Elsevier

Heart, Lung and Circulation

Volume 27, Issue 9, September 2018, Pages 1116-1120
Heart, Lung and Circulation

Review
What May the Future Hold for Sports Cardiology?

https://doi.org/10.1016/j.hlc.2018.05.193Get rights and content

The field of sports cardiology has advanced significantly over recent times. It has incorporated clinical and research advances in cardiac imaging, electrophysiology and exercise physiology to enable better diagnostic and therapeutic management of our patients. One important endeavour has been to try and better differentiate athletic cardiac remodelling from inherited cardiomyopathies and other pathologies. Whilst our diagnostic tools have improved, there have also been errors resulting from assumptions that the pathological traits observed in the general population would be generalisable to athletic populations. However, we have learnt that athletes with hypertrophic cardiomyopathy, for example, have many unique features when compared with non-athletic patients with hypertrophic cardiomyopathy. We are learning the limitations of cross-sectional observations and a greater number of prospective studies have been initiated which should enable us to more confidently interrogate the associations between exercise, cardiac remodelling and clinical outcomes. This review of the field enables some of the world’s experts in sports cardiology to reflect on where there is a need for research focus to advance knowledge and clinical care in sports cardiology.

Introduction

Cardiology is a unique specialty within internal medicine, in that it uses exercise as part of both the diagnosis and treatment of disease. The effect of exercise on cardiovascular function has long been a consideration in medicine but the sub-specialty of sports cardiology represents a relatively new discipline focussing on the clinical issues pertaining to athletes and exercise enthusiasts. The dominant topics of concern have related to the identification of structural heart disease and the management of cardiac arrhythmias, mainly aimed at prevention of sudden cardiac death and deterioration of cardiovascular function. Intense debate has surrounded the issue of pre-participation screening of athletes and this has dominated much of the sports cardiology agenda over the recent decade. The aim of this commentary is to reflect upon the current topics of interest in sports cardiology and to identify unresolved issues that are likely to receive attention in the decades to come.

Section snippets

What Is an Athlete?

In a field devoted to understanding cardiovascular adaptation and pathology in athletic individuals, it is remarkable that there is no standardised definition of what constitutes an “athlete”. The Bethesda guidelines have provided the best current definition of an athlete: “One who participates in an organized team or individual sport that requires regular competition against others as a central component, places a high premium on excellence and achievement, and requires some form of systematic

Pre-Participation Screening of Athletes, What Comes Next?

There has been considerable debate about the merits and concerns of including an electrocardiogram (ECG) in pre-participation screening of athletes highlighting the fact that a majority of causes of sudden cardiac death (SCD) in athletes are associated with electrocardiographic abnormalities that may lead to early treatment and preventative strategies [3]. On the other hand, it has been argued that the imperfect specificity of electrocardiographic testing when screening for rare conditions

Pathological Versus Physiological Remodelling

The sports cardiology literature is filled with studies that seek to discriminate healthy physiological athletic remodelling of the myocardium from pathological remodelling due to inherited cardiomyopathies, hypertensive or valvular heart disease. In a recent review, Nakamura and Sadoshima encapsulate the discussions of hundreds of articles in stating: “There are two types of hypertrophy: physiological and pathological” [11]. However, this orthodox view is being challenged in sports cardiology

A Shift Away From Comparing Diseased Cohorts to Athletes

There have been significant errors in the conclusions drawn from studies that have compared cohorts of patients with cardiac pathology with healthy athletes. Maron and Pelliccia have, perhaps, contributed more to the field of sports cardiology than any other investigators but their instructions on how to distinguish the athlete with borderline hypertrophy from the patient with hypertrophic cardiomyopathy (HCM) have recently been questioned. They suggested that cardiopulmonary fitness, diastolic

Towards a Specific Ethical Framework

When discussing ethics in sports, one usually focusses on the aspect of performance-enhancing drug intake, mainly pointing to the responsibility of the athletes themselves. In line with the previous paragraphs, the field of sports cardiology must address other important aspects. One is to define the boundaries of ‘professional training guidance’: even without considering drugs, we need to study other measures that optimise performance such as low-pressure chambers, high-altitude training,

A Need for Prospective Research

The field of sports cardiology is filled with cross-sectional observations of associations between exercise and changes in cardiac function and remodelling. This brings the potential for errors in assuming a causal relationship exists between phenomena. For example, it is often assumed that exercise is the cause of the enlarged hearts observed in athletes, but it is also possible that people with larger hearts are more likely to be successful athletes. The few examples of well-conducted

Conclusion

We have highlighted some of the current barriers to knowledge advancement in the understanding of the interaction between exercise and cardiovascular adaptation. The effect of exercise on the heart, vessels and metabolism can be profound and is an under-utilised model of discovery. The future is bright, and we look forward to showcasing evolving discoveries at future editions of the Baker Sports Cardiology symposia and in Heart Lung and Circulation.

Acknowledgements

The research being undertaken by the authors into the mechanisms of AF in athletes is funded by NHMRC project grant: APP1130353 Atrial remodelling and risk of arrhythmias in endurance athletes. A/Prof La Gerche is supported by a Career Development Fellowship from the National Health and Medical Research Council (NHMRC 1089039) and a Future Leaders Fellowship from the National Heart Foundation (NHF 100409) of Australia.

References (23)

  • B.J. Maron et al.

    Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: preamble, principles, and general considerations: a scientific statement from the American heart association and American college of cardiology

    Circulation

    (2015)
  • R. Beaudry et al.

    A modern definition of the athlete's heart-for research and the clinic

    Cardiol Clinics

    (2016)
  • J.A. Drezner et al.

    Why cardiovascular screening in young athletes can save lives: a critical review

    Br J Sports Med

    (2016)
  • B.J. Maron et al.

    Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12–25 years of age): a scientific statement from the American heart association and the American college of cardiology

    J Am Coll Cardiol

    (2014)
  • H. Van Brabandt et al.

    Harms and benefits of screening young people to prevent sudden cardiac death

    BMJ

    (2016)
  • B. Hamilton et al.

    Debate: challenges in sports cardiology; US versus European approaches

    Br J Sports Med

    (2012)
  • D. Corrado et al.

    Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program

    JAMA

    (2006)
  • A. La Gerche et al.

    Should pre-participation cardiovascular screening for competitive athletes be introduced in Australia? A timely debate in a sport-loving nation

    Heart Lung Circ

    (2011)
  • S. Kumar et al.

    New international guidelines for the interpretation of the electrocardiograph in athletes: a “traffic light” tool for maximising diagnostic specificity

    Heart Lung Circ

    (2017)
  • H. Heidbuchel

    The athlete's heart is a proarrhythmic heart, and what that means for clinical decision making

    Europace

    (2017)
  • M. Nakamura et al.

    Mechanisms of physiological and pathological cardiac hypertrophy

    Nat Rev Cardiol

    (2018)
  • Cited by (3)

    View full text