|Volume 6 Issue 244 Published - 14:00 UTC 08:00 EST 31-Aug-2004 Next Update - 14:00 UTC 08:00 EST 1-Sep-2004||Editor: Susan K. Boyer, RN
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Competitive sport and cardiomyopathy
The rationale for offering recommendations concerning the participation in competitive sport in athletes with cardiovascular disease is based on the widely accepted clinical perception, substantiated by scientific evidence 1, that individuals with underlying (even clinically silent) cardiovascular disease have an increased risk for sudden cardiac death, or worsen cardiac outcome (in comparison with normal individuals), because of regular exercise training and sport participation. The aim of the recommendations is to provide careful directions to physicians and consultant cardiologists, suggesting the type and intensity of sport activity that can be safely performed by the candidate with cardiovascular abnormality.
The particular interest for sport is dictated by the awareness that competitive athletes (in particular, elite and professional athletes) represent a special subset of our society not only for their outstanding performances, but also for the substantial economic benefit they gather, as well as the intense pressure they are exposed by sponsors, athletic associations and media.
Nature of the Recommendations
The Recommendations for Competitive Sport Participation represents the consensus document of an international panel of experts appointed by the European Society of Cardiology, including clinical cardiovascular specialists with experience in exercise physiology, sport medicine and clinical cardiovascular medicine. The present recommendations are based on published scientific evidence where available, and on personal experience and consensus of experts. The aim of the panel was to formulated indications which represent a reasonable balance between the risks and the benefits inherent with competitive sport participation, and not simply restrict sport activity that could be associated with increased risk. The recommendations represent, therefore, a prudent, contemporary, and practical document for advising competitive sport activity in patients with cardiovascular disease.
Implementation of the Recommendations within the European countries
At present, a large heterogeneity (or lack) of regulations exist in the European countries, with only a few (such as Italy) requiring a medical clearance of competitive athletes and, in individuals with cardiovascular disease, having implemented Guidelines (COCIS) which are considered the standard of medical care 2.
The panel believes that a common, unbiased management of competitive athletes with cardiovascular disease is now needed, in consideration of the unlimited opportunity for professional athletes to move across EU countries. A unique and appropriate consensus document will be of relevant medical (and legal) value for physicians and cardiologists when evaluating athletes with cardiovascular disease. In the absence of binding requirements established by law, the panel recommends that the present Recommendations represent the standard of medical care for evaluation of competitive athletes with cardiovascular disease across Europe. Adherence to these recommendations will have substantial and cost-effective impact on medical care, by enhancing the safety of athletic activities and reducing the legal controversies related to different (or lack of) regulations.
The role of the Examining Physician
Should the physician be the ultimate authority determining whether or not an athlete with cardiovascular disease can participate in competitive sport ? Or alternatively, can the athlete with cardiovascular disease just sign an informed consent and be engaged in a risky and potentially life-threatening sport activity ?
Due to the unique structure and pressures of competitive sports, individuals with heart disease may not always use proper independent judgment in assessing the overall risk associated with a competitive sport career. The panel believes that the examining physician (and consultant cardiologist) have the ethical, medical and legal obligation to inform exhaustively the candidate of the risks inherent with competitive athletic lifestyle and, when the cardiovascular risk appears to be unreasonably high, the physician should be responsible for the final decision, with the aim to prevent adverse clinical events and/or reduce risk for disease progression.
Protecting the athlete's health and physical well-being of the athlete is the paramount objective of the physician, regardless other non-medical considerations, such as the potential antagonistic positions of the sponsor or the athletic association, which may be economically dependent on the athlete's competitive activity. These recommendations are intended, therefore, to support the physician's decision in such difficult instances and to offer a medical protection to the athlete from the unsustainable hazard of competitive sport activity.
Recommendations for Competitive Sport and Cardiomyopathies
Cardiomyopathies represent a spectrum of primary myocardial diseases, mostly on genetic basis, which are characterized by cardiac hypertrophy (hypertrophic cardiomyopathy), or dilatation (dilated cardiomiopathy), or right ventricular abnormalities (right ventricular cardiomyopathy/dysplasia). Prevalence of cardiomyopathies in the general population is greater than previously expected, and about 0.2% for hypertrophic cardiomyopathy.
Clinical relevance of cardiomyopathies is based on the recognition that they represent the most common cause of sudden and unexpected cardiac death in association with exercise in young patients, including competitive athletes. The diagnosis of cardiomyopathies is based on accurate evaluation of the distinctive morphologic abnormalities and differentiation from physiologic cardiac changes associated with chronic athletic conditioning (i.e., the athlete's heart). A varied spectrum of symptoms may be present in patients with cardiomyopathies, such as palpitations, syncope (mostly on arrhythmic basis) dyspnea and fatigability. However, a substantial proportion of patients and athletes engaged in competitive activities, present only mild (or no) symptoms. Treatment of cardiomyopathies is focused on preventing the risk of sudden cardiac death (by controlling incidence of arrhythmias) and includes withdrawn of the patient from regular training and intensive athletic activities.
The Recommendations for Competitive Sport Participation provide directions for evaluating athletes with cardiomyopathies, suggesting the diagnostic testing needed for confirming the diagnosis (such as echocardiography, 12-lead ECG) and risk stratification (such as exercise testing and Holter ECG monitoring, or additional diagnostic testing according the individual case). In most instances, definite diagnosis of a cardiomyopathy precludes the candidate from participation in competitive sport, with the aim to reduce the risk for death or disease progression associated with athletic lifestyle.
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