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 An ICD is recommended for individuals with aborted SD. Recommendation grade: I. Evidence level: B. Individuals with sustained syncope or ventricular tachycardia despite the use of beta-blockers. Recommendation grade: IIa. Evidence level: B. Recommendations about competitive sports in this disease are quite restrictive: athletes with symptomatic or asymptomatic CPVT should not participate in competitive sports (except class IA). Recommendation grade: III. Evidence level: C. 6. Athletes with Valvular Heart Disease 6.1. Introduction The assessment and follow-up of physically active individuals with valve disease are important pillars of sports cardiology. For athletes with valvular heart disease, eligibility criteria are based on cohort studies and expert consensus. However, randomized clinical trials with prospective data are scarce. Athletes with intermediate degrees of valve disease are the most challenging group. Serial evaluation and stratification of disease severity are fundamental. As new symptoms develop, they should be treated promptly. To qualify for competition, athletes must initially be classified according to symptoms, degree of valvular damage and left ventricular dysfunction. Stage A: Asymptomatic athletes at risk of developing stenosis or significant valve regurgitation, e.g., mitral valve prolapse or BAV, as well as individuals whose physical examination is consistent with the underlying pathology (mitral, aortic ejection), but not classic valve dysfunction. Stage B: Asymptomatic athletes with mild-to-moderate valve disease with preserved LV function. Stage C: Asymptomatic athletes with severe valve diseasewith preserved LV systolic function (C1) or LV systolic dysfunction (C2). Stage D: Symptomatic athletes with severe valve disease (with or without LV dysfunction). 6.2. Aortic Valve Disease Aortic impairment is usually degenerative and is a result of aortic stenosis in middle-aged/elderly athletes and BAV in younger athletes. In Brazil, rheumatic etiology should be considered. Primary aortic diseases are common causes of aortic regurgitation, although there are also rheumatic and congenital causes (e.g., BAV). 210,211 6.2.1. Aortic Stenosis Aortic stenosis is considered a progressive disease and survival during the asymptomatic phase has been found similar to that of age-matched controls. 212 In 2010, approximately 40 million people worldwide aged 65 or older had aortic stenosis, and this number is expected to reach 72 million by 2030. 213 Lower exercise tolerance, effort dyspnea, and angina in athletes with systolic murmur are suggestive of clinically important aortic stenosis. Dyspnea is due to increased LV filling pressure or an inability to increase cardiac output with exercise. Aortic stenosis is also recognized as responsible for SD in young athletes, although the prevalence of less than 4%. 214 It is important to point out that almost 70% of SD episodes in subjects with severe aortic stenosis were not preceded by any of the classic symptoms of the disease. 212 Echocardiography with Doppler color flow mapping is the method of choice for diagnosis, classification and evaluation of aortic stenosis 215 (Table 11). Transthoracic echocardiography provides evidence of aortic valve anatomy (e.g., the number of cusps and the extent of calcification), as well as valve hemodynamics (to confirm severity) and their consequences on LV function. Pulmonary hypertension, concomitant valvular disease and aortic root dilation can also be evaluated. 216 Cardiac MRI is useful for patients with an unfavorable transthoracic window and/or when there is disagreement between two-dimensional echocardiographic parameters. 217 Computed tomography of the heart can be used to quantify valve calcification. A calcium score of less than 700 Agatston units excludes severe aortic stenosis and has a high negative predictive value. On the other hand, scores over 2,000 Agatston units suggest severe aortic stenosis. 213 Due to potential progressive aortic valve narrowing, athletes with mild or moderate (stage B) aortic stenosis should be assessed annually. In asymptomatic or oligosymptomatic patients, exercise testing (exercise stress testing or CPET) could reveal those with low functional capacity, intraoperative hypotension and/or electrocardiographic changes during exercise. Such findings will conflict with the recommendations about sports participation. Recently, Saeed et al. 218 analyzed almost 800 exercise tests and found that patients with moderate-to-severe asymptomatic aortic stenosis can perform the test safely and with good tolerability. In addition, event-free survival at 1 year was almost 90% in asymptomatic patients, but less than 70% in those who reported symptoms during exercise. BAV patients without stenosis (stage A) should have an annual physical examination to detect new heart murmurs. Athletes with mild-to-moderate aortic stenosis (stage B) should Table 11 – Aortic stenosis severity rating Impairment (degree) Jet velocity (m/s) Medium gradient (mmHg) Aortic valve area (cm 2 ) Mild < 3 < 25 > 1.5 Moderate 3-4 25-40 1.0-1.5 Severe > 4 > 40 < 1.0 (< 0.6 cm 2 /m 2 ) 348