The Master athlete: An extraordinary physiological model of aging study, a delicate issue for cardiologists and sports physicians

The prolongation of average life in the industrialized countries and the definitive demonstration of preventive and therapeutic role of regular physical exercise and sport, have greatly increased the number of middle-aged and older subjects engaged in the regular practice of sports activities, not only for fun or healthy purposes, but also at competitive level. The creation by sports federations of age categories (five years in five years) has strengthened the agonistic nature of the activity. Master athletes compete not only against adversaries of the same age group but even against themselves and the Time flowing inexorably. At the scientific and clinical level, two are the fundamental implications of this phenomenon. The first is the positive effect of a regular and intense performance training, both anaerobic and aerobic power. In the latter, regular and intense training is able to slow down significantly (even 50%) the natural, progressive decline of cardiorespiratory functions observed in healthy sedentary subjects of the same age. The second, the reverse of the medal, is the difficulty encountered by sports physician and cardiologist to correctly interpret the clinical/instrumental features of the Master athlete who undergoes pre-participation screening for competitive sports. It is not always easy to differentiate the physiological, adaptive, changes of a middle-aged and older athlete from the pathological ones, related to cardiovascular disease, typical of aging, such as ischemic heart disease, arrhythmias, hypertension, valvular diseases. These difficulties can only be solved by having an adequate knowledge of the clinical and instrumental manifestations of the Master Athlete’s Heart and individual cardiopathies, and with the careful use of all modern cardiological instrumental investigations. In addition to echocardiography and maximal ECG stress-test (preferably cardio-pulmonary test), the magnetic resonance imaging with Gadolinium, and coronary tomography (TC) are playing a decisive role. [1

The chemical and biological response of two remote mountain lakes in the Southern Central Alps (Italy) to twenty years of changing physical and chemical climate

Two small high mountain lakes in the Alps were monitored in 1984-2003 to follow their response to changes in human impact, such as deposition of atmospheric pollutants, fish stocking and climate change. The results were compared to occasional samplings performed in the 1940s, and to the remains found in sediment cores. When monitoring started, the most acid-sensitive of them, Lake Paione Superiore, was acidified, with evident effects in its flora and fauna: benthic diatoms assemblage was shifted towards aci- dophilous species, and zooplankton lost the dominant species, Arctodiaptomus alpinus. Palaeolimnological studies outlined that lake acidification paralleled the increasing input of long-range transported industrial pollutants, traced by spherical carbonaceous parti- cles. On the contrary, the biota of Lake Paione Inferiore appeared to be mainly affected by fish stocking. In the last twenty years, de- crease in acid load from the atmosphere led to an improvement in lake water quality, with an increase in both pH and alkalinity. First signs of biological recovery were identified, such as change in diatom flora and appearance of sensitive species among benthic insects. However, climate change and episodic deposition of Saharan dust were important driving factors controlling lake water chemistry. Further monitoring to assess the effects of climate change and of the increasing load of nitrogen and other pollutants is recommended. Key word: atmospheric deposition, acidification, plankton, benthos, diatom

Demographic, clinical, and service-use characteristics related to the clinician’s recommendation to transition from child to adult mental health services

Purpose: The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians’ advice to continue treatment at AMHS. Methods: Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians’ transition recommendations. Results: Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS. Conclusion: Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services

Cohort profile : demographic and clinical characteristics of the MILESTONE longitudinal cohort of young people approaching the upper age limit of their child mental health care service in Europe

Purpose: The presence of distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) impacts continuity of mental health treatment for young people. However, we do not know the extent of discontinuity of care in Europe nor the effects of discontinuity on the mental health of young people. Current research is limited, as the majority of existing studies are retrospective, based on small samples or used non-standardised information from medical records. The MILESTONE prospective cohort study aims to examine associations between service use, mental health and other outcomes over 24 months, using information from self, parent and clinician reports. Participants: Seven hundred sixty-three young people from 39 CAMHS in 8 European countries, their parents and CAMHS clinicians who completed interviews and online questionnaires and were followed up for 2 years after reaching the upper age limit of the CAMHS they receive treatment at. Findings to date: This cohort profile describes the baseline characteristics of the MILESTONE cohort. The mental health of young people reaching the upper age limit of their CAMHS varied greatly in type and severity: 32.8% of young people reported clinical levels of self-reported problems and 18.6% were rated to be ‘markedly ill’, ‘severely ill’ or ‘among the most extremely ill’ by their clinician. Fifty-seven per cent of young people reported psychotropic medication use in the previous half year. Future plans: Analysis of longitudinal data from the MILESTONE cohort will be used to assess relationships between the demographic and clinical characteristics of young people reaching the upper age limit of their CAMHS and the type of care the young person uses over the next 2 years, such as whether the young person transitions to AMHS. At 2 years follow-up, the mental health outcomes of young people following different care pathways will be compared. Trial registration number: NCT03013595

Bicuspid Aortic Valve and Premature Ventricular Beats in Athletes

Background: The aim of this study was to identify a possible link between bicuspid aortic valve (BAV) and premature ventricular beats (PVBs), particularly from left and right ventricular outflow tracts, and to investigate possible associations between these arrhythmias and echocardiographic abnormalities. Methods: A comparison of sportspeople with and without BAV was performed to identify PVBs’ occurrence in these two series. Then, subdividing the BAV group on the presence of cardiovascular complications due to BAV, we compared arrhythmic features between these two subgroups and echocardiographic findings between athletes with and without left and right outflow tract PVBs. Results: PVBs in 343 athletes with BAV were compared with 309 athletes without BAV, showing an increased frequency (29% vs. 11.8%, p < 0.001; OR 3.1; CI 2.1–4.7) and origin from the left (18.4% vs. 3.2%, p < 0.001, OR 6.7; CI 3.4–13.4) and right (15.2% vs. 3.6%, p < 0.001, OR 4.8; CI 2.5–9.5) outflow tracts compared to other ventricular areas (fascicular PVBs p = 0.81, other morphologies p = 0.58). No difference in PVBs’ occurrence was found between near normal valve BAV and pathological BAV, nor was a difference in echocardiographic characteristics found between patients with and without outflow tract arrhythmias. Conclusions: A possible causal link between BAV and PVBs was highlighted, but no association between PVBs and complicated BAV was emphasized

'A bridge over troubled water': a case report

Background Myocardial bridge (MB) is the most common inborn coronary artery variant, in which a portion of myocardium overlies a major epicardial coronary artery segment. Myocardial bridge has been for long considered a benign condition, although it has been shown to cause effort-related ischaemia.Case summary We present the case of a 17-year-old female patient experiencing chest pain during physical activity. Since her symptoms became unbearable, electrocardiogram and echocardiography were performed together with a coronary computed tomography scan, revealing an MB on proximal-mid left anterior descending artery. In order to unequivocally unmask the ischaemic burden lent by MB, the patient underwent coronary angiography and physiological invasive test: instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) were calculated, both at baseline and after dobutamine infusion (5 mu g/kg/min). At baseline, iFR value was borderline (= 0.89), whereas after dobutamine infusion and increase in the heart rate, the patient suffered chest pain. This symptom was associated with a decrease in the iFR value up to 0.77. Consistently, when FFR was performed, a value of 0.92 was observed at baseline, while after inotrope infusion the FFR reached the haemodynamic significance (= 0.79). Therefore, a medical treatment with bisoprolol was started.Discussion Our clinical case shows the importance of a comprehensive non-invasive and invasive assessment of MB in young patients experiencing chest pain, with significant limitation in the daily life. The coronary functional indexes allow to detect the presence of MB-derived ischaemia, thus guiding the decision to undertake a medical/surgical therapy

Diagnostic Workflow in Competitive Athletes with Ventricular Arrhythmias and Suspected Concealed Cardiomyopathies

The diagnosis of structural heart disease in athletes with ventricular arrhythmias (VAs) and an apparently normal heart can be very challenging. Several pieces of evidence demonstrate the importance of an extensive diagnostic work-up in apparently healthy young patients for the characterization of concealed cardiomyopathies. This study shows the various diagnostic levels and tools to help identify which athletes need deeper investigation in order to unmask possible underlying heart disease

Diagnostic Workflow in Competitive Athletes with Ventricular Arrhythmias and Suspected Concealed Cardiomyopathies

The diagnosis of structural heart disease in athletes with ventricular arrhythmias (VAs) and an apparently normal heart can be very challenging. Several pieces of evidence demonstrate the importance of an extensive diagnostic work-up in apparently healthy young patients for the characterization of concealed cardiomyopathies. This study shows the various diagnostic levels and tools to help identify which athletes need deeper investigation in order to unmask possible underlying heart disease

The role of extensive diagnostic work-up in young athletes and non-athletes with complex ventricular arrhythmias - Concealed cardiomyopathies in athletes with ventricular arrhythmias

Ventricular tachyarrhythmias (VA) represent the first cause of death in athletes. The difference between electroanatomic substrate in athletes and non-athletes with complex VA is unknown

Myocardial bridge evaluation towards personalized medicine: study design and preliminary results of the RIALTO registry

Myocardial bridge (MB) is the most frequent inborn coronary artery variant in which a portion of the myocardium overlies an epicardial coronary artery segment. Although MB has long been considered a benign entity, a growing body of evidence has suggested its association with angina and adverse cardiac events. However, to date, no data on long-term prognosis are available, nor on therapies improving cardiovascular outcomes. We are currently conducting an ambispective, observational, multicentre, study in which we enrol patients with a clinical indication to undergo coronary angiography (CA) and evidence of MB, aiming to describe the incidence of symptoms and cardiovascular events at baseline and at long-term follow-up (FUP). The role of invasive full-physiology assessment in modifying the discharge therapy and eventually the perceived quality of life and the incidence of major cardiovascular events will be analysed. Basal clinical-instrumental data of eligible and consenting patients have been acquired after CA; FUP was performed 6, 12, and 24 months after the angiographic diagnosis of MB. The primary endpoint of the study is the incidence of major adverse cardiovascular events (MACE), defined as the composite of cardiac death, myocardial infarction, cardiac hospitalization, and target vessel revascularization; the secondary endpoints are the rate of patients with Seattle Angina Questionnaire (SAQ) summary score <70 and the incidence of MACE in patients undergoing invasive intracoronary assessment. Among patients undergone FUP visits, we recorded 31 MACE at 6 months (11.6%), 16 MACE at 12 months (6.5%), and 26 MACE at 24 months (13.5%). The rate of patients with SAQ <70 is 18.8% at 6 months, 20.6% at 12 months, and 21.8% at 24 months. To evaluate the prognostic role of invasive intracoronary assessment, we compared MB patients who underwent only angiographic evaluation (Angio group) to those who underwent acetylcholine (ACH) provocative test with indication to calcium-channel blockers (CCBs) at discharge (Angio + ACH + CCBs group) and those who underwent functional assessment with fractional flow reserve (FFR) with indication to beta-blockers (BBs) at discharge (Angio + FFR + BBs group). After 2 years of FUP, the rate of MACE was significantly reduced in both Angio + ACH + CCBs group (6 vs. 25%, P = 0.029) and Angio + FFR + BBs group (3 vs. 25%, P = 0.005) compared with Angio group. The preliminary results of our study showed that MB may be a cause of angina and adverse cardiac events in patients referred to CA for suspected coronary artery disease (CAD). Full-physiology assessment unmasking MB-related ischaemia mechanisms, allowed to guide the treatment, personalizing the clinical management, improving the quality of life, and cardiovascular outcomes in patients with MB