Search

Nearly 35 years after its initial publication in 1989, the Italian Society of Sports Cardiology and the Italian Federation of Sports Medicine (FMSI), in collaboration with other leading Italian Cardiological Scientific Associations (ANCE - National Association of Outpatient Cardiology, ANMCO - National Association of Inpatient Cardiology, SIC - Italian Society of Cardiology), proudly present the 2023 version of the Cardiological Guidelines for Competitive Sports Eligibility. This publication is an update of the previous guidelines, offering a comprehensive and detailed guide for the participation of athletes with heart disease in sports. This edition incorporates the latest advances in cardiology and sports medicine, providing current information and recommendations. It addresses various topics, including the details of the pre-participation screening in Italy and recommendations for sports eligibility and disqualification in competitive athletes with various heart conditions. This revised version of the Cardiological Guidelines for Competitive Sports Eligibility, recorded in the Italian Guidelines Registry of the Italian Minister of Health, stands as a crucial resource for sports medicine professionals, cardiologists, and healthcare providers, marked by its completeness, reliability, and scientific thoroughness. It is an indispensable tool for those involved in the care, management and eligibility process of competitive athletes with heart conditions.

The bicuspid aortic valve (BAV) is the most common congenital heart defect among adults, often leading to severe valve dysfunction and aortic complications. Despite its clinical significance, uncertainties persist regarding the impact of sports participation on the natural course of BAV disease. The SPREAD (Sport PRactice and its Effects on Bicuspid Aortic valve Disease) study is a multicenter and multinational project designed to investigate this relationship. This paper outlines the study's design, and objectives. The study is divided into two phases; phase one involves a cross-sectional analysis comparing aortic dimensions and valve function among competitive athletes with BAV, athletes with tricuspid aortic valves (TAV), and sedentary individuals with BAV. The second phase is a prospective, longitudinal follow-up aiming to evaluate the impact of regular sports training on disease progression. The SPREAD study seeks to provide evidence-based insights into the effects of sports participation on BAV disease progression, guiding clinical decision-making regarding sports eligibility and risk stratification for individuals with BAV.

Background: Despite mounting evidence, the impact of the interplay between weather and pollution features on the risk of acute cardiac and cerebrovascular events has not been entirely appraised. The aim of this study was to perform a comprehensive cluster analysis of weather and pollution features in a large metropolitan area, and their association with acute cardiac and cerebrovascular events., Methods: Anonymized data on acute myocardial infarction (AMI) and acute cerebrovascular events were obtained from 3 tertiary care centers from a single large metropolitan area. Weather and pollution data were obtained averaging measurements from several city measurement stations managed by the competent regional agency for enviromental protection, and from the Metereological Center of Italian Military Aviation. Unsupervised machine learning was performed with hierarchical clustering to identify specific days with distinct weather and pollution features. Clusters were then compared for rates of acute cardiac and cerebrovascular events with Poisson models., Results: As expected, significant pairwise correlations were found between weather and pollution features. Building upon these correlations, hierarchical clustering, from a total of 1169 days, generated 4 separate clusters: mostly winter days with low temperatures and high ozone concentrations (cluster 1, N.=60, 5.1%), days with moderately high temperatures and low pollutants concentrations (cluster 2, N.=419, 35.8%), mostly summer and spring days with high temperatures and high ozone concentrations (cluster 3, N.=673, 57.6%), and mostly winter days with low temperatures and low ozone concentrations (cluster 4, N.=17, 1.5%). Overall cluster-wise comparisons showed significant differences in adverse cardiac and cerebrovascular events (P<0.001), as well as in cerebrovascular events (P<0.001) and strokes (P=0.001). Between-cluster comparisons showed that cluster 1 was associated with an increased risk of any event, cerebrovascular events, and strokes in comparison to cluster 2, cluster 3 and cluster 4 (all P<0.05), as well as AMI in comparison to cluster 3 (P=0.047). In addition, cluster 2 was associated with a higher risk of strokes in comparison to cluster 4 (P=0.030). Analysis adjusting for season confirmed the increased risk of any event, cerebrovascular events and strokes for cluster 1 and cluster 2., Conclusions: Unsupervised machine learning can be leveraged to identify specific days with a unique clustering of adverse weather and pollution features which are associated with an increased risk of acute cardiovascular events, especially cerebrovascular events. These findings may improve collective and individual risk prediction and prevention.

Background: Palpitations in athletes are usually benign, but the presence of major cardiac arrhythmias should be ruled out despite the infrequent appraisal of symptoms. External loop recorders (ELR) are promising to identify arrhythmias in these circumstances, but experiences in athletes are lacking. We aimed to investigate the feasibility and diagnostic yield of an ELR in athletes with unexplained palpitations in a cohort study., Methods: One hundred twenty-two consecutive subjects (61 athletes and 61 sedentary controls) with sporadic palpitations and inconclusive diagnosis were enrolled and equipped with an ELR. Findings were categorized as major and minor arrhythmic findings, non-arrhythmic findings or negative monitoring., Results: Long-term ELR monitoring was feasible in all subjects, with median duration of 12 (11; 15) days. Major arrhythmic events during palpitations were found in 9 (14.8%) athletes: 7 experienced sustained paroxysmal supraventricular tachycardia, and 2 had non sustained ventricular tachycardia. Minor arrhythmic events (premature supraventricular or ventricular beats) were observed in 13 athletes (21.3%). Non-arrhythmic findings (i.e., sinus rhythm or sinus tachycardia) were recorded in 28 athletes (45.9%), whereas 11 (18%) had negative monitoring. In the sedentary group, arrhythmic events were similar for types and frequency to athletes. The diagnostic yield of loop monitoring was 82.8% in the overall population and 82.0% in the athlete's group., Conclusions: In the management of an athlete symptomatic with unexplained palpitations after 24-hour ECG monitoring and stress test, ELR is an efficient tool to identify major arrhythmic events, which can be present in up to 10% of symptomatic athletes during practice and competition.

Background: Traditional combustible cigarette (TCC) smoking remains a major cause of preventable cardiovascular morbidity and mortality. Modified risk products (MRP) such as electronic vaping cigarettes (EVC) and heat-not-burn cigarettes (HNBC) may be safer than TCC but may still have detrimental oxidative, platelet and vascular effects of particular importance to people with symptomatic coronary artery disease (CAD)., Methods: We aimed to compare the acute coronary, systemic and environmental effects of two leading MRP in 20 TCC smokers admitted for invasive coronary assessment of CAD and willing to quit or after prior failed quitting attempts. After confirmation at angiography of an intermediate coronary stenosis, coronary flow reserve (CFR) will be appraised. Patients will then be randomized 1:1 to use a single EVC or a single HNBC in the catheterization laboratory, followed by repeat CFR measurement. The primary endpoint will be the change in CFR before and after product use. Quantitative coronary angiography, fractional flow reserve (FFR), and instantaneous wave-free ratio (iFR) will also be measured., Results: We expected to accrue results able to: 1) test whether MRP have in general a detrimental impact on coronary vascular function in TCC smokers; 2) test whether EVC have a different impact than HNBC on coronary function; 3) provide ancillary pathophysiologic and translational insights on the acute risk and safety profile of MRP in TCC smokers with established cardiovascular disease, including complex correlations between coronary, cardiac, systemic and environmental effects. In addition, by directly informing participants of their individual results, they will be further empowered to quit TCC., Conclusions: The Sapienza University of Rome-Vascular Assessment of Proatherosclerotic Effects of Smoking (SUR-VAPES) 3 trial will provide important insights into the pathophysiologic cardiovascular impact of EVC and HNBC, also suitable to inform patients and individualize their smoking cessation strategy.

Background: Infection due to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), i.e. coronavirus-associated disease 2019 (COVID-2019), may occasionally lead to acute respiratory distress syndrome (ARDS), requiring in the most severe cases extracorporeal membrane oxygenation (ECMO). Yet, limited data, if any, are currently available on the role of ECMO in critically ill patients with COVID-19. We aimed at providing a snapshot analysis of ECMO for COVID-19 in Europe., Methods: Freely available data on ECMO in COVID-19 patients reported by the European Extracorporeal Life Support Organization (EuroELSO) were extracted and analyzed after conversion into long format. The primary outcome was the incidence of death during ECMO. Bootstrapping and logistic regression were used for inferential estimates., Results: Details from a total of 333 patients treated in 90 institutions spanning 17 countries were obtained, with 22% women and mean age of 52 years. Death rate was 17.1% (95% confidence interval: 13.1% to 21.1%), even if significant between-center differences were found, with some institutions reporting 100% case fatality. Exploratory inferential analysis showed no nominally statistically significant association between death and gender (P=0.788), but a significant association was found with age, mainly due to increased case fatality in subjects >60 years (odds ratio: 4.80 [95% confidence interval 1.64 to 14.04], P=0.004)., Conclusions: ECMO may play an important role in critically ill patients with COVID-19 refractory to less invasive treatments. The increased risk of early death in older patients may be used to prioritize ECMO indication in resource-conscious settings, if confirmed externally.

In recent months SARS-CoV-2 has spread rapidly throughout the world. The case fatality rate is higher in cardiovascular disease and hypertension. Other comorbidities do not seem to confer the same risk, therefore the understanding of the relationship between infection and cardiovascular system could be a crucial point for the fight against the virus. A great interest is directed towards the angiotensin 2 converting enzyme (ACE 2) which is the SARS-CoV-2 receptor and creates important connections between the virus replication pathway, the cardiovascular system and blood pressure. All cardiovascular conditions share an imbalance of the renin angiotensin system in which ACE 2 plays a central role. In the early pandemic period, much confusion has appeared about the management of therapy with angiotensin converting enzyme inhibitors and angiotensin receptor blockers especially in infected patients and in those at risk of critical illness in case of infection. In this article we will try to reorder the major opinions currently emerging on this topic.

Active transportation is defined as travelling on foot, by bicycle or other non-motorized means, sometimes in combination with other forms of public transportation, in contrast with the use of motor vehicles. The prevalence of sedentary lifestyle and physical inactivity is a growing epidemic in most developed countries that spread over the last three decades; active transportation may be a promising approach to increase physical activity and reduce the risk of non-communicable diseases improving cardiorespiratory fitness and cardiometabolic health. The health benefits of physical activity in reducing mortality and morbidity have been proved by several publications. Cardiorespiratory fitness can be improved by regular physical activity with an amelioration of insulin sensitivity, blood lipid profile, body composition, inflammation, and blood pressure. Active transportation as a daily physical activity is less expensive compared to motor vehicle use. The advantages are remarkable in terms of contrasting obesity and sedentary lifestyle, decrease motor traffic congestion and mitigate climate change. Massive investments in policies and interventions aimed to increase active transportation are not generally promoted and there are differences in the prevalence of active transportation in the daily routine among different areas. As in the literature several studies as randomized trials or observational studies have been published, with different end-points, in order to investigate if active commuting may be the right answer to improve cardiorespiratory fitness and cardiometabolic health, we aimed to review the available evidences of cycling as an active transportation and to consider its benefits on health.

Aim: In patients affected by aortic valve stenosis (AS) it is mandatory to rule out coronary artery disease (CAD). The role of retrospectively ECG-gated 64-slice CT angiography (64-SCTA) was assessed in patients with AS referred for surgical valve replacement., Methods: Forty-two patients with AS underwent ECG-gated 64-SCTA of thoracic aorta, including the heart and coronary arteries, before surgical valve replacement. Images were evaluated by two independent readers and compared with surgical findings in terms of aortic valve calcification grading, valvular morphology, aortic valve annulus and sino-tubular junction diameters, and valvular area planimetry. Quantitative evaluation of cusps opening was also performed. Finally, the presence of CAD, thoracic aortic aneurysm and left ventricle hypertrophy were assessed., Results: Visualization of the aortic valve without motion artefacts was possible in 38 patients (90.5%). Valvular morphology was correctly assessed in all cases (100%). 64-SCTA correctly determined aortic valve calcification grading and the aortic valve annulus and sinotubular junction diameters in 100% of cases. The aortic valve planimetric area was assessed in 38 cases (90.5%). Ascending aortic aneurysms requiring surgical replacement were detected in 12 patients (28.6%). Significant left ventricle hypertrophy was found in 30 patients (71%)., Conclusion: Preoperative evaluation of patients undergoing surgical replacement for AS with 64-SCTA is feasible. 64-SCTA can rule out CAD and evaluate the status of the aortic valve and thoracic aorta in the same examination, obtaining relevant information for surgical planning.

Aim: Autologous pericardium annuloplasty (APA) is an alternative to prosthetic ring implantation for mitral valve (MV) repair, avoiding the use of foreign material and preserving the mitral annulus' physiological motion. However, data on durability are questionable. Therefore, we analyzed long-term outcomes of treating degenerative mitral regurgitation (MR) with APA., Methods: Four hundred ninety patients (mean age, 54.3±11.3 years, [15-77 years]; N.=360 men [74.1%]) who had undergone APA and neochordae implantation between July 1988 and December 2006 were retrospectively studied., Results: MR was purely degenerative in 434 (89.3%) patients; endocarditis was present in 44 (9.1%) patients; an anterior, posterior, or bileaflet prolapse was present in 32 (6.6%), 241 (49.6%), and 213 (43.8%) patients, respectively. Clinical follow-up was 100% complete at a median of 6.5 years (5th percentile, 0.9; 95th percentile, 14.9) with an echocardiographic study in 92% of patients. In-hospital mortality was 1% (5 deaths); overall and late cardiac mortality were 7.6% and 3.9% (37 and 19 deaths), respectively. Kaplan-Meier curves for overall survival, late cardiac survival, and freedom from reoperation at 15 years (20 cases) were 86% (95%CI 80-91), 93% (95%CI 88-96), and 93% (95%CI 88-96), respectively. At 15 years, freedom from recurrent MR (28 patients) and endocarditis (6 events) were 86% (95%CI 76-91) and 97% (95%CI 92-99). Dehiscence, significant calcification of APA, and hemolysis never occurred. At reoperations, annular pericardium appeared covered by a smooth layer of tissue., Conclusion: APA is feasible, safe, and cost-effective, providing long-term durability, high survival, and a low rate of valve-related complications.