Making prudent recommendations for return-to-play in adult athletes with cardiac conditions.

Clinicians who treat millions of adult athletes throughout the world may be faced with participation or return-to-play decisions in individuals with known or suspected cardiac conditions. Here we review existing published participation guidelines and analyze emerging data from ongoing registries and population-based studies pertaining to return-to-play decisions for cardiac conditions specifically affecting adult athletes. Considerations related to return-to-play decisions will vary according to age of the athlete, with inherited disorders being the main consideration in younger adult athletes aged 18 to 40 yr, and coronary artery disease being the main consideration in older adult athletes aged 40 yr and older. Although this arbitrary division is based on the epidemiology of underlying heart disease in these populations, the essential return-to-play decision process for both age groups is quite similar. Among the most widely used guidelines to make return-to-play decisions in this group of athletes are the 36th Bethesda Conference Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities. These have long been considered the "gold standard" for determining return-to-play decisions in young athletes in the United States. Other guidelines are available for unique purposes, including The European Society of Cardiology guidelines, and the American Heart Association published recommendations regarding participation of young patients (younger than 40 yr) with genetic cardiovascular diseases in recreational sports. The latter are consistent with the 36th Bethesda guidelines and cover common genetically based diseases such as inherited cardiomyopathies, channelopathy, and connective tissue disorders like Marfan's syndrome. The consensus on masters athletes (older than 40 yr) provides return-to-play decisions for a wide variety of conditioned states, from elite older athletes to walk-up athletes. For any adult athlete with a cardiac condition, return-to-play decisions following use of medications, ablation procedures, device implantation, corrective surgery, or coronary intervention depend on whether the procedure has sufficiently altered the risk for sudden cardiac events, and whether there is a potential for unfavorable interaction with cardiac performance.

Hypertension update and cardiovascular risk reduction in physically active individuals and athletes.

Hypertension is a prevalent disease worldwide. Its inadequate treatment leads to major cardiovascular complications, such as myocardial infarction, stroke, and heart failure. These conditions decrease life expectancy and are a substantial cost burden to health care systems. Physically active individuals and professional athletes are not risk free for developing this condition. Although the percentage of persons affected is substantially lower than the general population, these individuals still need to be thoroughly evaluated and blood pressure targets monitored to allow safe competitive sports participation. Regarding treatment, lifestyle modification measures should be routinely emphasized to athletes and active individuals with the same importance as for the general population. Medication treatment can be complicated because of restrictions by athletic organizations and possible limitations on maximal exercise performance. In addition, the choice of an antihypertensive drug should be made with consideration for salt and water losses that routinely occur in athletes, as well as preservation of exercise performance and endothelial function. First-line therapies for athletes and physically active individuals may be different from the general population. Some authorities believe that blocking the renin-angiotensin system with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) is more beneficial compared with diuretics because of ACE inhibitors and ARBs being able to avoid salt and water losses. Dihydropyridine calcium channel blockers (CCBs) are another reasonable choice. Despite effects on heart rate, nondihydropyridine CCBs do not appear to impair exercise performance. beta-Blockers are not used as a first-line therapy in athletes because of effects on exercise and prohibition by the National Collegiate Athletic Association and World Anti-Doping Agency in certain sports. In this article, we address the evidence on hypertension and its related treatments in active individuals to provide recommendations that allow the best competitive sports results and reduce cardiovascular risk.

Emerging cardiovascular risk factors that account for a significant portion of attributable mortality risk in chronic kidney disease.

Chronic kidney disease (CKD) increases cardiovascular risk and mortality. However, traditional cardiovascular risk factors do not adequately account for the substantial increase in mortality observed in CKD. The aim of this study was to examine the relative contributions of novel cardiovascular risk factors to the risk between CKD and mortality. The study population included 4,680 consecutive new patients from a tertiary care preventive cardiology program from 1996 to 2005. Estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease (MDRD) method. Baseline levels of traditional (low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, hypertension, triglycerides, total cholesterol, and fasting glucose) and emerging (apolipoproteins A-I and B, lipoprotein[a], fibrinogen, homocysteine, and high-sensitivity C-reactive protein) risk factors were examined. All-cause mortality was obtained from the Social Security Death Index. There were 278 deaths over a median follow-up period of 22 months. CKD (estimated glomerular filtration rate or=12.5 micromol/L (the top tertile) were associated with a sevenfold greater mortality risk. In conclusion, homocysteine and fibrinogen levels explain nearly 40% of the attributable mortality risk from CKD.

Pyridostigmine reduces QTc interval during recovery from maximal exercise in ischemic heart disease.

Following a randomized, cross-over, and double-blind design, 14 patients with coronary heart disease were submitted, to maximal cardiopulmonary exercise tests on a treadmill, 2 h after the oral administration of either placebo or pyridostigmine bromide (45 mg), a reversible cholinesterase inhibitor. One observer, who was blind to the experimental condition, measured RR and QT intervals over the 12 electrocardiographic leads in the first and third minute of active recovery from exercise. Paired t test was used to compare each variable measured in the same moment after placebo and pyridostigmine. Pyridostigmine reduced the QTc interval in the first minute of active recovery when compared to placebo (P=0.004). Two patients, whose heart rate recovery (1st minute) was below normal values (patient 1=4 bpm; patient 2=7 bpm; i.e. <12 bpm) presented with correction of this variable after pyridostigmine ingestion (patient 1=22 bpm; patient 2=36 bpm). Prospective trials should evaluate the impact of cholinergic stimulation with pyridostigmine on mortality.

Insights from internet-based remote intrathoracic impedance monitoring as part of a heart failure disease management program.

Changes in intrathoracic impedance (Z) leading to crossing of a derived fluid index (FI) threshold has been associated with heart failure (HF) hospitalization. The authors developed a remote monitoring program as part of HF disease management and prospectively examined the feasibility and resource utilization of monitoring individuals with an implanted device capable of measuring Z. An HF nurse analyzed all transmitted data daily, as they were routinely uploaded as part of quarterly remote device monitoring, and called the patient if the FI crossed the threshold (arbitrarily defined at 60 Omega) to identify clinically relevant events (CREs) that occurred during this period (eg, worsening dyspnea or increase in edema or weight). A total of 400 uploads were completed during the 4-month study period. During this period, 34 patients (18%) had an FI threshold crossing, averaging 0.52 FI threshold crossings per patient-year. Thirty-two of 34 patients contacted by telephone (94%) with FI threshold crossing had evidence of CREs during this period. However, only 6 (18%) had HF hospitalizations, 19 (56%) had reported changes in HF therapy, and 13 (38%) reported drug and/or dietary plan nonadherence. The average data analysis time required was 30 min daily when focusing on those with FI threshold crossing, averaging 8 uploads for review per working day and 5 telephone follow-ups per week. Our pilot observations suggested that Internet-based remote monitoring of Z trends from existing device interrogation uploads is feasible as part of a daily routine of HF disease management.