Cause cardiovascolari di non idoneità all'attività sportiva agonistica. Studio e follow-up di atleti non idonei nel decennio 2001-2010 presso la Medicina dello Sport di Noale (VE)
Objective. The main goal of pre-participation screening is to identify the cohort of athletes affected by cardiovascular diseases at risk of sudden death during sports. The aim of this work is to analyze the cardiovascular causes of disqualification from competitive sports in athletes (young and master athletes) consecutively screened at the Centre for Sport Medicine in Noale (VE) between 2001 and 2010, and to collect the long term follow-up data about these athletes.
Methods. During the 2001-2010 period, 35627 athletes were screened (aged ≤ 35 years 91% and Master athletes 9%, 29% female). The athletes ultimately disqualified were 99 (2‰), 94 (95%) because of cardiovascular causes and 5 (5%) non-cardiovascular causes. Cardiovascular conditions causing disqualification were distinctly analyzed in athletes ≤35 years of age and Master, and on the basis of the reasons for proceeding to further examinations, i.e. 2nd level examination (echocardiography, 24-h Holter monitoring, exercise testing, cardiac magnetic resonance-CMR-, computed tomography, myocardial perfusion scintigraphy) and 3rd level (coronary angiography, endomyocardial biopsy, electrophysiological study). A sub-study was carried out on athletes with the suspicion of left circumflex coronary artery origin from the right aortic sinus by echocardiography, running behind the aorta, in order to better clarify the current guidelines regarding sports eligibility.
Results. A) Young athletes, aged ≤ 35 years, eventually disqualified from participation in competitive sport were 63 (1.9‰). They were referred for further examination because of personal history of cardiovascular diseases in 15 (24%), heart murmurs or systemic hypertension at physical examination in 5 (8%), changes on the 12-lead electrocardiogram or submaximal exercise test (arrhythmias or myocardial ischemia) in 39 (62%); reasons remained unknown in 4 (6%). Cardiovascular causes of disqualification were: bicuspid aortic valve with dilatation of ascending aorta or valve incompetence/stenosis (12), mitral valve prolapse with polymorphic ventricular arrhythmias (10), arrhythmogenic right ventricular cardiomyopathy (3), hypertrophic cardiomyopathy (3), congenital coronary artery diseases (3), previous myocarditis (2), dilated cardiomyopathy (1), atherosclerotic coronary artery disease (1), atrial septal defect (1), previous surgical repair of atrial septal defect (1), coronary artery aneurysms post- Kawasaki disease (1), left ventricular diverticulum (1), systemic hypertension (2) pulmonary hypertension (1). Finally rhythm and conduction abnormalities included junctional or supraventricular arrhythmias (3), 3rd-degree atrioventricular block (1), long QT syndrome (1), atrial fibrillation (1), and idiopathic ventricular arrhythmias (15). In a mean follow up of 63±34 months, the clinical course was unremarkable. Altogether the cardiac disease at risk of sudden death in the young (hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, congenital coronary artery anomalies) were identified in 8 athletes and they were all referred for further examination because of positive 12-lead ECG or ventricular arrhythmias. In 3 athletes the cardiovascular disease was not confirmed by additional tests (false-positive results).
B) Master athletes disqualified from participation in competitive sport were 31 (1%). They were referred for further examination because of personal history of valve disease 1 (3%), systemic hypertension at physical examination 3 (10%), ECG abnormalities in 2 (7%), positive finding in maximal stress test (arrhythmias or myocardial ischemia) in 23 (74%). In 2 (6%) athletes data are not available. Cardiovascular causes of disqualification in Master athletes were: mitral valve prolapse with ventricular arrhythmias (5), atherosclerotic coronary artery disease (4), systemic hypertension con multiorgan damage (3), hypertrophic cardiomyopathy (2), arrhythmogenic right ventricular cardiomyopathy (1), dilated cardiomyopathy (1), ventricular arrhythmias in myocardial fibrosis of unknown etiology (2), mitral valve prolapse with moderate incompetence (1) and finally idiopathic ventricular arrhythmias (12). In a mean follow-up of 76±41 months there were no deaths or other major events. The most common structural cardiovascular disease was coronary artery atherosclerosis with 4 athletes identified because of myocardial ischemia during stress test e 2 athletes with ventricular arrhythmias and ischemic heart disease onset during follow-up.
A total of 27 athletes (15 young and 12 Master athletes) were eventually considered affected by idiopathic ventricular arrhythmias. Among the 25 with available clinical and instrumental data, CMR was performed in 11 (42%), with contrast enhancement in 6 (23%).
C) Among 11 athletes with suspicion of anomalous origin of the left circumflex coronary artery from the right aortic sinus, only 1 showed abnormalities at basal ECG (ST-T changes in inferior and lateral leads). The diagnosis of anomalous coronary course behind the aorta was confirmed in 9 athletes (82%), while in 2 athletes there were normal coronaries. In one athlete with ST abnormalities on effort, inducible ischemia at stress CMR with signs of late enhancement, angiography demonstrated an anomalous origin of the right coronary artery from the left aortic sinus running behind the aorta. This patient was disqualified from sport participation. Among the remaining 10 athletes, all with negative stress test, no clinical events occurred during a mean follow-up of 24 months, despite they continued to participate in sport activities.
Conclusions. The rate of disqualification at pre-participation screening because of cardiovascular diseases is higher in Master than young athletes (1% vs. 1,9‰), with a greater incidence of ischemic cardiovascular disease in the former. The athletes with ischemic heart disease had known cardiovascular risk factors. Our data confirm the absence of symptoms and signs in Master athletes with atherosclerotic coronary disease and the importance to carefully investigate athletes with known cardiovascular risk factors during pre-participation screening, and to refer athletes for further clinical and instrumental investigations even if the exercise test is ambiguous. It is important to thoroughly examine risk factors also in young people <35 years due the rare but not exceptional possibility of coronary artery disease at this age. Our data confirm the usefulness of pre-participation screening and the key role of 12-led ECG and stress test for the identification of cardiovascular disease at risk of sudden death during sport. Cardiovascular disease and cardiomyopathies have shown good prognosis. A systematic follow-up of athletes disqualified from competition has been carried out and drug or interventional therapies have seen undertaken when deemed necessary. Cardiac magnetic resonance findings, mostly useless or ambiguous in the first years of the observational period, revealed to be of utmost value in the identification of cardiomyopathies in the recent years mainly thanks to the late-enhancement technique introduction.
Our preliminary data show a good diagnostic value of echocardiography in detection of coronary anomalies with a retro-aortic course. In the absence of signs of myocardial ischemia, the prognosis during short-term follow-up of athletes with left circumflex coronary artery origin from the right aortic sinus seems excellent
