ABC | Volume 113, Nº3, September 2019

Special Article Oliveira Filho et al. Paralympics – addendum to the update on the guidelines for sport and exercise cardiology of the SBC and the SBMEE Arq Bras Cardiol. 2019; 113(3):339-344 Table 1 – Protocol for evaluating Paralympic athletes, according to the Medical Department of the Brazilian Paralympics Committee (http://www.cpb.org.br ) 1. Application of a standardized medical questionnaire, involving identification, personal and family history, sports history, and dietary and daily living habits; 2. Physical examination, with standardized medical form; 3. Laboratory exams: complete blood count, iron, ferritin, folic acid, vitamin B12, blood type, total lipids, cholesterol and fractions, triglycerides, uric acid, blood glucose, type I urine, creatinine, urea, sodium, potassium, testosterone, free testosterone, insulin, cortisol, free T4, free T3, T3, T4, TSH, serology for Chagas, herpes, HIV and HCV, total proteins, AST, ALT, GGT, alkaline phosphatase, calcium, and homocysteine; 4. Chest radiograph; 5. Resting ECG and ergometric test. evaluation should include male and female children, adolescents, adults, and masters/elderly athletes, and it should be the sole responsibility of the attending physician (class of recommendation: I, level of evidence: C). Evaluation should be comprehensive, considering the organism as a whole, with emphasis on physical and somatic aspects; it is necessary to bear in mind that, in physical training and athletic performance, there are interactions between physical disabilities, comorbities, and their respective sequelae (class of recommendation: I, level of evidence: C). Frequency of re-evaluation should be at the discretion of the attending physician, in accordance with each case’s characteristics; the primary aim of re-evaluation frequency should be safe athletic practice (class of recommendation: I, level of evidence: C). Evaluation of Paralympic athletes must follow the established protocol, which is summarized in Table 1. Following initial evaluation, based on the findings, specialized exams will be indicated at the attending physician’s discretion. Examples include cardiopulmonary exercise test (CPT), echocardiogram (ECHO), vectorcardiogram (VCG), computerized tomography, magnetic resonance, ultrasound, hemoglobin electrophoresis (to investigate sickle cell anemia), cardiological evaluation, ophthalmic evaluation, (to investigate Marfan syndrome, glaucoma, and retinal detachment), and orthopedic evaluation 8,9 (class of recommendation: I, level of evidence: C). For athletes with cerebral palsy, the spasticity assessment score (quantitative sports and functional classification [QSFC]) may be used, based on muscular conditions in the upper and lower limbs and the torso. The score may be used for clinical investigation, clinical treatment, and physical training. 10 Athletes who use wheelchairs or prostheses should be closely and thoroughly examined for decubitus sores or sores in the region of the prosthetic implant. The presence of ulcers in these areas will make the athletes temporarily ineligible, until the local conditions of the tegument have been restored (class of recommendation: I, level of evidence: C). The practice of urinary retention should be prohibited in athletes who use wheelchairs, owing to the risk of high elevations in blood pressure and stroke. In cases of neurogenic bladder, it is necessary to pay attention to the presence of subclinical urinary infection. The occurrence of athletic heart syndrome, considering the presence of 2 or more signs, affected 46% of Paralympic athletes. Signs of athletic heart syndrome occurred in 33% of clinical exams (murmurs and clicks), in 55% of electrocardiograms (bradycardia, incomplete right bundle branch block, overloads, T-wave alterations), in 15% dos vectorcardiogram (overloads), and in 5% of echocardiograms (cavity dimensions higher than normal). Signs occurred in 51% of athletes, with 46% of cases having 2 or more signs and 12% having 4 or more signs. ET was normal in 77% of athletes; ischemic ST segments were not found. Right bundle branch block was present in 23% of cases. 11 The following ECG alterations, classified as athletic ECG, were found in Paralympic athletes: primary alterations in ventricular repolarization, 6%; first-degree atrioventricular block, 2%; sinus bradycardia, 6%; block of the anterosuperior division of the left His bundle branch, 2%; right His bundle branch conduction disorder, 14%; early ventricular repolarization, 29%; left atrial overload, 2%; left ventricular overload, 39%. 12 Eight cases of late potentials were described on high- resolution electrocardiogram in 11% of athletes, and there was no evidence of heart disease in a consecutive series of 79 top athletes with disabilities. 13 In subgroups of Paralympic athletes, significant correlations have been described involving variables related to aerobic potential, anaerobic threshold, and morphological variations evaluated by echocardiogram, proving that athletic heart syndrome may occur in Paralympic athletes. 14 In Paralympic Judo athletes, the presence of athletic heart syndrome has been found in 64% of cases evaluated. 15 In subjective evaluations of young Paralympic athletes, it was found that parents might report lower perceived quality of life than their children. 16 Cardiopulmonary exercise test The bases of cardiopulmonary exercise testing protocols include: 1) reproducibility of athletic actions, according to the principle of specificity; 2) adequacy for the athletic modality and the athlete’s means of locomotion; 3) performance of tests with stability and safety, guaranteeing accuracy and reproducibility of measurements 11 (class of recommendation: I, level of evidence: B). Special care should be taken in relation to type and degree of disability, the athlete’s posture, room temperature, prior emptying of bladder, prevention of hypertension, the risk of seizures and accidents, blood pressure measurements, and 340