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Dr Antonio Pelliccia Discusses New ESC Guidelines on Sports, Exercise in Patients With CVD


The new guidelines can help cardiologists better advise patients with CVD on physical activity, said Antonio Pelliccia, MD, senior consultant and chief of cardiology at the Institute of Sports Medicine and Science, of the Italian National Olympic Committee.

The new guidelines are much more intuitive and can help cardiologists better advise patients with CVD on physical activity, said Antonio Pelliccia, MD, senior consultant and chief of cardiology at the Institute of Sports Medicine and Science, of the Italian National Olympic Committee.


The American Journal of Managed Care® (AJMC®): Can you introduce yourself and tell us about your work?

Dr. Pelliccia: My name is Antonio Pelliccia. I'm one of the co-chairs of this document, together with Professor Sanjay Sharma from London. Personally, I'm a senior cardiologist, the former chief of the Institute of Sports Medicine and Science of the Italian National Olympic Committee in Rome, Italy. As far as my background, I am a cardiologist and specialist in sports medicine. My primary interest is the knowledge and the pathophysiology of the cardiovascular system with regard to exercise and sports participation.

AJMC®: What will the 2020 Guidelines on Sports Cardiology and Physical Activity in Patients with Cardiovascular Disease consist of? Why are they important?

Dr. Pelliccia: We have to specify that these are the first official guidelines of the European Society of Cardiology but not the first documents regarding exercise and sport participation in patients with cardiovascular diseases. Regardless of the current document, [past documents] were mostly focused on prescribing sport and exercise, but mostly focused on competitive athletes because at that time, one of the main topics of interest for the cardiology community was sudden death in athletes. So those documents mostly aimed to make a diagnosis and to prevent those events.

Now the mission is quite different. Now in 2020 we are facing a pandemic of obesity, diabetes, metabolic disorders, not only in Europe, but also, even more in the United States. The awareness is that the cardiology societies and also scientific societies should prompt exercise and sport as a smart strategy to counteract the effects of this pandemic, try to stop the pandemic or try to improve the trends in diabetes and metabolic disorders, obesity and so on. Obviously sport is something that is appealing, is nice, is fun, is pleasant to do. So what we believe is that implementing, as much as possible, sports in patients with these disorders, including patients with cardiovascular disease, is the best preventive strategy. Facing this issue, we now have a number of issues related to cardiovascular diseases and the impact of exercise and sport on the natural course of cardiovascular disease. I have to say that for most of these diseases, there is relatively scarce scientific evidence in terms of double-blind trials, or weights for evaluating the effects of people with the disease doing sports versus people with the same disease not doing sports.

Scientific evidence exists for a few of these diseases. For instance, it exists for certain cardiomyopathies, specifically for arrhythmogenic cardiomyopathy. However, the same evidence does not exist for all the diseases. For instance, in hypertrophic cardiomyopathy, now there are emerging evidence that hypertrophic cardiomyopathy should not be considered the cause of death in any case where the patient is exposed to sports participation. This was a concern that was actually based on the evidence...related to top or elite athletes where a substantial number of these were found dead and found with this disease. So the scientific community was particularly afraid to allow sports participation in young individuals with hypertrophic cardiomyopathy. Now after decades of small case series, observations, case reports, there is still not a trial. But there is still emerging evidence not all hypertrophic cardiomyopathy patients are exposed to the risk of death or worsening the clinical course of the disease just because they are exercising or they are participating in sport. Personally, we added some data that are published. So now the current guidelines actually accept this idea, accept the idea that it can be possible even for patients with hypertrophic cardiomyopathy to undergo a risk stratification.

For those individuals that have a mild phenotypic expression of the disease, mild or no left ventricular outflow tract obstruction, no relevant arrhythmias, very mild or cursory, we have a C-score and a score less than 4 indicates a very low risk. If there are no symptoms and no recurrence of the sudden death among the relatives the overall scenario could be even better than the usual scenario. And those people can, selectively, obviously, be allowed to participate in competitive sports. Particularly, if we are talking about adult individuals, people that maybe haven't been walking, haven't been exercising for a long time. And this is what was discovered just by chance in the adult age. Here again, we published some data just recently.
So in this sense, the guidelines are novel because they are receiving the novelty of the new studies. In this sense, these European guidelines are even much more liberal than before. For instance, sport participation is allowed in certain instances in patients with hypertrophic cardiomyopathy, but also in patients with dilated cardiomyopathy in certain instances in patients with the left ventricular non-compaction and so on. But the same attitude, the same, I would like to call liberal attitude in terms of pushing people towards a more active lifestyle, the same attitude can be seen when the guidelines approach patients with valvular diseases, where for patients with relatively mild degrees of valvular diseases, artery stenosis, artery regurgitation, or even prosthesis, there is advise not only for evaluation and follow-up, but to allow and actually advise regular exercise and sports. Overall we are talking about in most cases recreational sports activity, but the guidelines offer specific advice even for competitive sports. So this is true for valvular diseases, cardiomyopathies etc.

Well, the main issue is coronary artery disease, people with maybe asymptomatic or mildly symptomatic coronary artery disease. And I have to mention last year in 2019, the European Society of Cardiology released the guidelines on chronic coronary syndrome, where there is a chapter about the identification of people with chronic coronary syndrome that are asymptomatic or mildly symptomatic. The current guidelines of sports also are aligned with these previous guidelines. They recognize, for detection of asymptomatic patients with a coronary artery disease, they recognize the main role of the imaging techniques, mostly coronary computed tomography, which is now widely available not only United States, but also in Europe. [The techniques] can provide really detailed anatomical, morphological assessments of the existence, degree, and type of the atherosclerotic lesions. However, morphology or anatomy of the coronary lesion is not the whole story, because we need also some tests for functional evaluation. In other terms, we need to understand if this lesion was enough to cause ischemia during exercise. This is the key point. Before advising people to exercise we should know, what is the potential risk of inducing ischemia. Exercise testing is still in Europe widely available. We rely on a combination of imaging testing and functional testing to define what? To define the people with chronic coronary syndrome, which are low-risk and high-risk. People with low-risk are people that have no evidence of ischemia during exercise, have been not measured arrhythmias during exercise, have normal left ventricular ejection fraction, and overall, clinical status very well controlled by the drugs. Those people are obviously allowed, and even advised to engage in regular exercise. On the other end, the people that are considered at that high-risk, either because of the severity or location or number of lesions, or because of the evidence of ischemia or because there is an unstable clinical situation, they should undergo medical and surgical treatment.

Finally, one of the other major issue is people with atrial fibrillation. These are the 2 pandemics: coronary disease and atrial fibrillation. Mostly people are middle aged. With regard to atrial fibrillation, the cardiology papers say that there is a new shaped relationship. Very high exercise training, particularly master athletes, seems to be promoting favor for atrial fibrillation. So, here the advice is a for recreational, just low-medium intensity exercise training, but even sports participation is allowed. Particularly I want add more detail on the permission about the sport participation. When we say sport, we say everything. We have in the guidelines a new classification of sports. Why is it new? Because the previous classification of sport is, in our view, relatively too complex, too complicated: Class 1, Class 1 B, etc. The usual clinical cardiologist doesn't understand. In our classification we have the 4 types of sports: skill, such as golfing, power, such as weightlifting, mixed, such as football, basketball, and endurance, such as cycling or rowing or marathon running. So, this classification is much more intuitive. In the classification there is also a graduation of the intensity. In other terms, looking at the figure of the classification, the clinical cardiologist, who doesn't know very much about exercise physiology, etc, etc. can recognize a sport with relatively low cardiovascular impact, medium cardiovascular impact, that can be advised to patients with conditions that are not perfect. From sports such as cycling, marathon running, triathlon etc, etc that can be advised only to patients with cardiovascular disease that are very well controlled.

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