Luisa Verdile

RELATION BETWEEN TRAINING-INDUCED LEFT VENTRICULAR HYPERTROPHY AND RISK FOR VENTRICULAR TACHYARRHYTHMIAS IN ELITE ATHLETES

The aim of this study was to analyze the relation between the magnitude of training-induced left ventricular (LV) hypertrophy and the frequency and complexity of ventricular tachyarrhythmias in a large population of elite athletes without cardiovascular abnormalities. Ventricular tachyarrhythmias are a common finding in athletes, but it is unresolved as to whether the presence or magnitude of LV hypertrophy is a determinant of these arrhythmias in athletes without cardiovascular abnormalities. From 738 athletes examined at a national center for the evaluation of elite Italian athletes, 175 consecutive elite athletes with 24-hour ambulatory (Holter) electrocardiographic recordings (but without cardiovascular abnormalities and symptoms) were selected for the study group. Echocardiographic studies were performed during periods of peak training. Athletes were arbitrarily divided into 4 groups according to the frequency and complexity of ventricular arrhythmias during Holter electrocardiographic monitoring. No statistically significant relation was evident between LV mass (or mass index) and the grade or frequency of ventricular tachyarrhythmias. In addition, a trend was noted in those athletes with the most frequent and complex ventricular ectopy toward lower calculated LV mass. In conclusion, ventricular ectopy in elite athletes is not directly related to the magnitude of physiologic LV hypertrophy. These data offer a measure of clinical reassurance regarding the benign nature of ventricular tachyarrhythmias in elite athletes and the expression of athletes heart.

Patterns of ventricular tachyarrhythmias associated with training, deconditioning and retraining in elite athletes without cardiovascular abnormalities.

Ventricular tachyarrhythmias commonly occur in trained athletes during ambulatory Holter electrocardiography and are usually associated with a benign course. Such arrhythmias have been demonstrated to be sensitive to short periods of athletic deconditioning; however, their response to retraining is not known. Twenty-four hour Holter electrocardiographic monitoring was performed at peak training and after 3 to 6 months of deconditioning and was repeated in the present study after 2, 6, and 12 months of retraining in 37 athletes with frequent and complex ventricular tachyarrhythmias and without cardiovascular abnormalities. These subjects showed partial (101 to 500 ventricular premature complexes [VPCs]/24 hours) or marked (<100 VPCs) reversibility of arrhythmias after deconditioning. Retraining initially resulted in a significant increase in arrhythmia frequency compared with deconditioning (from 280 ± 475 to 1,542 ± 2,186 VPCs; p = 0.005), couplets (0.14 ± 0.42 to 4.4 ± 8.2; p = 0.005), and nonsustained ventricular tachycardia (from 0 to 0.8 ± 1.8; p = 0.02). Subsequently, a progressive reduction was seen in the frequency of all ventricular arrhythmias during the 1 year of training to well below that at the peak training levels (VPCs 917 ± 1,630, couplets 1.8 ± 4.2, and nonsustained ventricular tachycardia 0.4 ± 1.2). Such annual arrhythmia reduction was significantly greater statistically in those athletes with marked reversibility after deconditioning than in the athletes with partial reversibility (69 ± 139 vs 1,496 ± 1,917 VPCs/24 hours, respectively; p = 0.007). No cardiac events or symptoms occurred during 1 year of follow-up. In conclusion, in elite athletes without cardiovascular disease, a resumption in intense training after deconditioning was associated with variable, but prolonged, suppression of ventricular ectopy. The absence of adverse clinical events or symptoms associated with the resumption of training supports the continued eligibility in competitive sports for such athletes and is also consistent with the benign nature of physiologic athletes heart syndrome.

Clinical significance of exercise-induced ventricular tachyarrhythmias in trained athletes without cardiovascular abnormalities

BACKGROUND Exercise-induced ventricular tachyarrhythmias raise clinical concern as a marker of increased risk in the presence of underlying cardiovascular disease. OBJECTIVE The aim of this study was to clarify the clinical significance of exercise-induced ventricular tachyarrhythmias in competitive athletes without evident cardiac abnormalities. METHODS Exercise electrocardiographic testing was performed in 5011 consecutive athletes without heart disease and analyzed for the occurrence of ventricular arrhythmias. RESULTS Of the 5011 athletes, 367 (7.3%) showed ≥1 premature ventricular beat (PVB), including 331 (6.6%) with ≤10 PVBs and 36 (0.7%) with >10 PVBs and/or ≥1 ventricular couplets, and/or ≥1 bursts of nonsustained ventricular tachycardia. The 331 athletes with ≤10 PVBs had no restriction from competitive sports, and repeated exercise testing over 3-12 months showed spontaneous reduction of arrhythmia (from 5.2 ± 4 to 4 ± 6 PVBs; P = .002), including 83 of 331 (23%) with disappearance of PVBs. The remaining 36 athletes were disqualified from sports because of frequent and/or complex arrhythmias; 23 showed reduction of arrhythmia at 3-12 months (from 46 ± 42 to 28 ± 11 PVBs, from 8 ± 10 to 3 ± 3 couplets, and from 3.6 ± 6 to 1 ± 1 nonsustained ventricular tachycardia; P = .05) and were readmitted to competition. The other 13 athletes with persistent arrhythmias were considered for radiofrequency ablation, of whom 6 were successfully treated with abolition of arrhythmias and permitted to return to competitive sports. No events or cardiovascular disease occurred in the 367 athletes over a follow-up period of 7.4 ± 5 years. CONCLUSION Exercise-induced ventricular tachyarrhythmias were present in a sizable minority of highly trained athletes without heart disease. These arrhythmias proved to be benign and not associated with adverse events or later development of cardiovascular disease.

Lack of correlation between ventricular late potentials and left ventricular mass in top-level male athletes.

PURPOSE The aim of this study was to establish: 1) the prevalence of abnormal signal-averaged electrocardiogram (SAECG) in a large population of top-level athletes and 2) the relationship between SAECG parameters and left ventricular mass. One-hundred and fifty-three elite male athletes without apparent heart disease, symptoms, or arrhythmias were studied. METHODS Fifty-six athletes (37%) had increased left ventricular mass (> 134 g.m(-2)). All athletes underwent time-domain SAECG on 300-400 heart beats recorded at rest from three bipolar orthogonal tests with a filter setting of 40-250 Hz. Criteria for abnormality were 1) filtered QRS duration > 114 ms, 2) duration of low-amplitude signals > 38 ms, or 3) root mean square voltage of the last 40 ms of the filtered QRS < 20 microV. RESULTS The prevalence of abnormal SAECG was 7.2% (abnormality of one parameter), 6.5% (abnormality of two parameters), and 5.8%(abnormality of three parameters). The prevalence of abnormal SAECG was similar in athletes with or without increased left ventricular mass. CONCLUSIONS In conclusion, this study showed: 1) the low rate of positive results of SAECG parameters in top-level male athletes, similar to that found in healthy sedentary subjects; and 2) the lack of correlation between left ventricular mass and overall SAECG parameters.

Are Olympic athletes free from cardiovascular diseases? Systematic investigation in 2352 participants from Athens 2004 to Sochi 2014

Context Olympic athletes represent model of success in our society, by enduring strenuous conditioning programmes and achieving astonishing performances. They also raise scientific and clinical interest, with regard to medical care and prevalence of cardiovascular (CV) abnormalities. Objective Our aim was to assess the prevalence and type of CV abnormalities in this selected athletes cohort. Design, setting and participants 2352 Olympic athletes, mean age 25±6, 64% men, competing in 31 summer or 15 winter sports, were examined with history, physical examination, 12-lead and exercise ECG and echocardiography. Additional testing (cardiac MRI, CT scan) or electrophysiological assessments were selectively performed when indicated. Main outcome measures Prevalence and type of CV findings, abnormalities and diseases found in Olympic athletes over 10 years. Results A subset of 92 athletes (3.9%) showed abnormal CV findings. Structural abnormalities included inherited cardiomyopathies (n=4), coronary artery disease (n=1), perimyocarditis (n=4), myocardial bridges (n=2), valvular and congenital diseases (n=45) and systemic hypertension (n=10). Primary electrical diseases included atrial fibrillation (n=2), supraventricular reciprocating tachycardia (n=14), complex ventricular tachyarrhythmias (non-sustained ventricular tachycardia, n=7; bidirectional ventricular tachycardia, n=1) or major conduction disorders (Wolff-Parkinson-White (WPW), n=1; Long QT syndrome (LQTS), n=2). Conclusions Our study revealed an unexpected prevalence of CV abnormalities among Olympic athletes, including a small, but not negligible proportion of pathological conditions at risk. This observation suggests that Olympic athletes, despite the absence of symptoms or astonishing performances, are not immune from CV disorders and might be exposed to unforeseen high-risk during sport activity.

Upper normal values of blood pressure response to exercise in Olympic athletes

BACKGROUND Exercise test is widespread performed in athletes to assess cardiovascular adaptations during effort; however, scarce information exists relative to the behavior of blood pressure during exercise in athletes. We sought to define the normal values and upper limits of blood pressure response to exercise in a large population of elite, healthy athletes. METHODS A total of 1,876 healthy, normotensive elite athletes (aged 25 ± 6 years, 64% male) underwent a comprehensive clinical evaluation including maximal bicycle exercise test. RESULTS At maximum exercise, the systolic blood pressure increased significantly (Δ = +69 ± 18 mm Hg; P< .001), whereas diastolic blood pressure showed minimal change (Δ = +1 ± 7 mm Hg; P= .001). The upper reference values were 220 mm Hg in male and 200 mm Hg in female athletes for systolic blood pressure, and 85 mm Hg in male and 80 mm Hg in female for diastolic blood pressure. A subgroup of 142 athletes (7.5%) showed high blood pressure response to exercise, that is, increase in systolic and/or diastolic blood pressure above the 95th percentile. Multivariate logistic regression analysis showed that endurance and mixed sport disciplines, body mass index, and baseline systolic blood pressure were the strongest determinants for high blood pressure response to exercise. CONCLUSION The gender-specific reference values for systolic and diastolic blood pressure at maximum exercise in athletes were defined. A small subset (7.5%) of athletes showed higher blood pressure response, in the absence of target organ disease or metabolic abnormalities, and associated with superior physical performance and larger cardiac remodeling.

Usefulness of transesophageal pacing during exercise for evaluating palpitations in top-level athletes

The aim of this study was to verify the use of transesophageal atrial pacing in reproducing tachyarrhythmias in 22 top-level athletes symptomatic for palpitations, with no evidence of arrhythmias or cardiac anomalies by the standard noninvasive diagnostic techniques. The transesophageal stimulation protocol was divided in 2 sections: at rest and during exercise on the bicycle ergometer in the upright position. Although transesophageal pacing at rest did not induce any arrhythmias in 18 of 22 athletes, during exercise it induced tachyarrhythmias. This occurred in all 16 athletes who had palpitations during physical activity. Electrophysiologic characteristics of induced atrial tachyarrhythmia suggested reentry within the atrioventricular node in 9 of 18 athletes: atrial fibrillation in 5, atrial flutter in 2, orthodromic reciprocating tachycardia due to concealed anomalous pathway in 1, and automatic atrial tachycardia in 1. This study stresses the clinical importance of palpitations during physical exercise and shows that transesophageal pacing performed during exercise is an important diagnostic tool in reproducing the previously described symptoms and in detecting the underlying tachyarrhythmias.

LONG-TERM SIGNIFICANCE OF EXERCISE-INDUCED VENTRICULAR TACHYARRHYTHMIAS IN ATHLETES WITHOUT CARDIOVASCULAR ABNORMALITIES

Abstract Category: 27. Clinical Electrophysiology—Ventricular ArrhythmiasSession-Poster Board Number: 1057-382 Authors: Luisa Verdile, Emanuele Guerra, Elvira De Blasiis, Roberto Ciardo, Filippo Quattrini, Fernando M. Di Paolo, Cataldo Pisicchio, Barbara Di Giacinto, Alessandro Biffi, Antonio Pelliccia, Institute of Sport Medicine and Science, Roma, Italy Background: Sudden death in athletes is presumably related to life-threatening ventricular arrhythmias occuring during sport activities. There are few data on clinical significance and risk for ventricular arrhythmias induced by exercise in athletes without apparent structural heart disease. To assess long-term clinical significance of exercise-induced tachyarrhythmias in athletes.Methods: We selected 12 athletes without cardiovascular abnormalities and frequent and/or complex ventricular arrhythmias. Selection criteria were the occurrence of ≥10 premature ventricular depolarization (PVDs) and/or ≥ 1 couplet induced by exercise test.The follow-up period was 9,18 ± 4,66 years during which the athletes underwent clinical evaluations, ECG and color-doppler echocardiography, 24-hours Holter monitoring and selectively, electrophysiologic study and cardiac magnetic resonance with late enhancement.Results: During the follow-up no athlete developed symptoms, events or evidence of cardiomyopathies. In 6 athletes (50%) the arrhythmias disappeared (in 2 athletes) or was substantially reduced (in 4).In 3 athletes arrhythmia was unchanged and in 2 worsened. These latter athletes underwent successfull radio-frequency ablation to allow resumption of athletic activity. A right ventricular outflow tract PVDs morphology was documented in 8 athletes (67%).Conclusions: Exercise induced ventricular arrhythmias in athletes without evidence of structural heart disease are associated with a good clinical outcome and with a trend of reduction over 9 years of follow-up.

ADAPTED EVALUATION PROTOCOLS FOR TEENAGE ATHLETES COMPETING AT YOUTH OLYMPIC GAMES: SAFEGUARDING AND PROTECTING YOUNG CHAMPIONS

Background Currently no clear indication are present for the pre-participation evaluation of adolescent elite athletes. Objective Our objective was to assess the efficacy of a tailored pre-participation evaluation protocol to assess health and eligibility of adolescent athletes, shortlisted for participation in the Youth Olympic Games. Design Setting and Patients Between 2010 and 2014, 247 adolescent elite athletes (53% females), mean age 16.3±1.01 years, competing in 22 summer and 15 winter sport disciplines, were evaluated through a tailored pre-participation protocol, which included 10 different health specialists. Main Outcome Measurements In 36 of the 247 athletes (14.5%), the pre-participation evaluation led to the final diagnosis of a pathological condition, including CV in 17 (6.8%), pulmonary in 11 (4.5%), endocrine in 5 (2.0%), infectious, neurological and psychiatric disorders in 1 each (0.4%). Among CV abnormalities, atrial septal defects were observed in 9 (3.6%), valvular diseases in 5 (2.0%), primary tachyarrhythmias in 2 (0.8%) and hypertension in 1 (0.4%). Pulmonary diseases consisted of allergic asthma, diagnosed in 11. Endocrine diseases included Hashimotos Thyroiditis in 2, Hypothyroidism in 2 and Androgen Insensitivity Syndrome in the remaining subject. Hepatitis B, Epilepsy Syndrome and Panic Disorder represented the remaining diagnoses, each in one individual. Results Based on current National and International Recommendations, none of the athletes was considered at high risk for acute events and all were eligible to compete at the Youth Olympic Games. All athletes with pathological conditions or abnormal findings were required to undergo a periodic follow up. Conclusions The specific pre-participation evaluation protocol implemented proved to be effective in identifying a wide range of disorders, in a significant proportion (14.5%) of adolescent Olympic athletes. The presented protocol should be considered for early identification of a wide spectrum of diseases in this population of athletes, allowing prompt treatment and minimising health consequences.

Elite Tennis Player with a Complete Atrio-Ventricular Block

This young elite tennis player, 14 years old, was referred for cardiologic evaluation in our Institute (in the year 1977) because of a second-degree atrio-ventricular (AV) block, type 1 observed on resting 12-lead ECG, performed at preparticipation screening. No known cardiovascular disease or symptoms (such as syncope, pre-syncope or dizziness and palpitations) were referred in the medical history. Family history was negative for known cardiovascular disease or sudden death.