Prevention of cardiovascular events in amateur athletes begins with a healthy lifestyle at school age

Athletes and people participating in sports or other forms of physical exercise are generally perceived as healthy with a unique lifestyle. However, a small proportion of athletes and sports participants die suddenly from a cardiac condition.^1,2 Most causes of sudden cardiac arrest or death (SCA/SCD) among young athletes ≤35 years are attributed to inherited and congenital cardiac conditions triggering life-threatening ventricular arrhythmia (VT/VF), such as hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy and an anomalous coronary artery that transverses between the aorta and the pulmonary artery.^1,3 In addition, some acquired cardiac conditions, such as blunt chest trauma and myocarditis (fever), are triggers for VT/VF inducing SCA/SCD. Among master athletes aged >35 years the most common causes of SCA/SCD are attributed to atherosclerotic coronary artery disease and hypertrophic cardiomyopathy.⁴ It is well-known that the use of certain substances (e.g. tobacco, alcohol highly caffeinated beverages and prohibited and illicit substances) may impair myocardial electrophysiological properties and induce cardiovascular events such as VT/VF in relation to exercise.³

The prevention of SCA/SCD among athletes and sports participants can be achieved through screening for high-risk cardiovascular conditions (HRCC), cardiopulmonary resuscitation (CPR) in unforeseen SCA, the control of major cardiovascular risk factors and abstention from exercise during a viral infection or fever.^3,5–8 Screening athletes for HRCC is advocated by the international cardiac societies and sports governing bodies.^3,5,6 The costs of ECG-inclusive screening for HRCC, including disease management, ranges between €67 and €90 000 per life-year saved.³ The screening costs among young adolescents (aged 12–18 years) has been reported as €45,500 per life-year saved.⁹ The secondary prevention of SCA/SCD can be achieved through arena safety programmes, including CPR and the use of an automated electrical defibrillator.^7,8

The control of the major cardiac risk factors (smoking, systemic hypertension, diabetes and dyslipidaemia) in low-risk groups (i.e. young people) can be achieved through lifestyle changes rather than the lifelong prescription of preventive drugs.¹⁰ Lifestyle changes to reduce the cardiovascular risk profile consist of regular physical exercise, the cessation of smoking, control of blood pressure, lipids and diabetes, and maintain a healthy body mass index of 20–25.¹¹ Regular physical exercise promotes a favourable cardiac risk profile (e.g. the control of blood pressure and blood lipid profiles and an increase in insulin sensitivity) and reduces cardiovascular events, especially from coronary artery disease. People who exercise regularly live longer, have fewer admissions to hospital, and are more physically fit than their sedentary peers. In addition, sedentary people resuming regular exercise have a relatively lower future risk of life-threatening VT/VF due to myocardial ischaemia.³ The cessation of smoking is the single most cost-effective intervention in the prevention of cardiovascular events.¹² Systemic hypertension (>115/75 mmHg) is an independent risk factor for cardiovascular events, with any increase in blood pressure (systolic 20 mmHg, diastolic 10 mmHg) doubling the cardiovascular risk.¹² A diet high in fibre, fruit and vegetables and low in sugars and salt is recommended for a favourable cardiac risk profile.^11,12

Despite worldwide educational programmes for the prevention of cardiovascular disorders, it seems that these programmes are still to be improved. In their paper entitled ‘Cardiovascular prevention and at-risk behaviours in a large population of amateur rugby players’, Chagué et al.¹³ from Dijon University Hospital in France examined cardiovascular safety during rugby practice among 5140 French amateur rugby players. Most of the 640 participants who completed the questionnaire on cardiovascular safety were men (90%) aged <35 years (80%). The cardiovascular safety education programme consisted of ten rules for safety, including ECG-inclusive screening for HRCC, CPR training programmes, abstaining from nicotine, alcohol, and illicit and prohibited substances, and abstention from sports participation during illness and especially during a fever. The results of the questionnaire among the French amateur rugby players were astonishing. Only 17% were aware of the rules for cardiovascular safety during rugby practice, only 27% attended screening for HRCC although this is recommended in France, 42% attended the CPR training programmes, >44% played rugby despite a fever, almost 35% reported smoking, almost 70% used alcohol, including over two-thirds of them two hours before practice, and almost 35% had a highly caffeinated beverage before and/or after the practice. The use of tobacco, alcohol and highly caffeinated beverages was almost equal to that in the French sedentary population.¹³

These data increase concerns about whether educational programmes for the prevention of exercise-related cardiac events are sufficient. As Chagué et al.¹³ state, it is clear that a more intensive programme of information and education of all sports participants is needed to improve their knowledge and awareness of good health to prevent cardiac events.¹³ It should be made clear that good health implies not only regular participation in sports or other forms of exercise, but also the intake of healthy drinks and food. However, the sports cardiology consensus papers do not always report discouragement of the use of substances that may induce cardiac morbidity and mortality. The cardiology and sports medical profession should take responsibility for an intensive discouragement policy to create more awareness of good health and the associated lifestyle required for a favourable cardiac risk profile at an early age. In addition, substances that may induce cardiovascular morbidity and mortality should be strongly discouraged, such as tobacco, alcohol highly caffeinated beverages, and prohibited and illicit substances. Consideration should be given to introducing these educational programmes and to implement them at an early age in life – for instance, in primary and secondary schools – and during the screening process for young athletes. The cardiology and sports medicine professions should consider implementing such preventive programmes in their consensus papers.

The prevention of cardiovascular events by increasing the awareness of the beneficial effects of lifestyle changes is a great challenge that must be continued if we are to reduce the burden of preventable cardiovascular events, especially among sport participants. It would be interesting to determine the long-term follow-up of cardiovascular events among the French amateur rugby players in the study group of Chagué et al.¹³

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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