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 Recommendation grade: I. Evidence level: C. Athletes with mild mitral stenosis (mitral valve area > 2.0 cm 2 , mean gradient < 10 mmHg at rest) in normal sinus rhythm may participate in any competitive sport. Recommendation grade: IIa. Evidence level: C. Athletes with significant mitral stenosis should not participate in competitive sports, with the possible exception of sports with low static and dynamic components (class IA). Athletes with any degree of mitral stenosis and atrial fibrillation or who have a history of atrial fibrillation on anticoagulant therapy should not participate in competitive sports involving collision/trauma risk. Recommendation grade: III. Evidence level: C. 6.3.2. Mitral Regurgitation The prevalence of mitral regurgitation is age dependent, with a frequency > 6% in adults over 65 years of age. 234 The pathogenesis varies frommitral-valve prolapse (sometimes with myxomatous degeneration) to rheumatic causes, connective tissue diseases (e.g., Marfan syndrome) and infective endocarditis, to secondary causes such as coronary artery disease and dilated cardiomyopathy. Diagnostic suspicion arises from auscultating a systolic murmur at the apex, which is confirmed and quantified by echocardiography. 220 Generally, athletes with mild or moderate mitral regurgitation are asymptomatic (Stage B). The severity of mitral regurgitation is related to LV regurgitant volume into the left atrium, with increased atrial pressure, increased ventricular diastolic volume and posterior LV dilation. 235 Due to overestimation of the LV ejection fraction, LV systolic dysfunction in athletes with mitral insufficiency is defined as a LV ejection fraction < 60% or LVSD > 40 mm. As in aortic regurgitation, it is difficult to distinguish LV dilation due to exercise from that caused by major mitral regurgitation when LVDD is < 60 mm (or < 40 mm/m 2 ). However, LVDD > 60 mm strongly suggests significant mitral regurgitation, thus justifying subsequent investigation. 210 Dynamic exercise generally decreases the regurgitant fraction due to reduced systemic vascular resistance. On the other hand, static exercise with increased systemic BP, HR and systemic vascular resistance increase regurgitant volume, which increases the pressure in pulmonary capillaries. The assessment of athletes with mitral regurgitation, which should occur at least annually, should include complete anamnesis and an echocardiogram. This test can noninvasively estimate pulmonary artery systolic pressure during exercise and is useful for decision making about the intensity of safe physical activity, especially in those with more severe mitral regurgitation. 210 The recommendations listed below should be considered in patients with secondary causes of mitral regurgitation (e.g., infective endocarditis, rupture of the mitral valve chordae) due to a marked increase in LV systolic pressure, which could further damage valve tissue. 6.3.2.1. Recommendations and Evidence Level Athletes with mitral regurgitation should be evaluated annually to continue participation in sports. Athletes with mitral regurgitation should undergo an exercise stress testing or CPET involving at least the activity level achieved in during training and competition, with a hemodynamic response to confirm symptom status. Athletes with mild-to-moderate mitral regurgitation, normal sinus rhythm, normal LV diameter and function, and normal pulmonary arterial pressures (stage B) may participate in any competitive sport. Recommendation grade: I. Evidence level: C. Athletes with moderate mitral regurgitation (stage B), normal sinus rhythm, normal LV ejection fraction, and moderate LV dilation (compatible with that resulting exclusively from exercise [LVDD < 60 mm or < 35 mm/m 2 in men or < 40 mm/m 2 in women) may participate in any sport. Recommendation grade: IIa. Evidence level: C. Athletes with significant mitral regurgitation, normal sinus rhythm, a normal LV ejection fraction at rest, and mild LV dilation (compatible with that which can only result from exercise [LVDD < 60 mm or < 35.3 mm/m 2 in men or < 40 mm/m 2 in women]) (stage C1) may participate in sports with a low-to-moderate static component and a low dynamic component, as well as in sports with a low static component and a moderate dynamic component (classes IA, IIA and IB ). Recommendation grade: IIb. Evidence level: C. Athletes with mitral regurgitation and significant LV dilation (LVDD ≥ 65 mm or ≥ 35.3 mm/m 2 [men] or ≥ 40 mm/m 2 [women]), pulmonary hypertension and LV ejection fraction < 60% or LVSD > 40 mm should not participate in any competitive sport, with the possible exception of low static and dynamic component sports (class IA). Athletes with mitral regurgitation and a history of atrial fibrillation and long-term anticoagulation therapy should not participate in sports that involve a risk of collision/trauma. Recommendation grade: III. Evidence level: C. 6.3.3. Mitral-Valve Prolapse This pathology, which has an estimated prevalence of 2% to 4% in the general population, appears to be more common in women. Diagnosed with echocardiography, it is defined as systolic displacement of one or both mitral leaflets ≥ 2 mm into the left atrium, as well as by the mitral annular plane in the 351