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doi:10.1093/eurheartj/ehu390
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treated, the patient undergoes two periods of exercise with a Outlining advice he gives to his patients, he said: I always tell them
wire placed beyond the stenosis to monitor pressure and flow. to warm up before exercise, especially if going out in cold weather
Dr Williams said that during the second period, coronary blood which may place additional strain on their heart. People were
flow increases and microvascular resistance decreases, despite a scared of intense exercise in the past, but I believe it potentially
reduction in perfusion pressure. Also, the augmentation indexa offers cardioprotective effects, provided the build-up to intense
measure of wave reflection and arterial stiffnessdecreases on exercise is slow and guided by the cardiac rehabilitation team. Most
second exercise, which indicates a relative reduction in afterload. importantly I would like to emphasise the benefits of exercise and
There is, therefore, still great uncertainty about the mechanism of cardiac rehabilitation, which is currently an under-prescribed asset.
warm-up angina. One possibility is that it is a direct effect of dilatation
of muscular conduit arteries during the first exercise period, especial- Conflict of interest: none declared.
ly the femoral and brachial arteries, thereby reducing the augmenta-
tion index on second exercise. Much interest has also been expressed
in the apparent similarities between warm-up angina and ischaemic
preconditioning, in which non-lethal ischaemia is associated with
reduced infarct size in a subsequent myocardial infarction.
However, the mechanisms seem to be different. At a molecular
level, one possible mechanism, according to Dr Williams, is
enlargement, right-ventricular hypertrophy, and left- and right-axis abnormal ECGs to 11.5% in black athletes and 5.3% in white athletes.
deviation; together, these constitute over 60% of all abnormalities. Significantly, all three criteria identified 98.1% of athletes with HCM.
Two studies published by our group in 2012 confirmed our suspi- Overall, the study detected 40 athletes with pathology. Of these
cions: although comprising a high burden of positive ECGs in elite ath- individuals, 25 were diagnosed with only minor congenital or valvular
letes, no evidence was found to support these five patterns to signify abnormalities. The remaining 15 were diagnosed with serious path-
serious cardiac disease.10,11 ology, defined as a condition implicated as a recognized cause of
Our observations led us to devise a set of refined ECG screening exercise-related SCD. All 15 cases were identified by a combination
criteria (Figure 1) whereby the above-mentioned ECG patterns, in- of history and 12-lead ECG, with 14 (93.3%) identified on the basis of
cluding anterior T-wave inversion in black athletes, were regarded ECG alone.
as normal finings if observed in isolation in an otherwise asymptom- During the screening period, a significant proportion of athletes
atic athlete with no relevant family history or examination findings. (n 3087) were required to undergo echocardiography as a stand-
On the basis of our own experience and in conjunction with the ard part of their clubs screening policy, regardless of history, exam-
Bethesda guidelines, we also increased the cut-off for an abnormal ination, or ECG findings. This cohort was used to determine the
corrected QT interval (QTc) to 470 ms in male and 480 ms in sensitivity and specificity of the screening process using each of the
female athletes. three ECG screening criteria. The refined criteria improved specifi-
In the current study, the impact of our refined criteria on the false- city in black athletes from 40.3% using the ESC recommendations
positive ECG rate was assessed in a large cohort of black (n 1208) to 84.2%, and in white athletes from 73.8% using the ESC recommen-
and white (n 4297) athletes undergoing pre-participation screen- dations to 94.1%. Importantly, sensitivity for detecting all cardiac con-
ing with history, examination, and 12-lead ECG between 2000 and ditions, including HCM, remained 70% in black and 60% in white
2012.12 The ECGs of all athletes were re-evaluated using the athletes, regardless of the criterion employed. Exclusion of minor
refined criteria, ESC recommendations, and Seattle Criteria, to de- pathology from our calculations resulted in a dramatic improvement
termine the number of positive results requiring athletes to in sensitivity to 100% in both black and white athletes without a com-
undergo further investigations. All three ECG criteria were also promise in specificity.
applied to a cohort of 103 young, asymptomatic athletes with The results of this study have furthered our understanding of
HCM to determine the number of individuals in which suspicion of benign vs. abnormal ECG patterns in athletes, and will have a signifi-
the condition was correctly raised by each criterion. cant impact on reducing the burden of false-positive results during
The ESC recommendations resulted in a staggering 40.4% of black pre-participation screening whilst maintaining sensitivity for serious
athletes exhibiting an abnormal ECG requiring further investigation cardiac conditions. Indeed, the ECG correctly identified 93.3% of
prior to being given clearance to compete. Importantly, almost one serious cardiac pathology that may otherwise have not been
in five white athletes (16.2%) also tested positive on the basis of detected. Further work should focus on reproducing our results in
the ESC recommendations. The Seattle criteria reduced the other centres screening large cohorts of elite athletes, and on
number of positive ECGs to 18.4% in black athletes and 7.1% in further improving ECG specificity in black athletes, a significant pro-
white athletes. However, the refined criteria further reduced portion of whom continue to exhibit positive ECG results.
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References
References are available as Supplementary material at European Heart Journal online.
adolescence, the less likely they were to have an MI 30 or 40 years At the time of the mens conscription they had a full medical exam-
later. ination, which included checking blood pressure, weight, height and
The study, published in the European Heart Journal,1 found that the muscle strength, as well as aerobic fitness. During the cycle test for
relationship between aerobic fitness and MI occurred regardless of aerobic fitness, the resistance was gradually increased at the rate of
the mens body mass index (BMI) when they were teenagers. 25 Watts/min2 until the men were too exhausted to continue. The
However, fit but overweight or obese men had a significantly final work rate (maximum watts) was used for the analysis. The
higher risk of a MI than unfit, lean men. average work rate for the men was 250 Watts.
Professor Peter Nordstrom, of Umea Uni- The men were followed for an average of 34 years (ranging from 5
versity, Umea, Sweden, who led the research, to 41 years) until the date of an MI, death, or 1 January 2011, which-
said: Our findings suggest that high aerobic ever came first. To investigate the link between aerobic fitness and
fitness in late adolescence may reduce the risk of a later MI, the mens results were divided into five groups.
risk of MI later in life. However, being very fit Compared with men in the highest fifth for aerobic fitness, men in
does not appear to fully compensate for the lowest fifth had 2.1-fold increased risk of an MI during the follow-
being overweight or obese. Our study suggests up period, after adjusting for BMI, age, place, and year of conscription.
that its more important not to be overweight or obese than to be fit, To investigate the joint effect of BMI and fitness with respect to risk
but that its even better to be both fit and of normal weight. of MIs, BMI were divided into four groups that matched the World
Prof Nordstrom and his colleagues analysed data from 743 498 Health Organizations BMI definitions: underweight/lean (BMI