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To compare the prevalence of myocardial fibrosis and coronary calcification in individuals who have performed very high levels of strenuous endurance exercise (SEE) (former male professional cyclists) and sex/age-matched controls.We used a cross-sectional (case-control) observational design, where cases were former finishers of ≥1 Grand Tour (Tour de France, Giro d' Italia or Vuelta a España) and controls were untrained individuals free of cardiovascular risk. All participants underwent cardiac magnetic resonance and cardiac computer tomography in the same center during years 2020-2021 to detect myocardial fibrosis (late gadolinium enhancement) and to quantify coronary calcium, respectively.23 cases (age 46 ± 6 years) and 59 controls (47 ± 7 years) were studied. Fibrotic patches were evidenced only in the left ventricle (LV), with a higher prevalence in cases (23% vs. 2% in controls, P = 0.006). However, fibrotic tissue was non-ischemic and of low extension (0.6 ± 0.4% of LV mass), and no significant differences were found between cases and controls for native T1 or T2 values. No between-group differences were found for coronary calcium indicators, including Agatston or density scores. Sub-analyses revealed no differences attending to whether cases were still performing regular SEE (n = 8) or not (n = 15) after professional retirement.Although former professional cyclists seemed to show a greater prevalence of myocardial fibrosis, the extension of fibrotic tissue was minimal and no alterations were found in coronary calcification indicators. While keeping in mind the low sample size of the cases' group, our results do not support evidence for major cardiac maladaptations with long-term exposure to SEE, at least in middle-aged adults.

El deporte a alta intensidad puede producir situaciones de riesgo, incluso fatales, en sujetos con anomalías cardiovasculares, por tanto, es fundamental un diagnóstico precoz de las cardiopatías para disminuir el riego. La valoración cardiológica en los deportistas requiere de una interpretación cuidadosa y detallada de las adaptaciones cardiacas al entrenamiento, siendo necesario conocer el corazón del deportista para no limitar la participación deportiva, especialmente en los casos limítrofes, y evitar truncar su vida deportiva con el consecuente detrimento en todos los aspectos de la vida del deportista.

Introduction and objectives: There are scarce data on left atrial (LA) enlargement and electrophysiological features in athletes. Methods: Multicenter observational study in competitive athletes and controls. LA enlargement was defined as LA volume indexed to body surface area ≥ 34mL/m2. We analyzed its relationship with atrial electrocardiography parameters. Results: We included 356 participants, 308 athletes (mean age: 36.4±11.6 years) and 48 controls (mean age: 49.3±16.1 years). Compared with controls, athletes had a higher mean LA volume index (29.8±8.6 vs 25.6±8.0mL/m2, P=.006) and a higher prevalence of LA enlargement (113 [36.7%] vs 5 [10.4%], P

Background Data regarding cardiovascular magnetic resonance (CMR) reference values in athletes have not been well determined yet. Using CMR normal reference values derived from the general population may be misleading in athletes and may have clinical implications. Aims To determine reference ventricular dimensions and function parameters and ratios by CMR in high performance athletes. Methods Elite athletes and age‐ and gender‐matched sedentary healthy controls were included. Anatomical and functional variables, including biventricular volumes, mass, systolic function, wall thickness, sphericity index and longitudinal function were determined by CMR. Results A total of 148 athletes (29.2 ± 9.1 years; 64.8% men) and 124 controls (32.1 ± 10.5 years; 67.7% men) were included. Left ventricular (LV) mass excluding papillary muscles was 67 ± 13 g/m2 in the control group and increased from 65 ± 14 g/m2 in the low intensity sport category to 83 ± 16 g/m2 in the high cardiovascular demand sport category; P 2, respectively; P Conclusions LV and RV masses, volumes, and wall thicknesses are higher in athletes than in sedentary subjects. Specific CMR reference ranges for athletes are provided and can be used as reference levels, rather than the standard upper limits used for the general population to exclude cardiomyopathy.

Although the benefits of regular physical activity on cardiovascular health are well established, the effects of strenuous endurance exercise (SEE) have been a matter of debate since ancient times. In this article, we aim to provide a balanced overview of what is known about SEE and the heart-from epidemiological evidence to recent cardiac imaging findings. Lifelong SEE is overall cardioprotective, with endurance master athletes showing in fact a youthful heart. Yet, some lines of research remain open, such as the need to elucidate the time-course and potential relevance of transient declines in heart function (or increases in biomarkers of cardiac injury) with SEE. The underlying mechanisms and clinical relevance of SEE-associated atrial fibrillation, myocardial fibrosis, or high coronary artery calcium scores also remain to be elucidated. © 2022 American Physiological Society. Compr Physiol 12:1-19, 2022.

PurposeWe assessed the occurrence of rhythm alterations in elite athletes with suspected risk using Holter monitoring, and the association of Holter-determined rhythm alterations with echocardiographic findings.MethodsA large cohort of Spanish elite athletes (N = 6,579, 34% female) underwent in-depth cardiological examination (including echocardiographic evaluation, and resting and exercise electrocardiogram [ECG]) between 01/02/1998 and 12/31/2018. Holter monitoring was performed in those reporting cardiovascular symptoms, with suspicion of cardiac structural abnormalities potentially associated with dangerous arrhythmias, or with resting/exercise ECG features prompting a closer examination. We assessed the occurrence of cardiac rhythm alterations, as well as the association between echocardiography-determined conditions and rhythm alterations.ResultsMost athletes (N = 5925) did not show any sign/symptom related to arrhythmia (including normal resting and exercise/post-exercise ECG results) whereas 9.9% (N = 654; 28% female; median age, 24 years [interquartile range 19–28]; competition experience [mean ± SD] 10±6 years) met the criteria to undergo Holter monitoring. Among the latter, sinus bradycardia was the most common finding (present in 96% of cases), yet with a relatively low proportion of severe (p = 0.02) arrhythmias, as well as between mild or moderate mitral regurgitation and ventricular arrhythmias (2.49; 1.03–6.01).ConclusionsIrrespective of the sports discipline, “dangerous” ventricular arrhythmias are overall infrequent even among young elite athletes who require Holter monitoring due to the presence of symptoms or abnormal echocardiographic/ECG findings, and do not seem to be associated with underlying serious cardiac structural pathologies.

Sin financiación 7.050 JCR (2021) Q1, 33/143 Cardiac & Cardiovascular Systems 0.407 SJR (2021) Q3, 205/356 Cardiology and Cardiovascular Medicine No data IDR 2021 UEM

Background There is debate about the magnitude of geometrical remodeling [i.e., left ventricle (LV) cavity enlargement vs. wall thickening] in the heart of elite athletes, and no limits of normality have been yet established for different sports. We aimed to determine sex- and sport-specific normative values of LV dimensions in elite white adult athletes. Methods This was a single-center, retrospective study of Spanish elite athletes. Athletes were grouped by sport and its relative dynamic/static component (Mitchell’s classification). LV dimensions were measured with two-dimensional-guided M-mode echocardiography imaging to compute normative values. We also developed an online and app-based calculator (https://sites.google.com/lapolart.es/athlete-lv/welcome?authuser=0) to provide clinicians with sports- and Mitchell’s category-specific Z-scores for different LV dimensions. Results We studied 3282 athletes (46 different sports, 37.8% women, mean age 23 ± 6 years). The majority (85.4%) showed normal cardiac geometry, particularly women (90.9%). Eccentric hypertrophy was relatively prevalent (13.4%), and concentric remodeling or hypertrophy was a rare finding (each Conclusions The majority of elite athletes had normal LV geometry, and although some presented with LV eccentric hypertrophy, concentric remodeling or hypertrophy was very uncommon. The present study provides sport-specific normative values that can serve to identify those athletes for whom a detailed examination might be recommendable (i.e., those exceeding the 95th percentile for their sex and sport).

Background Left atrial (LA) remodelling and enlargement in athletes is a well-kown component of the athlete's heart. However, information about the correlation between of LA enlargement and atrial electrophysiological features in athletes is scarce. Purpose Our aim was to characterize LA enlargement, P-wave duration, and the prevalence of interatrial block (IAB) in competitive athletes (with and without LA enlargement) and in controls. Methods ALMUDAINA (Analysis of Left atrial Measurements of Ultrasound Dilation Among International and National Athletes) was a nationwide, cross-sectional study involving 9 hospitals and sport clinics across Spain. Cases fulfilled the international consensus definition of a competitive athlete and were currently engaged in skill, power, mixed or endurance disciplines at a national or international level. The following P-wave parameters were analysed: 1) duration 2) voltage in lead I and 3) the presence of interatrial block (IAB). LA enlargement was defined as an indexed volume by body surface area ≥34 ml/m2, measured by transthoracic echocardiography. A contemporary cohort of otherwise healthy and active controls was used as a comparison group. Results Baseline clinical and echocardiographic characteristics of both cohorts are summarised in table 1 whereas electrocardiographic characteristics are displayed in table 2, respectively. 356 subjects were included, 308 athletes (mean age: 36.4±11.6 years) and 48 controls (mean age: 49.3±16.1 years). Athletes showed a higher mean LA indexed volume (29.8±8.6 vs. 25.6±8.0 mL/m2, P=0.006) and higher prevalence of LA enlargement (113 [36.7%] vs. 5 [10.4%], P Conclusions LA enlargement is prevalent in adult competitive athletes. However, ECG indexes of atrial electrophysiology were not different from healthy controls. Our data suggest that LA enlargement and IAB are two different entities. Funding Acknowledgement Type of funding sources: None.

Sin financiación 8.526 JCR (2021) Q1, 22/143 Cardiac & Cardiovascular Systems 1.689 SJR (2021) Q1, 45/356 Cardiology and Cardiovascular Medicine No data IDR 2021 UEM

Aims: to assess the association between physical activity (PA) or sports practice and risk of atrial fibrillation (AF). Methods: We systematically searched PubMed, SportDiscus, and the Cochrane Database of Systematic Reviews from inception to 21st October 2019 to identify systematic reviews and meta-analyses examining the relationship between PA or sport practice and the risk of AF. The methodological quality of included reviews was assessed, and we identified those associations that did not have excessive heterogeneity between studies, small study effects, and no evidence for excess significance. Results: Eleven meta-analyses were included in the umbrella review. We found evidence (with low heterogeneity and no excess significance, but with high risk of bias) that PA is not associated with AF risk, whether the former is expressed as total (n=43,672 participants, odds ratio [OR]=1.08, 95% confidence interval [CI]=0.97 to 1.21, p=0.17) or intense PA (n=152,925, OR=1.00, 95%CI=0.82 to 1.22, p=0.99), but sports practice is associated with a higher AF risk (n=9,113, OR=1.64, 95% CI=1.10 to 2.43, p=0.04). Conclusion: AF risk is independent of PA, but sports practice seems to increase AF risk. The methodological issues highlighted here, including lack of valid/objective methods for assessing AF and/or PA in most studies, no standardization of key terms such as ‘sport practice’ (with PA and sports practice used indistinctly in some reports) or ‘athletes’ (with those who are really competitive at the elite level seldom studied), should be considered in future studies to draw definite conclusions on the actual link between of PA/sports and AF risk. Sin financiación 8.526 JCR (2021) Q1, 22/143 Cardiac & Cardiovascular Systems 1.689 SJR (2021) Q1, 45/356 Cardiology and Cardiovascular Medicine No data IDR 2021 UEM

Sin financiación 8.526 JCR (2021) Q1, 22/143 Cardiac & Cardiovascular Systems 1.689 SJR (2021) Q1, 45/356 Cardiology and Cardiovascular Medicine No data IDR 2021 UEM

We present here three different clinical scenarios that illustrate the complexity of taking decisions in sports cardiology. Despite the availability of consensus documents, in clinical practice, decision-making process is most of the times in the grey zone.

Background The authors previously observed that some high-performance athletes, irrespective of type of sport, can show echocardiographically determined low left ventricular ejection fractions (LVEF

Mujer de 32 años que practica baloncesto a nivel competitivo. Acudió para un reconocimiento cardiológico preventivo. No tenía antecedentes personales o familiares de relevancia y se encontraba asintomática. En el examen físico no se hallaron datos significativos con pulsos periféricos presentes bilateralmente y simétricos. En la radiografía de tórax presentaba ausencia del botón aórtico con radiopacidad paratraqueal derecha, y en el ecocardiograma transtorácico se objetivó angulación derecha del arco aórtico e imagen sacular sugestiva de divertículo de Kommerel (DK). Estos hallazgos eran compatibles con un arco aórtico derecho. Se confirma el diagnóstico de sospecha con un TC (tomografía computarizada) aórtica.

[Background] Circulating microRNAs (c-miRNAs) are mediators of intercellular communication with great potential as cardiac biomarkers. The analysis of c-miRNAs in response to physiological stress, such as exercise, would provide valuable information for clinical practice and a deeper understanding of the molecular response to physical activity. Here, we analysed for the first time the acute exercise response of c-miRNAs reported as biomarkers of cardiac disease in a well-characterized cohort of healthy active adults. [Methods] Blood samples were collected immediately before and after (0 h, 24 h, 72 h) a 10-km race, a half-marathon (HM) and a marathon (M). Serum RNA from 10-km and M samples was extracted and a panel of 74 miRNAs analysed using RT-qPCR. c-miRNA response was compared with a panel of nine cardiac biomarkers. Functional enrichment analysis was performed. Pre- and post-M echocardiographic analyses were carried out. [Results]Serum levels of all cardiac biomarkers were upregulated in a dose-dependent manner in response to exercise, even in the absence of symptoms or signs of cardiac injury. A deregulation in the profiles of 5 and 19 c-miRNAs was observed for 10-km and M, respectively. Each race induced a specific qualitative and quantitative alteration of c-miRNAs implicated in cardiac adaptions. Supporting their discriminative potential, a number of c-miRNAs previously associated with cardiac disease were undetectable or stable in response to exercise. Conversely, “pseudo-disease” signatures were also observed. [Conclusions] c-miRNAs may be useful for the management of cardiac conditions in the context of acute aerobic exercise. [Translational aspects of the work] Circulating microRNAs could offer incremental diagnostic value to established and emerging cardiac biomarkers, such as hs-cTnT or NT-proBNP, in those patients with cardiac dysfunction symptoms after an acute bout of endurance exercise. Furthermore, circulating miRNAs could also show “pseudo-disease” signatures in response to acute exercise. Clinical practitioners should be aware of the impact caused by exercise in the interpretation of miRNA data., This work was supported in part by the Ministerio de Economía y Competitividad (DEP2012-39262 and DEP2015-69980-P to EI-G and IJCI-2016-29393 to DdG-C), by the Instituto de Salud Carlos III (FIS, PI11/00315 to AD) and European FEDER Funds, and by the Instituto de Salud Carlos III Sara Borrell Grant (CD14/00109 to DdG-C) and Río Hortega Grant (CM16/00128 to LA-R). CIBER Cardiovascular (CB16/11/00403 to DdG-C and VL-C) and CIBER Enfermedades Respiratorias (CB17/06/00021 to LA-R) are projects of the Instituto de Salud Carlos III.

Aims Diagnosis of Type-2 Brugada pattern remains challenging and it could be confused with other electrocardiogram (ECG) patterns presenting an r ′-wave in leads V1–V2 like in healthy athletes. This could impact their ability to perform competitive sports. The aim of the study was to evaluate, as a proof of concept, the new ECG criteria to differentiate the Type-2 Brugada pattern from the ECG pattern of healthy athletes depicting an r ′-wave in leads V1–V2. Methods and results Surface ECGs from 50 patients with Brugada syndrome and type-2 Brugada pattern and 58 healthy athletes with an r ′-wave in leads V1–V2 were analysed. Different criteria based on the characteristics of the triangle formed by the ascendant and descendant arms of the r ′-wave in leads V1–V2 were compared. The duration of the base of the triangle at 0.5 mV (5 mm) from high take-off ≥160 ms (4 mm) has a specificity (SP) of 95.6%, sensitivity (SE) 85%, positive predictive value (PPV) 94.4%, and negative predictive value (NPV) 87.9%. The duration of the base of the triangle at the isoelectric line ≥60 ms (1.5 mm) in leads V1–V2 has an SP of 78%, SE 94.8%, PPV 79.3%, and NPV 93.5%. The ratio of the base at isoelectric line/height from the baseline to peak of r ′-wave in leads V1–V2 has an SP of 92.1%, SE 82%, PPV 90.1%, and NPV 83.3%. Conclusions The three new ECG criteria were accurate to distinguish the Type-2 Brugada pattern from the ECG pattern with an r ′-wave in healthy athletes. The duration of the base of the triangle at 0.5 mV from the high take-off is the easiest to measure and may be used in clinical practice.

Background— There is limited information regarding the aortic root upper physiological limits in all planes in elite athletes according to static and dynamic cardiovascular demands and sex. Methods and Results— A cross-sectional study was performed in 3281 healthy elite athletes (2039 men and 1242 women) aged 23.1±5.7 years, with body surface area of 1.9±0.2 m 2 and 8.9±4.9 years and 19.2±9.6 hours/week of training. Maximum end-diastolic aortic root diameters were measured in the parasternal long axis by 2-dimensional echocardiography. Age, left ventricular mass, and body surface area were the main predictors of aortic dimensions. Raw values were greater in males than in females ( P 2 ; P =0.007), without significant differences at the sinus of Valsalva (16.3±1.9 versus 16.3±1.9 mm/m 2 ; P =0.797), and were smaller in men at the sinotubular junction (13.6±1.8 versus 13.8±1.8 mm/m 2 ; P =0.008) and the proximal ascending aorta (13.8±1.9 versus 14.1±1.9 mm/m 2 ; P =0.001). Only 1.8% of men and 1.5% of women had values >40 mm and 34 mm, respectively. Raw and corrected aortic measures at all levels were significantly greater in sports, with a high dynamic component in both sexes, except for corrected values of the sinotubular junction in women. Conclusions— Aortic root dimensions in healthy elite athletes are within the established limits for the general population. This study describes the normal dimensions for healthy elite athletes classified according to sex and dynamic and static components of their sports.

Sudden cardiac death (SCD) in professional athletes has a considerable impact on society. This visibility is amplified in soccer, as it is the most popular sport worldwide, with approximately 250 million registered players (∼113,000 professionals) [(1)][1]. Soccer is a demanding sport: during a

Resumen Los deportistas representan el estado de maxima salud, por lo que la muerte subita de un deportista joven es siempre un acontecimiento con un gran impacto social y que origina gran inquietud en su entorno. La muerte subita puede ser la primera manifestacion de la enfermedad, por lo que se dificulta la identificacion de sujetos en riesgo y su incidencia real es desconocida. Sin embargo, en los ultimos anos se han identificado diferentes enfermedades cardiovasculares que con mayor frecuencia son causa de la muerte subita de deportistas. Ademas de presentar los trabajos mas recientes sobre su incidencia, este articulo pretende revisar la controversia existente en torno al reconocimiento medico previo a la competicion como metodo para identificar a los deportistas con mayor riesgo y plantear unas sencillas recomendaciones sobre las pruebas que dicho reconocimiento debe incluir en cada caso

Introduccion y objetivos La enzima de conversion de angiotensina (ECA) se relaciona con el desarrollo de hipertrofia cardiaca y mejora de la condicion fisica. El objetivo del estudio es analizar la relacion entre el polimorfismo insercion/delecion (I/D) del gen de la ECA y la adaptacion al entrenamiento. Metodos Se estudio a 299 deportistas espanoles de alto nivel (193 varones y 106 mujeres) de 32 disciplinas deportivas, agrupadas segun sus componentes estatico y dinamico, mediante analisis de la composicion corporal, eco-Doppler en reposo y ergoespirometria. El genotipo de la ECA se determino mediante la tecnica de la reaccion en cadena de la polimerasa (PCR). Resultados El genotipo mas frecuente fue el heterocigoto DI (el 57,5 y el 54,7%), seguido de los homocigotos DD (el 30,6 y el 34,9%) e II (el 11,9 y el 10,4%), en varones y mujeres respectivamente. Hay diferencias en las adaptaciones morfologicas y funcionales entre las modalidades deportivas, pero no se obtuvo asociacion estadisticamente significativa con relacion al polimorfismo I/D de la ECA. En el estudio comparativo entre los distintos genotipos, solo en la muestra femenina se encontraron diferencias entre los grupos DD y DI en el indice de masa corporal y en la dimension superoinferior de la auricula derecha. Conclusiones El polimorfismo I/D del gen de la ECA parece que no influye en la adaptacion cardiovascular al entrenamiento; sin embargo, el genotipo DI es el mas frecuente, probablemente debido a un sesgo de la muestra, compuesta por deportistas de elite.

Objectives The purpose of this study was to evaluate ethnic differences in left ventricular (LV) remodeling between highly-trained athletes of African/Afro-Caribbean (black) and Caucasian (white) athletes. Background The upper limits of left ventricular hypertrophy (LVH) are established in white athletes and aid the differentiation of physiologic LVH from hypertrophic cardiomyopathy (HCM). However, there are few data regarding LV remodeling in black athletes, in whom deaths from HCM are more prevalent. Methods Between 2003 and 2007, 300 nationally ranked black male athletes (mean age 20.5 years) underwent 12-lead electrocardiogram and 2-dimensional echocardiography. The results were compared with 150 black and white sedentary individuals and 300 highly-trained white male athletes matched for age, size, and sport. Results Black athletes exhibited greater LV wall thickness and cavity size compared with sedentary black and white individuals. Black athletes had greater LV wall thickness compared with white athletes (11.3 ± 1.6 mm vs. 10 ± 1.5 mm; p 12 mm compared with 12 white athletes (4%), and 3% of black athletes exhibited LV wall thickness ≥15 mm compared with none of the white athletes. Black athletes with LVH displayed an enlarged LV cavity and normal diastolic function. Conclusions Black athletes develop a greater magnitude of LVH compared with white athletes; therefore, extrapolation of conclusions derived from white athletes has the potential of generating false-positive diagnoses of HCM in black athletes.

La falta de actividad fisica es un problema de salud publica que se reconoce como un factor independiente de riesgo de enfermedad coronaria. El riesgo relativo de la inactividad es similar al de la hipertension arterial, la hipercolesterolemia y el tabaquismo, por lo que el sedentarismo se asocia a un aumento simultaneo de las enfermedades cardiovasculares. La practica regular de ejercicio fisico a una intensidad ligera-moderada induce una serie de adaptaciones que producen los beneficios para la salud. Diferentes estudios han mostrado una relacion inversa entre ejercicio habitual y riesgo de enfermedad coronaria, eventos cardiacos y muerte. El ejercicio mejora el perfil lipidico y el control de la glucemia, reduce o previene la hipertension arterial, la obesidad y el estres, mejora la forma fisica y aumenta la longevidad. Sin embargo, la mayoria de las evidencias de sus beneficios se extraen de estudios observacionales, y aunque el consumo maximo de oxigeno y el tiempo de ejercicio durante la prueba de esfuerzo son potentes predictores de mortalidad, no hay acuerdo en la cantidad y la intensidad de la actividad fisica necesaria en prevencion primaria y secundaria. Por otro lado, aunque durante la realizacion de un ejercicio extenuante aumenta temporalmente el riesgo de infarto agudo de miocardio, el balance entre los riesgos y los beneficios es claramente favorable a estos, aunque hay un umbral minimo de gasto energetico seminal necesario para disminuir el riesgo cardiovascular.

Lack of physical activity in the general population is a public health problem and is recognized as an independent risk factor for the development of coronary disease. The relative risk of inactivity is similar to that of hypertension, hypercholesterolemia, and smoking. Consequently, a sedentary lifestyle is associated with a concurrent increase in cardiovascular disease. Engaging regularly in mild-to-moderate physical exercise results in a range of physiological adaptations that are beneficial for health. Various studies have demonstrated that there is an inverse relationship between regular exercise and the risk of coronary heart disease, cardiac events, and death. Exercise improves the lipid profile and glycemic control, reduces or prevents hypertension, obesity, and stress, and promotes fitness and longevity. However, most evidence for the benefits of exercise comes from observational studies and, although maximum oxygen uptake and the duration of exercise on an exercise stress test are powerful predictors of mortality, there is no agreement on the quantity or intensity of the physical activity needed for primary or secondary prevention. On the other hand, although there is a temporarily increased risk of acute myocardial infarction during exhaustive exercise, the balance of risks and benefits is strongly in favor of the benefits because there is a minimum threshold for the weekly energy expenditure required to reduce cardiovascular risk.

Resumen Introduccion y objetivos Este trabajo investiga las causas de muerte subita en Espana recogidas a traves del Registro Nacional de Muerte Accidental y Subita en Deportistas. Metodos Estudio retrospectivo y prospectivo de 180 casos de muerte desde el ano 1995 hasta la fecha actual. Resultados Ciento ochenta casos de muerte subita: 164 varones, 12 mujeres (4 no determinados). Deportes: futbol (40), ciclismo (39), atletismo (24), futbol sala y deportes de fronton (8 cada uno) y educacion fisica (7). Las causas mas frecuentes han sido: enfermedad ateromatosa coronaria (48), la miocardiopatia arritmogenica (11), la miocardiopatia hipertrofica (9), las anomalias coronarias congenitas (5), la hipertrofia ventricular izquierda idiopatica (4) y la estenosis valvular aortica (4). En mayores de 30 anos (96): enfermedad ateromatosa coronaria (73,43%), miocardiopatia arritmogenica (6,25%) y miocardiopatia hipertrofica (4,68%). En los fallecidos de 30 anos o menos (84): miocardiopatia arritmogenica (13,72%), la miocardiopatia hipertrofica (11,76%), anomalias coronarias congenitas (9,8%), la hipertrofia ventricular izquierda idiopatica (7,84%) y estenosis valvular aortica (5,88%). En estas edades la mayoria de las muertes fueron de origen indeterminado (27,45%). Conclusiones Dificultad para obtener datos completos de muerte subita en deportistas en nuestro pais, que muestran una importante incidencia en jovenes y en adultos de la quinta decada. Los deportes mas implicados son futbol, ciclismo y atletismo. Causa mas frecuente en mayores de 30 anos: enfermedad ateromatosa coronaria, y en menores de 30 anos: la muerte inexplicada en corazon estructuralmente normal es lo mas frecuente. Es necesario profundizar en la obtencion de los datos de las muertes subitas en deportistas a traves de este registro.

Rev Esp Cardiol 2004;57(6):495-8 495 (type I fibers), which are recruited and activated during moderate intensity exercise. Given the above, it is understandable that not all exercise or sporting activity will have the same effect on the lipid profile. Unfortunately, on many occasions the terms “physical exercise” and “sport” are used as synonyms, even though they describe different concepts. Physical exercise should be understood as planned, structured and repetitive exercise with the goal of maintaining or improving one or more components of physical fitness. Sport, though difficult to define, is a physical and intellectual human activity, competitive in nature and governed by institutionalized rules. The competitive character of sport is present in all its forms, though it is more evident in some than in others. Sports can be very different from one another, as can be the factors that limit both them and their specialities.3 This leads to many difficulties when trying to classify sports with the meeting of training needs in mind. According to their bioenergetic characteristics, sports can be classified as: a) aerobic, in which long duration, light-moderate intensity exercise dominates and in which the oxygen supply is essential for obtaining energy (e.g., the marathon, long distance swimming, tour cycling); b) alactic anaerobic, consisting of short, high intensity exercise in which energy is provided by ATP and phosphocreatine (e.g., 50 m and 60 m track events); c) lactic anaerobic, short duration, high intensity exercise (e.g., 400 m track events), and d) mixed, aerobic/anaerobic exercise (e.g., soccer, basketball, volleyball). According to the methodology of sports training, sports are classed as: a) strength and explosive strength sports (weightlifting, jumping, throwing); b) combat sports (boxing, fencing, judo); c) endurance sports (medium and long distance track events, swimming [except for events under 100 m], tour cycling); d) ball sports (soccer, volleyball, basketball), and e) coordination and competitive art sports (gymnastics, synchronized swimming, etc). Comparing the effects of different sports on the lipid profile can therefore be very difficult since, although the same energetic pathways are used, the intrinsic characteristics of training–and especially competition–can vary ED I TO R I A L S

La mayor parte de las pruebas de esfuerzo se realizan a pacientes adultos con cardiopatia isquemica en estudio o ya conocida. En los ultimos anos se ha producido la incorporacion de las tecnicas de imagen en este campo, mejorando asi la informacion aportada por la prueba de esfuerzo convencional. Pero cada vez existen mas situaciones que escapan a esta norma general, tanto en sujetos sanos (asintomaticos, atletas, discapacitados, etc.) como en pacientes con cardiopatias diferentes de la isquemica (insuficiencia cardiaca congestiva avanzada, hipertension, trastornos del ritmo, cardiopatias congenitas etc.). Todos estos aspectos justifican un documento de consenso en Espana, necesariamente multidisciplinario. Este documento revisa en profundidad la metodologia de las pruebas de esfuerzo convencionales, sin olvidar las realizadas con determinacion de consumo de oxigeno. El papel de esta exploracion en el manejo de la cardiopatia isquemica, asi como las aplicaciones de las tecnicas de imagen al campo del estres, ocupan un lugar fundamental en esta revision. Por ultimo, se analiza la utilidad de las pruebas de esfuerzo en diversas cardiopatias no isquemicas y en diferentes poblaciones de sujetos sanos.

This chapter includes general recommendations regarding the eligibility for recreational and competitive sports participation. Although based on the latest knowledge in sports medicine and cardiology, these recommendations should be updated according to advances in the understanding of the athlete's heart. Physical exercise plays an important role in the leisure time of our society. Many patients with cardiac disease don't want to give up their physical or sport activity programs. Moreover, there is no doubt that many cardiovascular abnormalities may benefit from a controlled physical exercise program. Understanding the cardiac adaptations to exercise training, individualised evaluation of each cardiac pathology and adequate exercise prescription is essential in order to minimize the risks for every cardiac patient.

The morphological and functional cardiac adaptations induced by physical training may be reflected in several athlete's electrocardiographic variants. Rhythm and heart rate disturbances are the most common findings, and sinus bradycardia is the most frequent adaptation. Non-specific intraventricular conduction delay and incomplete right bundle branch block are also frequent, but other bundle branch and fascicular blocks are extremely rare. While the atrioventricular conduction may be prolonged, the occurrence of first degree and type I second degree atrioventricular blocks depends on the individual's susceptibility. Advanced second and third degree atrioventricular blocks are exceptional, and when present, the possibility of underlying heart disease must be excluded. High QRS voltage is more frequent in male athletes, but its correlation with left ventricular hypertrophy is low. The ST segment elevation in the so called "early repolarization" pattern is typical of the athlete's electrocardiogram. Vagotonic or high T wave voltages and U waves are also frequent when sinus bradycardia is present. Tachyarrhythmias and increased automatism arrhythmias are rare and usually benign. The increased vagal tone is responsible for the suppression of the physiological and ectopic pacemakers. While Wolff-Parkinson-White syndrome per se does not exclude an athlete from sports activity, the risk of a sudden death makes it mandatory to perform an exhaustive cardiac evaluation. We may conclude that no sport can be considered arrhythmogenic or as a predisposing factor for malignant ventricular arrhythmias.

Introduction and objectives Angiotensin-converting enzyme (ACE) is associated with the development of cardiac hypertrophy and improved physical fitness. The objective of this study was to investigate the relationship between the ACE gene insertion/deletion (I/D) polymorphism and adaptation to sports training. Methods The study included 299 elite Spanish athletes (193 men and 106 women) from 32 different sports disciplines, which were grouped according to their static and dynamic components. All participants underwent body composition analysis, Doppler echocardiography at rest, and ergospirometry. Their ACE genotype was determined using the polymerase chain reaction. Results The most common genotype in both males and females was the deletion-insertion (DI) heterozygote (57.5% and 54.7%, respectively), followed by the DD homozygote (30.6% and 34.9%), and the II homozygote (11.9% and 10.4%). Differences in morphometric and functional cardiac adaptation were observed between the different sports disciplines, but there was no statistically significant relationship with the ACE I/D polymorphism. Moreover, when athletes with different genotypes were compared, the only differences observed were between the DD and DI groups in female athletes, who differed in body mass index and longitudinal right atrial dimension. Conclusions The ACE I/D polymorphism did not appear to influence cardiovascular adaptation in response to training. However, the DI genotype was the most common, probably because the sample was biased by being made up of elite athletes.

Circulating mesenchymal cells (cMCs) have a potential for regenerating damaged tissue, e.g., ischaemic myocardium. In patients (age range: 53-76 years) with stable coronary artery disease cMCs were determined before and after dynamic exercise of moderate (respiratory compensation threshold (RCT)) (n = 9 patients) or high intensity (RCT) (n = 11). Only high-intensity exercise (i.e., provoking signs of myocardial ischaemia in 3 patients and ventricular extrasystoles in another) induced a significant increase in cMCs (p = 0.009). These results support the hypothesis that intense exercise (near or at the point of myocardial ischaemia) is a potent stimulus for MC mobilisation.

This article contains a review of the main developments in cardiovascular disease prevention reported during the last year. In addition, the most recent clinical practice guidelines are also discussed. The aims of cardiovascular prevention are to reduce mortality and morbidity in individuals at a high risk and to help those at a low risk to maintain their status. Lifestyle modification and the reduction of modifiable cardiovascular risk factors are key to cardiovascular disease prevention. The implementation of clinical practice guidelines provides the primary means of achieving these goals.

We thank Dr Sugrue for raising the important point about the different metrics used to assess the validity of diagnostic tests and their interpretation.1 We also thank …