Cardiovascular risk of veterans' football: An observational cohort study with follow-up.

BACKGROUND: The cardiac stress for veteran football players during match is considerable. In this specific elderly population, the kinetics of exercise-induced cardiac troponin I (cTnI) and B-Type natriuretic peptide (BNP) could potentially be related to cardiovascular risk factors (CVRF) and cardiovascular disease and are therefore be investigated for their usefulness as an complement to established screening measures. METHODS: cTnI and BNP was measured in 112 veteran football players (age: 51 ± 10 years) within 30 minutes pre- and post-match. Players with elevated cTnI (cTnI-positive) and a control group (out of the 112 veteran players) with normal cTnI (cTnI-negative) underwent cardiac follow-up 4.2 ± 3.5 months post-match, comprising history, resting and stress ECG (including 30 minutes pre- and post cTnI and BNP), and echocardiography. RESULTS: In 33 players (29%) cTnI and in 6 players BNP (5%) exceeded the upper range limit for increased risk of myocardial damage (cTnI ≥ 5 ng/l) and myocardial wall stress (BNP ≥ 100 pg/ml) post-match, respectively. No correlation was observed between Δ cTnI (pre- vs. post-match) and the number of CVRF (r = -0.06, p = 0.50). Follow-up was conducted in 62 players (31 cTnI-positive and 31 cTnI-negative players) of which 6 (10%, 3 cTnI positive and 3 cTnI negative players) had cardiac abnormalities (hypertrophic cardiomyopathy n = 2, coronary artery disease n = 2, coronary artery anomaly n = 1, hypertensive heart disease n = 1). CONCLUSION: Veterans' football matches elicit increases in BNP and particularly cTnI in a considerable number of players. However, these biochemical alterations do not indicate acute cardiac damage as evidenced by follow-up. Routine determination of cardiac biomarkers is unlikely to improve cardiovascular screening in veteran football players.

Influence of a 7-day Transalpine Trail Run on cardiac biomarkers and myocardial function.

Intense physical exercise is known to increase cardiac biomarkers; however, it is unclear, whether this phenomenon is physiological, or if it indicates myocardial tissue injury. The aim of our study was to investigate the effects of seven consecutive days of excessive endurance exercise on continuous assessment of cardiac biomarkers, function, and tissue injury. During a 7-day trail-running competition (Transalpine Run, distance 267.4 km, altitude ascent/descent 15556/14450 m), daily blood samples were obtained for cardiac biomarkers (hs-TnT, NT-proBNP, and suppression of tumorigenicity-2 protein (ST2)) at baseline, after each stage and 24-48 h post-race. In addition, echocardiography was performed every second day, cardiac magnetic resonance imaging (CMR) before (n = 7) and after (n = 16) the race. Twelve (eight males) out of 17 healthy athletes finished all seven stages (average total finish time: 43 ± 8 h). Only NT-proBNP increased significantly (3.6-fold, p = 0.009) during the first stage and continued to increase during the race. Hs-TnT revealed an incremental trend during the first day (2.7-fold increase, p = 0.098) and remained within the pathological range throughout the race. ST2 levels did not change during the race. All cardiac biomarkers completely returned to physiological levels post-race. NT-proBNP kinetics correlated significantly with mild transient reductions in right ventricular function (assessed by TAPSE, tricuspid annular plane systolic function; r = -0.716; p = 0.014). No significant echocardiographic changes in LV dimensions, LV function, or relevant alterations in CMR were observed post-race. In summary, this study shows that prolonged, repetitive, high-volume exercise induced a transient, significant increase in NT-proBNP associated with right ventricular dysfunction without corresponding left ventricular functional or structural impairment.

Myocarditis Screening Methods in Athletes After SARS-CoV-2 Infection - a Systematic Review.

This review aims to elucidate the myocarditis incidence in SARS-CoV-2-positive athletes and to evaluate different screening approaches to derive sports cardiological recommendations after SARS-CoV-2 infection. The overall incidence of athletes (age span 17-35 years, 70% male) with myocarditis after SARS-CoV-2 infection was 1.2%, with a high variation between studies (which contrasts an incidence of 4.2% in 40 studies within the general population). Studies that used conventional screening based on symptoms, electrocardiogram, echocardiography, and cardiac troponin - only followed by cardiac magnetic resonance imaging in case of abnormal findings - reported lower myocarditis incidences (0.5%, 20/3978). On the other hand, advanced screening that included cardiac magnetic resonance imaging within the primary screening reported higher incidences (2.4%, 52/2160). The sensitivity of advanced screening seems to be 4.8 times higher in comparison to conventional screening. However, we recommend prioritization of conventional screening, as the economical load of advanced screening for all athletes is high and the incidence of myocarditis in SARS-CoV-2-positive athletes and the risk of adverse outcomes seems low. Future research will be important to analyze the long-term effects of myocarditis after infection with SARS-CoV-2 in athletes for risk stratification to optimally guide a safe return to sport.

Correlation of Walking Activity and Cardiac Hospitalizations in Coronary Patients for 1 Year Post Cardiac Rehabilitation: The More Steps, the Better!

Problem: Reducing risk by improving fitness is one of the main objectives of cardiac rehabilitation (CR). To estimate how the number of steps/day post-CR affects coronary patients' prognosis, we analyzed its correlation with the occurrence of death, hospitalizations, and heart complaints, and if and how other variables (ejection fraction (EF), gender, age) relate to those. Methods: One hundred eleven patients (male = 91, female = 20; average age ± standard deviation (SD): 61 ± 11 years) who had been in CR due to recent coronary revascularization or chronic coronary syndrome could be enrolled. Patients were advised to document their steps (daily), blood pressure (daily), weight (weekly) and occurrences of a cardiac event in a diary for 1 year post-CR. A Cox proportional hazard model was used to examine the influence of steps/day, EF, gender, and age until the occurrence of an event. Kaplan-Meier curves were generated to compare patients' profiles. Results: Average steps/day of patients post-CR were 7333 (SD 4426). Increased walking activity reduced risk for cardiac hospitalization (constant steps/day: 5000 vs 7500, hazard rate (HR) reduction of 0.43; 10 000 vs 12 500, HR reduction of 0.20) and risk was higher in patients with an EF < 55% versus EF ⩾ 55% (HR increase of 2.88). Median follow-up time post-CR was 218 days. No patient died, 25 were hospitalized. Discussion: Monitoring the number of steps of coronary patients post CR could be valuable for estimating patients' prognosis.

Cardiocirculatory Stress in Professional Football (Soccer) Coaches.

OBJECTIVE: It was intended to quantify cardiocirculatory stress and risk of professional football (soccer) coaches during competition. DESIGN: Descriptive cross-sectional study. SETTING: Medical screening examination and measurements during match. PARTICIPANTS: Seventeen coaches and 11 assistant coaches of the 2 highest German football leagues (male coaches; 46 ± 7 years; 8 ± 7 years in job). INDEPENDENT VARIABLES: Professional football matches with highly competitive character were chosen and monitored for elicited cardiocirculatory stress and possible damage. MAIN OUTCOME MEASURES: Indicators of general health status, occurrence of arrhythmias, and course of heart rate and cardiac biomarkers (brain natriuretic peptide [BNP], troponin I) during the match. RESULTS: Besides a few preexisting cardiovascular diseases, medical screening revealed a risk factor profile similar to the general population and above-average maximal/submaximal cycle ergometry performance: Pmax 2.9 ± 0.5 W*kg-1; PWC130 1.9 ± 0.5 W*kg-1. No match-induced changes were detected for BNP (20.5 ± 9.4 to 19.7 ± 10.7 pg/mL; P = 0.48) and troponin I (12.6 ± 16.5 to 10.5 ± 14.1 ng/L; P = 0.31). Maximal heart rate during the first and second half was 127 ± 15 and 132 ± 19 beats per minute, respectively. No match-induced arrhythmias of higher degree were detected. CONCLUSIONS: Head and assistant coaches of German professional football teams do not show any match-induced cardiac damage, despite considerable cardiocirculatory stress. Possibly, their above-average fitness level saves them from more detrimental outcomes.

Prediction of Successful Pharmacological Cardioversion in Acute Symptomatic Atrial Fibrillation: The Successful Intravenous Cardioversion for Atrial Fibrillation (SIC-AF) Score.

Background: Modern personalised medicine requires patient-tailored decisions. This is particularly important when considering pharmacological cardioversion for the acute treatment of haemodynamically stable atrial fibrillation and atrial flutter in a shared decision-making process. We aimed to develop and validate a predictive model to estimate the individual probability of successful pharmacological cardioversion using different intravenous antiarrhythmic agents. Methods: We analysed data from a prospective atrial fibrillation registry comprising 3053 cases of first-detected or recurrent haemodynamically stable, non-permanent, symptomatic atrial fibrillation presenting to an Austrian academic emergency department between January 2012 and December 2017. Using multivariable analysis, a prediction score was developed and externally validated. The clinical utility of the score was assessed using decision curve analysis. Results: A total of 1528 cases were included in the development cohort (median age 69 years, IQR 58−76; 43.9% female), and 1525 cases were included in the validation cohort (median age 68 years, IQR (58−75); 39.5% female). Finally, 421 cases were available for score development and 330 cases for score validation The weighted score included atrial flutter (8 points), duration of symptoms associated with AF (<24 h; 8 points), absence of previous electrical cardioversion (10 points), and the specific intravenous antiarrhythmic drug (amiodarone 10 points, vernakalant 11 points, ibutilide 13 points). The final score, the "Successful Intravenous Cardioversion for Atrial Fibrillation (SIC-AF) score," showed good calibration (R2 = 0.955 and R2 = 0.954) and discrimination in both sets (c-indices: 0.68 and 0.66) and net clinical benefit. Conclusions: A predictive model was developed to estimate the success of intravenous pharmacological cardioversion using different antiarrhythmic agents in a cohort of patients with haemodynamically stable, non-permanent, symptomatic atrial fibrillation. External temporal validation confirmed good calibration, discrimination, and clinical usefulness. The SIC-AF score may help patients and physicians jointly decide on the appropriate treatment strategy for acute symptomatic atrial fibrillation. Registration: NCT03272620.

FIFA Sudden Death Registry (FIFA-SDR): a prospective, observational study of sudden death in worldwide football from 2014 to 2018.

OBJECTIVE: To investigate the underlying causes and regional patterns of sudden death in football (soccer) players worldwide to inform and improve existing screening and prevention measures. METHODS: From 2014 to 2018 cases of sudden cardiac death (SCD), survived sudden cardiac arrest (SCA) and traumatic sudden death were recorded by media monitoring (Meltwater), a confidential web-based data platform and data synchronisation with existing national Sudden Death Registries (n=16). Inclusion criteria were met when sudden death occurred during football-specific activity or up to 1 hour afterwards. Death during other activities was excluded. RESULTS: A total of 617 players (mean age 34±16 years, 96% men) with sudden death were reported from 67 countries; 142 players (23%) survived. A diagnosis by autopsy or definite medical reports was established in 211 cases (34%). The leading cause in players >35 years was coronary artery disease (76%) and in players ≤35 years was sudden unexplained death (SUD, 22%). In players ≤35 years the leading cause of SCD varied by region: cardiomyopathy in South America (42%), coronary artery anomaly in North America (33%) and SUD in Europe (26%). Traumatic sudden death including commotio cordis occurred infrequently (6%). Cardiopulmonary resuscitation (CPR) resulted in a survival rate of 85% with the use of an automated external defibrillator (AED) compared with 35% without. CONCLUSIONS: Regional variation in SCD aetiology should be verified by expansion of national registries and uniform autopsy protocols. Immediate access to an AED at training and competition sites, as well as CPR training for players, coaches and staff members, is needed to improve survival from SCA.

Influence of an increased number of physical education lessons on the motor performance of adolescents-A non-interventional cohort study.

Increasing the amount of regular physical education lessons in school is currently discussed in many countries in order to increase physical activity in youth. The purpose of this study was to compare the motor performance of pupils from an observation group participating in a school trial of two additional physical education lessons (5 lessons of each 50 min/week) without a specific intervention program to a control group with a regular amount of three physical education lessons (3 lessons of each 50 min/week) as indicated by the standard Austrian school curriculum. In this cohort study motor performance of 140 adolescents (12.7±0.5 years) was assessed by means of the German Motor Performance Test 6-18 over a period of 1.5 years with measurement time points before (T1), after eight months (T2) and at the end of the observation period (T3). Two- and three-way mixed analysis of variance were used to detect time, group and interaction effects. Although the observation group demonstrated a higher total motor performance score at all time points (P = 0.005), the improvement over time in total motor performance (P < 0.001) was more pronounced in the control group. Girls and boys developed differently over time (time*gender interaction: P = 0.001), whereby group allocation did not affect this interaction (time*gender*group: P = 0.167). Anyway, girls of control group tend to benefit most of additional physical education lessons. Sports club members scored significantly higher in motor performance across the observation period (P = 0.018) irrespective of group allocation. These findings indicate that there could be a ceiling effect in what the pupils could achieve in terms of motor performance as the pupils of the observation group might have reached this point earlier than their counterparts in the control group. Nevertheless, sports club membership seems to reveal some benefits. Whether improving quality and specificity of the single physical lessons might be superior to merely adding additional ones needs to be confirmed in future studies.

Cardiac structure and function in response to a multi-stage marathon over 4486 km.

AIMS: To investigate whether participation in the Trans Europe Foot Race 2009 (TEFR), an ultramarathon race held over 64 consecutive days and 4486 km, led to changes in cardiac structure and function. METHODS: Cardiac magnetic resonance imaging was performed in 20 of 67 participating runners (two women; mean ± SD age 47.8 ± 10.4 years) at three time points (baseline scan at 294 ± 135 km (B), scan two at 1735 ± 86 km (T1) and scan three at 3370 ± 90 km (T2)) during the TEFR. Imaging included an assessment of left ventricular structure (mass) and function (strain). In parallel, cardiac troponin I, NT-pro-BNP, myostatin and GDF11 were determined in venous blood samples. A subsample of ten runners returned for a follow-up scan eight months after the race. RESULTS: Left ventricular mass increased significantly (B, 158.5 ± 23.8 g; T1, 165.1 ± 23.2 g; T2, 167 ± 24.6 g; p < 0.001) over the course of the race, although no significant change was seen in the remaining structural and functional parameters. Serum concentrations of cardiac troponin I and NT-proBNP significantly increased 1.5 - and 3.5-fold, respectively, during the first measurement interval, with no further increase thereafter (cardiac troponin I, 6.8 ± 3.1 (B), 16.9 ± 10.4 (T1) and 17.1 ± 9.7 (T2); NT-proBNP, 30.3 ± 22.8 (B), 135.9 ± 177.5 (T1) and 111.2 ± 87.3 (T2)), whereas the growth markers myostatin and GDF11 did not change. No association was observed with functional parameters, including the ejection fraction and the volume of both ventricles. The follow-up scans showed a reduction to baseline values (left ventricular mass 157 ± 19.3 g). CONCLUSIONS: High exercise-induced cardiac volume load for >2 months in ultra-endurance runners results in a physiological structural adaptation with no sign of adverse cardiovascular remodelling.

Exercise and sports after COVID-19-Guidance from a clinical perspective.

SARS-CoV-2 infection has emerged as not only a pulmonary but also potentially multi-organ disease, which may cause long-term structural damage of different organ systems including the lung, heart, vasculature, brain, liver, kidney, or intestine. As a result, the current SARS-CoV-2/COVID-19 pandemic will eventually yield substantially increased numbers of chronically diseased patients worldwide, particularly suffering from pulmonary fibrosis, post-myocarditis, chronic heart failure, or chronic kidney disease. Exercise recommendations for rehabilitation are complex in these patients and should follow current guidelines including standards for pre-exercise medical examinations and individually tailored exercise prescription. It is of utmost importance to start exercise training at an early stage after COVID-19 infection, but at the same time paying attention to the physical barriers to ensure safe return to exercise. For exercise recommendations beyond rehabilitation programs particularly for leisure time and elite athletes, more precise advice is required including assessment of sports eligibility and specific return-to-sports exercise programs. Because of the current uncertainty of long-term course of SARS-CoV-2 infection or COVID disease, long-term follow-up seems to be necessary.

Electrocardiographic and Echocardiographic Findings in Ghanaian Female Soccer Players.

OBJECTIVE: To examine the heart of Ghanaian adult and adolescent female soccer players using electrocardiography (ECG) and echocardiography (ECHO), and to describe typical ECG and ECHO findings in a cohort of west African female soccer players. DESIGN: Cross-sectional study of ECG and ECHO performed as part of precompetition medical assessment for 3 national female football teams preparing for various Fédération Internationale de Football Association (FIFA) tournaments in 2016. SETTING: Ghana National Football Association. PARTICIPANTS: Seventy-five female players playing for the National female football teams preparing for FIFA tournaments in 2016. INTERVENTIONS: Precompetition medical assessment using ECGs and ECHOs. MAIN OUTCOME MEASURE: Number of athletes with abnormal ECG and ECHO findings using the International ECG Interpretation criteria. RESULTS: Eight percent of the participants had T-wave inversions in lateral leads (V5-V6). Voltage criteria for left ventricular hypertrophy (LVH) were present in 35% of participants. A total of 2.7% of the players had LV wall thickness (LVWT) ≥12 mm with no player exceeding 13 mm. No player had LV cavity dimension greater than 60 mm. CONCLUSION: Ghanaian female soccer players seem to have a high prevalence of LVH and repolarization change. Although LVWT up to 12 mm might be normal in this cohort, deep T-wave inversions and LVWT ≥13 mm should always be further investigated and/or undergo a long-term follow.

Sports-Related Sudden Cardiac Arrest in Germany.

BACKGROUND: Knowledge about causes of sports-related sudden cardiac arrest (SrSCA) may influence national strategies to prevent such events. Therefore, we established a prospective registry on SrSCA to estimate the incidence and in particular describe the etiologies of SrSCA in the general population in Germany. METHODS: The registration of SrSCA based upon 4 pillars: a web-based platform to record SrSCA cases in competitive and recreational athletes, media-monitoring, cooperation with the German Resuscitation Registry, and 15 institutes of forensic medicine. RESULTS: After an observation period of 6 years, a total of 349 cases was recorded (mean age 48.0 ± 12.7 years); 109 subjects survived. Most of the cases occurred during nonelite competitive or recreational sports. Bystander cardiopulmonary resuscitation (CPR) was initiated in 262 cases (75%); however, rhythm analysis and defibrillation (if indicated) was mainly performed by medical services. In patients ≤ 35 years of age, premature coronary artery disease (CAD) and sudden arrhythmic death syndrome (SADS) prevailed, followed by myocarditis. In athletes ≥ 35 years of age, CAD predominated. CONCLUSIONS: Country-specific registries are necessary to define the national screening and prevention strategy optimally. In Germany, premature CAD, SADS, and myocarditis are the leading causes of SrSCA in young athletes, reinforcing the great disparity of the prevalence of cardiac diseases among different countries. Extension of on-site SCD-prevention campaigns, with training of CPR and explanation of the efficient use of automated external defibrillators (AEDs), may decrease the burden of SrSCD.

Electrocardiographic and Echocardiographic Findings in Elite Ghanaian Male Soccer Players.

OBJECTIVE: To analyze the athlete's heart of adult and adolescent elite male soccer players by electrocardiography (ECG) and echocardiography (ECHO) and to describe typical ECG and ECHO findings in this cohort (West African elite soccer players). DESIGN: A cross-sectional study of ECGs and ECHOs conducted as part of precompetition medical assessment for national male soccer teams preparing for various Fédération Internationale de Football Association (FIFA) tournaments in 2016 and 2017. SETTING: Ghana National Football Association. PARTICIPANTS: One hundred fifty-nine players playing for the National male soccer teams preparing for tournaments in 2016 and 2017. INTERVENTIONS: Precompetition medical assessment using ECGs and ECHOs. MAIN OUTCOME MEASURES: Number of athletes with abnormal ECGs and ECHO findings. RESULTS: Twenty-three percent of the players had abnormal ECGs. Nine percent of the participants had T-wave inversions in lateral leads (V5-V6). Sokolow-Lyon criteria for left ventricular hypertrophy were present in 64% of participants. Thirty-six (23%) players had left ventricular wall thickness (LVWT) ≥13 mm, with no player exceeding 16 mm. Four percent of players had left ventricular cavity dimension greater than 60 mm. Relative wall thickness >0.42 was present in 44% of the players. CONCLUSIONS: Uncommon ECG changes seem to be more common in elite Ghanaian soccer players compared with previously reported results for Caucasians and even mixed populations of black athletes. Although ST elevation, T-wave inversions, and LVWT up to 15 mm are common, ST depression, deep T-waves in lateral leads, and LVWT ≥16 mm always warrant further clinical and scientific investigations.

Electrocardiographic and Echocardiographic Findings in Black Athletes: A General Review.

BACKGROUND: Participation in regular physical activity produces electrophysiological and structural cardiac changes in electrocardiograms (ECGs) and echocardiographs (ECHOs) of athletes, and the term "athlete's heart" is used to describe these physiological cardiovascular adaptations. Extent and type of sporting discipline, age, sex, body dimensions, and ethnicity have an influence on cardiac remodeling. OBJECTIVE: As the recent scientific literature increasingly reports on ethnicity-specific ECG and ECHO findings in black athletes, it is the aim of this review to provide an overview of ECG and ECHO findings among athletes of black African/Afro-Caribbean descent. DATA SOURCES: A systematic search of PubMed and MEDLINE databases up to and including August 2017 was conducted using the following terms/phrases "black OR African OR Afro-Caribbean athlete heart," "black OR African OR Afro-Caribbean athlete electrocardiogram," and "black OR African OR Afro-Caribbean athlete echocardiogram." The search generated a total of 130 papers, out of which 16 original articles fitted our criteria and were selected for this review. MAIN RESULTS: The various studies reviewed revealed that about 10% to 30% of black African/Afro-Caribbean athletes had abnormal ECG. R/S voltage criteria exceeding hypertrophic indices were found in about 60% to 89% of black African/Afro-Caribbean athletes. ST-segment elevation (17%-90%) and T-wave inversions were also common findings among this ethnicity. About 10% to 12% of black African/Afro-Caribbean athletes had a left ventricular wall thickness ranging from 13 to 15 mm. Cavity dimensions ranged from 40 to 66 mm in black African/Afro-Caribbean athletes with a relative wall thickness >0.44. CONCLUSIONS: Updated ethnic-specific guidelines are required to discriminate physiological from pathologic hypertrophy and repolarization changes. Future studies should focus on homogeneous cohorts of African athletes.

Walking activity during ambulant cardiac rehabilitation is related to maximum working capacity, age, and smoking behavior.

BACKGROUND: A total of 6,500 to 8,000 steps per day are recommended for cardiovascular secondary prevention. The aim of this research was to examine how many steps per day patients achieve during ambulant cardiac rehabilitation (CR), and if there is a correlation between the number of steps and physical and cardiological parameters. METHODS: In all, 192 stable CR patients were included and advised for sealed pedometry. The assessed parameters included maximum working capacity and heart rate, body mass index (BMI), New York Heart Association (NYHA) class, ejection fraction (EF), coronary artery disease status, beta-blocker medication, age, sex, smoking behavior, and laboratory parameters. A regularized regression approach called least absolute shrinkage and selection operator (LASSO) was used to detect a small set of explanatory variables associated with the response for steps per day. Based on these selected covariates, a sparse additive regression model was fitted. RESULTS: The model noted that steps per day had a strong positive correlation with maximum working capacity (P=0.001), a significant negative correlation with higher age (P=0.01) and smoking (smoker: P<0.05; ex-smoker: P=0.01), a positive correlation with high-density lipoprotein (HDL), and a negative correlation with beta-blockers. Correlation between BMI and walking activity was nonlinear (BMI 18.5-24: 7,427±2,730 steps per day; BMI 25-29: 6,448±2,393 steps/day; BMI 30-34: 6,751±2,393 steps per day; BMI 35-39: 5,163±2,574; BMI >40: 6,077±1,567). CONCLUSION: Walking activity during CR is reduced in patients who are unfit, older, smoke, or used to smoke. In addition to training recommendations, estimated steps per day during CR could be seen as a baseline orientation that helps patients to stay generally active or even to increase activity after CR.