Apunts Medicina de l'Esport (English Edition) Apunts Medicina de l'Esport (English Edition)
Apunts Med Esport. 2017;52:11-6 - Vol. 52 Num.193

Cardiological contraindications in sports

Gonzalo Grazioli a, Daniel Brotons b, Fernando Pifarré b, Maria Sanz de la Garza a, Sílvia Montserrat a, Bàrbara Vidal a, Carles Miñarro c, Ramón Pi d, Georgia Sarquella-Brugada e, Josep Antoni Gutiérrez b, Josep Brugada a, Marta Sitges a

a Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
b Consell Català de l’Esport, Catalonia, Spain
c Centre d’Alt Rendiment, Sant Cugat del Vallès, Catalonia, Spain
d Futbol Club Barcelona, Barcelona, Catalonia, Spain
e Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Catalonia, Spain

Keywords

Pre-participation screening; Recommendations; Sudden cardiac death

Abstract

La muerte súbita en el deporte está causada en la mayoría de ocasiones por enfermedades cardiacas. El objetivo del cribado pre-participativo es poder identificar a los individuos que requieran un tratamiento específico para continuar el deporte o el cese de la práctica deportiva. La evidencia científica actual se basa en recomendaciones de expertos que en algunos casos son controvertidas y en ocasiones poco prácticas. Esta revisión tiene como objetivo dar un enfoque actualizado y pragmático de las recomendaciones en los deportistas con cardiopatía.

Article

Introduction

The cardiovascular benefits of moderate exercise are well established.1 However, exercise can occasionally cause sudden cardiac death in athletes with heart disease base.2 In this context, sport disqualification of affected individuals has proven to be a useful strategy in the only study with this objective.3

The recent update of the Bethesda conference4 provides recommendations C-level (expert opinion) for competitive athletes, but in some points differs from the European cardiomyopathies and valvular recommendations,5 arrhythmias and channelopathies,6,7 and congenital heart disease.8 The group of sports cardiology at the European Society of Cardiology9 included recommendations for non-competitive athletes, i.e.: those who practice recreational sport and physical activity in general, recommendations that had not been previously incorporated; also, in this publication a change of practical value is added at the time of giving a medical recommendation for conducting sports, changing the dynamic component of classification Mitchell10 (Table 1) by the percentage of heart rate (HR) maximum obtained in a stress test analysis of respiratory gases; or the equivalent in the Borg scale of perceived exertion (Table 2).

Table 1. Classification of Mitchell for sports

Table 2. Borg Scale

Definitions

The type of physical activity is of particular importance to the recommendation in the intensity of exercise. Here are some definitions to distinguish amongst different types of physical activity in which there is international consensus.

Physical activity

Any bodily movement produced by muscles contraction that increases the metabolic rate above resting level. Moderate activity is defined as an activity between 3-6 METs and vigorous when it is > 6 METs.8

Regular exercise

It is physical activity planned, structured and repetitive; which is performed for more than 30 min at least 3 days a week for the last 3 months with a moderate intensity; and it aims to maintain or improve physical fitness.11

Recreational sport

Physical activities without the need to compete or that have not a greater intensity than desired by the participant. The activity or sport can be organized or informal, and can be spontaneous or structured for competition among participants or teams. However, any participant may stop participating or may decrease the intensity of his participation at any time, without pressure to continue.8

Competitive sport

Organized sport, competitive, and in which physical activities are governed by rules to keep a clean game. There is pressure to train or play at a high intensity regardless of whether that intensity is required or recommended for the participant. The source of that pressure may be the athlete himself, teammates, coaches or spectators.8

Elite

Competitive athlete training over 6 hours a week who regularly competes at regional, national or international level.12

Recommendations

The objective of this review is to summarize the main anomalies and heart disease that can be found in athletes and aims to give a recommendation and general pattern of steps to follow in the case of recommendation of the cardiological aptitude for sports taking the main groups of heart disease, i.e.: cardiomyopathies (table 3), valvular heart and aorta (table 4), arrhythmias and channelopathies (table 5), and congenital heart disease (table 6). For each of the alterations a recommended intensity is given depending on the type of recreational or competitive sport exercise. In order to simplify this indication a red color was granted when competitive sport is contraindicated and recreational sport is permitted if a low static component (Mitchell I) and is carried out at a lower intensity than 60% maximum heart rate or less than 5 Borg Scale; a yellow color is granted only when the competitive sport is allowed in sports classification of Mitchell IA (i.e.: golf, bowling) and recreational sport is permitted if it is a low-moderate static component (Mitchell I and II) and carried out at a lower intensity than 75% maximum heart rate or less than 6 Borg Scale. However, it is noteworthy that the decision should always be individualized and customized according to the severity of the disease, comorbidities of the subject, mode and sport that is practiced and, importantly, personal environment of the subject.

Table 3. Recommendations cardiomyopathies9,13

Table 4. Recommendations and aortic valve disease9,14-16

Table 5. Recommendations arrhythmias and channelopathies6,7,17,18

Table 6. Recommendations in congenital heart disease9,19

Play again

Table 7 shows the recommendations on the procedure to return to competitive sport (“play again”) after the different cardiological therapeutic interventions that have been made. It is recommended, if the procedure has no complications, to start training progressively and scheduled in the days before competition.

Table 7. “Return to play” in competitive sport after interventional treatment

Conflict of interests

Authors declare that they do not have any conflict of interests.


Received 18 September 2016;
accepted 27 September 2016

* Corresponding author.
E-mail address:
grazioli@clinic.ub.es">grazioli@clinic.ub.es (G. Grazioli)

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