Pre-competition check-up: Strengthening the athletic heart

Introduction

Regular exercise offers important benefits to the cardiovascular system, improving cardiorespiratory fitness, muscle and bone health, and helping to reduce mortality from cardiovascular disease. However, safe participation of athletes in vigorous physical activities requires precompetitive diagnostic testing to prevent cardiovascular events.

The “sports heart” concept

The athlete's heart shows physiological morphological morphological adaptations to systematic exercise, which are summarized in the term “athlete's heart”. These adaptations vary according to the type of sport:

• Endurance sports (e.g., marathon): increased internal dimensions of the heart to improve cardiac output.

• Strength sports (e.g. weightlifting): thickening of the heart walls due to increased pressure during training.

• Mixed sports (e.g., soccer): combination of increased dimensions and wall thickening.

• The importance of precompetitive cardiac testing.

The prevention of sudden cardiovascular events in athletes is a key priority for the medical community. Guidelines from international cardiology organizations, such as the American Heart Association (AHA) and the European Society of Cardiology (ESC), recommend regular testing to ensure the safe participation of athletes in competitions.

Objectives of pre-competition testing

Identification of athletes at increased risk:

Family history of inherited cardiovascular disease.

History of juvenile sudden cardiac death.

Young people with unexplained syncopal episodes.

Prevention of unpleasant events such as sudden cardiac death.

Establishment of an allowable level of physical activity for athletes with cardiovascular disease.

Diagnostic methods

Pre-race screening includes:

• Taking an individual and family medical history.

• Medical examination.

• Personal and family medical history, medical examination and medical history.

• Cardiac ultrasound, if necessary.

In doubtful cases:

• Stress test.

• Cardiac magnetic resonance.

Conclusion

Pre-race cardiac screening is vital to ensure the health of athletes. Performed by qualified cardiologists at regular intervals, in accordance with scientific guidelines, it contributes to the prevention of cardiovascular events and safe participation in sport.

What experts recommend for participation in sporting activities according to age

In healthy people over 35 years of age, with a low cardiovascular risk, a basic cardiological check-up with family history, physical examination and resting electrocardiogram should precede participation in all sports. All of the above, with the addition of a fatigue test, should be performed in sedentary individuals and in individuals at high or very high cardiovascular risk who intend to participate in intense exercise programs or competitive sports, as well as in competitive club athletes.

In selected individuals, without known coronary artery disease, who are at very high risk for cardiovascular disease and who wish to participate in high or very high intensity exercise, further risk assessment with a functional imaging test (myocardial scintigraphy or stress echo), coronary CT, or carotid or femoral artery ultrasound may be necessary.

For adults over 65 years of age who are in good health and have no health problems, but have limited mobility, moderate aerobic exercise for at least 150 minutes per week is recommended. For older adults at risk for falls, strength training with exercises to improve balance and coordination is recommended at least 2 days per week. For sedentary adults aged 65 years or older who wish to participate in high-intensity activity, a full clinical evaluation, including a maximal fatigue test, should be considered.

Continued high and very high intensity activity, including competitive sports, can be performed in asymptomatic older athletes (master athletes) with low to moderate cardiovascular risk. Even patients with significant heart disease, such as myocardial infarction, heart failure, or after coronary angiography or cardiac surgery, should be included in a cardiac rehabilitation program of moderate to vigorous intensity aerobic exercise at least 3 times per week for 30 minutes at a time, under cardiological guidance.

Myths and truths about the athlete's heart

The observation that the heart of an athlete differs from that of an average adult has been made since 1890. Today, with the use of specialized diagnostic methods, we know that the heart presents physiological structural and functional adaptations to systematic exercise, which are summarized in the term “athlete's heart”.

The physiological remodeling of the cardiac muscle depends on the athlete's training needs, as occurs with all the muscles of the body. Different adaptations are distinguished in endurance sports with intense aerobic needs (long distance running, cycling, swimming) and other adaptations in strength sports with a high degree of anaerobic exercise (weightlifting, athletics throwing).

The heart of the marathon runner usually shows an increase in internal dimensions of up to 15% compared to people of the same sex and age who do not practice sport. In contrast, the heart of a weightlifter is mainly characterized by a wall thickening of up to 20%.

Most sports are characterized by combinations of aerobic and anaerobic exercise, such as the popular soccer, which is classified as a moderately anaerobic and at the same time highly aerobic sport. For this reason, in soccer players the changes observed in the heart are of mixed morphology, combining both an increase in the dimensions of the cardiac cavities and a thickening of the heart walls. In addition, especially in endurance sports, the resting heart rate is reduced and benign rhythm disturbances and certain forms of arrhythmia are induced, which usually disappear during exercise.

Intense exercise can become a detrimental process for the heart.

There is usually a reaction to an action. In the last two decades, in particular, certain strenuous endurance sports, such as triathlons, marathons, ultramarathons and iron man, have attracted increasing numbers of participants. Studies of these athletes have revealed increased levels of cardiac necrosis markers in several of them. In addition, it was observed that long-term sporting activity after the age of 30, with more than 1 500 hours in total and more than 5 hours of very intense exercise per week, increases the risk of atrial fibrillation, an arrhythmia that is often a cause of severe disability.

Consequently, the question arose as to whether in some people with a normal heart, frequent, repeated and very intense exhaustive exercise can lead to necrosis of cardiac cells and thus provide a substrate for malignant arrhythmias.

The aforementioned changes in heart structure due to exercise modify the usual and expected findings of both the cardiogram and echocardiogram in such a way that they resemble those recorded in pathological conditions such as myocardial infarction, inflammation and/or cardiomyopathies, which are the most frequent cause of sudden cardiac death in young professional athletes.

In addition, endurance sports in particular cause a reduction in resting heart rate and lead to the development of abnormalities of normal heart rhythm and certain forms of arrhythmia, which usually disappear during exercise.

The role of the specialist cardiologist in the diagnosis and follow-up of sportsmen and women

This point highlights the important role of the specialist cardiologist, who is systematically involved in the follow-up of athletes. He or she is called upon to recognize and differentiate findings due to normal adaptation of the heart to sport from those due to pathological conditions, such as cardiomyopathies, which often lead to tragic events on the field of play, especially in young athletes.

In addition, an erroneous diagnosis can deprive a young person from participating in sports activities, which can mark his or her life.