Sudden cardiac arrest in sports - need for uniform registration: A Position Paper from the Sport Cardiology Section of the European Association for Cardiovascular Prevention and Rehabilitation.

There are large variations in the incidence, registration methods and reported causes of sudden cardiac arrest/sudden cardiac death (SCA/SCD) in competitive and recreational athletes. A crucial question is to which degree these variations are genuine or partly due to methodological incongruities. This paper discusses the uncertainties about available data and provides comprehensive suggestions for standard definitions and a guide for uniform registration parameters of SCA/SCD. The parameters include a definition of what constitutes an 'athlete', incidence calculations, enrolment of cases, the importance of gender, ethnicity and age of the athlete, as well as the type and level of sporting activity. A precise instruction for autopsy practice in the case of a SCD of athletes is given, including the role of molecular samples and evaluation of possible doping. Rational decisions about cardiac preparticipation screening and cardiac safety at sport facilities requires increased data quality concerning incidence, aetiology and management of SCA/SCD in sports. Uniform standard registration of SCA/SCD in athletes and leisure sportsmen would be a first step towards this goal.

Atrial Size and Function in Athletes.

We wanted to explore whether change in LA (left atrium) size would influence LA function, or increase regurgitation in the atrioventricular valves. 595 male elite football players and 47 non-athletic controls were included. End-systolic LA volume and RA area and end-diastolic LV volume and RV area were measured by 2-dimensional (2D) echocardiography Pulsed and colour Doppler were used to estimate tricuspid and mitral regurgitations. 2D longitudinal strain of the 50 football players with the largest LA volumes were compared with the 50 players with the smallest LA volumes. The LA volumes in some athletes with large atria were more than tripled, compared to athletes with small atria. 2D strain however, could not reveal any impairment of LA function in the players with the largest atria, compared to those with the smallest LA. Tricuspid valve regurgitation was found in 343 (58%) of the athletes, compared to 17 (36%) of the controls (p<0.01), while mitral regurgitation was found in 116 (20%) football players and 7 (15%) controls (NS). Furthermore, the RA area was significantly larger in athletes with tricuspid regurgitation compared to athletes without. The present study demonstrated a huge variation in atrial size between the athletes. This variation, however, had no impact on LA function. Tricuspid regurgitation was significantly more prevalent among the athletes, than among the controls.

Prevalence of abnormal ECGs in male soccer players decreases with the Seattle criteria, but is still high.

Electrocardiogram (ECG) and echocardiography are mandatory in preparticipation cardiac screening in soccer players. Abnormal ECG findings usually require follow-up investigations. The main aim of this study was to compare the prevalence of abnormal ECG findings in male professional soccer players according to European Society of Cardiology's (ESC) recommendations and the Seattle criteria, and to assess the need for echocardiography. ECGs from 587 of 595 (99%) players were recorded with ClickECG, and measurements were derived with visually adjusted on-screen calipers on the computer-based averaged PQRST complex. Echocardiographic recordings were performed with Vivid 7/i and categorized according to reference values for athlete's heart. After the initial screening, 32 (5.5%) players were recommended for follow-up. The prevalence of abnormal ECGs was 29.3% vs 11.2% according to the ESC's recommendations and the Seattle criteria, respectively. None of the players with abnormal ECGs only according to the ESC's recommendations had abnormal echocardiograms. Echocardiography alone detected one player with abnormalities (athlete's heart). The Seattle criteria reduced the number of athletes with abnormal ECGs considerably compared with the ESC recommendations. Based on echocardiographic evaluations, this increased the specificity of the Seattle criteria, without increasing the number of false-negative ECGs. The need for mandatory echocardiography in soccer players seems limited.

Visual or computer-based measurements: important for interpretation of athletes' ECG.

BACKGROUND: ECG is recommended for preparticipation health examination in athletes. Owing to a lack of consensus on how to read and interpret athletes' ECGs, different criteria for abnormality are used. AIMS: To compare the prevalence of abnormal ECGs and test the correlation between visual and computer-based measurements. METHODS: In a preparticipation cardiac screening examination of 595 male professional soccer players aged 18-38 years, ECGs were categorised according to the European Society of Cardiology's (ESC) recommendations and the Seattle criteria, respectively. Visual measurements were conducted with callipers on-screen on the averaged PQRST complex in each lead, calculated by the trimmed mean. Computer-based measurements were derived from the medium beat. Heart rhythm and conduction were scored visually by a cardiologist. Categorical variables were compared by κ statistics (K) and continuous variables by intraclass correlation. RESULTS: ECGs of good quality were available from 579 players. According to the ESC's recommendations and Seattle criteria, respectively, ECGs were categorised as abnormal in 171 (29.5%) vs 64 (11.1%) players after visual assessment, and in 293 (50.6%; K=0.395) vs 127 (21.9%; K=0.564) after computer-based measurements. Intraclass correlation was very good for measurements of R and S wave amplitudes and moderate to very good for intervals. K was very good for pathological Q wave amplitudes and moderate for T wave inversions. CONCLUSIONS: Abnormal ECGs were more than twice as common after computer-based than after visual measurements. Such a difference will markedly influence the number of athletes who need further examinations. Reference values may need adjustments dependent on measurement methods.

The Scandinavian athlete's heart; echocardiographic characteristics of male professional football players.

This investigation explores the cardiac four-chamber remodeling response to training in male players in Norwegian professional football league, and ethnicity as determinants in the development of athlete's heart. Standard 2D echocardiographic examination and analysis of all four cavities were performed in 504 football players of Caucasian origin, 49 of African origin, and 47 matched Caucasian controls (<3 h training /week). All results were indexed to body surface area (BSA). Most athletes exhibited BSA-indexed values within normal ranges. Left ventricle (LV) mass was equally enlarged in both groups of athletes, but LV relative wall thickness and right ventricular (RV) relative wall thickness were increased in Africans compared with Caucasian athletes (0.37 ± 0.06 vs 0.33 ± 0.06 and 0.25 ± 0.06 vs 0.22 ± 0.04, respectively). Both LV and RV were smaller in Africans than in Caucasian athletes (67.8 ± 12.0 ml/m(2) vs 73.6 ± 13.2 ml/m(2) and 12.8 ± 2.1 vs 13.7 ± 2.4 cm(2) /m(2) , respectively, both P < 0.05), while left and right atria increased similarly. This first large-scale echocardiographic survey of elite football players in a Scandinavian league suggests use of BSA-indexed upper normal limits for both LV and RV in athletes. African athletes had significantly more concentric remodeled LV and RV than the Caucasian athletes.

Cardiovascular pre-participation screening does not distress professional football players.

BACKGROUND: It has been debated whether cardiovascular screening of athletes creates negative psychological reactions in those being screened. Neither the athletes' level of distress towards, nor their opinion about screening has actually been examined. Therefore, the aim of this study was to assess the level of distress among Norwegian elite male football players and their experiences of screening. METHODS: After screening, players completed a 10-item scale assessing their experience on a Likert scale. Their level of distress was measured with the intrusion sub-scale of Impact of Event Scale (IES) (7 items) on a six-point scale (grade 0-5). A sum score of ≥19 indicates a clinical stress problem. Twenty-five out of 28 teams, 441 of 591 players (75%, mean age 26 [18-39] years) consented to participate. RESULTS: Sixty-four percent felt more confident when playing football and 88% were satisfied having completed the screening. The majority (77%) felt a need for the screening and 84% would strongly recommend it to others. Sixteen percent were afraid that the screening result might have consequences for their own health, and 13% were afraid of losing their license to play football. Less than 3% experienced distress (IES ≥ 19). CONCLUSIONS: The majority of the players were satisfied having completed the screening, felt more confident and would recommend it to other players. Only a marginal proportion of the players were distressed by the screening, but were at least as likely to recommend it.

Stress reactivity to and recovery from a standardised exercise bout: a study of 31 runners practising relaxation techniques.

OBJECTIVE: To compare the efficacy in runners of two relaxation techniques with regard to exercise reactivity and recovery after exercise. METHODS: Thirty one adult male runners were studied prospectively for six months in three groups practising either meditation (n = 11) or autogenic training (n = 11) or serving as controls (n = 10). Before and after the six months relaxation intervention, indicators of reactivity to exercise and metabolism after exercise (blood lactate concentration, heart rate (HR), and oxygen consumption (VO2)), were tested immediately after and 10 minutes after exercise. Resting HR was also assessed weekly at home during the trial. State anxiety was measured before and after the intervention. RESULTS: After the relaxation training, blood lactate concentration after exercise was significantly (p<0.01) decreased in the meditation group compared with the control group. No difference was observed in lactate responses between the autogenic training group and the control group. There were no significant differences among the groups with regard to HR, VO2, or levels of anxiety. CONCLUSION: Meditation training may reduce the lactate response to a standardised exercise bout.

[Secondary prevention in coronary disease. A questionnaire study in Norwegian departments of internal medicine with emphasis on non-pharmacological intervention]. / Sekundaerprofylakse ved koronarsykdom. Spørreundersøkelse til norske indremedisinske avdelinger med spesiell vekt på ikke-farmakologisk intervensjon.

Research has shown that lifestyle intervention has a promising effect in patients with coronary heart disease, but little is known about the practice of such intervention. To explore this issue a questionnaire was sent to all departments of internal medicine in Norway (N = 67). 58 hospitals responded. The results showed that most hospitals offered physical training (49 hospitals) and dietary intervention programmes (51 hospitals) to patients with coronary heart disease, but only six hospitals offered a smoking cessation programme. The hospitals expressed a desire to expand the existing programmes (especially dietary intervention) and establish new ones (in particular smoking cessation), but claimed that lack of personnel and funds limited their activity. Only a few hospitals record in the medical journal that a patient has been informed about the significance of changes in lifestyle.

The effect of meditation on shooting performance.

OBJECTIVE: To study effects of meditation on the shooting performance. METHODS: 25 elite shooters were investigated in an independent groups design. The results in standardised test shootings indoors and in ordinary competitions outdoors were assessed before and after regular meditation training for the experimental group. The experience of tension during the test shootings was self recorded on a visual analogue scale (VAS). RESULTS: The competition results in the outdoor season (1993), just after the meditation training period, compared with the results the previous season (1992), were better in the meditation group (P < 0.05). No significant difference between the groups was observed in the test shootings before and after the relaxation intervention. A significant association was shown between low tension and the results in the test shootings (correlation r = 0.42, P < 0.0001; Wilcoxon rank sum test, z = -3.36, P < 0.001); 18% (= r2) of the variance in performance was explained by tension. CONCLUSIONS: Meditation may enhance competitive shooting performance.

Meditation: a modulator of the immune response to physical stress? A brief report.

OBJECTIVE: To test the hypothesis that stress reducing techniques such as meditation alter immune responses after strenous physical stress. METHODS: The hypothesis was tested by studying six meditating and six non-meditating male runners in a concurrent, controlled design. After a period of six months with meditation for the experimental group, blood samples were taken immediately before and after a maximum oxygen uptake test (VO2max). RESULTS: The increase in CD8+ T cells after VO2max was significantly less in the meditation group than in the control group (P = 0.04). The amount of CD2+ cells doubled after VO2max, mainly because of a rise in the CD8+ fraction. CONCLUSIONS: Meditation may modify the suppressive influence of strenous physical stress on the immune system.

[Time utilization in the preparation of medical records]. / Tidsbruk ved journalopptak.

The time available for preparing a medical record may be of importance for the resulting quality. We studied the records of 166 patients admitted to a medical department during a fortnight. 24 doctors registered the time spent on history taking, clinical examination and emergency treatment, paper work and other patient-associated tasks. The doctors received a mean of seven patients each, spending a mean of 53 (range 20-120) minutes in all. The mean time spent on clinical examination was 27 minutes, on paper work 18 minutes and on other tasks 11 minutes. Time of the day or age of the patient did not influence the time spent on the tasks. Only rarely (7%) did the doctor experience shortage of time.

[The medical record--content, interpretation and quality. Study of 100 medical records from a department of internal medicine]. / Journalen--innhold, forventning og kvalitet. En studie av 100 indremedisinske innkomstjournaler.

An evaluation of the primary medical records of 100 patients admitted to a medical department showed that several elements in the journal often had been left out. Therefore all doctors working in the department were asked for their opinion of the necessity for each of the elements in a journal. A comparison of these doctors' opinions with our registrations indicated that the actual "shortening" of the journals was probably a result of choice rather than mere chance. Despite a considerable amount of work trying to establish relevant criteria, we did not succeed in developing a reliable method for measuring the quality of the medical record. The journals recorded at night were significantly shorter than those recorded during the day. A follow-up note (or discharge of the patient within one day), was found in 80% of the journals. Quality standards of the medical record are lacking and should be developed.

[Vegetarians and vitamin B12. A controlled trial of vitamin B12 status in 63 lactovegetarians]. / Vegetarianere og vitamin B12. En kontrollert studie av vitamin B12-status hos 63 laktovegetarianere.

In this study vitamin B12 status was assessed in 63 adult long-term lactovegetarians and 63 controls. No significant difference in mean plasma levels of vitamin B12 was found between the two groups. In contrast to what might have been expected, the vegetarians showed a slight increase in the vitamin B12 levels with increasing number of years as vegetarians. There was a significant (r = 0.34, p = 0.01) correlation between oral intake of vitamin B12 in the lactovegetarians and the plasma levels of the vitamin. Folate in plasma and whole blood were significantly higher (p < 0.001) in the vegetarian group than in the control group. The findings do not indicate that lactovegetarians risk developing dietary-induced vitamin B12 deficiency.