Prevención de muerte súbita en el deporte mediante el cribado pre-participativo

[spa] La muerte súbita en el deporte tiene una incidencia relativamente baja, estimada en 1-2 cada 100.000 deportistas por año; sin embargo, tiene un gran impacto; generando una idea errónea contraria al paradigma que el deporte es beneficioso. HIPOTESIS: El cribado pre-participativo intenta disminuir la incidencia de muerte súbita en el deporte, identificando la mayoría de los individuos susceptibles a tenerla. OBJETIVOS: 1) Analizar la utilidad del ecocardiograma en el cribado pre-participativo; 2) Evaluar la utilidad de cada uno de los estudios utilizados en el cribado pre-participativo y el análisis de coste eficacia; 3) Evaluar la utilidad del ECG y el ecocardiograma Doppler en el diagnóstico diferencial de la Miocardiopatía Hipertrófica; 4) Estudiar el pronóstico de una respuesta hipertensiva exagerada durante el ejercicio. METODOLOGÍA: Se estudió una cohorte de 3000 deportistas competitivos, entre 12 y 35 años, de tres centros de alto rendimiento en los cuales se realizó una valoración pre-competitiva mediante; a) historia familiar/personal y examen físico, b) electrocardiograma, c) ecocardiograma, y d) prueba de esfuerzo. RESULTADOS: El ECG y el ecocardiograma fueron los estudios más útiles para detectar deportistas susceptibles de padecer muerte súbita en la edad adolescente o joven adulta. El ecocardiograma aporta mayor sensibilidad, detectando algunas alteraciones estructurales cardíacas que pueden pasar desapercibidas con el examen físico y el ECG; nuestros resultados sugieren la necesidad de la introducción del ecocardiograma al menos en el primer cribado pre-participativo de deportistas competitivos. La prueba de esfuerzo presentó mayor utilidad para el diagnóstico de arritmias con tratamiento específico. El cuestionario AHA presenta una débil utilidad diagnóstica siendo limitado su uso como único test de cribado. En nuestro medio el cribado pre-participativo fue costo efectivo para detectar deportistas susceptibles de sufrir una muerte súbita en el deporte. Para el diagnóstico diferencial entre miocardiopatía hipertrófica y corazón de deportista puede ser útil el espesor septal relativo > 0.54. La elevación de la presión arterial diastólica > 95 mmHg en el ejercicio máximo o de la presión arterial sistólica > 180 mmHg en el ejercicio moderado fueron los mejores predictores de hipertensión en los próximos 20 años.[eng] Sudden death in sports has a relatively low incidence, estimated at 1-2 per 100,000 athletes per year; however, it has a great impact; generating an erroneous idea contrary to the paradigm that sport is beneficial. HYPOTHESIS: Pre-participation screening attempts to reduce the incidence of sudden death in sports, identifying the majority of individuals susceptible to having it. OBJECTIVES: 1) To analyze the usefulness of echocardiography in pre-participation screening; 2) To evaluate the utility of each one of the studies used in the pre-participation screening and the cost effectiveness analysis; 3) To evaluate the usefulness of ECG and Doppler echocardiography in the differential diagnosis of hypertrophic cardiomyopathy; 4) Study the prognosis of an exaggerated hypertensive response during exercise. METHODOLOGY: A cohort of 3000 competitive athletes, between 12 and 35 years old, from three high performance centers in which a pre-competitive assessment was carried out by means of; a) family / personal history and physical examination, b) electrocardiogram, c) echocardiogram, and d) stress test. RESULTS: The ECG and the echocardiogram were the most useful studies to detect athletes susceptible to sudden death in the adolescent or young adult age. The echocardiogram provides greater sensitivity, detecting some cardiac structural alterations that can go unnoticed with the physical examination and the ECG; Our results suggest the need for the introduction of echocardiography at least in the first pre-participation screening of competitive athletes. The stress test was more useful for the diagnosis of arrhythmias with specific treatment. The AHA questionnaire has a weak diagnostic utility, its use being limited as the only screening test. In our setting, pre-participation screening was cost effective to detect athletes susceptible to sudden death in sports. For the differential diagnosis between hypertrophic cardiomyopathy and athlete's heart, relative septal thickness> 0.54 may be useful. Elevation of diastolic blood pressure> 95 mmHg in maximal exercise or systolic blood pressure> 180 mmHg in moderate exercise were the best predictors of hypertension in the next 20 years

Echocardiography in the evaluation of athletes

Echocardiography is currently a widely available imaging technique that can provide useful data in the field of sports cardiology particularly in two areas: pre-participation screening and analysis of the cardiac adaptation induced by exercise. The application of pre-participation screening and especially, the type and number of used diagnostic tests remains controversial. Echocardiography has shown though, higher sensitivity and specificity as compared to the ECG, following a protocol adapted to athletes focused on ruling out the causes of sudden death and the most common disorders in this population. It is still a subject of controversy the actual cost of adding it, but depending on the type of sport, echocardiography might be cost-effective if added in the first line of examination. Regarding the evaluation of cardiac adaptation to training in athletes, echocardiography has proved to be useful in the differential diagnosis of diseases that can cause sudden death, analysing both the left ventricle (hypertrophy cardiomyopathy, dilated cardiomyopathy, left ventricle non compaction) and the right ventricle (arrhythmogenic right ventricular cardiomyopathy). The aim of this paper is to review the current knowledge and the clinical practical implications of it on the field of echocardiography when applied in sport cardiology areas

Impact of common cardio-metabolic risk factors on fatal and non-fatal cardiovascular disease in Latin America and the Caribbean: an individual-level pooled analysis of 31 cohort studies

Background: Estimates of the burden of cardio-metabolic risk factors in Latin America and the Caribbean (LAC) rely on relative risks (RRs) from non-LAC countries. Whether these RRs apply to LAC remains un- known. Methods: We pooled LAC cohorts. We estimated RRs per unit of exposure to body mass index (BMI), systolic blood pressure (SBP), fasting plasma glucose (FPG), total cholesterol (TC) and non-HDL cholesterol on fatal (31 cohorts, n = 168,287) and non-fatal (13 cohorts, n = 27,554) cardiovascular diseases, adjusting for regression dilution bias. We used these RRs and national data on mean risk factor levels to estimate the number of cardiovascular deaths attributable to non-optimal levels of each risk factor. Results: Our RRs for SBP, FPG and TC were like those observed in cohorts conducted in high-income countries; however, for BMI, our RRs were consistently smaller in people below 75 years of age. Across risk factors, we observed smaller RRs among older ages. Non-optimal SBP was responsible for the largest number of attributable cardiovascular deaths ranging from 38 per 10 0,0 0 0 women and 54 men in Peru, to 261 (Dominica, women) and 282 (Guyana, men). For non-HDL cholesterol, the lowest attributable rate was for women in Peru (21) and men in Guatemala (25), and the largest in men (158) and women (142) from Guyana. Interpretation: RRs for BMI from studies conducted in high-income countries may overestimate disease burden metrics in LAC; conversely, RRs for SBP, FPG and TC from LAC cohorts are similar to those esti- mated from cohorts in high-income countries

Influence of gender on right ventricle adaptation to endurance exercise: an ultrasound two-dimensional speckle-tracking stress study

Background: Characteristic right ventricle (RV) remodelling is related to endurance exercise in male athletes (MAs), but data in female athletes (FAs) are scarce. Our aim was to evaluate sex-related influence on exercise-induced RV remodelling and on RV performance during exercise. Methods: Forty endurance athletes (>10 training hours/week, 50% female) and 40 age-matched controls (<3 h moderate exercise/week, 50% female) were included. Echocardiography was performed at rest and at maximum cycle-ergometer effort. Both ventricles were analysed by standard and speckle-tracking echocardiography. Results: Endurance training induced similar structural and functional cardiac remodelling in MAs and FAs, characterized by bi-ventricular dilatation [~34%, left ventricle (LV); 29%, RV] and normal bi-ventricular function. However, males had larger RV size (p < 0.01), compared to females: RV end-diastolic area (cm2/m2): 15.6 ± 2.2 vs 11.6 ± 1.7 in athletes; 12.2 ± 2.7 vs 8.6 ± 1.6 in controls, respectively, and lower bi-ventricular deformation (RV global longitudinal strain (GLS) (%): −24.0 ± 3.6 vs −29.2 ± 3.1 in athletes; −24.9 ± 2.5 vs −30.0 ± 1.9 in controls, and LVGLS: −17.5 ± 1.4 vs −21.9 ± 1.9 in athletes; −18.7 ± 1.2 vs −22.5 ± 1.5 in controls, respectively, p < 0.01). During exercise, the increase in LV function was positively correlated (p < 0.01) with increased cardiac output (∆%LV ejection fraction, r = +0.46 and ∆%LVGLS, r = +0.36). Improvement in RV performance was blunted at high workloads, especially in MAs. Conclusion: Long-term endurance training induced similar bi-ventricular remodelling in MAs and FAs. Independently of training load, males had larger RV size and lower bi-ventricular deformation. Improvement in RV performance during exercise was blunted at high workloads, especially in MAs. The potential mechanisms underlying these findings warrant further investigation.This work was partially funded by grants from the Generalitat de Catalunya FI-AGAUR 2014–2017 (RH 040991, M. Sanz), and from the Spanish Government (Plan Nacional I + D, Ministerio de Economia y Competitividad DEP2013-44923-P; TIN2014-52923-R and FEDER)

Influence of gender on right ventricle adaptation to endurance exercise: an ultrasound two-dimensional speckle-tracking stress study

Background: Characteristic right ventricle (RV) remodelling is related to endurance exercise in male athletes (MAs), but data in female athletes (FAs) are scarce. Our aim was to evaluate sex-related influence on exercise-induced RV remodelling and on RV performance during exercise. Methods: Forty endurance athletes (>10 training hours/week, 50% female) and 40 age-matched controls (<3 h moderate exercise/week, 50% female) were included. Echocardiography was performed at rest and at maximum cycle-ergometer effort. Both ventricles were analysed by standard and speckle-tracking echocardiography. Results: Endurance training induced similar structural and functional cardiac remodelling in MAs and FAs, characterized by bi-ventricular dilatation [~34%, left ventricle (LV); 29%, RV] and normal bi-ventricular function. However, males had larger RV size (p < 0.01), compared to females: RV end-diastolic area (cm2/m2): 15.6 ± 2.2 vs 11.6 ± 1.7 in athletes; 12.2 ± 2.7 vs 8.6 ± 1.6 in controls, respectively, and lower bi-ventricular deformation (RV global longitudinal strain (GLS) (%): −24.0 ± 3.6 vs −29.2 ± 3.1 in athletes; −24.9 ± 2.5 vs −30.0 ± 1.9 in controls, and LVGLS: −17.5 ± 1.4 vs −21.9 ± 1.9 in athletes; −18.7 ± 1.2 vs −22.5 ± 1.5 in controls, respectively, p < 0.01). During exercise, the increase in LV function was positively correlated (p < 0.01) with increased cardiac output (∆%LV ejection fraction, r = +0.46 and ∆%LVGLS, r = +0.36). Improvement in RV performance was blunted at high workloads, especially in MAs. Conclusion: Long-term endurance training induced similar bi-ventricular remodelling in MAs and FAs. Independently of training load, males had larger RV size and lower bi-ventricular deformation. Improvement in RV performance during exercise was blunted at high workloads, especially in MAs. The potential mechanisms underlying these findings warrant further investigation.This work was partially funded by grants from the Generalitat de Catalunya FI-AGAUR 2014–2017 (RH 040991, M. Sanz), and from the Spanish Government (Plan Nacional I + D, Ministerio de Economia y Competitividad DEP2013-44923-P; TIN2014-52923-R and FEDER)