Cardiological contraindications in sports
Contraindicaciones cardiológicas para la práctica deportiva
Gonzalo Graziolia, Daniel Brotonsb, Fernando Pifarréb, Maria Sanz de la Garzaa, Sílvia Montserrata, Bàrbara Vidala, Carles Miñarroc, Ramón Pid, Georgia Sarquella-Brugadae, Josep Antoni Gutiérrezb, Josep Brugadaa, Marta Sitgesa
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
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Antoni" "apellidos" => "Gutiérrez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 10 => array:3 [ "nombre" => "Josep" "apellidos" => "Brugada" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 11 => array:3 [ "nombre" => "Marta" "apellidos" => "Sitges" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Consell Català de l’Esport, Catalonia, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Centre d’Alt Rendiment, Sant Cugat del Vallès, Catalonia, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Futbol Club Barcelona, Barcelona, Catalonia, Spain" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] 4 => array:3 [ "entidad" => "Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Catalonia, Spain" "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Contraindicaciones cardiológicas para la práctica deportiva" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> The cardiovascular benefits of moderate exercise are well established.<span class="elsevierStyleSup">1</span> However, exercise can occasionally cause sudden cardiac death in athletes with heart disease base.<span class="elsevierStyleSup">2</span> In this context, sport disqualification of affected individuals has proven to be a useful strategy in the only study with this objective.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara"> The recent update of the Bethesda conference<span class="elsevierStyleSup">4</span> provides recommendations C-level (expert opinion) for competitive athletes, but in some points differs from the European cardiomyopathies and valvular recommendations,<span class="elsevierStyleSup">5</span> arrhythmias and channelopathies,<span class="elsevierStyleSup">6,7</span> and congenital heart disease.<span class="elsevierStyleSup">8</span> The group of sports cardiology at the European Society of Cardiology<span class="elsevierStyleSup">9</span> 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 Mitchell<span class="elsevierStyleSup">10</span> (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).</p><p class="elsevierStylePara"><img alt="Table 1. Classification of Mitchell for sports" src="276v52n193-90460846fig1.jpg"></img></p><p class="elsevierStylePara"><img alt="Table 2. Borg Scale" src="276v52n193-90460846fig2.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Definitions</span></p><p class="elsevierStylePara"> 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.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Physical activity</span></p><p class="elsevierStylePara"> 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.<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Regular exercise</span></p><p class="elsevierStylePara"> 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.<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Recreational sport</span></p><p class="elsevierStylePara"> 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.<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Competitive sport</span></p><p class="elsevierStylePara"> 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.<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Elite</span></p><p class="elsevierStylePara"> Competitive athlete training over 6 hours a week who regularly competes at regional, national or international level.<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Recommendations</span></p><p class="elsevierStylePara"> 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.</p><p class="elsevierStylePara"><img alt="Table 3. Recommendations cardiomyopathies9,13" src="276v52n193-90460846fig3.jpg"></img></p><p class="elsevierStylePara"><img alt="Table 4. Recommendations and aortic valve disease9,14-16" src="276v52n193-90460846fig4.jpg"></img></p><p class="elsevierStylePara"><img alt="Table 5. Recommendations arrhythmias and channelopathies6,7,17,18" src="276v52n193-90460846fig5.jpg"></img></p><p class="elsevierStylePara"><img alt="Table 6. Recommendations in congenital heart disease9,19" src="276v52n193-90460846fig6.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Play again</span></p><p class="elsevierStylePara"> 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.</p><p class="elsevierStylePara"><img alt="Table 7. “Return to play” in competitive sport after interventional treatment" src="276v52n193-90460846fig7.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interests</span></p><p class="elsevierStylePara"> Authors declare that they do not have any conflict of interests.</p><hr></hr><p class="elsevierStylePara"> Received 18 September 2016;<br></br> accepted 27 September 2016</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">* Corresponding author.<br></br> E-mail address:</span><a href="mailto:grazioli@clinic.ub.es" class="elsevierStyleCrossRefs">grazioli@clinic.ub.es</a> (G. Grazioli)</p>" "pdfFichero" => "276v52n193a90460846pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec937070" "palabras" => array:1 [ 0 => "Cribado preparticipativo; Recomendaciones; Muerte súbita cardíaca" ] ] ] "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec937071" "palabras" => array:1 [ 0 => "Pre-participation screening; Recommendations; Sudden cardiac death" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"> 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.</p>" ] "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"> Sudden death in sports is caused in most cases by heart disease. The aim of pre-participation screening is to identify individuals who require specific treatment to continue the sport or who should cease the practice of sport. Current scientific evidence is based on expert recommendations that in some cases are controversial and impractical. This review aims to give an updated approach and pragmatic recommendations in athletes with heart disease.</p>" ] ] "multimedia" => array:14 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "276v52n193-90460846fig1.jpg" "imagenAlto" => 515 "imagenAncho" => 700 "imagenTamanyo" => 72873 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Classification of Mitchell for sports" ] ] 1 => array:8 [ "identificador" => "tbl2" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "276v52n193-90460846fig2.jpg" "imagenAlto" => 154 "imagenAncho" => 700 "imagenTamanyo" => 17754 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Borg Scale" ] ] 2 => array:8 [ "identificador" => "tbl3" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "276v52n193-90460846fig3.jpg" "imagenAlto" => 312 "imagenAncho" => 700 "imagenTamanyo" => 67356 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations cardiomyopathies9,13" ] ] 3 => array:8 [ "identificador" => "tbl4" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "276v52n193-90460846fig4.jpg" "imagenAlto" => 397 "imagenAncho" => 700 "imagenTamanyo" => 74101 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations and aortic valve disease9,14-16" ] ] 4 => array:8 [ "identificador" => "tbl5" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "276v52n193-90460846fig5.jpg" "imagenAlto" => 471 "imagenAncho" => 700 "imagenTamanyo" => 86873 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations arrhythmias and channelopathies6,7,17,18" ] ] 5 => array:8 [ "identificador" => "tbl6" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "276v52n193-90460846fig6.jpg" "imagenAlto" => 596 "imagenAncho" => 700 "imagenTamanyo" => 111235 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations in congenital heart disease9,19" ] ] 6 => array:8 [ "identificador" => "tbl7" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "276v52n193-90460846fig7.jpg" "imagenAlto" => 197 "imagenAncho" => 700 "imagenTamanyo" => 38939 ] ] ] ] ] "descripcion" => array:1 [ "en" => "“Return to play” in competitive sport after interventional treatment" ] ] 7 => array:7 [ "identificador" => "tbl8" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Classification of Mitchell for sports" ] ] 8 => array:7 [ "identificador" => "tbl9" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Borg Scale" ] ] 9 => array:7 [ "identificador" => "tbl10" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Recommendations cardiomyopathies9,13" ] ] 10 => array:7 [ "identificador" => "tbl11" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Recommendations and aortic valve disease9,14-16" ] ] 11 => array:7 [ "identificador" => "tbl12" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Recommendations arrhythmias and channelopathies6,7,17,18" ] ] 12 => array:7 [ "identificador" => "tbl13" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" 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ISSN: 18866581Original language: English
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