Hilde Moseby Berge

Blood pressure and hypertension in athletes: a systematic review

Objective Hypertension is reported to be the most prevalent risk factor for cardiovascular disease in elite athletes. We aimed to review blood pressure (BP) and prevalence of hypertension in different elite athletes, and study whether there was an association between high BP and left ventricular hypertrophy (LVH). Methods A systematic review of studies reporting BP in athletes using search strategies developed for PubMed and EMBASE, including only studies with ≥100 participants. We collected data on BP, prevalence of hypertension, LVH and methods of BP measurement. Results Of 3723 records identified, 51 met the inclusion criteria. These included men and women (n=138u2005390), aged mostly between 18 and 40u2005years, from varied sports disciplines. Mean systolic BP varied from 109±11 to 138±7u2005mmu2005Hg and mean diastolic BP from 57±12 to 92±10u2005mmu2005Hg. Strength-trained athletes had higher BP than endurance-trained athletes (131.3±5.3/77.3±1.4 vs 118.6±2.8/71.8±1.2u2005mmu2005Hg, p<0.05), and there was a trend towards a higher BP in athletes training ≥10u2005h compared with others (121.8±3.8/73.8±2.5 vs 117.6±3.3/66.8±6.9, p=0.058), but overall there was no significant difference in BP between athletes and controls. The prevalence of hypertension varied from 0% to 83%. Some studies showed an association between high BP and LVH. Measurement methods were poorly standardised. Conclusions BP and prevalence of hypertension in athletes varied considerably partly because of variations in methodology, but type and intensity of training may contribute towards higher BP. High BP may be associated with LVH.

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 Cardiologys (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 athletes 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 ESCs recommendations and the Seattle criteria, respectively. None of the players with abnormal ECGs only according to the ESCs recommendations had abnormal echocardiograms. Echocardiography alone detected one player with abnormalities (athletes 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 18–38u2005years, ECGs were categorised according to the European Society of Cardiologys (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 ESCs 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.

BLOOD PRESSURE IN ELITE ATHLETES: A SYSTEMATIC REVIEW

Background High blood pressure (BP) is a leading cause of illness, and bilateral measurement of BP is recommended in IOCs preparticipation health examination. Still there is limited data on BP in elite athletes. Objective To describe blood pressure, prevalence of hypertension and subclinical organ damage (left ventricular hypertrophy) in elite athletes. Design Systematic review, using a comprehensive search strategy developed for PubMed. Setting We identified studies of BP in elite athletes, including only studies of ≥100 athletes. Of 2049 studies identified, only 40 studies met the inclusion criteria. Participants Elite athletes aged 18 to 35 years. Assessment of risk factors High BP; Left ventricular hypertrophy. Main outcome measurements Office and ambulatory BP; Prevalence of hypertension; Method of BP measurement; Associations between BP and left ventricular hypertrophy (determined by voltage criteria on ECG or left ventricular mass on echocardiography). Results Office BP was recorded from one to three times at each visit, and measurements were repeated at different time intervals in nine studies. Only one study measured BP in both arms, and only two studies measured ambulatory BP if office BP was high. Mean systolic BP varied from 112±11u2005mmHg to 138±7u2005mmHg and mean diastolic BP from 59±8u2005mmHg to 86±7u2005mmHg. Hypertension was not defined or defined differently, from ≥130/85u2005mmHg to ≥150/95u2005mmHg, and the prevalence of hypertension varied from 0 to 45%. Athletes of both genders and from different sports disciplines were mixed in half of the studies. Four studies showed an association between increased BP and left ventricular hypertrophy. Conclusions Definition and prevalence of hypertension and methods of BP measurement differed substantially between the studies, and only a few studies investigated the association between high BP and subclinical organ damage. Future studies should use standardised definitions and methods, and hypertension as a risk factor in athletes should be further investigated.

MEASUREMENT METHOD IS IMPORTANT FOR INTERPRETATION OF ATHLETES' ECG

Background Electrocardiography (ECG) is recommended as part of IOCs preparticipation health examination in athletes. The new Seattle criteria for interpreting ECG in athletes are developed with reference values for abnormality, but yet, no guidelines exist on how to perform the measurements. Objective To test the correlations between visual and computer-based measurements, and examine how method choice influences prevalence of abnormal ECG findings. Design Cross-sectional study on the Seattle criteria comparing visual and computer-based reading of ECGs. Setting Preparticipation cardiac screening examination of male professional football players in Norway during a preseason training camp in 2008. Participants Athletes aged 18–38 years. Assessment of risk factors All ECG findings suggestive of cardiomyopathy or primary electrical disease were categorized according to the Seattle criteria. Visually, the measurements were conducted with calipers on-screen on the average PQRST complex in each lead, calculated by the trimmed mean. Computer-based measurements were derived from the medium beat. For both, heart rhythm and conduction were scored visually by cardiologist. Main outcome measurements Prevalence of abnormal ECG findings, and differences between visual and computer-based measurements. Categorical variables were compared by kappa statistics (K). Results ECG of good quality were available from 579 (97%) of 595 players. The ECG was categorized as abnormal in 64 (11%) players after visual assessment, versus in 122 (21%) after computer-based measurements, mainly due to more abnormal Q wave durations (35), T wave inversions (24) and ST depressions (12) detected by the computer. Abnormal ECG findings suggestive of; cardiomyopathy were present in 62 versus 122 players (Κ=0.544), and primary electrical disease in 8 versus 6 players (Κ=0.855). Conclusions The correlations between visual and computer-based measurements are moderate. Clinically, this difference will influence the prevalence of abnormal ECG findings in athletes. Thus, method choice should always be reported in preparticipation health examination studies. Reference values may need adjustments dependent on measurement methods.

Elevated blood pressure in norwegian elite football players is associated with both increased sympathetic activity and LV mass

Background UEFA requires that all male players of the elite teams undergo cardiovascular screening, which was conducted as a research project in Norway. Objective To study the prevalence of elevated blood pressure (BP), and test if there were any relation to consequences of hypertension as increased left ventricle (LV) mass or diastolic dysfunction. Design Cross-sectional study. Setting Training-camp, La Manga, Spain, 2008. Participants All football players in the two elite-divisions in Norway were invited, 28 of 30 teams participated. 594 of 636 players finished the study. Assessment of risk factors Standard BP measurements, high BP is defined >=140/90 mm Hg according to ESC standards. Height and weight were self reported, body mass index (BMI), body surface area and pulse pressure (PP) were calculated. Main outcome measurements The echocardiographic parameters were indexed LV mass, relative wall thickness (RWT), heart rate (HR), and peak early (E) and late (A) diastolic transmitral velocities. The E/A ratio was calculated as an index for LV diastolic function. Results Mean age: 25 years (range 18–38), mean BMI: 23.7 kg/m2 (20–29) and mean BP: 122/69 mm Hg. 38 players (6.4%) had hypertension grade 1, and two had hypertension grade 2. There was a significant linear relationship between mean arterial pressure (MAP) and indexed LV mass, HR and PP with regression coefficient 0.26 (95% CI 0.08 to 0.44), 0.20 (95% CI 0.10 to 0.29), and 0.18 (95% CI 0.07 to 0.29), p<0.01. No such correlation was found between RWT, E/A ratio and MAP. Conclusion Elevated BP was associated with increased PP and HR, indicating increased sympathetic activity. Those with elevated BP had significantly increased indexed LV mass, indicating an early start of end organ damage. Considering that detection of elevated BP at one single occasion in young age may predict manifest hypertension later in life, our data support BP screening of athletes.