Cardiovascular considerations on recreational scuba diving. SEC-Clinical Cardiology Association/SEC-Working Group on Sports Cardiology consensus document.

The practice of recreational scuba diving has increased worldwide, with millions of people taking part each year. The aquatic environment is a hostile setting that requires human physiology to adapt by undergoing a series of changes that stress the body. Therefore, physical fitness and control of cardiovascular risk factors are essential for practicing this sport. Medical assessment is not mandatory before participating in this sport and is only required when recommended by a health questionnaire designed for this purpose. However, due to the significance of cardiovascular disease, cardiology consultations are becoming more frequent. The aim of the present consensus document is to describe the cardiovascular physiological changes that occur during diving, focusing on related cardiovascular diseases, their management, and follow-up recommendations. The assessment and follow-up of individuals who practice diving with previous cardiovascular disease are also discussed. This document, endorsed by the Clinical Cardiology Association of the Spanish Society of Cardiology (SEC) and the SEC Working Group on Sports Cardiology of the Association of Preventive Cardiology, aims to assist both cardiologists in evaluating patients, as well as other specialists responsible for assessing individuals' fitness for diving practice.

Aortic Diameters and Calcifications in Former World-Class Cyclists.

PURPOSE: Concerns on whether athletes--particularly older ones--are at an increased risk of pathological aortic dilation exist, and the prevalence of aortic calcifications in these individuals is unknown. We aimed to compare the dimensions, distensibility, and prevalence of calcifications in the thoracic aorta between former male professional cyclists (cases) and sex/age-matched controls. METHODS: We used a retrospective cohort design, where cases were former finishers of at least one Grand Tour (Tour de France, Giro d' Italia or Vuelta a España) and controls were untrained individuals with no previous sports history and free of cardiovascular risk. All participants underwent magnetic resonance and computer tomography assessments for the measurement of aortic dimensions and calcifications, respectively. RESULTS: Cases showed larger ( P < 0.05) dimensions than controls for aortic annulus, sinus, and arch, as well as for ascending and descending aorta. However, none of the participants presented with pathological aortic dilation (all diameters <40 mm). A slightly higher prevalence of calcifications in the ascending aorta was observed in cases (13% vs 0% in controls, P = 0.020). Subanalyses confirmed that cases who were still competing (masters category, n = 8) had larger aortic diameters ( P < 0.05) and a greater presence of calcifications in the ascending/descending aorta (38% vs 0% for both segments, P = 0.032) than those who had become inactive ( n = 15). No between-group differences were found for aortic distensibility. CONCLUSIONS: Former professional cyclists, particularly those who are still competing after retirement, show enlarged aortic diameters (albeit without exceeding upper limits of normality). Former professional cyclists also showed a slightly higher prevalence of calcifications in the ascending aorta than controls, although aortic distensibility was not compromised. The clinical relevance of these findings should be the subject of future studies.

Myocardial Work Index in Professional Football Players: A Novel Method for Assessment of Cardiac Adaptation.

BACKGROUND: The global myocardial work index (GWI), a novel, valid, and non-invasive method based on speckle-tracking echocardiography, could provide value for calculating left ventricular (LV) function and energy consumption in athletes. MATERIALS AND METHODS: We prospectively analyzed a single-center cohort of Spanish First-Division football players who attended a pre-participation screening program from June 2020 to June 2021, compared to a control group. All the individuals underwent an electrocardiogram and echocardiography, including two-dimensional speckle tracking and 4D-echo. The study aimed to evaluate the feasibility of myocardial work in professional football players and its correlations with other echocardiographic parameters. RESULTS: The study population comprised 97 individuals (49 professional players and 48 controls). The mean age was 30.48 ± 7.20 years old. The professional football players had significantly higher values of LVEDV (p < 0.001), LVESV (p < 0.001), LV-mass index (p = 0.011), PWTd (p = 0.023), and EA (p < 0.001) compared with the control group. In addition, the professional players had lower GCW (p = 0.003) and a tendency to show lower GWI values (p < 0.001). These findings could suggest that professional football players have more remodeling and less MW, related to their adaptation to intensive training. Significant differences in GLS (p = 0.01) and GWE (p = 0.04) were observed as a function of the septal thickness of the athletes. Irrespective of the MW variable, the parameters with better correlations across all the populations were SBP, DBP, and GLS. CONCLUSIONS: The GWI is a novel index to assess cardiac performance, with less load dependency than strain measurements. Future GWI analyses are warranted to understand myocardial deformation and other pathological differential diagnoses.

Myocardial Fibrosis and Coronary Calcifications Caused by Endurance Exercise? Insights from Former Professional Cyclists.

PURPOSE: This study aimed to compare the prevalence of myocardial fibrosis and coronary calcification in individuals who have performed very high levels of strenuous endurance exercise (SEE; former male professional cyclists) and sex/age-matched controls. METHODS: We used a retrospective cohort study design, where cases were former finishers of ≥1 Grand Tour (Tour de France, Giro d' Italia or Vuelta a España) and controls were untrained individuals free of cardiovascular risk. All participants underwent cardiac magnetic resonance and cardiac computer tomography in the same center during years 2020-2021 to detect myocardial fibrosis (late gadolinium enhancement) and to quantify coronary calcium, respectively. RESULTS: Twenty-three cases (age, 46 ± 6 yr) and 59 controls (47 ± 7 yr) were studied. Fibrotic patches were evidenced only in the left ventricle, with a higher prevalence in cases (23% vs 2% in controls, P = 0.006). However, fibrotic tissue was nonischemic and of low extension (0.6% ± 0.4% of left ventricle mass), and no significant differences were found between cases and controls for native T1 or T2 values. No between-group differences were found for coronary calcium indicators, including Agatston or density scores. Subanalyses revealed no differences attending to whether cases were still performing regular SEE ( n = 8) or not ( n = 15) after professional retirement. CONCLUSIONS: Although former professional cyclists seemed to show a greater prevalence of myocardial fibrosis, the extension of fibrotic tissue was minimal and no alterations were found in coronary calcification indicators. While keeping in mind the low sample size of the cases' group, our results do not support evidence for major cardiac maladaptations with long-term exposure to SEE, at least in middle-age adults.

Normative Values for Sport-Specific Left Ventricular Dimensions and Exercise-Induced Cardiac Remodeling in Elite Spanish Male and Female Athletes.

BACKGROUND: There is debate about the magnitude of geometrical remodeling [i.e., left ventricle (LV) cavity enlargement vs. wall thickening] in the heart of elite athletes, and no limits of normality have been yet established for different sports. We aimed to determine sex- and sport-specific normative values of LV dimensions in elite white adult athletes. METHODS: This was a single-center, retrospective study of Spanish elite athletes. Athletes were grouped by sport and its relative dynamic/static component (Mitchell's classification). LV dimensions were measured with two-dimensional-guided M-mode echocardiography imaging to compute normative values. We also developed an online and app-based calculator ( https://sites.google.com/lapolart.es/athlete-lv/welcome?authuser=0 ) to provide clinicians with sports- and Mitchell's category-specific Z-scores for different LV dimensions. RESULTS: We studied 3282 athletes (46 different sports, 37.8% women, mean age 23 ± 6 years). The majority (85.4%) showed normal cardiac geometry, particularly women (90.9%). Eccentric hypertrophy was relatively prevalent (13.4%), and concentric remodeling or hypertrophy was a rare finding (each < 0.8% of total). The proportion of normal cardiac geometry and eccentric hypertrophy decreased and increased, respectively, with the dynamic (in both sexes) or static component (in male athletes) of the sport irrespective of the other (static or dynamic) component. The 95th percentile values of LV dimensions did not exceed the following limits in any of the Mitchell categories: septal wall thickness, 12 mm (males) and 10 mm (females); LV posterior wall, 11 mm and 10 mm; and LV end-diastolic diameter, 64 mm and 57 mm. CONCLUSIONS: The majority of elite athletes had normal LV geometry, and although some presented with LV eccentric hypertrophy, concentric remodeling or hypertrophy was very uncommon. The present study provides sport-specific normative values that can serve to identify those athletes for whom a detailed examination might be recommendable (i.e., those exceeding the 95th percentile for their sex and sport).

Holter-determined arrhythmias in young elite athletes with suspected risk: Insights from a 20-year experience.

Purpose: We assessed the occurrence of rhythm alterations in elite athletes with suspected risk using Holter monitoring, and the association of Holter-determined rhythm alterations with echocardiographic findings. Methods: A large cohort of Spanish elite athletes (N = 6,579, 34% female) underwent in-depth cardiological examination (including echocardiographic evaluation, and resting and exercise electrocardiogram [ECG]) between 01/02/1998 and 12/31/2018. Holter monitoring was performed in those reporting cardiovascular symptoms, with suspicion of cardiac structural abnormalities potentially associated with dangerous arrhythmias, or with resting/exercise ECG features prompting a closer examination. We assessed the occurrence of cardiac rhythm alterations, as well as the association between echocardiography-determined conditions and rhythm alterations. Results: Most athletes (N = 5925) did not show any sign/symptom related to arrhythmia (including normal resting and exercise/post-exercise ECG results) whereas 9.9% (N = 654; 28% female; median age, 24 years [interquartile range 19-28]; competition experience [mean ± SD] 10±6 years) met the criteria to undergo Holter monitoring. Among the latter, sinus bradycardia was the most common finding (present in 96% of cases), yet with a relatively low proportion of severe (<30 bpm) bradycardia (12% of endurance athletes during night-time). Premature atrial and ventricular beats were also common (61.9 and 39.4%, respectively) but sinus pauses ≥3 s, high-grade atrioventricular blocks, and atrial fibrillation/flutter were rare (<1%). Polymorphic premature ventricular contractions (PVC, 1.4%) and idioventricular rhythm (0.005%) were also rare. PVC couplets were relatively prevalent (10.7%), but complex ventricular arrhythmias were not frequent (PVC triplets: 1.8%; sustained ventricular tachycardia: 0.0%; and nonsustained ventricular tachycardia: 1.5%). On the other hand, no associations were found between arrhythmias (including their different morphologies) and major cardiac structural alterations (including mitral prolapse). However, an association was found between mild mitral regurgitation and supraventricular (odds ratio 2.61; 95% confidence interval 1.08-6.32) and ventricular (2.80; 1.15-6.78; p = 0.02) arrhythmias, as well as between mild or moderate mitral regurgitation and ventricular arrhythmias (2.49; 1.03-6.01). Conclusions: Irrespective of the sports discipline, "dangerous" ventricular arrhythmias are overall infrequent even among young elite athletes who require Holter monitoring due to the presence of symptoms or abnormal echocardiographic/ECG findings, and do not seem to be associated with underlying serious cardiac structural pathologies.

Left atrial enlargement in competitive athletes and atrial electrophysiology.

INTRODUCTION AND OBJECTIVES: There are scarce data on left atrial (LA) enlargement and electrophysiological features in athletes. METHODS: Multicenter observational study in competitive athletes and controls. LA enlargement was defined as LA volume indexed to body surface area ≥ 34mL/m2. We analyzed its relationship with atrial electrocardiography parameters. RESULTS: We included 356 participants, 308 athletes (mean age: 36.4±11.6 years) and 48 controls (mean age: 49.3±16.1 years). Compared with controls, athletes had a higher mean LA volume index (29.8±8.6 vs 25.6±8.0mL/m2, P=.006) and a higher prevalence of LA enlargement (113 [36.7%] vs 5 [10.4%], P <.001), but there were no relevant differences in P-wave duration (106.3±12.5ms vs 108.2±7.7ms; P=.31), the prevalence of interatrial block (40 [13.0%] vs 4 [8.3%]; P=.36), or morphology-voltage-P-wave duration score (1.8±0.84 vs 1.5±0.8; P=.71). Competitive training was independently associated with LA enlargement (OR, 14.7; 95%CI, 4.7-44.0; P <.001) but not with P-wave duration (OR, 1.02; 95%CI, 0.99-1.04), IAB (OR, 1.4; 95%CI, 0.7-3.1), or with morphology-voltage-P-wave duration score (OR, 1.4; 95%CI, 0.9-2.2). CONCLUSIONS: LA enlargement is common in adult competitive athletes but is not accompanied by a significant modification in electrocardiographic parameters.

Exercise-Induced Cardiac Fatigue in Recreational Ultramarathon Runners at Moderate Altitude: Insights From Myocardial Deformation Analysis.

BACKGROUND: Controversy exists on the actual occurrence of exercise-induced cardiac fatigue (EICF) with ultraendurance exercise, as well as on whether factors such as age or training status might predispose to this condition. The present study aimed to assess the occurrence of EICF among recreational ultramarathon runners, as well as to determine potential predictive factors. METHODS: Nineteen male recreational runners (42 ± 12yrs) participated in a 55-km trial race at moderate altitude (1,800-2,500 m). Participants were evaluated before and after the race using Doppler echocardiography and myocardial deformation analysis. EICF was determined as a reduction >5% of either left ventricular global longitudinal strain (LVGLS) or right ventricular free wall strain (RVFWS). Demographical (age, body mass index), training (training experience, volume and intensity), competition (finishing time, relative intensity) and biochemical variables (blood lactate, creatine kinase [CK] and CK-MB) were assessed as predictors of EICF. RESULTS: A significant reduction in LVGLS (20.1 ± 2.1% at baseline vs. 18.8 ± 2.4% at post-race, p = 0.026), but not in RVFWS (27.4 ± 7.0 vs. 24.6 ± 5.3%, p = 0.187), was observed after the race. EICF was present in 47 and 71% of the participants attending to the decrease in LVGLS and RVFWS, respectively. No associations were found between any of the analyzed variables and EICF except for age, which was associated with the magnitude of decrement of RVFWS (r = 0.58, p = 0.030). CONCLUSIONS: Ultramarathon running at moderate altitude seems to induce EICF in a considerable proportion of recreational athletes.

Radiofrequency treatment for electrical storm: evolution and monitoring. / Tratamiento con radiofrecuencia de la tormenta eléctrica: evolución y seguimiento.

Introducción y objetivos: La tormenta eléctrica (TE) se caracteriza por episodios repetidos de taquicardia ventricular o fibrilación ventricular relacionados con mal pronóstico a corto y largo plazos. El objetivo fue evaluar la prevalencia, resultados y supervivencia de los pacientes sometidos a tratamiento intervencionista por TE en un centro de referencia. Métodos: Estudio unicéntrico, observacional y retrospectivo. Se revisaron los procedimientos de ablación por TE y se evaluaron las características basales de los pacientes, tipo de procedimiento, mortalidad total, recurrencia de arritmia, mortalidad cardiovascular y necesidad de trasplante. Resultados: Desde enero de 2009 hasta diciembre de 2016 se realizaron 67 procedimientos (38% de complejos: 19% de ablación endoepicárdica, 7.5% de crioablación epicárdica quirúrgica, 3% de simpatectomía, 3% de inyección coronaria con alcohol; 6% de apoyo con oxigenación con membrana extracorpórea) en 41 pacientes (61% de causa isquémica) por TE. La mortalidad intraprocedimiento fue del 1.5%. La mediana de seguimiento fue de 23.5 meses (RIQ, 14.2-52.7). Tras el primer ingreso por TE (uno o varios procedimientos), la mortalidad a un año fue de 9.8%. La incidencia acumulada de trasplante cardiaco por TE fue de 2.4%. En el análisis multivariado, el riesgo de recurrencias arrítmicas o muerte por cualquier causa fue significativamente mayor en pacientes con arritmias clínicas inducibles (HR, 9.03; p = 0.017). Conclusiones: El tratamiento de pacientes con TE, instituido en un centro de referencia y con experiencia, se relacionó con una tasa baja de recurrencia y supervivencia elevada, con una tasa de trasplante cardiaco por TE muy baja. Ante una recurrencia temprana es recomendable practicar un nuevo procedimiento durante el ingreso. Introduction and objective: Electrical storm (ES) is characterized by repeated episodes of ventricular tachycardia or ventricular fibrillation, with poor short and long term prognosis. Our objective was to evaluate the prevalence, results of interventional treatment and survival of patients undergoing interventional treatment for ES in our center. Methods: Retrospective, unicentric and observational study. ES ablation procedures were revised and data regarding baseline characteristics of the patients, type of procedure, total mortality, recurrence of arrhythmia, cardiovascular mortality and the need for transplantation were evaluated. Results: From January 2009 to December 2016, 67 procedures (38% complex procedures: 19% epicardial ablation, 7.5% surgical epicardial crioablation, 3% simpatectomy, 3% coronary alcohol injection, 6% extracorporeal membrane oxygenation support) were performed in 41 patients (61% Ischemic etiology) due to ES. Intraprocedural mortality was 1.5%. The median follow-up was 23.5 months (IQR [14.2-52.7]). After the first admission for ES (one or several procedures), 1-year mortality was 9.8%. The cumulative incidence of cardiac transplantation was 2.4%. The risk of arrhythmic recurrences or death was significantly higher in patients with inducible clinical arrhythmias after ablation (HR: 9.03, p = 0.017). Conclusions: The treatment of patients with ES, performed in a reference center, allows obtaining good rates of recurrence and survival, with very low rates of cardiac transplantation for ES. In the presence of an early recurrence, it is advisable to perform a new procedure during admission.

Tratamiento con radiofrecuencia de la tormenta eléctrica: evolución y seguimiento / Radiofrequency treatment for electrical storm: evolution and monitoring

Resumen Introducción y objetivos: La tormenta eléctrica (TE) se caracteriza por episodios repetidos de taquicardia ventricular o fibrilación ventricular relacionados con mal pronóstico a corto y largo plazos. El objetivo fue evaluar la prevalencia, resultados y supervivencia de los pacientes sometidos a tratamiento intervencionista por TE en un centro de referencia. Métodos: Estudio unicéntrico, observacional y retrospectivo. Se revisaron los procedimientos de ablación por TE y se evaluaron las características basales de los pacientes, tipo de procedimiento, mortalidad total, recurrencia de arritmia, mortalidad cardiovascular y necesidad de trasplante. Resultados: Desde enero de 2009 hasta diciembre de 2016 se realizaron 67 procedimientos (38% de complejos: 19% de ablación endoepicárdica, 7.5% de crioablación epicárdica quirúrgica, 3% de simpatectomía, 3% de inyección coronaria con alcohol; 6% de apoyo con oxigenación con membrana extracorpórea) en 41 pacientes (61% de causa isquémica) por TE. La mortalidad intraprocedimiento fue del 1.5%. La mediana de seguimiento fue de 23.5 meses (RIQ, 14.2-52.7). Tras el primer ingreso por TE (uno o varios procedimientos), la mortalidad a un año fue de 9.8%. La incidencia acumulada de trasplante cardiaco por TE fue de 2.4%. En el análisis multivariado, el riesgo de recurrencias arrítmicas o muerte por cualquier causa fue significativamente mayor en pacientes con arritmias clínicas inducibles (HR, 9.03; p = 0.017). Conclusiones: El tratamiento de pacientes con TE, instituido en un centro de referencia y con experiencia, se relacionó con una tasa baja de recurrencia y supervivencia elevada, con una tasa de trasplante cardiaco por TE muy baja. Ante una recurrencia temprana es recomendable practicar un nuevo procedimiento durante el ingreso.

Abstract Introduction and objective: Electrical storm (ES) is characterized by repeated episodes of ventricular tachycardia or ventricular fibrillation, with poor short and long term prognosis. Our objective was to evaluate the prevalence, results of interventional treatment and survival of patients undergoing interventional treatment for ES in our center. Methods: Retrospective, unicentric and observational study. ES ablation procedures were revised and data regarding baseline characteristics of the patients, type of procedure, total mortality, recurrence of arrhythmia, cardiovascular mortality and the need for transplantation were evaluated. Results: From January 2009 to December 2016, 67 procedures (38% complex procedures: 19% epicardial ablation, 7.5% surgical epicardial crioablation, 3% simpatectomy, 3% coronary alcohol injection, 6% extracorporeal membrane oxygenation support) were performed in 41 patients (61% Ischemic etiology) due to ES. Intraprocedural mortality was 1.5%. The median follow-up was 23.5 months (IQR [14.2-52.7]). After the first admission for ES (one or several procedures), 1-year mortality was 9.8%. The cumulative incidence of cardiac transplantation was 2.4%. The risk of arrhythmic recurrences or death was significantly higher in patients with inducible clinical arrhythmias after ablation (HR: 9.03, p = 0.017). Conclusions: The treatment of patients with ES, performed in a reference center, allows obtaining good rates of recurrence and survival, with very low rates of cardiac transplantation for ES. In the presence of an early recurrence, it is advisable to perform a new procedure during admission.

Young athletes' ECG: Incomplete right bundle branch block vs crista supraventricularis pattern.

BACKGROUND: Incomplete right bundle branch block (IRBBB) is prevalent among athletes, but its etiology remains to be clearly elucidated and the commonly advocated mechanism, an intraventricular conduction delay, does not explain all cases. In the general population, an apparently similar phenomenon but with different pathophysiology and potential consequences, "crista supraventricularis pattern" (CSP, defined as QRS ≤ 100 ms, S wave <40 ms in I or V6 together with an RSR´ pattern in lead-V1) has been described. Yet, this manifestation has not been studied in athletes. Given that IRBBB can be associated with some serious conditions (including Brugada syndrome, arrhythmogenic cardiomyopathy, or atrial septal defects) the differentiation between IRBB and CSP could enhance the accuracy of the pre-participation screening (PPS). We thus aimed to determine the prevalence of CSP in young athletes. METHODS: Observational study of standard 12-lead resting ECG in a cohort of children (5-16 years) attending a PPS program (August 2018-May 2019). RESULTS: 6,401 children (mean ± SD age 11.2 ± 2.9 years, 99.2% Caucasian, 93.8% male, 97.2% soccer players) were studied. We found CSP in 850 participants (prevalence = 13.3% [95% confidence interval 12.5-14.1]) whereas 553 (8.6%) had IRBBB. The proportion of athletes showing an S1S2S3 pattern was higher in those with CSP compared with the other QRS morphologies (P < .05). CONCLUSIONS: CSP might have been overlooked in previous reports of sports PPS for children and misdiagnosed as IRBBB, as the proportion of the former condition was higher. Our findings might add useful information to improve the interpretation of the young athletes' ECG and thus the diagnostic value of PPS.

The Grey Zone and the Complexity of Clinical Decisions in Sports Cardiology.

We present here three different clinical scenarios that illustrate the complexity of taking decisions in sports cardiology. Despite the availability of consensus documents, in clinical practice, decision-making process is most of the times in the grey zone.

Apparent Ventricular Dysfunction in Elite Young Athletes: Another Form of Cardiac Adaptation of the Athlete's Heart.

BACKGROUND: The authors previously observed that some high-performance athletes, irrespective of type of sport, can show echocardiographically determined low left ventricular ejection fractions (LVEF; <52%) together with normal heart rates and nondilated left ventricular (LV) cavities under resting conditions. The aim of this study was to determine if this phenomenon is associated with dyssynchronous motion of the interventricular septum relative to the lateral LV wall. METHODS: Results of M-mode and two-dimensional echocardiography and pulsed-wave, pulsed-wave tissue, and color tissue Doppler were compared in 70 athletes (mean age, 20 ± 7 years; 77% men) with low LVEFs (<52%) participating in a wide variety of sports and a control group of 564 athletes (mean age, 22 ± 7 years; 61% men) with normal LVEFs (≥52%). RESULTS: No between-group differences were found in cardiac dimensions or QRS duration (indicating no electrical dyssynchrony in the low-LVEF group compared with the normal-LVEF group), but analysis of mechanical interventricular and intraventricular dyssynchrony showed that time intervals between QRS onset and the different systolic waves were all lengthened in the low-LVEF group (P < .05 for all). Values of interventricular mechanical delay were higher in the low-LVEF group (P = .012), though they did not reach pathologic limits. Peak aerobic performance was independent of LVEF. The results did not change materially when analyzing data separately by sex or sport. CONCLUSIONS: Some young highly trained athletes might show depressed LVEF (<52%) with a nondilated LV cavities in the early phase of cardiac adaptations, which seems to be linked to longer LV contraction times, with the right ventricle unaffected. These echocardiographic findings, although not highly prevalent, could be considered another characteristic of the cardiac adaptations to the demands of elite sports with no detriment in performance.