Interpretation and management of premature ventricular beats in athletes: An expert opinion document of the Italian Society of Sports Cardiology (SICSPORT)

Arrhythmic Mitral Valve Prolapse and Sports Activity: Pathophysiology, Risk Stratification, and Sports Eligibility Assessment

“…Complex VAs include ventricular fibrillation (VF), nonsustained, and sustained ventricular tachycardia (NSVT and VT), while frequent VAs mainly include premature ventricular complexes with a ≥5% burden at Holter monitoring [ 5 , 32 ]; at present, the authors of the expert consensus statement refrain from giving PVC morphology/origin-specific recommendations, to streamline the easy identification of AMVP patients in several clinical contexts and even outside referral centers. However, from a sports cardiology perspective, it appears of the utmost importance that in the presence of one or more PVCs at baseline 12-lead ECG or during exercise stress testing (which is mandatory in Italy for the assessment of competitive sports eligibility) several characteristics be assessed besides the presence and burden of PVCs [ 33 , 34 ]. These include QRS morphology (especially the presence of a non-fascicular [i.e., with duration ≥ 130 ms] right bundle branch block-like configuration), PVC polymorphism (at least two morphologies with each one representing ≥10% of PVC burden), precocity (the R-on-T phenomenon, couplets with short R-R interval), and PVC relationship with exercise (PVCs persisting or with increasing burden during maximal exercise stress testing), which should raise the suspicion of AMVP and mandate further assessments, including 24 h Holter monitoring with a training session, maximal ECG stress testing, and gadolinium-enhanced cardiac magnetic resonance imaging (CMR) [ 33 , 34 ].…”

“…The EHRA expert consensus statement on AMVP suggests exercise stress testing in order to assess adrenergic-dependent arrhythmias and exercise tolerance in AMVP patients [ 5 ]. From a sports cardiology perspective, exercise-induced VAs or VAs persisting during maximal exercise stress testing may suggest higher sports-related arrhythmic risk and warrant 24 h Holter monitoring, echocardiography, and CMR to rule out other risk features, especially when VAs are reproducible in two distinct tests [ 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 ]. Consistently, a recent study on the clinical value of the preparticipation screening protocol in Italy (which includes personal/family history taking, physical examination, resting 12-lead ECG, and exercise stress testing) showed that among the three patients diagnosed with AMVP, there were abnormal findings at exercise stress testing in each case (100% sensitivity), while resting ECG was always normal (0% sensitivity), and physical examination was unremarkable in one subject (66% sensitivity), potentially supporting the importance of exercise testing in unmasking the AMVP phenotype [ 84 ].…”

“…Similarly, according to Italian guidelines for the assessment of sports eligibility, CMR should cautiously be performed in the presence of phenotypic risk features (family history of SCD, moderate or severe MR, MAD, bileaflet MVP, syncope/pre-syncope, complex PVCs, NSVT/VT, and LV dilation or dysfunction), in order to identify or rule out myocardial fibrosis, which may further refine the sports eligibility assessment [ 61 ]. However, for a rational use of resources, the clinical evaluation of the athlete with known or suspected MVP should always start with first-line tests (physical examination; 12-lead ECG), includes a comprehensive echocardiographic assessment, and a maximal ECG stress testing, with no need to proceed to CMR in the absence of phenotypical features associated with AMVP [ 33 , 61 ].…”

“…However, antiarrhythmic drugs are usually not tolerated or undesired by athletes, due to the profound resting sinus bradycardia seen in (especially endurance) athletes, the risk of impaired exercise performance, and therefore lack of therapeutic tolerance. Catheter ablation may represent an important treatment option for athletes with AMVP [ 33 , 60 ].…”

“…Recommended levels of exercise to maximize the health benefits derived from physical activity have been reported at 7.5 MET h/week, and the study by Five et al suggested that the risk of severe VAs does not increase until 9.6 MET h/week [ 30 ], but dedicated prospective studies involving MVP patients are still needed to confirm these recommendations. The prognosis of PVC morphologies traditionally considered to be common and indicate low risk of SCD among athletes (i.e., monomorphic outflow tract/fascicular PVCs) remains to be assessed in the setting of AMVP [ 5 , 33 ], especially considering that a specific association of PVCs morphologies compatible with origin from right ventricular outflow tract alternating with fascicular system/papillary muscle PVCs was found to be common in AMVP patients with prior aborted SCD [ 66 ]. Although genetic testing may be considered for AMVP with familiar clustering or syndromic stigmata, further studies should be conducted on the topic [ 42 ].…”