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 ascending reticular activating system, and its indirect action includes displacing endogenous catecholamines from their sites in nerve endings. Its most pronounced general side effects are insomnia, dizziness, profuse sweating, tremors and euphoria; the cardiovascular effects are palpitations, tachycardia and precordial discomfort; cerebral hemorrhage is the neurological effect. 8.3.1.4. Cocaine Cocaine causes generalized vasoconstriction, with the main consequence being hypertension. Although cocaine use causes more intense vasoconstriction in the central nervous system, it can also affect other organs such as the kidneys, resulting in glomerular, tubular, vascular and interstitial changes that lead to renal damage. 306,307 Cocaine may also cause acute myocardial infarction, cardiac arrhythmias, congestive cardiomyopathy, myocarditis, subarachnoid hemorrhage, aortic rupture, rhabdomyolysis, arterial hypertension, spontaneous or exercise-induced myocardial ischemia, and cardiac SD. 8.3.1.5. Ecstasy Ecstasy is a hallucinogen similar to amphetamine. Due to its low cost and availability in tablet form, its popularity and consumption have increased significantly. Ecstasy increases the release of serotonin, dopamine and norepinephrine by presynaptic neurons. It also prevents the metabolism of these neurotransmitters by inhibiting monoamine oxidase. Its main cardiovascular effects are hypertension, tachycardia and arrhythmias, which can lead to SD. 308-310 8.4. Evaluating Athletes and the Organization and Planning of Emergency Care Sports-related SD is a dramatic event, and some measures can (and should) be taken by doctors to try to prevent this rare but tragic complication of sports/exercise. 8.4.1. Aspects Related to the Athlete 8.4.1.1. Pre-participation Screening Considering that, in most cases, sports-related SD is caused by known or undiagnosed heart disease, everyone who intends to participate in sports should undergo PPS, regardless of age. This clinical examination should be preceded by a thorough anamnesis with particular attention paid to family history of cardiovascular disease and SD. PPS, in attempting to detect these pathologies, is the most efficient way to prevent a fatal cardiovascular event. 311 In 2009, the International Olympic Committee published a paper on the importance of periodic medical evaluation in elite athletes. 312,313 Although isolated clinical examination may fail to detect all forms of heart disease with the potential to cause SD, this procedure, whose emphasis on examining the cardiovascular system is preceded by a thorough anamnesis and previous pathological history (including family history), is nevertheless the first step in proper evaluation of the athlete. The clinical examination should ideally include a resting 12- lead ECG. Although there is disagreement between U.S. (who recommend only anamnesis and physical examination) and European authorities (who recommend adding 12-lead ECG to anamnesis and clinical examination), 314 the Brazilian Society of Cardiology considers 12-lead ECG as mandatory at the first cardiological examination. 315 Resting ECG can diagnose numerous heart diseases that can lead to SD, including long QT syndrome, 316 Brugada syndrome, 193 Wolf-Parkinson- White syndrome 317 and HCM. 318 The European protocol, which includes anamnesis, physical examination and ECG, is currently used by the International Olympic Committee, the Italian Olympic Committee, FIFA and the Union of European Football Associations. 292,319,320 The clinical examination should include family and personal history and specific screening for Marfan syndrome. 312 A more detailed approach to PPS is available in another section of this Guideline. 8.4.1.2. Regarding the Athlete’s Preparation Follow-up for athletes must be thorough. To prevent clinical and cardiovascular events, basic preventive measures, such as adequate nutrition and hydration are also important, respecting rest periods and avoiding training and competition during the hottest periods of the day. Athletes in training and competition must be monitored and observed by qualified medical staff, preferably who have experience in sports medicine and first aid in case of emergency. 8.4.2. Aspects Related to Training Venues and Competition 8.4.2.1. Emergency Care and Medical Contingency Planning In addition to procuring the necessary equipment for cases of cardiorespiratory arrest, training and competition venues should develop a medical contingency plan that includes personnel trained in cardiorespiratory resuscitation and optimized transport to a hospital with advanced cardiac life support when applicable. 286,321 8.4.2.2. Automatic External Defibrillators The AED is a computerized device that can identify the occurrence of ventricular fibrillation and tachycardia, the cardiac abnormalities that respond to shock. These devices should be available for use in less than 5 minutes at training venues and competitions, clubs, arenas, stadiums, gyms and cardiovascular rehabilitation clinics, which should also have a team trained in cardiopulmonary resuscitation. 145,322 Among young athletes, CPR arrest usually occurs after intense training sessions or during a competition. Although the occurrence of these events is rare (corresponding to 1% of those occurring in middle-aged or older adults), prompt care and successful resuscitation increase long-term survival. 323,324 357