Regular physical activity has emerged as a cornerstone of preventive and therapeutic care in Congenital Heart Diseases (CHDs). Growing evidence demonstrates that structured exercise not only improves both functional capacity and psychological well-being but also exerts favorable cardiovascular and metabolic effects. However, the participation in physical activities of CHDs patients remains limited due to common misconceptions about exercise safety and the absence of standardized guidelines.This document presents the Italian proposal for exercise prescription in CHDs, jointly promoted by the Italian Federation of Sports Medicine (FMSI) and the Italian Society of Sports Cardiology (SIC Sport) with the collaboration of the Italian Association of Hospital Cardiologists (ANMCO) and the Italian Society of Cardiology (SIC). The Italian proposal establishes a structured, evidence-based framework for exercise prescription indicating the approaches to monitoring and to individualizing the physical program according to the disease’s complexity and patient’s profile.The model integrates a three-step method: (1) the identification of the most appropriate exercise type, (2) the individual program customization, and (3) the longitudinal monitoring of cardiovascular response. Risk stratification is performed using echocardiographic, hemodynamic, and cardiopulmonary exercise testing (CPET) parameters, which allow the safe exercise threshold to be defined. The exercise prescription is based on the FITT principle (Frequency, Intensity, Time, Type) emphasizing progressive aerobic and combined regimens over static exercise.

AIMS:Pre-participation cardiovascular screening (PPS) is essential for preventing SCD in athletes, yet ECG interpretation requires expertise and remains resource-intensive. We aimed to evaluate the feasibility and diagnostic performance of a deep learning (DL) model for analysis of clinical data and resting 12‑lead ECG obtained during routine PPS in competitive athletes. METHODS:In this prospective single center observational study, competitive athletes aged 18 to 60 years and undergoing routine PPS were enrolled. PPS included medical history, physical examination, resting and exercise ECG. Athletes were classified as fit or not fit for competitive sports according to clinical evaluation. Resting ECG and clinical variables were analyzed using a multimodal DL architecture. Model performance was assessed using stratified 10-fold cross-validation against PPS clinical classification. RESULTS:A total of 526 athletes were enrolled (72% male, median age of 27 years (IQR: 20-41); 166 (32%) had a negative PPS result. The test setting (10-fold cross-validation), the model achieved moderate discrimination with an accuracy of 0.64 ± 0.08, SE 0.68 ± 0.15, SP 0.61 ± 0.17, F1-score 0.72 ± 0.1, PPV 0.80 ± 0.07, NPV 0.48 ± 0.12, AUC 0.72(0.66-0.78). Training performances reached accuracy of 0.70 ± 0.06, SE 0.73 ± 0.12, SP 0.67 ± 0.14, F1-score 0.77 ± 0.07, AUC 0.79 (0.74-0.83. CONCLUSION:Automated DL-based analysis of 12‑lead ECG during PPS is feasible and showed encouraging diagnostic performance in competitive athletes. Although wider experience and external validation is required, AI-assisted multimodal ECG interpretation may represent a useful adjunct to physician assessment for cardiovascular risk stratification in sport screening programs.

BACKGROUND:In adults over 35 years of age, ischemic heart disease (IHD) is the predominant cause of exercise-related acute coronary events and sudden cardiac death. Master athletes, despite high levels of fitness, are not immune to coronary atherosclerosis, which often remains clinically silent until precipitated by exertional stress. Recent data challenge the assumption that long-term endurance training offers protection against coronary artery disease (CAD), revealing a non-negligible prevalence of subclinical atheroma even in asymptomatic athletes. OBJECTIVE:To examine the evolving role of coronary computed tomography angiography (CCTA) in the primary prevention of IHD in master athletes, with a focus on risk stratification, plaque characterization, and integration into sports eligibility assessment. CONTENT:Technological advances have enhanced the diagnostic performance of CCTA, allowing not only the detection of obstructive disease but also the identification of high-risk plaque features, such as low-attenuation fibro-lipid core, positive remodelling, and microcalcifications. In selected older athletes with elevated risk profiles or equivocal stress tests, CCTA provides valuable anatomical information that often eludes functional testing alone. Italian guidelines (COCIS 2023) include CCTA in the evaluation of intermediate-to-high-risk master athletes, emphasizing a risk-adapted approach rather than blanket screening. CONCLUSIONS:CCTA may refine cardiovascular risk assessment in master athletes by detecting subclinical but clinically relevant CAD, potentially improving long-term outcomes and guiding individualized recommendations for sports participation. While broader implementation must consider cost, radiation exposure, and the risk of overdiagnosis, selective use of CCTA appears justified in targeted high-risk populations. Prospective studies are needed to validate this strategy and define its role within comprehensive athlete evaluation frameworks.

Background/Objectives: Ventricular repolarization abnormalities (VRA) represent a grey area in athlete screening: some patterns are physiological, while others are precursors to heart disease. Objective: to clarify the natural history of VRA and the associated factors of structural diagnosis. Methods: Retrospective observational single-center study of athletes with resting or stress VRA at the first evaluation, with normal echocardiography; minimum follow-up of 2 years. Clinical data, resting and stress ECG, echocardiography, and selective advanced imaging throughout follow-up were collected. Primary outcome: cardiovascular diagnosis at follow-up; time-to-event analysis and associations between ECG characteristics and diagnosis. Results: Fifty-three athletes (mean age 22.2 ± 9.2 years; 92.5% male) were included; 60.4% had resting VRA, and 100% had exercise-induced VRA at baseline. Over 7.3 ± 4.5 years, 28/53 (52.8%) received a diagnosis; median time-to-detection was 7.0 years (95% CI 6.0-not reached); RMST10 was 6.7 years (95% CI 5.7-7.7). Diagnoses included hypertrophic cardiomyopathy (24.5%), non-ischaemic left-ventricular scar (11.3%), myocardial bridging (7.5%), hypertensive remodelling (5.7%), coronary anomaly (1.9%), and ventricular pre-excitation (1.9%). Persistence of resting VRA from baseline to follow-up was more frequent in athletes with a final diagnosis (p = 0.01), whereas topography and exercise-induced abnormalities did not discriminate groups. Advanced imaging contributed substantially to case ascertainment. No major adverse cardiovascular events have been identified throughout follow-up. Conclusions: In athletes with screening-detected VRA and normal echocardiography, persistence of resting VRA was associated with higher detection of a cardiovascular diagnosis, while exercise-induced changes alone show limited diagnostic yield. The long median time-to-detection supports prolonged, pre-planned surveillance, with priority for advanced imaging in profiles with persistent abnormalities. These findings align with a risk-adapted, personalized management strategy in sports cardiology.

BACKGROUND: Sport practice may elevate the risk of cardiovascular events, including sudden cardiac death, in athletes with undiagnosed heart conditions. In Italy, pre-participation screening includes a resting ECG and either the Harvard Step Test (HST) or maximal exercise testing (MET), but the relative efficacy of the latter two tests for detecting arrhythmias and heart conditions remains unclear. METHODS: This study examined 511 paediatric athletes (8–18 years, 76.3% male) without known cardiovascular, renal, or endocrine diseases. All athletes underwent both HST and MET within 30 days. Absolute data and data relative to theoretical peak heart rates, arrhythmias (supraventricular and ventricular) and cardiovascular diagnoses were collected. RESULTS: HST resulted in a lower peak heart rate than MET (181.1 ± 9.8 vs. 187.5 ± 8.1 bpm, p < 0.001), but led to the detection of more supraventricular (18.6% vs. 13.1%, p < 0.001) and ventricular (30.5% vs. 22.7%, p < 0.001) arrhythmias, clustering during recovery (p = 0.014). This pattern was significant in males but not females. Among athletes diagnosed with cardiovascular diseases (22.3%), HST identified more ventricular arrhythmias (26.3% vs. 18.4%, p = 0.05), recovery-phase arrhythmias (20.2% vs. 14.0%, p = 0.035), and polymorphic arrhythmias (6.1% vs. 1.8%, p = 0.025). CONCLUSIONS: HST detects arrhythmias more effectively than MET in young male athletes, especially during recovery. More ventricular arrhythmias were highlighted even in athletes with cardiovascular conditions.

BACKGROUND:Ventricular arrhythmias (VAs) are a major concern in athletes. We sought to determine the prognostic role of noninvasive and invasive assessments in athletes with complex VAs. METHODS:One-hundred-ninety athletes (82% men; 28 [19-43] years; 148 [78%] competitive athletes) with frequent or exercise-induced premature ventricular complexes or nonsustained ventricular tachycardia were included in a multicenter cohort study and categorized based on VA ECG morphology into common (n=99) and uncommon (n=91) VA groups. Each athlete underwent a comprehensive diagnostic workup, including cardiac magnetic resonance in 94% (n=178) and electrophysiology study/electroanatomical mapping in 87% (n=166). The primary end point was the occurrence of sudden death or sustained VAs during long-term follow-up. RESULTS:Athletes with uncommon VA morphology had higher rates of abnormal findings at multimodality assessment and more final diagnoses of structural heart disease. Over a median follow-up of 6.2 (4.3-8.1) years, 7 (4%) athletes experienced a primary outcome event, including 1 sudden death. Interestingly, no events occurred in athletes with common morphology VAs. In univariable Cox models, factors associated with the primary end point included uncommon VA morphology (P=0.003), lack of VA suppression (P=0.049), and nonsustained ventricular tachycardia/ventricular tachycardia induction (P=0.010) during stress testing, late gadolinium enhancement (P=0.045), electroanatomical scar regions (P=0.022), and sustained VA inducibility by electrophysiology study (P<0.001). Incorporating findings of invasive tests improved prediction of primary outcome events over clinical/noninvasive findings in isolation (log-likelihood ratio for nested models, P=0.004). A survival tree model based on VA morphology, late gadolinium enhancement, VA response to exercise testing, and electroanatomical mapping allowed risk stratification, identifying subgroups of athletes without primary outcome events during follow-up. Among 148 competitive athletes, 101 (68%) regained eligibility after 3 months of detraining, but only 42 (28%) continued long-term. CONCLUSIONS:A comprehensive diagnostic assessment integrating ECG, stress testing, and imaging findings, along with the selective use of invasive electrophysiology assessments, may help refine the prognostic evaluation of athletes with complex VAs.

The COCIS 2023 guidelines represent the latest update on competitive sports eligibility for athletes with heart disease, developed by the Italian Society of Sports Cardiology and associated medical societies. These updated guidelines reflect advancements in cardiology and sports medicine and introduce clear class of recommendations and levels of evidence for assessing athletes with heart disease. This document focuses on the differences between the 2023 and 2017 versions, particularly regarding athletes with arrhythmias. The guidelines integrate new scientific evidence, including modifications to criteria for specific arrhythmic conditions like Wolf-Parkinson-White (WPW) Syndrome, Brugada Syndrome, long QT syndrome (LQTS), and premature ventricular beats (PVBs). Updates on the return-to-play timing after successful catheter ablation are also included. Key updates include the revised arrhythmic risk thresholds for WPW syndrome; these guidelines also expand recommendations for asymptomatic pre-excitation cases. In Brugada Syndrome, eligibility remains dependent on the presence of malignant arrhythmias and genetic risk factors, with scoring systems to aid risk stratification. For LQTS, eligibility is reconsidered for asymptomatic individuals with a negative phenotype and a positive genotype, with beta-blocker use. Additionally, the management of PVBs is refined, with new criteria for further investigation and risk assessment. COCIS 2023 introduces a more nuanced, evidence-based approach to the eligibility of athletes with arrhythmias. The guidelines provide clinicians with detailed recommendations for managing a variety of arrhythmic conditions. As scientific research advances, these guidelines will continue to evolve, ensuring safe athletic participation for individuals with cardiovascular conditions.

Athletic activity can increase the risk of cardiovascular events, including sudden cardiac death, particularly in athletes with undiagnosed heart conditions (1). In Italy, pre-participation screening protocols incorporate resting ECG along with either the Harvard Step Test (HST) or Maximal Exercise Test on treadmill or cycle-ergometer (MET) (2). However, the relative effectiveness of HST and MET in detecting arrhythmias and underlying heart conditions is not well established (3). The primary objective of the study is to delineate a different arrhythmogenic profile between HST and TEM in a paediatric population. The present study evaluated 511 paediatric athletes (ages 8–18, 76.3% males) without a known history of cardiovascular, renal, or endocrine disorders. Each participant underwent both the HST and MET within a 30-day period. The data collected included the type of sport practised (according to the ESC classification) and level of participation, the absolute value and the percentage relative to the expected peak heart rate, the occurrence of both supraventricular and ventricular arrhythmias, the subsequent diagnosis of cardiovascular abnormalities. The specific characteristics of arrhythmias, including focality, morphology, complexity, and period of exercise of occurrence, were also noted. The HST elicited lower peak heart rates compared to MET (181.1 ± 9.8 vs. 187.5 ± 8.1 bpm, p < 0.001) but identified higher rates of supraventricular (18.6% vs. 13.1%, p < 0.001) and ventricular arrhythmias (30.5% vs. 22.7%, p < 0.001), particularly during the recovery phase (p = 0.014). This trend was prominent in male athletes but not in females. Among athletes diagnosed with cardiovascular anomalies (22.3%), the HST was more effective in detecting ventricular arrhythmias (26.3% vs. 18.4%, p = 0.05), recovery-phase arrhythmias (20.2% vs. 14.0%, p = 0.035), and polymorphic arrhythmias (6.1% vs. 1.8%, p = 0.025). The HST demonstrates superior efficacy over MET in detecting arrhythmias, especially during recovery, in young male athletes. This test also highlights a higher prevalence of ventricular arrhythmias in athletes with underlying cardiovascular conditions.Population baseline characteristicsArrhythmias prevalence compared HST-MET

The new section on ischemic heart disease (IHD) among the Italian Sports Cardiology Guidelines (COCIS) provides updated recommendations for the evaluation, management and eligibility of athletes with known or suspected IHD. Emphasizing a risk-stratified approach, the guidelines integrate clinical, functional, and imaging assessments to determine the safety of competitive sports participation. Key updates include considerations for athletes with asymptomatic or subclinical disease. This paper discusses COCIS criteria for risk evaluation in three clinical settings: suspected or stable coronary artery disease (CAD), after revascularization, post-myocardial infarction.

Anomalous origin of coronary artery (AOCA) is a rare congenital disease where a coronary artery arises from a wrong sinus of Valsalva, associated with an increased risk of sudden death. Anomalous origin of the left coronary artery (AOLCA) has the worst prognosis. High-risk anatomy features are a slit-like ostium, acute takeoff angle, orifice >1cm above the sinotubular junction or an interarterial/intramural course. Surgery is recommended in patients with angina symptoms and stress-induced myocardial ischemia; it should be considered in asymptomatic patients with evidence of myocardial ischemia or with AOLCA and high-risk anatomy. After surgery, sport participation may be considered, if the high-risk anatomy is corrected and the patient is asymptomatic, with no exercise-inducible myocardial ischemia or complex ventricular arrhythmias. We aimed to assess surgery outcome, cardiovascular function, persistence of symptoms and return to sport of sportspeople with AOCA after surgical repair. We included 19 (mean age at surgery 18.9±9.1 ys, 17 male) athletes (14 competitive, 3 professional and 2 non-competitive) with surgery-corrected AOCA (15 with anomalous origin of the right coronary artery, AORCA; 4 with AOLCA). Preoperative assessment included echocardiography (ECHO) and cardiopulmonary exercise testing (CPET). Postoperative follow-up involved repeated ECHO and CPET at 3, 6, and 12 months, with further follow-up every 6 months (mean 41.5±51.2 months, max 18 ys). Before surgery, 10 subjects (4 AOLCA, 6 AORCA) had symptoms (chest pain, palpitation, dyspnea and/or syncope), persisting in 4 (2 AOLCA, 2 AORCA) after procedure. Post-surgery complications: 2 new-onset mild aortic regurgitations, 2 pericarditis, 1 pneumothorax. Postoperatively, 11 subjects resumed competitive sport (2 at professional level), 6 chose to quit sport practice and 2 were disqualified (1 AOLCA due to persistence of high-risk anatomy, 1 AORCA due to coexistence of myocardial bridge and stress-induced myocardial ischemia). At post-surgery follow-up, significant reductions in right ventricle systolic longitudinal parameters were observed, compared to pre-surgery ECHO. No significant changes were noted at CPET. Compared to those who chose to stop sport, athletes showed: at ECHO, a significantly greater end-diastolic right ventricular area at preoperative and last evaluation; at CPET, a significantly higher VO2max at each timepoint. Return to sport after successful AOCA surgery is related to improvements in both clinical symptoms and exercise capacity, in absence of inducible myocardial ischemia or complex ventricular arrhythmias during exercise. Unlike those who decided to stop sports, athletes showed higher VO2max over time, reflecting better cardiovascular fitness. Even in patients not eligible for competitive sports, controlled physical exercise, properly prescribed and monitored, should be considered to enhance functional recovery.VO2maxTAPSE trend

Cardiopulmonary exercise testing (CPET) is an innovative yet underutilized non-invasive tool in clinical practice, used to identify ischemia-induced cardiac dysfunction in patients with both obstructive and non-obstructive coronary artery disease (CAD), assess prognosis, and evaluate treatment efficacy. However, the role of CPET in detecting angiographically significant stenosis and the correlation between abnormalities in ventilatory gas analysis and CAD severity remains poorly understood. To identify new correlations between CPET parameters collected during exercise and recovery and the presence and/or severity of CAD. The study included 45 males over 35 years (mean age 62.6, SD 10.2) who underwent CPET before coronary CT angiography (CCTA) due to suspected CAD. CPET data were collected during exercise (peak heart rate [HR], peak respiratory exchange ratio [RER], absolute and normalized peak O2 uptake [VO2peak and VO2/kg], oxygen uptake efficiency slope [OUES], peak O2 pulse [VO2/HR], ventilatory efficiency slope [VE/VCO2 slope]) and during recovery (VO2peak decay slope during early recovery [VO2/t-slope], peak O2 and CO2 half-life [½t-R-VO2 and ½t-R-VCO2], ratio of O2 and CO2 at 3 minutes of recovery and at peak exercise [VO2-3’R/VO2peak and VCO2-3’R/VCO2peak], RER overshoot [RERmag]). Based on CCTA results, patients were classified into two groups: STEN- (absence of coronary stenosis) and STEN+ (presence of coronary stenosis). Based on the latest guidelines, CAD-RADS 2.0 was used to classify coronary plaque severity at CCTA. The STEN- (17 patients, 37.8%) and STEN+ (28 patients, 62.2%) differed in CPET parameters during exercise (VO2/kg, p=0.034; OUES, p=0.003; VO2/HR, p=0.009) and recovery (VO2/t-slope, p=0.018). A strong negative correlation was found between CPET values during exercise (VO2/kg, VO2/HR, OUES) and VO2/t-slope during recovery, respectively: r = -0.708, p < 0.001; r = -0.651, p < 0.001; r = -0.55, p < 0.001. Specifically, VO2/kg correlated with most of the ventilatory parameters measured during recovery (VO2/t-slope, ½t-R-VO2, ½t-R-VCO2, VO2-3’R/VO2peak, VCO2-3’R/VCO2peak, RERmag). The severity of stenosis according to CAD-RADS 2.0 showed a modest negative correlation with CPET parameters (VO2/kg, r = -0.35, p = 0.034; OUES, r = -0.391, p = 0.017; VO2/HR, r = -0.358, p = 0.03) and a modest positive correlation with VO2/t-slope during recovery (r = 0.342, p = 0.038). A similar pattern was observed for plaque burden (P) at CCTA: VO2/kg, r = -0.361, p = 0.028; OUES, r = -0.445, p = 0.006; VO2/t-slope, r = 0.331, p = 0.045; VO2-3’R/VO2peak, r = 0.326, p = 0.049. This study provides further evidence on the role of both exercise and recovery CPET parameters in distinguishing CAD from non-CAD patients. The analysis of ventilatory gas patterns during recovery offers valuable additional data for the identification, stratification, and non-invasive monitoring of CAD patients.Differences in CPET parametersCorrelation between CPET and CAD-RADS2.0

We have read the commentary on our article entitled ‘Differences in Arrhythmia Detection Between Harvard Step Test and Maximal Exercise Testing in a Paediatric Sports Population’ [...]

Nearly 35 years after its initial publication in 1989, the Italian Society of Sports Cardiology and the Italian Federation of Sports Medicine (FMSI), in collaboration with other leading Italian Cardiological Scientific Associations (ANCE - National Association of Outpatient Cardiology, ANMCO - National Association of Inpatient Cardiology, SIC - Italian Society of Cardiology), proudly present the 2023 version of the Cardiological Guidelines for Competitive Sports Eligibility. This publication is an update of the previous guidelines, offering a comprehensive and detailed guide for the participation of athletes with heart disease in sports. This edition incorporates the latest advances in cardiology and sports medicine, providing current information and recommendations. It addresses various topics, including the details of the pre-participation screening in Italy and recommendations for sports eligibility and disqualification in competitive athletes with various heart conditions. This revised version of the Cardiological Guidelines for Competitive Sports Eligibility, recorded in the Italian Guidelines Registry of the Italian Minister of Health, stands as a crucial resource for sports medicine professionals, cardiologists, and healthcare providers, marked by its completeness, reliability, and scientific thoroughness. It is an indispensable tool for those involved in the care, management and eligibility process of competitive athletes with heart conditions.

Background: The bicuspid aortic valve (BAV) is a congenital heart defect that can lead to certain complications (aortic stenosis, regurgitation, dilatation and endocarditis), the diagnosis and clinical monitoring of which are effectively entrusted to transthoracic echocardiography (TTE). The impact of training on the natural history of the disease remains unclear. Methods: A retrospective cohort of athletes with uncomplicated BAV aged 18–50 years, who underwent at least 2 TTEs with a minimum follow-up of 5 years, subdivided according to the level of physical activity during follow-up into ‘’untrained’’ and ‘’trained’’, was collected. RESULTS: 47 athletes (87.3% male, median 21.0, (18.0; 33.0) years) were included. Median follow-up was 11.6 (8.4; 16.3) years. No statistically significant difference in the growing rate of aorta, left ventricle, nor a significant worsening of aortic stenosis and regurgitation was found. Moreover, there was no significant correlation between weekly training minutes during follow-up and the echocardiographic parameters related to heart size and function. Conclusions: In BAV without major complications, high training volumes do not correspond to a more rapid and significant deterioration in valve function nor to a more rapid increase in aortic or cardiac chamber size.

AIMS:Myocardial bridging (MB) is a frequent congenital anomaly of the epicardial coronary arteries commonly considered a benign condition. However, in some cases a complex interplay between anatomical, clinical and physiology factors may lead to adverse events, including sudden cardiac death. Coronary CT angiography (CCTA) emerged as the gold standard noninvasive imaging technique for the evaluation of MB. Aim of the study was to evaluate MB prevalence and anatomical features in a large population of patients who underwent CCTA for suspected CAD and to identify potential anatomical and clinical predictors of adverse cardiac events at long-term follow-up. METHODS AND RESULTS:Two-hundred and six patients (mean age 60.3 ± 11.8 years, 128 male) with MB diagnosed at CCTA were considered. A long MB was defined as ≥25 mm of overlying myocardium, whereas a deep MB as ≥2 mm of overlying myocardium. The study endpoint was the sum of the following adverse events: cardiac death, bridge-related acute coronary syndrome, hospitalization for angina or bridge-related ventricular arrhythmias and MB surgical treatment. Of the 206 patients enrolled in the study, 9 were lost to follow-up, whereas 197 (95.6%) had complete follow-up (mean 7.01 ± 3.0 years) and formed the analytic population. Nineteen bridge-related events occurred in 18 patients (acute coronary syndrome in 7, MB surgical treatment in 2 and hospitalization for bridge-related events in 10). Typical angina at the time of diagnosis and long MB resulted as significant independent predictors of adverse outcome. CONCLUSIONS:Typical angina and MB length ≥ 25 mm were independent predictors of cardiac events.

Transthoracic echocardiography (TTE) is routinely required during pre-participation screening in the presence of symptoms, family history of sudden cardiac death or cardiomyopathies <40-year-old, murmurs, abnormal ECG findings or in the follow-up of athletes with a history of cardiovascular disease (CVD). TTE is a cost-effective first-line imaging modality to evaluate the cardiac remodeling due to long-term, intense training, previously known as the athlete's heart, and to rule out the presence of conditions at risk of sudden cardiac death, including cardiomyopathies, coronary artery anomalies, congenital, aortic and heart valve diseases. Moreover, TTE is useful for distinguishing physiological cardiac adaptations during intense exercise from pathological behavior due to an underlying CVD.In this expert opinion statement endorsed by the Italian Society of Sports Cardiology, we discussed common clinical scenarios where a TTE is required and conditions falling in the grey zone between the athlete's heart and underlying cardiomyopathies or other CVD. In addition, we propose a minimum dataset that should be included in the report for the most common indications of TTE in sports cardiology clinical practice.

Abstract Background Ventricular arrhythmias (VAs) are an important source of concern among athletes. Purpose To determine the prognostic role of non-invasive and invasive diagnostic assessments among athletes with complex VAs. Methods We included 215 athletes (83% male; 28 [19-43] years) with complex VAs in a prospective, multi-center cohort study. At baseline, each athlete underwent a prespecified comprehensive diagnostic workup, which included cardiac magnetic resonance (CMR) in 202 subjects, and electrophysiology study (EPS)/electroanatomical mapping (EAM) in 190. The primary study endpoint was the occurrence of sudden death or sustained VAs during long-term follow-up. Results During a median follow-up of 6.2 (4.4-8.1) years, 16 (7%) athletes had a primary outcome event, including one sudden cardiac death. In univariable Cox models, sustained VAs at presentation (p<0.001), uncommon VA morphology(p=0.004), syncope(p=0.005), abnormal ECG (p=0.003), VAs induction/persistence at exercise testing(p=0.021), late gadolinium enhancement (LGE;p=0.006), low-voltage areas (p=0.003) and late potentials (p<0.001) at EAM, and sustained VA induction by EPS (p<0.001) were all associated with increased risk of primary outcome events. The association of late potentials and EPS inducibility with primary outcome events was confirmed after controlling for all non-invasive predictors at univariable analysis, and the incorporation of findings of invasive tests allowed improved prediction of primary outcome events over clinical/non-invasive findings in isolation (log-likelihood ratio for nested models, p=0.043). Younger age (p=0.032), being a professional athlete (p=0.006), and absence of LGE (p=0.029) were independently associated with higher odds of uninterrupted competitive sports practice until last follow-up. Conclusions A comprehensive diagnostic assessment integrating clinical/ECG findings with CMR and EPS/EAM in selected cases may provide important prognostic information among athletes with complex VAs.