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 Table 1 – Details to be included in a personal and family history assessment for athletes Has any doctor ever told you that you have a heart problem? Have there been cases of sudden death or heart disease in your family? Precordial pain or discomfort on exertion or at rest Do you feel chest pain when exercise? Pre-syncope or syncope, especially if related to exertion Do you lose your balance due to dizziness and/or loss of consciousness? Are there cases of heart disease, sudden death before age 50 or cardiac arrhythmias In your family? Arrhythmias Observe palpitations (skipped beats or heart racing) Previously diagnosed pathologies Previous history of heart murmur Previous history of hypertension Previous history of metabolic disease Use of performance enhancing substances/ use of any medication Live/lived in an area with endemic Chagas disease Do you have any bone or joint problems that could be made worse by physical activity? Do you currently take some type of medication? Question directly about anti-hypertensive, NSAID, anabolics, illicit drugs, and alcohol consumption Is there any other reason why you should not perform physical activity? Family members with genetic diseases; hypertrophic cardiomyopathy, dilated cardiomyopathy, channelopathies, arrhythmias, Marfan syndrome NSAID: nonsteroidal anti-inflammatory drug. 2.2. Anamnesis and Physical Examination Ideally, all candidates for moderate-to-high intensity exercise should undergo PPS, which can identify risk factors and signs and symptoms suggestive of cardiovascular, pulmonary, metabolic or locomotor disorders. 12-14 In anamnesis, issues related to exercise, including family history of disease or sports-related cardiovascular events, should be prioritized. However, a detailed investigation of family history with respect to heart disease or other SD-related diseases must be performed. To do this, adequate knowledge of these medical conditions and a cardiological approach are important. 10,15,16 In PPS it should be considered that cardiac adaptations to physical exercise are frequency, intensity, and duration dependent and vary among different sports and training systems, as well as among individuals. 17 Due to the latter aspect, different adaptations can be found in individuals involved in similar physical activities. It should be pointed out that the modifications involved in what is referred to as “athlete’s heart syndrome” should initially be considered as normal physiological adaptations to exercise, of a transient nature and without negative repercussions on an individual’s health. 18 The Physical Activity Readiness Questionnaire can be applied systematically during anamnesis. This questionnaire, developed in Canada, should be combined with basic questions asked by a physician (Table 1) about cases of SD or inherited heart diseases, family history of sickle cell disease or other hemoglobinopathies, as well as the patient’s origin. Determining the patient’s origin is important, since certain regions have endemic diseases, such Chagas’ disease, or have a higher prevalence of congenital diseases, such as the Veneto region of Italy, where there is a higher prevalence of arrhythmogenic right ventricular dysplasia (ARVD). 19,20 Particular care should be taken when obtaining information about licit or illicit drug use that could be considered as doping or that could be harmful to health (i.e., which could cause SD or other undesirable events). 21,22 Important symptoms include: palpitations, syncope, chest pain or discomfort, exertional dyspnea, dizziness/asthenia, or any other symptom triggered by exercise. Accurate sensitivity is needed to determine whether mentioned symptoms indicate a disease state or are merely the consequence of more intense training or competition. For both amateur and professional athletes, if syncope occurs during exercise rather than post-effort, a detailed investigation should be conducted to discard a primary arrhythmic event. 23 The physical examination should include inspection for certain clinical conditions, such as anemia, posture changes, infectious foci (e.g., dental), severe systemic or infectious diseases, bronchial asthma, obesity, diabetes mellitus, systemic arterial hypertension, and changes in pulmonary or cardiovascular auscultation. A search for signs related to possible cardiovascular disease should be prioritized, such as: heart murmur, third and fourth heart sounds, valve clicks, pulse changes in the upper and lower limbs, signs of Marfan syndrome or other aortic diseases (e.g., Loeys-Dietz syndrome), as well as adequate blood pressure (BP) in both arms at the first evaluation. 14,24,25 Recommendation for anamnesis and physical examination Recommendation grade Evidence level Amateur athletes I C Professional athletes I A 2.3. Complementary Exams Laboratory tests, in principle, are unnecessary: requests for them should be based on clinical data, especially cardiocirculatory issues. Routine laboratory tests include: complete blood count, fasting glucose, urea, creatinine, sodium 331