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Evaluation of Athletes with Arrhythmias View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Ghent University Academic Bibliography REVIEW ARTICLE Recommendations and cardiological evaluation of athletes with arrhythmias Part 2 J. Hoogsteen, J.H. Bennekers, E.E. van der Wall, N.M. van Hemel, A.A.M. Wilde, H.J.G.M. Crijns, A.P.M. Gorgels, J.L.R.M. Smeets, R.N.W. Hauer, J.L.M. Jordaens, M.J. Schalij Confronted with a competitive or recreational Key words: arrhythmias, athletes, evaluation, recom- athlete, the physician has to discriminate between mendations benign, paraphysiological and pathological ar- rhythmias. Benign arrhythmias do not represent a Bradyarrhythmias risk for SCD, nor do they induce haemodynamic consequences during athletic activities. These Sinus bradycardia arrhythmias are not markers for heart disease. Sinus bradycardia is defined as a rhythm lower than Paraphysiological arrhythmias are related to 50 beats/min. Related to the type ofsporting activity athletic performance. Long periods of endurance 50 to 90% of athletes show sinus bradycardia with a training induce changes in rhythm, conduction mean heart rate of50 beats/min.' Sinus bradycardias and repolarisation. These changes are fillly with rates of25 beats/min are recorded especially at reversible and disappear when the sport is night. Sinus arrhythmia is a very common finding. terminated. Pathological arrhythmias have There is awide range in prevalence ofsinus arrhythmia haemodynamic consequences and express disease, in athletes, ranging from 13 to 91%. Asymptomatic such as sick sinus syndrome, cardiomyopathy or sinoatrial pauses ofbetween 2 to 3 sec are commonly inverse consequences ofphysical training. recorded in endurance athletes.2'3 A resting sinus rate Arrhythmias can be classified as bradyarrhythmias below 40 beats/min that does not increase more than and tachyarrhythmias. Conduction disorders can 100 beats/min during exercise is an abnormal finding be seen in fast as well as in slow arrhythmnias. (Neth and cardiological evaluation is indicated. ECG and HeartJ2004;12:214-22.) Holter monitoring can be used and sometimes electro- physiology studies (EPS) in specific cases. Symptomatic pauses ofmore than 3 sec are abnormal4 and require cardiological evaluation including ECG, Holter monitoring, exercise testing, echocardiography and EPS. J. Hoogsteen Maxima Medical Centre, PO Box 7777, 5500 MB Veldhoven J.H. Bennekers Sick sinus syndrome Martini Hospital, Groningen The prevalence ofthis disorder is not well defined. In E.E. van der Wall the literature, a prevalence of 0.17% is mentioned by M.J. SchalU Kulbertus, et al.5 Several intrinsic as well as extrinsic Leiden University Medical Centre, Leiden factors can cause sick sinus syndrome. Longstanding N.M. van Hemel isotonic loading causes volume stress ofthe myocardium Heart Lung Centre Utrecht, St Antonius Hospital, Nieuwegein and results in a dilatation ofthe heart chambers. It has A.A.M. Wilde University Hospital Amsterdam, Academic Medical Centre been suggested that the process ofdilatation ofthe atria H.J.G.M. Criljns and ventricles in combination with extreme vagal A.P.M. Gorgels stimulation and changes in the collagen/fibrosis ratio J.L.R.M. Smeets could be a substrate for the development ofsick sinus University Hospital Maastricht syndrome.6 The changes at atrial level could disrupt the R.N.W. Hauer interaction between pacemaker cells. It is likely that Heart Lung Centre Utrecht contributes to this J.L.M. Jordaens genetic predisposition syndrome. University Hospital Rotterdam Recommendation Correspondence to: J. Hoogsteen Athletes with presyncope or syncope should not E-mail: [email protected] participate in sports because loss ofconsciousness may 214 Netherlands Heart Journal, Volume 12, Number 5, May 2004 Recommendations and cardiological evaluation of athletes with arrhythmias be hazardous for the athlete himselfor others. Athletes should undergo cardiological evaluation. If the AV with a normal or structurally abnormal heart in which block is infranodal permanent pacing may be required. the bradyarrhythmia is asymptomatic and disappears with exercise and in which the (sinus) bradycardia rate Second-degree type IIAVblock increases appropriately during exercise mayparticipate This type ofAV block occurs in 8% ofathletes.3 This in all competitive sports. They have to be re-examined abnormality is often related to a structural heart periodically to determine that training does not disorder. Evaluation ofathletes with this abnormality aggravate the bradyarrhythmia. is similar to athletes with type I AV block. Athletes with symptoms such as impaired con- sciousness and fatigue related to the arrhythmia should Recommendation be treated and should not participate in sports because Athletes with intrahisian and infrahisian type II second loss ofconsciousness may be hazardous for the athlete degree AV block should be treated with permanent himselfor others. Ifthe athlete is asymptomatic for a pacing before athletic activity. six-month period during treatment, he mayparticipate in all competitive sports after cardiological re-exam- Acquired complete heart block ination. Athletes with symptomatic tachy-brady syn- Acquired complete heart block is rare in athletes. It drome or an inappropriate increase of exercise heart can be permanent or transient. The incidence lies rate should be treated. Ifasymptomatic for six months, between 0.02 and 0.00017%. In a normal population they may participate in low-intensity competitive the incidence is 0.0002%.3 Ifthird degree AV block is sports. Athletes with pacemakers should not engage present evaluation is necessary to exclude underlying in sports with danger of bodily collision. (Class IC: heart disease. In some cases vagal over-stimulation field hockey, soccer. Class IIA: diving, motorcycling. plays an important role and a period ofdetraining could Class IIB: rugby. Class IIC: basketball, ice hockey, be successful in the management of a symptomatic team handball. Class IIIA: bobsledding, karate, judo, athlete with a third degree AV block. water-skiing. Class IIIB: downhill skiing, wrestling. Class IIIC: boxing). Recommendation Athletes with normal hearts and asymptomatic Disorders of atrioventricular conduction transient complete AV block that disappears during In the athletic population AV conduction disorders exercise andwho show an appropriate increase in heart are not uncommon and it is assumed that these rate may participate in all competitive sports. Athletes disorders are related to the intensity and length ofthe with symptoms of fatigue, near syncope or syncope training period.7 should have a pacemaker implanted before they par- ticipate in competitive sports. First-degree AVblock First-degree AV block is a benign conduction ab- Atrioventricular escape andjunctional rhythm normality and the incidence is between 10 and 33% in Atrioventricular escape and junctional rhythms are athletes compared with 0.65% in the general popu- common arrhythmias in athletes.3 They are the result of lation.3 training andvagal over-stimulation. Clinical evaluation and recommendations are the same as those for Second-degree AVblock symptomatic athletes with sinus node dysfunction. Second-degree AV block could be a sign of organic heart disease, but is not uncommon in endurance Recommendation athletes. The incidence of type I second-degree AV Athletes with normal hearts and normal heart rate block is between 23 and 40% in athletes compared response to activity without sustained AVnodal orAV with 5.7% in a normal population.3 Exercise-induced junctional tachycardia mayparticipate in all competitive second-degree AV block is uncommon and clinically sports. Athletes with structural heart disease may important because it can result in significant dyspnoea participate in competitive sports, depending on the or syncope during sportng activities. limitations ofthe structural heart disease. Recommendation Bundle branch block Athletes with normal hearts and no worsening or The mean QRS width in athletes is between 90 and 100 improvement of the AV block with exercise may msec. Incomplete right bundle branch block (RBBB) participate in all competitive sports. Athletes with is common in highly trained athletes. For male athletes structural heart disease, in whom AV block disappears the incidence is 16.7% and for female athletes it is 0.2%. or does not worsen with exercise or recovery, may The incidence ofa complete RBBB in female athletes participate in all competitive sports, as determined by is 0.2% and for male athletes 1.2%.8 Complete left limitations ofthe cardiac abnormality. Athletes without bundle branch block (LBBB) is uncommon in athletes symptoms, in whom the AV block initially appears to and is probably more likely to be associated with under- worsen with exercise or during the recovery period lying heart disease than RBBB.9"10 Exercise-induced Netherlands Heart Journal, Volume 12, Number 5, May 2004 215 Recommendations and cardiological evaluation of athletes with arrhythmias LBBB is a rare electrocardiographic observation in arrhythmia after four to six months and ifthere is no athletes. LBBB may represent heart disease and structural heart disease, the athlete may participate in requires full examination. all competitive sports. Athletes with atrial tachycardia without structural heart disease, with ventricular rates Recommendation comparable with those of an appropriate sinus Athletes with asymptomatic, incomplete RBBB and tachycardia during physical activity with
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