Mass General team calls for more ‘sports’ in cardiovascular training

A Massachusetts General Hospital team, led by Aaron Baggish, MD, director of Mass General’s Cardiovascular Performance Program, has defined a curriculum to address the rising number of competitive athletes and highly active people (CAHAP) who may be at increased risk of cardiovascular (CV) events. The curriculum is proposed in response to a lack of competency standards in sports cardiology as the field grows.

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Reported in the Journal of the American College of Cardiology, the curriculum has four core competencies.

Differentiation of Exercise-induced Cardiac Remodeling (EICR)

Sports cardiologists are encouraged to understand the American Heart Association (AHA)/American College of Cardiology (ACC) classification of sports, modern exercise physiology and EICR that involve both static and dynamic stress. Among key learnings are:

• Factors behind EICR variability
• Structural and functional patterns of CV adaptation for forms of exercise and the variants within CAHAP in non-invasive imaging
• Athlete-specific ECG interpretation

Evaluation of Symptomatic CAHAP

Sport cardiologists should evaluate CAHAP and their unique considerations when they present with symptoms suggestive of CV disease. The curriculum advises those in the specialty to understand the basic principles of general cardiology and exercise physiology.

Management of CAHAP With CV Disease

The publication urges sports cardiologists to learn and understand the AHA/ACC Eligibility and Disqualification Recommendations for Competitive Athletes and the approach for determining eligibility for CAHAP with CV diagnoses. Among key learnings around CAHAP are:

• Physical activity guidelines for the general population that emphasize differentiating the role of exercise for health promotion versus athletic performance
• Common genetic and acquired forms of heart muscle disease that are associated with risk of adverse events during exercise
• Guidelines for diagnosis, risk stratification and management of genetic and acquired forms of heart muscle disease

Collaborative Pre-participation CV Screening

The core curriculum encourages sports cardiologists to comprehend the AHA/ACC recommendations for pre-participation CV screening (PPCS) and that the pre-participation physical evaluation (PPE-4) is the current standard of care along with the need for standardized tools and PPCS’ limitations. Among key learnings are:

• How to rapidly and effectively handle abnormal findings
• There is insufficient data to define the effect of PPCS on sudden cardiac death
• Controversial role of testing, including the use of ECG and non-invasive imaging

Interesting Takeaways

The authors believe the curriculum will raise standards in sports cardiology clinical care, training, board certification and research. They believe a sports cardiologist can optimize a CAHAP care team.

Highlighted in the framework are areas of consensus as well as questions that still need answers. For example, it is understood that EICR reveals itself differently across athletic populations and is influenced by factors, such as age, gender and genetics. It’s also known that the scope of EICR is expanding beyond left ventricle structure and diastolic function to other aspects of the heart. These changes may not be detected or ruled out through reliance on ECG.

Unsettled questions include whether ECG interpretations can be correlated with definitive clinical outcomes, including those related to EICR. To date, no large clinical trials have answered this.

The framework emphasizes non-invasive imaging of EICR and how it can show three common “gray zones”: thick left ventricular walls, left ventricle chamber and dilated right ventricle chamber. Each zone has its own set of differential diagnoses. For example, left and right ventricle dilation from EICR appears similar to chamber dimensions in patients with CV disease. Only through a review of key metrics and testing results can benign EICR be accurately distinguished from myocardial pathology unrelated to exercise.

A similar differential diagnostic process should occur when CAHAP present with symptoms of chest pain, palpitations, syncope or impaired exercise capacity. For chest pain, the importance of age as a criterion is stressed. CAHAP under 35 with chest pain rarely have underlying cardiovascular disease (approximately 6% do), but they can have life-threatening diseases such as congenital disease valvular disease or hypertrophic cardiomyopathy. By contrast, CAHAP who are over 35 years of age and have chest pain often have atherosclerotic disease.

In terms of managing CAHAP with known cardiac diagnoses, the authors believe that their curriculum complements the 2015 ACC and AHA recommendations for competitive athletes and extends to non-competitive athletes.

Read our Q and A with the authors of this sports cardiology curriculum. 

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