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Sudden cardiac arrest and death occur among competitive and recreational athletes across the entire spectrum of age, sex, and level of competition. These events are tragic, potentially preventable, and represent a global public health concern. Currently, the precise incidence of sudden cardiac arrest and death among all athletes is uncertain due to the lack of both mandatory case reporting and the infrastructure to process all cases that occur within the general population. Disparities in outcomes between Black and White athletes also exist without explanation. Causes of sudden cardiac arrest and death are age-dependent, with genetic heart conditions and unexplained cases (ie, normal autopsy) predominant among younger athletes, and coronary artery disease accounting for most cases among veteran Masters athletes. Determining best practices for prevention of primary sudden cardiac arrest and death, including preparticipation screening, remains controversial. However, secondary prevention grounded in an emergency action plan incontrovertibly represents a fundamental aspect of comprehensive cardiac care for all athletes. [ABSTRACT FROM AUTHOR]

Introduction: Chest discomfort is a common clinical challenge in emergency departments nationwide and stress testing is frequently used to risk stratify patients presenting with this complaint. Understanding contemporary patterns of stress test utilization according to pretest risk and downstream consequences is critical in this era of value-based healthcare. Methods: We conducted a retrospective study of patients who presented to one academic emergency department with chest discomfort and who underwent non-invasive imaging for risk stratification in 2017. Physicians reviewed charts of a randomly selected subset of 175 patients who underwent stress testing and stratified them by retrospectively calculated HEART scores. Among patients with reversible ischemia on stress testing, we assessed downstream testing and subsequent coronary interventions. Results: Among 175 patients, the mean age was 60±10 years, 51% were female, 56% were black, and 22% had a history of coronary artery disease (CAD). By HEART score, 18%, 72%, and 10% were low, intermediate, and high risk for clinically significant CAD, respectively. Twenty-four (13.7%) had stress tests positive for ischemia, and 11 (6.3%) underwent diagnostic cardiac catheterization. Of the 175 patients, four (2.3%) underwent coronary revascularization, all of whom were intermediate-risk. Among the 18% of low-risk individuals, two had reversible ischemia without significant CAD on catheterization. Conclusion: In a contemporary cohort at a large academic center, there is a low yield of detecting clinically significant CAD with stress testing among patients presenting with chest discomfort. In addition, 18% of all patients undergoing stress testing were low risk and did not require further risk stratification but underwent unnecessary downstream testing. Development of a clear pathway may help to optimize resource utilization in this population. [ABSTRACT FROM AUTHOR]

Routine exercise leads to cardiovascular adaptations that differ based on sex. Use of cardiac testing to screen athletes has driven research to define how these sex-based adaptations manifest on the electrocardiogram and cardiac imaging. Importantly, sex-based differences in cardiovascular structure and outcomes in athletes often parallel findings in the general population, underscoring the importance of understanding their mechanisms. Substantial gaps exist in the understanding of why cardiovascular adaptations and outcomes related to exercise differ by sex because of underrepresentation of female participants in research. As female sports participation rates have increased dramatically over several decades, it also remains unknown if differences observed in older athletes reflect biological mechanisms vs less lifetime access to sports in females. In this review, we will assess the effect of sex on cardiovascular adaptations and outcomes related to exercise, identify the impact of sex hormones on exercise performance, and highlight key areas for future research. [Display omitted] • Exercise performance, cardiac adaptation, and outcomes of exercise differ based on sex. • Female sex appears protective against exercise-associated coronary artery calcification, myocardial fibrosis, atrial fibrillation, and sudden cardiac death. • Greater representation of females in research will improve understanding of the causes of sex-based differences in the effect of exercise on the cardiovascular system. [ABSTRACT FROM AUTHOR]