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 and ventilatory equivalents (VE/VO 2 and VE/VCO 2 ). 62 CPET is already included in cardiological evaluation of HF patients, 63 in identifying the etiology of effort dyspnea 64 , and has more recently been considered capable of identifying myocardial ischemia 65,66 or abnormal responses after cardiac surgery. 67 In patients with chest pain, changes in the oxygen pulse during CPET make its diagnostic and predictive accuracy greater than an exercise stress testing for detecting or excluding myocardial ischemia. 68 It is the procedure of choice when a valid and precise measurement of an athlete’s aerobic condition is required and HR thresholds must be determined for exercise prescription. Recommendation Recommendation grade Evidence level Amateur athletes IIa C Professional athletes I B For more precise stratification of exercise-limiting factors IIa A CPET should be used when there is a change in resting ECG that may interfere in its interpretation or when there are suspicious hemodynamic responses. Recommendation grade: IIa. Evidence level: B. The routine use of CPET to stratify risk of sudden death in apparently healthy children and adolescents does not seem especially useful. Recommendation grade: III. Evidence level: B. 2.3.5. Echocardiogram An echocardiogram may play a relevant role in PPS since it can diagnose the main diseases involved in SD in athletes (Table 5). It can also help distinguish between physiological alterations in the athlete’s heart and HCM painlessly, quickly and at a relatively low cost. However, it should be reserved for cases where there is a clinical/family history of heart disease or when a physical examination gives suspicious results, as well as when changes in resting ECG indicate cardiomyopathy. 69 Furthermore, in known cases of congenital heart disease, especially those of low complexity, when physical activity and even high-performance sports are not contraindicated, a periodic ECG helps evaluate the evolution of the condition in question and its correct management. Doppler echocardiogram associated with physical effort is important when verifying cardiac function during exercise, and it can aid in diagnosis and determining the course of treatment, especially for HCM patients. 28 2.3.6. Recommendations The European Society of Cardiology, in light of the findings of Corrado et al. 6 (the previously mentioned 25-year Italian follow up of athletes), has established a screening program for individuals between 12 and 35 years of age that includes an initial examination consisting of family history, a physical examination, and 12-lead ECG. Additional tests will only be performed after positive findings in initial evaluation. 70 Using ECG in programs for young asymptomatic athletes (12 to 35 years of age) has proven to be a high-cost strategy, and no population studies with adequate follow-up have proven its efficacy. Although this test is considered the most practical method for detecting cardiac structural changes, its use as a screening tool is generally reserved for elite athletes, especially in clubs or teams with the necessary financial resources. ECG may indicate the presence of congenital abnormalities in athletes, even when the results are normal. However, since most of these changes are not implicated in the genesis of SD, its use has not been routinely recommended, especially given that its diagnostic power in asymptomatic athletes with normal physical examination results is very low. 71 When CAD is suspected in the initial evaluation, further investigation should be carried out with more accurate examinations: ECG with physical or pharmacological stress, myocardial scintigraphy with physical or pharmacological stress or dynamic cardiac MRI. Studies have suggested introducing a limited echocardiogram that is restricted to the two-dimensional mode, which can be performed in 5 minutes. The results showed good sensitivity and specificity for diagnosing various SD-related conditions in athletes, especially HCM, 72 which is implicated in more than 30% of SD cases in young athletes. At the present time, ECG is considered a confirmatory diagnostic modality to be performed after suspicious results are found in PPS. Recommendation grade: I. Evidence level: A. There is no evidence to support the use of routine ECG in population screening programs for asymptomatic individuals. Recommendation grade: III. 2.3.7. Other Complementary Tests The use of other diagnostic tools, whether laboratory, graphic, imaging, invasive or non-invasive, should comply with clinical criteria and scientific evidence already established in the literature, depending on the PPS findings. Table 5 – Main causes of sudden death in athletes Age < 35 Age > 35 Hypertrophic cardiomyopathy Coronary artery disease Arrhythmogenic right ventricular dysplasia Anomalous origin of coronary arteries Myocarditis Valve disease Pre-excitation syndrome Conduction system disease 336