Sports Medicine: Just the Facts

CHAPTER 25 • CARDIOVASCULAR CONSIDERATIONS 147

U.S. Olympic Committee (Fuentes, Rosenberg, and

Davis, 1996).

• Restriction of activity for athletes with hypertension
  depends on the degree of target organ damage and on
  the overall control of the blood pressure (Maron and
  Mitchell, 1994; Committee on Sports Medicine and
  Fitness, 1997).


• The presence of mild to moderate hypertension with
  no target organ damage or concomitant heart disease
  should not limit eligibility for competitive sports
  (Maron et al, 2001). Athletes with severe degrees of
  hypertension should be restricted, particularly from
  static sports, until their hypertension is controlled.
  When hypertension coexists with other cardiovascular
  diseases, eligibility for competitive sports is usually
  based on the severity of the other associated condi-
  tion. In children and adolescents, the presence of
  severe hypertension or target organ disease warrants
  restriction until hypertension is under adequate con-
  trol. The presence of significant hypertension should
  not limit a young athlete’s eligibility for competitive
  athletics.

CORONARY ARTERY DISEASE
IN ATHLETES

•Vigorous exercise represents a dangerous paradox for
cardiovascular disease (Maron, 2000). While it may be
a potent preventive tool, it can also represent substan-
tial risk for the susceptible individual. This is particu-
larly poignant for the athlete with an established
diagnosis of CAD.

• These individuals will absolutely require careful risk

stratification prior to returning to their active lifestyle

(Kugler, O’Connor, and Oriscello, 2001). They will

require procedures for left ventricular assessment,

maximal treadmill testing to determine functional

capacity, and testing for inducible ischemia. Patients

should be tested on their medications.

• The 26th Bethesda Conference (Maron and Mitchell,
  1994) defines clear stratification criteria (Table 25-7)
  accompanied by activity recommendations (Table 25-8).
  This provides a general and conservative approach to
  the individual in regards to competitive sports.


• The American College of Sports Medicine has recently
  published guidelines that assist the primary care physi-
  cian in guiding the level of aerobic intensity (American
  College of Sports Medicine, 2000) (Table 25-9).

TABLE 25-7 Stratification Categories for Cad Patients
by 26th Bethesda Conference
mildly increased risk substantially increased risk
LVEF >50% LVEF <50% at rest
Normal exercise tolerance for age, Evidence of exercise-induced
i.e., >10 METS if < age 50 myocardial ischemia

9 METS if age 50–59
8 METS if age 60–69
7 METS if > age 70
Absence of exercise-induced
ischemia by exercise testing
Absence of exercise-induced Evidence of exercise-induced
complex ventricular arrhythmia complex ventricular arrhythmias
Absence of hemodynamically Evidence of hemodynamically
significant stenosis in all major significant stenosis of a major
coronary arteries if angiography coronary artery (>50%) if
performed or successful angiography performed
myocardial revascularization by
surgical or percutaneous
techniques

SOURCE: (Maron and Mitchell, 1994; Kugler and O’Connor, 2001)

TABLE 25-8 Summary of 26th Bethesda Conference

Recommendations for Patients with Coronary

Artery Disease

General

1. All athletes should understand that the risk of a cardiac event with
   exertion is probably increased once coronary artery disease is present.


2. Athletes should be informed of the nature of prodromal symptoms
   and should be instructed to promptly cease their sports activity and
   contact their physician if symptoms appear.
   Specific


3. Mildly increased risk. May participate in low and moderate static
   and low dynamic competitive sports (IA and IIA) and avoid
   intensely competitive situations.


4. Substantially increased risk. May participate in low intensity
   competitive sports (IA) after careful assessment and
   individualization. These patients should be reevaluated every 6
   months and should undergo repeat exercise testing at least yearly.

SOURCE: (Maron and Mitchell, 1994; Kugler and O’Connor, 2001)

TABLE 25-9 Signs and Symptoms Below which an Upper

Limit for Exercise Intensity Should be Set*

Onset of angina or other symptoms of cardiovascular insuffciency

Plateau or decrease in systolic blood pressure, systolic blood pressure of

>240 mm Hg, or diastolic blood pressure of >110 mmHg

Greater than or equal to 1 mm ST-segment depression, horizontal,

or downsloping

Radionuclide evidence of left ventricular dysfunction or onset of

moderate-to-severe wall motion abnormalities during exertion

Increased frequency of ventricular arrhythmias

Other significant ECG disturbances (e.g., second degree or third degree

AV block, atrial fibrillation, supraventricular tachycardia, complex

ventricular ectopy)

Other signs/symptoms of intolerance to exercise

SOURCE: (Americal College of Sports Medicine, 2000)

*The peak exercise rate should generally be at least 10 bpm below the

heart rate associated with any of the above-referenced criteria. Other

variables (e.g., the corresponding systolic blood pressure response and

perceived exertion), however, should also be considered when

establishing the exercise intensity.