Paolo Zeppilli

Recommendations for interpretation of 12-lead electrocardiogram in the athlete.

Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed.

Concealed cardiomyopathies in competitive athletes with ventricular arrhythmias and an apparently normal heart: role of cardiac electroanatomical mapping and biopsy.

BACKGROUND The diagnosis of subtle structural heart disease in competitive athletes with ventricular arrhythmias (VAs) and an apparently normal heart is challenging. Three-dimensional electroanatomic mapping (EAM) has been demonstrated to reliably identify low-voltage areas that correspond to different cardiomyopathic substrates. OBJECTIVE The purpose of this study was to test whether EAM may help in the diagnosis of concealed cardiomyopathies in athletes with VAs and an apparently normal heart. METHODS We studied 13 consecutive competitive athletes (12 males, age 30 ± 13 years) who had documentation of VAs within the previous 6 months on 12-lead electrocardiogram (ECG), 24-hour Holter ECG, or ECG exercise testing and who were judged as having a structurally normal heart after a thorough noninvasive evaluation, including signal-averaged ECG, transthoracic echocardiogram, and cardiac magnetic resonance imaging. Depending on the presumed site of VA origin according to 12-lead ECG criteria, patients underwent right or left ventricular EAM and EAM-guided endomyocardial biopsy. RESULTS Presenting arrhythmias included sustained ventricular tachycardia (n = 3), multiple episodes of nonsustained ventricular tachycardia (n = 7), and frequent ventricular ectopic beats (>1,000 during 24 hours; n = 3). Three patients had a history of syncope. Twelve (92%) patients had at least one low-voltage region at EAM, which corresponded at EAM-guided endomyocardial biopsy to the histological diagnosis of active myocarditis in seven patients and of arrhythmogenic right ventricular cardiomyopathy in five. In one patient the histological evidence of contraction band necrosis allowed the unmasking of caffeine and ephedrine abuse. CONCLUSIONS Electroanatomical substrate mapping may help diagnose concealed myocardial diseases in competitive athletes presenting with recent-onset VAs and an apparently normal heart. Further studies are warranted to assess the prognostic implications of such subtle myocardial abnormalities.

Exercise prescription for the prevention and treatment of cardiovascular diseases: part II.

Epidemiological, clinical and laboratory studies have provided definitive evidence that physical activity is able to improve fitness and reduce cardiovascular morbidity and mortality. Moreover, physical exercise also seems to significantly reduce the risk of developing other chronic diseases such as obesity, osteoporosis, diabetes, tumours and depression. Promoting physical activity in the general population is therefore one of the primary objectives of our healthcare institutions. Although the benefits of an active lifestyle have been demonstrated by numerous scientific data, only a few numbers of Italians and Europeans take up regular physical exercise. To promote physical activity, both in the general population and in subjects affected by cardiovascular diseases, the Italian Federation of Sports Medicine, the Italian Society of Sports Cardiology, the Italian Association of Hospital Cardiologists, the Italian Society of Cardiology, the Italian Association of Out-of-Hospital Cardiologists and the Italian Group of Cardiac Rehabilitation have promoted the constitution of a Task Force made up of experts in the fields of sports cardiology. The document produced by the Task Force is intended for healthcare professionals and deals with the role of physical activity in the prevention and treatment of cardiovascular diseases. It examines the beneficial effects of physical activity on the cardiovascular system, while analysing the possible risks involved and how they can be avoided. The rational principles underlying the prescription of physical activity in the cardiologic setting are described, as are the modalities for prescribing such activity.

Italian cardiological guidelines for sports eligibility in athletes with heart disease: part 1.

In Italy the existence of a law on health protection of competitive sports since 1982 has favored the creation and the revision of these cardiological guidelines (called COCIS), which have reached their fourth edition (1989-2009). The present article is the second English version, which has summarized the larger version in Italian. The experience of the experts consulted in the course of these past 20 years has facilitated the application and the compatibility of issues related to clinical cardiology to the sports medicine field. Such prolonged experience has allowed the clinical cardiologist to acquire knowledge of the applied physiology of exercise and, on the other hand, has improved the ability of sports physicians in cardiological diagnostics. All this work has produced these guidelines related to the judgment of eligibility for competitive sports in the individual clinical situations and in the different cardiovascular abnormalities and/or heart disease. Numerous arguments are debated, such as interpretation of the athletes ECG, the utility of a preparticipation screening, arrhythmias, congenital heart disease, cardiomyopathies, arterial hypertension, ischemic heart disease and other particular issues.

Amateur boxing in the last 59 years. Impact of rules changes on the type of verdicts recorded and implications on boxers’ health

Background/aim Several changes have occurred in Olympic boxing (OB) in the last few decades, influencing the results in official competitions. The aim of this study was to assess how the evolution of rules changed the rate of the results that can influence boxers’ health. Methods From a web-research, the results of OB tournaments from 1952 to 2011 were reviewed (29 357 bouts). For each event, rate of knockout (KO), referee-stop contest (RSC), RSC-Head (RSCH), RSC-Injury (RSCI), RSC-Outclassed (RSCO), abandon, disqualification and points decisions were recorded. In our analysis we investigated the changes that occurred after the introduction of the standing-count rule (1964), mandatory head guard (1984), computerised scoring system (1992), RSCO (2000–2009) and modification of bout formula 3×3 min rounds (3×3, until 1997, 5×2 min rounds (5×2) until 1999, 4×2 min rounds (4×2) until 2008, 3×3 from 2009). Results The most important results were: (1) an RSCI rate increase (0.72–2.42%, p<0.03) after the standing-count rule; (2) a lower RSCI (0.60%, p<0.001) and higher RSCH (1.31–4.92%, p<0.001) and RSC (9.71–13.05%, p<0.03) rate with mandatory head guard; (3) a KO rate reduction (6.44–2.09%, p<0.001) with the computerised scoring system; (4) an RSC (13.15–5.91%, p<0.05) and RSCH (4.23–1.41%, p<0.001) rate reduction comparing 5×2–4×2 bouts. Conclusions In the last six decades, along with rule changes in OB, a clear reduction of health challenging results was observed. In the near future, older rules will be adopted (no head guard and a manual scoring system). Continued medical surveillance is important to ensure that new rule changes do not result in poor medical outcomes for the boxers.

Medical survey of female boxing in Italy in 2002–2003

Background: Female boxing has been permitted in Italy since 2001. According to the latest Italian laws, athletes applying to become boxers have to pass a pre-participation medical examination. Objective: To collect novel medical information from the pre-participation visits and mandatory pre-competition and post-competition examinations for all fights involving Italian female boxers in 2002–2003. Methods: A retrospective study on all official female boxing competitions in Italy from January 2002 to October 2003 was conducted. A prospective study on 28 amateur female boxers was also carried out. Results: Retrospective study: data from 664 examinations were collected. Pre-match examinations were negative. After competitions, 19/645 visits showed some injuries, with mild, soft tissue facial lesions, epistaxis, and hand-wrist problems being the most common. Prospective study: no major lesions were found during the study. One fibroadenoma, one ovarian cyst, and one intramural uterine myoma were found. One boxer was referred to a neurologist because of non-specific electroencephalographic (EEG) abnormalities, which persisted six months later. On a re-admission examination, which was needed because of a contest that was stopped because the referee judged that she was receiving blows to the head that were dangerous, one boxer showed non-specific EEG alterations and nystagmus. A cerebral magnetic resonance imaging scan was normal. She was allowed to participate in competitions again when her EEG returned to normal and clinical signs disappeared. Deviation of the nasal septum was quite common (68%). No major eye injuries were reported. Conclusion: Probably because of the correct preventive medical approach, female boxing is much safer than expected, and no major lesions (requiring hospital admission) were reported. Any lesions to the breast and reproductive system could not be considered to be boxing related.

Bicuspid aortic valve: an innocent finding or a potentially life-threatening anomaly whose complications may be elicited by sports activity?

The bicuspid aortic valve is the most frequent congenital anomaly of the heart in adults. Since the 1970s, with the advent of two-dimensional echocardiography, the in-vivo diagnosis of bicuspid aortic valve has become easier and greater attention has been paid to this anomaly in normal young people, particularly in sportsmen because, from a theoretical point of view, physical exercise may stress the abnormal aortic valve, favouring an early deterioration of the valve itself, as well as a dilation of the ascending aorta. Although the bicuspid aortic valve may remain without clinical consequences for a lifetime, it may be responsible for severe complications such as aortic stenosis, aortic insufficiency, endocarditis and aortic dilation/dissection, sometimes requiring surgery. Moreover, the bicuspid aortic valve may be associated with other cardiovascular anomalies, mainly aortic coarctation. At present there are no prospective studies dealing with effect of physical training and competitive sports on the natural course of the bicuspid aortic valve. However, in order to take any decision about sports eligibility, sports physicians should perform an initial accurate staging of the bicuspid aortic valve, taking into account haemodynamic factors, aortic complications and associated significant cardiovascular anomalies. A strict follow-up, with serial cardiological controls, is mandatory as well as antibiotic prophylaxis for endocarditis, particularly in subjects engaged in contact sports.

Early repolarization in the athlete

An “abnormal” resting electrocardiogram is common in top-ranking, endurance-trained athletes ([1][1]). These abnormalities belong to physiological changes induced by training, as sinus bradycardia, high QRS and T-wave voltages, and early repolarization (ER), consisting of an elevation of QRS–

Female boxing in Italy: 2002-2007 report

Objective To collect medical data on womens boxing. Design Cross-sectional and longitudinal study. Setting Medical examinations requested by Italian laws. Participants A retrospective study was conducted on all female boxing competitions in Italy from April 2001 to December 2007. Sixty-one amateur female boxers were evaluated longitudinally. Interventions (1) Retrospective study: All pre-/postmatch medical reports were analysed. (2) Prospective study: Breast, gynaecologic, brain, eyes, ear, nose and throat examinations were carried out. Main outcome measurements (1) Retrospective study: Any injury assessed before/after the match. (2) Prospective study: Health problems which could be related to boxing activity. Results (1) Retrospective study: Data from 5600 examinations were collected. Precompetition, a medical problem was recorded in three athletes (one conjunctiva hyperemia, one zygomatic bruise, one eyelid haematoma). Post competition, 51/2800 medical checks showed mild common injuries, such as soft tissue facial lesions, epistaxis and hand-wrist problems. Only one concussion was recorded with hospitalisation (for a thorough evaluation). Another athlete was hospitalised for a nasal fracture. (2) Prospective study: Two fibroadenomas, three ovarian cysts and one intramural uterine myoma were diagnosed. In four boxers, non-specific electroencephalographic abnormalities were detected, however, with a normal brain MRI in three (the fourth is still waiting for the radiologic procedure). Nasal septum deviation was common (42.6%) and a transmissive hypoacusia was observed in two athletes. No major eye injuries were reported. Conclusions Female boxing seems to be a safe sport with a very low incidence of events requiring hospitalisation. No specific diseases in female boxers could be observed, in particular regarding the breast and reproductive system.

Aborted sudden death in a young football player due to anomalous origin of the left coronary artery: successful surgical correction

Congenital anomalies of coronary arteries may precipitate sudden death in young athletes. We describe the case of a 14-year-old soccer player who developed chest pain and syncope during physical exertion, as the first manifestation of an abnormal aortic origin of the left coronary artery from the right coronary sinus. Correct identification by transthoracic echocardiography and confirmation by coronary angiography were made. Two years after the successful surgical correction, the boy had no recurrence of symptoms.