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Social support is one of the most reliable predictors of better health outcomes, including lower cardiovascular disease morbidity and mortality. Although past research has focused on links between social support and health outcomes, much less work has explored whether social support is a mediator of the association between other psychological factors and cardiovascular disease. This chapter thus reviews the literature linking stress and depression to social support. It leverages the larger literature linking social support to health-relevant outcomes to propose a support mediational model linking stress and depression to cardiovascular health. Direct evidence for the model will be a priority for future research, along with the exploration of novel intervention implications.

The past three decades has seen a tremendous rise in black athletes competing at every level of sport. Data from pre-participation programmes have informed our knowledge particularly of black (African/Afro-Caribbean) athletes. It is now well-established that as with white counterparts, black athletes reveal a high prevalence of benign, exercise-related ECG changes, particularly ST segment elevation, voltage criteria for left ventricular hypertrophy and early repolarization. Black athletes also exhibit a higher prevalence of T-wave inversion as well as a greater degree of left ventricular hypertrophy on echocardiogram than white athletes. Such findings overlap to greater extent with primary cardiomyopathies and may contribute to the higher incidence of sudden cardiac death observed in this ethnic group compared to white athletes.

Aims: To characterize the most common electrocardiographic (ECG) abnormalities in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC), including anterior T-wave inversion (TWI) and to compare the characteristics of TWI in patients with ARVC and in a cohort of young healthy athletes and sedentary individuals.Methods and results : The study population consisted of 162 patients with a definite diagnosis of ARVC and 129 young controls with anterior TWI. Cardiac disease was excluded in all controls after a comprehensive diagnostic work-up. The ECG was abnormal in 131 patients with ARVC (81%). Abnormalities included anterior TWI (n = 82, 51%), QRS duration ratio V2:V5 >1.2 (n = 51, 31%), prolonged terminal S wave activation duration in V2 >55 ms (n = 42, 26%), inferior TWI (n = 30, 18%), and lateral TWI (n = 26, 16%). The J-point preceding anterior TWI was 1.2 (52%) and inferior or lateral TWI (47%).Conclusion: The ECG is frequently abnormal in patients with ARVC and anterior TWI is the most common feature. Anterior TWI is usually accompanied by other abnormalities in ARVC, which are uncommon in healthy individuals. J point

Item does not contain fulltext Current guidelines of the European Society of Cardiology advocate regular physical activity as a Class IA recommendation for the prevention and treatment of cardiovascular disease. Despite its undisputed multitude of beneficial effects, competitive athletes with arterial hypertension may be exposed to an increased risk of cardiovascular events. This document is an update of the 2005 recommendations and will give guidance to physicians who have to decide on the risk of an athlete during sport participation.

Here, we use a simple and effective method to accomplish energy level alignment and thus electron injection barrier control in organic light emitting diodes (OLEDs) with a conventional architecture based on a green emissive copolymer. In particular, a series of functionalized zinc porphyrin compounds bearing π-delocalized triazine electron withdrawing spacers for efficient intramolecular electron transfer and different terminal groups such as glycine moieties in their peripheral substitutes are employed as thin interlayers at the emissive layer/Al (cathode) interface to realize efficient electron injection/transport. The effects of spatial (i.e., assembly) configuration, molecular dipole moment and type of peripheral group termination on the optical properties and energy level tuning are investigated by steady-state and time-resolved photoluminescence spectroscopy in F8BT/porphyrin films, by photovoltage measurements in OLED devices and by surface work function measurements in Al electrodes modified with the functionalized zinc porphyrins. The performance of OLEDs is significantly improved upon using the functionalized porphyrin interlayers with the recorded luminance of the devices to reach values 1 order of magnitude higher than that of the reference diode without any electron injection/transport interlayer.

Motivated by the excellent electron-transfer capability of porphyrin molecules in natural photosynthesis, we introduce here the first application of a porphyrin compound to improve the performance of planar perovskite solar cells. The insertion of a thin layer consisting of a triazine-substituted Zn porphyrin between the TiO2 electron transport layer and the CH3NH3PbI3 perovskite film significantly augmented electron transfer toward TiO2 while also sufficiently improved the morphology of the perovskite film. The devices employing porphyrin-modified TiO2 exhibited a significant increase in the short-circuit current densities and a small increase in the fill factor. As a result, they delivered a maximum power conversion efficiency (PCE) of 16.87% (average 14.33%), which represents a 12% enhancement compared to 15.01% (average 12.53%) of the reference cell. Moreover, the porphyrin-modified cells exhibited improved hysteretic behavior and a higher stabilized power output of 14.40% compared to 10.70% of the re...

In the present work, we effectively modify the TiO2 electron transport layer of organic solar cells with an inverted architecture using appropriately engineered porphyrin molecules. The results show that the optimized porphyrin modifier bearing two carboxylic acids as the anchoring groups and a triazine electron-withdrawing spacer significantly reduces the work function of TiO2, thereby reducing the electron extraction barrier. Moreover, the lower surface energy of the porphyrin-modified substrate results in better physical compatibility between the latter and the photoactive blend. Upon employing porphyrin-modified TiO2 electron transport layers in PTB7:PC71BM-based organic solar cells we obtained an improved average power conversion efficiency up to 8.73%. Importantly, porphyrin modification significantly increased the lifetime of the devices, which retained 80% of their initial efficiency after 500 h of storage in the dark. Because of its simplicity and efficacy, this approach should give tantalizing g...

BACKGROUND: Familial evaluation after a sudden death with negative autopsy (sudden arrhythmic death syndrome; SADS) may identify relatives at risk of fatal arrhythmias.OBJECTIVES: This study aimed to assess the impact of systematic ajmaline provocation testing using high right precordial leads (RPLs) on the diagnostic yield of Brugada syndrome (BrS) in a large cohort of SADS families.METHODS: Three hundred three SADS families (911 relatives) underwent evaluation with resting electrocardiogram using conventional and high RPLs, echocardiography, exercise, and 24-h electrocardiogram monitor. An ajmaline test with conventional and high RPLs was undertaken in 670 (74%) relatives without a familial diagnosis after initial evaluation. Further investigations were guided by clinical suspicion.RESULTS: An inherited cardiac disease was diagnosed in 128 (42%) families and 201 (22%) relatives. BrS was the most prevalent diagnosis (n = 85, 28% of families; n = 140, 15% of relatives). Ajmaline testing was required to unmask the BrS in 97% of diagnosed individuals. The use of high RPLs showed a 16% incremental diagnostic yield of ajmaline testing by diagnosing BrS in an additional 49 families. There were no differences of the characteristics between individuals and families with a diagnostic pattern in the conventional and the high RPLs. On follow-up, a spontaneous type 1 Brugada pattern and/or clinically significant arrhythmic events developed in 17% (n = 25) of the concealed BrS cohort.CONCLUSIONS: Systematic use of ajmaline testing with high RPLs increases substantially the yield of BrS in SADS families. Assessment should be performed in expert centers where patients are counseled appropriately for the potential implications of provocation testing.

Aims Obesity is an increasing public health problem and a risk factor for cardiovascular diseases. The aim of the study was to determine the main features and aetiologies in a large cohort of sudden cardiac deaths that occurred in obese subjects. Methods Between 1994 and 2014, 3684 consecutive cases of unexpected sudden cardiac death were referred to our cardiac pathology centre. This study was confined to young individuals (age ≤ 35 years) for whom information about body mass index was available and consisted of 1033 cases. Results Two-hundred and twelve individuals (20%) were obese. In obese sudden cardiac death victims the main post-mortem findings were: normal heart (sudden arrhythmic death syndrome) ( n = 108; 50%), unexplained left ventricular hypertrophy ( n = 25; 12%) and critical coronary artery disease ( n = 25; 12%). Less common were hypertrophic cardiomyopathy ( n = 4; 2%) and arrhythmogenic right ventricular cardiomyopathy ( n = 4;2%). When compared with non-obese sudden cardiac death victims, sudden arrhythmic death syndrome was less common (50% vs. 60%, P Conclusions Various conditions underlie sudden cardiac death in obesity, with a prevalence of sudden arrhythmic death syndrome, left ventricular hypertrophy and coronary artery disease. The degree of left ventricular hypertrophy measured by heart weight is excessive even after correction for body size. Almost one in four young obese sudden death patients show some degree of coronary artery disease, underscoring the need for primary prevention in this particular subgroup.

Sudden cardiac death (SCD) in any young person is a devastating event. The value of cardiac pre-participation screening (PPS) in young athletes has been intensely debated in the medical community and public health arena.1 One of the shortcomings of attempts to identify athletes with heart disease is the lack of established risk stratification protocols. Consequently, athletes are offered a ‘blanket approach’, with a considerable number of athlete disqualifications to save the few at high risk of exercise-associated arrhythmias. This analysis considers the ethical implications of disqualification of athletes with heart disease from competitive sport in the context of available evidence, contemporary medical recommendations and legal structures, as well as emerging genetic diagnostics. ### Eligibility recommendations for athletes with heart disease There is a lack of consensus in eligibility recommendations for athletes with heart disease aimed at medical practitioners. The discrepancies are due to multiple factors including: (1) the lack of evidence base relating to risk stratification of athletes for most conditions predisposing to exercise-related SCD(as a consequence, the recommendations are expert opinion based (level of evidence C)), (2) Cultural differences, and(3) Differences in legal contexts (if physicians are legally liable, disqualification decisions tend to be more conservative as physicians can be held accountable for adverse events).2 In addition, the label of ‘disqualification’ can be tantamount to loss of employment or ‘being fired’ when the athlete receives substantial financial remuneration or has a professional status. ### Ethical arguments in favour of medical disqualification #### Precaution Disqualification of athletes with heart disease from competitive sport as a precautionary measure relies heavily on evidence that disqualification of at-risk athletes improves morbidity and mortality. In the 36th Bethesda conference, the authors state: ‘The increased risk of sudden death associated with intense athletic participation is a controllable risk factor, and the devastating impact of even infrequent sudden deaths in this young population underscores the wisdom of the conservative nature of these recommendations’.3 The …

OBJECTIVES: This study sought to investigate the effect of different types of exercise on left ventricular (LV) geometry in a large group of female and male athletes.BACKGROUND: Studies assessing cardiac adaptation in female and male athletes indicate that female athletes reveal smaller increases in LV wall thickness and cavity size compared with male athletes. However, data on sex-specific changes in LV geometry in athletes are scarce.METHODS: A total of 1,083 healthy, elite, white athletes (41% female; mean age 21.8 ± 5.7 years) assessed with electrocardiogram and echocardiogram were considered. LV geometry was classified into 4 groups according to relative wall thickness (RWT) and left ventricular mass (LVM) as per European and American Society of Echocardiography guidelines: normal (normal LVM/normal RWT), concentric hypertrophy (increased LVM/increased RWT), eccentric hypertrophy (increased LVM/normal RWT), and concentric remodeling (normal LVM/increased RWT).RESULTS: Athletes were engaged in 40 different sporting disciplines with similar participation rates with respect to the type of exercise between females and males. Females exhibited lower LVM (83 ± 17 g/m2 vs. 101 ± 21 g/m2; p < 0.001) and RWT (0.35 ± 0.05 vs. 0.36 ± 0.05; p < 0.001) compared with male athletes. Females also demonstrated lower absolute LV dimensions (49 ± 4 mm vs. 54 ± 5 mm; p < 0.001) but following correction for body surface area, the indexed LV dimensions were greater in females (28.6 ± 2.7 mm/m2 vs. 27.2 ± 2.7 mm/m2; p < 0.001). Most athletes showed normal LV geometry. A greater proportion of females competing in dynamic sport exhibited eccentric hypertrophy compared with males (22% vs. 14%; p < 0.001). In this subgroup only 4% of females compared with 15% of males demonstrated concentric hypertrophy/remodeling (p < 0.001).CONCLUSIONS: Highly trained athletes generally show normal LV geometry; however, female athletes participating in dynamic sport often exhibit eccentric hypertrophy. Although concentric remodeling or hypertrophy in male athletes engaged in dynamic sport is relatively common, it is rare in female athletes and may be a marker of disease in a symptomatic athlete.

Background: Anterior T-wave inversion (ATWI) on electrocardiography (ECG) in young white adults raises the possibility of cardiomyopathy, specifically arrhythmogenic right ventricular cardi...

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

Photovoltaic devices based on organic semiconductors and organo-metal halide perovskites have not yet reached the theoretically predicted power conversion efficiencies while they still exhibit poor environmental stability. Interfacial engineering using suitable materials has been recognized as an attractive approach to tackle the above issues. We introduce here a zinc porphyrin-triazine-bodipy donor-π bridge-acceptor dye as a universal electron transfer mediator in both organic and perovskite solar cells. Thanks to its "push-pull" character, this dye enhances electron transfer from the absorber layer toward the electron-selective contact, thus improving the device's photocurrent and efficiency. The direct result is more than 10% average power conversion efficiency enhancement in both fullerene-based (from 8.65 to 9.80%) and non-fullerene-based (from 7.71 to 8.73%) organic solar cells as well as in perovskite ones (from 14.56 to 15.67%), proving the universality of our approach. Concurrently, by forming a hydrophobic network on the surface of metal oxide substrates, it improves the nanomorphology of the photoactive overlayer and contributes to efficiency stabilization. The fabricated devices of both kinds preserved more than 85% of their efficiency upon exposure to ambient conditions for more than 600 h without any encapsulation.

ObjectiveDistinguishing early dilated cardiomyopathy (DCM) from physiological left ventricular (LV) dilatation with LV ejection fraction MethodsThirty-five asymptomatic active males with DCM, 25 male athletes in the ‘grey zone’ and 24 male athletes with normal LV ejection fraction underwent N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement, ECG and exercise echocardiography. Grey-zone athletes and patients with DCM underwent cardiovascular magnetic resonance (CMR) and Holter monitoring.ResultsLarger LV cavity dimensions and lower LV ejection fraction were the only differences between grey-zone and control athletes. None of the grey-zone athletes had abnormal NT-proBNP, increased ectopic burden/complex arrhythmias or pathological late gadolinium enhancement on CMR. These features were also absent in 71%, 71% and 50% of patients with DCM, respectively. 95% of grey-zone athletes and 60% of patients with DCM had normal ECG. During exercise echocardiography, 96% grey-zone athletes increased LV ejection fraction by >11% from baseline to peak exercise compared with 23% of patients with DCM (p63% in 92% grey-zone athletes compared with 17% patients with DCM (p11% from baseline to peak exercise or achieve a peak LV ejection fraction >63% had sensitivity of 77% and 83%, respectively, and specificity of 96% and 92%, respectively, for predicting DCM.ConclusionComprehensive assessment using a cascade of routine investigations revealed that exercise stress echocardiography has the greatest discriminatory value in differentiating between grey-zone athletes and asymptomatic patients with DCM. Our findings require validation in larger studies.

Background Data on the natural history of genotype positive/phenotype negative (G+/P-) hypertrophic cardiomyopathy (HCM) patients identified as a part of genetic cascade screening in different age groups is limited. Purpose To describe the rate of conversion to overt HCM phenotype in G+/P- subjects in relation with the age who were identified in a specialized clinic in a single center. Methods We retrospectively identified 56 consecutive HCM G+/P− subjects followed in our center specialized clinic between Jan 2012-Jan 2019. Demographics, family history of sudden cardiac death (SCD) and presence of symptoms were collected. All of them underwent baseline investigations including ECG, echocardiogram and/or cardiac magnetic resonance (CMR) and 24 hour monitor at baseline and during follow up. Overt HCM phenotype was defined as left ventricular hypertrophy (LVH) ≥13mm in the echocardiogram or CMR. Results We identified 56 HCM G+/P− subjects from 34 different families. 22 subjects were ≤18 years old with a mean age of 11.6±0.9 years (IQR [P25-P75] 9–16 years) and 32 subjects were >18 years old with a mean age of 38.1±2.2 years (IQR [P25-P75] 27–48 years). Mean time of follow up was 35.2±34.4 months (IQR [P25-P75] 4.25–50.25 years). 60.7% (34) of them were female and 82.1% (46) were of Caucasian ethnicity. Most of the subjects with no evidence LVH were asymptomatic but small number had symptoms, 8.9% (5), and 3.6% (2) were treated with betablockers for palpitations. Family history of SCD was present in 57.1% (32) of the subjects and 35.7% (20) had a relative with an implantable cardiac defibrillator (ICD). MYBPC3 gene mutations were identified in 62.5% (35) of subjects, followed by MYH7 gene mutation in 23.2% (13) of the cases. None of the subjects under 18 year old developed HCM during the period of observation, however 7 subjects (21.9%), mean age 48.6±10.5 years, 71.4% (5) females, showed progression to HCM in the >18 years old group. All of them had pathogenic MYBPC3 gene variants. No differences were found in gender, ethnicity, symptoms or family history of SCD in the G+/P− vs HCM group. There were no differences on the presence of ECG abnormalities and no episodes of NSVT were recorded in any of the groups. Baseline E/e' values of those with new HCM vs G+/P− were higher (8.2±3.3 vs 5.6±1.7, p=0.014). Conclusions In our cohort, rate of progression to HCM phenotype was 21.9% of >18 years old HCM G+/P- subjects. The mean age at the time of developing the phenotype was 48.6±10.5 years old and all the patients were asymptomatic for cardiac symptoms. Echocardiographic E/e' values were increased. This data supports the need of life long follow up of this group of patients with ongoing clinical evaluation. Acknowledgement/Funding ESC clinical grant

Background The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) is often challenging and some structural abnormalities typical of the disease may overlap with changes reflective of cardiac adaptation to exercise. Purpose The aim of the study was to assess the performance of the cardiac magnetic resonance (CMR) 2010 Task Force Criteria (TFC) in a cohort of patients with definite diagnosis of ARVC and define the overlap with a cohort of highly trained athletes of similar age and sex. Methods We compared the CMR features of 43 patients (mean age 49±17 years, 49% males, 32 (74%) genotyped) with a definite diagnosis of ARVC according to the revised TFC to 97 (mean age 45±16 years, 61% males) highly-trained athletes of similar age and sex, in whom cardiac disease was excluded after comprehensive work-up. Results The CMR was abnormal in 37 (86%) patients. The right ventricle (RV) was affected in isolation in 17 (39%) patients, with 18 (42%) patients exhibiting biventricular involvement and 2 (5%) patients showing isolated left ventricular (LV) involvement. The most common RV abnormalities were regional wall motion abnormalities (RWMA) (n=34; 79%), RV dilatation fulfilling a major or minor volume TFC (n=18; 42%), impaired systolic function (RV ejection fraction (EF) ≤45%: n=17; 40%) and myocardial fibrosis (n=13; 30%). The predominant LV abnormality was myocardial fibrosis (n=20; 47%), with a small proportion of patients exhibiting RWMA (n=6; 14%) and impaired systolic function (LVEF Conclusions The great majority (86%) of patients with ARVC demonstrates structural abnormalities suggestive of cardiomyopathy on CMR but only 53% fulfills any of the CMR TFC. Only a small proportion (16%) of older athletes demonstrate significant RV dilatation that overlaps with the volume criteria for ARVC, in juxtaposition to younger athletes who exhibit a greater degree of overlap. The emergence of ARVC as a biventricular disease provides an opportunity to re-evaluate the diagnostic criteria and include LV involvement in conjunction with RV involvement to improve diagnostic accuracy. Acknowledgement/Funding CRY (Cardiac Risk in the Young) charity

Sudden cardiac death (SCD) is often associated with structural abnormalities of the heart during autopsy. This study sought to compare the diagnostic yield of postmortem genetic testing in (1) cases with structural findings of uncertain significance at autopsy to (2) cases with autopsy findings diagnostic of cardiomyopathy. We evaluated 57 SCD cases with structural findings at cardiac autopsy. Next-generation sequencing using a panel of 77 primary electrical disorder and cardiomyopathy genes was performed. Pathogenic and likely pathogenic variants were classified using American College of Medical Genetics (ACMG) consensus guidelines. In 29 cases (51%) autopsy findings of uncertain significance were identified whereas in 28 cases (49%) a diagnosis of cardiomyopathy was established. We identified a pathogenic or likely pathogenic variant in 10 cases (18%); in 1 (3%) case with non-specific autopsy findings compared with 9 (32%) cases with autopsy findings diagnostic of cardiomyopathy (p = 0.0054). The yield of genetic testing in SCD cases with autopsy findings consistent with cardiomyopathy is comparable with the yield in cardiomyopathy patients that are alive. Genetic testing in cases with findings of uncertain significance offers lower clinical utility than in cardiomyopathy, with lower yields than detected previously. This highlights the need for stringent evaluation of variant pathogenicity.

This paper presents a brief summary of the recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology (EAPC) on sports-participation in patients with coronary artery disease, coronary artery anomalies or spontaneous dissection of the coronary arteries, all entities being associated with myocardial ischaemia.1 Given the wealth of evidence supporting the benefits of exercise for primary and secondary prevention of coronary artery disease, individuals should be restricted from competitive sport only when a substantial risk of adverse event or disease progression is present. These recommendations aim to encourage regular physical activity including participation in sports and, with reasonable precaution, ensure a high level of safety for all individuals with coronary artery disease. The present document is based on available current evidence, but in most instances because of lack of evidence, also on clinical experience and expert opinion.

Item does not contain fulltext Owing to its undisputed multitude of beneficial effects, European Society of Cardiology guidelines advocate regular physical activity as a class IA recommendation for the prevention and treatment of cardiovascular disease. Nonetheless, competitive athletes with arterial hypertension may be exposed to an increased risk of cardiovascular events. Guidance to physicians will be given in this summary of our recently published recommendations for participation in competitive sports of athletes with arterial hypertension.

AimTo assess the emergency response planning and prevention strategies for sudden cardiac arrest (SCA) across a wide range of professional football clubs in England.MethodsA written survey was sent to all professional clubs in the English football league, namely the Premiership, Championship, League 1 and League 2. Outcomes included: (1) number of clubs performing cardiac screening and frequency of screening; (2) emergency planning and documentation; (3) automated external defibrillator (AED) training and availability; and (4) provision of emergency services at sporting venues.Results79 clubs (86%) responded to the survey. 100% clubs participated in cardiac screening. All clubs had AEDs available on match days and during training sessions. 100% Premiership clubs provided AED training to designated staff. In contrast, 30% of lower division clubs with AEDs available did not provide formal training. Most clubs (n=66; 83%) reported the existence of an emergency action plan for SCA but formal documentation was variable. All clubs in the Premiership and League 1 provided an ambulance equipped for medical emergencies on match days compared with 75% of clubs in the Championship and 66% in League 2.ConclusionsThe majority of football clubs in England have satisfactory prevention strategies and emergency response planning in line with European recommendations. Additional improvements such as increasing awareness of European guidelines for emergency planning, AED training and mentorship with financial support to lower division clubs are necessary to further enhance cardiovascular safety of athletes and spectators and close the gap between the highest and lower divisions.

Background International recommendations for interpreting the athlete’s ECG define a short PR interval as Purpose To investigate the prevalence of short PR in young athletes and its association with age, gender and ethnicity. Methods Between 2011–2014, 15,572 athletes aged 14–35 underwent cardiac screening including an ECG. An athlete was defined as an individual participating in sport ≥6hrs/wk. ECGs were analysed by 2 independent experts. Athletes in whom the PR interval was not fixed were excluded. A short PR was defined as Results Amongst 15,572 athletes (mean age 18.6 years, 92% white, 80% male), the mean PR interval was 151msec and shorter in females vs. males, white vs. non-white and adolescent (≤16 years) vs. older (17–35 years) athletes (table 1). An isolated short PR was present in 765 (4.9%) athletes and was more common in females vs. males (6.2% vs. 4.2%; p Conclusions A short PR interval is a fairly frequent finding in this cohort with a predilection for younger and female athletes. Possible explanations for shorter conduction time include anatomically smaller hearts, higher sympathetic tone or enhanced resting AV node conduction. The high frequency of short PR in young athletes suggests that in the absence of an accessory pathway or symptoms its presence should not prompt further investigation. Long-term follow-up studies are required in order to draw definitive conclusions.

Background The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) is often challenging and structural abnormalities typical of the disease may overlap with changes reflective of cardiac adaptation to exercise. The aim of the study was to assess the performance of the cardiac magnetic resonance (CMR) 2010 Task Force Criteria (TFC) in a cohort of patients with definite diagnosis of ARVC and define the overlap with a cohort of highly trained athletes of similar age and sex. Methods We compared the CMR features of 43 patients (mean age 49±17 years, 49% males, 32 (74%) genotyped) with a definite diagnosis of ARVC according to the revised TFC to 97 (mean age 45±16 years, 61% males) highly-trained athletes of similar age and sex, where cardiac disease was excluded after comprehensive work-up. Results The CMR was abnormal in 37 (86%) patients. The RV was affected in isolation in 17 (39%) patients, with 18 (42%) patients exhibiting biventricular involvement and 2 (5%) patients showing isolated left ventricular involvement. The most common RV abnormalities were regional wall motion abnormalities (RWMA) (n=34; 79%), RV dilatation fulfilling a major or minor volume TFC (n=18; 42%), impaired systolic function (RVEF ≤45%: n=17; 40%) and myocardial fibrosis (n=13; 30%). The predominant LV abnormality was myocardial fibrosis (n=20; 47%), with a small proportion of patients exhibiting RWMA (n=6; 14%) and impaired systolic function (LVEF Twenty-three (53%) patients fulfilled a major (n=14; 32%) or a minor (n=9; 21%) CMR TFC. Sixteen (16%) athletes exceeded the cut-off values for RV volumes used as a major (n=10; 10%) or a minor (n=6; 6%) TFC with an inverse relationship between age and RV volumes (r=-0.41, p=0.001). None of the athletes fulfilled the TFC for RV ejection fraction. Applying the CMR TFC to the ARVC patient population, showed a sensitivity of 33% for the major and 28% for the minor criteria. Applying the RV volume and systolic function TFC values in the entire study population, showed a sensitivity of 53%, a specificity between 83% and an accuracy of 0.68. Please see (Figure 1). Conclusion The great majority (86%) of patients with ARVC demonstrate structural abnormalities suggestive of cardiomyopathy on CMR but only 53% fulfil any of the CMR TFC. A small proportion (16%) of older athletes demonstrate significant RV dilatation that overlaps with the volume criteria for ARVC. The emergence of ARVC as a biventricular disease provides an opportunity to re-evaluate the diagnostic criteria and include LV involvement in conjunction with RV involvement to improve diagnostic accuracy. Conflict of Interest no

Background Structural cardiac adaptations caused by hypertension present a diagnostic challenge when differentiating from hypertrophic cardiomyopathy (HCM), using traditional imaging techniques such as echocardiography (echo). Cardiac magnetic resonance imaging (CMR) offers reproducible anatomical, functional quantification as well as myocardial tissue characterisation which discriminates between hypertension and HCM. Purpose To identify hypertensive individuals with undiagnosed HCM using CMR imaging. Methods 100 consecutive African Caribbean (AC) and Caucasian hypertensive patients underwent CMR at a tertiary centre dedicated blood pressure clinic (55% male, mean age 51 years). In keeping with ESC guidelines, end diastolic wall thickness (EDWT) ≥ 15mm identified individuals within the “grey zone” between hypertension and with a potential HCM diagnosis.19 individuals were referred on to the dedicated inherited cardiac conditions clinic for further evaluation. Four patients expressed a definitive LV phenotype and were diagnosed with HCM. CMR parameters were compared in three groups: Hypertensive (HTN), grey zone Hypertensive (GZH) and HCM. See figure 1 and table 1. Results CMR demonstrated end diastolic wall thickness (EDWT) >11 mm in 50% of hypertensives. 73% of the referred patients were AC and all 4 HCM patients were also AC. All referrals demonstrated EDWTs ≥14mm, 9 (47%) demonstrated late gadolinium enhancement of which 3 (16%) had HCM. Three had asymmetrical septal hypertrophy – 2 were in the HCM cohort and one underwent endomyocardial biopsy confirming HTN. Left ventricular mass index (LVMI) was significantly higher in GZH compared to HTN (p Conclusion This study reports a 4% prevalence of HCM among hypertensive patients - 20 × greater than in the general population - which would not be diagnosed using echo alone. Screening hypertensive individuals with CMR is not yet routine but we advocate its use in these individuals especially in those of AC ethncitiy and in those in the “grey zone”, to identify undiagnosed HCM, which has significant implications for lifestyle modification and family screening. Conflict of Interest none

OBJECTIVES: The authors studied the response rates and relative sensitivity of the most common agents used in the sodium-channel blocker (SCB) challenge. BACKGROUND: A type 1 Brugada electrocardiographic pattern precipitated by an SCB challenge confers a diagnosis of Brugada syndrome. METHODS: Patients undergoing an SCB challenge were prospectively enrolled across Canada and the United Kingdom. Patients with no prior cardiac arrest and family histories of sudden cardiac death or Brugada syndrome were included. RESULTS: Four hundred twenty-five subjects underwent SCB challenge (ajmaline, n = 331 [78%]; procainamide, n = 94 [22%]), with a mean age of 39 ± 15 years (54% men). Baseline non-type 1 Brugada ST-segment elevation was present in 10%. A total of 154 patients (36%) underwent signal-averaged electrocardiography, with 41% having late potentials. Positive results were seen more often with ajmaline than procainamide infusion (26% vs. 4%, p < 0.001). On multivariate analysis, baseline non-type 1 Brugada ST-segment elevation (odds ratio [OR]: 6.92; 95% confidence interval [CI]: 3.15 to 15.2; p < 0.001) and ajmaline use (OR: 8.76; 95% CI: 2.62 to 29.2; p < 0.001) were independent predictors of positive results to SCB challenge. In the subgroup undergoing signal-averaged electrocardiography, non-type 1 Brugada ST-segment elevation (OR: 9.28; 95% CI: 2.22 to 38.8; p = 0.002), late potentials on signal-averaged electrocardiography (OR: 4.32; 95% CI: 1.50 to 12.5; p = 0.007), and ajmaline use (OR: 12.0; 95% CI: 2.45 to 59.1; p = 0.002) were strong predictors of SCB outcome. CONCLUSIONS: The outcome of SCB challenge was significantly affected by the drug used, with ajmaline more likely to provoke a type 1 Brugada electrocardiographic pattern compared with procainamide. Patients undergoing SCB challenge may have contrasting results depending on the drug used, with potential clinical, psychosocial, and socioeconomic implications.

Physiological adaptation to exercise manifests on the surface ECG with phenotypes that occasionally overlap with those present in patients with cardiomyopathy, one of the leading causes of exercise-related cardiac death in young athletes. In the era of pre-participation screening, differentiation of physiology from pathology is crucial given the potential consequences of an erroneous diagnosis or false reassurance. This chapter provides a comprehensive overview of the ECG anomalies that may cause diagnostic dilemmas in clinical practice, delineates the size of the ‘ECG grey zones’, and provides practical algorithms for ascertaining which ECG phenotypes require further evaluation.

Contains fulltext : 209356.pdf (Publisher’s version ) (Closed access) Myocardial diseases are associated with an increased risk of potentially fatal cardiac arrhythmias and sudden cardiac death/cardiac arrest during exercise, including hypertrophic cardiomyopathy, dilated cardiomyopathy, left ventricular non-compaction, arrhythmogenic cardiomyopathy, and myo-pericarditis. Practicing cardiologists and sport physicians are required to identify high-risk individuals harbouring these cardiac diseases in a timely fashion in the setting of preparticipation screening or medical consultation and provide appropriate advice regarding the participation in competitive sport activities and/or regular exercise programmes. Many asymptomatic (or mildly symptomatic) patients with cardiomyopathies aspire to participate in leisure-time and amateur sport activities to take advantage of the multiple benefits of a physically active lifestyle. In 2005, The European Society of Cardiology (ESC) published recommendations for participation in competitive sport in athletes with cardiomyopathies and myo-pericarditis. One decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of cardiomyopathies and myo-pericarditis. The present document, therefore, aims to offer a comprehensive overview of the most updated recommendations for practicing cardiologists and sport physicians managing athletes with cardiomyopathies and myo-pericarditis and provides pragmatic advice for safe participation in competitive sport at professional and amateur level, as well as in a variety of recreational physical activities.

Sudden cardiac arrest is responsible for 50% of cardiovascular mortality; most occur during or shortly after exertion and progress to sudden cardiac death. Sudden cardiac death in sports is rare but more frequent than previously thought and represents a highly tragic event, especially when it affects young athletes. The causes of sudden cardiac death may be cardiac or noncardiac. Of the cardiac causes, inherited or congenital heart disease predominates in young athletes ( 35 years). The majority of the individuals are asymptomatic, without clinical or family history, and commonly sudden cardiac arrest is the first clinical manifestation of the disease. Preventative strategies such as pre-participation cardiovascular screening with an ECG offer the opportunity to identify young athletes at risk and provide appropriate treatment and exercise recommendations. However, cardiac screening remains controversial amidst concerns relating to false-positive results, lack of expertise and resources and cost-effectiveness. Another major preventative strategy is early recognition of a sudden cardiac arrest and provision of prompt emergency care. A well-established emergency plan, including personnel training with regular practice, aiming for the immediate initiation of chest compressions and early defibrillation is crucial to good outcomes.

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Genetic cardiomyopathies are complex diseases with heterogeneous clinical presentation and phenotypes. Early descriptions of cardiomyopathies originated from case studies involving individuals with severe, paradigmatic presentation, which provided insight into the worst-case scenarios of these conditions. With time, improved diagnostic sensitivity and awareness of cardiomyopathies has uncovered a more heterogeneous disease spectrum, including mild phenotypes overlapping with physiological variation. This diagnostic 'grey area' poses important dilemmas, particularly in athletes. Current screening policies have the potential to identify affected individuals at very early stages, leading to effective prevention of cardiomyopathy-related complications such as sudden cardiac death. Conversely, however, some physicians actively impose diagnoses on individuals who perceive themselves to be disease-free. In addition, the high sensitivity of contemporary diagnostic techniques carries a serious risk of misinterpreting physiological variation as disease. In this Review, three of the most common and controversial areas are discussed, including left ventricular hypertrophy; left ventricular dilatation, noncompaction, and fibrosis; and arrhythmias originating from the right ventricle. A systematic and cautious approach is necessary in patients with mild phenotypes suggestive of, but not definitely diagnostic for, cardiomyopathies. Preventing the mislabelling of healthy individuals and overdiagnosis should be a priority, with the aim to combine adequate counselling and optimal protection.

Introduction: Athletes can exhibit abnormal electrocardiogram (ECG) phenotypes that require further evaluation prior to competition. These are apparently more prevalent in high-intensity endurance sports. The purpose of this study was to assess the association between ECG findings in athletes and intensity of sport and level of competition. Methods: A cohort of 3423 competitive athletes had their ECGs assessed according to the Seattle criteria (SC). The presence of abnormal ECGs was correlated with: (1) intensity of sport (low/moderate vs. at least one high static or dynamic component); (2) competitive level (regional vs. national/international); (3) training volume (≤20 vs. >20 hours/week); (4) type of sport (high dynamic vs. high static component). The same endpoints were studied according to the ‘Refined Criteria’ (RC). Results: Abnormal ECGs according to the SC were present in 225 (6.6%) athletes, more frequently in those involved in high-intensity sports (8.0% vs. 5.4%; p=0.002), particularly in dynamic sports, and competing at national/international level (7.1% vs. 4.9%; p=0.028). Training volume was not significantly associated with abnormal ECGs. By multivariate analysis, high-intensity sport (OR 1.55, 1.18-2.03; p=0.002) and national/international level (OR 1.50, 95% CI 1.04-2.14; p=0.027) were independent predictors of abnormal ECGs, and these variables, when combined, doubled the prevalence of this finding. According to the RC, abnormal ECGs decreased to 103 (3.0%), but were also more frequent in high-intensity sports (4.2% vs. 2.0%; p20 horas/semana); 4) tipo de desporto (elevados componentes dinâmico versus estático). Os mesmos endpoints foram estudados pelos Refined Criteria (RC). Resultados: De acordo com os SC, 225 (6,6%) atletas tinham alterações patológicas, mais frequentes nos envolvidos em desportos de elevada intensidade (8,0 versus 5,4%; p=0,002), sobretudo dinâmica, e em nível nacional/internacional (7,1 versus 4,9%; p=0,028). O volume de treino não esteve significativamente associado a estas alterações. Em análise multivariada, desporto de elevada intensidade (OR 1,55, IC 95% 1,18-2,03; p=0,002) e o nível nacional/internacional (OR 1,50, IC 95% 1,04-2,14; p=0,027) foram preditores independentes de ECG anormais, variáveis que combinadas duplicaram a prevalência. Com os RC o número de ECG patológicos decresceu para 103 (3,0%), também mais frequentes nos desportos de elevada intensidade (4,2 versus 2,0%; p

Background\ud High false positive rates and the subsequent cost of additional investigations provide a major obstacle to screening young athletes for cardiac disease with an electrocardiogram (ECG). However, the actual cost of ECG has never been assessed systematically in a large cohort of athletes.\ud Objective\ud This study investigated the financial implications associated with ECG interpretation in athletes according to the 2010 European Society of Cardiology (ESC) and the more contemporary Seattle and refined ECG interpretation criteria.\ud Methods\ud Between 2011 and 2014, 4,925 previously unscreened athletes aged 14-35 years were prospectively evaluated with history, physical examination and an ECG interpreted with the 2010 ESC recommendations. Athletes with abnormal results underwent secondary investigations, the costs of which were based on the UK National Health Service Tariffs. The impact on cost after applying the Seattle and refined criteria was evaluated retrospectively.\ud Results\ud 1,072 (21.8%) athletes revealed an abnormal ECG based on the 2010 ESC recommendations. 11.2% athletes required echocardiography, 1.7% exercise stress test, 1.2% Holter, 1.2% cardiac MRI and 0.4% other tests. The Seattle and refined criteria reduced the number of positive ECGs to 6.0% and 4.3% respectively. 15 (0.3%) athletes were diagnosed with potentially serious cardiac disease using all three criteria. The overall cost of de-novo screening using the 2010 ESC recommendations amounted to $539,888, equating to $110 per athlete and $35,993 per serious diagnosis. The Seattle and refined criteria reduced the cost to $92 and $87 per athlete screened and $30,251 and $28,510 per serious diagnosis respectively, representing a 21% cost saving per athlete screened.\ud Conclusion\ud Contemporary ECG interpretation criteria are associated with significant cost reductions for a de-novo screening program in athletes which may be cost permissive for some financially endowed sporting organisations.

Background Accurate knowledge of causes of sudden cardiac death (SCD) in athletes and its precipitating factors is necessary to establish preventative strategies. Objectives This study investigated causes of SCD and their association with intensive physical activity in a large cohort of athletes. Methods Between 1994 and 2014, 357 consecutive cases of athletes who died suddenly (mean 29 ± 11 years of age, 92% males, 76% Caucasian, 69% competitive) were referred to our cardiac pathology center. All subjects underwent detailed post-mortem evaluation, including histological analysis by an expert cardiac pathologist. Clinical information was obtained from referring coroners. Results Sudden arrhythmic death syndrome (SADS) was the most prevalent cause of death (n = 149 [42%]). Myocardial disease was detected in 40% of cases, including idiopathic left ventricular hypertrophy (LVH) and/or fibrosis (n = 59, 16%); arrhythmogenic right ventricular cardiomyopathy (ARVC) (13%); and hypertrophic cardiomyopathy (HCM) (6%). Coronary artery anomalies occurred in 5% of cases. SADS and coronary artery anomalies affected predominantly young athletes (≤ 35 years of age), whereas myocardial disease was more common in older individuals. SCD during intense exertion occurred in 61% of cases; ARVC and left ventricular fibrosis most strongly predicted SCD during exertion. Conclusions Conditions predisposing to SCD in sports demonstrate a significant age predilection. The strong association of ARVC and left ventricular fibrosis with exercise-induced SCD reinforces the need for early detection and abstinence from intense exercise. However, almost 40% of athletes die at rest, highlighting the need for complementary preventive strategies.

Solid masses of the pancreas represent a variety of benign and malignant neoplasms of the exocrine and endocrine tissues of the pancreas. A tissue diagnosis is often required to direct therapy in the face of uncertain diagnosis or if the patient is not a surgical candidate either due to advanced disease or comorbidities. Endoscopic ultrasound (EUS) is a relatively new technology that employs endoscopy and high-frequency ultrasound (US). EUS involves imaging of the pancreatic head and the uncinate from the duodenum and imaging of the body and tail from the stomach. It has been shown to be a highly sensitive method for the detection of pancreatic masses. It is superior to extracorporeal US and computed tomographic (CT) scans, especially when the pancreatic tumor is smaller than 2-3 cm. Although EUS is highly sensitive in detecting pancreatic solid masses, its ability to differentiate between inflammatory masses and malignant disease is limited. Endoscopic retrograde cholangiopancreatography (ERCP) brushing, CT-guided biopsies, and transabdominal ultrasound (US) have been the standard nonsurgical methods for obtaining a tissue diagnosis of pancreatic lesions, but a substantial false-negative rate has been reported. Transabdominal US-guided fine-needle aspiration biopsy (US-FNAB) has been used for tissue diagnosis in patients with suspected pancreatic carcinoma. It has been shown to be highly specific, with no false-positive diagnoses. With the advent of curvilinear echoendoscopes, transgastric and transduodenal EUS-FNAB of the pancreas have become a reality EUS with FNAB has revolutionized the ability to diagnose and stage cancers of the gastrointestinal tract and assess the pancreas. Gastrointestinal cancers can be looked at with EUS and their depth of penetration into the intestinal wall can be determined. Any suspicious appearing lymph nodes can be biopsied using EUS/FNAB. The pancreas is another organ that is well visualized with EUS. Abnormalities such as tumors and cysts of the pancreas can be carefully evaluated using EUS and then biopsied with FNAB. There are many new applications of EUS using FNAB. Researchers are looking to deliver chemotherapeutics into small pancreatic cancers and cysts. Nerve blocks using EUS/FNAB to inject numbing medicines into the celiac ganglia, a major nerve cluster, are now routinely performed in patients with pain due to pancreatic cancer. The aim of this study is to perform a review of the literature regarding the usefulness of EUS/FNAB in the diagnosis of pancreatic adenocarcinoma.

Automotive is considered one of the driving use cases for the 5th Generation (5G) systems, which currently formulates numerous scenarios and Key Performance Indicators (KPIs), via advanced Vehicle-to-everything (V2X) services and applications. Minimum end-to-end delay, as well as advanced contextual awareness requirements, pose novel architectural and functional challenges. This paper exploits two key enablers, namely Multiple Access/Mobile Edge Computing (MEC) and Network Function Virtualization (NFV), and acts in a two-fold manner: Firstly, it proposes a hybrid architecture for 5G systems, which exploits the afore-mentioned technologies, and performs computing resources’ selection among MEC and/or centralized, cloud-based resources (as VNFs), towards efficient service orchestration. The second contribution of this paper is a novel V2X service and algorithm, namely VRU-safe, that operates on top of the proposed architecture. VRU-Safe is an efficient, lightweight, low time complexity scheme, capable of identifying and predicting potential imminent road hazards between moving vehicles and Vulnerable Road Users (VRUs). The performance and viability of the proposed solutions are evaluated in a real-world 5G testbed in Europe.

Regular physical exercise is responsible for structural, electrical and functional changes in the heart, the so-called ‘athletes heart’. Hemodynamic load during exercise may lead to aortic remodeling. Investigations of the aorta in athletes have been limited and is vague whether the hemodynamic

Having already entered the initial phase of the 5th generation networks (5G) era, the network ecosystems have already begun comprising a plethora of coexisting 3GPP and non-3GGP Radio Access Technologies (RATs). Deployment scenarios envision a multi-layer use of macro, micro and femto-cells, where multi-mode end devices, supporting different applications, are served by heterogeneous access technologies. At the same time, this heterogeneous environment results in an abstract pool of resources, moving away from the traditional cell concept and exposing the network administrator with the collective resources in time, frequency, and space. An imperative need is thus created, to obtain an overview of the network and radio conditions in order to respond in an optimal way. The concepts of Software Defined Networking (SDN) and Software Defined Radio (SDR), when applied in a coordinated and sophisticated manner, may prove of utmost importance towards addressing the aforementioned challenges. The concept of network slicing -that enables the creation of several virtual networks with diverse characteristics, on top of common infrastructure- further reinforces the flexibility and dynamicity of the network. To this end, we present and evaluate a Cross Layer Controller (CLC), which acts on top of well-established SDN and SDR technologies, and monitors in real-time the conditions in the radio environment, as well as the transport network traffic, in a unified way; based on this dynamic input, CLC enforces sophisticated, end-to-end resource allocation policies and pairing mechanisms between network slices from different network segments, highlighting thus, the feature of cross layer resource management and dynamic adaptation. The experimentation results demonstrate the considerable gains acquired from the proposed solution.

‘Athlete’s heart’ is associated with several structural and electrophysiological adaptations, which are reflected on the 12-lead electrocardiogram (ECG) and imaging studies. Most studies investigating cardiac remodelling in athletes are based on cohorts of white, adult, male athletes competing in the most popular sports. Evidence suggests, however, that sporting discipline and the athlete’s sex and ethnicity are important determinants of cardiovascular adaptation to exercise. Athletes competing in endurance sports demonstrate more pronounced adaptations in comparison to athletes performing static or resistance training. The ECG of endurance athletes is more likely to demonstrate repolarization anomalies in the anterior leads and ventricular dilatation on imaging studies, causing considerable overlap with arrhythmogenic right ventricular cardiomyopathy and dilated cardiomyopathy. Female athletes exhibit less pronounced adaptations compared to males, in terms of the prevalence of ECG changes and absolute cardiac dimensions. Importantly, female endurance athletes are more likely to demonstrate eccentric hypertrophy compared to males, suggesting that concentric remodelling or hypertrophy in female endurance athletes is unlikely to be the consequence of physiological adaptation to training. The most pronounced paradigm of ethnically distinct cardiovascular adaptation to exercise stems from Black athletes, who exhibit a significantly higher prevalence of repolarization anomalies and left ventricular hypertrophy compared to white athletes, making the differentiation between athlete’s heart and hypertrophic cardiomyopathy challenging in this ethnic group.

ObjectivesAortic root dilatation is reported in young athletes; however, it is unclear whether such remodelling is physiological or, whether it represents a potential aortopathy. This observational study investigated the prevalence and progression of aortic root dilatation in young athletes competing at regional or national level.MethodsBetween 2003 and 2015, 3781 athletes aged 19±5.9 years (63.3% male) underwent echocardiography as part of a cardiac screening programme to identify athletes with structural abnormalities. Athletes trained for an average of 16.7 hours per week. Aortic diameter was measured at the level of sinuses of Valsalva. Results were compared with 806 controls. Athletes with an enlarged aortic diameter were followed up for 5±1.5 years.ResultsAthletes revealed a larger mean aortic diameter compared with controls (28.3±4.1 vs 27.8±4.1 mm; p=0.01). The 99th percentile value for aortic diameter in the athlete cohort was defined as the upper limit and was 40 mm in males and 38 mm in females. The aortic diameter measured >40 mm in five male (0.17%) (40–43 mm) and >38 mm in six female (0.4%) (39–41 mm) athletes. During follow-up, none of the athletes with an enlarged aortic diameter showed progressive aortic enlargement compared with the first assessment (40.6±0.9 vs 40.5±0.7 mm in males; (p=0.111) and 38.3±0.6 vs 38.0±0.7 mm in females; (p=0.275)).ConclusionsA small minority (0.3%) of athletes reveal an enlarged aortic diameter. Medium-term follow-up does not reveal progressive enlargement of the aortic diameter indicative of aortopathy. Longer surveillance studies are necessary to elucidate the precise significance of an enlarged aortic diameter in athletes.

Background: T-wave inversion (TWI) is common in patients with cardiomyopathy. However, up to 25% of athletes of African/Afro-Caribbean descent (black athletes) and 5% of white athletes also have TWI of unclear clinical significance despite comprehensive clinical evaluation and long-term follow-up. The aim of this study was to determine the diagnostic yield from genetic testing, beyond clinical evaluation, when investigating athletes with TWI. Methods: We investigated 50 consecutive asymptomatic black and 50 white athletes 14 to 35 years of age with TWI and a normal echocardiogram who were referred to a UK tertiary center for cardiomyopathy and sports cardiology. Subjects underwent exercise testing, 24-hour ambulatory ECG, signal-averaged ECG, cardiac magnetic resonance imaging, and a blood-based analysis of a comprehensive 311-gene panel for cardiomyopathies and ion channel disorders associated with TWI, including hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy, left ventricular noncompaction, long-QT syndrome, and Brugada syndrome. Results: In total, 21 athletes (21%) were diagnosed with cardiac disease on the basis of comprehensive clinical investigations. Of these, 8 (38.1%) were gene positive (myosin binding protein C[ MYBPC3 ], myosin heavy chain 7 [ MYH7 ], galactosidase alpha [ GLA ], and actin alpha, cardiac muscle 1 [ ACTC1 ] genes) and 13 (61.9%) were gene negative. Of the remaining 79 athletes (79%), 2 (2.5%) were gene positive (transthyretin [ TTR ] and sodium voltage-gated channel alpha subunit 5 [ SCN5A ] genes) in the absence of a clinical phenotype. The prevalence of newly diagnosed cardiomyopathy was higher in white athletes compared with black athletes (30.0% versus 12%; P=0 .027). Hypertrophic cardiomyopathy accounted for 90.5% of all clinical diagnoses. All black athletes and 93.3% of white athletes with a clinical diagnosis of cardiomyopathy or a genetic mutation capable of causing cardiomyopathy exhibited lateral TWI as opposed to isolated anterior or inferior TWI; the genetic yield of diagnoses from lateral TWI was 12.3%. Conclusions: Up to 10% of athletes with TWI revealed mutations capable of causing cardiac disease. Despite the substantial cost, the positive diagnostic yield from genetic testing was one half that from clinical evaluation (10% versus 21%) and contributed to additional diagnoses in only 2.5% of athletes with TWI in the absence of a clear clinical phenotype, making it of negligible use in routine clinical practice.

BACKGROUND: Reports on the incidence and causes of sudden cardiac death among young athletes have relied largely on estimated rates of participation and varied methods of reporting. We sought to investigate the incidence and causes of sudden cardiac death among adolescent soccer players in the United Kingdom. METHODS: From 1996 through 2016, we screened 11,168 adolescent athletes with a mean (±SD) age of 16.4±1.2 years (95% of whom were male) in the English Football Association (FA) cardiac screening program, which consisted of a health questionnaire, physical examination, electrocardiography, and echocardiography. The FA registry was interrogated to identify sudden cardiac deaths, which were confirmed with autopsy reports. RESULTS: During screening, 42 athletes (0.38%) were found to have cardiac disorders that are associated with sudden cardiac death. A further 225 athletes (2%) with congenital or valvular abnormalities were identified. After screening, there were 23 deaths from any cause, of which 8 (35%) were sudden deaths attributed to cardiac disease. Cardiomyopathy accounted for 7 of 8 sudden cardiac deaths (88%). Six athletes (75%) with sudden cardiac death had had normal cardiac screening results. The mean time between screening and sudden cardiac death was 6.8 years. On the basis of a total of 118,351 person-years, the incidence of sudden cardiac death among previously screened adolescent soccer players was 1 per 14,794 person-years (6.8 per 100,000 athletes). CONCLUSIONS: Diseases that are associated with sudden cardiac death were identified in 0.38% of adolescent soccer players in a cohort that underwent cardiovascular screening. The incidence of sudden cardiac death was 1 per 14,794 person-years, or 6.8 per 100,000 athletes; most of these deaths were due to cardiomyopathies that had not been detected on screening. (Funded by the English Football Association and others.).