Rev . Medicina Desportiva informa , 2018 ; 9 ( 4 ): 2
Interview
Dr . Hélder Dores Cardiologist . Hospital das Forças Armadas and Hospital da Luz . Lisbon
Who is Dr . Helder Dores ?
I ’ m a cardiologist and a doctor at Hospital das Forças Armadas and Hospital da Luz in Lisbon , where I coordinate the sports cardiology . Also , I ’ m assistant at NOVA Medical School and I ’ m doing a PhD program .
You have been very dedicated to sports cardiology . Where does this interest come from ?
First of all , it comes from the passion for sport in general , as a practitioner and spectator , and several circumstances came together and created this inevitable interest . On military medicine , sports cardiology is of paramount importance due to the evaluation of persons subjected to intense exercise training . Realizing that this medical specialty could be differentiating , I performed an internship in a reference center in London , under the guidance of Professor Sanjay Sharma . Altogether , it came out that a significant part of my clinical practice is sports cardiology .
Despite the rigorous sports medical evaluation ( SME ), with many cardiologic exams , sudden death still occurs in sport . Are we failing ?
I wouldn ’ t say we are failing , but still there is so much to do . It is utopian to say that the risk of sudden death may be null because several causes are paroxysmal , and it might be the first disease manifestation . However , the correct Interpretation of the ECG allows the identification of most causes of sudden death in athletes , directly or after additional investigations . Due to the inability to identify all subjects at increased risk , and as the majority of the cases occur during or immediately after the exercise , is crucial to have medical emergency equipment and trained professionals at the sports venues .
Certainly , the SME in the young is different from the one for the elderly practitioner ...
The main objective of SME is to identify athletes with increased risk of sudden death , whose epidemiology varies with the age range , justifying a different assessment . In the young athletes the ECG is essential because the main causes of sudden death are hereditary diseases , while among veterans the main cause is coronary artery disease , emphasizing the importance of risk stratification and early detection of coronary artery disease with risk scores and additional exams , where the stress testing is the most used . Since risk stratification based on clinical characteristics and stress testing has some limitations , more objective markers have been developed that may change the paradigm of this evaluation in the future .
And should be different for the leisure practitioner and for the athlete ?
In my opinion , the level of the athlete should not be the main factor to differentiate the methodology of evaluation . This dichotomy is controversial – an athlete can be registered in golf or run recreationally trails longer than 100km ! The increased number of recreational sports practitioners is healthful , but carries additional risks . Many people begin regular exercise training on the middle-age , with risk factors or even previous cardiovascular events . At least the individuals involved in organized sports should be subjected to some kind of evaluation . However , we must not forget that adding so many variables , especially bureaucratic , can reduce the adherence to a healthy lifestyle . Other problem is the difference between to do a SME and just fulfill the form ! In short , it is needed to optimize the evaluation of athletes and to discuss the pros and cons in extending this assessment to recreational sport .
The inclusion of echocardiogram in the SME routine is discussed . When should it be performed ?
In my opinion , the echocardiogram should not be a routine examination due to both clinical and economic reasons . It is first-line exam in the presence of symptoms and “ pathological ” changes on ECG . It is also recommended for the overgrading medical exam and before some specific competitions . A strategy that can be discussed is to perform at least one echocardiogram on the youth ages to exclude congenital heart disease , but the costs of this strategy would be unfeasible for such widespread application .
... and what are the other more recent exams that can help define the fitness of the candidate for exercise ?
Among the latest exams the MRI is the gold-standard to exclude structural pathology , and it makes sense in the presence of a “ pathological ” ECG and a normal echocardiogram . Another increasingly used exam , especially in veteran athletes with high cardiovascular risk , chest pain or changes on the stress testing , is the cardiac Angio-CT . Besides the high negative predictive value to exclude coronary disease , it can identify other changes associated with sudden death , such as anomalous coronary origin and coronary bridging .
In the future , the genetic evaluation of the athlete will certainly be a routine exam ...
I don ’ t know if it will be routine , but it could be applied to multiple situations . For the evaluation of physical capacities , partially genetic determined , there are available tests that define the individual profile and evaluate some variables , such as aerobic capacity , strength or predisposition to injury . In this way , it may be possible to identify the type of exercise most appropriate for each individual and to predict the ability to succeed . Clinically , genetic evaluation will allow an earlier diagnosis of hereditary diseases , especially in cases in the ‘ gray zone ’ with overlap between physiological and pathological changes .
2 july 2018 www . revdesportiva . pt