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Cardiorespiratory fitness (CRF), as one of the most potent prognostic factors in medicine, is followed longitudinally to guide clinical management. Coronavirus disease 2019 (COVID-19) pandemic-related changes in lifestyle stand to influence CRF.To assess the influence of the pandemic on perceived CRF in athlete patients and evaluate how perceived CRF change was related to demographics, pre-pandemic measured CRF, and current physical activity (PA).Prospective cohort study, utilizing electronic survey.Tertiary care sports cardiology clinical practice.Adult athlete patients without COVID-19 with pre-pandemic measured CRF using cardiopulmonary exercise testing.Not applicable.Perceived change in CRF since pandemic onset; association between perceived CRF change and demographics, PA, health status, and pre-pandemic measured CRF assessed via analysis of variance (ANOVA).Among 62 participants (male: 71%, 50.1 ± 12.1 years old), 40% (25/62) reported no change and 32% (20/62) reported an increase in perceived CRF since pandemic onset. Among the 27% (17/62) who reported a decrease in perceived CRF, in most (12/17), this was characterized as only mild. Demographics and pre-pandemic measured CRF did not differ across groups of perceived CRF change. Participants with a moderate or greater decrease in perceived CRF regarded their overall health (via Euro Quality of Life Visual Analogue Scale) as worse than other groups (ANOVA, p = .001). Although total PA was similar across groups, those who had improvement in perceived CRF reported higher levels of moderate intensity PA (ANOVA, p = .008).The majority of participants perceived that they had maintained or improved CRF over the pandemic. Findings from this study suggest that a reduction in perceived CRF from pre-pandemic values in athletic patients in clinical practice may not result from population-wide pandemic changes in lifestyle. Worse health status and lower levels of moderate intensity PA were associated with perceived reduction in CRF over the pandemic in athlete patients.

ObjectiveTo assess the prevalence and clinical implications of persistent or exertional cardiopulmonary symptoms in young competitive athletes following SARS-CoV-2 infection.MethodsThis observational cohort study from the Outcomes Registry for Cardiac Conditions in Athletes included 3597 US collegiate athletes after SARS-CoV-2 infection. Clinical characteristics, advanced diagnostic testing and SARS-CoV-2-associated sequelae were compared between athletes with persistent symptoms >3 weeks, exertional symptoms on return to exercise and those without persistent or exertional symptoms.ResultsAmong 3597 athletes (mean age 20 years (SD, 1 year), 34% female), data on persistent and exertional symptoms were reported in 3529 and 3393 athletes, respectively. Persistent symptoms >3 weeks were present in 44/3529 (1.2%) athletes with 2/3529 (0.06%) reporting symptoms >12 weeks. Exertional cardiopulmonary symptoms were present in 137/3393 (4.0%) athletes. Clinical evaluation and diagnostic testing led to the diagnosis of SARS-CoV-2-associated sequelae in 12/137 (8.8%) athletes with exertional symptoms (five cardiac involvement, two pneumonia, two inappropriate sinus tachycardia, two postural orthostatic tachycardia syndrome and one pleural effusion). No SARS-CoV-2-associated sequelae were identified in athletes with isolated persistent symptoms. Of athletes with chest pain on return to exercise who underwent cardiac MRI (CMR), 5/24 (20.8%) had probable or definite cardiac involvement. In contrast, no athlete with exertional symptoms without chest pain who underwent CMR (0/20) was diagnosed with probable or definite SARS-CoV-2 cardiac involvement.ConclusionCollegiate athletes with SARS-CoV-2 infection have a low prevalence of persistent or exertional symptoms on return to exercise. Exertional cardiopulmonary symptoms, specifically chest pain, warrant a comprehensive evaluation.

Initial guidelines recommended a 12-lead electrocardiogram (ECG) in young competitive athletes following SARS-CoV-2 infection to screen for myocarditis. However, no data are available that detail ECG findings before and after SARS-CoV-2 infection in young athletes without clinical or imaging evidence of overt myocarditis. This study applied the International Criteria for ECG interpretation in a cohort of 378 collegiate athletes to compare ECG findings at baseline and during the acute phase of SARS-CoV-2 infection. Our results suggest that ECG changes can occur in the absence of definitive SARS-CoV-2 cardiac involvement in young competitive athletes.

ObjectivesPersistent or late-onset cardiopulmonary symptoms following COVID-19 may occur in athletes despite a benign initial course. We examined the yield of cardiac evaluation, including cardiopulmonary exercise testing (CPET), in athletes with cardiopulmonary symptoms after COVID-19, compared CPETs in these athletes and those without COVID-19 and evaluated longitudinal changes in CPET with improvement in symptoms.MethodsThis prospective cohort study evaluated young (18–35 years old) athletes referred for cardiopulmonary symptoms that were present>28 days from COVID-19 diagnosis. CPET findings in post-COVID athletes were compared with a matched reference group of healthy athletes without COVID-19. Post-COVID athletes underwent repeat CPET between 3 and 6 months after initial evaluation.ResultsTwenty-one consecutive post-COVID athletes with cardiopulmonary symptoms (21.9±3.9 years old, 43% female) were evaluated 3.0±2.1 months after diagnosis. No athlete had active inflammatory heart disease. CPET reproduced presenting symptoms in 86%. Compared with reference athletes (n=42), there was similar peak VO2 but a higher prevalence of abnormal spirometry (42%) and low breathing reserve (42%). Thirteen athletes (62%) completed longitudinal follow-up (4.8±1.9 months). The majority (69%) had reduction in cardiopulmonary symptoms, accompanied by improvement in peak VO2 and oxygen pulse, and reduction in resting and peak heart rate (all pConclusionDespite a high burden of cardiopulmonary symptoms after COVID-19, no athlete had active inflammatory heart disease. CPET was clinically useful to reproduce symptoms with either normal testing or identification of abnormal spirometry as a potential therapeutic target. Improvement in post-COVID symptoms was accompanied by improvements in CPET parameters.

Oxygen uptake (V̇o 2 ) at exercise onset is determined in part by acceleration of pulmonary blood flow ([Formula: see text]). Impairments in the [Formula: see text] response can decrease exercise tolerance. Prior research has shown that voluntary respiratory maneuvers can augment venous return, but the corollary impacts on cardiac function, [Formula: see text] and early-exercise V̇o 2 remain uncertain. We examined 1) the cardiovascular effects of three distinct respiratory maneuvers (abdominal, AB; rib cage, RC; and deep breathing, DB) under resting conditions in healthy subjects (Protocol 1, n = 13), and 2) the impact of pre-exercise DB on pulmonary O 2 transfer during initiation of moderate-intensity exercise (Protocol 2, n = 8). In Protocol 1, echocardiographic analysis showed increased right ventricular (RV) cardiac output and left ventricular (LV) cardiac output (RVCO and LVCO, respectively), following AB (by +23 ± 13 and +18 ± 15%, respectively, P < 0.05), RC (+23 ± 16; +14 ± 15%, P < 0.05), and DB (+27 ± 21; +23 ± 14%, P < 0.05). In Protocol 2, DB performed for 12 breaths produced a pre-exercise increase in V̇o 2 (+801 ± 254 mL·min -1 over ∼6 s), presumably from increased [Formula: see text], followed by a reduction in pulmonary O 2 transfer during early phase exercise (first 20 s) compared with the control condition (149 ± 51 vs. 233 ± 65 mL, P < 0.05). We conclude that 1) respiratory maneuvers enhance RVCO and LVCO in healthy subjects under resting conditions, 2) AB, RC, and DB have similar effects on RVCO and LVCO, and 3) DB can increase [Formula: see text] before exercise onset. These findings suggest that pre-exercise respiratory maneuvers may represent a promising strategy to prime V̇o 2 kinetics and thereby to potentially improve exercise tolerance in patients with impaired cardiac function.NEW & NOTEWORTHY We demonstrate that different breathing maneuvers can augment both right and left-sided cardiac output in healthy subjects. These maneuvers, when performed immediately before exercise, result in a pre-exercise "cardiodynamic" increase in oxygen uptake (V̇o 2 ) associated with a subsequent reduction in the "cardiodynamic" V̇o 2 normally seen during early exercise. We conclude that pre-exercise breathing maneuvers are a plausible tool worthy of additional study to prime V̇o 2 kinetics and improve exercise tolerance in patients with cardiovascular disease.

Supplemental Digital Content is available in the text., Background: Cardiac involvement among hospitalized patients with severe coronavirus disease 2019 (COVID-19) is common and associated with adverse outcomes. This study aimed to determine the prevalence and clinical implications of COVID-19 cardiac involvement in young competitive athletes. Methods: In this prospective, multicenter, observational cohort study with data from 42 colleges and universities, we assessed the prevalence, clinical characteristics, and outcomes of COVID-19 cardiac involvement among collegiate athletes in the United States. Data were collected from September 1, 2020, to December 31, 2020. The primary outcome was the prevalence of definite, probable, or possible COVID-19 cardiac involvement based on imaging definitions adapted from the Updated Lake Louise Imaging Criteria. Secondary outcomes included the diagnostic yield of cardiac testing, predictors for cardiac involvement, and adverse cardiovascular events or hospitalizations. Results: Among 19 378 athletes tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, 3018 (mean age, 20 years [SD, 1 year]; 32% female) tested positive and underwent cardiac evaluation. A total of 2820 athletes underwent at least 1 element of cardiac triad testing (12-lead ECG, troponin, transthoracic echocardiography) followed by cardiac magnetic resonance imaging (CMR) if clinically indicated. In contrast, primary screening CMR was performed in 198 athletes. Abnormal findings suggestive of SARS-CoV-2 cardiac involvement were detected by ECG (21 of 2999 [0.7%]), cardiac troponin (24 of 2719 [0.9%]), and transthoracic echocardiography (24 of 2556 [0.9%]). Definite, probable, or possible SARS-CoV-2 cardiac involvement was identified in 21 of 3018 (0.7%) athletes, including 15 of 2820 (0.5%) who underwent clinically indicated CMR (n=119) and 6 of 198 (3.0%) who underwent primary screening CMR. Accordingly, the diagnostic yield of CMR for SARS-CoV-2 cardiac involvement was 4.2 times higher for a clinically indicated CMR (15 of 119 [12.6%]) versus a primary screening CMR (6 of 198 [3.0%]). After adjustment for race and sex, predictors of SARS-CoV-2 cardiac involvement included cardiopulmonary symptoms (odds ratio, 3.1 [95% CI, 1.2, 7.7]) or at least 1 abnormal triad test result (odds ratio, 37.4 [95% CI, 13.3, 105.3]). Five (0.2%) athletes required hospitalization for noncardiac complications of COVID-19. During clinical surveillance (median follow-up, 113 days [interquartile range=90 146]), there was 1 (0.03%) adverse cardiac event, likely unrelated to SARS-CoV-2 infection. Conclusions: SARS-CoV-2 infection among young competitive athletes is associated with a low prevalence of cardiac involvement and a low risk of clinical events in short-term follow-up.

Objectives Patients resuscitated from an out-of-hospital circulatory arrest (OHCA) commonly present without an obvious etiology. We assessed the diagnostic capability and safety of early head-to-pelvis computed tomography (CT) imaging in such patients. Methods From November 2015 to February 2018, we enrolled 104 patients resuscitated from OHCA without obvious cause (idiopathic OHCA) to an early sudden-death CT (SDCT) scan protocol within 6 h of hospital arrival. The SDCT protocol included a noncontrast CT head, an electrocardiogram-gated cardiac and thoracic CT angiogram, and a nongated venous-phase abdominopelvic CT angiogram. Patients needing urgent cardiac catheterization or hemodynamically unable to tolerate SDCT were excluded. Cardiac CT analyses were blinded, but other SDCT findings were clinically available. Primary endpoints were the number of OHCA causes identified by SDCT compared to the adjudicated cause and critical diagnoses identified by SDCT, including resuscitation complications. Safety endpoints were acute kidney injury (AKI) and inappropriate treatments based on SDCT findings. Acute coronary syndrome was the presumed etiology if any major coronary artery had a >50% stenosis without another OHCA cause. Results SDCT scans occurred within 1.9 ± 1.0 h of hospital arrival and identified 39% (41/104) of all OHCA causes and 95% (39/41) of causes potentially identifiable by SDCT. Critical findings were identified by SDCT in 98% (43/44) of patients that included potentially life-threatening resuscitation complications of liver or spleen laceration (n = 6); pneumothorax or thoracic organ laceration (n = 8); and mediastinal, pericardial, or vascular hemorrhage (n = 3). SDCT exclusively identified 13 (13%) OHCA causes that would otherwise not be identified without SDCT imaging. No inappropriate treatments resulted from SDCT findings. AKI was common (28%) but only one (1%) patient required new dialysis. Conclusions This observational cohort study suggests that early SDCT scanning is safe, can expedite the diagnosis of potential causes, and can meaningfully change clinical management after idiopathic OHCA.

PURPOSE OF REVIEW: Cardiopulmonary exercise testing (CPET) is a tool designed to assess the integrated function of the cardiac, pulmonary, vascular and musculoskeletal systems to produce an exercise effort. CPET may be performed for performance purposes as part of optimizing a training program or for clinical purposes in athletes with established cardiovascular disease or in those with symptoms suggestive of cardiopulmonary pathology. Most normative values used for CPET parameters have been derived in the general population, in whom there will be expected differences in exercise physiology as compared to a trained athlete. In this review, our goal is to examine current available data on expected findings on CPET in athletes, highlight how these differ from the general population-derived normative values, and identify areas in need of further research to optimize the application of CPET in athletes. RECENT FINDINGS: Athletes demonstrate differences in exercise hemodynamic and gas exchange profiles as compared to non-athletes including: higher cardiac output, faster heart rate recovery, higher peak V̇O(2), higher prevalence of exercise-induced arterial hypoxemia, and lower breathing reserve. SUMMARY: CPET is an important tool to optimize performance and assess for underlying pathology in an athletic population. The impact of routine, vigorous physical activity on exercise physiology should be integrated into determination of what constitutes a normal CPET result in an athletic individual.

Valvular heart disease is prevalent in older athletes with primarily degenerative valvular disorders and younger athletes with congenital or genetic syndromes. Limited data exist on the risks and benefits of exercise for athletes with underlying valvular disorders, so current guidelines are primarily based upon expert consensus. This review focuses on the current data, guideline recommendations, and emerging clinical conundrums for athletes with common valvular heart conditions including aortic stenosis, bicuspid aortic valve (BAV), mitral regurgitation (MR), mitral valve prolapse (MVP), and thoracic aortic aneurysms. Aortic growth appears similar in athletes compared to non-athletes with BAV. Return to exercise following mitral valve repair for primary MR does not seem to lead to significant valve deterioration or adverse outcomes in short-term follow-up. Longitudinal cohort studies of athletes with MVP have suggested that ventricular arrhythmias can be common, but sudden cardiac death is rare. Aortic dilation is uncommon in young otherwise healthy athletes, but can commonly be found in older endurance and strength athletes. Valvular heart conditions in athletes are prevalent in clinical practice; however, there are limited data on the outcomes in these patients to drive guideline development and clinical decision-making. Future research should focus on defining the risks of continual exercise on outcomes in patients with known valvular disease, the optimal time for valve repair/replacement, and the risks of returning to exercise following valvular intervention.

Preparticipation screening for conditions associated with sudden cardiac death (SCD) is required in college athletes. Previous cost analyses used theoretical models based on variable assumptions, but no study used real-life outcomes.The purpose of this study was to compare disease prevalence, positive findings, and costs of 2 different screening strategies: history and physical examination alone (HP) or with an electrocardiogram (HP+ECG).De-identified preparticipation data (2009-2017) from Pacific-12 Conference institutions were abstracted for cardiovascular history questions, cardiovascular physical examination, and ECG result. Secondary testing, cardiac diagnoses, return to play outcomes, and complications from testing were recorded. The costs of screening and secondary testing were based on the Centers for MedicareMedicaid Services Physician Fee Schedule.A total of 8602 records (4955 HP, 3647 HP+ECG) were included. Eleven conditions associated with SCD were detected (2 HP only, 9 HP+ECG). The prevalence of cardiovascular conditions associated with SCD discovered with HP alone was 0.04% (1/2454) compared to 0.24% (1/410) when ECG was added (P = .01) (odds ratio 5.17; 95% confidence interval 1.28-20.85; P = .02). Cost of screening and secondary testing with HP alone was $130 per athlete and in the ECG-added group was $152 per athlete. The cost per diagnosis was $312,407 in the HP group and $61,712 in the ECG-added group. There were no adverse outcomes from secondary testing or treatment.HP with the addition of ECG is 6 times more likely to detect a cardiovascular condition associated with SCD than without. The addition of ECG improves the cost efficiency per diagnosis by 5-fold and should be considered at college institutions with appropriate resources.

Electrocardiogram (ECG) screening in athletes enhances the detection of conditions associated with sudden cardiac death (SCD), but concerns remain for false positive results when conducted outside of specialized centers. This study compared ECG interpretation in college athletes between local physicians and a sports cardiology center (SCC).Screening ECGs in athletes from eight Pacific-12 Conference institutions performed between 2010 and 2016 were included. Local interpretation was compared to SCC interpretation using both the Seattle Criteria (SCC-SC) and the International Criteria (SCC-IC).A total of 2445 athlete ECGs (mean age 18.5 years; 57.1% male; 63.2% Caucasian and 15.3% African American) were reviewed. The proportion of ECGs classified as abnormal was similar between local and SCC-SC interpretation (3.5% vs. 3.4%, respectively; p = .94), but was lower by SCC-IC interpretation (1.5%, p .001). ECG abnormalities interpreted as normal by local physicians but as abnormal by SCC-SC (n = 33) and SCC-IC (n = 16) standards included: pathological Q waves (n = 15 SCC-SC; n = 3 SCC-IC), T-wave inversions (n = 8 both), and ST-depressions (n = 3 both). There was a 97.5% ECG interpretation agreement and substantial interobserver reliability (k = 0.611, p .001) between local and SCC-SC interpretation in athletes screened starting one year after publication of the Seattle Criteria (n = 1388). Both local and SCC physicians correctly identified six abnormal ECGs associated with conditions at risk of SCD.ECG interpretation by local physicians at college universities had similar accuracy compared to a specialized SCC with a low overall abnormal rate, similar sensitivity, and substantial interobserver reliability. Uniform application of current ECG interpretation standards is recommended to further improve accuracy.

To test the diagnostic accuracy of ECG-gated coronary computed tomography angiography (CCTA) to detect coronary artery disease (CAD) among survivors of out-of-hospital circulatory arrest (OHCA).We prospectively studied head-to-pelvis computed tomography (CT) scanning (6 h from hospital arrival) in OHCA survivors. This sub-study tested the primary outcome of CCTA diagnostic accuracy to identify obstructive CAD (≥50% stenosis) compared to clinically-ordered invasive coronary angiography. Patients were not optimized with beta receptor blockade or nitroglycerin. Secondary analyses included CCTA accuracy for CAD in major coronary arteries, obstructive disease at ≥70% stenosis threshold, and where non-evaluable CCTA segments were considered either obstructive or non-obstructive.Of the 104 enrolled OHCA survivors, 28 (27%) received both CT and invasive angiography in this sub study. All CCTA studies were evaluable although 49/346 (14%) individual coronary segments were unevaluable, primarily due to being too small to evaluate (65%). Patient-level diagnostic accuracy for the ≥50% stenosis threshold was high at 0.93 (95% CI 0.77-0.98) with a specificity of 1.0 (95% CI 0.8-1.0), sensitivity of 0.85 (95%CI 0.58-0.96), negative predictive value of 0.88 (95% CI 0.66-0.97) and positive predictive value of 1.0 (0.74-1.0). When non-evaluable segments were considered obstructive, the sensitivity rose to 0.92 (95% CI 0.67-0.99) with lower specificity of 0.27 (95% CI 0.11-0.52).Early CCTA of OHCA survivors has high diagnostic accuracy to detect obstructive coronary artery disease. However, the number of non-diagnostic coronary segments is high suggesting further CCTA refinement is needed, such as the pre-CCTA use of nitroglycerin.NCT03111043 https://clinicaltrials.gov/ct2/show/record/NCT03111043.

INTRODUCTION: Pre-participation cardiovascular screening (PPCS) in athletes is recommended by numerous medical and sporting societies. While there is consensus that young athletes should be screened prior to participation in competitive sports, there are on-going debates regarding the true incidence of sudden cardiac death (SCD), the most frequent causes of SCD, and the optimal methods for PPCS. AREAS COVERED: This review focuses on the current evidence for the incidence of SCD, causes of SCD, and the pros and cons of a history and physical exam (H&P) and electrocardiogram (ECG) in PPCS of young competitive athletes. EXPERT OPINION: With significant controversy surrounding PPCS in athletes, a large-randomized trial powered for mortality is needed to assess the utility of PPCS and to define the optimal screening methods to detect cardiovascular diseases that may lead to SCD in competitive athletes. Until a trial of this caliber is created, controversy will remain and heterogeneity in care will exist. Future research should also define the optimal timing and frequency of PPCS given age-related penetrance of certain diseases, create evidence-based history questionnaires, continue to optimize ECG screening criteria, and create more learning modules for ECG interpretation in athletes.

PURPOSE OF REVIEW: The purpose of this review was to highlight the current recommendations, data, and limitations for methods of cardiovascular screening in athletes. RECENT FINDINGS: While the history and physical (H&P) alone remains the cornerstone for preparticipation cardiovascular screening (PPCS) in athletes, the advent of modern electrocardiographic (ECG) screening criteria has drastically increased sensitivity and decreased false positive rates for screening. Advanced imaging techniques remain an important component of secondary testing after an athlete has an abnormal initial screening exam, however, the use of imaging for universal screening has not been rigorously tested to date. Current disqualification guidelines have now begun to emphasize shared decision making between the provider and athlete in situations of clinical equipoise. SUMMARY: All major medical and sporting societies recommend PPCS using a focused medical history and physical examination for all competitive athletes, but there remains controversy about the role of ECG and advanced imaging in PPCS. Future research should focus on the creation of a randomized trial that is powered for mortality that can truly assess the utility of PPCS in athletes.

Syncope is a commonly encountered and challenging problem in medical practice. Presentations are variable, and the causal mechanism often remains elusive even after extensive (and often expensive) evaluation. Clinical practice guidelines have been developed to help guide the multidisciplinary approach necessary to diagnose and manage the broad spectrum of patients presenting with syncope. The American College of Cardiology/American Heart Association, in collaboration with the Heart Rhythm Society, published its first syncope guidelines in 2017. The European Society of Cardiology released the fourth iteration of its syncope guidelines in 2018. This review highlights the differences and congruencies between the 2 sets of recommendations, their implications for clinical practice, the remaining gaps in understanding, and areas of future research.

Purpose Although exercise testing guidelines define cutoffs for an exaggerated exercise systolic blood pressure (SBP) response, SBPs above these cutoffs are not uncommon in athletes given their high exercise capacity. Alternately, guidelines also specify a normal SBP response that accounts for metabolic equivalents (METs; mean [SD] of 10 [2] mm Hg per MET or 3.5 mL/kg/min oxygen consumption [ V ˙ o 2 ]). SBP and V ˙ o 2 increase less during exercise in females than males. It is not clear if sex-based differences in exercise V ˙ o 2 are related to differences in SBP or if current recommendations for normal increase in SBP per MET produce reasonable estimates using measured METs (ie, V ˙ o 2 ) in athletes. We therefore examined sex-based differences in exercise SBP indexed to V ˙ o 2 in athletes with the goal of defining normative values for exercise SBP that account for fitness and sex. Methods Using prospectively collected data from a single sports cardiology program, normotensive athlete patients were identified who had no relevant cardiopulmonary disease and had undergone cardiopulmonary exercise testing with cycle ergometry or treadmill. The relationship between ΔSBP (peak – rest) and Δ V ˙ o 2 (peak – rest) was examined in the total cohort and compared between sexes. Findings A total of 413 athletes (mean [SD] age, 35.5 [14] years; 38% female; mean [SD] peak V ˙ o 2 , 46.0 [10.2] mL/kg/min, 127% [27%] predicted) met the inclusion criteria. The ΔSBP correlated with unadjusted Δ V ˙ o 2 (cycle: R2 = 0.18, treadmill: R2 = 0.12; P V ˙ o 2 was higher in female than male athletes (cycle: 25.6 [7.2] vs 21.1 [7.3] mm Hg/L/min; treadmill: 21.6 [7.2] vs 17.0 [6.2] mm Hg/L/min; P V ˙ o 2 was adjusted for body size and converted to METs, female and male athletes had similar mean (SD) ΔSBP /ΔMET (cycle: 6.0 [2.1] vs 5.8 [2.0] mm Hg/mL/kg/min; treadmill: 4.7 [1.8] vs 4.8 [1.7] mm Hg/mL/kg/min). Implications In this cohort of athletes without known cardiopulmonary disease, observed sex-based differences in peak exercise SBP were in part related to the differences in Δ V ˙ o 2 between male and female athletes. Despite lower peak SBP, ΔSBP/unadjusted Δ V ˙ o 2 was paradoxically higher in female athletes. Future work should define whether this finding reflects sex-based differences in the peripheral vascular response to exercise. In this athletic cohort, ΔSBP/ΔMET was similar between sexes and much lower than the ratio that has been proposed by guidelines to define a normal SBP response. Our observed ΔSBP/ΔMET, based on measured rather than estimated METs, provides a clinically useful estimate for normal peak SBP range in athletes.

Aims Accurate interpretation of cardiopulmonary exercise testing (CPET) relies on age, gender, and exercise modality-specific reference values. To date, clinically applicable CPET reference values derived from a source population of endurance athletes (EAs) have been lacking. The purpose of this study was to generate CPET reference values for use in the clinical assessment of EA. Methods and Results Prospective data accrued during the clinical care of healthy EA were used to derive CPET reference values and to develop novel equations for V˙O2peak. The performance of these equations was compared to the contemporary standard of care equations and assessed in a discrete EA validation cohort. A total of 272 EA (age = 42 ± 15 years, female = 31%, V˙O2peak = 3.6 ± 0.83 L/min) met inclusion criteria and comprised the derivation cohort. V˙O2peak prediction equations derived from general population cohorts described a modest amount of V˙O2peak variability [R2 = 0.58–0.70, root mean square error (RMSE) = 0.46–0.54 L/min] but were mis-calibrated (calibration-in-the-large = 0.45–1.18 L/min) among EA leading to significant V˙O2peak underestimation. Newly derived, externally validated V˙O2peak prediction equations for EA that included age, sex, and height for both treadmill (R2 = 0.74, RMSE = 0.42 L/min) and cycle ergometer CPET (Cycle: R2 = 0.69, RMSE = 0.42 L/min) demonstrated improved accuracy. Conclusion Commonly used V˙O2peak prediction equations derived from general population cohorts perform poorly among competitive EA. Newly derived CPET reference values including novel V˙O2peak prediction equations may improve the clinical utility of CPET in this rapidly growing patient population.

Aim To review data for non-invasive imaging in the diagnosis of non-traumatic out-of-hospital cardiac arrest (OHCA). Data sources We searched MEDLINE, EMBASE, Cochrane library, and clinicaltrials.gov databases from inception to January 2017 for studies utilizing non-invasive imaging to identify potential causes of OHCA [computed tomography (CT), ultrasound including echocardiography, and magnetic resonance (MRI)]. Study selection Inclusion criteria were the following: (1) randomized control trials, cohort studies or observational studies; (2) contained a population ≥18 years old with non-traumatic OHCA who underwent diagnostic imaging with CT, MRI, echocardiography, or abdominal ultrasound; (3) imaging was obtained for diagnostic purposes; (4) patients were alive or were undergoing cardiopulmonary resuscitation at the time of imaging; (5) contained potential causes of OHCA. Endpoints studied were the number of potential OHCA causes identified, diagnostic accuracy measures (sensitivity, specificity, positive and negative predictive values), and diagnostic utility (number of imaging findings with reported changes in clinical management). Results Of the total 5722 studies identified, 17 (0.3%) met inclusion criteria. The majority of studies assessed the utility of CT in OHCA (n = 10), and potential causes of OHCA were found in 8–54% of patients following head, abdominal and/or chest CT. Only 1/17 (6%) studies reported diagnostic accuracy measures, and 9/17 (53%) studies included a time to imaging criteria within 24 h. Conclusion Although non-invasive imaging is commonly performed in patients after OHCA, its diagnostic utility remains poorly characterized. Prospective studies are needed for appropriate imaging selection and their potential impact on treatment and outcome.

Background Routine physical activity stimulates numerous morphologic and functional adaptations of the cardiac system, which are commonly referred to as exercise-induced cardiac remodeling (EICR). EICR has been well documented in elite and recreational athletes, but comparatively little is known about the “reverse” cardiac adaptations during detraining in an athletic population. Objective To assess the morphologic and functional cardiac effects of detraining in athletes. Methods Eligible studies were identified in PubMed from inception to May 2020. Studies were included if they assessed the cardiac effects of detraining periods in athletes. Results A total of 16 studies from the literature search were identified and included in this review. These studies included athletes from multiple different sporting disciplines and detraining periods ranged from 3 weeks to 13 years. Detraining periods led to significantly decreased right ventricular and left (LV) ventricular dimensions, LV mass, and LV wall thickness, but only limited changes in systolic and diastolic functional parameters were observed. Conclusions From the limited data available in this population, cardiac atrophy has been observed with short periods of detraining (1–8 weeks) but often spares systolic and diastolic heart function. Supplemental exercise training during times of rehabilitation to combat cardiac regression has not been vigorously studied in athletes, so the ideal frequency, intensity, and modality of exercise needed to maintain EICR remains unclear.

Importance Population-specific normative data are essential for the evaluation of competitive athletes. At present, there are limited data defining normal electrocardiographic (ECG) and echocardiographic values among elite US soccer players. Objective To describe ECG and echocardiographic findings in healthy elite US soccer players. Design, Setting, and Participants This cross-sectional study analyzed Federation Internationale de Football Association-mandated screening sessions performed at US Soccer National Team training locations from January 2015 to December 2019. US women's and men's national team soccer players undergoing mandated cardiovascular screening were included. Main Outcomes and Measures Normal training-related and abnormal ECG findings were reported using the International Recommendations for Electrocardiographic Interpretation in Athletes. Echocardiographic measurements of structural and functional parameters relevant to cardiovascular remodeling were assessed relative to American Society of Echocardiography guideline-defined normal ranges. Results A total of 238 athletes (122 [51%] female; mean [SD] age, 20 [4] years; age range, 15-40 years) were included. Male athletes demonstrated a higher prevalence of normal training-related ECG findings, while female athletes were more likely to have abnormal ECG patterns (14 [11%] vs 0 in male cohort), largely accounted for by abnormal T-wave inversions. Echocardiography revealed no pathologic findings meeting criteria for sport restriction, but athletes frequently exceeded normal ranges for structural cardiac parameters responsive to exercise-induced remodeling including body surface area-indexed left ventricular (LV) mass (58 of 113 female athletes [51%] and 67 of 114 male athletes [59%]), indexed LV volume (89 of 115 female athletes [77%] and 76 of 111 male athletes [68%]), and LV wall thickness (37 of 122 female athletes [30%] and 47 of 116 male athletes [41%]). Age-stratified analysis revealed age-dependent increases in LV wall thickness, mass, and volumes among female athletes and LV wall thickness and mass among male athletes. Conclusions and Relevance These data represent the first set of comprehensive normative values for elite US soccer players and one of the largest sport-specific echocardiographic remodeling studies in female athletes. Abnormal ECG findings were more common in female athletes, while both female and male athletes frequently exceeded clinical normality cut points for remodeling-associated echocardiographic parameters.

This study investigated the association between left ventricular ejection fraction (LVEF) and the risk of ventricular arrhythmias (VA), heart transplantation, and death in cardiac sarcoidosis (CS). We identified 110 CS patients meeting 2014 Heart Rhythm Society (HRS) diagnostic criteria with baseline LVEF35% (n = 32) or ≥35% (n = 78). The primary end point was sustained VA or sudden cardiac death (SCD), and secondary end points included risk of heart transplantation, death, or a composite. Logistic regression determined risk factors for VA/SCD, and Cox proportional hazards regression analysis was performed for secondary end points. Receiver operating curve analysis determined the best discrimination point of LVEF for each end point; sensitivity analyses evaluated the effects of higher LVEF on each end point. Over a follow-up of 2.6 (range 1.0 to 5.8) years, 49 (44.5%) CS patients experienced VA/SCD, including 19 of 32 (59.4%) with LVEF35%, and 30 of 78 (38.5%) with LVEF ≥35%. After adjustment, LVEF35% was not significantly associated with an increased risk of VA/SCD compared with LVEF ≥35% (odds ratio 1.3, 95% confidence intervals 0.5 to 3.7). Although LVEF35% was associated with an increased risk of heart transplantation and death (28.1% vs 12.8%, p = 0.05), this was not significant after adjustment (hazard ratio 1.7, 95% confidence intervals 0.5 to 9.0, p = 0.53). In conclusion, patients with CS experience high rates of VA, SCD, and heart transplantation, even when LVEF is mildly impaired or normal. Patients with LVEF35% are at particularly elevated risk of VA/SCD. Our findings highlight the imperative to investigate arrhythmia risk in all patients with CS, even in the setting of an otherwise reassuring LVEF.

Introduction: Myocardial injury is common after out-of-hospital-cardiac arrest (OHCA). However, little is known about the role of early serial hs-TnT in patients with OHCA for identifying myocardial injury, and whether the prevalence and severity of injury differs according to cardiac (CV) vs noncardiac (non-CV) cause of OHCA. Hypothesis: Early hs-TnT will demonstrate high rates of myocardial injury after OHCA regardless of etiology. However, in the first 6 hours after OHCA the extent of hs-TnT elevation and rate of rise will be higher in patients with CV vs non-CV etiology. Methods: Multicenter retrospective study including OHCA patients presenting from 4/1/2018 to 4/1/2019. Hs-TnT was drawn as part of routine clinical care. Results: Baseline hs-TnT was measured in 120 patients after OHCA due to CV (n=51) and non-CV (n=69) etiologies, with subsequent serial hs-TnT values at 1hr, 3hrs, and 6hrs. Hs-TnT was greater than the 99 th percentile in 97% (115/120) of patients and myocardial injury (hs-TnT> 52ng/L) was detected in 88% (105/120) of patients (no difference between CV vs non-CV etiology). Median hs-TnT values were compared between CV and non-CV etiologies of OHCA identifying no difference in hs-TnT at baseline (Figure: 54 [IQR 18-134] vs. 41 [IQR 19-100]; p=0.357) but significantly higher hs-TnT in patients with CV etiology at 1hr (159 [IQR 80-392] vs 93 [IQR 42-247]; p=0.049), 3hrs (400 [IQR 168-1005] vs 151 [IQR 75-401] p=0.009), and 6hrs (746 [IQR 248-1965] vs 251 [IQR 75-580]; p=0.001). Additionally, hs-TnT rise from baseline was present in both CV and non-CV etiologies but was significantly higher in patients with CV etiology (p = 0.005). Conclusions: As identified by hs-TnT, myocardial injury was prevalent in patients with both CV and non-CV cause of OHCA. Baseline hs-TnT was no different in patients with CV vs non-CV cause, however, over the first 6 hours both absolute value and rate of hs-TnT rise were significantly higher for patients with CV vs non-CV etiology of OHCA.

Introduction: Head computed tomography (CT) is frequently performed in survivors of out-of-hospital cardiac arrest (OHCA). However, the clinical utility of routine, early head CT in these patients is not well understood. We sought to characterize the associations between findings on early head CT with presenting characteristics and outcomes in survivors of OHCA. Hypothesis: Presence of early intracranial swelling is associated with poor outcomes. Methods: This is a retrospective analysis from a multicenter cohort of 432 patients with non-traumatic OHCA between 2/1/17 through 4/1/19. Patients were included if they underwent head CT Result: Early head CT ( Conclusions: In survivors of non-traumatic OHCA, routine, early (

Introduction: Out-of-hospital circulatory arrest (OHCA) is commonly assumed to be from a cardiac cause although routine early invasive coronary angiography (ICA) remains controversial and has a relatively high proportion of studies without obstructive coronary artery disease (CAD). The ability of coronary CT angiography (CCTA) to detect significant CAD in OHCA survivors has not been evaluated. Methods: The prospective CT-FIRST trial enrolled 104 OHCA survivors who had an early (50% stenosis. Patient-level diagnostic accuracy calculations for CCTA to identify obstructive CAD used ICA as the standard. Results: Of the 104 enrolled patients, 28 (27%) had both CT and ICA. All CCTA studies were evaluable. Diagnostic accuracy data are shown in the Table. Overall, diagnostic accuracy measures were excellent between CCTA and ICA at the patient level. Conclusions: Early CCTA in OHCA survivors has high diagnostic accuracy for obstructive coronary artery disease and could be used as a gatekeeper to ICA.

Introduction: The role of cardiac biomarkers in patients after out-of-hospital cardiac arrest (OHCA) has been subject to recent research due to myocardial stress and injury associated with cardiac arrest. However, it remains unclear to what extent NT-proBNP can be used as a prognostic tool after OHCA. Hypothesis: Baseline NT-proBNP is an independent predictor of mortality in patients after OHCA. Methods: Multicenter retrospective observational cohort study including non-traumatic OHCA patients presenting from 2/1/2017 to 4/1/2019. Relationship between NT-proBNP quartiles and mortality was assessed through unadjusted and adjusted (age, gender, presenting rhythm) analyses with logistic regression. Results: Baseline NT-proBNP values were obtained for 283 patients on presentation after OHCA with median 965 pg/mL (IQR 157-3550). Levels did not differ by arrest etiology (cardiac vs noncardiac) or presenting rhythm. NT-proBNP levels correlated with age (r = 0.44, p Conclusion: In this multicenter cohort of patients with shockable and nonshockable OHCA, increased levels of NT-proBNP were predictive of an increased risk of in-hospital mortality even after adjustment for age, gender, and presenting rhythm.

Background Patients surviving an out-of-hospital cardiac arrest (OHCA) commonly present without an obvious etiology, but computed tomography (CT) can provide rapid, comprehensive anatomic evaluation of potential OHCA causes. Purpose To assess the diagnostic capabilities of whole body CT imaging in OHCA survivors. Methods From 11/2015 to 2/2018, the CT-FIRST (CT Feasibility In Resuscitated patient for Sudden death Triage) protocol enrolled 104 OHCA survivors without obvious OHCA cause to an early (50% stenosis was identified in major coronary artery(ies). Results SDCT scans identified 39% (41/104) of all OHCA causes and 95% (41/43) of causes potentially identifiable with SDCT (Table). No inappropriate treatments resulted from SDCT findings. SDCT changed or expedited treatments in 21/23 (95%) patients, including antibiotics, anticoagulants, and invasive evaluations or treatments. SDCT found or confirmed resuscitation complications including liver/spleen laceration (n=5), pneumothorax (n=7), and hemopericardium (n=1). N=104 OHCA Cause SDCT Diagnosis of OHCA Cause N (%) N (%) Acute coronary syndrome 13 (13%) 13 (100%) Cardiomyopathy 8 (8%) 7 (88%) Pneumonia 11 (11%) 11 (100%) Hemorrhagic stroke 3 (3%) 3 (100%) Pulmonary embolism 4 (3%) 4 (100%) Perforated viscus 2 (2%) 2 (100%) Gut necrosis 1 (1%) 1 (100%) Pulmonary hemorrhage 1 (1%) 1 (100%) Substance use 22 (21%) 0 (0%) Unknown 7 (7%) 0 (0%) Other 32 (31%) 0 (0%) Conclusion This pilot study suggests the SDCT protocol has considerable promise to diagnose OHCA causes and complications of resuscitation, as well as change clinical treatment. Acknowledgement/Funding Medic One Foundation

Syncope is a commonly encountered and challenging problem in medical practice. Presentations are variable, and the causal mechanism often remains elusive even after extensive (and often expensive) evaluation. Clinical practice guidelines have been developed to help guide the multidisciplinary approach necessary to diagnose and manage the broad spectrum of patients presenting with syncope. The American College of Cardiology/American Heart Association, in collaboration with the Heart Rhythm Society, published its first syncope guidelines in 2017. The European Society of Cardiology released the fourth iteration of its syncope guidelines in 2018. This review highlights the differences and congruencies between the 2 sets of recommendations, their implications for clinical practice, the remaining gaps in understanding, and areas of future research.

The number of female athletes participating in sports has increased exponentially over the past century. While cardiac adaptations to exercise have been well described, female athletes have been underrepresented in many prior studies. More recently, important research has embraced gender as an important biologic variable. We will review this work in order to examine how gender influences the impact of exercise on the heart. Exercise-induced cardiac remodeling (EICR) manifests slightly differently in male and female athletes. Specifically, female athletes have fewer signs of EICR on the electrocardiogram than male athletes, though are more likely to have anterior T wave inversions in the absence of cardiac disease. Cardiac enlargement due to exercise follows a different pattern in female versus male athletes, with females having similar chamber size when adjusted for body size but lower left ventricular mass. Recent research also suggests that female masters athletes may be less likely to have excess coronary disease, atrial fibrillation, and myocardial fibrosis, all of which have been posited though not proven to be sequelae of long-term endurance exercise in males. Gender appears to be an important modifier of the relationship between exercise and associated cardiac remodeling. The biological mechanisms underlying gender-based differences in EICR are poorly understood and will be an important area of future research.

Introduction The diagnosis of cardiac sarcoidosis (CS) is difficult to ascertain due to the insensitivity of endomyocardial biopsy. Current diagnostic criteria require a positive endomyocardial biopsy or extra-cardiac biopsy with clinical features suggestive of CS. Common tests for diagnosis of pulmonary sarcoidosis include bronchoalveolar lavage (BAL), lung and mediastinal lymph node (MLN) biopsies. Our objective was to determine the diagnostic utility of these tests in patients with suspected CS and without prior history of pulmonary involvement. Methods This retrospective cohort study included 37 patients without history of extra-cardiac sarcoidosis referred for suspected CS. All patients underwent chest computed tomography (CT) staged using the modified Scadding criteria, and had BAL, and/or lung or MLN biopsy. BAL cellular analyses with lymphocytes>15% and/or CD4/CD8 ratio≥ 4 were considered suggestive of sarcoidosis. The number of positive biopsies and BALs were compared between normal CT (Scadding stage 0) and abnormal CT (Scadding stage 1–4) groups. Results A definitive diagnosis of sarcoidosis was ascertained in 18/31 (58%) patients undergoing lung or lymph node biopsy, and a potential diagnosis in 18/27 (67%) patients with BAL CD4/CD8>4 or lymphocytes>15%. Of the 12 patients in the normal CT group, 4/10 (40%) had positive lung biopsies, and 9/12 (75%) patients had either positive biopsy or BAL criteria. Conclusions In suspected cardiac sarcoidosis, a diagnosis of extra-cardiac sarcoidosis was ascertained in a majority of patients irrespective of degree of lung involvement on chest CT. Our results support referral for pulmonary biopsy/bronchoalveolar lavage in suspected CS to confirm the diagnosis of sarcoidosis.

Orthotopic heart transplant (OHT) is increasingly used for end-stage heart failure due to cardiac sarcoidosis (CS). However, concern regarding long-term outcomes in patients with CS after OHT persists because of multiorgan involvement.Baseline demographics and invasive hemodynamics were measured in 12 patients with CS and 28 patients with nonischemic cardiomyopathy requiring OHT at the time of transplantation, 1 week after OHT, and in routine follow-up. Primary endpoints included changes in pulmonary artery pressure, right ventricular stroke work index, and pulmonary compliance. Secondary endpoints included degree of allograft rejection and death.During a mean follow-up of 73.8 months, no differences in pulmonary artery pressures, right ventricular stroke work index, or cardiac index were observed in patient with CS (n = 12) compared with those without CS (n = 28) between 1 week after OHT and the most recent follow-up. Long-term follow-up showed that pulmonary hemodynamics remained normal in the CS group. International Society for Heart and Lung Transplantation (ISHLT) 1990 grade ≥ 1a rejection occurred less frequently in the CS group (17% vs 68%, P = 0.006), and 0 of 12 patients in the CS group experienced histologic or clinical recurrence of sarcoidosis or ≥2 rejection. Patients with CS had excellent survival after OHT, with 0 deaths or significant rejection.Patients with CS have similar post-transplant hemodynamics as patients without CS, without evidence of right ventricular dysfunction or pulmonary hypertension. Neither significant rejection nor recurrence of sarcoid in the allograft was observed in this cohort of patients with CS. Survival is similar between patients with CS and those without CS. Heart transplant is a viable strategy in selected patients with CS with excellent outcomes.

Background Prior studies have shown that late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) and fluorodeoxyglucose (FDG) positron emission tomography (PET) confer incremental risk assessment in patients with cardiac sarcoidosis (CS). However, the incremental prognostic value of the combined use of LGE and FDG compared to either test alone has not been investigated, and this is the aim of the present study. Methods Retrospective observational study of 56 symptomatic patients with high clinical suspicion for CS who underwent LGE-CMR and FDG-PET and were followed for the occurrence of death and/or malignant ventricular arrhythmias (VA). Results The combination of PET and CMR yielded the following groups: 1) LGE-negative/normal-PET (n=20), 2) LGE-positive/abnormal-FDG (n=20), and 3) LGE-positive/normal FDG (n=16). After a median follow-up of 2.6years (IQR 1.2–4.1), 16 patients had events (7 deaths, 10 VA). All, but 1, events occurred in patients with LGE. LGE-positive/abnormal-FDG (7 events, HR 10.1 [95% CI 1.2–84]; P =0.03) and LGE-positive/normal-FDG (8 events, HR 13.3 [1.7–107]; P =0.015) patients had comparable risk of events compared to the reference LGE-negative/normal-PET group. In adjusted Cox-regression analysis, presence of LGE (HR 18.1 [1.8–178]; P =0.013) was the only independent predictor of events. Conclusion CS patients with LGE alone or in association with FDG were at similar risk of future events, which suggests that outcomes may be driven by the presence of LGE (myocardial fibrosis) and not FDG (inflammation).

Key Points Question How does a previously developed clinical decision rule (termed the UN10 rule), designed to predict futility during in-hospital cardiac arrest, perform in a large national sample? Findings In this cohort study of 96 509 patients with in-hospital cardiac arrest, the percentage of patients who satisfied the UN10 rule for futility and survived (6.3%) was substantially higher than the initial derivation cohort (0%) and single-center validation cohort (1.1%). Meaning A revalidation study of the UN10 rule in a large cohort demonstrated moderate predictive ability to identify patients with poor survival; however, survival rates of patients who met all UN10 criteria were much higher than previous studies., This cohort study assesses the performance of the UN10 clinical decision rule to predict futility during in-hospital cardiac arrest in a US national sample of patients who experienced in-hospital cardiac arrest., Importance Several clinical decision rules (CDRs) have been developed to help practitioners know when to safely terminate resuscitative efforts after in-hospital cardiac arrest (IHCA). The UN10 rule, a CDR that uses 3 intra-arrest variables, has been shown to predict a poor chance of survival to discharge. However, its large-scale applicability in clinical settings remains unknown. Objective To assess the performance of a parsimonious CDR in a national cohort of individuals with IHCA. Design, Setting, and Participants This retrospective cohort study used a nationwide cohort from the American Heart Association Get With the Guidelines–Resuscitation IHCA registry to derive a sample of 96 509 patients from 716 US hospitals who experienced IHCA from January 1, 2000, to January 26, 2016. Data analysis began in January 2018 and concluded in June 2018. Exposures The UN10 rule uses 3 variables: (1) unwitnessed arrest, (2) nonshockable rhythm, and (3) no return of spontaneous circulation within 10 minutes of resuscitative efforts. The CDR indicates futility if all 3 criteria are met. This CDR was analyzed according to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline. Main Outcomes and Measures The primary outcome was survival to hospital discharge following resuscitation. Favorable neurologic status at discharge was also assessed. Overall rates of survival and survival with favorable neurologic status (cerebral performance category score, 1 or 2) were compared with predicted values by the UN10 rule using 2 × 2 contingency tables. Results Of 96 509 patients, 55 761 (57.8%) were men, and the mean (SD) age was 67.1 (15.3) years. In total, 18 713 patients (19.4%) survived to discharge, and 16 134 patients (16.7%) were discharged with a favorable neurologic status. Overall, 15 838 patients (16.4%) met all 3 criteria for futility in the UN10 rule. A total of 1005 patients (6.3%) who met the UN10 rule survived to discharge, and 754 (4.8%) survived with favorable neurologic status. The percentage of patients meeting the UN10 rule (ie, predicting futile resuscitation) who actually survived in our study cohort was substantially higher than the initial derivation cohort (0%) and single-center validation cohort (1.1%). The positive predictive value of the UN10 rule was 93.7% (95% CI, 93.3%-94.0%), which was lower than the initial derivation cohort (100%; 95% CI, 97.5%-100%) and validation cohort (98.9%; 95% CI, 96.5%-99.7%). Conclusions and Relevance Patients who met the UN10 rule were associated with unfavorable neurologic status and low rates of survival after IHCA. Yet their survival rates are higher than reported in the initial validation study, raising the question of whether the UN10 rule may have limited utility as a definitive measure of futility during resuscitations in real-world clinical settings.

Sudden cardiac death (SCD) is the leading cause of death in college athletes during sports [(1)][1]. Pre-participation examinations are required in college athletes, although the best screening protocol to identify cardiovascular diseases known to cause SCD is debated. The purpose of this study was

Cancer survivorship has been greatly impacted with the development of modern cancer treatments. While significant strides have been made in managing many types of cancer, now physicians face new challenges. Over the past decades, cardiovascular events in cancer survivors have increased in prevalence, driving the development of multidisciplinary cardio-oncology programs. Additionally, as cancer patients live longer, their risk of developing secondary cardiovascular events increases. The rapid development of novel cancer therapies will continue to generate questions of cardiac risk and cardiac protection in cancer patients over time. We wish to outline the development of cardio-oncology in its present state, and provide future perspectives for the discipline.