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 1. Presentation and Introduction Movement is a part of daily life for humans, who must get from one place to another, pick up and carry things, relate to others or simply move for the pleasure of moving. Caspersen et al.’s, 1 classic definition (1985) will be used in this Update, in which all body movement produced by the skeletal muscles that results in energy expenditure is considered physical activity. Physical exercise can be conceptualized as a special type of physical activity that is planned, structured and repetitive, whose ultimate or intermediate goal is to maintain or improve health, physical conditioning, body aesthetics or performance in competition. 1 Although sports are often associated with leisure, they can also be a person’s main activity: individuals can characterize themselves as professional athletes when it becomes their means of livelihood or an important source of income. Recently, the concept of athlete was formally defined as someone who simultaneously meets the following four criteria: (a) trains to improve sports performance or results; (b) actively participates in sports competitions; (c) is formally recognized at a local, regional or national level; (d) regards competition as a main activity (way of life) or as a focus of personal interest, devoting several hours to training every day or most days, exceeding the time allocated to other professional or leisure activities. 2 Those who exercise regularly and but only compete occasionally, such as in marathons or other mass sports events, should be called amateur athletes. 2 Thus, although primarily directed to professional athletes, many aspects covered in this Update also apply to amateurs and some apply to non-athletes who exercise regularly. These updated guidelines for sports and exercise cardiology will address the following topics: pre-participation screening, structural and non-structural heart diseases, genetic aspects of these pathologies, valvular disease, the hearts of female athletes, as well as basic life support for athletes. Some topics in the 2013 Guidelines 3 will be covered in future publications or can be consulted in other specific Guidelines. In summary, this document serves as a de facto update for this field of knowledge and can be applied in clinical practice. 2. Pre-Participation Screening 2.1. Introduction Clinical pre-participation screening (PPS) for sports activities should be understood as a standardized systematic medical evaluation that can cover a broad population of professional and amateur athletes before participating in regular moderate-to-intense exercise. Its purpose is to identify cardiovascular diseases that are incompatible with certain types of exercise. The main objective of this screening, which is conducted prior to initiating training and periodically afterwards, is the prevention of cardiovascular diseases and the early detection of diseases that cause sudden cardiac death (SD). This can be achieved by temporarily or permanently suspending the exercise or by treating the potentially fatal conditions that it could trigger. The American Heart Association, 4 the European Society of Cardiology 5 and the Brazilian Society of Exercise and Sports Medicine 3 recommend PPS for all professional athletes. PPS can also be recommended for correctly prescribing moderate-to-high intensity exercise for non-professionals. Corrado et al. 6 demonstrated the importance of PPS for preventing SD. Over a 26-year period during which PPS was introduced as a federal law in Italy (1979-2004), the incidence of SD in screened athletes was reduced by 89%: from 3.6 per 100,000 person-years in 1979-1980 to 0.4 per 100,000 person-years in 2003-2004. At present, one of the main issues in PPS is cost-effectiveness. Some societies, such as the American Heart Association, advocate screening with only a questionnaire and a physical examination, believing that the financial and psychological costs associated with false positive results in complementary examinations, such as electrocardiograms (ECG), do not justify the potential benefits. 4 However, the European Society of Cardiology and numerous sporting associations (e.g., FIFA, the NBA), support the use of resting ECG, since it has been shown to affect the incidence of SD among athletes. 7,8 Although we do not have randomized studies comparing the two models of evaluation, we suggest that PPS for professional athletes should include 12-lead resting ECG, since, first, it helps guarantee their safety and, second, the investments involved in their training. 9-11 These issues will be addressed in this document, which aims to establish norms for PPS in our country. For didactic purposes, as well as due to clinical, physiological, and epidemiological differences, we have chosen to divide PPS candidates into two groups: amateur athletes and professional athletes. When considering various aspects of exercise, such as intensity, training frequency and volume, a zone of intersection will always exist between these groups. Nevertheless, the medical evaluator’s good judgment and individual experience will be fundamental in choosing a way forward in these cases. In light of such divisions, it is of fundamental importance to understand the distinction this Guideline determines between amateur and professional athletes: Amateurs: adults who participate in regular, moderate- to-high intensity sports activities who occasionally compete, although without professional ties to the sport. Professionals: 2 • Individuals who train to improve their sports performance • Individuals who actively participate in competitions • Individuals who train and compete as their main activity or as a focus of personal interest. They devote a number of hours on most days to training, exceeding the time spent in other professional or leisure activities. However, professional athletes can also be classified according to age: • Young athletes – 12 to 17 years. • Adult athletes – 18 to 35 years. • Master athletes – 35 years or older. 330