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      Arrhythmias and Adaptations of the Cardiac Conduction System in Former National Football League Players

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          Abstract

          Background

          Habitual high‐intensity endurance exercise is associated with increased atrial fibrillation ( AF) risk and impaired cardiac conduction. It is unknown whether these observations extend to prior strength‐type sports exposure. The primary aim of this study was to compare AF prevalence in former National Football League ( NFL) athletes to population‐based controls. The secondary aim was to characterize other conduction system parameters.

          Methods and Results

          This cross‐sectional study compared former NFL athletes (n=460, age 56±12 years, black 47%) with population‐based controls of similar age and racial composition from the cardiovascular cohort Dallas Heart Study‐2 (n=925, age 54±9 years, black 53%). AF was present in 28 individuals (n=23 [5%] in the NFL group; n=5 [0.5%] in the control group). After controlling for other cardiovascular risk factors in multivariable regression analysis, former NFL participation remained associated with a 5.7 (95% CI: 2.1–15.9, P<0.001) higher odds ratio of AF. Older age, higher body mass index, and nonblack race were also independently associated with higher odds ratio of AF, while hypertension and diabetes mellitus were not. AF was previously undiagnosed in 15/23 of the former NFL players. Previously undiagnosed NFL players were rate controlled and asymptomatic, but 80% had a CHA 2 DS 2VASc score ≥1. Former NFL players also had an 8‐fold higher prevalence of paced cardiac rhythms (2.0% versus 0.25%, P<0.01), compared with controls. Furthermore, former athletes had lower resting heart rates (62±11 versus 66±11 beats per minute, P<0.001), and a higher prevalence of first‐degree atrioventricular block (18% versus 9%, P<0.001).

          Conclusions

          Former NFL participation was associated with an increased AF prevalence and slowed cardiac conduction when compared with a population‐based control group. Former NFL athletes who screened positive for AF were generally rate controlled and asymptomatic, but 80% should have been considered for anticoagulation based on their stroke risk.

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          Most cited references19

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          Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study.

          Atrial fibrillation is the most common arrhythmia in elderly persons and a potent risk factor for stroke. However, recent prevalence and projected future numbers of persons with atrial fibrillation are not well described. To estimate prevalence of atrial fibrillation and US national projections of the numbers of persons with atrial fibrillation through the year 2050. Cross-sectional study of adults aged 20 years or older who were enrolled in a large health maintenance organization in California and who had atrial fibrillation diagnosed between July 1, 1996, and December 31, 1997. Prevalence of atrial fibrillation in the study population of 1.89 million; projected number of persons in the United States with atrial fibrillation between 1995-2050. A total of 17 974 adults with diagnosed atrial fibrillation were identified during the study period; 45% were aged 75 years or older. The prevalence of atrial fibrillation was 0.95% (95% confidence interval, 0.94%-0.96%). Atrial fibrillation was more common in men than in women (1.1% vs 0.8%; P<.001). Prevalence increased from 0.1% among adults younger than 55 years to 9.0% in persons aged 80 years or older. Among persons aged 50 years or older, prevalence of atrial fibrillation was higher in whites than in blacks (2.2% vs 1.5%; P<.001). We estimate approximately 2.3 million US adults currently have atrial fibrillation. We project that this will increase to more than 5.6 million (lower bound, 5.0; upper bound, 6.3) by the year 2050, with more than 50% of affected individuals aged 80 years or older. Our study confirms that atrial fibrillation is common among older adults and provides a contemporary basis for estimates of prevalence in the United States. The number of patients with atrial fibrillation is likely to increase 2.5-fold during the next 50 years, reflecting the growing proportion of elderly individuals. Coordinated efforts are needed to face the increasing challenge of optimal stroke prevention and rhythm management in patients with atrial fibrillation.
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            International Recommendations for Electrocardiographic Interpretation in Athletes.

            Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On February 26-27, 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.
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              Sinus node disease and arrhythmias in the long-term follow-up of former professional cyclists.

              Significant brady- and tachyarrhythmias may occur in active endurance athletes. It is controversial whether these arrhythmias do persist after cessation of competitive endurance training. Among all 134 former Swiss professional cyclists [hereafter, former athletes (FAs)] participating at least once in the professional bicycle race Tour de Suisse in 1955-1975, 62 (46%) were recruited for the study. The control group consisted of 62 male golfers matched for age, weight, hypertension, and cardiac medication. All participants were screened with history, clinical and echocardiographic examination, ECG, and 24 h ECG. The time for the last bicycle race of FAs was 38 +/- 6 years. The mean age at examination was 66 +/- 6 years in controls and 66 +/- 7 years in FAs (P = 0.47). The percentage of study participants with >4 h current cardiovascular training per week was identical. QRS duration (102 +/- 20 vs. 95 +/- 13 ms, P = 0.03) and corrected QTc interval (416 +/- 27 vs. 404 +/- 18, P = 0.004) were longer in FAs. There was no significant difference in the number of isolated atrial or ventricular premature complexes, or supraventricular tachycardias in the 24 h ECG; however, ventricular tachycardias tended to occur more often in FAs than in controls (15 vs. 3%, P = 0.05). The average heart rate was lower in FAs (66 +/- 9 vs. 70 +/- 8 b.p.m.) (P = 0.004). Paroxysmal or persistent atrial fibrillation or flutter was reported more often in FAs (P = 0.028). Sinus node disease (SND), defined as bradycardia of 2.5 s (6 vs. 0%), was more common in FA (16%) than in controls (2%, P = 0.006). Observed survival of all FAs was not different from the expected. Among FAs, SND occurred significantly more often compared with age-matched controls, and there is trend towards more frequent ventricular tachycardias. Further studies have to evaluate prevention of arrhythmias with extreme endurance training, the necessity of regular follow-up of heart rhythm, and management of arrhythmias in former competitive endurance athletes.
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                Author and article information

                Contributors
                pheland@ccf.org
                Journal
                J Am Heart Assoc
                J Am Heart Assoc
                10.1002/(ISSN)2047-9980
                JAH3
                ahaoa
                Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
                John Wiley and Sons Inc. (Hoboken )
                2047-9980
                24 July 2019
                06 August 2019
                : 8
                : 15 ( doiID: 10.1002/jah3.2019.8.issue-15 )
                : e010401
                Affiliations
                [ 1 ] Department of Cardiovascular Medicine, Heart and Vascular Institute Cleveland Clinic Foundation Cleveland OH
                [ 2 ] Division of Cardiology UT Southwestern Medical Center Dallas TX
                [ 3 ] Johns Hopkins Ciccarone Center for the Prevention of Heart Disease Baltimore MD
                [ 4 ] MedStar Sports Medicine Baltimore MD
                [ 5 ] Cedars‐Sinai Heart Institute Los Angeles CA
                Author notes
                [*] [* ] Correspondence to: Dermot Phelan, MD, PhD, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J1‐5, Cleveland, OH 44195. E‐mail: pheland@ 123456ccf.org
                Article
                JAH34235
                10.1161/JAHA.118.010401
                6761649
                31337251
                0985f2ba-69d9-4f42-9441-81ccf20c408f
                © 2019 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

                History
                : 25 January 2019
                : 20 May 2019
                Page count
                Figures: 0, Tables: 5, Pages: 9, Words: 7151
                Funding
                Funded by: National Center for Advancing Translational Sciences
                Award ID: UL1TR001105
                Funded by: National Institutes of Health
                Funded by: National Football League
                Funded by: NFL Players Care Foundation Healthy Body and Mind Screening Program
                Funded by: Reynolds Foundation
                Categories
                Original Research
                Original Research
                Arrhythmia and Electrophysiology
                Custom metadata
                2.0
                jah34235
                06 August 2019
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.6.7 mode:remove_FC converted:06.08.2019

                Cardiovascular Medicine
                athlete's heart,atrial fibrillation,conduction disease,national football league,risk factors,epidemiology,cardiovascular disease

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