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Background Sudden cardiac arrest (SCA) is the leading cause of death in athletes during exercise. The effectiveness of school-based automated external defibrillator (AED) programmes has not been established through a prospective study. Methods A total of 2149 high schools participated in a prospective observational study beginning 1 August 2009, through 31 July 2011. Schools were contacted quarterly and reported all cases of SCA. Of these 95% of schools confirmed their participation for the entire 2-year study period. Cases of SCA were reviewed to confirm the details of the resuscitation. The primary outcome was survival to hospital discharge. Results School-based AED programmes were present in 87% of participating schools and in all but one of the schools reporting a case of SCA. Fifty nine cases of SCA were confirmed during the study period including 26 (44%) cases in students and 33 (56%) in adults; 39 (66%) cases occurred at an athletic facility during training or competition; 55 (93%) cases were witnessed and 54 (92%) received prompt cardiopulmonary resuscitation. A defibrillator was applied in 50 (85%) cases and a shock delivered onsite in 39 (66%). Overall, 42 of 59 (71%) SCA victims survived to hospital discharge, including 22 of 26 (85%) students and 20 of 33 (61%) adults. Of 18 student-athletes 16 (89%) and 8 of 9 (89%) adults who arrested during physical activity survived to hospital discharge. Conclusions High school AED programmes demonstrate a high survival rate for students and adults who suffer SCA on school campus. School-based AED programmes are strongly encouraged.

Background/aims Adult black athletes (BA) exhibit left ventricular hypertrophy (LVH) on echocardiography and marked ECG repolarisation changes resembling those observed in hypertrophic cardiomyopathy (HCM). Limited data are available for adolescent BA, the group most vulnerable to exercise-related sudden cardiac death. Methods Between 1996 and 2011, 245 male and 84 female adolescent BA from a wide variety of sporting disciplines underwent cardiac evaluation including ECG and echocardiography. Athletes exhibiting T-wave inversions and/or echocardiographic LVH were investigated further for quiescent cardiomyopathies. Results were compared with 903 adolescent white athletes (WA) and 134 adolescent sedentary black controls (BC). Results LVH on echocardiography was present in 7% of BA compared to only 0.6% of WA and none of the BC. In the very young (<16 years), 5.5% of BA, but none of the WA, demonstrated LVH. Within the BA group, LVH was more prevalent in men compared to women (9% vs 1.2%, p=0.012). T-wave inversions were present in 22.8% BA, 4.5% WA and 13.4% BC. T-wave inversions in BA occurred with similar frequency in men and women and were predominantly confined to leads V1–V4. T-wave inversions in the lateral leads, commonly associated with cardiomyopathies, were present in 2.4% of BA. On a further evaluation and mean follow-up of 8.3 years, none of the athletes exhibited HCM. Conclusions Athletic training has a pronounced effect on adolescent BA. Black athletes as young as 14 years of age may exhibit left ventricular wall thicknesses of 15 mm and marked repolarisation changes resembling HCM. Male and female BA demonstrate a high prevalence of T-wave inversions.

Life-threatening medical emergencies are an infrequent but regular occurrence on the football field. Proper prevention strategies, emergency medical planning and timely access to emergency equipment are required to prevent catastrophic outcomes. In a continuing commitment to player safety during football, this paper presents the FIFA Medical Emergency Bag and FIFA 11 Steps to prevent sudden cardiac death. These recommendations are intended to create a global standard for emergency preparedness and the medical response to serious or catastrophic on-field injuries in football.

ObjectivesMyocardial fibrosis (MF) is associated with an increased predisposition to adverse cardiac events. The accumulation of high-volume and high-intensity exercise over an extended duration potentially increases the risk of MF. Specific electrocardiographic markers have been correlated with the presence of MF. This study assessed the prevalence of MF-related electrocardiographic markers in a Track and Field Master Athletics Cohort (TaFMAC).MethodsTwelve-lead resting electrocardiograms (ECGs) were conducted on 155 athletes (90 males and 65 females) participating in the World Masters Athletics 2022. The ECG markers associated with MF, including pathological Q waves, inverted T waves, fragmented QRS complex, and prolonged QRS complex, were compared among different athletic specialities (endurance athletes n=51, sprinters n=69 and strength and power n=35).ResultsOverall, 71 instances of MF-related markers were identified from 155 ECG recordings (46%). Fragmented QRS emerged as the most common marker, with a prevalence of 29% in endurance and strength and power athletes, and 35% in sprinters. No significant group differences were observed in the prevalence of MF markers, whether analysed collectively (p=0.467) or individually (pathological Q waves p=0.367, inverted T waves p=0.309, fragmented QRS complex p=0.747 and prolonged QRS complex p=0.132).ConclusionsThe prevalence of MF markers, as determined by resting ECG, was evident in nearly half of masters athletes, irrespective of sex and sporting specialisation. These findings suggest resting ECG as a promising non-invasive method for the early identification of MF in athlete’s hearts.

High-intensity interval training (HIT) improves peak oxygen consumption (VO2peak) in de novo heart transplant (HTx) recipients. It remains unclear whether this improvement early after HTx is solely dependent on peripheral adaptations, or due to a linked chain of central and peripheral adaptations. The objective of this study was to determine whether HIT results in structural and functional adaptations in the cardiovascular system. Eighty-one de novo HTx recipients were randomly assigned to participate in either 9 months of supervised HIT or standard care exercise-based rehabilitation. Cardiac function was assessed by echocardiogram and the coronary microcirculation with the index of microcirculatory resistance (IMR) at baseline and 12 months after HTx. Cardiac function as assessed by global longitudinal strain was significantly better in the HIT group than in the standard care group (16.3±1.2% vs 15.6±2.2%, respectively, treatment effect = -1.1% (95% CI -2.0% to -0.2%), p=0.02), as was the end-diastolic volume (128.5±20.8 mL vs 123.4±15.5 mL, respectively, treatment effect=4.9 mL (95% CI 0.5 to 9.2 mL), p=0.03). There was a non-significant tendency for IMR to indicate improved microcirculatory function (13.8±8.0 vs 16.8±12.0, respectively, treatment effect = -4.3 (95% CI -9.1 to 0.6), p=0.08). When initiated early after HTx, HIT leads to both structural and functional cardiovascular adaptations. NCT01796379.

IntroductionThe cardiovascular benefits of physical exercise are well-known. However, vigorous exercise has also been associated with adverse cardiac effects. To improve our understanding of cardiovascular adaptation to exercise versus maladaptation and pathology, the limits of adaptation should be firmly established using state-of-the-art diagnostic modalities. We therefore initiated the Evaluation of Lifetime participation in Intensive Top-level sports and Exercise (ELITE) cohort to investigate the longitudinal (beneficial and pathological) cardiovascular effects of intensive elite sports and exercise.Methods and analysisELITE is a prospective, multicentre, longitudinal cohort study. Elite athletes, from the age of sixteen, are recruited in The Netherlands. The primary objective is to determine the association between elite sports and exercise-induced cardiac remodelling, cardiac pathology, and health benefits over time. Secondary objectives include determining and identifying genetic profiles of elite athletes, and how these are associated with cardiac indices. ELITE will collect data from consultations, electrocardiography, echocardiography and cardiac magnetic resonance imaging, and training- and injury data. ELITE will also collect blood for biobanking and cardiogenetics. Follow-up will take place at intervals of two to five years, and after the elite athletes’ professional careers have ended. In addition, a subcohort of ELITE has been established to investigate cardiac sequelae following infections associated with myocardial involvement, including SARS-CoV-2. ELITE is a prospective observational study; therefore, analyses will be primarily explorative.Ethics and disseminationThis study has been approved by the Medical Ethics Review Board of the Amsterdam University Medical Centers (NL71682.018.19). The results of the study will be disseminated by publication in peer-reviewed journals (Netherlands Trial Register number: NL9328).

BackgroundOut-of-hospital cardiac arrest (OHCA) in the young is a tragic event. Regular exercise reduces cardiovascular disease (CVD) risk but, at certain intensities and volumes, is associated with increased OHCA risk. Understanding symptoms, risk factors and aetiology is central for primary prevention.ObjectiveAssess symptoms and risk factors related to OHCA aetiology in young Norwegians, and the role of exercise volume.MethodWe obtained data from the Norwegian Cardiac Arrest Registry (2015–2017), medical records, autopsy reports and questionnaires. Inclusion criteria were ages 12–49 years and OHCA of presumed cardiac aetiology.ResultsData from 134 individuals (81 survivors, 53 deceased) showed that CVD symptoms were present during both rest/everyday activity and exercise in most victims, and were reported by more survivors than by next-of-kin of the deceased (78% vs 60%). Only 12% had symptoms just during exercise. Ischaemic heart disease was the leading cause (58% in males vs 38% in females), followed by structural, non-ischaemic heart disease. Sudden unexpected death syndrome (SUDS) was most common in individuals aged ≤35 years. Risk factors were present in 74%, with family history for CVD most prevalent (51%) and overweight in at least 33%. There were no significant differences in symptoms, risk factors or OHCA aetiology related to exercise volume prior to OHCA.ConclusionSymptoms and CVD risk factors were prevalent in young Norwegians suffering OHCA regardless of exercise volume. Ischaemic heart disease was the leading cause of OHCA. We suggest evaluating symptoms carefully and addressing risk factors to prevent OHCA in young Norwegians regardless of exercise habits.

ObjectiveLow energy availability (LEA) is common in athletes. Disturbances in sex hormone levels due to insufficient energy availability have been suggested to influence cholesterol metabolism and impact the overall risk for cardiovascular disease. We assessed the relationship between Low Energy Availability in Females Questionnaire (LEAF-Q) and Eating Disorder Examination Questionnaire Short (EDE-QS) scores with cholesterol levels in a cross-sectional study of female athletes.MethodFinnish national- to international-level female athletes self-reported physiological symptoms of LEA, including menstrual disturbances, using the LEAF-Q (n=176) and eating disorder symptoms using the EDE-QS (n=294). Serum cholesterol concentrations (mmol/L) were determined from venous blood samples. We analysed the relationship between the different variables using Pearson’s r and linear regression. We also studied separately participants representing lean sports, that is, sports that emphasise leanness (LEAF-Q, n=60; EDE-QS, n=80).ResultsLEA symptoms were common; 72 (41%) of 176 participants scored ≥8 points in the LEAF-Q, which is indicative of a high risk of problematic LEA. A one-point increase in LEAF-Q score was associated with a small, non-significant increase in low-density lipoprotein (LDL) cholesterol level (beta=0.024, 95% CI −0.0011 to 0.049, p=0.061). Higher EDE-QS scores were associated with higher LDL cholesterol levels (beta=0.028, 95% CI 0.0098 to 0.046, p=0.0029). These associations were somewhat stronger among athletes representing lean sports (LEAF-Q and LDL: beta=0.043, 95% CI 0.0041 to 0.08, p=0.031; EDE-QS and LDL: beta=0.036, 95% CI 0.0041 to 0.068, p=0.028).ConclusionIn this study, LEAF-Q and EDE-QS were associated with higher LDL cholesterol levels among athletes representing lean sports.

Sports medicine is a medical specialty that supports the performance of professional and amateur athletes while maintaining their health. Sports medicine professionals need to ensure the safe participation of athletes in sports activities achieved through a periodical preparticipation evaluation (PPE) and a regular medical monitoring of the athletes’ health in accordance with the latest recommendations regarding health condition and medical history, physical working capacity, training period and programme, recovery, nutrition, use of supplements, injuries prevention and safe return to play.In order to harmonise these national variations in the content and application of the PPE, the EFSMA Scientific and Educational Commission proposes a ‘gold standard’ for elite athletes across Europe.Important objectives of PPE are early detection and prevention of severe complications during sports activities both in leisure time and competitive sports. The PPE should entail the following diagnostic components: health status, anthropometry, functional and exercise capacity.It is of utmost importance to develop and implement preventive strategies such as the PPE. Besides monitoring the health status of athletes, the PPE plays an important role in the selection process, bringing valuable information for coaches and supporting a personalised treatment approach. Screening of athletes through a standardised digital PPE could be beneficial for a better understanding of the impact of long-term physical activity. Furthermore, PPE leads the scientific community to a way of working closer together in the interest of the athletes.

IntroductionThe association of physical activity (PA) with subclinical cardiovascular disease (CVD) is unclear. Clarifying this relationship may inform cardiovascular prevention strategies.MethodsWe performed a systematic review (CRD42021226089) using Medline, Embase, CINAHL and Cochrane (1 January 2000 to 1 September 2023). Studies published with adult populations exploring the relationship between objectively measured PA and subclinical CVD were included. Subclinical CVD was assessed using: ankle-brachial index (ABI); arterial stiffness; carotid artery disease; coronary artery atherosclerosis; endothelial function; and measures of cardiac structure and function. The Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) and Cochrane Risk of Bias tools were used for quality review.ResultsOf 68 included studies, most supported an inverse relationship between PA and subclinical CVD. Arterial stiffness was the most common outcome (n=40), and 33 studies suggested that less sedentary behaviour (SB), increased PA and/or higher intensity PA was associated with less arterial stiffness. Ten studies of carotid artery disease (total n=18), six of endothelial function (n=10), two of coronary artery disease (n=3) and all of ABI (n=6) suggested that PA or less SB is associated with less subclinical disease. Five studies assessing cardiac structure/function (n=6) suggested alterations in structure/function with PA.ConclusionsPA reduces the risk of CVD events, and this systematic review demonstrates that some of the benefits may be mediated by an inverse association between PA and subclinical CVD. Interventions to increase PA are important for CVD prevention, so we provide a comprehensive overview of which surrogate outcome measures may be most useful to assess future CVD prevention interventions.PROSPERO registration numberCRD42021226089.