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Whether morphologic left ventricular (LV) changes in elite athletes are associated with altered diastolic properties is undefined. The aim of this study was to investigate LV diastolic properties in a large population of Olympic athletes compared to untrained controls.A total of 1,145 Olympic athletes (61% men), and 154 controls, free of cardiovascular disease, underwent two-dimensional echocardiography, Doppler echocardiography, and Doppler tissue imaging.Athletes had similar E velocities (87 ± 15 vs 89 ± 16 cm/sec, P = .134) but significantly decreased A velocities (47 ± 10 vs 56 ± 12 cm/sec, P.001) compared with controls, with increased E/A ratios (1.93 ± 0.50 vs 1.63 ± 0.35, P.001) and values ranging up to 4.8. Isovolumic relaxation (83 ± 13 vs 71 ± 16 msec, P.001) and deceleration times (203 ± 40 vs 181 ± 36 msec, P.001) were longer in athletes compared with controls. Doppler tissue imaging e' (13.8 ± 2.2 vs 16.2 ± 3.7 cm/sec, P.001) and a' (7.2 ± 1.8 vs 8.5 ± 2.1 cm/sec, P.001) were lower in athletes than in controls, but their ratio was not different between groups; E/e' ratios (6.37 ± 1.2 vs 5.72 ± 1.33, P.001) were mildly higher in athletes. Subgroup analysis for type of sport showed that endurance athletes had the lowest A and a' velocities and the largest E/A ratios. Gender analysis revealed that men had significantly lower E and A velocities, as well as e', e'/a' ratios, and E/e' ratios (P.01), compared with women.This study provides normal values for Doppler echocardiographic and Doppler tissue imaging parameters describing diastolic function in elite athletes, which may be implemented as reference values in the clinical assessment of athlete's heart and prove useful in understanding the physiologic limits of cardiac adaptations in athletes.

Left atrial (LA) fibrosis with increased stiffness has been assumed to be the substrates for occurrence of atrial arrhythmias in athletes. However, this hypothesis has not yet been confirmed in humans. Aim of this study was, therefore, to assess LA remodeling and stiffness in competitive athletes. 150 competitive athletes and 90 age and sex-matched sedentary subjects were analyzed by speckle-tracking echocardiography to measure peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS). LA stiffness was determined using E/e’ ratio in conjunction with PALS. Left ventricular (LV) stiffness was also calculated. LA volume index was greater in athletes as compared with controls (24.6 ± 7.3 vs. 18.4 ± 7.8 mL/m2, p

Background Exercise-induced ventricular tachyarrhythmias raise clinical concern as a marker of increased risk in the presence of underlying cardiovascular disease. Objective The aim of this study was to clarify the clinical significance of exercise-induced ventricular tachyarrhythmias in competitive athletes without evident cardiac abnormalities. Methods Exercise electrocardiographic testing was performed in 5011 consecutive athletes without heart disease and analyzed for the occurrence of ventricular arrhythmias. Results Of the 5011 athletes, 367 (7.3%) showed ≥1 premature ventricular beat (PVB), including 331 (6.6%) with ≤10 PVBs and 36 (0.7%) with >10 PVBs and/or ≥1 ventricular couplets, and/or ≥1 bursts of nonsustained ventricular tachycardia. The 331 athletes with ≤10 PVBs had no restriction from competitive sports, and repeated exercise testing over 3–12 months showed spontaneous reduction of arrhythmia (from 5.2 ± 4 to 4 ± 6 PVBs; P = .002), including 83 of 331 (23%) with disappearance of PVBs. The remaining 36 athletes were disqualified from sports because of frequent and/or complex arrhythmias; 23 showed reduction of arrhythmia at 3–12 months (from 46 ± 42 to 28 ± 11 PVBs, from 8 ± 10 to 3 ± 3 couplets, and from 3.6 ± 6 to 1 ± 1 nonsustained ventricular tachycardia; P = .05) and were readmitted to competition. The other 13 athletes with persistent arrhythmias were considered for radiofrequency ablation, of whom 6 were successfully treated with abolition of arrhythmias and permitted to return to competitive sports. No events or cardiovascular disease occurred in the 367 athletes over a follow-up period of 7.4 ± 5 years. Conclusion Exercise-induced ventricular tachyarrhythmias were present in a sizable minority of highly trained athletes without heart disease. These arrhythmias proved to be benign and not associated with adverse events or later development of cardiovascular disease.

A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology.

Worldwide, each year more than 7 million people experience myocardial infarction, in which one-year mortality rates are now in the range of 10%, but vary with patient characteristics. The consequences are even more dramatic: among patients who survive, 20% suffer a second cardiovascular event in the first year and approximately 50% of major coronary events occur in those with a previous hospital discharge diagnosis of ischaemic heart disease. The people behind these numbers spur this call for action. Prevention after myocardial infarction is crucial to reduce risk and suffering. Evidence-based interventions include optimal medical treatment with anti-platelets and statins, achieve-ment of blood pressure, lipid and blood glucose targets, and appropriate lifestyle changes. The European Society of Cardiology and its constituent bodies are determined to embrace this challenge by developing a consensus document in which the existing gaps for secondary prevention strategies are reviewed. Effective interventions in relation to the patients, healthcare providers and healthcare systems are proposed and discussed. Finally, innovative strategies in hospital as well as in outpatient and long-term settings are endorsed.

In British Journal of Sports Medicine , Toresdahl et al describe the preparticipation cardiovascular (CV) screening practices implemented for athletes participating in the 2016 Rio Olympic Games.1 This study is of particular importance because it highlights the range of CV screening in the world’s most elite athletes. The chief medical officers (CMOs) present in Rio completed an online survey about the CV screening conducted in their countries for athletes selected to participate in the 2016 Olympic Games. Over 80% of the CMOs replied to the survey, providing a reliable picture of current CV screening practices in Olympic athletes. Most countries (70%) perform annual CV screening, with 85% implementing a personal and family history and 75% also using a screening ECG. Expense and lack of a cardiology consultant were cited as the most common reasons not to include ECG. The issue of preparticipation CV screening with or without ECG has been vigorously debated within the scientific community since 2006 when Corrado et al 2 demonstrated a substantial decrease in sudden cardiac death (SCD) in Italian athletes following implementation of an ECG-based national screening programme. The Italian experience has generated considerable criticism over time, with numerous papers supporting or …

Congenital abnormalities of the coronary arteries here described are an uncommon form of structural heart disease. Nevertheless, they deserve attention because may cause chest pain and, in some cases, sudden cardiac death even during exercise. Traditional angiography has limitations due to its projectional and invasive nature. The recent development of the 320-slide multi-detector computer tomography with low radiation exposure has the potential to modify the current diagnostic work-up, as it allows even in young people a timely identification of clinical significant coronary anomalies minimizing the risks related to radiation exposure.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On February 26-27, 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

Training-induced right ventricular (RV) enlargement is frequent in athletes. Unfortunately, RV dilatation is also a common phenotypic expression and one of the diagnostic criteria of arrhythmogenic RV cardiomyopathy (ARVC). The current echocardiographic reference values derived from the general population can overestimate the presence of RV dilatation in athletes. We performed a meta-analysis of the literature to derive the proper reference values for assessing RV enlargement in competitive athletes. We conducted systematic review of English-language studies in the MEDLINE, Scopus, and Cochrane databases investigating RV size and function by echocardiography and by cardiac magnetic resonance (CMR) in competitive athletes. In total, 6,806 and 740 competitive athletes were included for the echocardiographic and CMR quantification of the RV, respectively. In this review, we present normal reference values for RV size and function to be applied in competitive athletes according to the disciplines practiced. The reference ranges reported in this review suggest that physicians should be aware that application of the current recommendations for normal population could be misleading when evaluating athletes. We suggest using these normative reference values, obtained in competitive athletes, to avoid the potential for mistakenly concluding, in this specific population, that RV size or function are abnormal.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD. The 2nd Summit on Electrocardiographic Interpretation in Athletes was sponsored by the American Medical Society for Sports Medicine, the FIFA Medical Assessment and Research Center (F-MARC), and the National Collegiate Athletic Association (NCAA). Participating medical societies included the American College of Cardiology (ACC) Sports & Exercise Council, and the Section on Sports Cardiology of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR), a registered branch of the European Society of Cardiology (ESC).

The aim of the present study was to evaluate the prevalence, determinants, and clinical management of systemic hypertension in a large cohort of competitive athletes: 2,040 consecutive athletes (aged 25 ± 6 years, 64% men) underwent clinical evaluation including blood test, electrocardiogram, exercise test, echocardiography, and ophthalmic evaluation. Sixty-five athletes (3%) were identified with hypertension (men = 57; 87%) including 5 with a secondary cause (thyroid dysfunction in 3, renal artery stenosis in 1, and drug induced in 1). The hypertensive athletes had greater left ventricular hypertrophy and showed more often a concentric pattern than normotensive ones. Moreover, they showed a mildly reduced physical performance and were characterized by a higher cardiovascular risk profile compared with normotensive athletes. Multivariate logistic regression analysis showed that family hypertension history (odds ratio 2.05; 95% confidence interval 1.21 to 3.49; p = 0.008) and body mass index (odds ratio 1.32; 95% confidence interval 1.23 to 1.40; p0.001) were the strongest predictors of hypertension. Therapeutic intervention included successful lifestyle modification in 57 and required additional pharmacologic treatment in 3 with essential hypertension. Secondary hypertension was treated according to the underlying disorder. After a mean follow-up of 18 ± 6 months, all hypertensive athletes had achieved and maintained optimal control of the blood pressure, without restriction to sport participation. In conclusion, the prevalence of hypertension in athletes is low (3%) and largely related to family history and overweight. In the vast majority of hypertensives, lifestyle modifications were sufficient to achieve an optimal control of blood pressure values.

Atrial fibrillation (AF) is an important and highly prevalent arrhythmia, which is associated with significantly increased morbidity and mortality, including a four- to five-fold increased risk for stroke,1,2 a two-fold increased risk for dementia,3,4 a three-fold risk for heart failure,2 a two-fold increased risk for myocardial infarction,5,6 and a 40–90% increased risk for overall mortality.2,7 The constantly increasing number of AF patients and recognition of increased morbidity, mortality, impaired quality of life, safety issues, and side effects of rhythm control strategies with antiarrhythmic drugs, and high healthcare costs associated with AF have spurred numerous investigations to develop more effective treatments for AF and its complications.8 Although AF treatment has been studied extensively, AF prevention has received relatively little attention, while it has paramount importance in the prevention of morbidity and mortality, and complications associated with arrhythmia and its treatment. Current evidence shows a clear association between the presence of modifiable risk factors and the risk of developing AF. By implementing AF risk reduction strategies aiming at risk factors such as obesity, hypertension, diabetes, and obstructive sleep ap-noea (OSA), which are interrelated, we impact upon the escalating incidence of AF in the population and ultimately decrease the healthcare burden of associated co-morbidities of AF. To address this issue, a Task Force was convened by the European Heart Rhythm Association and the European Association of Cardiovascular Prevention and Rehabilitation, endorsed by the Heart Rhythm Society and Asia-Pacific Heart Rhythm Society, with the remit to comprehensively review the published evidence available, to publish a joint consensus document on the prevention of AF, and to provide up-to-date consensus recommendations for use in clinical practice. In this document, our aim is to summarize the current evidence on the association of each modifiable risk factor with AF and the available data on the impact of possible interventions directed at these factors in preventing or reducing the burden of AF. While the evidence on AF prevention is still emerging, the topic is not fully covered in current guidelines and some aspects are still controversial. Therefore, there is a need to provide expert recommendations for professionals participating in the care of at-risk patients and populations, with respect to addressing risk factors and lifestyle modifications. Health economic considerations Atrial fibrillation is a costly disease, both in terms of direct, and indirect costs, the former being reported by cost of illness studies as per-patient annual costs in the range of US $2000–14200 in North America and of €450–3000 in Europe.9 In individuals with AF or at risk of developing AF, any effective preventive measure, intervention on modifiable risk factors or comorbidities, as well as any effective pharmacological or non-pharmacological treatment has the aim to reduce AF occurrence, thromboembolic events and stroke, morbidity and, possibly, mortality related to this arrhythmia. Apart from the clinical endpoints, achievement of these goals has economic significance, in terms of positive impact on direct and indirect costs and favourable cost–effectiveness at mid- or long-term, in the perspective of healthcare systems.10–12 In view of the epidemiological profile of AF and progressive aging of the population,13 an impressive increase of patients at risk of AF or affected by AF,14 also in an asymptomatic stage, is expected in the next decades, inducing a growing financial burden on healthcare systems, not only in Europe and North America, but also worldwide.15,16 In consideration of this emerging epidemiological threat due to AF, it is worth considering a paradigm shift, going beyond the conventional approach of primary prevention based on treatment of AF risk factors, but, instead, considering the potential for ‘primordial’ prevention, defined as prevention of the development of risk factors predisposing to AF in the first place.17 This approach, aimed at avoiding the emergence and penetration of risk factors into the population, has been proposed in general terms for the prevention of cardiovascular diseases17 and should imply combined efforts of policymakers, regulatory and social service agencies, providers, physicians, community leaders, and consumers, in an attempt to improve social and environmental conditions, as well as individual behaviours, in the pursuit of adopting healthy lifestyle choices.16 Since a substantial proportion of incident AF events can be attributable to elevated or borderline levels of risk factors for AF,18 this approach could be an effective way to reduce the financial burden linked to AF epidemiology. In terms of individual behaviour and adoption of a ‘healthy lifestyle’, it is worth considering that availability of full healthcare coverage (through health insurance or the healthcare system) may in some cases facilitate the unwanted risk of reducing, at an individual level, the motivation to adopt all the preventive measures that are advisable, in line with the complex concept of ‘moral hazard effect’.19 Patient education and patient empowerment are the correct strategies for avoiding this undesirable effect.

Context Olympic athletes represent model of success in our society, by enduring strenuous conditioning programmes and achieving astonishing performances. They also raise scientific and clinical interest, with regard to medical care and prevalence of cardiovascular (CV) abnormalities. Objective Our aim was to assess the prevalence and type of CV abnormalities in this selected athlete's cohort. Design, setting and participants 2352 Olympic athletes, mean age 25±6, 64% men, competing in 31 summer or 15 winter sports, were examined with history, physical examination, 12-lead and exercise ECG and echocardiography. Additional testing (cardiac MRI, CT scan) or electrophysiological assessments were selectively performed when indicated. Main outcome measures Prevalence and type of CV findings, abnormalities and diseases found in Olympic athletes over 10 years. Results A subset of 92 athletes (3.9%) showed abnormal CV findings. Structural abnormalities included inherited cardiomyopathies (n=4), coronary artery disease (n=1), perimyocarditis (n=4), myocardial bridges (n=2), valvular and congenital diseases (n=45) and systemic hypertension (n=10). Primary electrical diseases included atrial fibrillation (n=2), supraventricular reciprocating tachycardia (n=14), complex ventricular tachyarrhythmias (non-sustained ventricular tachycardia, n=7; bidirectional ventricular tachycardia, n=1) or major conduction disorders (Wolff-Parkinson-White (WPW), n=1; Long QT syndrome (LQTS), n=2). Conclusions Our study revealed an unexpected prevalence of CV abnormalities among Olympic athletes, including a small, but not negligible proportion of pathological conditions at risk. This observation suggests that Olympic athletes, despite the absence of symptoms or astonishing performances, are not immune from CV disorders and might be exposed to unforeseen high-risk during sport activity.

Electrocardiographic changes in athletes are common and usually reflect benign structural and electrical remodelling of the heart as a physiological adaptation to regular and sustained physical training (athlete's heart). The ability to identify an abnormality on the 12-lead ECG, suggestive of underlying cardiac disease associated with sudden cardiac death (SCD), is based on a sound working knowledge of the normal ECG characteristics within the athletic population. This document will assist physicians in identifying normal ECG patterns commonly found in athletes. The ECG findings presented as normal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Aims Little is known about the adaptation of the right ventricle (RV) to endurance exercise in children. The aim of this study was to assess the effects of 5months of intensive training on RV morphology and function in preadolescent endurance athletes. Methods Ninety-four children were evaluated in this study. Fifty-seven male competitive swimmers (aged 10.8±0.2years) were evaluated before (baseline) and after 5months of the training (peak-training), and compared to 37 age- and sex-matched non-athlete children evaluated at baseline and after 5months of natural growth. All subjects were asymptomatic, with negative family history for cardiomyopathies. Results At baseline no differences were found between athletes and controls for indexed RV outflow tract (RVOT) (18.5±2.7 vs. 16.8±5.0mm/m 2 , p =0.18) and RV basal end-diastolic diameter (EDD) (24.9±4.1 vs. 23.6±3.0mm/m 2 , p =0.15). After 5months, indexed RVOT and RV basal EDD significantly increased in athletes (20.2±2.9mm/m 2 and 25.4±3.3mm/m 2 , p p =0.84 and p =0.25). Despite the increase in RV size, RV function remained normal in athletes, with no changes in RV fractional area change ( p =0.97), s′ value ( p =0.22), and RV longitudinal strain ( p =0.28). Conclusions Endurance training influences the growing heart of male preadolescent athletes with an addictive increase in RV dimensions, with a preserved RV function. Therefore, in children engaged in endurance sports the increase in RV size associated with normal RV function represents a physiological expression of the athlete's heart and should not be misinterpreted as an expression of incipient RV cardiomyopathy.

AMI : acute myocardial infarction ARVC : arrhythmogenic right ventricular cardiomyopathy BrS : Brugada syndrome CACS : coronary artery calcium score CAD : coronary artery disease ChD : Chagas heart disease CMR : cardiac magnetic resonance CPVT : catecholaminergic polymorphic ventricular tachycardia CTCA : computed tomography coronary angiography CV : cardiovascular DCM : dilated cardiomyopathy EAPCR : European Association for Cardiovascular Prevention and Rehabilitation HCM : hypertrophic cardiomyopathy LGE : late gadolinium enhancement LQTS : long QT syndrome LV/RV : left/right ventricle LVH : left ventricle hypertrophy NSVT : non-sustained ventricular tachycardia PPE : preparticipation evaluation PVC : premature ventricular contractions SCA/SCD : sudden cardiac arrest/death TTE : transthoracic echocardiography VF : ventricular fibrillation VT : ventricular tachycardia Sudden cardiac death (SCD) associated with athletic activity is a rare but devastating event. Victims are usually young and apparently healthy, and while many of these deaths remain unexplained, a substantial number of victims harbour an underlying and potentially detectable cardiovascular (CV) disease.1–4 The vast majority of these events are due to malignant tachyarrhythmias, usually ventricular fibrillation (VF) or ventricular tachycardia (VT) degenerating into ventricular fibrillation (VF), occurring in individuals with arrhythmogenic disorders (e.g. hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, channelopathies). Intensive exercise training and competitive sport participation is a trigger that may favour insurgence of ominous ventricular tachyarrhythmias in predisposed individuals.5 Consequently, there is a great interest in early identification of at-risk individuals for whom appropriate treatment, followed or not by physical activity adjustment, may be implemented to minimize the risk of SCD. However, the role of pre-participation evaluation (PPE) in athletes as a feasible and efficient strategy to identify individuals at risk has remained controversial. …

Background— The clinical profile and arrhythmic outcome of competitive athletes with isolated nonischemic left ventricular (LV) scar as evidenced by contrast-enhanced cardiac magnetic resonance remain to be elucidated. Methods and Results— We compared 35 athletes (80% men, age: 14–48 years) with ventricular arrhythmias and isolated LV subepicardial/midmyocardial late gadolinium enhancement (LGE) on contrast-enhanced cardiac magnetic resonance (group A) with 38 athletes with ventricular arrhythmias and no LGE (group B) and 40 healthy control athletes (group C). A stria LGE pattern with subepicardial/midmyocardial distribution, mostly involving the lateral LV wall, was found in 27 (77%) of group A versus 0 controls (group C; P P =0.52). All athletes with stria pattern showed ventricular arrhythmias with a predominant right bundle branch block morphology, 13 of 27 (48%) showed ECG repolarization abnormalities, and 5 of 27 (19%) showed echocardiographic hypokinesis of the lateral LV wall. The majority of athletes with no or spotty LGE pattern had ventricular arrhythmias with a predominant left bundle branch block morphology and no ECG or echocardiographic abnormalities. During a follow-up of 38±25 months, 6 of 27 (22%) athletes with stria pattern experienced malignant arrhythmic events such as appropriate implantable cardiac defibrillator shock (n=4), sustained ventricular tachycardia (n=1), or sudden death (n=1), compared with none of athletes with no or LGE spotty pattern and controls. Conclusions— Isolated nonischemic LV LGE with a stria pattern may be associated with life-threatening arrhythmias and sudden death in the athlete. Because of its subepicardial/midmyocardial location, LV scar is often not detected by echocardiography.

Recently, an unexpectedly large prevalence of Left Ventricular Non Compaction (LVNC) has been reported in athletes, raising the question of the appropriateness of current diagnostic criteria. We sought to describe prevalence and clinical characteristics of athletes with suspected LVNC in a large cohort of Olympic athletes.Over 29months, 2501 consecutive athletes underwent a cardiac evaluation including physical examination, ECG, exercise test and echocardiography. Additional investigations (Cardiac Magnetic Resonance and/or genetic testing) were selectively performed in athletes with abnormal ECGs, ventricular arrhythmias, borderline LV dysfunction or positive family history.Of the 2501 athletes, 36 (1.4%) showed prominent trabeculations suggestive for LVNC. Of these, 3 (0.1%) were considered to be affected by LVNC, based on presence of LV dysfunction (ejection fraction50%) and/or positive family history and genetic testing; these athletes were cautiously restricted from competitions and entered a clinical follow-up program. The remaining 33 athletes, in the absence of LV impairment or familial cardiac diseases, were considered normal (n=24) or unlikely affected (n=9), regardless of the extent of the trabeculations.In a large athlete population, a marked LV trabecular pattern was seen in 1.4%. Only a small subset of these athletes (0.1%) showed familial, clinical and morphologic changes supporting the diagnosis of LVNC. In the vast majority of the athletes, the increased trabeculations were not associated with LV dysfunction and/or positive family history, likely representing a morphologic LV variant, deprived of clinical significance.

BackgroundSport participation (SP) of individuals with impairments has recently grown exponentially. Scarce scientific data, however, exist regarding cardiovascular (CV) risk associated with competitive SP.ObjectiveAssessing the prevalence of CV abnormalities and the risk for SP in Paralympic athletes (PA).MethodsPA (n=267; 76% men), aged 35±9 years, engaged in 18 sport disciplines, with a spectrum of lesions including: spinal cord injury (paraplegia and spina bifida) (n=116); amputation, poliomyelitis, cerebral palsy and other neuromuscular and/or skeletal disorders (Les autres) or visual impairment (n=151) entered the study. CV evaluation included history, PE, 12-lead and exercise ECG, echocardiography. Of these, 105 participated in ≥2 consecutive games, and had evaluations available over a 6±4 year follow-up.ResultsStructural CV abnormalities were identified in 33 athletes (12%), including arrhythmogenic cardiomyopathies in 3, aortic root dilation in 3, valvular diseases in 7 (mitral valve prolapse in 4, bicuspid aortic valve in 3) and systemic hypertension in 11 (4%). In addition, ventricular (polymorphic, couplets or non-sustained ventricular tachycardia) or supraventricular tachyarrhythmias (atrial flutter, paroxysmal atrial fibrillation or SVT) were identified in 9 others. Over a 6-year follow-up, 6 of the 105 athletes (6%) developed CV diseases, including dilated cardiomyopathy in 1 and systemic hypertension in 5.ConclusionsPA present an unexpected high prevalence of CV abnormalities (12%), including a non-trivial proportion of diseases at risk for sudden death (2%), such as arrhythmogenic cardiomyopathies and dilated aortic root. This observation suggests that tailored recommendations for preparticipation screening and safe SP in this special athletic population are timely and appropriate.

We appreciated the interest of Barison and colleagues in our International Consensus Statement on the treatment of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D).1 Our document provided a comprehensive overview and recommendations for risk stratification and therapy of patients fulfilling the diagnostic criteria for ARVC/D. These criteria had been addressed by a previous International Task Force consensus document dedicated to diagnosis of ARVC/D.2 According to the revised criteria proposed by the International Task Force in 2010, the diagnosis of ARVC/D is based on the presence of major and minor criteria encompassing electrocardiographic, arrhythmic, morphological, histopathologic, and genetic factors. Diagnosis of definite ARVC/D is fulfilled in the presence of 2 major criteria or 1 major plus 2 minor or 4 minor criteria from different groups; the ARVC/D diagnosis is possible or borderline in the presence of insufficient criteria. In their Letter to the Editor, Barison and colleagues emphasized the valuable role of cardiac magnetic resonance (CMR) for diagnosis of ARVC/D, which relies on its ability to combine evaluation of ventricular size, function, and regional wall motion with characterization by late-gadolinium enhancement (LGE) of fibro-fatty myocardial scar, which is the hallmark lesion of ARVC/D. We totally agree that CMR is becoming the gold standard tool for detection of structural and functional ventricular abnormalities in ARVC/D. In the 2010 International Task Force consensus document, CMR was appropriately included among the diagnostic imaging techniques, and specific CMR reference values for normal (and abnormal) ventricular size, systolic function, and regional dyssynergy were provided. Tissue characterization by LGE was not included among these diagnostic criteria because of the potential risk of misdiagnosis of ARVC/D related to the difficulty of assessing LGE at the level of the thin right ventricular wall and possible confusion with normal epicardial fat tissue. More recently, the frequent involvement by the disease of the left ventricular wall in the form of epicardial-mediomural LGE has been recognized. As pointed out by the authors, LV LGE may enhance sensitivity for early/minor or predominant left variants of the ARVC/D; however, its diagnostic accuracy remains to be established. The prognostic role of CMR and, in particular, of postcontrast sequences for tissue characterization in patients with a diagnosis of definitive ARVC/D remains elusive. In our consensus statement on the treatment of ARVC/D, we performed a systematic review of outcome studies on ARVC/D available in the literature to identify predictor variables that were associated with an increased risk of major arrhythmic events (ie, sudden cardiac death, appropriate defibrillator interventions, or defibrillator therapy on fast ventricular tachycardia/ventricular fibrillation), nonsudden cardiac death, or heart transplantation in at least 1 published multivariable analysis. Although the predicting value of CMR for worse arrhythmic outcome was shown in the general population of patients showing premature ventricular beats with a left bundle branch morphology4 and in patients with suspected diagnosis of ARVC/D,5 no specific features of CMR, either alone or in combination, have been reported yet as independent predictors of life-threatening arrhythmic events in patients with a definite diagnosis of ARVC/D. This lack of evidence underscores the importance of undertaking future studies on this field.

Item does not contain fulltext Sports cardiology is a new and rapidly evolving subspecialty. It aims to elucidate the cardiovascular effects of regular exercise and delineate its benefits and risks, so that safe guidance can be provided to all individuals engaging in sports and/or physical activity in order to attain the maximum potential benefit at the lowest possible risk. The European Society of Cardiology (ESC) advocates systematic preparticipation cardiovascular screening in an effort to identify competitive athletes at risk of exercise-related cardiovascular events and sudden cardiac death. However, the implementation of preparticipation screening is hindered because of lack of structured training and as a result lack of sufficient expertise in the field of sports cardiology. In 2008 the European Society of Cardiology published a core curriculum for the general cardiologist, in which sports cardiology was incorporated within the topic 'Rehabilitation and Exercise Physiology'. However, the exponential rise in knowledge and the growing demand for expertise in the field of sports cardiology dictates the need to systematically structure the knowledge base of sports cardiology into a detailed curriculum. We envisage that the curriculum would facilitate more uniform training and guideline implementation throughout Europe, and safeguard that evaluation and guidance of competitive athletes or individuals who wish to engage in leisure-time sports activities is performed by physicians with expertise in the field. The current manuscript provides a comprehensive curriculum for sports cardiology, which may serve as a framework upon which universities and national and international health authorities will develop the training, evaluation and accreditation in sports cardiology.

International audience; BACKGROUND: Scarce data are available regarding the electrocardiographic (ECG) and echocardiographic changes in athletes of Asian origin. DESIGN: We investigate the ECG and echocardiographic patterns in Japanese (J) compared with African-Caribbean (AC) and Caucasian (C) athletes. METHODS: A total of 282 professional soccer players (68 J, 96 AC and 118 C) matched for age, gender, sport and level of achievement was examined. RESULTS: ECGs were without alterations in 62% of J (versus 69% of C, p = non significant and 44% of AC, p < 0.001). The most common alterations in J were sinus bradycardia (69%), incomplete right bundle branch block (RBBB; 43%), early repolarization (18%), isolated increase in R/S-wave (10%), Q-waves (9%). Remarkably, no J athlete showed deeply T-wave inversion, in contrast to 6% of AC (p < 0.05). Occasionally, J showed J-point upward/domed ST-elevation with inverted/biphasic T-wave (6% versus 16.5% in AC, p < 0.01). J demonstrated larger left ventricular (LV) cavity compared with AC and C players (55.2 ± 3.3 versus 52.2 ± 3.8 and 53.9 ± 3.7 mm, respectively, p < 0.01), with an important subset ( > 4%) presenting a markedly enlarged cavity (>60 mm), in the presence of normal systolic/diastolic function and no segmental abnormalities. Therefore, J showed a more eccentric remodelling compared with AC and C (relative wall thickness: 0.31 ± 0.05, 0.38 ± 0.06 and 0.36 ± 0.06, respectively, p < 0.01). CONCLUSION: J players show the most eccentric LV remodelling compared with C and AC players. In association, certain training-related ECG patterns, i.e. sinus bradycardia and isolated increase in R/S-wave voltage, are present in a larger proportion of J players than previously described in C players. Conversely, no J athlete showed deeply T-wave inversion, as commonly found in AC and occasionally in C.

Objectives The goal of this study was to define electrocardiographic (ECG) and echocardiographic characteristics of adolescent African athletes. Background Recent observations in African athletes reported large prevalence of left ventricular (LV) hypertrophy and ECG abnormalities. No data, so far, exist for adolescent Africans, which comprise a growing proportion of competitive/professional athletes. Methods The study included 154 soccer players participating at the 8th African Under-17 Championship of 2009, representing Algeria, Burkina Faso, Cameroon, Gambia, Guinea, Malawi, Nigeria, and Zimbabwe. For comparison, 62 Italian players with similar ages, sport achievements, and training schedules were included. Results African athletes showed higher R5/S1-wave voltages than Caucasian athletes (48.6 ± 12.1 mm vs. 34.1 ± 8.9 mm; p Conclusions African athletes displayed large proportion of ECG abnormalities, including a striking increase in R/S-wave voltage, ST-segment elevation, and deeply inverted or diffusely flat T waves by adolescence. LV remodeling in African athletes was characterized by a disproportionate wall thickening than in Caucasians but similar cavity size. Finally, distinctive peculiarities existed in African athletes according to the country (and ethnic) origin.

Despite several efforts using two-dimensional echocardiography and cardiac magnetic resonance in the diagnosis of left ventricular noncompaction (LVNC), there are no universally accepted diagnostic criteria. The aim of this study was to describe the extent of noncompacted myocardium using a new three-dimensional echocardiographic parameter.Seventeen patients with diagnoses of LVNC on the basis of two-dimensional echocardiographic and clinical criteria, 26 Olympic rowing athletes, and 49 healthy volunteers underwent three-dimensional echocardiography. By offline analysis, left ventricular volumes, mass, ejection fraction, and sphericity index were calculated. Trabeculated left ventricular volume (TLV) was calculated as the difference between left ventricular end-diastolic volume obtained including and excluding the trabeculae in the cavity contour. TLV was also normalized by left ventricular end-diastolic volume (TLV%).TLV and TLV% were significantly higher in patients with LVNC (33.7 ± 10.9 mL and 24 ± 7%) as opposed to controls (7.1 ± 2.2 mL, P.001, and 6 ± 2%, P.001, respectively) and athletes (8.0 ± 3.0 mL, P.001, and 5 ± 2%, P.001, respectively). In detail, on receiver operating characteristic curve analysis, optimal cutoff values of 15.8 mL for TLV and 12.8% for TLV% were determined for the identification of LVNC (area under the curve, 1.00; P.001). Mild positive correlations of TLV and TLV% were found with sphericity index (r = 0.294, P = .004, and r = 0.301, P = .004, respectively), and mild negative correlations were found with ejection fraction (r = -0.454, P.001, and r = -0.217, P = .038, respectively).Because of high spatial resolution and accuracy in volumetric quantification, three-dimensional echocardiography allows accurate measurement of the extent of noncompacted myocardium and identification of patients with LVNC.

Background: Benefit of fitness on children with type 1 diabetes mellitus (T1DM) is still debated. Aim: To evaluate the influence of physical activity on metabolic balance and exercise tolerance in prepubertal children affected by T1DM. Methods: We analyzed 35 pre-/peripubertal T1DM children and 31 matched controls using an activity monitor (SenseWear Armbad) and physical activity questionnaire (PAQ) to assess energy expenditure (EE), total and active, sedentary and physical activities (h/day and Mets = metabolic equivalents). The maximal cardiopulmonary exercise test (CPET) was also performed. Results: Total physical activities and total and active EE (>3 Mets) resulted higher in controls than in T1DM patients and self-reported perception of physical and sedentary activities was altered in T1DM children as well in controls and were different from the measured data. No differences were found in CPET parameters with the exception of a higher maximal blood pressure in T1DM children. In multivariate analysis HbA1c negatively correlated with VO2. Conclusion: Prepubertal T1DM children seem to have a lower level of physical activity and EE and a probable altered feeling of physical and sedentary activities. On the other hand, T1DM children do not show any alteration of cardiovascular performance, although glycemic control (HbA1c) may play a role in cardiovascular performance.

In a previous paper, as the first of a series of three on the importance of characteristics and modalities of physical activity (PA) and exercise in the management of cardiovascular health within the general population, we concluded that, in the population at large, PA and aerobic exercise capacity clearly are inversely associated with increased cardiovascular disease risk and all-cause and cardiovascular mortality and that a dose–response curve on cardiovascular outcome has been demonstrated in most studies. More and more evidence is accumulated that engaging in regular PA and exercise interventions are essential components for reducing the severity of cardiovascular risk factors, such as obesity and abdominal fat, high BP, metabolic risk factors, and systemic inflammation. However, it is less clear whether and which type of PA and exercise intervention (aerobic exercise, dynamic resistive exercise, or both) or characteristic of exercise (frequency, intensity, time or duration, and volume) would yield more benefit for each separate risk factor. The present paper, therefore, will review and make recommendations for PA and exercise training in the management of cardiovascular health in individuals with cardiovascular risk factors. The guidance offered in this series of papers is aimed at medical doctors, health practitioners, kinesiologists, physiotherapists and exercise physiologists, politicians, public health policy makers, and individual members of the public. Based on previous and the current literature overviews, recommendations from the European Association on Cardiovascular Prevention and Rehabilitation are formulated regarding type, volume, and intensity of PA and regarding appropriate risk evaluation during exercise in individuals with cardiovascular risk factors. ispartof: European Journal of Preventive Cardiology vol:19 issue:5 pages:1005-1033 ispartof: location:England status: published

Sudden cardiac death in a young athlete is a tragic and high-profile event. The best way to prevent such deaths is, however, highly debated. The Italian experience informed the European recommendation for the inclusion of a 12-lead ECG in screening tests for all athletes.1,2 Although American authors have acknowledged the possible benefits of such an approach, many have expressed concern over the portability of such a model to the US healthcare system. Concern has focused in particular on the idea of mandatory testing, cost effectiveness, the availability of practitioners qualified to interpret ECGs, and the burden of false-positive results. With professional sports organizations such as the International Olympic Committee, the National Basketball Association, the National Football League, and the Union of European Football Associations endorsing or implementing screening programs for their athletes, with a recent analysis suggesting a degree of cost effectiveness in line with other accepted medical interventions,3 and with the American Heart Association offering a cautious endorsement to the idea of local programs,4 volunteer-led testing programs across the US have begun to emerge. Thus, although no detailed guidance for the interpretation of the athlete's ECG exists, many physicians will be called on to interpret an athlete's ECG. Editorial see p 669 A principal obstacle to such interpretation is the difficulty in distinguishing abnormal patterns from physiological effects of training. Many clinical and ECG findings that may be a cause of concern in the general population are normal for athletes. In addition, the test characteristics of the ECG for different findings vary according to age, sex, ethnicity, sport, and level of training. In particular, different challenges exist for younger athletes because of the evolution of the ECG with age. This is further complicated by historical …

Arrhythmogenic cardiomyopathy (AC) is an inherited heart muscle disease characterized pathologically by right ventricular (RV) fibrofatty myocardial replacement and clinically by ventricular electric instability, which may lead to cardiac arrest from ventricular fibrillation (VF), mostly in young people and athletes. AC shows a propensity for life-threatening ventricular arrhythmias during physical exercise, and participation in competitive athletics has been associated with an increased risk for sudden cardiac death (SCD). In addition, physical sport activity has been implicated as a factor promoting acceleration of disease progression. Identification of affected athletes by preparticipation screening has proved to result in mortality reduction during sports activity. This article examines the role of AC in causing SCD in young competitive athletes and addresses prevention strategy based on identification of affected athletes at preparticipation screening.

Ventricular tachyarrhythmias commonly occur in trained athletes during ambulatory Holter electrocardiography and are usually associated with a benign course. Such arrhythmias have been demonstrated to be sensitive to short periods of athletic deconditioning; however, their response to retraining is not known. Twenty-four hour Holter electrocardiographic monitoring was performed at peak training and after 3 to 6 months of deconditioning and was repeated in the present study after 2, 6, and 12 months of retraining in 37 athletes with frequent and complex ventricular tachyarrhythmias and without cardiovascular abnormalities. These subjects showed partial (101 to 500 ventricular premature complexes [VPCs]/24 hours) or marked (

Background— Few data are available that address the impact of athletic training on aortic root size. We investigated the distribution, determinants, and clinical significance of aortic root dimension in a large population of highly trained athletes. Methods and Results— Transverse aortic dimensions were assessed in 2317 athletes (56% male), free of cardiovascular disease, aged 24.8±6.1 (range, 9 to 59) years, engaged in 28 sports disciplines (28% participated in Olympic Games). In males, aortic root was 32.2±2.7 mm (range, 23 to 44; 99th percentile=40 mm); in females, aortic root was 27.5±2.6 mm (range, 20 to 36; 99th percentile=34 mm). Aortic root was enlarged ≥40 mm in 17 male (1.3%) and ≥34 mm in 10 female (0.9%) subjects. Over an 8-year follow-up period, aortic dimension increased in these male athletes (40.9±1.3 to 42.9±3.6 mm; P P =0.11) in female athletes. Multiple regression and covariance analysis showed that aortic dimension was largely explained by weight, height, left ventricular mass, and age ( R 2 =0.63; P P Conclusions— An aortic root dimension >40 mm in highly conditioned male athletes (and >34 mm in female athletes) is uncommon, is unlikely to represent the physiological consequence of exercise training, and is most likely an expression of a pathological condition, mandating close clinical surveillance.

various modifications of the Erythrocyte Sedimentation Rate (ESR) determination have been suggested since the original Westergren procedure that has been adopted as the gold standard by the International Council for Standardization in Haematology (ICSH). Recently, an automated method, (Alifax Test 1), based on a technique completely different from Westergren, has been introduced. In this comparative study, ESR of blood from 680 patients with various rheumatic diseases was determined on both Test 1 and the StaRRsed automated ESR analyser which performs measurements in accordance with ICSH specifications. Furthermore the robustness of the new technique was evaluated. Direct correlation of Test 1 and StaRRsed measurements confirmed the results of previous studies: an overall correlation coefficient of R = 0.90. However, further statistical analysis showed that, depending on the instrument that was used, in 78 samples (i.e. 11.5%) the results could lead to different treatment suggestions. Furthermore it appeared that several procedural factors could influence the final Test 1 outcome. Due to its sensitivity for procedural variations, Test 1 measurements should be carried out under strictly standardized conditions. Especially at the higher ESR levels the Test 1 technique is, however, not a reliable alternative for the ICSH approved 'Westergren' method

Test 1 is a recently introduced technique claiming to determine Erythrocyte Sedimentation Rate (ESR) in 20 s. In contrast to the original Westergren procedure this new technique uses undiluted blood and operates at 37 degrees C. It is hypothesized that Test 1 is in fact an erythrocyte aggregometer and does not measure any sedimentation. Test 1 results were compared to those obtained with StaRRsed, an automated ESR analyser based on the Westergren technique, and the results of both were correlated to various indices of red blood cell (RBC) aggregation, obtained with an aggrego--meter (LORCA). Measurements were made on blood from 75 patients with various rheumatic disorders. Furthermore, blood that was experimentally manipulated in order to affect RBC aggregation, i.e. by changing the hematocrit, by diminishing plasma protein concentration, by inducing hyperaggregation or by RBC rigidification, was tested on all three instruments. Generally in patient blood, Test 1 results demonstrated a higher correlation with the various aggregation parameters than StaRRsed. Highest correlation (R = -0.8)) with both Test 1 and StaRRsed outcome were seen with I(20), a RBC aggregation parameter directly related to the backscatter intensity. All experimentally induced changes in RBC aggregation paralleled closely those obtained with Test 1 while StaRRsed results followed a different course. The results obtained in this study strongly support the hypothesis that Test 1 measures only the RBC aggregation process and does not cover any of the indices directly linked to the sedimentation process as determined by the Westergren method

Contains fulltext : 89482.pdf (Publisher’s version ) (Closed access) Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed. 01 januari 2010

Aspiration to reduce the risks of athletic field deaths prompted the American Heart Association and European Society of Cardiology (ESC) to establish consensus guidelines for eligibility/disqualification decisions in competitive athletes with cardiovascular abnormalities. Since 2005, the Bethesda Conference #36 and the ESC consensus documents have been relied upon by physicians from different parts of the world. The 2 consensus documents emanate from largely different cultural, social, and legal backgrounds existing in the U.S. and Europe and, although several recommendations are similar, in some instances the Bethesda Conference #36 and the ESC consensus documents suggest different approaches to disqualification decisions and implications for clinical practice, raising the possibility that confusion and discrepancies will contaminate the management of competitive athletes with cardiovascular disease. In the present article, the differences between the 2 documents are critically viewed, with special attention to genetic cardiovascular diseases relevant to sudden death in young athletes, through the prism of different cultural backgrounds, societal attitudes, and also perceptions regarding exposure to legal liability in the U.S. and Europe. In conclusion, it seems appropriate at some time to consider assembling updated recommendations for sports eligibility/disqualification that assimilate both the U.S. and European perspectives, with the aspiration of creating a unique and authoritative document applicable to the global sports medicine community.

In 1982 a nationwide program of pre-participation screening including 12-lead electrocardiography (ECG) was launched in Italy. The aim of this article is to examine whether this 25-year screening program should be considered a valid and advisable public health strategy. The analysis of data coming from the long-running Italian experience indicates that ECG screening has provided adequate sensitivity and specificity for detection of potentially lethal cardiomyopathy or arrhythmias and has led to substantial reduction of mortality of young competitive athletes by approximately 90%. Screening was feasible thanks to the Italian Health System, which is developed in terms of health care and prevention services, and because of the limited costs of cardiovascular evaluation in the setting of a mass program. On the basis of current scientific evidence the implementation of a mass-screening program aimed to prevent athletic-field sudden cardiac death should be at least carefully considered by public health administrators worldwide.

We worked out a position paper on cardiac-computed tomography (CCT) endorsed by the Working Group on CCT and Nuclear Cardiology of the Italian Society of Cardiology. The CCT clinical indications were discussed and formulated according to the following two modalities: a brief paragraph dedicated to each indication, with the description of clinical usefulness of different indications; and each indication was rated by the technical panel for appropriateness, using a score assessing whether the use of CCT for each indication is appropriate, uncertain, or inappropriate. All conventional CCT clinical indications, regarding coronary and noncoronary evaluation, were discussed and rated. Moreover, we wrote specific sections regarding the newest CCT applications, such as stress perfusion computed tomography, noninvasive evaluation of fractional flow reserve, and CCT use in athletes. The present study has the following two main objectives: because the diagnostic performance of coronary computed tomography angiography (CCTA) is strictly dependent on adequate technology and local expertise, we strove to provide clinical recommendations on CCTA that may help Italian physicians involved with this diagnostic tool; and to give an update on new indications of CCTA, such as its use for safely discharging patients with suspected acute coronary syndromes from the emergency department, and latest clinical results that have been made possible by the remarkable technology developments of the scanners.

This article is the report of an International Symposium endorsed by the European Society of Cardiology, held within the Venice Arrhythmias 2007: 10th International Workshop on Cardiac Arrhythmias (Venice, October 2007). The topics of the Symposium are the following: how to stratify the risk of sudden death in the athletes; the role of different diagnostic examinations in the risk stratification of sudden death in the athletes; controversies on arrhythmias and sport; and exercise prescription in patients with arrhythmias. Eur J Cardiovasc Prev Rehabil14:707-714 © 2007 The European Society of Cardiology

Long-term athletic training is associated with changes in cardiac morphology, commonly described as "athlete's heart." Although numerous studies have investigated the effects of training on cardiac dimensions, most are limited to male Caucasian athletes, and few data are available regarding the effect of long-term exercise training on the woman's heart. This article reviews the athlete's heart in relation to gender and race.

Aims The implementation of 12-lead ECG in the pre-participation screening of young athletes is still controversial and number of issues are largely debated, including the prevalence and spectrum of ECG abnormalities found in individuals undergoing pre-participation screening. Methods and results We assessed a large, unselected population of 32 652 subjects [26 050 (80%) males], prospectively examined in 19 clinics associated to Italian Sports Medicine Federation. Most were young amateur athletes, aged 8–78 years (median 17), predominantly students (68%), engaged predominantly in soccer (39%), volleyball or basketball (8% each), athletics (6%), cycling (5%), swimming (4%). The ECG patterns were evaluated according to commonly used clinical criteria. The 12-lead ECG patterns were considered normal in 28 799 of the 32 652 athletes (88.2%) and abnormal in 3853 (11.8%). The most frequent abnormalities included prolonged PR interval, incomplete right bundle branch block (RBBB) and early repolarization pattern (total 2280, 7.0%). Distinct ECG abnormalities included deeply inverted T-waves in > 2 precordial and/or standard leads (751, 2.3%), increased R/S wave voltages suggestive of LV hypertrophy (247, 0.8%), conduction disorders, i.e. RBBB (351, 1.0%), left anterior fascicular block (162, 0.5%), and left bundle branch block (19, 0.1%). Rarely, cardiac pre-excitation pattern (42, 0.1%) and prolonged QTc interval (1, 0.03%) were found. Conclusion In a large, unselected population of young athletes undergoing pre-participation screening, the prevalence of markedly abnormal ECG patterns, suggestive for structural cardiac disease, is low (