IJCS | Volume 32, Nº4, July/August 2019

431 Braga et al. Sudden cardiac arrest in athletes Int J Cardiovasc Sci. 2019;32(4):428-432 Case Report Clinically, three phases have been described in ARVC. In the “concealed phase,” patients are often asymptomatic. In the overt “electrical phase,” they present symptomatic arrhythmias with/without structural abnormalities in imaging tests. Progressive disease may result in RV, LV or biventricular HF combined or not with VA. 5 Cardiac arrest can be the first manifestation, as in our case, even in the concealed phase. 4,5 Our patient had some abnormalities on the previous ECG and on the 24-hour Holter that could suggest the diagnosis, such as inverted T wave in V1-V3 leads and frequent PVC. Indeed, in recent international recommendations for electrocardiographic interpretation in athletes, anterior inverted T wave in non-black athletes and > 2 PVC per 10 seconds tracing are considered ECG abnormalities. 7 However, these abnormalities are nonspecific and, after normal TTE, our patient was cleared to sport practice. CMR is the preferred imaging method for ARVC diagnosis. It is useful not only in RV morphological and functionevaluation, but also in tissuecharacterization. Late gadoliniumenhancement can be visible predominantly in subepicardial RVwall and/or LV inferolateral (observed in this case) or inferoseptal regions, contributing to the early diagnosis of left-sided disease. 8 Current task force criteria forARVCdiagnosis 9 includes major and minor criteria concerning morphological RV abnormalities (by TTE, CMR or angiography), pathological abnormalities in RV endomyocardial biopsy (EB), depolarization and repolarization changes in ECG, VA, and family history. In the presence of 2major criteria, 1 major and 2 minor criteria or 4 minor criteria, ARVC diagnosis is considered definitive. Our patient fulfilled 2 major and 2 minor criteria: 1 major criteria of morphological RV abnormalities (RV dilatation and RV systolic dysfunction with regional dyskinesia in TTE/CMR), 1 major criteria of repolarization abnormalities (inverted T waves in precordial leads) and 2 minor criteria of VA (NSVT with RV outflowmorphology and > 500 PVC in 24-hour Holter monitoring). He had no depolarization abnormalities or family history of ARVC or SCD. Given the results of non-invasive investigation, EB was dismissed. Advising against competitive/endurance sports is the first step in the treatment of ARVC. Beta- blockers prevent exertion-induced VT/VF and are recommended in the presence of HF, as well as the remaining standard HF therapy. Antiarrhythmic drug therapy has a role in patients with symptomatic frequent PVC/NSVT or many other appropriate ICD therapies. 10 ICD therapy is recommended in patients with history of aborted SCD and hemodynamically poorly tolerated ventricular tachycardia. 10 Conclusion This case presents a malignant ARVC presentation in a young athlete with previous subtle abnormalities in medical exams. It highlights the missing details on clinical evaluation even when a comprehensive medical examination is performed. All patients’ data need to be carefully analyzed in order to early detect cardiac disease, like ARVC, and reduce SCD in this population. Disqualification of affected patients from competitive sports might be life-saving. Authors Contribution Conception and design of the research: Braga M. Acquisition of data: Braga M, Araújo P. Analysis and interpretation of the data: Braga M. Araujo P. Writing of the manuscript: Braga M, Dias P, Vasconcelos M, Almeida R, Maciel MJ. Critical revision of the manuscript for intellectual content: Braga M, Dias P, Vasconcelos M, Almeida R, Maciel MJ. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associated with any thesis or dissertation work. Ethics approval and consent to participate This article does not contain any studies with human participants or animals performed by any of the authors.