Abstract
Owing to its undisputed multitude of beneficial effects, European Society of Cardiology guidelines advocate regular physical activity as a class IA recommendation for the prevention and treatment of cardiovascular disease. Nonetheless, competitive athletes with arterial hypertension may be exposed to an increased risk of cardiovascular events. Guidance to physicians will be given in this summary of our recently published recommendations for participation in competitive sports of athletes with arterial hypertension.
Introduction
This is a summary of our recent position paper for participation in competitive sports of athletes with arterial hypertension.1 Timely identification of hypertensive individuals is paramount in the setting of pre-participation screening, in order to implement a healthier lifestyle, appropriate management and follow-up.2–5
Our panel of experts proposes recommendations which represent the best possible balance between risks and benefits inherent with competitive sports participation, based on scientific evidence, when available, and consensus of experts. Detailed information on the classification, prevalence, evaluation and recommendation for patients with arterial hypertension can be found in the current European Society of Hypertension/European Society of Cardiology guidelines.6
In this document, competitive athletes are defined as individuals of all ages who engage in exercise training on a regular basis and participate in official sports competition, be it as amateurs or professionals.7,8
Classification
Hypertension is defined as systolic blood pressure (BP) ≥140 mmHg and/or diastolic BP ≥ 90 mmHg (Table 1), repeatedly measured in the office.9 Importantly, children and adolescents have lower BP levels with normal values <120/80 mmHg.10,11 In adults the threshold for an elevated 24-h ambulatory BP (ABPM) is ≥130/80 mmHg (daytime: ≥135/85 mmHg; nighttime: ≥120/70 mmHg).6,9,12 The cuff size should be chosen according to the circumference of the athlete's arm, and in the case of asymmetric exercises (e.g. shot put, tennis, etc.) BP can be measured in the non-dominant arm.
Classification of blood pressure according to the European Society of Cardiology Guidelines.6
| Systolic | Diastolic | ||
|---|---|---|---|
| Optimal | <120 | and | <80 |
| Normal | 120–129 | and/or | 80–84 |
| High normal | 130–139 | and/or | 85–89 |
| Grade 1 hypertension | 140–159 | and/or | 90–99 |
| Grade 2 hypertension | 160–179 | and/or | 100–109 |
| Grade 3 hypertension | ≥180 | and/or | ≥110 |
| Isolated systolic hypertension | ≥140 | and | <90 |
| Systolic | Diastolic | ||
|---|---|---|---|
| Optimal | <120 | and | <80 |
| Normal | 120–129 | and/or | 80–84 |
| High normal | 130–139 | and/or | 85–89 |
| Grade 1 hypertension | 140–159 | and/or | 90–99 |
| Grade 2 hypertension | 160–179 | and/or | 100–109 |
| Grade 3 hypertension | ≥180 | and/or | ≥110 |
| Isolated systolic hypertension | ≥140 | and | <90 |
Classification of blood pressure according to the European Society of Cardiology Guidelines.6
| Systolic | Diastolic | ||
|---|---|---|---|
| Optimal | <120 | and | <80 |
| Normal | 120–129 | and/or | 80–84 |
| High normal | 130–139 | and/or | 85–89 |
| Grade 1 hypertension | 140–159 | and/or | 90–99 |
| Grade 2 hypertension | 160–179 | and/or | 100–109 |
| Grade 3 hypertension | ≥180 | and/or | ≥110 |
| Isolated systolic hypertension | ≥140 | and | <90 |
| Systolic | Diastolic | ||
|---|---|---|---|
| Optimal | <120 | and | <80 |
| Normal | 120–129 | and/or | 80–84 |
| High normal | 130–139 | and/or | 85–89 |
| Grade 1 hypertension | 140–159 | and/or | 90–99 |
| Grade 2 hypertension | 160–179 | and/or | 100–109 |
| Grade 3 hypertension | ≥180 | and/or | ≥110 |
| Isolated systolic hypertension | ≥140 | and | <90 |
Isolated systolic hypertension and isolated diastolic hypertension correspond to an elevated systolic BP with normal diastolic BP or an elevated diastolic BP with normal systolic BP, respectively.
Subjects with elevated BP in the clinic and normal home blood pressure monitoring (HBPM) and/or ABPM have white-coat or isolated clinic hypertension, those with normal office BP but elevated HBPM and/or ABPM have masked hypertension.13,14
During exercise, physiologically systolic BP increases and diastolic BP remains stable or mildly decreases. An exaggerated BP response during exercise testing has been related to incident hypertension.15 In Olympic athletes systolic BP of 220 mmHg in males and 200 mmHg in females measured during cycle ergometry are beyond the 95th percentile16 and thus warrant further follow-up evaluation including ABPM.17
Evaluation
Clinical history, assessment of cardiovascular risk, physical examination and subsequent diagnostic tests for target organ damage as well as secondary causes, which may account for 5–10%, have to be performed. Indeed, widely used supplements, energy drinks, medications (including anti-inflammatory drugs or thyroid hormones for weight reduction) or performance enhancing substances (e.g. erythropoietin, anabolic steroids) are an underestimated cause of secondary hypertension.18,19
In the case of borderline office measurements or in athletes with white coat or masked hypertension, HBPM and ABPM also during training sessions should be performed.
Echocardiography has its place to assess left ventricular (LV) hypertrophy (increased relative wall thickness (RWT) of >0.42 (RWT = interventricular septum + posterior wall/end-diastolic diameter) and mass (>110 g/m2 in men, >95 g/m2 in women),20,21 impaired relaxation (measured by tissue Doppler echocardiography) or systolic dysfunction (assessed by longitudinal strain analysis),22,23 valves and the ascending aorta.
Long-term, high volume and high intensity endurance sport itself may induce enlargement of all cardiac cavities and mild LV hypertrophy, better known as athlete's heart. Whereas these physiologic adaptations are reversible by detraining,24 remodelling caused by hypertension is not, but is amenable to effective BP lowering therapy.
Exercise testing (with electrocardiogram (ECG) and BP monitoring)25 should be routinely performed to assess exercise capacity and to rule out exercise-induced hypertension. At least annual follow-up preferably with ABPM and with particular attention to cardiovascular risk factors is warranted, but without restriction from any competitive sport.16
Risk stratification
The terms low, moderate, high and very high risk correspond to approximate absolute 10-year risks of cardiovascular mortality of <1%, 1–4%, 5–10% and >10%, respectively, according to the European SCORE system as defined by the 2016 European Society of Cardiology (ESC) prevention guidelines.26
Recommendations
General recommendations
Athletes with hypertension should be treated according to general guidelines.6 Appropriate non-pharmacological measures should be considered as the first step: salt restriction, weight reduction when obesity is present, alcohol restriction, increased consumption of vegetables and fruits, smoking cessation, discontinuation of supplements, ergogenic and/or anti-inflammatory drugs. Aerobic exercise programmes should complement athletes' training schedules. (Level of evidence: IB)
Athletes should be periodically reassessed and in the case of low or moderate risk, drug treatment is initiated when hypertension persists, for example, three months after appropriate lifestyle changes have been implemented or when out-of-office BP remains elevated. It is not recommended to initiate antihypertensive therapy at high normal BP; however, lifestyle changes are encouraged. Antihypertensive drug therapy should be started promptly in athletes with grade 3 hypertension and/or high or very high risk for cardiovascular complications (Table 3). (Level of evidence: IB)
Relevant clinical characteristics for the risk stratification of patients with hypertension.6
| Risk factors | • Men > 55 years; woman > 65 years • Diabetes mellitus • Smoking • Dyslipidaemia • Abdominal obesity • Premature cardiovascular disease in family (men < 55 years; women < 65 years) |
|---|---|
| Target organ damage | • LV hypertrophy induced by hypertension • Diastolic dysfunction • Ultrasound evidence of arterial wall thickening or atherosclerotic plaque • Hypertensive eye fundus • Increase in serum creatinine (men 1.3–1.5 mg/dl, women 1.2–1.4 mg/dl) • Microalbuminuria |
| Associated clinical conditions | • Atrial fibrillation • Cerebrovascular disease • Ischaemic heart disease • Heart failure • Peripheral vascular disease • Renal impairment, proteinuria • Advanced retinopathy |
| Risk factors | • Men > 55 years; woman > 65 years • Diabetes mellitus • Smoking • Dyslipidaemia • Abdominal obesity • Premature cardiovascular disease in family (men < 55 years; women < 65 years) |
|---|---|
| Target organ damage | • LV hypertrophy induced by hypertension • Diastolic dysfunction • Ultrasound evidence of arterial wall thickening or atherosclerotic plaque • Hypertensive eye fundus • Increase in serum creatinine (men 1.3–1.5 mg/dl, women 1.2–1.4 mg/dl) • Microalbuminuria |
| Associated clinical conditions | • Atrial fibrillation • Cerebrovascular disease • Ischaemic heart disease • Heart failure • Peripheral vascular disease • Renal impairment, proteinuria • Advanced retinopathy |
LV: left ventricular.
Relevant clinical characteristics for the risk stratification of patients with hypertension.6
| Risk factors | • Men > 55 years; woman > 65 years • Diabetes mellitus • Smoking • Dyslipidaemia • Abdominal obesity • Premature cardiovascular disease in family (men < 55 years; women < 65 years) |
|---|---|
| Target organ damage | • LV hypertrophy induced by hypertension • Diastolic dysfunction • Ultrasound evidence of arterial wall thickening or atherosclerotic plaque • Hypertensive eye fundus • Increase in serum creatinine (men 1.3–1.5 mg/dl, women 1.2–1.4 mg/dl) • Microalbuminuria |
| Associated clinical conditions | • Atrial fibrillation • Cerebrovascular disease • Ischaemic heart disease • Heart failure • Peripheral vascular disease • Renal impairment, proteinuria • Advanced retinopathy |
| Risk factors | • Men > 55 years; woman > 65 years • Diabetes mellitus • Smoking • Dyslipidaemia • Abdominal obesity • Premature cardiovascular disease in family (men < 55 years; women < 65 years) |
|---|---|
| Target organ damage | • LV hypertrophy induced by hypertension • Diastolic dysfunction • Ultrasound evidence of arterial wall thickening or atherosclerotic plaque • Hypertensive eye fundus • Increase in serum creatinine (men 1.3–1.5 mg/dl, women 1.2–1.4 mg/dl) • Microalbuminuria |
| Associated clinical conditions | • Atrial fibrillation • Cerebrovascular disease • Ischaemic heart disease • Heart failure • Peripheral vascular disease • Renal impairment, proteinuria • Advanced retinopathy |
LV: left ventricular.
Classification of hypertension stages according to blood pressure levels, presence of cardiovascular risk factors, hypertension-mediated organ damage, or comorbidities. Cardiovascular risk is illustrated for a middle-aged male. The cardiovascular risk does not necessarily correspond to the actual risk at different ages. The use of the SCORE system is recommended for formal estimation of cardiovascular risk for treatment decisions.6
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Risk factors used for stratification: BP level (high normal BP; grades 1–3); gender and age (men ≥ 55 years; women ≥ 65 years); smoking; dyslipidaemia (total cholesterol > 190 mg/dl and/or low-density lipoprotein cholesterol > 115 mg/dl and/or high-density lipoprotein cholesterol < 40 mg/dl in men and <46 mg/dl in women); fasting plasma glucose 102–125 mg/d; abnormal glucose tolerance test; body mass index ≥ 30 kg/m2; abdominal obesity (men ≥ 102 cm; women ≥ 88 cm); first degree family history of premature cardiovascular disease (men < 55 years; women < 65 years). Organ damage: hypertension-induced left ventricular hypertrophy; carotid wall thickening or plaque; carotid-femoral pulse wave velocity >10 m/s; ankle–brachial index < 0.9; CKD with estimated glomerular filtration rate (eGFR) 30–60 ml/min per 1.73 m2; presence of micro-albuminuria. Established cardiovascular or renal disease: cerebrovascular disease; coronary heart disease; heart failure; symptomatic peripheral artery disease; CKD eGFR < 30 ml/min per 1.73 m2; proteinuria; advanced retinopathy (haemorrhages; exudates; papilloedema).
BP: blood pressure; CKD: chronic kidney disease; CVD: cardiovascular disease; DBP: diastolic blood pressure; HMOD: hypertension-mediated organ damage; SBP: systolic blood pressure.
Classification of hypertension stages according to blood pressure levels, presence of cardiovascular risk factors, hypertension-mediated organ damage, or comorbidities. Cardiovascular risk is illustrated for a middle-aged male. The cardiovascular risk does not necessarily correspond to the actual risk at different ages. The use of the SCORE system is recommended for formal estimation of cardiovascular risk for treatment decisions.6
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Risk factors used for stratification: BP level (high normal BP; grades 1–3); gender and age (men ≥ 55 years; women ≥ 65 years); smoking; dyslipidaemia (total cholesterol > 190 mg/dl and/or low-density lipoprotein cholesterol > 115 mg/dl and/or high-density lipoprotein cholesterol < 40 mg/dl in men and <46 mg/dl in women); fasting plasma glucose 102–125 mg/d; abnormal glucose tolerance test; body mass index ≥ 30 kg/m2; abdominal obesity (men ≥ 102 cm; women ≥ 88 cm); first degree family history of premature cardiovascular disease (men < 55 years; women < 65 years). Organ damage: hypertension-induced left ventricular hypertrophy; carotid wall thickening or plaque; carotid-femoral pulse wave velocity >10 m/s; ankle–brachial index < 0.9; CKD with estimated glomerular filtration rate (eGFR) 30–60 ml/min per 1.73 m2; presence of micro-albuminuria. Established cardiovascular or renal disease: cerebrovascular disease; coronary heart disease; heart failure; symptomatic peripheral artery disease; CKD eGFR < 30 ml/min per 1.73 m2; proteinuria; advanced retinopathy (haemorrhages; exudates; papilloedema).
BP: blood pressure; CKD: chronic kidney disease; CVD: cardiovascular disease; DBP: diastolic blood pressure; HMOD: hypertension-mediated organ damage; SBP: systolic blood pressure.
The goal of antihypertensive therapy is to reduce BP to <140/90 mmHg and to <140/85 mmHg in diabetic athletes,6 although the current trend is to adopt lower values, that is, <130/80, as recently advocated in the American College of Cardiology/American Heart Association (ACC/AHA) guidelines.27 (Level of evidence: IB)
With regard to white coat or masked hypertension, ABPM may be particularly useful in assessing the real BP load and current evidence indicates that antihypertensive drugs are not required, unless the patient has comorbid risk factors placing him or her at high or very high risk (Table 3). Regular follow-up and non-pharmacological measures are recommended.28 (Level of evidence: IB)
Choice of drugs
Athletes who compete at national and/or international level have to review the current list of prohibited substances and methods of the World Anti-Doping Association29 before starting drug therapy. If required, a therapeutic use exemption has to be obtained in order to receive the authorization to take the needed medicine.
Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are the preferred choice as they do not affect exercise capacity and are not on the doping list. However, they shall not be given to females during reproductive years, because of potential adverse foetal/neonatal effects.
Alternatively or additionally calcium channel blockers are a preferred choice in athletes. If more than one drug is required, combination drugs should be considered as they may improve compliance. Beta-blockers are rarely used as second line therapy, as they can generally not be given in athletes with bradycardia <50/min and/or second or third degree atrioventricular block. Furthermore, different beta-blockers (selective/non-selective, older/newer compounds, with/without vasodilatory properties) negatively impact aerobic exercise performance, which may interfere with compliance. Also, beta-blockers are prohibited and considered as doping in some sports, such as archery and shooting, where control of tremor is sought.9,30
Diuretics are banned at all times and in all sports, since they may mask performance-enhancing drugs.31,32
Recommendations for competitive sports participation
Recommendations are based on risk stratification and with the understanding that the clinical condition is stable and that general recommendations for the management of hypertension are observed as described above (Table 4).
In patients with low or moderate cardiovascular risk, usually no restrictions apply. If BP values are not normalized, temporary restriction from competitive sport is recommended, with possible exception of skill disciplines (Figures 1 and 2).
In patients with high-risk or very high-risk in whom control of BP has been achieved, participation in all competitive sports is possible, with the exception of power disciplines (Figures 1 and 2). If BP values are not well controlled, temporary restriction from competitive sport is recommended.
Pre-participation examination in competitive athletes with arterial hypertension
Evaluation includes family and personal history (hx), cardiovascular (CV) risk profile, physical examination, blood pressure (BP) and resting 12-lead electrocardiogram (ECG). Additional tests according to current guidelines. If BP is < 140/90 mmHg (<140/85 mmHg in diabetic), all competitive sports are allowed. Otherwise, no competitive sports until normalization of values. Depending on associated clinical conditions (ACC) and/or target organ damage (TOD) restrictions may apply (Table 4).
Classification of different sports disciplines.
Sport disciplines are divided according to acute physiologic responses (i.e. heart rate and blood pressure (BP)) and long-term impact on cardiac output and remodelling. Skill sports: achievement depends on technical or bodily skill. Increase in heart rate is accompanied by modest increase in BP and cardiac output. No cardiac remodelling. Power sports: achievement depends on explosive muscle power (i.e. high-static exercise). Substantial increase in heart rate and BP during repeated bursts. Cardiac remodelling with increase in left ventricle (LV) wall thickness and modest increase in LV cavity size and function occurs. Mixed sports: alternating phases of dynamic and/or static work and recovery (e.g. ball and team sports). Duration and exercise intensity vary largely according to type of sport and the role the athlete plays. Phasic increases in heart rate and BP may reach near-maximum values, alternating with recovery phases. There is cardiac remodelling with increase in LV cavity size and modest change in LV wall thickness. Endurance sports: prolonged and intensive high-dynamic, often associated with high-static exercise at near maximal cardiac output, through increase in heart rate and BP over several hours. Cardiac remodelling with significant increase in LV cavity size and wall thickness is present.
General recommendations for competitive sport participation in athletes with systemic hypertension. Individual recommendations need to also consider cardiovascular risk profile, target organ damage and associated clinical condition.
| Criteria for eligibility | Recommendations | Evaluation | Follow-up |
|---|---|---|---|
| BP: well controlled Further RFs: none TOD: none ACC: none | All sports | History, PE, ECG, ET; echoa | Yearly |
| BP: well controlled Further RFs: well controlled TOD: none ACC: none | All sports | History, PE, ECG, ET; echo | 6–12 months |
| BP: well controlled Further RFs: well controlled TOD: present ACC: none | All sports, except power sports known to severely increase BP | History, PE, ECG, ET; echo | Six months |
| BP: well controlled Further RFs: well controlled TOD: none or present ACC: present | All sports, except power sports known to severely increase BPb | History, PE, ECG, ET; echo | Six months |
| Criteria for eligibility | Recommendations | Evaluation | Follow-up |
|---|---|---|---|
| BP: well controlled Further RFs: none TOD: none ACC: none | All sports | History, PE, ECG, ET; echoa | Yearly |
| BP: well controlled Further RFs: well controlled TOD: none ACC: none | All sports | History, PE, ECG, ET; echo | 6–12 months |
| BP: well controlled Further RFs: well controlled TOD: present ACC: none | All sports, except power sports known to severely increase BP | History, PE, ECG, ET; echo | Six months |
| BP: well controlled Further RFs: well controlled TOD: none or present ACC: present | All sports, except power sports known to severely increase BPb | History, PE, ECG, ET; echo | Six months |
Physical examination includes BP measurements according to guidelines.5
aEchocardiography according to clinical condition, but once every 1–2 years.
Eligibility depending on type and severity of ACC and/or TOD.
ACC: associated clinical condition; BP: blood pressure; ECG: electrocardiogram; echo: echocardiography; ET: exercise testing; PE: physical examination; RF: risk factor; TOD: target organ damage
General recommendations for competitive sport participation in athletes with systemic hypertension. Individual recommendations need to also consider cardiovascular risk profile, target organ damage and associated clinical condition.
| Criteria for eligibility | Recommendations | Evaluation | Follow-up |
|---|---|---|---|
| BP: well controlled Further RFs: none TOD: none ACC: none | All sports | History, PE, ECG, ET; echoa | Yearly |
| BP: well controlled Further RFs: well controlled TOD: none ACC: none | All sports | History, PE, ECG, ET; echo | 6–12 months |
| BP: well controlled Further RFs: well controlled TOD: present ACC: none | All sports, except power sports known to severely increase BP | History, PE, ECG, ET; echo | Six months |
| BP: well controlled Further RFs: well controlled TOD: none or present ACC: present | All sports, except power sports known to severely increase BPb | History, PE, ECG, ET; echo | Six months |
| Criteria for eligibility | Recommendations | Evaluation | Follow-up |
|---|---|---|---|
| BP: well controlled Further RFs: none TOD: none ACC: none | All sports | History, PE, ECG, ET; echoa | Yearly |
| BP: well controlled Further RFs: well controlled TOD: none ACC: none | All sports | History, PE, ECG, ET; echo | 6–12 months |
| BP: well controlled Further RFs: well controlled TOD: present ACC: none | All sports, except power sports known to severely increase BP | History, PE, ECG, ET; echo | Six months |
| BP: well controlled Further RFs: well controlled TOD: none or present ACC: present | All sports, except power sports known to severely increase BPb | History, PE, ECG, ET; echo | Six months |
Physical examination includes BP measurements according to guidelines.5
aEchocardiography according to clinical condition, but once every 1–2 years.
Eligibility depending on type and severity of ACC and/or TOD.
ACC: associated clinical condition; BP: blood pressure; ECG: electrocardiogram; echo: echocardiography; ET: exercise testing; PE: physical examination; RF: risk factor; TOD: target organ damage
Leisure-time and amateur sport activities
Regular exercise training has been shown to reduce morbidity and mortality33 and is thus a class IA indication.26 Patients are advised to perform at least 30 min of moderate-intensity, preferably (but not exclusively) aerobic-exercise training, 5–7 days per week.6
Follow-up
Patients need to be followed up regularly by their physicians. In addition, during annual pre-competition medical examination BP needs to be measured at rest and during exercise testing. Furthermore, possible reversal or progression of existing target organ damage has to be assessed by ECG, echocardiography, kidney testing and/or retinal examination.
An ACC/AHA statement34 recommends athletes with hypertension who wish to engage in training for competitive sports to undergo prior clinical assessment including BP, which is in keeping with this position statement and our ESC consensus statement.35
Summary
The prevalence of arterial hypertension is high overall, increasing with age and unfavourably influenced by Western diet and behaviour even in athletes. Therefore, screening should also focus on adolescent athletes. Special considerations have to be given regarding the pharmacological treatment of hypertension in athletes. While eligibility for competitive sports may have to be restricted if target organ damage is present, an athlete with well-controlled BP, having no additional risk factors or target organ damage, is eligible for competition in all sports.
Author contribution
Authorship: JN, MB, FC, SC, PP, FQ, LS, PEA, AB, AP, HKR, CS, FVB, NP-G, EES, MH, ALG, MP, SS, and AP contributed to the conception or design of the work. JN, MB, FC, SC, PP, FQ, LS, PEA, AB, AP, HKR, CS, FVB, NP-G, EES, MH, ALG, MP, SS and AP contributed to the acquisition, analysis, or interpretation of data for the work. JN, MB, FC, SC, PP, FQ, LS, PEA, AB, AP, HKR, CS, FVB, NP-G, EES, MH, ALG, MP, SS and AP drafted the manuscript. JN, MB, FC, SC, PP, FQ, LS, PEA, AB, AP, HKR, CS, FVB, NP-G, EES, MH, ALG, MP, SS and AP critically revised the manuscript. All gave final approval and agree to be accountable for all aspects of work ensuring integrity and accuracy.
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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