Background Management of left ventricular outflow tract obstruction (LVOTO) in competitive athletes with hypertrophic cardiomyopathy (HCM) is challenging, particularly when obstruction is exercise-induced and medical therapy is poorly tolerated. Case Summary A 28-year-old professional athlete presented with recurrent syncope. Resting imaging showed asymmetric septal hypertrophy without obstruction, but stress echocardiography revealed severe dynamic LVOTO (peak gradient: 150 mm Hg). Beta-blockers caused fatigue with persistent gradients. After shared decision-making, mavacamten was initiated. Follow-up stress imaging demonstrated complete resolution of LVOTO with preserved systolic function. The athlete returned to professional competition and remained event-free at 2 years. Discussion Current guidelines emphasize shared decision-making for athletes with HCM. This case highlights the importance of stress imaging to unmask LVOTO and supports mavacamten as a viable alternative. Take-Home Messages Stress testing is critical in symptomatic athletes with HCM. Mavacamten may permit alleviation of LVOTO and safe return to play.

BACKGROUND:There are limited data detailing cardiac structural changes associated with intensive athletic training in professional soccer athletes. The lack of sport-specific cardiac reference ranges may complicate differentiation of physiologic athletic remodeling from underlying cardiac pathology. OBJECTIVES:The objective of the study was to characterize echocardiographic cardiac remodeling patterns in a large cohort of male professional soccer athletes and provide sport-specific reference data for clinical interpretation. METHODS:We performed a cross-sectional echocardiographic study of 1,368 male Major League Soccer athletes screened during the 2018 to 2023 seasons using standardized transthoracic echocardiography protocols in accordance with American Society of Echocardiography guidelines. RESULTS:Athletes ranged in age from 21 to 39 years (mean age 25.8 [3.7] years). Among the cohort, 324/1,368 (23.7%) athletes were Black, 392/1,368 (28.7%) Hispanic, and 623/1,368 (45.5%) White. Increased left ventricular (LV) internal diameter in diastole (>58 mm) was present in 115/1,368 athletes (8.5%; 95% CI: 7.0%-10.0%), whereas 262/878 athletes (29.8%; 95% CI: 26.8%-32.8%) demonstrated right ventricular enlargement. The mean LV mass index was 97.2 [16.9] g/m2 (95% CI: 96.3-98.1), with 187/1,326 athletes (14.1%; 95% CI: 12.2%-16.0%) meeting the criteria for LV hypertrophy. Eccentric hypertrophy was present in 127/1,326 athletes (9.6%), concentric hypertrophy in 60/1,326 athletes (4.5%), and concentric remodeling in 241/1,326 athletes (18.2%). CONCLUSIONS:Increased cardiac dimensions and concentric remodeling patterns are frequently present in professional soccer athletes. These findings provide sport-specific echocardiographic reference data that may assist clinicians in distinguishing physiologic athletic remodeling from cardiovascular pathology in elite soccer athletes.

AIM:The American College of Cardiology/American Heart Association Scientific Statement, "Clinical Considerations for the Care of the Tactical Athlete With Cardiovascular Abnormalities," was written to provide guidance and education for clinicians caring for the tactical athlete (ie, firefighters, law enforcement officers, military) with cardiovascular disease or risk for cardiovascular disease, and for the organizations overseeing the care and wellness of these athletes. The considerations are shaped by the interaction between occupational demands and fit for full duty assessments, including risk discussions about how a cardiovascular event in a tactical athlete could impact teammates' well-being, community safety, and overall mission success. METHODS:This scientific statement is organized into 11 sections focused on cardiovascular disease processes and other topics that are relevant when considering the potential risks and benefits of performing tasks specific to the tactical athlete. Task forces, comprised of experts in tactical athlete domains, sports cardiology, and the respective topics covered, were assigned to each section, and specific "Clinical Considerations Tables" for clinicians to reference were prepared. Comprehensive literature reviews and an emphasis on tactical athlete-focused data, as available, were integral in the writing of all clinical considerations presented. The framework mirrors that of the recently published, "Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology." STRUCTURE:The specific sections in this document include: Section 1: Tactical Tasks Classification; Section 2: The Tactical Athlete Preparticipation Cardiac Evaluation; Section 3: Ethical and Legal Aspects of Tactical Clinical Management; Section 4: Genetic Cardiomyopathies; Section 5: Myocarditis and Other Acquired Cardiac Conditions; Section 6: Congenital Heart Disease; Section 7: Aortopathy, Bicuspid Aortic Valve, and Spontaneous Coronary Artery Dissection; Section 8: Syncope, SCA, Arrhythmias, and Devices; Section 9: Cardiac Channelopathies; Section 10: Older Tactical Athlete; Section 11: Environmental Exposures, PED/S, and Additional Cardiac Conditions and Considerations. Each section provides a summary detailing the rationale for key clinical considerations and the respective Clinical Considerations Table(s).

Exercise and physical activity are recognized as essential tools to optimize fitness and longevity, improve overall health, and reduce the risk of cardiovascular disease and other major comorbidities. However, there are inherent risks associated with participation in sports and exercise, regardless of the level of competition or skill required. As such, there is a need for cardiologists to understand the unique aspects of competitive and recreational athletics, as well as sport and exercise science, as it relates to overall heart health and cardiovascular risk. In this article, we provide an overview of the essential aspects of sports and exercise cardiology. We describe the roles and responsibilities of a sports and exercise cardiologist as a member of a comprehensive team of experts who provide care of athletes at all levels of sport, emphasize the importance of risk stratification and prevention of sudden cardiac arrest, the role of exercise for maintaining and optimizing overall health in the general population, describe the growing field of sports electrophysiology and also discuss unique aspects of sports cardiology applied to environmental health and care of the tactical athlete. Knowledge gaps and directions for future clinical and research investigation are reviewed.

BACKGROUND:Sudden cardiac arrest disproportionately affects youths from lower socioeconomic neighborhoods, yet the mechanisms of this disparity in youth athletes remain unclear. METHODS:We retrospectively analyzed the HeartBytes National Youth Cardiac Registry (Simon's Heart, a US nonprofit for sudden cardiac death prevention), in which youth athletes aged <17 years completed standardized cardiovascular symptom questionnaires before attending community-based preparticipation screening events, including physical exam and 12-lead ECG, across the United States between April 2015 and May 2024. Neighborhood opportunity was determined by linking residential zip code to census tract level child opportunity index 3.0 scores (range 1-100; higher values indicate greater opportunity), a composite spanning educational, health, environmental, and social and economic domains, with athletes grouped into national quintiles. Multivariable logistic regression examined associations between child opportunity index quintile and exercise-related cardiac symptoms and ECG abnormalities, adjusting for demographics, anthropometrics, hemodynamics, and comorbidities. RESULTS:Among 7843 youth athletes (median age, 14 years; 38.9% female; 83.0% White), distribution across child opportunity index quintiles was 7.4% very low, 4.3% low, 6.7% moderate, 16.7% high, and 65.0% very high. Compared with the very high quintile, athletes in the very low quintile had higher prevalence of exercise-related chest pain (9.1% versus 3.7%), exercise-related fatigue (11.4% versus 7.0%), and abnormal ECGs (10.0% versus 5.1%; all P<0.001). After multivariable adjustment, participants in the very high child opportunity index quintile had lower odds of exercise-related chest pain (adjusted odds ratio, 0.45 [95% CI, 0.32-0.63]), exercise-related fatigue (adjusted odds ratio, 0.65 [95% CI, 0.47-0.87]), and abnormal ECGs (adjusted odds ratio, 0.58 [95% CI, 0.42-0.82]) relative to the very low quintile. CONCLUSIONS:Youth athletes from lower-opportunity neighborhoods were underrepresented in preparticipation screening and demonstrated higher prevalence and adjusted odds of exercise-related cardiac symptoms and ECG abnormalities. Prospective longitudinal studies are needed to determine clinical significance and inform equitable screening strategies.

Exercise training improves cardiovascular health and reduces the risk for future cardiovascular events and mortality. However, emerging evidence suggests that Masters athletes may have a higher prevalence of cardiovascular abnormalities, such as atrial arrhythmias, coronary atherosclerosis, aortic dilatation, and myocardial fibrosis, compared to their less active peers. The clinical management of Masters athletes may be challenging as available guidelines for such conditions are generally based on data derived from symptomatic sedentary patients, limiting their applicability to highly trained individuals. Other unique challenges in the clinical assessment of Masters athletes include differences in symptomatic presentations compared to sedentary individuals, potential resistance to the initiation of pharmacologic treatment, and the increasing availability of consumer wearable health data that may provide relevant information on their cardiovascular health status. The purpose of this joint EAPC/ESC and ACC Clinical Consensus Statement is to provide an in-depth update on the current state of knowledge on abnormal cardiovascular findings in Masters athletes. We present an expert-based approach on the diagnostic assessment, management, and prognosis of (i) atrial fibrillation, (ii) bradyarrhythmias, (iii) ventricular arrhythmias, (iv) coronary atherosclerosis, (v) aortic dilatation, (vi) myocardial fibrosis, and (vii) exercise-induced arrhythmogenic cardiomyopathy. Clinical challenges, areas of ongoing controversy, and uncertainty and the potential underlying mechanisms are discussed. We also present future perspectives and research directives to further refine current best practice strategies. This includes the need for clinical outcome studies, dedicated randomized controlled trials in athletes, and international registries with diverse populations and longitudinal follow-up to evaluate the natural history of cardiac abnormalities and facilitate development of evidence-based approaches in the clinical management of Masters athletes with cardiovascular abnormalities.

Background Acute myocardial infarction in young competitive athletes is uncommon but requires consideration of a broad underlying differential diagnosis. Case Summary A 22-year-old male collegiate swimmer with no significant past medical or family history presented to the hospital with an ST-segment elevation myocardial infarction. After a comprehensive diagnostic evaluation, the athlete was deemed to have acute plaque rupture secondary to underlying coronary artery disease. Appropriate treatments were implemented, and return-to-play was considered. In accordance with guideline-based risk stratification and shared decision making, the athlete returned to competitive swimming. Discussion Acute myocardial infarction as a consequence of coronary artery disease is uncommon among young competitive athletes. Athletes who present with acute myocardial infarction require an understanding of potential etiologies, appropriate diagnostic evaluations, and clinical management strategies. Take-Home Message Acute coronary syndromes are rare in young competitive athletes and require a focused history and physical examination and a comprehensive diagnostic work-up.

Sports cardiology is a cardiovascular subspecialty that cares for competitive athletes and highly active individuals with cardiovascular risk factors and/or disease. Exercise can lead to physiological, structural, and electrical cardiac remodeling while also contributing to maladaptive changes, including arrhythmias. These nuances have contributed to the emergence of sports electrophysiology as a specialized extension within sports cardiology, dedicated to understanding arrhythmias, including best practices in arrhythmia management in this patient group. Although the diagnosis and treatment of arrhythmias in athletes often parallel standard electrophysiological practices, there are differences and factors to be taken into account. Examples include exercise type and intensity; potential performance effects and side effects of antiarrhythmic therapies; timing and indications for catheter ablation; device selection and programming for cardiac implantable electronic devices when applicable; interpretation of cardiovascular testing; and return-to-play guidance. In this state-of-the-art review, athletic electrical remodeling, clinical considerations for arrhythmia management in athletes, device-related matters, and future directions for the evolving field of sports electrophysiology are discussed. This document builds on recent clinical references by providing practical clinical guidance for electrophysiologists and cardiovascular clinicians who care for athletic patients with arrhythmias and formally introduces the concept of "sports electrophysiology" within sports cardiology as a novel discipline.

AIM:The American College of Cardiology/American Heart Association Scientific Statement, "Clinical Considerations for the Care of the Tactical Athlete With Cardiovascular Abnormalities," was written to provide guidance and education for clinicians caring for the tactical athlete (ie, firefighters, law enforcement officers, military) with cardiovascular disease or risk for cardiovascular disease, and for the organizations overseeing the care and wellness of these athletes. The considerations are shaped by the interaction between occupational demands and fit for full duty assessments, including risk discussions about how a cardiovascular event in a tactical athlete could impact teammates' well-being, community safety, and overall mission success. METHODS:This scientific statement is organized into 11 sections focused on cardiovascular disease processes and other topics that are relevant when considering the potential risks and benefits of performing tasks specific to the tactical athlete. Task forces, comprised of experts in tactical athlete domains, sports cardiology, and the respective topics covered, were assigned to each section, and specific "Clinical Considerations Tables" for clinicians to reference were prepared. Comprehensive literature reviews and an emphasis on tactical athlete-focused data, as available, were integral in the writing of all clinical considerations presented. The framework mirrors that of the recently published, "Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology." STRUCTURE:The specific sections in this document include: Section 1: Tactical Tasks Classification; Section 2: The Tactical Athlete Preparticipation Cardiac Evaluation; Section 3: Ethical and Legal Aspects of Tactical Clinical Management; Section 4: Genetic Cardiomyopathies; Section 5: Myocarditis and Other Acquired Cardiac Conditions; Section 6: Congenital Heart Disease; Section 7: Aortopathy, Bicuspid Aortic Valve, and Spontaneous Coronary Artery Dissection; Section 8: Syncope, SCA, Arrhythmias, and Devices; Section 9: Cardiac Channelopathies; Section 10: Older Tactical Athlete; Section 11: Environmental Exposures, PED/S, and Additional Cardiac Conditions and Considerations. Each section provides a summary detailing the rationale for key clinical considerations and the respective Clinical Considerations Table(s).

BACKGROUND:Major League Soccer (MLS) is composed of an ethnically diverse athlete population for which electrocardiogram (ECG) analysis has not been previously reported. OBJECTIVES:This paper evaluated MLS player ECGs and characterized ECGs as having normal, borderline, and/or abnormal ECG findings based on the international criteria. Echocardiographic data were analyzed when history, physical, or ECG findings were abnormal. METHODS:This was a cross-sectional study of MLS players from 2017 to 2020. RESULTS:A total of 706 athletes were included in this study. Athletes were predominantly Caucasian 346 (49%), followed by Black, 85 (26%), and Hispanic, 175 (25%). The mean (SD) age was 24.5 (4.3) years with an age range of 15 to 37 years. The most common abnormal ECG finding was T wave inversion (TWI) (total percent of TWI). Black athletes had a greater proportion of ECGs with any isolated TWI, with 11.9%, compared to Caucasian (5.2%, P = 0.005) and Hispanic (5.7%, P = 0.040) athletes. Subgroup analysis of those with abnormal TWI revealed mostly structurally normal hearts. The most common borderline finding was left axis deviation, with Black athletes having a statistically greater proportion of left axis deviation when compared to Caucasian athletes (3.8% vs 1.2%, P = 0.043). Training-related ECG changes are highly prevalent among professional male soccer players regardless of race. CONCLUSIONS:The most common ECG abnormality and borderline finding per international criteria are TWI and left atrial enlargement, respectively. Both were more prevalent in Black athletes. Echocardiography did not reveal underlying cardiovascular disease during follow-up even in the presence of abnormal ECG findings.

This American Heart Association/American College of Cardiology scientific statement on clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities or diseases is organized into 11 distinct sections focused on sports-specific topics or disease processes that are relevant when considering the potential risks of adverse cardiovascular events, including sudden cardiac arrest, during competitive sports participation. Task forces comprising international experts in sports cardiology and the respective topics covered were assigned to each section and prepared specific clinical considerations tables for practitioners to reference. Comprehensive literature review and an emphasis on shared decision-making were integral in the writing of all clinical considerations presented.

Background: Sleep apnea is common among male competitive athletes and may be associated with early cardiovascular risk. Among female athletes, the prevalence and outcomes of sleep apnea have not been described. Objectives: The objective of the study was to comprehensively assess sleep health and associations with markers of cardiovascular risk in an observational cohort of U.S. collegiate female athletes. Methods: We conducted a cross-sectional analysis of female collegiate athletes from 2 National Collegiate Athletic Association Division-I programs that included comprehensive measures of sleep health with home-based sleep studies and Pittsburgh Sleep Quality Index surveys; anthropometrics; echocardiography; and vascular applanation tonometry. Prevalence of sleep apnea and associations between sleep apnea and anthropometric data, systolic and diastolic blood pressure, arterial stiffness, and measures of left ventricular structure and function were assessed. Results: A total of 68 female collegiate athletes (18.00 [18.00, 20.00] years; 63% freshmen; 25% basketball, 41% softball, 34% volleyball) participated in this study. Mild sleep apnea (apnea-hypopnea index ≥5, N = 17, 25%) and poor sleep quality (Pittsburgh Sleep Quality Index >5, N = 24, 36%) were common. Athletes with sleep apnea were older (19.0 [18.0, 21.0] vs 18.00 [18.00, 19.00] years, P = 0.03) and had higher lean mass (61.6 [58.5, 67.3] vs 54.2 [51.8, 59.3] kg, P < 0.01) and pulse wave velocity (5.3 [5.1, 6.0] vs 4.9 [4.5, 5.4] m/s, P = 0.01). Lean mass independently predicted sleep apnea (OR: 1.14; 95% CI: 1.04-1.28; P < 0.01) and higher apnea-hypopnea index was independently associated with higher arterial stiffness (β = 0.09; 95% CI: 0.04-0.15; P < 0.01). Conclusions: Poor sleep health, including sleep apnea, was common in this cohort of U.S. collegiate female athletes. Future longitudinal research, focused on sex-specific differences and cardiovascular outcomes, in competitive athletes with sleep-disordered breathing is warranted.