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 or discretely dilated LV and a normal ejection fraction may participate in any sport (with frequent reassessment). Recommendation grade: I. Evidence level: C. Athletes with mild to moderate aortic regurgitation (stage B), a physiological response to a maximal exercise testing, a moderately dilated LV (LVSD<50mm [men], <40mm [women] or <25mm/m 2 [both sexes]) and a normal ejection fractionmay participate in any sport (with frequent reassessment). Recommendation grade: IIa. Evidence level: C. Athletes with severe aortic regurgitation (stage C1), a physiological response to a maximal exercise testing, a moderately dilated LV (LVSD < 50 mm [men], < 40 mm [women] or < 25 mm/m 2 [both sexes]), a normal ejection fraction and no progression of aortic impairment or LV regurgitation according to echocardiography may participate in any sport (with frequent reassessment). Athletes with aortic regurgitation whose aortic diameters are 41 to 45 mm may participate in sports in which there is no risk of collision (with frequent reassessment). Recommendation grade: IIb. Evidence level: C. Symptomatic athletes with significant aortic regurgitation (stage D), LV systolic dysfunction with an ejection fraction < 50% (stage C2), LVSD > 50 mm or > 25 mm/m 2 (stage C2) or a significant increase in LVDD (> 70 mm or ≥ 35.3 mm/ m 2 [men], > 65 mm or ≥ 40.8 mm/m 2 [women]) should not participate in competitive sports. Recommendation grade: III. Evidence level: C. 6.2.3. Bicuspid Aortic Valve BAV is the most common congenital heart disease, affecting 1.3% of the population. 228 There is already consensus that an association exists between BAV and changes in vascular connective tissue, and that dilation of the aortic root can occur, including a risk of dissection, even in the absence of hemodynamically significant aortic stenosis or aortic regurgitation. 229,230 6.2.3.1. Recommendations Athletes with BAV but not aortic root dilation (less than 40 mm, or equivalent in children and adolescents according to body surface area), significant aortic stenosis, or aortic regurgitation may participate in any competitive sport. Athletes with BAV and aortic root measurements between 40 and 45 mm may participate in competitive sports with a low-to-moderate static component or a low-to-moderate dynamic component (classes IA, IB, IIA and IIB) but should avoid sports that involve a risk of collision or trauma. Athletes with BAV and aortic root dilation greater than 45 mm may participate only in competitive sports with low static and dynamic components (class IA). 6.3. Mitral Valve Disease 6.3.1. Mitral Stenosis A mitral valve area of 4 to 6 cm 2 is considered normal. Mitral stenosis affects women twice as frequently as men. 231 As mitral stenosis progresses, particularly when the area becomes smaller than 2 cm 2 , a diastolic pressure gradient develops between the left atrium (LA) and the LV, causing elevation in LA pressures and decreased flow towards the LV. 232 Frequently of rheumatic origin, mitral stenosis rarely causes SD. However, exercise may lead to a marked increase in pulmonary and pulmonary capillary pressure, sometimes culminating in acute pulmonary edema. 233 Athletes with mitral stenosis are more likely to develop atrial fibrillation as a result of strenuous exercise in an already enlarged atrium. Systemic embolization is the main complication, but there is no evidence that strenuous exercise increases risk. When atrial fibrillation occurs in an athlete with mitral stenosis, anticoagulant therapy should be applied. As in other valvular heart diseases, the evaluation of athletes with mitral stenosis requires a well-documented anamnesis, as well as an echocardiogram (Table 12). 215 This disease is considered severe when there is a resting mean transmitral gradient of 5 to 10 mmHg, which is dependent on transvalvular flow and the diastolic filling phase, factors that vary widely with increased heart rate during exercise. 210 Athletes with mitral stenosis, whether asymptomatic or with minimal symptoms, should perform an exercise testing involving at least the activity level achieved during training/ competition, especially if the disease severity is uncertain. The intensity of physical activity should depend on the size of the left atrium and the severity of the defect. Pulmonary artery systolic pressure during exercise can be estimated noninvasively with an echocardiogram, which can be of great value in quantitative analysis of the safe training range for mitral stenosis patients. 210 6.3.1.1. Recommendations and Evidence Level Athletes with mitral stenosis should undergo an annual evaluation to continue participating in sports. An exercise testing should be performed involving at least the activity level achieved during training/competition with a hemodynamic response to confirm the symptom status. Table 12 – Echocardiographic features of severe mitral stenosis Mitral valve area < 1.5 cm 2 Mean left atrial/left ventricular diastolic gradient ≥ 10 mmHg Pulmonary artery systolic pressure ≥ 50 mmHg at rest Pulmonary artery systolic pressure ≥ 60 mmHg on effort 350