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Ramon Hernandez -Molina. Atletico de Madrid Football Club, Spain

Football elite players : Special exercise practise and cardiac repercussions . Sport cardiac evaluation consensus is needed to prevent abnormal cardiovascular events. Ramon Hernandez -Molina. Atletico de Madrid Football Club, Spain. TABLE OF CONTENTS.

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Ramon Hernandez -Molina. Atletico de Madrid Football Club, Spain

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  1. Football elite players: Special exercise practise and cardiac repercussions. Sport cardiac evaluation consensus is needed to prevent abnormal cardiovascular events. RamonHernandez-Molina. Atletico de Madrid Football Club, Spain

  2. TABLE OF CONTENTS Soccer competitive and athlete definition Exercise characteristics Sudden death SCD causes Guidelines Atletico de Madrid, clinical assesments conclusions

  3. SOCCER PLAYER PATRICK EKENG DIES AFTER CARDIAC ARREST DURING A MATCH!May 7, 2016

  4. On 26 June 2003. Marc-Vivien Foé collapsed. And died.

  5. Hungarian soccer player Miklos Feher. He died in 2004 during a game in Portugal.

  6. "deaths on field". Retrieved 8 February 2014.

  7. What is an soccer elite player? First. Anatlethe Second, an elite player

  8. Why an atlethe CBS NEWSJuly 1, 2014, 5:44 PM Being a professional soccer player requires Super-fit factors: speed, balance, flexibility, and strength -- key components of all-around fitness – (HELGERUD, J., L. C. ENGEN, U. WISLØFF, and J. HOFF. Aerobic endurance training improves soccer performance. Med. Sci. Sports Exerc., Vol. 33, No. 11, 2001, pp. 1925–1931.) “World Cup players are at the top of their game.” .

  9. Soccer exercise characteristics The average work intensity, measured as percent of maximal heart rate (fcmax), during a 90-min soccer match is close to the lactate threshold (LT), or 80–90% of fcmax. (HELGERUD, J., L. C. ENGEN, U. WISLØFF, and J. HOFF. Aerobic endurance training improves soccer performance. Med. Sci. Sports Exerc., Vol. 33, No. 11, 2001, pp. 1925–1931.) This may be partly explained by the 150-250 brief intense actions a top-class player performs during a game. the rate of anaerobic energy turnover is high during periods of a game. Bangsbo Jens; Mohr Magni; Krustrup Peter Physical and metabolic demands of training and match-play in the elite football player. Journal of sports sciences 2006;24(7):665-74. During a soccer game, a sprint bout occurs approximately every 90 seconds, each lasting an average of 2–4 seconds. Sprinting constitutes 1–11% of the total distance covered during a mat corresponding to 0.5–3.0% of effective play time. Physiology of Soccer, An Update. Stølen T, et al. Sports Med 2005; 35 (6): 501-536

  10. Player CBS NEWSJuly 1, 2014, 5:44 PM "Soccer players need to be able to create intense but short bursts of speed, quickly change direction and conduct skillful actions while moving at high speeds,"  Usually, elite soccer players were older and had significantly higher professional experience than amateur players. Nowadays, elite soccer players participate in the game for longer than traditional . (Reilly, 1994,1996) This is probably due to fact that professional level of game-play requires competent and well-versed players and commercial attractions of maintaining players' career as long as possible Sporis, G, Jukic, I, Ostojic, SM, and Milanovic, D. Fitness profiling in soccer: physical and physiologic characteristics of elite players. J Strength Cond Res 23(7):

  11. Soccer exercise characteristics Aerobic evaluation in soccer.Fdez de Silva,J. et al;Rev Bras Cineantropom Desempenho Hum 2011, 13(5):384-391 Bangsbo Jens; Mohr Magni; Krustrup Peter Physical and metabolic demands of training and match-play in the elite football player. Journal of sports sciences 2006;24(7):665-74. Match activities. Soccer is characterized by a series of acyclic actions that develop during a match in the form of high--intensity running, jumping, heading, and kicking. typical distance covered by an outfield player at a top-level during a match is 10-13 km with the midfield players being superior to players in the other positions.

  12. Energy production while playing soccer Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review. Higgins JP. Et al. J Sports Med (Hindawi Publ Corp);2013 is mainly dependent on aerobic metabolism; however, the work intensity can approach the anaerobic threshold, which is defined as the highest exercise intensity where the production and removal of lactate are equal (usually at 80–90% of maximum heart rate)

  13. Soccer and Sudden Cardiac Death Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review. Higgins JP. Et al. J Sports Med (Hindawi Publ Corp);2013 Sudden cardiac death (SCD) in young competitive athletes (<35 years old) is a tragic event that has been brought to public attention in the past few decades. The incidence of SCD is reported to be 1-2/100,000 per year, with athletes at a 2.5 times higher risk. athletes over 35 experienced SCD most commonly due to atherosclerotic CAD Soccer is the most popular sport in the world, played by people of all ages. Due to elite soccer players nowadays are older than on previous years before. The cardiovascular risk is rising.

  14. SCD in soccer players Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review. Higgins JP. Et al. J Sports Med (Hindawi Publ Corp);2013 • Soccer characteristics with high cardiovascular demand and isotonic work put athletes at greatest risk for SCD • SCD in athletes is most commonly due to congenital and/or acquired cardiovascular disease. • Different studies have reported various cardiac diseases as the most common cause. • In studies done in the United States, • hypertrophic cardiomyopathy (HCM) was the most common cause. • followed by congenital coronary artery anomalies(CCA), • myocarditis, • arrhythmogenic right ventricular cardiomyopathy (ARVC); • ion channelopathies such as long QT and Brugada syndrome. • SCD can also be induced by a traumatic blow to the chest (commotio • cordis). • Also, the incidence of SCD is known to be greater in males than females.

  15. Studies reporting SCD in soccers case studies of SCD in soccer that have been found to be due to CCA on autopsy The studies shows that in Italy and much of the rest of the world, the sport in which SCD occurs most often is soccer Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review. Higgins JP. Et al. J Sports Med (Hindawi Publ Corp);2013

  16. SCD in Spain soccers The listed results focused on athletes under the age of 35, since it is known that athletes over 35 experienced SCD most commonly due to atherosclerotic CAD M. P. Suarez-Mier and B. Aguilera, “Causes of sudden death during sports activities in Spain,” Revista Espa˜nola de Cardiologia, vol. 55, no. 4, pp. 347–358, 2002.

  17. Electrocardiographic interpretation in athletes: the ‘Seattle Criteria’ Drezner JA, et al. Br J Sports Med 2013;47:122–124. doi:10.1136/bjsports-2012-092067 On 13–14 February 2012, an international group of experts in sports cardiology and sports medicine convened in Seattle, Washington, to define contemporary standards for ECG interpretation in athletes The majority of disorders associated with increased risk of sudden cardiac death (SCD), such as cardiomyopathies and primary electrical diseases, are suggested by abnormal findings present on a 12-lead ECG. the interpretation of an athlete’s ECG is the ability to accurately differentiate findings suggestive of a potentially lethal cardiovascular disorder from benign physiological adaptations occurring as the result of regular, intense training (ie, athlete’s heart).

  18. Drezner JA, et al. Br J Sports Med 2013;47:122–124. doi:10.1136/bjsports-2012-092067

  19. Drezner JA, et al. Br J Sports Med 2013;47:122–124. doi:10.1136/bjsports-2012-092067

  20. Hypertrophic Cardiomyopathy (HCM). Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review. Higgins JP. Et al. J Sports Med (Hindawi Publ Corp);2013 HCM is known to be the most common cause of SCD in young athletes in the United States It has a prevalence of 1 in 500 in several countries including USA, Europe, Japan, China, and East Africa. The pathophysiology lies in autosomal dominantmutations in 11 or more genes encoding thick and thin contractile myofilament protein components of the sarcomere or the adjacent Z-disc. These mutations lead to the histopathological finding of myocyte disarray.

  21. Hypertrophic Cardiomyopathy (HCM). Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review. Higgins JP. Et al. J Sports Med (Hindawi Publ Corp);2013 • Suspicion for this diagnosis is suggested by cardiac symptoms, with the findings of a murmur or abnormal electrocardiogram. • Abnormal ECG patterns are present in the majority of HCM patients (75–95%); • these findings include markedly increased R- or S-wave voltages, deep and prolonged Qwaves, and deeply inverted T-waves. • The diagnosis is confirmed by 2D echocardiogram or cardiovascular MRI. • Imaging findings show an absolute increase in the left ventricular wall thickness (to 21-22mm on average), which can also be associated with mild right ventricular hypertrophy. • The cause of death in these high-intensity players is due to subendocardial ischemia that leads to ventricular fibrillation and other tachyarrhythmias.

  22. Congenital Coronary Artery Anomalies. Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review. Higgins JP. Et al. J Sports Med (Hindawi Publ Corp);2013 In young competitive athletes, CCA are the second most common cause of SCD in athletes under 35, associated with 15–25% of cases. the most common malformation of Valsalva, either the right from the left coronary sinus or the left from the right coronary sinus, with a proximal course between the aorta and the pulmonary trunk. Patients usually present with cardiac symptoms including exertional syncope and chest pain. The diagnosis is most commonly confirmed by transthoracic echocardiography in children and is supplemented by MRI and CT angiography. Timely diagnosis of CCA is critical because athletes must be restricted from competitive activity to prevent SCD and CCA are surgically correctable .

  23. Arrhythmogenic Right Ventricular Cardiomyopathy(ARVC). Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review. Higgins JP. Et al. J Sports Med (Hindawi Publ Corp);2013 On August 25, 2007, a soccer game between La Liga Spanish teams Sevilla and Getafe was played at Sanchez Pizjuan Stadium. During the 35th minute of the game, 22-year-old Sevilla defender Antonio Puerta crouched next to the penalty box, then collapsed. His autopsy revealed ARVC. in Spain it was found to be a predominant pathology associatedwith SCD in athletes <30 years old. that disease prevalence is between 1 in 2000 and 1 in 5000.

  24. Arrhythmogenic Right Ventricular Cardiomyopathy(ARVC). Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review. Higgins JP. Et al. J Sports Med (Hindawi Publ Corp);2013 characterized by structural and functional abnormalities of the right ventricle, ranging from regional wall motion abnormalities and ventricular aneurysms to global ventricular dilation and dysfunction. ventricular arrhythmias that lead to SCD. Symptoms of ARVC include palpitations, syncope, cardiac arrest, hear failure or SCD in adolescents or young individuals. The presence of T-wave inversions in V1-V3 or premature ventricular complexes (PVCs) of LBBB morphology on 12 lead ECG are the clues noted during cardiovascular screening.

  25. Mitral valve prolapse J Am Coll Cardiol. 1986 Jan;7(1):231-6.Mitral valve prolapse: definition and implications in athletes.Jeresaty RM. Mitral valve prolapse is probably the most common cardiac valve disorder, affecting approximately 5% of the population. a mitral valve prolapse syndrome, consisting of nonspecific symptoms, repolarization changes on the electrocardiogram and arrhythmias. it would appear reasonable to disqualify athletes with mitral valve prolapse in the following circumstances: history of syncope; disabling chest pain; complex ventricular arrhythmias, particularly if induced or worsened by exercise; significant mitral regurgitation; prolonged QT interval; Marfan's syndrome; and family history of sudden death.

  26. Commotio Cordis. Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review. Higgins JP. Et al. J Sports Med (Hindawi Publ Corp);2013 when blunt trauma to the chest leads to ventricular fibrillation and therefore cardiac arrest (most commonly during the T-wave upstroke on ECG, causing a PVC, which leads to ventricular fibrillation) In seven of the cases regarding international studies involving soccer, a traumatic blow caused by a soccer ball to the chest led to commotio cordis .

  27. Brugada Syndrome • Syncope and cardiac arrest: occurs commonly during sleep or rest. • The lack of a prodrome has been reported to be more common in patients with ventricular fibrillation documented as the cause of syncope in patients with Brugada syndrome. Drugs & Diseases > Cardiology Brugada Syndrome Updated: Jan 09, 2017  Author: Jose M Dizon characterized by sudden death associated with one of several ECG patterns characterized by incomplete right bundle-branch block and ST-segment elevations in the anterior precordial leads.

  28. Cases without a Known Cause. S. V. de Noronha, S. Sharma,M. Papadakis, S.Desai,G.Whyte, and M. N. Sheppard, “Aetiology of sudden cardiac death in athletes in the United Kingdom: a pathological study,” Heart, vol. 95, no. 17, pp. 1409–1414, 2009.. In the studies reviewing SCD and sport, there has always been a percentage of the sample in which the cause of SCD could not be determined by autopsy. A study in the UK reported soccer as the most common sport associated with SCD in ages 11–35, but the autopsies of athletes from all sports had a morphologically normal heart in 23% of cases Moreover, given the high prevalence of ion channel disorders found in family members of individuals who experienced SCD, more research is needed on the efficacy of screening the relatives of these individuals and prevention of SCD. While most studies excluded positive toxicological findings, the cardiac effects of steroids and other medications may predispose to SCD

  29. current guidelines The current guidelines for preparticipation screening have not reached a consensus; in 2004 and 2005 the European Society of Cardiology and International Olympic Committee published notably similar guidelines, which contrasted the American guidelines. The main difference was the addition of a 12-lead ECG to the history and physical examination. This decision had been based on the study done by Corrado that showed a significantly decreased incidence of SCD due to HCM in the Italian population. However, the low specificity of ECG as a screening tool in an athletic population is a major disadvantage for its use. In 2005, FIFA took action to prevent SCD in soccer.

  30. current guidelines Prior to the 2006 World Cup in Germany, the FIFA Medical Assessment and Research Centre developed and implemented a comprehensive precompetition medical assessment tailored specifically to this population. The cardiovascular screening included a personal and family history, physical examination, a 12-lead resting ECG, as well as an exercise ECG and an echocardiogram. The results showed that cardiovascular preparticipation screening in international elite soccer teams seemed appropriate and that while ECG and echocardiography with further standardization could be useful, exercise stress testing remained questionable. Moreover, it was previously believed that preparticipation screening distressed soccer players due to the fear of being removed from competition. However, a study done with Norwegian professional soccer players found that the players felt more confident after screening and would recommend it to other players.

  31. Further guidelines Future studies on SCD in soccer and other sports involves more detailed reporting of SCD by cause and associated sport. There was a case by Zeller et al. in the shown Table, of SCD in a 26-year-old soccer player whose only suggestive finding was marked early repolarization on ECG. Furthermore, other study reported a statistically significant QT prolongation at rest in professional soccer players when compared to aged matched controls. Future studies need to be directed towards identifying further cardiac risk factors. That may lead to SCD in soccer players.

  32. Own experience. Atlético de Madrid From last 8 yr. Has been evaluating the elite soccer players permanently, on the 1st team on Atletico de Madrid club de futbol. All players have been submitted to a planned full periodic annual review regarding their physical status. According their cardiovascular evaluation, physical exam, 12 leads ecg strip, transthoracic echocardigram, and treadmill exercise test, is anually performed. Extra cardiovascular periodical review is performed every six months on all players. This review includes after trainning physical exam, 12 leads long recorded ecg. And transthoracic echorcardiogramme.

  33. Portable devices used

  34. Atletico de Madrid players characteristics Age. From 19 to 36 yrs. Mean. 25 yr. Old. All of them submitted to at least one prior full medical exam at signing club contract. Most of them provides previous medical exams from their previous soccer clubs. No one main cardiovascular finding on annual programmed review, except one intracardiac mixoma previously found on a precontracted player, solved by surgery without consequencies up today.

  35. Other physical and fittness assesments Wearables with telemetry capabilities are used to monitorize activity parametres during training periods of the 1st team. Those, clothes can be adapted to transmit active ECG during training exercises.

  36. Genetic Testing for players Ability Circulation 2004;109:2807-2816 Intensive and systematic training increases the risk of sudden cardiac death in genetically positive athletes Recommended in athletes and mandatory in those athletes with family history of sudden cardiac death. Family members of genetically positive athletes although from the clinical point of view were asymptomatic. Sportsmen with a history of syncope, although echo, ECG and exercise test are normal All soccer players from 1st male and female teams were submitted to a genetic testing procedure to assess and prevent risk factors.

  37. List of personal medical findings on elite players. From 2013 to 2017 a total of 55 registres were obtained from individual cardiac assessments on principal soccer players. The players nowadays, belongs mainly to Atletico de Madrid, but several of them are in different main european teams. All of them were submitted to physical examination,12-leads ECG with long recording capabilities, and echocardiogramme. No special clinical abnormalities report were obtained. A total of 29 registres were abnormal. 52.7% related to ECG and/or echo abnormalities.

  38. ECG findings. Incomplete RBBB were obtained on 14 players 24.4% Incomplete RBBB plus mitral prolapse were on 7 players 12.7 % Biventricular growth , on 1 player. 1.81% Incomplete LBBB, plus left ventricular hypertrophy on 1 player. 1.81%. Long P-R plus inversion of T wave from V3 to V5, on 1 player. 1.81%. Long P-R on 2 players. 3.6%. Long P-R with PSV beats. on 1 player. 1.81%. Paroximal atrial fibrilation, on 1 player. 1.81%. Brugada Syndrome, on 1 player. 1.81%.

  39. Echocardiogramme findings mitral prolapse with incomplete RBBB were on 7 players 12.7% mitral prolapse without ECG abnormalities, on 2 players. 3.6% left ventricular hypertrophy in 1 player. 1.81%.

  40. Conclusions • Soccer characteristics with high cardiovascular demand and isotonic work put athletes at greatest risk for SCD • SCD in athletes is most commonly due to congenital and/or acquired cardiovascular disease. • Due to elite soccer players nowadays are older than on previous years before. The cardiovascular risk is rising. • An intensive, permanent and normalized care is mandatory to: • Premature identification of cardiac abnormalities. • Adequate triage of abnormalities regarding player safety. • Full follow up of players with a cardiac problem pre diagnosed. • Quick solutions to cardiac problems of soccer players

  41. Conclusions « Soccer cardiac evaluation consensus is needed to prevent abnormal cardiovascular events.”

  42. Specialthanks DrJoseMarìa Villalón Head of medicalservices, Atletico de Madrid Club de fútbol

  43. Thanks a lot !

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