine recommended follow-up of high office blood pressure (OBP) in male professional football players and secondary study indicators of sympathetic activity. METHODS: Players with high OBP (cases) from a previous screening of 594 players (n=28) were matched for age and ethnicity with players with optimal OBP (controls). High ABP was defined as a mean of ≥135/85 mm Hg during daytime and ≥120/75 mm Hg during night-time. The players replied to questions regarding follow-up of high OBP. High night-time ABP and lack of nocturnal dip (≤10% decline in average BP) were taken as indicators of increased sympathetic activity. RESULTS: 26 cases and 26 controls, mean age 28±4 years, were included. 15 (58%) of the cases had sustained hypertension and 11 (42%) white coat hypertension. Among the controls, 17 (65%) had normotension and 9 (35%) masked hypertension. ABP during night-time was high in 23 (88%) of the cases and in 16 (64%) of the controls, and nocturnal dip was absent in 9 (35%) and 11 (42%), respectively. 10 (38%) of the cases had no follow-up of high OBP. CONCLUSIONS: More than one-third of the players with optimal OBP had masked hypertension during daytime and more than half of all players had high ABP during night-time, which are novel findings in athletes. Together with the reduced nocturnal dip, this might indicate increased sympathetic activity. Follow-up of high OBP after preparticipation screening is random and should be organised.

Consensus document regarding cardiovascular safety at sports arenas: position stand from the European Association of Cardiovascular Prevention and Rehabilitation (EACPR), section of Sports Cardiology.

Mass gathering events in sports arenas create challenges regarding the cardiovascular safety of both athletes and spectators. A comprehensive medical action plan, to ensure properly applied cardiopulmonary resuscitation, and wide availability and use of automated external defibrillators (AEDs), is essential to improving survival from sudden cardiac arrest at sporting events. This paper outlines minimum standards for cardiovascular care to assist in the planning of mass gathering sports events across Europe with the intention of local adaptation at individual sports arenas, to ensure the full implementation of the chain of survival.