Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions: Part 1: Supraventricular arrhythmias. A position statement of the Section of Sports Cardiology and Exercise from the European Association of Preventive Cardiology (EAPC) and the European Heart Rhythm Association (EHRA), both associations of the European Society of Cardiology.

Symptoms attributable to arrhythmias are frequently encountered in clinical practice. Cardiologists and sport physicians are required to identify high-risk individuals harbouring such conditions and provide appropriate advice regarding participation in regular exercise programmes and competitive sport. The three aspects that need to be considered are: (a) the risk of life-threatening arrhythmias by participating in sports; (b) control of symptoms due to arrhythmias that are not life-threatening but may hamper performance and/or reduce the quality of life; and (c) the impact of sports on the natural progression of the underlying arrhythmogenic condition. In many cases, there is no unequivocal answer to each aspect and therefore an open discussion with the athlete is necessary, in order to reach a balanced decision. In 2006 the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology published recommendations for participation in leisure-time physical activity and competitive sport in individuals with arrhythmias and potentially arrhythmogenic conditions. More than a decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of these conditions. The present document presents a combined effort by the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology and the European Heart Rhythm Association to offer a comprehensive overview of the most updated recommendations for practising cardiologists and sport physicians managing athletes with supraventricular arrhythmias, and provides pragmatic advice for safe participation in recreational physical activities, as well as competitive sport at amateur and professional level. A companion text on recommendations in athletes with ventricular arrhythmias, inherited arrhythmogenic conditions, pacemakers and implantable defibrillators is published as Part 2 in Europace.

Brief recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: Summary of a Position Statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC).

This paper presents a brief summary of the recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology (EAPC) on sports-participation in patients with coronary artery disease, coronary artery anomalies or spontaneous dissection of the coronary arteries, all entities being associated with myocardial ischaemia.1 Given the wealth of evidence supporting the benefits of exercise for primary and secondary prevention of coronary artery disease, individuals should be restricted from competitive sport only when a substantial risk of adverse event or disease progression is present. These recommendations aim to encourage regular physical activity including participation in sports and, with reasonable precaution, ensure a high level of safety for all individuals with coronary artery disease. The present document is based on available current evidence, but in most instances because of lack of evidence, also on clinical experience and expert opinion.

Brief recommendations for participation in competitive sports of athletes with arterial hypertension: Summary of a Position Statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC).

Owing to its undisputed multitude of beneficial effects, European Society of Cardiology guidelines advocate regular physical activity as a class IA recommendation for the prevention and treatment of cardiovascular disease. Nonetheless, competitive athletes with arterial hypertension may be exposed to an increased risk of cardiovascular events. Guidance to physicians will be given in this summary of our recently published recommendations for participation in competitive sports of athletes with arterial hypertension.

Evidence of reduced parasympathetic autonomic regulation in inflammatory joint disease: A meta-analyses study.

BACKGROUND: Rheumatoid arthritis (RA) and spondyloarthritis (SpA) are inflammatory joint disorders (IJD) with increased risk of cardiovascular disease (CVD). Autonomic dysfunction (AD) is a risk factor for CVD, and parasympathetic AD is linked to key features of IJD such as inflammation, physical inactivity and pain. Heart-rate variability (HRV) is a marker of cardiac AD. The study objective was to compare parasympathetic cardiac AD, measured by HRV, between patients with IJD and healthy controls, using meta-analysis methodology, and to examine the impact of inflammation, physical inactivity and pain on HRV in IJD. METHODS: Medline, Embase and Amed were searched. Inclusion criteria were adult case-control studies published in English or a Scandinavian language, presenting HRV data in IJD. Two measures of HRV and 3 from the Ewing protocol were selected: square root of mean squared difference of successive R-R intervals (RMSSD), high frequency (HF), Ewing protocol; standing (E-S), breathing (E-B) and Valsalva (E-V). Patients with RA, SpA and healthy controls were compared separately using random-effects meta-analyses of standardized mean differences (SMD). RESULTS: In all, 35 papers were eligible for inclusion. For RMSSD the pooled SMD (95% CI) RA vs. controls was -0.90 (-1.35 to -0.44), for SpA vs. controls; -0.34 (-0.73 to 0.06). For HF pooled SMD RA vs. controls was -0.78 (-0.99 to -0.57), for SpA vs. controls; -0.04 (-0.22 to 0.13). All Ewing parameters were significantly lower in cases, except for E-V which was comparable between cases and controls in patients with RA. CONCLUSION: Patients with IJD have cardiac parasympathetic AD which is related to inflammation.

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.

Blood pressure in professional male football players in Norway.

OBJECTIVES: Scarce data exist on blood pressure (BP) and secondary effects in young athletes. Hence, we aimed to study prevalence of high BP (≥140/90 mmHg) and the association to arterial compliance, left ventricle mass and left atrium volume. METHODS: A Norwegian preparticipation cardiac screening of male professional football players enrolled 493 white European, 47 matched controls, 49 black and 53 players of other ethnicity. BP was measured as a mean of two measurements. Height and weight were self-reported, and body surface area (BSA) was calculated. The echocardiographic parameters were indexed to BSA. Heart rates (HRs) by electrocardiography and pulse pressure (PP) were considered as surrogates for sympathetic activity. Arterial compliance was calculated as stroke volume(BSA)/PP. RESULTS: The players mean age was 25 years (18-38) and mean BP 122/69 ± 11/8 mmHg. There were no significant differences in prevalence of hypertension between all players, 39 (7%), and controls, four (9%), or between white, 32 (7%), and black, five (10%), players. There was a significant positive linear relationship between BP and left ventricle mass(BSA), left atrium volume(BSA), stroke volume(BSA), HR and PP, and negative relationship to arterial compliance(BSA). CONCLUSION: Although the prevalence of high BP in professional football players was low, our data indicate a novel association between elevated BP and reduced arterial compliance, increased left ventricle mass and left atrium volume even in young athletes. This emphasizes closer focus on BP measurements and standardized follow-up after preparticipation screening of athletes.

Position paper: proposal for a core curriculum for a European Sports Cardiology qualification.

Sports cardiology is a new and rapidly evolving subspecialty. It aims to elucidate the cardiovascular effects of regular exercise and delineate its benefits and risks, so that safe guidance can be provided to all individuals engaging in sports and/or physical activity in order to attain the maximum potential benefit at the lowest possible risk. The European Society of Cardiology (ESC) advocates systematic preparticipation cardiovascular screening in an effort to identify competitive athletes at risk of exercise-related cardiovascular events and sudden cardiac death. However, the implementation of preparticipation screening is hindered because of lack of structured training and as a result lack of sufficient expertise in the field of sports cardiology. In 2008 the European Society of Cardiology published a core curriculum for the general cardiologist, in which sports cardiology was incorporated within the topic 'Rehabilitation and Exercise Physiology'. However, the exponential rise in knowledge and the growing demand for expertise in the field of sports cardiology dictates the need to systematically structure the knowledge base of sports cardiology into a detailed curriculum. We envisage that the curriculum would facilitate more uniform training and guideline implementation throughout Europe, and safeguard that evaluation and guidance of competitive athletes or individuals who wish to engage in leisure-time sports activities is performed by physicians with expertise in the field. The current manuscript provides a comprehensive curriculum for sports cardiology, which may serve as a framework upon which universities and national and international health authorities will develop the training, evaluation and accreditation in sports cardiology.

Increased heart rate variability during nondirective meditation.

PURPOSE: Meditation practices are in use for relaxation and stress reduction. Some studies indicate beneficial cardiovascular health effects of meditation. The effects on the autonomous nervous system seem to vary among techniques. The purpose of the present study was to identify autonomic nerve activity changes during nondirective meditation. MATERIALS AND METHODS: Heart rate variability (HRV), blood pressure variability (BPV), and baroreflex sensitivity (BRS) were monitored in 27 middle-aged healthy participants of both genders, first during 20 min regular rest with eyes closed, thereafter practising Acem meditation for 20 min. Haemodynamic and autonomic data were collected continuously (beat-to-beat) and non-invasively. HRV and BPV parameters were estimated by power spectral analyses, computed by an autoregressive model. Spontaneous activity of baroreceptors were determined by the sequence method. Primary outcomes were changes in HRV, BPV, and BRS between rest and meditation. RESULTS: HRV increased in the low-frequency (LF) and high-frequency (HF) bands during meditation, compared with rest (p = 0.014, 0.013, respectively). Power spectral density of the RR-intervals increased as well (p = 0.012). LF/HF ratio decreased non-significantly, and a reduction of LF-BPV power was observed during meditation (p < 0.001). There was no significant difference in BRS. Respiration and heart rates remained unchanged. Blood pressure increased slightly during meditation. CONCLUSION: There is an increased parasympathetic and reduced sympathetic nerve activity and increased overall HRV, while practising the technique. Hence, nondirective meditation by the middle aged may contribute towards a reduction of cardiovascular risk.

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.

ESC Study Group of Sports Cardiology: recommendations for participation in leisure-time physical activity and competitive sports for patients with ischaemic heart disease.

BACKGROUND: Evidence for the proper management of ischemic heart disease (IHD) in the general population is well established, but recommendations for physical activity and competitive sports in these patients are scarce. The aim of the present paper was to provide such recommendations to complement existing ESC and international guidelines on rehabilitation and primary/secondary prevention. DESIGN AND METHODS: Due to the lack of studies in this field, the current recommendations are the result of consensus among experts. Sports are classified into low/moderate/high dynamic and low/moderate/high static, respectively. RESULTS: Patients with a definitive IHD and higher probability of cardiac events are not eligible for competitive sports (CS) but for individually designed leisure time physical activity (LPA); patients with definitive IHD and lower probability of cardiac events as well as those with no IHD but with a positive exercise test and high risk profile (SCORE > 5%) are eligible for low/moderate static and low dynamic (IA-IIA) sports and individually designed LPA. Patients without IHD and a high risk profile+ a negative exercise-test and those with a low risk profile (SCORE < 5%) are allowed all LPA and competitive sports with a few exceptions. CONCLUSIONS: Individually designed LPA is possible and encouraged in patients with and without established IHD. Competitive sports may be restricted for patients with IHD, depending on the probability of cardiac events and the demands of the sport according to the current classification.

Hemodynamic changes during long meditation.

Changes in heart rate (HR) and blood pressure (BP) in advanced male meditators during 1 hr of meditation were compared with matched control participants resting for 1 hr. Also, changes in HR and BP during 3-hr meditation were analyzed. HR was recorded continuously during meditation (n = 38) and the control rest (n = 21). BP was measured before and after the meditation (n = 44) and the rest (n = 30). During the first hour, HR declined more in the meditators than the controls (p < .01). Within participant variability of HR was significantly lower during meditation than rest (p < .05). In the second hour of meditation, HR declined further (p = .01). BP was unaffected by either meditation or rest. In conclusion, meditation reduced the level of HR and within participant variability of HR more than rest. HR continued to decline during the second hour of meditation.

The effects of long meditation on plasma melatonin and blood serotonin.

BACKGROUND: The benefits of meditation are well documented, but the biochemical mechanisms have not been fully identified. One effect mechanism may be via influence on neurotransmitters. MATERIAL/METHODS: Therefore, plasma melatonin and blood serotonin concentrations were measured before and after one hour of meditation in advanced male meditators (n=27, mean age 46 years). They were compared with a matched reference group (n=29, mean age 43 years) who rested for one hour. In the meditators, melatonin and serotonin from before and after three consecutive hours of meditation were also compared. RESULTS: Initially, the median melatonin level was 4.9 pg/ml-1 in the meditators and 3.1 pg/ml-1 in the reference group (p<0.01). After one hour of practice, melatonin had decreased to a median of 3.4 pg/ml-1 in the meditators (p<0.0001), but was unchanged in the reference group. After three hours of meditation, melatonin had declined further in the meditators. After one hour of practice, serotonin concentrations decreased in both the meditators and the reference group (p<0.01). CONCLUSIONS: The findings suggest that advanced meditators have higher melatonin levels than non-meditators. Melatonin decreases during long meditation, a finding the study does not explain. Serotonin declines after both one-hour meditation and rest, indicating that serotonin may be a marker of general rest and not meditation-specific relaxation.