Tweet
ESC Congress 2004: Competitive sport and cardiomyopathy
The recommendations of the study group of sports cardiology of the ESC
__________________________________________________ ________
The rationale for offering recommendations concerning the participation in
competitive sport in athletes with cardiovascular disease is based on the
widely accepted clinical perception, substantiated by scientific evidence 1,
that individuals with underlying (even clinically silent) cardiovascular
disease have an increased risk for sudden cardiac death, or worsen cardiac
outcome (in comparison with normal individuals), because of regular exercise
training and sport participation. The aim of the recommendations is to
provide careful directions to physicians and consultant cardiologists,
suggesting the type and intensity of sport activity that can be safely
performed by the candidate with cardiovascular abnormality.
The particular interest for sport is dictated by the awareness that
competitive athletes (in particular, elite and professional athletes)
represent a special subset of our society not only for their outstanding
performances, but also for the substantial economic benefit they gather, as
well as the intense pressure they are exposed by sponsors, athletic
associations and media.
Nature of the Recommendations
The Recommendations for Competitive Sport Participation represents the
consensus document of an international panel of experts appointed by the
European Society of Cardiology, including clinical cardiovascular
specialists with experience in exercise physiology, sport medicine and
clinical cardiovascular medicine. The present recommendations are based on
published scientific evidence where available, and on personal experience
and consensus of experts. The aim of the panel was to formulated indications
which represent a reasonable balance between the risks and the benefits
inherent with competitive sport participation, and not simply restrict sport
activity that could be associated with increased risk. The recommendations
represent, therefore, a prudent, contemporary, and practical document for
advising competitive sport activity in patients with cardiovascular disease.
Implementation of the Recommendations within the European countries
At present, a large heterogeneity (or lack) of regulations exist in the
European countries, with only a few (such as Italy) requiring a medical
clearance of competitive athletes and, in individuals with cardiovascular
disease, having implemented Guidelines (COCIS) which are considered the
standard of medical care 2.
The panel believes that a common, unbiased management of competitive
athletes with cardiovascular disease is now needed, in consideration of the
unlimited opportunity for professional athletes to move across EU countries.
A unique and appropriate consensus document will be of relevant medical (and
legal) value for physicians and cardiologists when evaluating athletes with
cardiovascular disease. In the absence of binding requirements established
by law, the panel recommends that the present Recommendations represent the
standard of medical care for evaluation of competitive athletes with
cardiovascular disease across Europe. Adherence to these recommendations
will have substantial and cost-effective impact on medical care, by
enhancing the safety of athletic activities and reducing the legal
controversies related to different (or lack of) regulations.
The role of the Examining Physician
Should the physician be the ultimate authority determining whether or not an
athlete with cardiovascular disease can participate in competitive sport ?
Or alternatively, can the athlete with cardiovascular disease just sign an
informed consent and be engaged in a risky and potentially life-threatening
sport activity ?
Due to the unique structure and pressures of competitive sports, individuals
with heart disease may not always use proper independent judgment in
assessing the overall risk associated with a competitive sport career. The
panel believes that the examining physician (and consultant cardiologist)
have the ethical, medical and legal obligation to inform exhaustively the
candidate of the risks inherent with competitive athletic lifestyle and,
when the cardiovascular risk appears to be unreasonably high, the physician
should be responsible for the final decision, with the aim to prevent
adverse clinical events and/or reduce risk for disease progression.
Protecting the athlete's health and physical well-being of the athlete is
the paramount objective of the physician, regardless other non-medical
considerations, such as the potential antagonistic positions of the sponsor
or the athletic association, which may be economically dependent on the
athlete's competitive activity. These recommendations are intended,
therefore, to support the physician's decision in such difficult instances
and to offer a medical protection to the athlete from the unsustainable
hazard of competitive sport activity.
Recommendations for Competitive Sport and Cardiomyopathies
Cardiomyopathies represent a spectrum of primary myocardial diseases, mostly
on genetic basis, which are characterized by cardiac hypertrophy
(hypertrophic cardiomyopathy), or dilatation (dilated cardiomiopathy), or
right ventricular abnormalities (right ventricular
cardiomyopathy/dysplasia). Prevalence of cardiomyopathies in the general
population is greater than previously expected, and about 0.2% for
hypertrophic cardiomyopathy.
Clinical relevance of cardiomyopathies is based on the recognition that they
represent the most common cause of sudden and unexpected cardiac death in
association with exercise in young patients, including competitive athletes.
The diagnosis of cardiomyopathies is based on accurate evaluation of the
distinctive morphologic abnormalities and differentiation from physiologic
cardiac changes associated with chronic athletic conditioning (i.e., the
athlete's heart). A varied spectrum of symptoms may be present in patients
with cardiomyopathies, such as palpitations, syncope (mostly on arrhythmic
basis) dyspnea and fatigability. However, a substantial proportion of
patients and athletes engaged in competitive activities, present only mild
(or no) symptoms. Treatment of cardiomyopathies is focused on preventing the
risk of sudden cardiac death (by controlling incidence of arrhythmias) and
includes withdrawn of the patient from regular training and intensive
athletic activities.
The Recommendations for Competitive Sport Participation provide directions
for evaluating athletes with cardiomyopathies, suggesting the diagnostic
testing needed for confirming the diagnosis (such as echocardiography,
12-lead ECG) and risk stratification (such as exercise testing and Holter
ECG monitoring, or additional diagnostic testing according the individual
case). In most instances, definite diagnosis of a cardiomyopathy precludes
the candidate from participation in competitive sport, with the aim to
reduce the risk for death or disease progression associated with athletic
lifestyle.
The recommendations of the study group of sports cardiology of the ESC
__________________________________________________ ________
The rationale for offering recommendations concerning the participation in
competitive sport in athletes with cardiovascular disease is based on the
widely accepted clinical perception, substantiated by scientific evidence 1,
that individuals with underlying (even clinically silent) cardiovascular
disease have an increased risk for sudden cardiac death, or worsen cardiac
outcome (in comparison with normal individuals), because of regular exercise
training and sport participation. The aim of the recommendations is to
provide careful directions to physicians and consultant cardiologists,
suggesting the type and intensity of sport activity that can be safely
performed by the candidate with cardiovascular abnormality.
The particular interest for sport is dictated by the awareness that
competitive athletes (in particular, elite and professional athletes)
represent a special subset of our society not only for their outstanding
performances, but also for the substantial economic benefit they gather, as
well as the intense pressure they are exposed by sponsors, athletic
associations and media.
Nature of the Recommendations
The Recommendations for Competitive Sport Participation represents the
consensus document of an international panel of experts appointed by the
European Society of Cardiology, including clinical cardiovascular
specialists with experience in exercise physiology, sport medicine and
clinical cardiovascular medicine. The present recommendations are based on
published scientific evidence where available, and on personal experience
and consensus of experts. The aim of the panel was to formulated indications
which represent a reasonable balance between the risks and the benefits
inherent with competitive sport participation, and not simply restrict sport
activity that could be associated with increased risk. The recommendations
represent, therefore, a prudent, contemporary, and practical document for
advising competitive sport activity in patients with cardiovascular disease.
Implementation of the Recommendations within the European countries
At present, a large heterogeneity (or lack) of regulations exist in the
European countries, with only a few (such as Italy) requiring a medical
clearance of competitive athletes and, in individuals with cardiovascular
disease, having implemented Guidelines (COCIS) which are considered the
standard of medical care 2.
The panel believes that a common, unbiased management of competitive
athletes with cardiovascular disease is now needed, in consideration of the
unlimited opportunity for professional athletes to move across EU countries.
A unique and appropriate consensus document will be of relevant medical (and
legal) value for physicians and cardiologists when evaluating athletes with
cardiovascular disease. In the absence of binding requirements established
by law, the panel recommends that the present Recommendations represent the
standard of medical care for evaluation of competitive athletes with
cardiovascular disease across Europe. Adherence to these recommendations
will have substantial and cost-effective impact on medical care, by
enhancing the safety of athletic activities and reducing the legal
controversies related to different (or lack of) regulations.
The role of the Examining Physician
Should the physician be the ultimate authority determining whether or not an
athlete with cardiovascular disease can participate in competitive sport ?
Or alternatively, can the athlete with cardiovascular disease just sign an
informed consent and be engaged in a risky and potentially life-threatening
sport activity ?
Due to the unique structure and pressures of competitive sports, individuals
with heart disease may not always use proper independent judgment in
assessing the overall risk associated with a competitive sport career. The
panel believes that the examining physician (and consultant cardiologist)
have the ethical, medical and legal obligation to inform exhaustively the
candidate of the risks inherent with competitive athletic lifestyle and,
when the cardiovascular risk appears to be unreasonably high, the physician
should be responsible for the final decision, with the aim to prevent
adverse clinical events and/or reduce risk for disease progression.
Protecting the athlete's health and physical well-being of the athlete is
the paramount objective of the physician, regardless other non-medical
considerations, such as the potential antagonistic positions of the sponsor
or the athletic association, which may be economically dependent on the
athlete's competitive activity. These recommendations are intended,
therefore, to support the physician's decision in such difficult instances
and to offer a medical protection to the athlete from the unsustainable
hazard of competitive sport activity.
Recommendations for Competitive Sport and Cardiomyopathies
Cardiomyopathies represent a spectrum of primary myocardial diseases, mostly
on genetic basis, which are characterized by cardiac hypertrophy
(hypertrophic cardiomyopathy), or dilatation (dilated cardiomiopathy), or
right ventricular abnormalities (right ventricular
cardiomyopathy/dysplasia). Prevalence of cardiomyopathies in the general
population is greater than previously expected, and about 0.2% for
hypertrophic cardiomyopathy.
Clinical relevance of cardiomyopathies is based on the recognition that they
represent the most common cause of sudden and unexpected cardiac death in
association with exercise in young patients, including competitive athletes.
The diagnosis of cardiomyopathies is based on accurate evaluation of the
distinctive morphologic abnormalities and differentiation from physiologic
cardiac changes associated with chronic athletic conditioning (i.e., the
athlete's heart). A varied spectrum of symptoms may be present in patients
with cardiomyopathies, such as palpitations, syncope (mostly on arrhythmic
basis) dyspnea and fatigability. However, a substantial proportion of
patients and athletes engaged in competitive activities, present only mild
(or no) symptoms. Treatment of cardiomyopathies is focused on preventing the
risk of sudden cardiac death (by controlling incidence of arrhythmias) and
includes withdrawn of the patient from regular training and intensive
athletic activities.
The Recommendations for Competitive Sport Participation provide directions
for evaluating athletes with cardiomyopathies, suggesting the diagnostic
testing needed for confirming the diagnosis (such as echocardiography,
12-lead ECG) and risk stratification (such as exercise testing and Holter
ECG monitoring, or additional diagnostic testing according the individual
case). In most instances, definite diagnosis of a cardiomyopathy precludes
the candidate from participation in competitive sport, with the aim to
reduce the risk for death or disease progression associated with athletic
lifestyle.
Comment