运动员潜在心血管疾病筛查面临的挑战

研究表明,与非运动员相比,同样心脏基础的运动员发生心脏性猝死的风险更高,因此关注运动员的心脏病筛查非常有必要;但运动员心脏与心脏疾病存在众多重叠之处,且针对黑人运动员的研究甚少,黑人运动员异常心电图发生率更高,更为运动员心血管病筛查增加了难度。详细回顾运动员心脏性猝死的常见病因,并深刻剖析运动员心血管筛查面临的挑战及困境。     

运动员猝死

运动员猝死(athletic sudden death)又称运动性猝死(exercise sudden death),指在运动中或运动后即刻出现症状,6 h内发生的非创伤性死亡[1].运动员猝死事件给运动员群体带来恐慌,使人们参加体育运动产生顾虑.事实上运动员猝死发生率很低.     

运动员心电图判定标准

心源性猝死是运动员在运动时死亡的主要原因,其发生与遗传性、结构性或电学性心脏病密切相关,大部分可通过12导联心电图(ECG)异常来识别。由于高强度的耐力训练,运动员心脏可发生生理性重构,导致训练相关性ECG与潜在心脏疾患引起的ECG改变发生一定重叠,极易相互混淆。运动员常见的正常心电图有心室肥大、不完全性右束支传导阻滞、早期复极、窦性心动过缓、房性异位心律、Ⅰ度房室传导阻滞等。     

运动员T波改变发生机制及其临床意义的探讨

目的 探讨运动员T波改变的发生机制。方法 观察24例青少年运动员的T波改变，分析改变的原因及临床意义。结果 24例T波倒置者在做极量运动或异丙基肾上腺素试验后T波均直立。结论 运动员引起的T波改变是良性神经系统功能改变。系长期运动后，心脏发生的适应性改变，使得调控心血管的植物神经功能失衡。交感神经、迷走神经各自为政，失去了相互制约相互协调，使心肌复极异常，致T波倒置。认为系运动员良性T波倒置，属运动员心脏综合症。     

运动与营养

运动训练期间为维持热量平衡,对运动员需增添食物。女运动员有容易发生缺铁的危险,月经过少和闭经的发生率增加,应对这些异常进行检查和治疗。在耐力性项目比赛前有使用糖负荷法以增加肌糖原含量。赛前不宜进食简单糖类,以免发生高胰岛素血症而导致低血糖。在长时间的激烈运动期问可间歇饮稀葡萄糖液。比赛期间运动员最需要补充液体,水是最合适的饮料,一般不需补充电解质。     

中国部分大学生运动员早复极发生率及相关导联和形态分析

目的了解大学生运动员早复极(ER)发生率及特点。方法对2011年、2012年、2013年9月进入北京体育大学竞技体育类专业的大学生运动员进行入学健康体检,包括病史询问、体格检查、心电图检查等,对收集到的1 215份心电图进行分析。ER诊断:连续2个导联R波降支的顿挫或切迹(正向)≥0.1 m V(伴或不伴J点抬高);或连续2个导联J点抬高(STj)≥0.1 m V而不伴R波降支的顿挫或切迹;V1~3导联J点抬高不作为ER的诊断标准。结果共检出ER 436例,发生率35.9%,男运动员(874名)的ER发生率高于女运动员(341名)(39.4%vs 27.0%,P0.05);下壁导联ER发生率25.8%(314例),下壁伴前壁导联ER发生率6.8%(83例),前壁导联ER发生率3.0%(37例),男运动员多导联ER发生率高于女运动员(P0.05);形态上,顿挫型ER发生率18.9%(230例),切迹型ER发生率7.2%(88例),单纯ST段抬高型发生率9.7%(118例),顿挫型ER中,男运动员伴STj≥0.1 m V抬高的发生率高于女运动员(13.5%vs 2.3%,P0.05)。结论在我国大学生运动员中,ER总发生率35.9%,部位以下壁导联最为多见,形态以顿挫型最多,男女运动员ER发生率及发生部位有所不同。     

年轻竞技运动员猝死因素的分析

年轻运动员猝死往往是一种不可预料的事件，据统计大约每２０万竞技运动员中有一名发生。虽然许多年轻运动员的猝死是不可预知或预防的，但是通过仔细的病史分析及体格检查，有些是可以得到确认的。年龄超过３５岁的成年人，大约９０％的猝死原因是冠状动脉粥样硬化性心脏...     

青少年游泳运动员早复极心电图特征分析

目的探讨10￣14岁青少年游泳运动员心室早复极的心电图特征和意义。方法选取10￣14岁青少年游泳运动员139例,以心电图下壁(Ⅱ、Ⅲ、aVF)和侧壁(Ⅰ、aVL、V4、V5、V6)导联中至少连续两个导联的J点抬高作为早复极的指标,将运动员分为J点无抬高、J点抬高<0.1mV和J点抬高≥0.1mV三组。以运动员为试验组,同龄普通青少年为对照组,比较其J点抬高的发生概率和程度,以及心室率、QTc和RV5+SV1振幅的差异性。并分别比较三组运动员心室律、QTc和RV5+SV1的差异性。结果①与同龄青少年相比,青少年游泳运动员J点抬高以及抬高≥0.1mV的比例升高(p<0.01),但均未超过0.2mV;②与同龄青少年相比,青少年游泳运动员心率较慢,QTc较长(p<0.01);③与同龄青少年相比,青少年游泳运动员RV5+SV1均在正常范围内且差异无统计学意义;④三组运动员组间比较,随着J点的抬高,心率有轻微下降的趋势,QTc有轻微延长的趋势,但RV5+SV1差异无统计学意义。结论①在10￣14岁青少年游泳运动员中,J点抬高是一个较为普遍的现象,但一般不超过0.2mV。如果J点抬高≥0.2mV,则发生恶性室性心律失常的概率可能会增加,因此有必要给予密切监控和进一步检查;②随着J点的抬高,心室率轻微减慢和QTc轻微延长的趋势,可能意味着J点抬高的程度与心输出量的增加和迷走神经兴奋性升高有一定的关联;③本研究没有发现青少年游泳运动员的早复极与左室高电压有相关性。     

心电图在运动员猝死防治中的价值

运动性猝死[exercise（athletic）sudden death]是与运动有关的猝死的简称,属于在运动中发生的心源性猝死（suddencardiac death,SCD）。1991年世界卫生组织和国际心脏病学会将其定义为：有或无症状的运动员或体育锻炼者在运动中或运动后24 h内的意外死亡[1]。对于年轻运动员（〈35岁）     

运动后迟发性低血压的临床特征和意义

运动后晕厥晟常见的原因为血管减压性晕厥或称之为血管迷走神经性晕厥，其基本特征为运动后发生头晕、恶心、脸色苍白，甚至晕厥．同时伴有明显心率减慢，血压下降，平卧后自行缓解，常见于年轻的女性运动员以及新运动员参加重大比赛时，其确切机理并不明了。作曾报道运动试验后发生类似的情况，本对这一问题作进一步报道。     

Risk of competitive sport in young athletes with heart disease

The majority of sudden deaths in young athletes occur in the context of underlying inherited or genetic cardiac disorders. The evaluation of every athlete regarding underlying cardiac disease is impractical and therefore needs to be targeted at those who are at a higher risk. A practical approach would be to channel efforts towards athletes with cardiac symptoms, those with a family history of inherited cardiac disease, and those with a family history of premature sudden death. There are potential pitfalls in the evaluation of young athletes using non-invasive tests when making the distinction between physiological adaptations to exercise and cardiac pathology. Physicians evaluating young athletes need to be aware of the spectrum of physiological adaptations and to be familiar with conditions responsible for sudden death in this population.     

Sudden cardiac death in athletes

Sudden cardiac death in athletes is an uncommon but extremely visible event because of the high profile of amateur and professional athletes and the expected excellent health of these athletes. However, paradoxically, athletic performance may immediately increase the risk of ventricular arrhythmias and sudden cardiac death while run reducing atherosclerosis, which thus improves cardiovascular health and longevity. In athletes younger than 30 years, the most common underlying causes are due to inherited heart disease. In the older athletes, sudden death is generally due to arrhythmias in the context of coronary artery disease. Many athletes with aborted sudden death, arrhythmia-related syncope, or high-risk genetic disorders benefit from therapy with implanted cardioverter/defibrillators (ICDs) . Although ICD therapy can effectively abort sudden death, implantation of an ICD generally prohibits an individual from all competitive athletics except low-intensity sports. The screening of athletes has been notoriously inadequate; however, the optimal screening strategies have yet to be determined. Recommendations for participation in competitive athletics generally follow the recently published 36th Bethesda Conference Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities.     

Pre-participation examination of competitive athletes: role of the ECG

Sudden cardiac death in athletes is rare but has a wide social impact because it confronts the general population with the paradox that athletes perceived and admired as the fittest and healthiest suddenly drop dead during their sport. Mass media coverage is guaranteed in the case of sudden cardiac death of a top athlete, while other competitive and noncompetitive athletes of all ages, team members, sponsors, as well as huge parts of society remain puzzled and frightened. Therefore, debate is ongoing regarding how to minimize the number of fatalities, and the search continues for a cost-effective preparticipation screening for competitive athletes. Despite the fact that routine ECG screening would be widely available and rather inexpensive, debate continues regarding whether this should be part of initial screening for every athlete before starting to train at high intensity as well as during annual checkups. The role of ECGs in preparticipation examinations of competitive athletes is intensively discussed because there is a lack of strict criteria for which ECG findings should generate further workup. In this article, we analyze the main publications on sudden cardiac death, focusing on the benefit of ECG screening in preparticipation examination as it has been shown to be feasible and effective in identifying athletes at risk of sudden cardiac death.     

Mort subite cardiaque et anomalies de connexion des artères coronaires : connaissances et questions

Some anomalous connections of the coronary arteries may be associated with a risk of sudden cardiac death. In opposite with others cardiac diseases at risk of sudden cardiac death, the relationship between these congenital abnormalities and the risk of sudden cardiac death are not well understood. A correction of the anomaly is generally indicated after an aborted sudden cardiac death. Primary prevention strategy after the discovery of an anomaly at risk is debated. Even if the absolute risk of sudden death is very low, a pre-participation screening in young athletes may be discussed due to a non-rare incidence.     

Sudden Cardiac Death in the Adolescent Athlete: History,Diagnosis, and Prevention

Sudden cardiac death in young athletes is a devastating condition that occurs without warning. While most middle and high school athletes require preparticipation screening, many predisposing conditions go undiagnosed until they occur. The frequency of sudden cardiac death is often under-reported because there is no mandatory system for reporting sports-related death in high school sports. Additionally, there is debate about the cost-effectiveness of more advanced screening tests, such as electrocardiogram, due to high false-positive rates. It is, however, accepted that participants with a family history of sudden cardiac death should undergo more in-depth screening. If sudden cardiac arrest occurs, it is important for the patient to undergo immediate defibrillation. Community outreach to ensure that automated external defibrillators are present at athletic events, as well as cardiopulmonary resuscitation training for coaches, could potentially save lives. Ultimately, prevention of sudden cardiac death depends on physician awareness of how to properly screen and identify those at risk, and how to best be prepared if sudden cardiac arrest occurs.     

Causes of sudden death in competitive athletes

Cardiovascular diseases responsible for sudden unexpected death in highly conditioned athletes are largely related to the age of the patient. In most young competitive athletes (less than 35 years of age) sudden death is due to congenital cardiovascular disease. Hypertrophic cardiomyopathy appears to be the most common cause of such deaths, accounting for about half of the sudden deaths in young athletes. Other cardiovascular abnormalities that appear to be less frequent but important causes of sudden death in young athletes include congenital coronary artery anomalies, ruptured aorta (due to cystic medial necrosis), idiopathic left ventricular hypertrophy and coronary artery atherosclerosis. Diseases that appear to be very uncommon causes of sudden death include myocarditis, mitral valve prolapse, aortic valve stenosis and sarcoidosis. Cardiovascular disease in young athletes is usually unsuspected during life, and most athletes who die suddenly have experienced no cardiac symptoms. In only about 25% of those competitive athletes who die suddenly is underlying cardiovascular disease detected or suspected before participation and rarely is the correct clinical diagnosis made. In contrast, in older athletes (greater than or equal to 35 years of age) sudden death is usually due to coronary artery disease, and rarely results from congenital heart disease.     

Treatment of athletes with cardiac disease or arrhythmias

Opinion statement Ventricular arrhythmias and sudden cardiac death in the athlete are uncommon but extremely visible because of the high profile of amateur and professional athletes. In athletes under the age of 30 years, the incidence of sudden death is low and in most cases occurs in individuals with inherited heart disease. In the older athlete, sudden death is more common and is generally due to arrhythmias in the context of coronary artery disease. Many athletes with aborted sudden death, arrhythmia-related syncope, or high-risk genetic disorders benefit from therapy with implantable cardioverterdefibrillators (ICDs). Although ICD therapy can effectively abort sudden death, implantation of an ICD generally prohibits an individual from all competitive athletics except low-intensity sports. Recommendations for participation in competitive athletics generally follow the recently published 36th Bethesda Conference Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities.     

Cardiac Screening of Young Athletes: a Practical Approach to Sudden Cardiac Death Prevention

Purpose of review

We aim to report on the current status of cardiovascular screening of athletes worldwide and review the up-to-date evidence for its efficacy in reducing sudden cardiac death in young athletes.

Recent findings

A large proportion of sudden cardiac death in young individuals and athletes occurs during rest with sudden arrhythmic death syndrome being recognised as the leading cause. The international recommendations for ECG interpretation have reduced the false-positive ECG rate to 3% and reduced the cost of screening by 25% without compromising the sensitivity to identify serious disease. There are some quality control issues that have been recently identified including the necessity for further training to guide physicians involved in screening young athletes.

Summary

Improvements in our understanding of young sudden cardiac death and ECG interpretation guideline modification to further differentiate physiological ECG patterns from those that may represent underlying disease have significantly improved the efficacy of screening to levels that may make screening more attractive and feasible to sporting organisations as a complementary strategy to increased availability of automated external defibrillators to reduce the overall burden of young sudden cardiac death.

     

How to manage athletes with ventricular arrhythmias

Young competitive athletes are perceived by the general population to be the healthiest members of society. The possibility that highly trained athletes may have a potentially serious cardiac condition that can predispose to life-threatening tachyarrhythmias or sudden cardiac death seems paradoxical. Thus, differentiating the benign, exercise-induced physiologic changes from true pathologic conditions with risk of sudden death is critical for developing appropriate screening strategies to reduce the risk of these adverse events.     

Sudden cardiac death in athletes

Sudden cardiac death in athletes, although relatively uncommon, is a well-recognized condition generally associated with some congenital abnormalities. It, however, continues to be of vast interest to the public as athletes are seen as a distinct group of individuals who are especially able to tolerate more intense physical activities than the general population. Obviously, intense activities predispose susceptible athletes to sudden cardiac death, hence the importance of pre-participation screening tests. As the cost of healthcare continues to be on the rise, there will be increasing difficulty justifying a nation-wide method of screening cost-effectively. This article is intended to describe the possible underlying causes of sudden cardiac death discovered thus far, as well as methods for detection, pre-participation guidelines, and emerging therapy.