ABC | Volume 112, Nº3, March 2019

Updated The Brazilian Society of Cardiology and Brazilian Society of Exercise and Sports Medicine Updated Guidelines for Sports and Exercise Cardiology - 2019 Arq Bras Cardiol. 2019; 112(3):326-368 Content 1. Presentation and Introduction ......................................................330 2. Pre-Participation Screening ...........................................................330 2.1. Introduction ......................................................................................330 2.2. Anamnesis and Physical Examination ...............................................331 2.3. Complementary Exams .....................................................................331 2.3.1. Twelve-Lead Electrocardiogram ....................................................332 2.3.1.1. Introduction ...............................................................................332 2.3.1.2. Method ......................................................................................332 2.3.1.3. Analysis ......................................................................................332 2.3.1.4. Changes .....................................................................................332 2.3.2. Electrocardiogram: Physiological Changes vs. Changes Suggestive of Heart Disease .....................................................................................332 2.3.3. Exercise Stress Testing ..................................................................334 2.3.3.1. Variables to be Evaluated in an Exercise Stress Testing .............334 2.3.3.1.1. Functional Capacity ................................................................334 2.3.3.1.2. Chest Pain ...............................................................................334 2.3.3.1.3. ST-T Segment ..........................................................................334 2.3.3.2. Blood Pressure ...........................................................................334 2.3.3.3. Heart Rate ..................................................................................335 2.3.3.4. Cardiac Arrhythmias ..................................................................335 2.3.4. Cardiopulmonary Exercise Testing ...............................................335 2.3.5. Echocardiogram ............................................................................... 336 2.3.6. Recommendations ........................................................................336 2.3.7. Other Complementary Tests .........................................................336 2.3.8. Final Recommendations ...............................................................337 3. Genetic Evaluation and Exercise ...................................................337 3.1. Positive Genotype and Negative Phenotype ......................................337 4. Individuals with Cardiomyopathies and Myocarditis .................338 4.1. Hypertrophic Cardiomyopathy ...........................................................338 4.1.1. Genetics and Hypertrophic Cardiomyopathy ...............................339 4.1.2. Complementary Exams in Hypertrophic Cardiomyopathy ...........339 4.1.2.1. Electrocardiogram ......................................................................339 4.1.2.2. Echocardiogram .........................................................................339 4.1.2.2.1. Transthoracic Doppler Echocardiogram .................................339 4.1.2.2.2. Transesophageal Doppler Echocardiogram ............................340 4.1.2.3. Cardiac Magnetic Resonance Imaging .......................................340 4.1.2.4. Exercise Tests and Hypertrophic Cardiomyopathy ....................340 4.1.2.4.1. Exercise Testing Recommendations for Patients with Hypertrophic Cardiomyopathy ...............................................................340 4.1.2.4.2. The Role of Maximal Cardiopulmonary Exercise Testing in Hypertrophic Cardiomyopathy ...............................................................341 4.1.3. Sports and Hypertrophic Cardiomyopathy ...................................341 4.2. Arrhythmogenic Right Ventricular Dysplasia .....................................341 4.2.1. Diagnosis and Management of Athletes with Suspected Arrhythmogenic Right Ventricular Dysplasia ..........................................342 4.2.1.1. Echocardiogram .........................................................................342 4.2.1.2. Cardiac Magnetic Resonance Imaging .......................................342 4.3. Myocarditis .......................................................................................342 4.3.1. Recommendations for Athletes with Myocarditis .........................342 4.4. Dilated Cardiomyopathy ....................................................................343 4.4.1. Complementary Exams for Dilated Cardiomyopathy ...................343 4.4.1.1. Exercise Stress Testing and Cardiopulmonary Exercise Testing ...343 4.4.1.2. Echocardiogram .........................................................................343 4.4.1.3. Cardiac Magnetic Resonance Imaging .......................................343 4.4.2. Sports and Dilated Cardiomyopathy ............................................343 4.4.2.1. Recommendations for Athletes Diagnosed with Dilated Cardiomyopathy .....................................................................................343 4.5. Non-Compacted Cardiomyopathy ......................................................344 4.5.1. Sports and Non-Compacted Cardiomyopathy ..............................344 4.5.1.1. Recommendations for Athletes Diagnosed with Non-Compacted Cardiomyopathy .....................................................................................344 4.6. Chagas Disease ................................................................................344 5. Channelopathies .............................................................................345 5.1. Introduction ......................................................................................345 5.2. Long QT Syndrome ............................................................................345 5.2.1. Genetic Alterations in Long QT Syndrome ...................................345 5.2.2. Risk Stratification in Long QT Syndrome ......................................345 5.2.3. Recommendations for Athletes with Long QT Syndrome .............345 5.3. Short QT Syndrome ..........................................................................346 5.4. Brugada Syndrome ...........................................................................347 5.5. Catecholaminergic Polymorphic Ventricular Tachycardia ..................347 6. Athletes with Valvular Heart Disease ...........................................348 6.1. Introduction ......................................................................................348 6.2. Aortic Valve Disease .........................................................................348 6.2.1. Aortic Stenosis ..............................................................................348 6.2.1.1. Recommendations and Evidence Level ......................................349 6.2.2. Aortic Regurgitation ......................................................................349 6.2.2.1. Recommendations and Evidence Level ......................................349 6.2.3. Bicuspid Aortic Valve ....................................................................350 6.2.3.1. Recommendations .....................................................................350 6.3. Mitral Valve Disease ..........................................................................350 6.3.1. Mitral Stenosis ..............................................................................350 6.3.1.1. Recommendations and Evidence Level ......................................350 6.3.2. Mitral Regurgitation ......................................................................351 6.3.2.1. Recommendations and Evidence Level ......................................351 6.3.3. Mitral-Valve Prolapse ....................................................................351 6.3.3.1. Recommendations .....................................................................352 6.3.4. Tricuspid Stenosis .........................................................................352 6.3.4.1. Recommendations .....................................................................352 6.3.5. Tricuspid Regurgitation .................................................................352 6.3.5.1. Recommendations .....................................................................353 6.3.6. Multivalvular Heart Disease .........................................................353 6.3.6.1. Recommendations .....................................................................353 6.4. Sports After Valve Surgery ................................................................353 6.4.1. Recommendations and Evidence Level .........................................353 6.4.2. Transcatheter Aortic Valve Implantation .......................................353 7. Athlete’s Heart Syndrome in Women ...........................................353 7.1. Introduction ......................................................................................353 7.2. Complementary Exams .....................................................................354 7.2.1. Twelve-Lead Electrocardiogram ....................................................354 7.2.1.1. Electrocardiogram: Physiological Changes vs. Changes Suggestive of Heart Disease .....................................................................................354 7.3. Echocardiogram ................................................................................354 7.4. Exercise Testing .................................................................................354 7.5. Sudden Death ...................................................................................355 8. Basic Life Support for Athletes .....................................................355 8.1. Sudden Death among Athletes .........................................................355 8.2. Initial Care for Athletes .....................................................................355 8.3. Special Aspects in Preventing Exercise/Sports-Related Sudden Death .......................................................................................................356 8.3.1. Doping: Illicit Substances in Sports ..............................................356 8.3.1.1. Anabolic Steroids .......................................................................356 8.3.1.2. Ephedrine ...................................................................................356 8.3.1.3. Amphetamines ...........................................................................356 8.3.1.4. Cocaine ......................................................................................357 8.3.1.5. Ecstasy .......................................................................................357 8.4. Evaluating Athletes and the Organization and Planning of Emergency Care .....................................................................................357 8.4.1. Aspects Related to the Athlete ......................................................357 8.4.1.1. Pre-Participation Screening .......................................................357 8.4.1.2. Regarding the Athlete’s Preparation ..........................................357 8.4.2. Aspects Related to Training Venues and Competition ..................357 8.4.2.1. Emergency Care and Medical Contingency Planning ................357 8.4.2.2. Automatic External Defibrillators ..............................................357 References ............................................................................................358 329