Mats Börjesson

Electrocardiographic interpretation in athletes: the ‘Seattle Criteria’

Sudden cardiac death (SCD) is the leading cause of death in athletes during sport. Whether obtained for screening or diagnostic purposes, an ECG increases the ability to detect underlying cardiovascular conditions that may increase the risk for SCD. In most countries, there is a shortage of physician expertise in the interpretation of an athletes ECG. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from abnormal findings suggestive of pathology. On 13–14 February 2012, an international group of experts in sports cardiology and sports medicine convened in Seattle, Washington, to define contemporary standards for ECG interpretation in athletes. The objective of the meeting was to develop a comprehensive training resource to help physicians distinguish normal ECG alterations in athletes from abnormal ECG findings that require additional evaluation for conditions associated with SCD.

Normal electrocardiographic findings: recognising physiological adaptations in athletes

Electrocardiographic changes in athletes are common and usually reflect benign structural and electrical remodelling of the heart as a physiological adaptation to regular and sustained physical training (athletes heart). The ability to identify an abnormality on the 12-lead ECG, suggestive of underlying cardiac disease associated with sudden cardiac death (SCD), is based on a sound working knowledge of the normal ECG characteristics within the athletic population. This document will assist physicians in identifying normal ECG patterns commonly found in athletes. The ECG findings presented as normal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Abnormal electrocardiographic findings in athletes: recognising changes suggestive of primary electrical disease

Cardiac channelopathies are potentially lethal inherited arrhythmia syndromes and an important cause of sudden cardiac death (SCD) in young athletes. Other cardiac rhythm and conduction disturbances also may indicate the presence of an underlying cardiac disorder. The 12-lead ECG is utilised as both a screening and a diagnostic tool for detecting conditions associated with SCD. Fundamental to the appropriate evaluation of athletes undergoing ECG is an understanding of the ECG findings that may indicate the presence of a pathological cardiac disease. This article describes ECG findings present in primary electrical diseases afflicting young athletes and outlines appropriate steps for further evaluation of these ECG abnormalities. The ECG findings defined as abnormal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Physical activity in adolescents and adults with congenital heart defects; individualized exercise prescription

Studies in patients with congenital heart disease (CHD) indicate that the majority of individuals participating in such programs achieve significant improvement of their exercise capacity and psychological state.1 The challenge is to ensure safe participation in regular physical activity (PA) in order to avoid the detrimental effects associated with sedentary life style.nn### Why are physical activity recommendations for adolescents and adults with congenital heart disease needed?nnThe improved surgical techniques and clinical care of children with CHD have led to a considerable increase in the population of patients with CHD who reach adulthood, and the number of adults is expected to grow at a rate of 5% per year.2 Cardiac rehabilitation programs in patients with CHD have shown improvements in peak-VO2.3–5 Additionally, regular physical exercise is associated with lower risk of future obesity and ischaemic heart disease.3 Paradoxically, only a minority of CHD patients (19%) receives formal PA advice,4 and are often encouraged towards a sedentary lifestyle as a result of overprotection,5 and uncertainty as to which physical activities and with what intensity should be recommended.1 This is of particular importance when one considers that children with CHD are more likely to be overweight because of physical inactivity compared with children without CHD.6 On the other end of the spectrum, young patients may reject exercise limitations and engage in unsafe sporting practices.nnExisting exercise guidelines are of limited value for the majority of patients with CHD because they focus predominantly on competitive athletes.7 Consequently, they cover less than 1% of the CHD population and applying these recommendations to leisure time activities would be too restrictive. In addition, in all current recommendations, the decision making process is primarily based on the individual anatomic lesions. As a result formulating recommendations becomes complex and the documents are long and impractical ( Figurexa01 ).8 …

The effect of physical activity or exercise on key biomarkers in atherosclerosis--a systematic review.

OBJECTIVEnThis systematic review aimed to summarize published papers on the effect of physical activity (PA)/exercise on key atherosclerotic factors in patients with risk factors for or established cardiovascular disease (CVD).nnnMETHODSnStudies involving PA and cytokines, chemokines, adhesion molecules, CRP and angiogenic factors were searched for in Medline and Cochrane library. Original human studies of more than 2 weeks of PA intervention were included. Study quality was assessed according to the GRADE system of evidence.nnnRESULTSnTwenty-eight papers fulfilled the inclusion criteria. PA decreases the cytokines, tumor necrosis factor-a (TNF-a), interleukin-6 (IL-6), and interferon-y IFN-y (high, moderate and low evidence, respectively). The effect of PA on chemokines; stromal derived factor-1 (SDF-1), interleukin-8 (IL-8) (insufficient evidence) and monocyte chemoattractant protein-1 (MCP-1) (low evidence) was inconclusive. Aerobic exercise decreased the adhesion molecules, vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule-1 (ICAM-1) (moderate and high evidence, respectively), while effects of PA on E- and P-selectin were inconclusive. PA decreases C-reactive protein (CRP) (high evidence). The angiogenic actors, endothelial progenitor cells (EPCs) are increased (high evidence) and VEGF is decreased (moderate evidence) by PA. The effect of PA on these factors seems to depend on the type and duration of exercise intervention and patient factors, such as presence of ischemia.nnnCONCLUSIONnAs presented in this review, there is a high level of evidence that physical activity positively affects key players in atherosclerosis development. These effects could partly explain the scientifically proven anti-atherogenic effects of PA, and do have important clinical implications.

Prevention and management of non-communicable disease: the IOC consensus statement, Lausanne 2013

Morbidity and mortality from preventable, non-communicable chronic disease (NCD) threatens the health of our populations and our economies. The accumulation of vast amounts of scientific knowledge has done little to change this. New and innovative thinking is essential to foster new creative approaches that leverage and integrate evidence through the support of big data, technology, and design thinking. The purpose of this paper is to summarize the results of a consensus meeting on NCD prevention sponsored by the International Olympic Committee (IOC) in April, 2013. Within the context of advocacy for multifaceted systems change, the IOC’s focus is to create solutions that gain traction within health care systems. The group of participants attending the meeting achieved consensus on a strategy for the prevention and management of chronic disease that includes the following:1.Focus on behavioural change as the core component of all clinical programs for the prevention and management of chronic disease.2.Establish actual centres to design, implement, study, and improve preventive programs for chronic disease.3.Use human-centered design in the creation of prevention programs with an inclination to action, rapid prototyping and multiple iterations.4.Extend the knowledge and skills of Sports and Exercise Medicine (SEM) professionals to build new programs for the prevention and treatment of chronic disease focused on physical activity, diet and lifestyle.5.Mobilize resources and leverage networks to scale and distribute programs of prevention.True innovation lies in the ability to align thinking around these core strategies to ensure successful implementation of NCD prevention and management programs within health care. The IOC and SEM community are in an ideal position to lead this disruptive change. The outcome of the consensus meeting was the creation of the IOC Non-Communicable Diseases ad-hoc Working Group charged with the responsibility of moving this agenda forward.

Cardiorespiratory Fitness Protects Against Stress-Related Symptoms of Burnout and Depression

OBJECTIVEnTo examine how cardiorespiratory fitness and self-perceived stress are associated with burnout and depression. To determine if any relationship between stress and burnout/depression is mitigated among participants with high fitness levels.nnnMETHODSn197 participants (51% men, mean age=39.2 years) took part in the study. The Åstrand bicycle test was used to assess cardorespiratory fitness. Burnout was measured with the Shirom-Melamed Burnout Questionnaire (SMBQ), depressive symptoms with the Hospital Anxiety and Depression Scale (HAD-D). A gender-matched stratified sample was used to ensure that participants with varying stress levels were equally represented.nnnRESULTSnParticipants with moderate and high fitness reported fewer symptoms of burnout and depression than participants with low fitness. Individuals with high stress who also had moderate or high fitness levels reported lower scores on the SMBQ Tension subscale and the HAD-D than individuals with high stress, but low fitness levels.nnnCONCLUSIONnBetter cardiovascular fitness seems to be associated with decreased symptoms of burnout and a better capacity to cope with stress.nnnPRACTICAL IMPLICATIONSnPromoting and measuring cardiorespiratory fitness can motivate employees to adopt a more physically active lifestyle and thus strengthen their ability to cope with stress exposure and stress-related disorders.

Sudden cardiac death in athletes.

A ‘paradox of sport’ is that in addition to the undisputed health benefits of physical activity, vigorous exertion may transiently increase the risk of acute cardiac events. In general, the risk of sudden cardiac death (SCD) approximately doubles during physical activity and is 2‐ to 3‐fold higher in athletes compared to nonathletes. The incidence of SCD in young athletes is in fact very low, at around 1–3 per 100 000, but attracts much public attention. Variations in incidence figures may be explained by the methodology used for data collection and more importantly by differences between subpopulations of athletes. The incidence of SCD in older (≥35 years) athletes is higher and may be expected to rise, as more and older individuals take part in organized sports. SCD is often the first clinical manifestation of a potentially fatal underlying cardiovascular disorder and usually occurs in previously asymptomatic athletes. In the young (<35 years), SCD is mainly due to congenital/inherited cardiac abnormalities, whilst coronary artery disease (CAD) is the most common cause in older athletes. Cardiac screening including family/personal history, physical examination and resting electrocardiogram (ECG) may identify individuals at risk and has the potential to decrease the risk of SCD in young athletes. Screening including the ECG has a high sensitivity for underlying disease in young athletes, but the specificity needs to be improved, whereas the sensitivity of screening without the use of ECG is very low. The screening modality recommended for young athletes is of limited value in older athletes, who should receive individualized screening with cardiac stress testing for patients with high risk of underlying CAD. As cardiovascular screening will never be able to identify all athletes at risk, adequate preparedness is vital in case of a potentially fatal event at the sporting arena/facility. Firstly, we will review the magnitude of the problem of SCD in athletes of different ages, as well as the aetiology. Secondly, we will focus on how to prevent SCD in athletes of all ages, reviewing cardiovascular screening recommendations as well as emergency preparedness and arena safety.

Cardiorespiratory Fitness, Sedentary Behaviour and Physical Activity Are Independently Associated with the Metabolic Syndrome, Results from the SCAPIS Pilot Study.

Background Previous studies on the relation between lifestyle and the metabolic syndrome lack one or several aspects of the physical activity pattern in the analyses or cardiorespiratory fitness. Likewise, both uni- and triaxial accelerometry have been used, though, the predictive validity of these two modes has not been compared. Objectives The aims of the present study were firstly to investigate the independent relation between cardiorespiratory fitness and physical activity pattern to the metabolic syndrome (MetS) and secondly to examine the predictive validity of uni- and triaxial accelerometry, respectively. Methods Data was extracted from the SCAPIS pilot study (n=930, mean age 57.7 yrs). Physical activity pattern was assessed by accelerometry. Cardiorespiratory fitness was estimated using cycle ergometry. MetS was defined per the Adult Treatment Panel III from the National Cholesterol Education Program definition. Results Time spent sedentary (OR: 2.38, 95% CI: 1.54-4.24 for T3 vs T1), in light intensity (OR: 0.50, 95% CI: 0.28-0.90) and in moderate-to-vigorous activity (OR: 0.33, 95% CI: 0.18-0.61), as well as cardiorespiratory fitness (OR: 0.24, 95% CI:0.12-0.48), were all independently related to the prevalence of MetS after adjustment for potential confounders, fitness and/or the other aspects of the physical activity pattern. In addition, we found that triaxial analyses were more discriminant, with ORs farther away from the reference group and additional significant ORs. Conclusion The finding that several aspects of the physical activity pattern reveal independent relations to the MetS makes new possible targets for behaviour change of interest, focusing on both exercise and everyday life. When assessing the risk status of a patient, it is advised that triaxial accelerometry is used.

The "Saltin-Grimby Physical Activity Level Scale" and its application to health research.

The use of a four‐level questionnaire to assess leisure time physical activity (PA) and its validation is reviewed in this paper. This questionnaire was first published in 1968 and has then been used by more than 600 000 subjects, especially in different population studies in the Nordic countries. A number of modifications to the questionnaire have been published. These are mostly minor changes, such as adding practical examples of activities to illustrate the levels of PA. Some authors have also added duration requirements that were not included for all levels of PA in the original version. The concurrent validity, with respect to aerobic capacity and movement analysis using objective measurements has been shown to be good, as has the predictive validity with respect to various risk factors for health conditions and for morbidity and mortality.