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Background Most patients with atherosclerotic cardiovascular disease remain at (very) high risk for recurrent events due to suboptimal risk factor control. Aims This study aimed to quantify the potential of maximal risk factor treatment on 10-year and lifetime risk of recurrent atherosclerotic cardiovascular events in patients 1 year after a coronary event. Methods and results Pooled data from six studies are as follows: RESPONSE 1, RESPONSE 2, OPTICARE, EUROASPIRE IV, EUROASPIRE V, and HELIUS. Patients aged ≥45 years at ≥6 months after coronary event were included. The SMART-REACH score was used to estimate 10-year and lifetime risk of recurrent atherosclerotic cardiovascular events with current treatment and potential risk reduction and gains in event-free years with maximal treatment (lifestyle and pharmacological). In 3230 atherosclerotic cardiovascular disease patients (24% women), at median interquartile range (IQR) 1.1 years (1.0–1.8) after index event, 10-year risk was median (IQR) 20% (15–27%) and lifetime risk 54% (47–63%). Whereas 70% used conventional medication, 82% had ≥1 drug-modifiable risk factor not on target. Furthermore, 91% had ≥1 lifestyle-related risk factor not on target. Maximizing therapy was associated with a potential reduction of median (IQR) 10-year risk to 6% (4–8%) and of lifetime risk to 20% (15–27%) and a median (IQR) gain of 7.3 (5.4–10.4) atherosclerotic cardiovascular disease event-free years. Conclusions Amongst patients with atherosclerotic cardiovascular disease, maximizing current, guideline-based preventive therapy has the potential to mitigate a large part of their risk of recurrent events and to add a clinically important number of event-free years to their lifetime.

OBJECTIVE: To systematically investigate and document the infrastructure, practices, recommendations, and clinical consequences of a structured, organized sports cardiology multidisciplinary team (MDT) for athletes and patients who wish to engage in sports and exercise. PATIENTS AND METHODS: We established bimonthly sports cardiology MDT meetings, with a permanent panel of experts in sports cardiology, genetics, pediatric cardiology, cardiovascular imaging, electrophysiology, and sports and exercise medicine. Cases were referred nationally or internationally by cardiologists/sports physicians. We retrospectively analyzed all MDT cases (April 10, 2019 through May 13, 2020) and collected clinical follow-up data up to 1 year after the initial review. RESULTS: A total of 115 athletes underwent MDT review; of them, 11% were women, 65% were recreational athletes, and 54% were performing "mixed" type of sports; the mean age was 32±16 years. An MDT review led to a diagnosis revision of "suspected cardiac pathology" to "no cardiac pathology" in 38% of the athletes and increased the number of definitive diagnoses (from 77 to 109; P=.03). We observed fewer "total sports restrictions" (from 6 to 0; P=.04) and more tailored sports advice concerning "no peak load/specific maximum load" (from 10 to 26; P=.02). At the 14±6-month follow-up, 112 (97%) athletes reported no cardiovascular events, 111 (97%) athletes reported no (new) cardiac symptoms, 113 (98%) athletes reported adherence to the MDT sports advice, and no diagnoses were revised. CONCLUSION: Our experiences with a comprehensive sports cardiology MDT demonstrate that this approach leads to higher percentages of definitive diagnoses and fewer cardiac pathology diagnoses, more tailored sports advice with excellent rates of adherence, and fewer total sports restrictions. Our findings highlight the added value of sports cardiology MDTs for patient and athlete care.

Lower cardiorespiratory fitness (CRF) and physical activity (PA) associate with higher cardiovascular disease (CVD) risk, but the relationship between CRF and PA in people who have rheumatoid arthritis (RA) at an increased CVD risk (CVD-RA) is not known. The objectives of this study were to determine the levels of CRF and PA in people who have CVD-RA and to investigate the association of CRF with PA in people who have CVD-RA. A total of 24 consecutive patients (19 women) with CVD-RA (> 4% for 10-year risk of fatal CVD development as calculated using the Systematic Coronary Risk Evaluation)-were included in the study. CRF was assessed with a graded maximal exercise test determining maximal oxygen uptake (VO2max). PA was assessed with an accelerometer to determine the amount of step count, sedentary, light and moderate-to-vigorous physical activity (MVPA) minutes per day. Mean age of patients was 65.3 ± 8.3 years. CRF mean values were 16.3 ± 1.2 ml·kg-1 min-1, mean step count per day was 6033 ± 2256, and the mean MVPA time was 16.7 min per day. Significant positive associations were found for CRF with step count (B = 0.001, P = 0.01) and MVPA time (B = 0.15, P = 0.02); a negative association was found for CRF with sedentary time (B = - 0.02, P = 0.03). CRF is low and is associated with step count, sedentary time and MVPA time in people who have RA at an increased CVD risk.

Cardiac rehabilitation (CR) has evolved as an important part of the treatment of patients with cardiovascular disease. However, to date, its full potential is fairly underutilised. This review discusses new developments in CR aimed at improving participation rates and long-term effectiveness in the general cardiac population. It consecutively highlights new or challenging target groups, new delivery modes and new care pathways for CR programmes. These new or challenging target groups include patients with atrial fibrillation, obesity and cardiovascular disease, chronic coronary syndromes, (advanced) chronic heart failure with or without intracardiac devices, women and frail elderly patients. Also, the current evidence regarding cardiac telerehabilitation and loyalty programmes is discussed as new delivery modes for CR. Finally, this paper discusses novel care pathways with the integration of CR in residual risk management and transmural care pathways. These new developments can help to make optimal use of the benefits of CR. Therefore we should seize the opportunities to reshape current CR programmes, broaden their applicability and incorporate them into or combine them with other cardiovascular care programmes/pathways.

Background: Marital status is associated with prognosis in patients with cardiovascular disease (CVD). However, the influence of partners on successful modification of lifestyle-related risk factors (LRFs) in secondary CVD prevention is unclear. Therefore, we studied the association between the presence of a partner, partner participation in lifestyle interventions and LRF modification in patients with coronary artery disease (CAD). Methods: In a secondary analysis of the RESPONSE-2 trial (n = 711), which compared nurse-coordinated referral to community-based lifestyle programs (smoking cessation, weight reduction and/or physical activity) to usual care in patients with CAD, we investigated the association between the presence of a partner and the level of partner participation on improvement in >1 LRF (urinary cotinine

Background COVID-19 has been associated with myocardial abnormalities on cardiac magnetic resonance imaging (CMR). We report a case of COVID-19 myocarditis in an elite athlete. Case summary A male, 21-year-old elite football player had tested positive for SARS-CoV-2 on a polymerase-chain-reaction test and was referred for cardiac evaluation after experiencing palpitations after returning to sports (RTS). Biochemical evaluation demonstrated elevated N-terminal pro b-type natriuretic peptide (NT-proBNP) and high-sensitive Troponin T. Echocardiography demonstrated left ventricular function within normal ranges for athletes but with diminished basal, posterolateral, and septal strain. Cardiac magnetic resonance imaging (CMR) showed increased T1 values and late gadolinium enhancement (LGE) in the basolateral and mid-ventricular posterior segments. Focal COVID-19 myocarditis was diagnosed and the patient remained restricted from sports, in line with the 2020 ESC sports cardiology guidelines. Two months later, his electrocardiogram (ECG) showed inferoposterolateral T-wave inversion (TWI). Serial imaging studies were performed to optimize RTS timing. Cardiac magnetic resonance imaging showed persistently increased T1/T2 values and persistent LGE at 5 and 7 months. At 9 months, 18 F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)-computerized tomography (CT) demonstrated no pathologically increased cardiac FDG-uptake. Subsequent exercise ECG and Holters demonstrated no complex ventricular arrhythmias. The patient made a complete return to elite competitive sports, without any adverse events at 15 months of follow-up. Discussion Cardiac symptoms in athletes post-COVID-19 should prompt cardiac evaluation. As COVID-19 myocarditis inflammation can persist beyond the 3–6 months of recommended sports restriction, a more personalized approach to RTS timing can be warranted. In cases with myocardial oedema without other signs of inflammation, FDG-PET-CT can be of added value to assess active myocardial inflammation.

Objective Structured electrocardiography (ECG) analysis is used to screen athletes for high-risk cardiovascular conditions (HRCC) to prevent sudden cardiac death. ECG criteria have been specified and recommended for use in young athletes ≤ 35 years. However, it is unclear whether these ECG criteria can also be applied to master athletes >35 years. Aim The purpose of this study was to test whether the existing ECG criteria for detecting HRCC in young athletes can be applied to master athletes. Methods We conducted a cross-sectional study among athletes >35 years screened for HRCC between 2006 and 2010. We performed a blinded retrospective analysis of master athletes’ ECGs, separately applying European Society of Cardiology (ESC)-2005, Seattle, and International criteria. HRCC were defined using recommendations from the international cardiac societies American Heart Association and American College of Cardiology, and ESC, based on ECG screening and cardiovascular evaluation (CVE). Results We included 2578 master athletes in the study, of whom 494 had initial screening abnormalities mandating CVE. Atrial enlargement (109, 4.1%) and left ventricular hypertrophy (98, 3.8%) were the most common ECG abnormalities found using the ESC-2005 or Seattle criteria. Applying the International criteria, ST-segment deviation (66, 2.6%), and T-wave inversion (58, 2.2%) were most frequent. The ESC-2005 criteria detected more HRCC (46, 1.8%) compared with the Seattle (36, 1.4%) and International criteria (33, 1.3%). The most frequently detected HRCC was coronary artery disease (24, 0.9%). Conclusion ECG criteria recommended for use in young athletes can be applied to master athletes’ ECGs to detect HRCC. The ESC-2005 criteria had the highest sensitivity for detecting HRCC among master athletes.

While the beneficial effects of secondary prevention of cardiovascular disease are undisputed, implementation remains challenging. A gap between guideline-mandated risk factor targets and clinical reality was documented as early as the 1990s. To address this issue, research groups in the Netherlands have performed several major projects. These projects address innovative, multidisciplinary strategies to improve medication adherence and to stimulate healthy lifestyles, both in the setting of cardiac rehabilitation and at dedicated outpatient clinics. The findings of these projects have led to changes in prevention and rehabilitation guidelines.

The coronavirus disease 2019 (COVID-19) pandemic has led to preventive measures worldwide. With the decline of infection rates, less stringent restrictions for sports and exercise are being implemented. COVID-19 is associated with significant cardiovascular complications; however there are limited data on cardiovascular complications and long-term outcomes in both competitive (elite) athletes and highly active individuals. Based on different categories of disease severity (asymptomatic, regional/systemic symptoms, hospitalisation, myocardial damage, and/or myocarditis), in this point-of-view article we offer the (sports) cardiologist or sports physician in the Netherlands a practical guide to pre-participation screening, and diagnostic and management strategies in all athletes >16 years of age after COVID-19 infection.

Background In individuals with neuromuscular diseases (NMD), symptoms of muscle weakness, fatigue and pain may limit physical activity. Inactivity leads to reduced physical fitness, which further complicates daily life functioning. Due to inconclusive evidence regarding exercise in NMD, the optimal training approach and strategies to preserve an active lifestyle remain to be determined. The physical activity programme I’M FINE, consisting of individualized aerobic exercise to improve physical fitness and coaching to preserve an active lifestyle, was therefore developed. The primary objective of this study will be to evaluate the efficacy of the I’M FINE programme in terms of improved physical fitness in individuals with slowly progressive NMD, compared to usual care. Methods A multicentre, assessor-blinded, two armed, randomized controlled trial will be conducted in a sample of 90 individuals with slowly progressive NMD. Participants motivated to improve their reduced physical fitness will be randomized (ratio 1:1) to the I’M FINE intervention or usual care. The I’M FINE intervention consists of a six-month physical activity programme, including individualized home-based aerobic exercise to improve physical fitness (i.e. peak oxygen uptake), and motivational interviewing coaching (e.g. goal setting, self-management) to adopt and preserve an active lifestyle. Measurements will be performed at baseline, post-intervention, and at 12- and 18-months follow-up. The primary outcome is peak oxygen uptake (VO2 peak) directly post intervention. Main secondary outcomes are physical capacity, muscle strength, self-efficacy, daily activity, quality of life and markers of metabolic syndrome. The primary analysis compares change in VO2 peak post-intervention between the intervention and usual care group, with analysis of covariance. Discussion The I’M FINE study will provide evidence regarding the efficacy of a physical activity intervention on the physical fitness and active lifestyle over the short- and long-term in individuals with slowly progressive NMD. These outcomes could potentially improve the (inter)national guidelines for efficacy of aerobic exercise programmes and provide insight in achieving a more active lifestyle in NMD. Trial registration (5/11/2018): Netherlands Trial Register NTR7609 (retrospectively registered), https://www.trialregister.nl/trial/7344. However, the Ethics Review Committee of the Amsterdam Medical Center (AMC) approved the study protocol on 7/11/2017. No adjustments were made to the approved study protocol before the first participant enrolment and registration. Registration was done after the second participant enrolment and the information in the register corresponds one on one with the approved study protocol.

Background Left ventricular false tendons (LVFTs) are common. There is conflicting evidence whether LVFTs have clinically important electrophysiological effects. The aim of this study was to investigate, in a highly active population: 1) the prevalence of LVFTs, 2) the association between LVFTs and abnormalities on the resting 12-lead-electrocardiograms (ECG) and 3) the association of LVFTs with ventricular arrhythmias. Methods A retrospective cohort study was performed using data from military personnel in active service who were referred to the Cardiology Department of the Central Military Hospital in Utrecht, The Netherlands, in 2017. Data of resting 12-lead-electrocardiography, transthoracic echocardiography, ambulatory ECG monitoring, exercise testing, the prevalence of traditional cardiovascular risk factors and relevant clinical data were obtained from the electronic patient data charts. Results In total, 125 subjects were included in the analysis. The overall prevalence of LVFTs was 40% and the they were predominantly located from the mid-IVS top the apical segment of the LV (type 4). Non-significant T-Wave Abnormalities (NS-TWA) were significantly more prevalent in subjects with LVFTs and were predominantly localized in the lateral leads. There was no increased risk of any arrhythmia. Follow-up data of 3.2 years showed no difference in the occurrence of major adverse cardiac events. Conclusion In this highly active group subjects, the presence of an LVFT did not yield an increased arrhythmogenic risk compared to subjects without a LVFT.

Lifestyle management is the cornerstone of both primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) and the importance of lifestyle management is emphasised by all major guidelines. Despite this, actual implementation of lifestyle management is poor. Lifestyle modification includes smoking cessation, weight loss, dietary change, increasing physical inactivity, and stress management. This review summarises evidence-based opportunities and challenges for healthcare professionals to promote healthy lifestyles at an individual level for the prevention of ASCVD.

The high prevalence and burden of cardiovascular diseases (CVD) is largely attributable to unhealthy lifestyle factors such as smoking, alcohol consumption, physical inactivity and unhealthy food habits. Prevention of CVD, through the promotion of healthy lifestyles, appears to be a Sisyphean task for healthcare professionals, as the root causes of an unhealthy lifestyle lie largely outside their scope. Since most lifestyle choices are habitual and a response to environmental cues, rather than rational and deliberate choices, nationwide policies targeting the context in which lifestyle behaviours occur may be highly effective in the prevention of CVD. In this point-of-view article, we emphasise the need for government policies beyond those mentioned in the National Prevention Agreement in the Netherlands to effectively reduce the CVD risk, and we address the commonly raised concerns regarding ‘paternalism’. Supplementary Information The online version of this article (10.1007/s12471-021-01628-w) contains supplementary material, which is available to authorized users.

BACKGROUND Remote coaching might be suited for providing information and support to patients with coronary artery disease (CAD) in the vulnerable phase between hospital discharge and the start of cardiac rehabilitation (CR). OBJECTIVE The goal of the research was to explore and summarize information and support needs of patients with CAD and develop an early remote coaching program providing tailored information and support. METHODS We used the intervention mapping approach to develop a remote coaching program. Three steps were completed in this study: (1) identification of information and support needs in patients with CAD, using an exploratory literature study and semistructured interviews, (2) definition of program objectives, and (3) selection of theory-based methods and practical intervention strategies. RESULTS Our exploratory literature study (n=38) and semistructured interviews (n=17) identified that after hospital discharge, patients with CAD report a need for tailored information and support about CAD itself and the specific treatment procedures, medication and side effects, physical activity, and psychological distress. Based on the preceding steps, we defined the following program objectives: (1) patients gain knowledge on how CAD and revascularization affect their bodies and health, (2) patients gain knowledge about medication and side effects and adhere to their treatment plan, (3) patients know which daily physical activities they can and can’t do safely after hospital discharge and are physically active, and (4) patients know the psychosocial consequences of CAD and know how to discriminate between harmful and harmless body signals. Based on the preceding steps, a remote coaching program was developed with the theory of health behavior change as a theoretical framework with behavioral counseling and video modeling as practical strategies for the program. CONCLUSIONS This study shows that after (acute) cardiac hospitalization, patients are in need of information and support about CAD and revascularization, medication and side effects, physical activity, and psychological distress. In this study, we present the design of an early remote coaching program based on the needs of patients with CAD. The development of this program constitutes a step in the process of bridging the gap from hospital discharge to start of CR.

ObjectivesQuantification of pericardial/myocardial involvement and risks of sudden cardiac arrest/sudden cardiac death (SCA/SCD) after SARS-CoV-2 infection in athletes who return to sports.DesignSystematic review on post-SARS-CoV-2 infection pericardial/myocardial manifestations in athletes.Data sourcesCombinations of key terms in Medline, Embase and Scopus (through 2 June 2021).Eligibility criteria for selecting studiesInclusion: athletes, with cardiovascular magnetic resonance (CMR) or echocardiography after recovery from SARS-CoV-2 infection, including arrhythmia outcomes. Exclusion: study population ≥1 individual comorbidity and mean age 64 years. Quality assessment was performed using Joanna Briggs Institute Critical Appraisal tools checklists.ResultsIn total, 12 manuscripts (1650 papers reviewed) comprising 3131 athletes (2198 college/student athletes, 879 professional athletes and 54 elite athletes) were included. The prevalence of myocarditis on echocardiography and/or CMR was 0%–15%, pericardial effusion 0%–58% and late gadolinium enhancement (LGE) 0%–46%. Weighted means of diagnosed myocarditis were 2.1% in college/student athletes and 0% in elite athletes. The prevalence of LGE was markedly lower in studies with high-quality assessment scores (3%–4%) versus low scores (38%–42%). A single study reported reversibility of myocardial involvement in 40.7%. No important arrhythmias were reported. Ten studies (n=4171) reporting postrecovery troponin T/I found no clear relationship with cardiac abnormalities.Summary/conclusionAthletes have an overall low risk of SARS-CoV-2 pericardial/myocardial involvement, arrhythmias and SCA/SCD. Rates of pericardial/myocardial abnormalities in athletes are highly variable and dependent on study quality. Troponin screenings seem unreliable to identify athletes at risk for myocardial involvement. Prospective athlete studies, with pre-SARS-CoV-2 imaging (CMR), including structured follow-up and arrhythmia monitoring, are urgently needed.

Background: Genetic variants associated with cardiomyopathies (CMPs) are prevalent in the general population. In young athletes, CMPs account for roughly a quarter of sudden cardiac death, with further unexplained clustering in specific sports. Consequently, most CMPs form a contraindication for competitive sports. We hypothesized that genetic variants might (paradoxically) improve physical performance early in life while impairing cardiac function later in life. Methods: Systematic PubMed search was done to investigate whether genetic variants in genes associated with CMPs could be related to beneficial performance phenotypes. Summary: In a limited number of studies (n = 6), 2,860 individuals/subjects with genetic variants were able to outperform those without said variants, as measured by running speed (∼38 m/min in heterozygous [HET] mice, n = 6, vs. ∼32 m/min in wild type [WT] mice, n = 7, p = 0.004) and distance (966 ± 169 km HET mice vs. 561 ± 144 km WT mice, p = 0.0035, n = 10), elite athlete status in endurance athletes (n = 1,672, p = 1.43 × 10−8), maximal oxygen uptake in elite athletes (absolute difference not provided, n = 32, p = 0.005), maximal oxygen uptake in unrelated individuals (n = 473, p = 0.0025), personal records in highly trained marathon runners (2:26:28 ± 0:06:23 min HET, n = 32, vs. 2:28:53 ± 0:05:50 min without polymorphism, n = 108, p = 0.020), and peripheral muscle force contraction in patients following a cardiac rehabilitation program (absolute values not provided, n = 260). Key Message: Beneficial effects in genetic variants associated with CMPs could hypothetically play a role in the selection of young athletes, consequently explaining the prevalence of such genetic variants in athletes and the general population.

Background/Introduction Transthoracic echocardiography (TTE) is often the first diagnostic imaging modality of choice in athlete care to differentiate between physiological adaptation to sports and pathology. Mechanical strain as outcome measure, i.e. left ventricular (LV) global longitudinal strain (GLS), has been suggested as a tool to detect early signs of myocardial diseases in athletes. However, low or very low rates of myocardial deformation can also be associated with cardiac adaptation to sports. We hypothesize that observing decreased cardiac deformation in elite athletes may be a sign of an outspoken relaxed cardiac state, rather than pathology. Therefore, we investigated whether a short exercise bout can normalize strain values in elite athletes with abnormal resting GLS. Methods We prospectively enrolled elite athletes who participated in the ELITE (Evaluation of Lifetime Participation in Intensive Top-level Sports and Exercise) cohort. In short, ELITE is a prospective athlete cohort, which collects medical history, ECG, TTE and cardiac magnetic resonance (CMR) data in elite athletes (Olympic/Paralympic level or comparable). For this analysis, we analysed TTEs of asymptomatic athletes without cardiovascular disease and with a structurally normal heart on CMR. TTE (Vivid, GE) was performed in each athlete according to guidelines at rest. After a short exercise bout, consisting of 20 squats, additional measurements were performed when heart-rate (HR) was comparable to HR during pre-exercise measurements. TTE data was assessed using EchoPAC (GE). Paired t-tests were calculated for functional parameters; boxplots for pre- and post-exercise measurements; and GLS delta (pre- to post-exercise) for each athlete was calculated were plotted; using R. GLS ≥−16% was considered decreased and −16% ≥ GLS >−18% borderline. Results Our population comprised 51 athletes (35% women), with a mean age (±SD) of 26.4±5.2 years, and mean BSA of 2±0.3m2. Athletic disciplines consisted of road cycling (n=25), hockey (n=7), swimming (n=5), and 7 miscellaneous sports (n=14). We observed an increase of myocardial deformation after a short bout of exercise: mean GLS delta of 2.6±2% (pre- vs post-exercise GLS: −18.2±2.1% vs −20.8±1.9%; P≤0.001; Figure, A). Furthermore, mean LV stroke volumes were 94±19ml vs 103±23ml (P=0.020), ejection fractions (EF) 57±4% vs 60±4% (P≤0.001), and HR 55±10bpm vs 54±13bpm (P=0.8). Finally, we found a decreased strain in 8 athletes (16%), in 7 of which increased to normal values. Mean delta GLS was 4.5±2.2 (pre- vs post-exercise GLS: −14.9±1.1% vs −19.4±2.7%, P=0.002, Figure, B). The athlete who did not show an increase to normal GLS levels had a decreased LV EF (42%), but showed no other signs of cardiac pathology (MRI, biomarkers, complaints). Conclusion In athletes with abnormal GLS at rest, performing a short exercise bout may provide a pragmatic method to separate decreased GLS due to true pathology from sports adaptation. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Amsterdam Movement Sciences

Background/Introduction The prognosis of peri- and myocarditis can be negatively influenced by intensive exercise and sports. Therefore sustained cardiac involvement after recovery from COVID-19 in athletes is of particular relevance for the prevention of sudden cardiac arrest/sudden cardiac death (SCA/SCD). To date, only small sample-size studies are available, or studies predominantly focusing on hospitalized and severely ill patients. We aimed to address this knowledge gap in a comprehensive, systematic review of peri-/myocardial involvement after SARS-CoV-2 infection in athletes versus healthy non-athletes. Purpose Quantification of peri-/myocardial involvement and risks of SCA/SCD after SARS-CoV-2 infection in athletes as compared with healthy non-athletes. Methods We performed a systematic search with a combination of key terms in Medline (Ovid), Embase (Ovid) and Scopus (through March 8th 2021). To capture potential non- peer-reviewed COVID-19 SCA/SCD reports we performed monthly scoping internet searches. Inclusion criteria: athletes/non-athletes, with cardiovascular magnetic resonance (CMR) or echocardiography after recovery from SARS-CoV-2 infection, including arrhythmia outcomes. Exclusion criteria: study population ≥1 individual comorbidity and mean age 64 years. Results We included 16 manuscripts (933 papers reviewed) comprising 1129 athletes (284 college/student-, 807 professional- and 38 elite athletes) and 382 healthy non-athletes. Athletes vs non-athletes reported myocarditis on echocardiography and/or CMR in 0–15% vs 45–60%, LGE in 0–46% vs 0–74% (Figure 1), and pericardial effusion in 8–58% vs 0–47% (Figure 2). Weighted means of diagnosed myocarditis were 3% in athletes (3.5% college/student-, and 0% elite athletes) and 56.6% in non-athletes. No important arrhythmias were reported. Systematic internet query identified 2 collapsed post-COVID-19 athletes during exercise, 1 lethal. Ten studies (n=1301) reporting post-recovery troponin T/I found no clear relationship with cardiac abnormalities. Summary/Conclusions Rates of peri-/myocardial abnormalities in athletes/healthy non-athletes after SARS-CoV-2 infection are variable, ranging from 0–74%, and predominantly seen on CMR. Athletes have a lower risk of peri-/myocardial involvement, and myocarditis (0–3.5% vs 56.5%) than non-athletes after SARS-CoV-2 infection. Risks of SCA/SCD appear low, but data are lacking. Troponin screenings seems unreliable to identify athletes at risk for myocardial involvement. Prospective studies, with pre-COVID-19 imaging (CMR), in athletes, including follow-up and arrhythmia monitoring, are urgently needed. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Dutch Olympic Committee*Dutch Sports Federation (NOC*NSF)Amsterdam Movement Sciences (AMS) Figure 1. Total peri-/myocardial LGE (%)Figure 2. Total pericardial effusion (%)

BACKGROUND:The Systematic COronary Risk Evaluation - Older Persons (SCORE-OP) algorithm is developed to assess 10-year risk of death due to cardiovascular disease (CVD) in individuals aged ≥65 years. We studied the performance of SCORE-OP in the European Prospective Investigation of Cancer Norfolk (EPIC-Norfolk) prospective population cohort.METHODS:10-year CVD mortality as predicted by SCORE-OP was compared with observed CVD mortality among individuals in the EPIC-Norfolk cohort. Persons aged 65-79 years without known CVD were included in the analysis. CVD mortality was defined as death due to ischemic heart disease, cardiac failure, cerebrovascular disease, peripheral-artery disease or aortic aneurysm. Predicted 10-year CVD mortality was calculated by the SCORE-OP algorithm, and compared to observed mortality rates. The area under the receiver operator characteristics curve (AUROC) was calculated to evaluate discriminative power. Calibration was evaluated by calculating ratios of predicted vs observed mortality and by Hosmer-Lemeshow tests.RESULTS:A total of 6590 individuals (45.8% men), mean age 70.2 years (standard deviation 3.3) were included. The predicted mortality by SCORE-OP was 9.84% (95% confidence interval (CI) 9.76-9.92) and observed mortality was 10.2% (95% CI 9.52-11.04), ratio 0.96. AUROC was 0.63 (95% CI 0.60-0.65), and X2 was 3.3 (p = 0.92).CONCLUSION:SCORE-OP overall accurately estimates the rate of CVD mortality in a general population aged 65-79 years. However, while calibration is excellent, the discriminative power of the SCORE-OP is limited, and as such cannot be readily implemented in clinical practice for this population.

Introduction: Patients with kinesiophobia (fear of movement) avoid physical activity. Avoidance of physical activity is linked to adverse cardiac events and thus needs to be targeted. However, there is no contemporary measurement tool to assess kinesiophobia in cardiac patients. Therefore data on prevalence of kinesiophobia are lacking in patients attending Cardiac Rehabilitation (CR). The Tampa Scale for Kinesiophobia (TSK-NL Heart) is a 17 item questionnaire using a 4 point Likert scale (score range 17 to 68 points) to measurekinesiophobia). Purpose: To study the test-retest reliability and construct validity of the TSK-NL Heart and to assess the distribution of kinesiophobia in patients. Methods: Patients referred for CR were asked to fill in the TSK-NL Heart and the Cardiac Anxiety Questionnaire (CAQ). After five days patients filled in the TSK-NL Heart for the second time. Test-retest reliability of the TSK-NL Heart was assessed with the Interclass Correlation Coefficient (ICC) and construct validity with the Spearman Rank Correlation Coefficient (r) by correlating the TSK-NL Heart with the CAQ. The distribution of kinesiophobia in cardiac patients was assessed by determining the median score with range and quartiles (Q1-4) since there is no well validated cut off point of the TSK-NL Heart. Nevertheless, recent studies have used a score >37 as an indication for Kinesiophobia. Results: We included 116 patients in this study with a median age of 64, 5 years old who were mainly referred for CR after a PCI procedure for STEMI. Substantial agreement was found for the overall ICC of the TSK (ICC = 0.67; p = < 0.001). With regard to construct validity, a moderate strong correlation was found between the TSK and CAQ (r= 0.57; p = < 0.001). Scores of the TSK-NL Heart ranged from 26 to 56 points with a median patient score of 39.Q1 = 26-33, Q2 = 33-39, Q3 = 39-44, Q4 = 4456. Conclusion: The TSK-NL Heart has substantial test-retest reliability and a moderate to strong correlation with the CAQ suggesting construct validity. The scores on CAQ and the TSK indicate that cardiac anxiety and fear of movement is present in a large proportion of cardiac patients. Further research is necessary to investigate the impact of kinesiophobia on objectively measured physical activity and to develop treatment strategies for kinesiophobia in cardiac patients

Funding Acknowledgements Type of funding sources: None. Background An important factor related to low physical activity in cardiac patients is fear of movement (kinesiophobia). The setting of cardiac rehabilitation (CR) seems suitable for targeting kinesiophobia. Nevertheless, the impact of CR on kinesiophobia is currently unknown, partly due to the absence of information on the responsiveness of instruments to measure kinesiophobia. Purpose To determine the responsiveness of the Dutch version of the Tampa Scale for Kinesiophobia questionnaire (TSK-NL Heart), to asses changes in kinesiophobia during participation in CR and to assess predictors of high levels of kinesiophobia at completion of CR. Methods This study was performed among 109 patients (mean age: 61 years; 76% men) who participated in a 6- till 12-week CR program. Kinesiophobia was measured using the TSK-NL Heart questionnaire. To determine the responsiveness of the TSK-NL Heart, the Cardiac Anxiety Questionnaire (CAQ) and the general anxiety scale of the Hospital Anxiety and Depression Scale (HADS-A) were used as external measures. All questionnaires were completed pre- and post-CR. Internal responsiveness was estimated by calculating the effect size (ES) and standardized response mean (SRM). External responsiveness was determined by calculating the correlation between change scores on the TSK-NL heart and on the external measures. Furthermore, univariate logistic regression analysis was performed with the dichotomized TSK-NL Heart score post-CR as dependent variable (high vs low scores) and baseline characteristics (age, sex, reason for referral and pre-CR scores on the TSK-NL Heart, CAQ and HADS) as predictor variables. Results Prevalence of a high levels of kinesiophobia improved from 40.4% pre-CR to 25.7% at completion of CR (p = 0.05). Both the ES and the SRM of the TSK change score were moderate for patients with an improved CAQ and HADS-A score (respectively ES = 0.52; SRM = 0.57 and ES = 0.54; SRM = 0.60) and small for patients with a stable score (ES = 0; SRM = 0 and ES = 0.26; SRM = 0.36). There was a moderate correlation between the TSK-NL Heart change score and the CAQ (Rs = 0.30, p = 0.023) and a small correlation between the TSK-NL Heart change score and the HADS-A (Rs =0.21, p = 0.107). The odds of having high kinesiophobia levels post-CR were increased by having a high level of kinesiophobia pre-CR (OR= 9.83, 95%CI: 3.52-27.46), a higher baseline score on the CAQ (OR = 1.12, 95%CI: 1.06-1.19), and a higher baseline score on the HADS-A (OR = 1.26, 95% CI: 1.11-1.42). Conclusion The TSK-NL Heart has moderate responsiveness. In addition, this study shows that there are reductions in kinesiophobia during the course of CR. Nevertheless, a large number of patients (26%) still had high levels of kinesiophobia at completion of CR. Interventions targeting kinesiophobia should focus on patients that enter CR with high levels of kinesiophobia, cardiac anxiety and generic anxiety.

Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Dutch Research Council INTRODUCTION Cardiac rehabilitation (CR) is the cornerstone of secondary prevention. After hospital discharge, patients have to wait for participation in CR while often feeling overwhelmed by their cardiac event and in need of tailored information and support. PURPOSE The objective of this study was to develop a remote (digital) intervention to bridge the gap from hospital discharge to CR. METHODS We developed an intervention by completing the first three steps of the intervention mapping protocol. Step 1: identification of information- and support needs from the literature and semi-structured interviews. Step 2: Describing performance objectives for the intervention and selecting determinants. Step 3: Generation of program themes and theory based change methods. RESULTS (Step 1) The following Information- and support needs were identified from the literature (n = 33) and semi structured interviews (n = 22): information about pathology and intervention, medication and side effects, daily physical activities, psychological distress, body signals and social support. Advanced communication and pedagogical skills of the health care provider and the ability to build trust were described as important prerequisites for the intervention. (Step 2) The following performance objectives were formulated: (1) Patients gain knowledge on how their cardiac illness and procedure affects their bodies and health, (2) Patients gain knowledge about medication and side effects, (3) Patients know which daily physical activities they can and can’t do after hospital discharge and are physically active, (4) Patients and informal caregivers can deal with psychological distress and know how to discriminate between harmful and harmless body signals. Objectives were described per determinant (knowledge, skill, attitude, social influence, self-efficacy and outcome expectation). (Step 3) A comprehensive remote intervention was developed using theory based coaching strategies, a digital patient platform and information videoclips. CONCLUSION This study describes the information and support needs of patients after cardiac hospitalization and offers a remote intervention that bridges the gap form hospital discharge to CR. Abstract Figure. BRIDGE2CARE

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Dutch Olympic Committee*Dutch Sports Federation (NOC*NSF) Amsterdam Movement Sciences (AMS) Most studies investigating the cardiotropic effects of SARS-CoV-2 focus on cardiac complications in severely ill patients. Little is known about eventual sustained cardiac involvement after recovery from COVID-19, especially in patients with a moderate or mild course of illness. Furthermore, as physical exercise can potentially worsen the prognosis of patients with COVID-19 peri- or myocarditis, cardiac involvement in athletes or in the physically active population warrants investigation. Finally, the risk of arrhythmias in such individuals remains largely unknown. We aim to provide a comprehensive overview of myocardial and pericardial involvement after SARS-CoV-2 infection, long-term cardiac sequelae after infection, and risks of SCD/SCD in a predominantly healthy/physical active population, including athletes. We performed a systematic PubMed and MedRxiv search through December 19th, 2020, with the combined terms or synonyms for: COVID-19, SARS-CoV-2, cardiovascular imaging, cardiac MRI, athletes. Exclusion criteria were: no CMR investigations reported, ≥1 comorbidities, age ≤16 years, and reviews. Two investigators independently screened and assessed all identified manuscripts, and additionally searched for reported arrhythmia outcomes. The initial search yielded 127 papers; after extensive review, we included a total of nine papers comprising 607 recovered post-COVID patients/athletes. The table summarises the main CMR findings. No study reported arrhythmias except for Ho et al. who found 18% undefined arrhythmias at baseline. In 5 studies in 201 patients, the weighted mean for the prevalence of elevated T1 was 55%, elevated T2 48%, myocardial LGE 35%, and pericardial LGE 17%. One study (Knight et al.) did not report T1 and T2 measurements. Ho et al. and Ming-Yen et al. found respectively 40% and 19% of patients to meet the Lake Louise Criteria (LLC) for myocarditis; Puntmann et al. reported that 60% had active myocardial inflammation. Second, in 1 study in 139 healthcare workers, the mean for the prevalence of elevated T1 was 42%, T2 4%, LGE 30%, and 5% met LCC for myocarditis. Third, in 3 studies in 96 athletes, the weighted mean for the prevalence of elevated T1 was 21%, T2 24%, myocardial LGE 4%, and pericardial LGE 29%. Brito et al., Clark et al. and Rajpal et al. reported that respectively 0%, 5% and 15% met the LCC for myocarditis. Studies investigating peri- and myocardial sequelae after SARS-CoV-2 infection report varying prevalences of cardiac abnormalities. Such studies are limited in numbers, generally include a low number of individuals, and report no follow-up; only 1 study reported non-specified arrhythmia outcomes. Based on the available studies, the short-term risk for post-COVID-19 SCD due to arrhythmias caused by myocardial inflammation appears to be low. Prospective investigations in larger, well-defined populations, including longer-term follow up and arrhythmia monitoring, are urgently needed. Abstract Figure.

Objectives: The primary objective was to determine the responsiveness of the Dutch version of the 13-item Tampa Scale for Kinesiophobia for cardiac patients (TSK-NL Heart). The secondary objective was to assess changes in kinesiophobia during cardiac rehabilitation.Methods: Kinesiophobia was measured pre- and post-cardiac rehabilitation using the TSK-NL Heart questionnaire in 109 cardiac patients (61 years; 76% men). The effect size of kinesiophobia score changes was calculated for the full population. A measure that is responsive to change should produce higher effects sizes in patients in whom kinesiophobia improves. Therefore, effect sizes were also calculated for patients who did or did not improve on selected external measures. For this step, the Cardiac Anxiety Questionnaire (CAQ) and the Hospital Anxiety and Depression Scale (HADS) were completed as external measures in a subsample of 58 patients.Results: The effect size of the TSK-NL Heart for the full study population was small (0.29). In line with the study hypothesis the effect size was higher (moderate) for patients with improved CAQ (0.52) and HADS scores (0.54). Prevalence of high kinesiophobia levels decreased from 40% pre-cardiac rehabilitation to 26% post-cardiac rehabilitation (p = 0.004).Conclusion: The TSK-NL Heart has moderate responsiveness and can be used to measure changes in kinesiophobia. Improvements in kinesiophobia were observed during cardiac rehabilitation. Nevertheless, high levels of kinesiophobia were still highly prevalent post-cardiac rehabilitation. LAY ABSTRACTFear of movement (kinesiophobia) is common in patients referred for cardiac rehabilitation. Before interventions can be designed to target kinesiophobia, the impact of current cardiac rehabilitation programmes on kinesiophobia should be studied. Kinesiophobia is measured with the Tampa Scale for kinesiophobia (TSK-Heart). In order to measure the effect of cardiac rehabilitation on kinesiophobia, the TSK-Heart should be able to detect changes in the level of kinesiophobia (responsiveness). This study determined the responsiveness of the TSK-Heart and assessed changes in the level of kinesiophobia during cardiac rehabilitation, and shows that the TSK-Heart has moderate responsiveness. In addition, it was found that the prevalence of high levels of kinesiophobia, decreased from 40% before cardiac rehabilitation to 26% after cardiac rehabilitation.

Sports cardiology is a rapidly evolving subspecialty of cardiology, with a growing demand for expertise. To improve patient care, clinicians, patients, and athletes (recreational to elite) should be able to easily identify specialised care pathways, expertise centres and clinicians with sports cardiology expertise. To this purpose, several international societies and organisations recommend establishing a local and national sports cardiology infrastructure. We therefore aimed to establish The Netherlands Sports Cardiology Map. We conducted a web-based survey, which was published on the Netherlands Society of Cardiology home page (2019–2020) and in which each cardiology department or clinic was asked to provide information on sports cardiology expertise and the current infrastructure. Of the 46 respondent centres, 28 (61%) reported that they had expertise in sports cardiology, of which 22 (79%) had specific expertise in one or more specific types of sports. Integrated multidisciplinary meetings were reported by 43% of the centres (n = 12/28). Only two centres reported ongoing research projects that had been approved by an institutional review board. The Netherlands Sports Cardiology Map is an important step towards improving the existing infrastructure and developing network medicine for sports cardiology.

Background/Introduction The grey zone between cardiac adaptation to sports and exercise and (early stages of) cardiac pathology constitutes one of the greatest challenges for clinicians involved in the care for (elite level) athletes. Cardiac magnetic resonance imaging (CMR) with late gadolinium enhancement (LGE) is a central diagnostic tool to help differentiate between physiological adaptation and pathology. LGE as seen in myocardial fibrosis has been shown to be a strong predictor for cardiac events. While general (ie. dynamic, static sports) levels of physiological adaptation in athletes have been described, sports-specific CMR findings are essentially lacking, and a systematic sport-specific investigation of LGE is absent. Purpose To establish a sports-specific baseline for CMR indices in apparently healthy, male elite water polo players. Methods We performed a cross-sectional study in Olympic-level male water polo players. All athletes were asymptomatic and were examined during pre-participation screening. The athletes underwent a comprehensive CMR protocol consisting of long- and short-axis cine imaging, LGE and was performed on two 3 Tesla MRI-scanners (Philips). CMR data were analysed using Circle Cardiovascular Imaging software, and statistical analyses were performed in R. Results We screened 24 athletes with a mean age (±SD) of 24.2±3.6 years and body surface area (BSA) of 2.23±0.2 m2. The athletes had indexed end-diastolic volumes of 101.87±33.01 ml and 104.51±43.24 ml, stroke volumes of 140.70±33.23 and 139.44±29.93 ml, and ejection fractions of 56.68±9.07% and 52.98±8.18%, in the left- and right ventricle, respectively. Thirteen athletes (54.2%) had LGE consistent with hinge point fibrosis (HPF+) (one case example presented in the figure). Another two athletes had other patterns of LGE (LGE+). There was a trend towards having a smaller BSA in the LGE+ and HPF+ groups (2.18±0.17 m2 in LGE+ vs 2.31±0.10 m2 in LGE−, p=0.056, and 2.18±0.18 m2 in HPF+ vs 2.29±0.10 m2 in HPF−, p=0.072). Conclusion Myocardial fibrosis is present in more than 50% of asymptomatic elite water polo players, with a predilection for the inferior hinge point. Our findings in asymptomatic elite athletes suggest that HPF could be a normal finding in athletes instead of an early sign of pathology. Further studies are warranted to investigate if the HPF is associated with long-term cardiac changes or the development of cardiac pathology. Figure 1. Late gadolinium enhanced short axis image (left) combined with a polar map of cardiac segmentation (right) depicting the fibrosis pattern in a case of an elite male water polo player alongside the inferior hinge point - as expressed in the percentage of myocardium exceeding the mean signal intensity of reference myocardium plus six-times standard deviation. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Harald Jørstad has received funding from the Amsterdam Movement Sciences and the National Olympic Committee & National Sports Federation

Introduction Interventions to reduce lifestyle-related risk factors (LRFs) such as overweight, physical inactivity and smoking are effective in the secondary prevention of cardiovascular events. However, evidence of the effects of lifestyle-related secondary prevention programmes in older patients with coronary artery disease (CAD) is less conclusive than in younger patients. Purpose To compare the treatment effect on lifestyle-related risk factors (LRFs) in older (≥65 years) versus younger ( Methods The RESPONSE-2 trial was a community-based lifestyle intervention trial (N=824) comparing nurse-coordinated referral to a comprehensive set of three lifestyle interventions (physical activity, weight reduction and/or smoking cessation) to care as usual. The primary outcome was the proportion of patients with improvement at 12 months follow-up (N=711) in at least 1 LRF (without deterioration in the other LRFs). In the current analysis, we assessed if the overall beneficial treatment effect of the RESPONSE-2 intervention varied by age. Results At baseline, older patients (n=245, 69.2±3.9) had significantly more serious cardiovascular risk profiles and comorbidities (hypertension, diabetes mellitus and peripheral artery disease) than younger patients (n=579, 53.7±3.9). The overall treatment effect did not vary by age (OR overall 1.67, 95% CI 1.22 - 2.31). However, older patients were more likely to achieve ≥5% weight loss (OR old 5.58, 95% CI 2.77–11.26 vs. OR young 1.57, 95% CI 0.98 - 2.49, P interaction=0.003) and younger patients were more likely to show non-improved individual LRFs (OR old 0.38, 95% CI 0.22–0.67 vs. OR young 0.88, 95% CI 0.61–1.26, P interaction=0.01). Conclusion Despite more serious cardiovascular risk profiles and comorbidities among older patients, nurse-coordinated referral to community-based lifestyle interventions was at least as successful in improving LRFs in older as in younger patients. Higher age alone should not be a reason to withhold lifestyle interventions in patients with CAD. LRFs at 12 months follow-up Funding Acknowledgement Type of funding source: Private company. Main funding source(s): The RESPONSE-2 trial was sponsored by Weight Watchers International, Inc. (New York, New York) and Philips Consumer Lifestyle (the Netherlands). This work was also supported by the Netherlands Organisation for Scientific Research (NWO) to PJ.

Background We performed an extended follow-up of the RESPONSE-2 trial, which evaluated a new secondary prevention strategy for patients with coronary artery disease (CAD). Selective loss to follow-up (LTFU) however, may induce biased results. Objectives To assess LTFU and its implications on the internal validity of the trial at extended follow-up. Methods RESPONSE-2 (N=824) was a randomised trial of nurse-coordinated referral of CAD patients to ≤3 commercial lifestyle interventions, on top of usual-care, or to usual-care alone. The primary outcome was assessed at 1-year follow-up, after which the interventions were discontinued. An extended follow-up was performed two years later. We evaluated overall selective LTFU, between-group selective LTFU and within-group selective LTFU, by comparing baseline characteristics, compliance with the lifestyle interventions (intervention group only) and achievement of lifestyle-related risk factor (LRF) targets at 1-year follow-up for attendees and non-attendees of the extended follow-up. In all variables a standardized mean difference (SMD) of ≥0.2 with a p-value Results In total, 520 patients attended the extended follow-up: 266/411 in the intervention and 254/413 in the control group. Patients LTFU were generally younger (56.5 vs. 59.3 years; SMD=0.299), more often baseline smokers (37% vs. 22%; SMD=0.334) and had less often quit smoking directly after hospitalization (17% vs. 25%; SMD=0.203). We found no evidence of between-group selective LTFU and several indications of within-group selective LTFU (table). Intervention group attendees were more compliant with the lifestyle interventions compared with non-attendees (weight loss: SMD=0.450; p≤0.05 and physical activity: SMD=0.516; p≤0.01) Conclusion Baseline LRF control, compliance with the lifestyle interventions and achievement of LRF targets were less favourable for non-attendees of the extended follow-up. Effective handling of missing data is recommended to minimize loss of contrast due to within-group selective LTFU and to ensure generalizability of results. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): The RESPONSE-2 trial was sponsored by Weight Watchers International, Inc. (New York, New York) and Philips Consumer Lifestyle (the Netherlands). The sponsors had no role in the design, data collection, data analysis, data interpretation, and writing of the manuscript.

Sudden cardiac arrest (SCA), which occurs at a rate of about 1 in ~50 000 athlete years, is the most common cause of death in exercising young athletes.1 SCA is most frequently caused by lethal cardiac arrhythmias—that is, ventricular fibrillation (VF). If clinicians recognise key features of SCA early and accurately, they can immediately begin cardiopulmonary resuscitation (CPR) and use an automated external defibrillator (AED) as needed.2 This review aims to (1) assist health professionals recognise the signs (and avoid common pitfalls) of SCA and (2) emphasise best practice responder strategies for SCA on the pitch. Miklos Feher, a striker for Benfica, suffered a SCA on 25 January 2004. The event can be viewed at: https://youtu.be/T7-kKy_XDQU. The underlying cause of death was later reported to be VF in a patient with hypertrophic cardiomyopathy. How can clinicians and sports professionals rapidly recognise SCA on the field of play? Recognising SCA on the pitch can be challenging due to the sports setting, other mimicking causes and the rapid onset of signs following cerebral hypoperfusion. To prevent death or serious sequelae, it is key that clinicians recognise SCA immediately and start adequate management (ie, CPR and defibrillation). Figure 1 is a schematic of SCA from time T=0–60 s with corresponding signs, ECG, blood pressure tracing and breathing pattern. Prolonged, sudden cerebral hypoperfusion causes a typical …

Sport and exercise medicine (SEM) physicians are faced with the challenge of advising elite athletes with (suspected) COVID-19 wishing to return to play. Elite athletes are markedly different from the typical hospitalised patients with COVID-19. Elite athlete populations have a low prevalence of overweight and obesity, hypertension and smoking, and of lifestyle-related diseases, such as atherosclerotic coronary artery disease, congestive heart failure and obstructive lung disease, all of which are associated with severe COVID-19.1–3 However, from an athlete’s point of view, COVID-19 sequelae leading to even a small long-term decrease in physical performance capacity can be career limiting. To assist SEM physicians in their medical support of athletes returning to intensive training and competitive sport, this issue of the British Journal of Sports Medicine includes a practical guide by London’s Professor Mathew Wilson et al .4 In a comprehensive, multidisciplinary document, they propose a clear, disease-oriented clinical pathway for cardiac and pulmonary medical decision making to support return to play. Laudable is that Wilson et al also include psychological factors that should be considered in the postlockdown setting where return to play takes place. They include an integrated flowchart which includes both cardiac and pulmonary considerations. …

Knowledge about the changes in endothelial function after ST-elevation myocardial infarction (STEMI) is of substantial interest, but serial data are scarce. The aim of the present study was to noninvasively evaluate whether endothelial function, as assessed shortly after primary percutaneous coronary intervention (PPCI) for STEMI, may improve until 12-month follow-up. This prospective observational cohort study was performed in patients in the RESPONSE randomized trial who participated in a substudy and underwent noninvasive assessment of endothelial function at 1 (baseline), 6, and 12-month follow-up after treatment of a STEMI by PPCI. The reactive hyperemia peripheral artery tonometry (RH-PAT) method was used to assess endothelial function (higher RH-PAT index signifies better function). Of the 70 study participants, who were 57.4 ± 9.7 years of age, 55 (78.6%) were male and 9 (13%) had diabetes. The endothelial function deteriorated significantly during follow-up: the RH-PAT index at baseline, 6, and 12-month follow-up was 1.90 ± 0.58, 1.81 ± 0.57, and 1.69 ± 0.49, respectively (p = 0.04). Although patients were carefully treated in outpatient clinics and adequate pharmacological therapy was prescribed, we noted an increase in total cholesterol (p = 0.001), LDL cholesterol (p = 0.002), HbA1C (p = 0.054), and diastolic blood pressure (p = 0.047) However, multivariate analysis revealed that this increase in cardiovascular risk factors could not explain the observed deterioration in endothelial function. In patients with STEMI, we observed a significant deterioration in endothelial function during 12 months after PPCI that could not be explained by changes in the traditional cardiovascular risk profile.

Contains fulltext : 190474.pdf (Publisher’s version ) (Open Access) Sudden cardiac arrest or death (SCA/SCD) in athletes has a low event rate. Pre-participation or eligibility screening is a widely accepted method of primary prevention of SCA/SCD in athletes. Most European countries and international sports governing bodies perform ECG-inclusive screening. However, implementation of a resting 12-lead ECG in pre-participation or eligibility cardiac screening is still a topic of debate. Recently, the 'International recommendations for electrocardiographic interpretation in athletes' was published in three leading international medical journals. These international ECG criteria are based on studies with detailed information on resting 12-lead ECG of Caucasian and Afro-Caribbean athletes or on consensus in case evidence was lacking. Normal, borderline and abnormal ECG findings in young athletes (age 12-35 years) are clearly described and illustrated to assist the screening physician in interpreting ECGs of athletes correctly.In this 'point of view paper' we will discuss whether these new ECG criteria actually help prevent SCA/SCD in athletes.

Introduction: The number of grown-up congenital heart disease (GUCH) patients is steadily increasing. Unfortunately, the majority of these patients suffer from late sequelae, with heart failure being the most common cause of death. Exercise training is beneficial and safe in patients with acquired heart failure, as well as in asymptomatic GUCH patients. However, its effect remains unknown in symptomatic GUCH patients. This could cause reticence on positive sports advice, with possible counterproductive effects. Areas covered: A review of current literature was performed to evaluate the effect of exercise training in symptomatic (NYHA≥2) GUCH patients. The search yielded a mere three studies including symptomatic patients, and another six studies including also patients in NYHA 1 without making clear distinction between the NYHA subgroups. Expert commentary: Suboptimal trial designs, low patient numbers, and homogeneity of investigated cardiac anomalies make this review insufficient to draw definite conclusions. However, all studies describe overall positive effects of exercise training in symptomatic GUCH patients in terms of exercise capacity and quality of life. There were no safety concerns. Larger-scaled, randomized controlled trials are needed to obtain certainty.

Background: The combination of high levels of high-sensitive C-reactive protein (hs-CRP) and lipoprotein-associated phospholipase-A2 (Lp-PLA2) was recently shown to correlate with increased cardiovascular risk. Endothelial dysfunction is also known to be a risk factor for cardiovascular events. Aim: To test among patients with previous ST-elevation myocardial infarction (STEMI) the hypothesis that high levels of both hs-CRP and Lp-PLA2 may be associated with impaired endothelium-dependent vasodilatation. Methods: In this substudy of the RESPONSE randomized trial, we used reactive hyperemia peripheral artery tonometry (RH-PAT) 4 to 6 weeks after STEMI and primary percutaneous coronary intervention (PPCI) to non-invasively assess endothelial function (RH-PAT index 239 μg/L, respectively). Results: Patients were 57.4 ± 9.7 years and 53 (77.9%) were men. 11 (16%) patients were classified as high-risk and 57 (84%) as low-to-intermediate-risk. The RH-PAT index was 1.68 ± 0.22 in high-risk and 1.95 ± 0.63 in low-to-intermediate-risk patients (p = 0.17). Endothelial dysfunction was present in 8 (72.7%) high-risk and 26 (45.6%) low-to-intermediate-risk patients (p = 0.09). Framingham risk score, NT-proBNP and fibrinogen levels were higher in high-risk patients (p ≤ 0.03). Conclusion: In this population of patients with recent STEMI and PPCI, we observed between patients with high hs-CRP and Lp-PLA levels and all other patients no more than numerical differences in endothelial function that did not reach a statistical significance. Nevertheless, further research in larger study populations may be warranted.

Objectives: To determine the psychometric properties of a questionnaire to assess fear of movement (kinesiophobia): the Tampa Scale for Kinesiophobia (TSK-NL Heart), and to investigate the prevalence of kinesiophobia in patients attending cardiac rehabilitation.Methods: A total of 152 patients were evaluated with the TSK-NL Heart during intake and 7 days later. Internal consistency, test-retest reliability and construct validity were assessed. For construct validity, the Cardiac Anxiety Questionnaire (CAQ) and the Hospital Anxiety and Depression Scale (HADS) were used. The factor structure of the TSK-NL Heart was determined by a principal component analysis (PCA).Results: After removal of 4 items due to low internal consistency, the TSK-NL Heart showed substantial reliability (intraclass correlation coefficient; ICC: 0.80). A strong positive correlation was found between the TSK-NL Heart and the CAQ (rs: 0.61). Strong positive correlations were found between the TSK-NL Heart and de HADS (Anxiety) (rs: 0.60) and between the TSK-NL Heart and the CAQ (rs: 0.61). The PCA revealed a 3-factor structure as most suitable (fear of injury, avoidance of physical activity, perception of risk). High levels of kinesiophobia were found in 45.4% of patients.Conclusion: The 13-item TSK-NL Heart has good psychometric properties, and we recommend using this version to assess kinesiophobia, which is present in a substantial proportion of patients referred for cardiac rehabilitation.Keywords: Tampa Scale for Kinesiophobia; cardiac rehabilitation; exercise; fear of movement; physical activity; cardiovascular disease

ObjectiveTo compare the treatment effect on lifestyle-related risk factors (LRFs) in older (≥65 years) versus younger (MethodsThe RESPONSE-2 trial was a community-based lifestyle intervention trial (n=824) comparing nurse-coordinated referral with a comprehensive set of three lifestyle interventions (physical activity, weight reduction and/or smoking cessation) to usual care. In the current analysis, our primary outcome was the proportion of patients with improvement at 12 months follow-up (n=711) in ≥1 LRF stratified by age.ResultsAt baseline, older patients (n=245, mean age 69.2±3.9 years) had more adverse cardiovascular risk profiles and comorbidities than younger patients (n=579, mean age 53.7±6.6 years). There was no significant variation on the treatment effect according to age (p value treatment by age=0.45, OR 1.67, 95% CI 1.22 to 2.31). However, older patients were more likely to achieve ≥5% weight loss (OR old 5.58, 95% CI 2.77 to 11.26 vs OR young 1.57, 95% CI 0.98 to 2.49, p=0.003) and younger patients were more likely to show non-improved LRFs (OR old 0.38, 95% CI 0.22 to 0.67 vs OR young 0.88, 95% CI 0.61 to 1.26, p=0.01).ConclusionDespite more adverse cardiovascular risk profiles and comorbidities among older patients, nurse-coordinated referral to a community-based lifestyle intervention was at least as successful in improving LRFs in older as in younger patients. Higher age alone should not be a reason to withhold lifestyle interventions in patients with CAD.

Background Having a partner is associated with better prognosis in patients with cardiovascular disease. However, the influence of partners on modification of patients' lifestyle-related risk factors (LRFs) is unclear. Therefore, we studied the influence of partners and the level of partner participation on LRF modification in patients after an acute coronary syndrome (ACS) or revascularization. Methods The RESPONSE-2 trial was a community-based lifestyle intervention trial comparing nurse-coordinated referral to a comprehensive set of lifestyle interventions (physical activity, weight reduction and/or smoking cessation) to usual care. In the current analysis, we investigated the association of having a partner on the improvement in >1 LRF without deterioration in other LRFs at 12 months follow-up. Secondary, the influence of the level of partner participation (participating partner, non-participating partner and no partner) in the intervention group was studied. Results In total 824 individuals (411 intervention, 413 control) were included in the analysis. The presence of a partner was comparable in both groups (intervention 74%, control 69%). In the intervention group, 48% of partners participated in the lifestyle interventions. Overall, having a partner was positively associated with improvement in LRFs (odds ratio (OR) 2.57 (95% confidence interval (CI) 1.57–4.21), p Conclusion Having a partner is associated with improvement on LRFs in patients after ACS or revascularization. Moreover, patients with participating partners in the lifestyle programs were most successful in LRF modification. Involvement of partners in lifestyle interventions should be considered in routine practice. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Netherlands Organisation for Scientific Research (NWO)

IntroductionTransitioning out of professional football is a challenging time in most players’ lives. During these preretirement and postretirement years, professional footballers may struggle with their mental, musculoskeletal, neurocognitive and cardiovascular health. Currently, longitudinal data about these health conditions are lacking. This article presents the design of a prospective cohort study with the primary aim of gathering epidemiological evidence about the onset and course of mental, musculoskeletal, neurocognitive and cardiovascular health conditions in professional footballers during their preretirement and postretirement years and evaluating the associations between risk indicators and the health conditions under study in these players.Methods and analysisAn observational prospective cohort study with repeated measurements over a follow-up period of 10 years will be conducted among at least 200 professional footballers (male; 27 (±1) years old). Mental health will be explored by assessing symptoms of distress, anxiety, depression, sleep disturbance, alcohol misuse, drug misuse and disordered eating. Musculoskeletal health will be explored by assessing severe joint injury and related surgery, clinical and radiological osteoarthritis, and joint function (hips, knees and ankles). Neurocognitive health will be explored by assessing the concussion, brain structure and functioning, and neurocognitive functioning. Cardiovascular health will be explored by assessing blood pressure, lipid profile and ECG abnormalities.Ethics and disseminationEthical approval for the study was provided by the Medical Ethics Review Committee of the Amsterdam University Medical Centers. The results of the study will be submitted to peer-reviewed journals, will be presented at scientific conferences and will be released in the media (postpublication).Trial registration numberThe Dutch Trial Registry (Drake Football Study NL7999).

Background Rheumatoid arthritis (RA) is associated with low levels of cardiorespiratory fitness (CRF), especially in patients with RA and cardiovascular (CV) risk. The optimization of management of CV risk in patients with RA is an important aim in the treatment, including also exercise, particularly in patients with RA with a high CV risk, defined as a 10-year CV risk of 20% or higher. However, exercise to improve CRF in these patients is challenging since professionals should take multiple factors into account, such as comorbid conditions related to CV risk. It is unknown which intensity of exercise improves CRF and is safe for patients with RA and CV risk. Objectives To design a tailor-made exercise therapy program to improve CRF for RA patients with CV risk >20%. Methods To design a tailor-made exercise therapy program, patients and experts’ opinions were collected, and a systematic literature search on exercise programs in RA and CV risk factors was performed. The ACSM guidelines were also used to gain insight into frequency, intensity, type and progression of the exercises. In addition, a cardiology rehabilitation team and an arthritis rehabilitation team were consulted during the development of the program. The designed program was partly based on cardiac rehabilitation protocols and especially the way the training load was increased, taking into account the joint load. Finally, the developed exercise program was discussed and approved by an expert panel of patients, rheumatologists, a cardiologist, physical therapists and researchers in rheumatology. The designed program was tested on 10 patients in which the feasibility and safety was tested. Results Intensity of exercises was based on the results from the baseline exercise tests showing that on average the VO2max was under the standard. The maximum Heart Rate (HR max), which was on average (mean, SD) 140.6 (10.9) beats per minute, was used to determine the individually performed intensity of exercises. The duration of the program was 12 weeks. Patients had two training sessions per week with a duration of one hour each. To guarantee safety, the training load was progressively increased, and the tolerability was assessed at every training. Exercises consisted of aerobic and muscle strength exercises. The first four weeks patients trained 30 minutes (which were spread over three exercises) on 65% of the HR max which was gradually increased until 75% of the HR max in the sixth week. From the fifth week three exercises to improve muscle strength were added to the program. From the seventh week interval training started, with a peak of 85% of the HR max and a rest of 65% of the HR max. The program also included motivational interviewing because one of the main reasons for a high CV risk is the inactivity during daily life. All patients were motived to perform 30 minutes of moderate exercises every day at home. Conclusion A tailor-made exercise program to improve cardiorespiratory fitness in patients with RA and CV risk is developed, based on the opinion and experience of patients and health professionals and supported by a literature review and guidelines. A progressively increase in intensity of the exercise program, based on the individual maximum HR, is tolerable and safe and might increase cardiorespiratory fitness in patients with RA and CV risk. References [1] Metsios, et al. Rheumatology2015Dec;54(12):2215-20. Disclosure of Interests Joelle van den Hoek : None declared, Martin van der Esch : None declared, Marike van der Leeden : None declared, Willem Lems Speakers bureau: Amgen Inc., Merck, Eli Lilly and Pfizer, George Metsios: None declared, George D Kitas Speakers bureau: GDK has received honoraria for lectures, participation in advisory boards and/or hospitality by Roche, Abbvie, Pfizer, Novartis, UCB, BMS, GSK and received grant support from Lilly., Joost Dekker: None declared, Wilma Scholte op Reimer : None declared, Harald Jorstad: None declared, Merel J. l’Ami: None declared, Maaike Heslinga: None declared, Michael Nurmohamed Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Menarini, MSD, Mundipharma, Pfizer, Roche, Sanofi and UCB, Consultant for: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Menarini, MSD, Mundipharma, Pfizer, Roche, Sanofi and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Menarini, MSD, Mundipharma, Pfizer, Roche, Sanofi and UCB

INTRODUCTION: Dutch cardiovascular disease (CVD) prevention guidelines recommend the use of modified SCORE risk charts to estimate 10-year risk of fatal and nonfatal CVD (myocardial infarction, cerebrovascular disease and congestive heart failure). This combined risk is derived from the SCORE mortality risk using multipliers. These multipliers have been shown to underestimate overall CVD risk. We aimed to compare the current Dutch risk charts with charts that estimate a broader range of clinically relevant CVD using updated multipliers. METHODS: We constructed new risk charts for 10-year CVD using updated, recently published multipliers from the EPIC-Norfolk study, based on ratios of fatal CVD to clinically relevant CVD (fatal plus nonfatal CVD requiring hospitalisation for ischaemic heart disease, cardiac failure, cerebrovascular disease, peripheral artery disease, and aortic aneurysm). Our primary outcome was the proportion of the three risk categories, i. e. 'high risk' (>20% 10-year risk), 'intermediate risk' (10-19%) and 'low risk' (