Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 6: Hypertension
2015; Lippincott Williams & Wilkins; Volume: 132; Issue: 22 Linguagem: Inglês
10.1161/cir.0000000000000242
ISSN1524-4539
AutoresHenry R. Black, Domenic Sica, Keith C. Ferdinand, William B. White,
Tópico(s)Cardiovascular and exercise physiology
ResumoHomeCirculationVol. 132, No. 22Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 6: Hypertension Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBEligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 6: HypertensionA Scientific Statement from the American Heart Association and the American College of Cardiology Henry R. Black, MD, FAHA, Chair, Domenic Sica, MD, Keith Ferdinand, MD, FAHA, FACC and William B. White, MDon behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology Henry R. BlackHenry R. Black , Domenic SicaDomenic Sica , Keith FerdinandKeith Ferdinand and William B. WhiteWilliam B. White and on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology Originally published2 Nov 2015https://doi.org/10.1161/CIR.0000000000000242Circulation. 2015;132:e298–e302Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2015: Previous Version 1 IntroductionAn elevation of blood pressure (BP) in the systemic circulation (hypertension) is the most common cardiovascular condition in the general population and considered to be the most ubiquitous cardiovascular risk factor in competitive athletes. Competitive athletes include those athletes involved in organized sports that typically occur in schools, communities, and professional leagues, including but not limited to intramural and league sports in which medical supervision is typically required. Although most competitive athletes are between the ages of 20 and 40 years, many younger people now participate in competitive athletics. The 2013 update from the American Heart Association using the National Health and Nutrition Examination (NHANES) data from 2007 to 2010 estimates that 9.1% of men aged 20 to 34 years and 6.7% of women of that age are hypertensive, based on having an elevated BP measurement or answering "yes" to the question, "Are you taking antihypertensive medication or were you told that you had hypertension?"1 The prevalence in children and adolescents is estimated to be ≈3.5%, with higher percentages in older and obese children.2 The diagnosis of hypertension is based on the subject having an elevated BP at or above certain levels measured by routine sphygmomanometry under appropriate conditions on at least 2 separate occasions separated by at least 1 week.3 However, BP measurements in the competitive athlete are typically obtained by different healthcare providers, which makes it particularly necessary that the testing conditions be standardized before the diagnosis of hypertension is made. People >18 years of age with a BP >140 mm Hg systolic and/or >90 mm Hg diastolic are considered to have hypertension.3 In children and adolescents, hypertension is defined as average systolic or diastolic BP levels greater than the 95th percentile for sex, age, and height; however, earlier physical maturation of the competitive athlete leaves open to question when an adult age criterion for hypertension should be applied to the adolescent.4 In determining the level of competitive athletic activity that a hypertensive person may engage in, it is also important to determine the degree of hypertension-related target-organ damage. Although hypertension has been associated with an increased risk for complex ventricular arrhythmias and sudden death, this cardiovascular risk factor per se has not been implicated in sudden death in young competitive athletes.5 For the general population, increased levels of noncompetitive recreational physical activity are generally regarded as beneficial. With physical activity, BP typically falls, the incidence of hypertension drops,6,7 and protection against stroke is afforded.8 Those who are hypertensive derive protection from both all-cause and cardiovascular mortality by maintaining higher levels of cardiorespiratory fitness.9Assessment of BPBP should be accurately measured in all people who wish to participate in competitive athletics before they begin training. BP should be measured by standard techniques, using the guidelines listed in the Table. It is common in young athletes to have their BP measured with an inappropriately sized BP cuff because of their often larger (>33 cm) midarm circumference. In these people, BP measured this way is often spuriously increased and results in unnecessary referrals to clinicians for evaluation and consideration of antihypertensive therapy. Also, there are often discrepancies between in-office and out-of-office BP measurements. For example, elevations induced by anxiety related to the medical examination are seen in young people concerned about the potential negative consequences of the examination. Anxiety-related BP elevations may be marked by elevations in heart rate, which further complicates the interpretation of the physical examination findings. In such instances, it is advisable to obtain unbiased and more comprehensive information through the use of 24-hour ambulatory BP monitoring. In some people, extremely high BPs may occur on a single measurement. In this type of patient, ambulatory BP monitoring would help to further stratify the athlete's risk of hypertension at present or in the future if borderline values were obtained. Ambulatory BP measurement in people with elevated exercise BP values improves the prediction of left ventricular hypertrophy (LVH) by echocardiography and development of sustained hypertension according to 1 study with an 8-year follow-up.10Table. Guidelines for Clinic (or Office) BP MeasurementPosture BP obtained in the seated position is recommended. The subject should sit quietly for 5 min, with the back supported in a chair, with feet on the floor and the arm supported at the level of the heart, before BP is recorded.Circumstances No caffeine should be ingested during the hour preceding the reading, and no smoking during the 30 min preceding the reading. A quiet, warm setting should be available for BP measurements.Equipment Cuff size The bladder should encircle and cover at least 80% of the length of the arm; if it does not, use a larger cuff. If bladder is too short, misleadingly high readings may result.Manometer Use a validated electronic (digital) device, a recently calibrated aneroid or mercury column sphygmomanometer.Technique Number of readings On each occasion, take at least 2 readings, separated by as much time as is practical. If readings vary by >10 mm Hg, take additional readings until 2 consecutive readings are within 10 mm Hg. If the arm pressure is elevated, take the measurement in 1 leg to rule out aortic coarctation (particularly in patients 160 mm Hg or a diastolic BP >100 mm Hg) or who have a suggestion of target-organ damage on history or physical examination, a screening echocardiogram is advisable to distinguish physiological hypertrophy attributable to physical exercise (athlete's heart) versus pathological LVH from hypertension. Athletes with normal (or physiological) hypertrophy have echocardiographic and other imaging evidence of increased posterior and septal wall thicknesses with normal cavity chamber size accompanied by normal rates of left ventricular filling during diastole14; in contrast, hypertrophy caused by hypertension, although having similar structural findings, has both impaired rates of left ventricular filling and slow isovolumic relaxation times.15 If needed, the pathophysiology of cardiac hypertrophy attributable to physiological causes versus pathophysiological causes (hypertension) can be discriminated with echocardiography using Doppler imaging or magnetic resonance imaging as a tertiary methodology. People with larger body size and blacks may have an increase in wall thicknesses on echocardiography, which should be correlated with ECG, clinical signs and symptoms, and family history before they are advised against participation in competitive sports. It is rare for physiological increased left ventricular wall thicknesses to exceed 13 mm and indicates the advisability of a referring the patient for further evaluation for hypertrophic cardiomyopathy with ECG, clinical assessment, and family history. Of note, LVH is more prevalent in blacks and is an independent predictor of diminished cardiovascular survival.16 The ECG is widely available, inexpensive, and has high specificity but poor sensitivity for detection of LVH; however, the combination of an abnormal ECG, any signs and symptoms of heart disease, and a positive family history for premature cardiac death warrants further evaluation. Cardiac stress testing is not warranted unless there are symptoms that occur with maximal exercise. The competitive athlete need not routinely require orthostatic BP determinations unless the athlete is symptomatic in the upright position in a volume replete state.In an adolescent or young adult (ie, 200 mm Hg during an exercise treadmill test may suggest underlying hypertension. This person may benefit from further investigation, including 24-hour ambulatory BP monitoring, to document true sustained hypertension.18 A hypertensive responsive to exercise testing may also indicate an independent risk for cardiovascular events and mortality.19RecommendationsIt is reasonable that the presence of stage 1 hypertension in the absence of target-organ damage should not limit the eligibility for any competitive sport. Once having begun a training program, the hypertensive athlete should have BP measured every 2 to 4 months (or more frequently, if indicated) to monitor the impact of exercise (Class I; Level of Evidence B).Before people begin training for competitive athletics, it is reasonable that they undergo careful assessment of BP, and those with initially high levels (>140 mm Hg systolic or >90 mm Hg diastolic) should have comprehensive out-of-office measurements to exclude errors in diagnosis. Ambulatory BP monitoring with proper cuff and bladder size would be the most precise means of measurement (Class I; Level of Evidence B).Those with prehypertension (BP of 120/80 mm Hg–139/89 mm Hg) should be encouraged to modify their lifestyles but should not be restricted from physical activity. Those with sustained hypertension should have screening echocardiography performed. Athletes with LVH beyond that seen with "athlete's heart" should limit participation until BP is normalized by appropriate antihypertensive drug therapy (Class IIa; Level of Evidence B).It is reasonable that athletes with stage 2 hypertension (a systolic BP >160 mm Hg or a diastolic BP >100 mm Hg), even without evidence of target-organ damage, should be restricted, particularly from high static sports, such as weight lifting, boxing, and wrestling, until hypertension is controlled by either lifestyle modification or drug therapy (Class IIa; Level of Evidence B).When prescribing antihypertensive drugs, particularly diuretic agents, for competitive athletes, it is reasonable for clinicians to use drugs already registered with appropriate governing bodies and if necessary obtain a therapeutic exemption (Class IIa; Level of Evidence B).When hypertension coexists with another cardiovascular disease, it is reasonable that eligibility for participation in competitive athletics is based on the type and severity of the associated condition (Class IIa; Level of Evidence C).DisclosuresWriting Group DisclosuresWriting Group MemberEmploymentResearch GrantOther Research SupportSpeakers' Bureau/HonorariaExpert WitnessOwnership InterestConsultant/Advisory BoardOtherHenry R. BlackNew York University (Retired)NoneNoneNoneNoneNoneNoneNoneKeith FerdinandTulane UniversityBoehringer Ingelheim*NoneNoneNoneNoneAmgen*; AstraZeneca*; Boehringer Ingelheim*; Sanofi*NoneDomenic SicaVirginia Commonwealth UniversityNoneNoneNoneNoneNoneNoneNoneWilliam B. WhiteUniversity of ConnecticutNoneNoneNoneNoneNoneNoneNoneThis table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be "significant" if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.Reviewer DisclosuresReviewerEmploymentResearch GrantOther Research SupportSpeakers' Bureau/HonorariaExpert WitnessOwnership InterestConsultant/Advisory BoardOtherLawrence FineNHLBINoneNoneNoneNoneNoneNoneNoneSamuel S. GiddingNemours FoundationGlaxoSmithKline†NoneNoneNoneNoneNoneNoneMartha A. GulatiOhio State UniversityNoneNoneNoneNoneNoneNoneNoneChristina SalazarLawrence Memorial HospitalNoneNoneNoneNoneNoneNoneNoneRichard A. SteinNew York UniversityNoneNoneNoneNoneNoneNoneNoneThis table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be "significant" if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.†Significant.FootnotesThe American Heart Association and the American College of Cardiology make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.The Preamble and other Task Force reports for these proceedings are available online at http://circ.ahajournals.org (Circulation. 2015;132:e256–e261; e262–e266; e267–e272; e273–e280; e281–e291; e292–e297; e303–e309; e310–e314; e315–e325; e326–e329; e330–e333; e334–e338; e339–e342; e343–e345; and e346–e349).This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on June 24, 2015, and the American Heart Association Executive Committee on July 22, 2015, and by the American College of Cardiology Board of Trustees and Executive Committee on June 3, 2015.The American Heart Association requests that this document be cited as follows: Black HR, Sica D, Ferdinand K, White WB; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 6: hypertension: a scientific statement from the American Heart Association and the American College of Cardiology. Circulation. 2015;132:e298–e302.This article has been copublished in the Journal of the American College of Cardiology.Copies: This document is available on the World Wide Web sites of the American Heart Association (my.americanheart.org) and the American College of Cardiology (www.acc.org). A copy of the document is available at http://my.americanheart.org/statements by selecting either the "By Topic" link or the "By Publication Date" link. To purchase additional reprints, call 843-216-2533 or e-mail [email protected].Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the "Policies and Development" link.Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the "Copyright Permissions Request Form" appears on the right side of the page.References1. 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December 1, 2015Vol 132, Issue 22 Advertisement Article InformationMetrics © 2015 by the American Heart Association, Inc. and the American College of Cardiology Foundation.https://doi.org/10.1161/CIR.0000000000000242PMID: 26621647 Originally publishedNovember 2, 2015 Keywordscardiovascular abnormalitiesathletesblood pressure measurementAHA Scientific StatementshypertensionPDF download Advertisement SubjectsStatements and Guidelines
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