Publications by authors named "Antonio Pelliccia"

175 Publications

Strategies to minimize the risk for acute coronary events in long-distance races: insights from the prospective RACE Paris Registry.

Eur J Prev Cardiol 2020 Oct 15. Epub 2020 Oct 15.

Department of Medicine, Institute of Sport Medicine and Science, Largo Piero Gabrielli 1, 00197 Rome, Italy.

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http://dx.doi.org/10.1093/eurjpc/zwaa028DOI Listing
October 2020

Clinical correlates and outcome of the patterns of premature ventricular beats in Olympic athletes: a long-term follow-up study.

Eur J Prev Cardiol 2020 Jun 2. Epub 2020 Jun 2.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy.

Background: The pattern of premature ventricular beats, as a clue to site of origin, may help identify underlying cardiac diseases.

Aim: To assess the value of premature ventricular beat patterns in managing athletes with ventricular arrhythmias.

Methods: Athletes with 50 or more isolated premature ventricular beats/24 hours, and/or multifocal and/or repetitive premature ventricular beats at baseline, and/or exercise, and/or 24-hour electrocardiograms were selected for this analysis. Premature ventricular beats were defined as 'common' (outflow tract or fascicular origin), or 'uncommon' (other morphologies and/or multifocal or repetitive).

Results: From 4595 athletes consecutively examined, 205 (4%, 24.6 ± 6.9 years, 67% men) were included, 118 (58%) with uncommon and 87 (42%) with common premature ventricular beats. In particular, 81 (39%) showed complex patterns; 63 (31%) right/left ventricular outflow tract origin; 24 (12%) fascicular origin; 20 (10%) right bundle branch block pattern, intermediate/superior axis, wide QRS; and 17 (8%) left bundle branch block pattern, intermediate/superior axis. Uncommon premature ventricular beat patterns were predominant among men (62% vs. 38%; P < 0.001) but not among women. Uncommon premature ventricular beats were equally prevalent in endurance, mixed and skill disciplines, but lower in power sports. Cardiac diseases were detected in 11 (5%), 10 with uncommon patterns. Over a 6-year follow-up, cardiac diseases occurred in four (0.6%/year), all with uncommon patterns. Overall, cardiac diseases at baseline and during follow-up were detected in 14/118 athletes with uncommon versus one/87 with common premature ventricular beats (P = 0.003).

Conclusions: Evaluation of premature ventricular beat patterns in Olympic athletes identified cardiac diseases, requiring disqualification and/or follow-up, in 12% with uncommon versus 1% with common patterns. This result suggests that athletes with uncommon premature ventricular beat patterns should undergo comprehensive cardiac evaluation and/or serial follow-up, irrespective of gender or sporting discipline.
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http://dx.doi.org/10.1177/2047487320928452DOI Listing
June 2020

Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions: Part 1: Supraventricular arrhythmias. A position statement of the Section of Sports Cardiology and Exercise from the European Association of Preventive Cardiology (EAPC) and the European Heart Rhythm Association (EHRA), both associations of the European Society of Cardiology.

Eur J Prev Cardiol 2020 Jun 29. Epub 2020 Jun 29.

Italian National Olympic Committee, Institute of Sport Medicine and Science, Italy.

Symptoms attributable to arrhythmias are frequently encountered in clinical practice. Cardiologists and sport physicians are required to identify high-risk individuals harbouring such conditions and provide appropriate advice regarding participation in regular exercise programmes and competitive sport. The three aspects that need to be considered are: (a) the risk of life-threatening arrhythmias by participating in sports; (b) control of symptoms due to arrhythmias that are not life-threatening but may hamper performance and/or reduce the quality of life; and (c) the impact of sports on the natural progression of the underlying arrhythmogenic condition. In many cases, there is no unequivocal answer to each aspect and therefore an open discussion with the athlete is necessary, in order to reach a balanced decision. In 2006 the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology published recommendations for participation in leisure-time physical activity and competitive sport in individuals with arrhythmias and potentially arrhythmogenic conditions. More than a decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of these conditions. The present document presents a combined effort by the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology and the European Heart Rhythm Association to offer a comprehensive overview of the most updated recommendations for practising cardiologists and sport physicians managing athletes with supraventricular arrhythmias, and provides pragmatic advice for safe participation in recreational physical activities, as well as competitive sport at amateur and professional level. A companion text on recommendations in athletes with ventricular arrhythmias, inherited arrhythmogenic conditions, pacemakers and implantable defibrillators is published as Part 2 in Europace.
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http://dx.doi.org/10.1177/2047487320925635DOI Listing
June 2020

The 2020 ESC Guidelines on Sport Cardiology.

Eur Heart J 2021 Jan;42(1):5-6

Institute of Sports Medicine and Science Largo Piero Gabrielli 1. Rome 00197 Roma, Italy

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http://dx.doi.org/10.1093/eurheartj/ehaa734DOI Listing
January 2021

A promising future: the Journal's Editor-in-Chief perspective.

J Sports Med Phys Fitness 2021 01;61(1)

Institute of Sports Medicine and Science, Rome, Italy -

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http://dx.doi.org/10.23736/S0022-4707.20.12013-9DOI Listing
January 2021

Female Athlete's Heart: Sex Effects on Electrical and Structural Remodeling.

Circ Cardiovasc Imaging 2020 12 15;13(12):e011587. Epub 2020 Dec 15.

Institute of Sports Medicine and Science, Rome, Italy (F.B., E.L., V.M., B.D.G., A.P.).

Background: Most of our knowledge on training-induced cardiac remodeling is derived from men, with the paucity of data from women representing an important gap in knowledge. The aim of the study was to define the electrocardiographic and morphological features of female athlete's heart, with special attention to differences related to sex and sport.

Methods: Seven hundred twenty Olympic athletes (360 females and 360 age- and sport-matched males, mean age: 23±5 years) were evaluated by clinical, resting, and exercise electrocardiography and echocardiography.

Results: Anterior T-wave inversion was more common in females than males (<0.05). Left ventricular (LV) wall thickness and LV mass were greater in men (<0.001). Females had smaller absolute but greater indexed LV and right ventricular (RV) dimensions as compared to males. Most women had normal LV geometry (80.8%). A progressive increase in LV/RV dimensions was observed in women from those engaged in skill, power, to mixed and endurance disciplines, with the endurance ones demonstrating the greatest degree of RV dilatation. Women had a peculiar biventricular adaptation, with higher LV/RV (1.41±0.16 versus 1.36±0.15, <0.0001) and lower RV inflow/outflow ratio (<0.001), as compared to men.

Conclusions: Sex significantly affects cardiac remodeling in athletes, with females presenting a different electrical and structural remodeling. Women maintain a normal LV geometry, with relative larger increase of cavity dimensions compared with men. Type of sport has a relevant impact, with endurance athletes exhibiting the greatest degree of RV and LV dimensional remodeling. The present study confirms the need for a sex-based approach for interpreting the complex features of athlete's heart in women.
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http://dx.doi.org/10.1161/CIRCIMAGING.120.011587DOI Listing
December 2020

Physiologic and Clinical Features of the Paralympic Athlete's Heart.

JAMA Cardiol 2021 Jan;6(1):30-39

Italian Paralympic Committee, Rome, Italy.

Importance: Paralympic medicine is a newly adopted term to describe the varied health care issues associated with athletes in the Paralympics. Scarce scientific data, however, are currently available describing the cardiac remodeling in Paralympic athletes.

Objective: To investigate the physiological and clinical characteristics of the Paralympic athlete's heart and derive the normative values.

Design, Setting, And Participants: This is a single-center study on a relatively large cohort of Paralympic athletes, conducted at the Italian Institute of Sport Medicine and Science. Paralympic athletes free of cardiac or systemic pathologic conditions other than their cause of disability were selected for participation in the Paralympic Games from January 2000 to June 2014. Athletes were arbitrarily classified for disability in 2 groups: those with spinal cord injuries (SCI) and those with non-SCI (NSCI). Data analysis occurred from March 2019 to June 2020.

Main Outcomes And Measures: The primary outcome was the difference in cardiac remodeling in Paralympic athletes according to disability type and sports discipline type. Athletes underwent cardiac evaluation, including 12-lead and exercise electrocardiograms, echocardiography, and cardiopulmonary exercise testing.

Results: Among 252 consecutive Paralympic athletes (median [interquartile range (IQR)] age, 34 [29-41] years; 188 men [74.6%]), 110 had SCI and 142 had NSCI. Those with SCI showed a higher prevalence of abnormal electrocardiogram findings than those with NSCI (13 of 110 [11.8%] vs 6 of 142 [4.2%]; P = .003), smaller left ventricular end-diastolic dimension (median [IQR], 48 [46-52] vs 51 [48-54] mm; P = .001) and left ventricular mass index (median [IQR], 80.6 [69-94] vs 91.3 [80-108] g/m2; P = .001), and lower peak oxygen uptake (VO2) (median [IQR], 27.1 [2-34] vs 38.5 [30-47] mL/min/kg; P = .001) in comparison with those with NSCI. Regarding sport discipline, endurance athletes had a larger left ventricular cavity (median [IQR], 52 [47-54] vs 49 [47-53] mm; P = .006) and higher peak VO2 (median [IQR], 46 [39-55] vs 30 [25-35] mL/min/kg; P = .001) than athletes in nonendurance sports.

Conclusions And Relevance: Cardiac remodeling in Paralympic athletes differed by disability and sport discipline. Having NSCI lesions and engaging in endurance sports were associated with the largest left ventricular cavity and left ventricular mass and highest VO2 peak. Having SCI lesions and engaging in nonendurance disciplines, on the contrary, were associated with the smallest left ventricular cavity and mass and lowest VO2 peak.
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http://dx.doi.org/10.1001/jamacardio.2020.4306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7512121PMC
January 2021

Life-long running with calcified coronary plaques: Should we be concerned?

Rev Port Cardiol 2020 Sep 11. Epub 2020 Sep 11.

Institute of Sport Medicine and Science, Rome, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.repc.2020.08.001DOI Listing
September 2020

Recommendations for participation in competitive sport in adolescent and adult athletes with Congenital Heart Disease (CHD): position statement of the Sports Cardiology & Exercise Section of the European Association of Preventive Cardiology (EAPC), the European Society of Cardiology (ESC) Working Group on Adult Congenital Heart Disease and the Sports Cardiology, Physical Activity and Prevention Working Group of the Association for European Paediatric and Congenital Cardiology (AEPC).

Eur Heart J 2020 11;41(43):4191-4199

Cardiology Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, Blackshaw Rd, Tooting, London SW17 0QT, UK.

Improved clinical care has led to an increase in the number of adults with congenital heart disease (CHD) engaging in leisure time and competitive sports activities. Although the benefits of exercise in patients with CHD are well established, there is a low but appreciable risk of exercise-related complications. Published exercise recommendations for individuals with CHD are predominantly centred on anatomic lesions, hampering an individualized approach to exercise advice in this heterogeneous population. This document presents an update of the recommendations for competitive sports participation in athletes with cardiovascular disease published by the Sports Cardiology & Exercise section of the European Association of Preventive Cardiology (EAPC) in 2005. It introduces an approach which is based on the assessment of haemodynamic, electrophysiological and functional parameters, rather than anatomic lesions. The recommendations provide a comprehensive assessment algorithm which allows for patient-specific assessment and risk stratification of athletes with CHD who wish to participate in competitive sports.
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http://dx.doi.org/10.1093/eurheartj/ehaa501DOI Listing
November 2020

Yield and clinical significance of genetic screening in elite and amateur athletes.

Eur J Prev Cardiol 2020 Jul 2:2047487320934265. Epub 2020 Jul 2.

CEINGE - Biotecnologie Avanzate, Italy.

Aims: The purpose of this study was to assess the value of genetic testing in addition to a comprehensive clinical evaluation, as part of the diagnostic work-up of elite and/or amateur Italian athletes referred for suspicion of inherited cardiac disease, following a pre-participation screening programme.

Methods: Between January 2009-December 2018, of 5892 consecutive participants, 61 athletes were investigated: 30 elite and 31 amateur athletes. Elite and amateur athletes were selected, on the basis of clinical suspicion for inherited cardiac disease, from two experienced centres for a comprehensive cardiovascular evaluation. Furthermore, the elite and amateur athletes were investigated for variants at DNA level up to 138 genes suspected to bear predisposition for possible cardiac arrest or even sudden cardiac death.

Results: Of these 61 selected subjects, six (10%) had diagnosis made possible by a deeper clinical evaluation, while genetic testing allowed a definite diagnosis in eight (13%). The presence of 3 clinical markers (i.e. family history, electrocardiogram and/or echocardiographic abnormalities, exercise-induced ventricular arrhythmias) was associated with a higher probability of positive genetic diagnosis (75%), compared with the presence of two or one clinical markers (14.2%, 8.1%, respectively, -value = 0.004).

Conclusion: A combined clinical and genetic evaluation, based on the subtle evidence of clinical markers for inherited disease, was able to identify an inherited cardiac disease in about one-quarter of the examined athletes.
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http://dx.doi.org/10.1177/2047487320934265DOI Listing
July 2020

Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions: Part 1: Supraventricular arrhythmias. A position statement of the Section of Sports Cardiology and Exercise from the European Association of Preventive Cardiology (EAPC) and the European Heart Rhythm Association (EHRA), both associations of the European Society of Cardiology.

Eur J Prev Cardiol 2020 Jun 29:2047487320925635. Epub 2020 Jun 29.

Italian National Olympic Committee, Institute of Sport Medicine and Science, Italy.

Symptoms attributable to arrhythmias are frequently encountered in clinical practice. Cardiologists and sport physicians are required to identify high-risk individuals harbouring such conditions and provide appropriate advice regarding participation in regular exercise programmes and competitive sport. The three aspects that need to be considered are: (a) the risk of life-threatening arrhythmias by participating in sports; (b) control of symptoms due to arrhythmias that are not life-threatening but may hamper performance and/or reduce the quality of life; and (c) the impact of sports on the natural progression of the underlying arrhythmogenic condition. In many cases, there is no unequivocal answer to each aspect and therefore an open discussion with the athlete is necessary, in order to reach a balanced decision. In 2006 the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology published recommendations for participation in leisure-time physical activity and competitive sport in individuals with arrhythmias and potentially arrhythmogenic conditions. More than a decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of these conditions. The present document presents a combined effort by the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology and the European Heart Rhythm Association to offer a comprehensive overview of the most updated recommendations for practising cardiologists and sport physicians managing athletes with supraventricular arrhythmias, and provides pragmatic advice for safe participation in recreational physical activities, as well as competitive sport at amateur and professional level. A companion text on recommendations in athletes with ventricular arrhythmias, inherited arrhythmogenic conditions, pacemakers and implantable defibrillators is published as Part 2 in Europace.
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http://dx.doi.org/10.1177/2047487320925635DOI Listing
June 2020

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators.

Europace 2021 Jan;23(1):147-148

Department of Cardiology, University of Padova, Padova, Italy.

This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.
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http://dx.doi.org/10.1093/europace/euaa106DOI Listing
January 2021

Diagnosis of arrhythmogenic cardiomyopathy: The Padua criteria.

Int J Cardiol 2020 11 16;319:106-114. Epub 2020 Jun 16.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy.

The original designation of "Arrhythmogenic right ventricular (dysplasia/) cardiomyopathy"(ARVC) was used by the scientists who first discovered the disease, in the pre-genetic and pre-cardiac magnetic resonance era, to describe a new heart muscle disease predominantly affecting the right ventricle, whose cardinal clinical manifestation was the occurrence of malignant ventricular arrhythmias. Subsequently, autopsy investigations, genotype-phenotype correlations studies and the increasing use of contrast-enhancement cardiac magnetic resonance showed that the fibro-fatty replacement of the myocardium represents the distinctive phenotypic feature of the disease that affects the myocardium of both ventricles, with left ventricular involvement which may parallel or exceed the severity of right ventricular involvement. This has led to the new designation of "Arrhythmogenic Cardiomyopathy" (ACM), that represents the evolution of the original term of ARVC. The present International Expert Consensus document proposes an upgrade of the criteria for diagnosis of the entire spectrum of the phenotypic variants of ACM. The proposed "Padua criteria" derive from the diagnostic approach to ACM, which has been developed over 30 years by the multidisciplinary team of basic researchers and clinical cardiologists of the Medical School of the University of Padua. The Padua criteria are a working framework to improve the diagnosis of ACM by introducing new diagnostic criteria regarding tissue characterization findings by contrast-enhanced cardiac magnetic resonance, depolarization/repolarization ECG abnormalities and ventricular arrhythmia features for diagnosis of the left ventricular phenotype. The proposed diagnostic criteria need to be further validated by future clinical studies in large cohorts of patients.
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http://dx.doi.org/10.1016/j.ijcard.2020.06.005DOI Listing
November 2020

Clinical outcomes in adult athletes with hypertrophic cardiomyopathy: a 7-year follow-up study.

Br J Sports Med 2020 Aug 12;54(16):1008-1012. Epub 2020 Jun 12.

Departement of Medicine, Azienda Ospedaliera Sant Andrea, Roma, Lazio, Italy.

Objective: Current guidelines recommend precautionary disqualification from competitive sports in patients with hypertrophic cardiomyopathy (HCM). We assessed the incidence of cardiovascular events in a cohort of patients with HCM engaged in long-term exercise programmes and competitive sport.

Methods: We reviewed data on 88 consecutive athletes diagnosed with HCM, from 1997 to 2017; 92% male, 98% Caucasian, median age 31 (IQR: 19-44) years. All participated in regular exercise programmes and competitive sport at study entry.We performed follow-up evaluation after 7±5 (1-21) years. 61 (69%) of the athletes had substantially reduced or stopped exercise and sport (ie, HCM-detrained), and 27 had continued with regular training and sport competitions (HCM-trained). At baseline evaluation, both groups were similar for age, gender balance, symptoms, ECG abnormalities, extent of left ventricular hypertrophy, arrhythmias and risk profile for sudden cardiac death/arrest.

Results: During the follow-up period, two participants suffered sudden cardiac arrest or death (0.3% per year) both outside of sport participation. In addition, 19 (22%) reported symptoms (syncope in 3, palpitations in 10, chest pain in 4 and dyspnoea in 2). The Kaplan-Meier analyses of freedom from combined sudden cardiac arrest/death and symptoms (log-rank test p=0.264) showed no differences between HCM-trained and detrained patients.

Conclusion: In this adult cohort of low-risk HCM athletes, voluntary decision to pursue in participation in competitive sport events was not associated with increased risk for major cardiac events or clinical worsening compared with decision to reduce or withdraw from exercise programmes and sport. Similar results may not be seen in younger or racially diverse athlete populations, or in patients with more severe HCM phenotypes.
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http://dx.doi.org/10.1136/bjsports-2019-100890DOI Listing
August 2020

Clinical correlates and outcome of the patterns of premature ventricular beats in Olympic athletes: a long-term follow-up study.

Eur J Prev Cardiol 2020 Jun 2:2047487320928452. Epub 2020 Jun 2.

Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy.

Background: The pattern of premature ventricular beats, as a clue to site of origin, may help identify underlying cardiac diseases.

Aim: To assess the value of premature ventricular beat patterns in managing athletes with ventricular arrhythmias.

Methods: Athletes with 50 or more isolated premature ventricular beats/24 hours, and/or multifocal and/or repetitive premature ventricular beats at baseline, and/or exercise, and/or 24-hour electrocardiograms were selected for this analysis. Premature ventricular beats were defined as 'common' (outflow tract or fascicular origin), or 'uncommon' (other morphologies and/or multifocal or repetitive).

Results: From 4595 athletes consecutively examined, 205 (4%, 24.6 ± 6.9 years, 67% men) were included, 118 (58%) with uncommon and 87 (42%) with common premature ventricular beats. In particular, 81 (39%) showed complex patterns; 63 (31%) right/left ventricular outflow tract origin; 24 (12%) fascicular origin; 20 (10%) right bundle branch block pattern, intermediate/superior axis, wide QRS; and 17 (8%) left bundle branch block pattern, intermediate/superior axis. Uncommon premature ventricular beat patterns were predominant among men (62% vs. 38%;  < 0.001) but not among women. Uncommon premature ventricular beats were equally prevalent in endurance, mixed and skill disciplines, but lower in power sports. Cardiac diseases were detected in 11 (5%), 10 with uncommon patterns. Over a 6-year follow-up, cardiac diseases occurred in four (0.6%/year), all with uncommon patterns. Overall, cardiac diseases at baseline and during follow-up were detected in 14/118 athletes with uncommon versus one/87 with common premature ventricular beats ( = 0.003).

Conclusions: Evaluation of premature ventricular beat patterns in Olympic athletes identified cardiac diseases, requiring disqualification and/or follow-up, in 12% with uncommon versus 1% with common patterns. This result suggests that athletes with uncommon premature ventricular beat patterns should undergo comprehensive cardiac evaluation and/or serial follow-up, irrespective of gender or sporting discipline.
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http://dx.doi.org/10.1177/2047487320928452DOI Listing
June 2020

Exercise in the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) era: A Question and Answer session with the experts Endorsed by the section of Sports Cardiology & Exercise of the European Association of Preventive Cardiology (EAPC).

Eur J Prev Cardiol 2020 Aug 1;27(12):1242-1251. Epub 2020 Jun 1.

Cardiology Clinical Academic Group, St George's, University of London, UK.

Regular exercise has multiple benefits for physical and mental health, including the body's ability to combat infections. The current COVID-19 pandemic and the social distancing measures employed to curtail the impact of the infection are likely to reduce the amount of usual physical activity being performed by most individuals, including habitual exercisers. The uncertainties relating to the impact of the SARS-CoV-2 virus on the heart may cause increased anxiety, particularly in athletes who need to sustain a vigorous exercise regime in order to maintain their skills and fitness in preparation for return to competition after a short re-training period. The aim of this document is to provide practical answers to pertinent questions being posed by the sporting community, in an attempt to offer reassurance, promote safe participation in exercise during as well as after the COVID-19 pandemic and provide a framework of management for physicians caring for athletes.
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http://dx.doi.org/10.1177/2047487320930596DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717284PMC
August 2020

Return to play after the COVID-19 pandemic: a commentary by the Editor in Chief.

J Sports Med Phys Fitness 2020 05;60(5):675-676

Istituto di Medicina e Scienza dello Sport "Antonio Venerando, " Rome, Italy -

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http://dx.doi.org/10.23736/S0022-4707.20.11137-XDOI Listing
May 2020

Interpretation of T-wave inversion in physiological and pathological conditions: Current state and future perspectives.

Clin Cardiol 2020 Aug 7;43(8):827-833. Epub 2020 Apr 7.

Institute of Sports Medicine and Science, Rome, Italy.

The presence of T-wave inversion (TWI) at 12-lead electrocardiogram (ECG) in competitive athletes is one of the major diagnostic challenges for sports physicians and consulting cardiologists. Indeed, while the presence of TWI may be associated with some benign conditions and it may be occasionally seen in healthy athletes presenting signs of cardiac remodeling, it may also represent an early sign of an underlying, concealed structural heart disease or life-threatening arrhythmogenic cardiomyopathies, which may be responsible for exercise-related sudden cardiac death (SCD). The interpretation of TWI in athletes is complex and the inherent implications for the clinical practice represent a conundrum for physicians. Accordingly, the detection of TWI should be viewed as a potential red flag on the ECG of young and apparently healthy athletes and warrants further investigations because it may represent the initial expression of cardiomyopathies that may not be evident until many years later and that may ultimately be associated with adverse outcomes. The aim of this review is, therefore, to report an update of the literature on TWI in athletes, with a specific focus on the interpretation and management.
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http://dx.doi.org/10.1002/clc.23365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7403675PMC
August 2020

Low QRS voltages in Olympic athletes: Prevalence and clinical correlates.

Eur J Prev Cardiol 2020 09 30;27(14):1542-1548. Epub 2020 Mar 30.

Institute of Sport Medicine and Science, Italy.

Background: Recently, novel interest in low QRS voltages was prompted by the observation that low QRS voltages are present in arrhythmogenic cardiomyopathy patients, even before occurrence of symptoms/events.

Aim: The purpose of this study was to assess prevalence and clinical correlates of low QRS voltages in Olympic athletes, evaluated and followed-up within our cardiovascular screening programme.

Methods: Five hundred and sixteen athletes consecutively examined (2010-2011) were included in this study. A low QRS voltage was defined as amplitude of QRS <0.5 mV in limb and/or <1.0 mV in precordial leads. Cardiovascular evaluation included 12-lead and exercise electrocardiogram, echocardiography and, selectively, additional tests to confirm diagnosis. Athletes were followed-up for 5 ± 2 (1-9) years.

Results: The majority of athletes (493; 96%) showed normal/increased R/S-wave voltages, but 23 (4%) had low QRS voltages. No differences were observed in low QRS voltage athletes compared to normal/increased QRS voltages for QRS duration, QTc and PR intervals, left ventricular cavity size and mass, or gender and sport participated. However, premature ventricular beats, occurred more frequently in low QRS voltages (39% vs 7%;  < 0.001), with patterns suggesting origin from left or right free wall. No diseases or events were registered in low QRS voltage athletes over the follow-up.

Conclusions: In Olympic athletes, the prevalence of low QRS voltages was 4%. Athletes with low QRS voltages did not differ from other athletes according to sport participated in or cardiac dimensions. However, more frequently (39% vs 7%) they showed premature ventricular beats, originating from either the left or right free ventricular wall. Therefore, long-term follow-up with serial clinical evaluations is needed in low QRS voltage athletes, in order to definitely clarify the clinical significance.
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http://dx.doi.org/10.1177/2047487320914758DOI Listing
September 2020

Brief recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: Summary of a Position Statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC).

Eur J Prev Cardiol 2020 05 12;27(7):770-776. Epub 2019 Sep 12.

Institute for Sports Medicine and Science, Italian Olympic Committee, Rome, Italy.

This paper presents a brief summary of the recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology (EAPC) on sports-participation in patients with coronary artery disease, coronary artery anomalies or spontaneous dissection of the coronary arteries, all entities being associated with myocardial ischaemia. Given the wealth of evidence supporting the benefits of exercise for primary and secondary prevention of coronary artery disease, individuals should be restricted from competitive sport only when a substantial risk of adverse event or disease progression is present. These recommendations aim to encourage regular physical activity including participation in sports and, with reasonable precaution, ensure a high level of safety for all individuals with coronary artery disease. The present document is based on available current evidence, but in most instances because of lack of evidence, also on clinical experience and expert opinion.
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http://dx.doi.org/10.1177/2047487319876186DOI Listing
May 2020

The electrocardiogram in the diagnosis and management of patients with hypertrophic cardiomyopathy.

Heart Rhythm 2020 01 10;17(1):142-151. Epub 2019 Aug 10.

Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy.

In an era of rapid technological development and evolving diagnostic possibilities, the electrocardiogram (ECG) is living an authentic "renaissance" in myocardial diseases. To date, the ECG remains an irreplaceable first step when evaluating patients with hypertrophic cardiomyopathy (HCM) and an abnormal ECG may be the only manifestation of disease at an early stage. In some instances, specific electrical anomalies may differentiate HCM from phenocopies such as cardiac amyloidosis and glycogen storage diseases. The exponential growth in knowledge of the complexity of HCM has led to new challenges in terms of early identification of the disease, differential diagnosis, risk stratification, and development of targeted therapies. In this scenario, the apparently "old fashioned" ECG and the array of ECG-based techniques, ranging from Holter monitoring and loop recorders to exercise testing, are as contemporary as ever. In the present review, we discuss the current role of the ECG in the diagnosis and management of HCM, focusing on various clinical settings where its appropriate use and interpretation can make a difference.
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http://dx.doi.org/10.1016/j.hrthm.2019.07.019DOI Listing
January 2020

Brief recommendations for participation in competitive sports of athletes with arterial hypertension: Summary of a Position Statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC).

Eur J Prev Cardiol 2019 09 24;26(14):1549-1555. Epub 2019 May 24.

Paracelsus Medical University, Salzburg, Austria.

Owing to its undisputed multitude of beneficial effects, European Society of Cardiology guidelines advocate regular physical activity as a class IA recommendation for the prevention and treatment of cardiovascular disease. Nonetheless, competitive athletes with arterial hypertension may be exposed to an increased risk of cardiovascular events. Guidance to physicians will be given in this summary of our recently published recommendations for participation in competitive sports of athletes with arterial hypertension.
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http://dx.doi.org/10.1177/2047487319852807DOI Listing
September 2019

Exercise and sports participation in patients with thoracic aortic disease: a review.

Expert Rev Cardiovasc Ther 2019 Apr 21;17(4):251-266. Epub 2019 Mar 21.

a Department of Cardiology , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands.

Introduction: Current guidelines recommend patients with thoracic aortic disease (TAD) including inherited aortopathies to avoid heavy exercise. However, evidence supporting the negative advice on exercise is scarce. We aimed to provide an up-to-date systematic review of the available evidence on risks and benefits of exercise and sports participation in TAD patients. Areas covered: A systematic search was performed in Medline, Embase and Web of Science: thoracic aortic aneurysm or thoracic aortic dissection or inheritable aortopathies including Marfan Syndrome (MFS), Loeys-Dietz syndrome, Turner Syndrome, Ehlers-Danlos syndrome, bicuspid aortic valve (BAV) and sports, exercise or athletes. The resulting 1,652 manuscripts were reviewed by two independent observers. Eventually, 26 studies and 12 case-reports were included, reporting on thoracic aortic dimensions in athletes, exercise related acute aortic dissections, and exercise in BAV and MFS patients. Expert opinion: Blood pressure elevation during exercise may be associated with an increased risk of acute aortic dissection; however, no controlled trials have longitudinally evaluated the effect of exercise on survival or the risk of aortic dissection in TAD patients. Mouse-model studies suggest beneficial effects of exercise in the setting of a dilated aorta in MFS. There is a clear need for prospective research in this field.
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http://dx.doi.org/10.1080/14779072.2019.1585807DOI Listing
April 2019

Left ventricular hypertrophy in world class elite athletes is associated with signs of improved cardiac autonomic regulation.

Eur J Prev Cardiol 2019 Feb 12:2047487319830534. Epub 2019 Feb 12.

1 BIOMETRA Department, University of Milan, Italy.

Aim: In this study we sought to assess whether in elite athletes the physiological increase in cardiac mass attending severe long-term training leading to athlete's heart is accompanied by an improvement of autonomic performance, as assessed by post exercise vagal indices and a novel unitary Autonomic Nervous System Index for sports (ANSIs).

Methods: The study involved 500 elite athletes (23.9 ± 6.4 years) participating in a screening organised by the National Italian Olympic Committee. All subjects underwent a complete medical examination, rest and stand autonomic assessment (heart rate variability) as well as bicycle exercise. ANSIs was also derived as radar plot from rest, stand and heart rate recovery individual proxies of autonomic nervous system regulation. All subjects were grouped into those with left ventricular hypertrophy present (LVH(+)), or not (LVH(-)), according to recognised thresholds.

Results: We observed that LVH(+) athletes (24.8%) showed a marked increase of post-exercise vagal indices ( p < 0.001) and of ANSIs ( p < 0.001), while no difference was observed for heart-rate variability indices. These changes were contingent upon sport intensity categories.

Conclusions: Elite athletes with physiological cardiac hypertrophy (LVH(+)) present a selective profile of indices of autonomic nervous system performance, characterised by increases of markers of vagal recovery and of the novel unitary autonomic index for sports while RR variance and spectral indices seem to be unmodified. Athlete's heart may be characterised by a specific combination of anatomical and neurocardiac remodeling. This approach might furnish potential warning signs differentiating normal training induced physiology from pathological adaptation.
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http://dx.doi.org/10.1177/2047487319830534DOI Listing
February 2019

High blood pressure response to exercise predicts future development of hypertension in young athletes.

Eur Heart J 2019 01;40(1):62-68

Institute of Sports Medicine and Science, Rome, Largo Piero Gabrielli, Roma, Italy.

Aims: Due to superior exercise performance, athletes show higher blood pressure (BP) at peak exercise compared to untrained individuals. Thus, higher reference values for peak exercise systolic and diastolic BP were reported specifically for athletes. However, the prognostic significance of high blood pressure response (HBPR) to exercise has not yet been clarified in this population.

Methods And Results: One hundred and forty-one normotensive athletes with HBPR to exercise were compared to 141 normotensive athletes with normal blood pressure response (NBPR) to exercise, matched for gender, age, body size, and type of sport. All athletes were followed up for 6.5 ± 2.8 years. Over follow-up, no cardiac events occurred; 24 athletes were diagnosed essential hypertension (8.5%). Specifically, 19 (13.5%) belonged to the HBPR compared with 5 (3.5%) in the NBPR group (P = 0.003). Kaplan-Meier analysis confirmed that the incidence of hypertension during follow-up was higher in the HBPR group (log-rank χ2P-value = 0.009). Multivariable analysis by Cox proportional hazard survival model showed that resting BP and HBPR at baseline evaluation were the strongest predictors of incident hypertension (χ2 for the model 30.099; P < 0.001). Specifically, HBPR was associated with a hazard ratio of 3.6 (95% confidence interval 1.3-9.9) of developing hypertension. Over follow-up exercise capacity, as well as morphologic and functional cardiac parameters in athletes from both groups did not change significantly.

Conclusion: The present study showed that an exaggerated BP response to exercise increased the risk for incident hypertension in highly trained and normotensive athletes over a middle-term period.
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http://dx.doi.org/10.1093/eurheartj/ehy810DOI Listing
January 2019

Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis: position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC).

Eur Heart J 2019 01;40(1):19-33

Cardiology Clinical Academic Group, St George's, University of London, London, UK.

Myocardial diseases are associated with an increased risk of potentially fatal cardiac arrhythmias and sudden cardiac death/cardiac arrest during exercise, including hypertrophic cardiomyopathy, dilated cardiomyopathy, left ventricular non-compaction, arrhythmogenic cardiomyopathy, and myo-pericarditis. Practicing cardiologists and sport physicians are required to identify high-risk individuals harbouring these cardiac diseases in a timely fashion in the setting of preparticipation screening or medical consultation and provide appropriate advice regarding the participation in competitive sport activities and/or regular exercise programmes. Many asymptomatic (or mildly symptomatic) patients with cardiomyopathies aspire to participate in leisure-time and amateur sport activities to take advantage of the multiple benefits of a physically active lifestyle. In 2005, The European Society of Cardiology (ESC) published recommendations for participation in competitive sport in athletes with cardiomyopathies and myo-pericarditis. One decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of cardiomyopathies and myo-pericarditis. The present document, therefore, aims to offer a comprehensive overview of the most updated recommendations for practicing cardiologists and sport physicians managing athletes with cardiomyopathies and myo-pericarditis and provides pragmatic advice for safe participation in competitive sport at professional and amateur level, as well as in a variety of recreational physical activities.
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http://dx.doi.org/10.1093/eurheartj/ehy730DOI Listing
January 2019

Pre-participation health evaluation in adolescent athletes competing at Youth Olympic Games: proposal for a tailored protocol.

Br J Sports Med 2019 Sep 17;53(17):1111-1116. Epub 2018 Nov 17.

Sports Medicine and Science Institute, CONI, Rome, Italy.

Objective: To promote sports participation in young people, the International Olympic Committee (IOC) introduced the Youth Olympic Games (YOG) in 2007. In 2009, the IOC Consensus Statement was published, which highlighted the value of periodic health evaluation in elite athletes. The objective of this study was to assess the efficacy of a comprehensive protocol for illness and injury detection, tailored for adolescent athletes participating in Summer or Winter YOG.

Methods: Between 2010 and 2014, a total of 247 unique adolescent elite Italian athletes (53% females), mean age 16±1,0 years, competing in 22 summer or 15 winter sport disciplines, were evaluated through a tailored pre-participation health evaluation protocol, at the Sports Medicine and Science Institute of the Italian Olympic Committee.

Results: In 30 of the 247 athletes (12%), the pre-participation evaluation led to the final diagnosis of pathological conditions warranting treatment and/or surveillance, including cardiovascular in 11 (4.5%), pulmonary in 11 (4.5%), endocrine in five (2.0%), infectious, neurological and psychiatric disorders in one each (0.4%). Based on National and International Guidelines and Recommendations, none of the athletes was considered at high risk for acute events and all were judged eligible to compete at the YOG. Athletes with abnormal conditions were required to undergo a periodic follow-up.

Conclusions: The Youth Pre-Participation Health Evaluation proved to be effective in identifying a wide range of disorders, allowing prompt treatment, appropriate surveillance and avoidance of potential long-term consequences, in a significant proportion (12%) of adolescent Italian Olympic athletes.
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http://dx.doi.org/10.1136/bjsports-2018-099651DOI Listing
September 2019