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Circulation. 2001;103:327-334

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(Circulation. 2001;103:327.)
© 2001 American Heart Association, Inc.

AHA Science Advisory

Recommendations for Preparticipation Screening and the Assessment of Cardiovascular Disease in Masters Athletes

An Advisory for Healthcare Professionals From the Working Groups of the World Heart Federation, the International Federation of Sports Medicine, and the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention

Barry J. Maron, MD, Chair; Claudio Gil S. Araújo, MD; Paul D. Thompson, MD; Gerald F. Fletcher, MD; Antonio Bayés de Luna, MD; Jerome L. Fleg, MD; Antonio Pelliccia, MD; Gary J. Balady, MD; Francesco Furlanello, MD; Steven P. Van Camp, MD; Roberto Elosua, MD; Bernard R. Chaitman, MD; Terry L. Bazzarre, PhD


Key Words: AHA Science Advisory • exercise • prevention • coronary disease • aging

In recent years, there has been a major international focus on both the risks and benefits of exercise, as well as the relationship between physical activity and cardiovascular health at all ages.1 2 3 4 5 6 7 8 Based on more than 40 observational epidemiological studies, physical inactivity and sedentary lifestyle are recognized as major risk factors for the development of coronary heart disease, adverse cardiovascular events, and mortality.9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Regular aerobic exercise (occupational or leisure time) confers many health benefits, may reduce the risk for fatal and nonfatal myocardial infarction and other coronary events,1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 and has been promoted as a national public health agenda in several countries for both primary and secondary prevention of cardiovascular disease.3 4 5 6 7 22 24 29 30

Conversely, acute vigorous physical exertion may trigger sudden death or myocardial infarction31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 in the presence of underlying heart disease,48 particularly in individuals not accustomed to such activity or to regular exercise.31 32 33 35 41 51 52 52A 52B As sedentary individuals begin (or reinitiate) an exercise program, there is a period of increased risk during which exertion can provoke a cardiac event, whereas such risk associated with habitual exercise in active individuals is relatively low.31 Also, it is generally assumed that particularly strenuous exertion or sports competition may predispose athletes to greater cardiac risk than nonstrenuous physical activity. Nevertheless, there is widespread agreement that the overall benefits of exercise usually outweigh associated risks.1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 35 Mechanisms by which exercise may protect patients from coronary events have also been proposed.53 54

Prior expert consensus documents have addressed the risk for sudden death associated with sports participation in competitive or recreational athletes with cardiovascular disease, including the criteria for disqualification and eligibility,49 50 51 55 56 and the screening of general populations for detection of cardiac abnormalities.47 50 51 These previous recommendations49 50 55 56 57 58 59 have focused largely on young competitive athletes or older athletes in recreational sports settings such as health and fitness facilities.51

Consequently, in the present scientific statement, the panel addressed issues relevant to competitive sports participants at the masters level primarily in midlife and beyond, cognizant of the unique psychological and physiological stresses that competition places on such athletes, particularly those with cardiovascular disease.22 52 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 It is believed that by offering prudent insights and advice to physicians concerning the screening and detection of cardiac disease, as well as recommendations for sports clearance and eligibility in such older athletes, this document may contribute to the prevention of cardiac catastrophes and events during exercise.

Scope and Definition of Masters Sports Competition

The designation of a competitive athlete refers to one who participates in an organized team or individual sport that requires regular competition against others, places a high premium on excellence and achievement, and requires systematic training.49 It is understood that this definition is somewhat arbitrary, because many individuals participate in casual sporting activities in a competitive fashion, and in some organized sports the distinctions between truly competitive and recreational physical activity may be ambiguous.

Masters sports are organized forms of competition specifically designed for older athletes. The stimuli for continuing in sports or beginning involvement at relatively advanced ages are wide-ranging but include an awareness that physical inactivity is a risk factor for cardiovascular disease and associated events, as well as emotional and motivational issues such as self-image and prior success in sports.

Masters sports participation is rapidly growing and consists of a rather loose and unofficial conglomeration of many independent organizations representing a wide variety of athletic disciplines at the international, national, and local levels of competition. Presently, more than 50 countries sponsor masters sporting events, with the most participation in the United States, Canada, Western Europe, and parts of Asia and South America. Although difficult to tabulate precisely, participation rates are substantial worldwide, involving many thousands who aspire to organized competition and recognition in a variety of team and individual sports on a regular basis. Organized masters programs include {approx}50 sports, many characterized by intense competition, and most commonly swimming (including aquatic sports such as diving and water polo), track and field, soccer, rowing, basketball, tennis and other racquet sports, weight lifting, orienteering, rugby, ice hockey, cycling, and skiing. In addition, there are substantial numbers of participants in endurance sports such as marathons, long-distance road racing, and triathlons, and more recently, competition in so-called extreme sports.

Masters participants range widely in age but are typically older than 35 years, with many more than 40 to 50 years of age, and they are predominantly male. Certain masters sports competition may begin earlier (eg, at >25 years of age in some swimming associations). Despite the wide range in age of masters athletes, the primary focus of the present document is on participants >40 years of age. Masters athletes may include conditioned, experienced competitive athletes who continue to compete after their formal careers end but also include "walk-up" competitors (sometimes referred to as "weekend warriors") with only sporadic training regimens, as well as those who resume competition after long periods of physical inactivity.

Aging and Cardiovascular Function

Aerobic cardiovascular function declines with age,60 64 68 69 73 74 as evidenced by the progressive decrease in maximal oxygen consumption (O2max) at an average rate of {approx}10% per decade after age 25. Whether vigorous endurance exercise training blunts this rate of decline in O2max remains controversial.63 67 69 71 Nevertheless, older endurance athletes usually retain greater aerobic capacity than their sedentary counterparts of the same age and sex.60 62 63 71 72 73 The possibility that the normal age-associated decline in cardiovascular performance might be attenuated by exercise training in older individuals suggests a potential benefit for participation in organized masters sports.66 67

Cardiovascular Risks of Masters Sports

Causes of Sudden Death or Morbidity
Masters sports programs primarily comprise apparently normal and healthy individuals from the general population. However, unlike most organized sports for young people, some participating masters athletes compete with known, documented cardiovascular disease. By far, atherosclerotic coronary artery disease is the most common form of heart disease relevant to the masters population as a cause of morbidity or sudden death. Occasionally, such athletes may harbor other congenital or acquired heart diseases with the potential to cause sudden death, such as hypertrophic cardiomyopathy, aortic stenosis, dilated cardiomyopathy, mitral valve prolapse, and myocarditis. Masters athletes, typical of their age group, could also be expected to be susceptible to particular arrhythmias and conduction abnormalities75 76 77 (eg, atrial fibrillation and flutter, sick sinus syndrome, and atrioventricular block).

Prevalence
The frequency with which sudden cardiac death (due primarily to coronary artery disease) occurs during organized masters competition or training is not known with precision. Nevertheless, it is possible to extrapolate from available information in the older general athletic population of marathon racers,37 apparently healthy male athletes and sports participants,31 36 and joggers.36 39 These data suggest a risk for sudden cardiac death in the range of 1:15 000 joggers per year or 1:50 000 participants in marathons, with a marked predominance of deaths in men. On the other hand, the risk in young high school and college-aged athletes has been calculated to be {approx}1:200 000 to 1:300 000 per academic year.46 78

Other observations also suggest that death and cardiac events such as exercise-related myocardial infarction are not rare in older athletic populations.32 33 36 37 38 39 40 41 42 43 44 45 The aforementioned prevalence figures were obtained in US populations, and the incidence of coronary artery disease and sudden cardiac death related to exercise may well differ in other countries and regions of the world. Nevertheless, as participation in masters sports accelerates throughout the world, greater numbers of athletes will be enrolled in intensive training programs or competition abruptly after long periods away from strenuous training and the competitive sports arena, often without preparticipation medical evaluations. Therefore, the prevalence of cardiac events among these athletes may increase further, and it is this subset of athletes that is a major focus of this document.

General Objectives of Preparticipation Screening

As a prudent and beneficial measure, preparticipation medical evaluations are recommended for athletes before entry into masters sports training programs. At present, such examinations are limited, inconsistent, or nonexistent. A major objective of this process would be to identify (or raise the suspicion of) occult cardiovascular disease that has the potential to cause sudden cardiac death, nonfatal myocardial infarction, stroke, angina, acute coronary syndromes, or heart failure (when triggered by intense athletic activity or abrupt burst exertion); this warrants evaluation and recommendations regarding future participation in competitive athletics. In athletes with known cardiovascular disease, the purpose of this preparticipation evaluation is to determine whether continued sports participation is judicious and consistent with the severity and status of their disease.

Therefore, such screening evaluations represent the opportunity to formulate recommendations for the initiation or resumption of participation in competitive sports, as well as the mechanism by which reentry into a training regimen might best be effected. Cardiovascular evaluation should be repeated if symptoms intervene or perceived risk increases, or for other clinical reasons based on the judgment of the personal physician. However, in general, asymptomatic status does not confer immunity from cardiac events, and subsequent, periodic clinical examinations may be prudent.

The proposed medical evaluation and its objectives may differ with regard to national origin or culture. One example is Italy, where, under a national governmental program, competitive athletes at all levels undergo compulsory annual medical clearance, including evaluation for cardiovascular disease by certified sports medicine physicians.58 This mandatory screening protocol is extended for any athlete, regardless of age, who is engaged in official organized sports activities, including many masters competitions. In addition to a standard history and physical examination, noninvasive tests such as the 12-lead ECG and submaximal exercise test are performed, as well as 2-dimensional echocardiography or maximal exercise testing (treadmill or bicycle ergometer) if judged appropriate at the discretion of the examining sports medicine physician.

Specific Recommendations for the Preparticipation Cardiovascular Evaluation

History and Physical Examination
The preparticipation evaluation should emphasize the detection of previously undiagnosed coronary artery disease. It is proposed that the personal and family history and physical examination for masters athletes adopt the 12 relevant points of the American Heart Association preparticipation screening recommendations50 (TableDown).


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  		Table 1. AHA Consensus Panel Recommendations for Preparticipation Screening50

ECG Exercise Testing
Symptom-limited maximal ECG exercise testing (with treadmill or cycle ergometer) is a widely used and well-established test for the detection of coronary artery disease that may also indirectly predict patient outcome.23 79 80 81 82 83 84 85 86 87 88 The exercise ECG is a relatively effective and inexpensive test for myocardial ischemia due to coronary artery disease in a moderate- to high-risk asymptomatic population. Interpretation of the test includes exercise capacity, as well as clinical, hemodynamic, and electrocardiographic responses.23 79 80 81 An important ECG finding is >1 mm (0.10 mV) of horizontal or downsloping ST-segment depression for >80 ms during and/or in the first minutes of the recovery period.23 Additional risk stratification is possible by considering the degree of ST-segment depression, hypotensive blood pressure response to maximal exercise (relative to baseline), complex ventricular ectopy, and reduced exercise capacity, which are frequently associated with severe coronary artery disease, ischemic myocardial dysfunction, and poor prognosis.23 79 80 81 82 83 84 85 86 87 88 89 90 91

It is recognized that the absolute risk of a major event during physical activity is small in asymptomatic patients without known cardiac disease. Nevertheless, it is recommended that those masters athletes having a moderate-to-high cardiovascular risk profile for coronary artery disease,23 91 92 93 and who desire to enter vigorous competitive situations, undergo exercise testing. Specifically, this risk profile would include men more than 40 to 45 years old or women more than 50 to 55 years old (or postmenopausal) with 1 or more independent coronary risk factors. These include the following: hypercholesterolemia or dyslipidemia (total cholesterol >200 mg/dL; elevated low-density lipoprotein [LDL] cholesterol [>130 mg/dL]; low high-density lipoprotein [HDL] cholesterol [<35 mg/dL for men; <45 mg/dL for women]); systemic hypertension (systolic blood pressure >140 mm Hg or diastolic pressure >90 mm Hg); current or recent cigarette smoking; diabetes mellitus (fasting plasma glucose >=126 mg/dL or treatment with insulin or oral hypoglycemics); or history of myocardial infarction or sudden cardiac death in a first-degree relative <60 years old. In addition, an exercise test is recommended for those masters athletes of any age with symptoms suggestive of underlying coronary disease and for those >=65 years old even in the absence of risk factors and symptoms.

Because most exercise testing is performed in adults with symptoms of known or suspected ischemic heart disease, the panel acknowledges that the use of the exercise ECG to screen an asymptomatic general athletic cohort for coronary artery disease is a complex issue.23 There are limitations in negative predictive value, as well as in the accuracy for positive identification of disease in such a population (which has not been conclusively defined because coronary arteriography is rarely performed in individuals with normal treadmill tests).8 23 80 Therefore, nonselective use of the exercise ECG in low-risk populations is associated with poor positive predictive accuracy23 and false-positive tests that can have negative psychological implications and result in unnecessary and costly medical testing, as well as adverse consequences in relation to employment and insurance. Consequently, the routine use of the exercise ECG in healthy asymptomatic athletes without major risk factors is not recommended.

Nevertheless, findings from the Multiple Risk Factor Intervention Trial (MRFIT) suggest that in asymptomatic populations with coronary risk factors, development of a positive exercise ECG test for myocardial ischemia is associated with a higher incidence of future coronary events6 81 82 83 86 such as angina pectoris, acute myocardial infarction, or sudden death by as much as 15 times in men and 5 times in women.18 24 85 86 In the Seattle Heart Watch Study,81 asymptomatic men over 40 years of age with >1 coronary risk factor and >2 abnormal features on exercise testing (including chest pain during maximal exertion, exercise duration <6 minutes on the Bruce protocol, failure to attain at least 90% of age-predicted maximal heart rate, or ischemic ST-segment depression) showed a 30-fold increment in 5-year cardiac risk; the greater the number of risk factors (ie, pretest probability), the more substantial is the potential value of screening.

Maximal graded exercise testing serves only as a preliminary evaluation to estimate the likelihood that coronary artery disease is present. A positive test necessitates further diagnostic evaluation to establish more definitively the presence and anatomic severity of the atherosclerotic arterial narrowing. On the other hand, a negative exercise test does not rule out the presence of coronary artery disease.

Other Testing
The standard 12-lead ECG is of limited diagnostic value for detecting coronary artery disease in an asymptomatic masters population, particularly given the variability of ECG patterns associated with athletic training.94 Nevertheless, the ECG, when used as part of a preparticipation screening evaluation, may occasionally identify unexpected evidence of a healed myocardial infarction and can also be particularly helpful in detecting certain diseases less common in the masters population, such as hypertrophic cardiomyopathy95 96 ; long-QT, Brugada, and Wolff-Parkinson-White syndromes; and arrhythmogenic right ventricular cardiomyopathy.97 98 99 For these reasons, a standard 12-lead ECG is recommended as part of a routine evaluation for all masters athletes (male and female) >40 years old.

Measurement of maximal oxygen consumption by ventilatory gas analysis is dependent on many factors (age, sex, body composition, and training),61 62 63 64 67 68 69 74 has not been shown to add relevant clinical information over that of the standard exercise ECG for predicting coronary heart disease, and is, in fact, more costly. At present, directly measured maximal oxygen uptake and anaerobic threshold are more often used as measures of physical and cardiovascular fitness and to develop an index of aerobic capacity, as well as for training evaluations in athletic populations.

Diagnostic echocardiography is indicated when clinical, historical, or physical findings suggest the possibility of valvular heart disease (particularly aortic stenosis), hypertrophic cardiomyopathy with or without left ventricular outflow obstruction, arrhythmogenic right ventricular cardiomyopathy, or prior myocardial infarction.50 57 89 95 96 99

Education
Another objective of the preparticipation evaluation is the education of athletes regarding various aspects of self-monitoring and risk of cardiovascular events. Making the athlete aware of the nature and significance of warning signs or symptoms of cardiovascular disease (such as angina pectoris, anginal equivalents, or impaired consciousness), the risk of a cardiovascular event associated with the abrupt onset of intense athletic training in otherwise sedentary and untrained individuals, and the importance of modifying identified cardiovascular risk factors all represent critical educational issues.

Guidelines for Disqualification and Eligibility

In determining the criteria for cardiovascular disqualification from masters sports, the panel relied on a review of the available literature, personal experience, and the consensus recommendations of Bethesda Conference No. 26, designed to promote eligibility standards for competitive athletes.55 The recommendations take into consideration a large number of cardiovascular conditions, the severity of these diseases, and profiles of sporting activity and training that estimate the intensity of physical exertion and its potential impact as a trigger for sudden cardiac death and/or disease progression. In general, organized sports requiring vigorous physical activity, such as basketball, track, or swimming, pose greater cardiovascular risk and are therefore less desirable than low-intensity competitive sports, such as golf and bowling, given the same cardiac disease of similar severity. There is particular concern that risk may be increased for those former trained athletes who enter masters competition and participate in short-distance or short-duration events involving maximal "burst"-type exertion (eg, certain swimming and cycling events, track sprinting, basketball, tennis, and soccer) with little or no recent formal training.

These recommendations should not create barriers to exercise and its varied physiological and psychological benefits for older athletes. Finally, these recommendations should not be regarded as mandatory or absolute but are offered only as guidelines and do not prohibit individualization by practition-ers exercising their independent clinical judgment.

Atherosclerotic Coronary Artery Disease
For the purpose of this discussion, coronary artery disease is defined as narrowing of a major coronary artery (generally regarded as >50% luminal diameter narrowing), as documented by coronary angiography. Acute myocardial infarction also frequently occurs in association with atherosclerotic luminal narrowing of <50%.

For athletes with documented ischemic heart disease (whether or not symptoms are present and regardless of whether prior myocardial infarction or complete revascularization has occurred), it is not advisable to participate in high-intensity competitive masters sports, and such individuals should be confined to competitive sports judged to be of low intensity. The low-intensity class of sports, as defined by Bethesda Conference No. 26, is principally represented by competition in sports such as golf and bowling.55

This restriction on high-intensity sports (or any physical activity that triggers ischemic symptoms) is particularly pertinent for masters athletes, because the emotional impact of competitive situations may mask ischemic symptoms and augment risk for precipitating unstable angina, myocardial infarction, or sudden cardiac death. These guidelines should not, however, be construed as a prohibition against regular (recreational and noncompetitive) exercise, which is generally advisable for patients with coronary artery disease owing to the cardiovascular benefits derived from such physical activity.1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 52A 52B

The probability of an exercise-induced cardiac event is generally higher in the presence of more severe coronary atherosclerosis and heart disease. Consequently, the aforementioned general restrictions on high-intensity competitive sports should be most closely followed in patients with any of the following criteria:

  1. impaired left ventricular systolic function under resting conditions (ejection fraction <50%);
  2. evidence of exercise-induced myocardial ischemia, including angina, positive ECG, or positive imaging findings with exercise testing;
  3. evidence of exercise-induced frequent or complex supraventricular or ventricular arrhythmias, including nonsustained ventricular tachycardia;
  4. exercise-induced systolic hypotension.

Some masters athletes with mild atherosclerotic disease, normal left ventricular function, and no inducible ischemia or arrhythmias may be allowed to participate in more vigorous competitive sports, but this clearance should be provided on a case-by-case basis and with full understanding by both the patient and physician that such vigorous exercise probably increases the risk of an acute cardiac event.

Systemic Hypertension
Effort should be made to normalize blood pressure by drugs or lifestyle before training or competition is initiated. The presence of systemic hypertension of a mild degree (stage 1, 140 to 159 mm Hg systolic or 90 to 99 mm Hg diastolic blood pressure) in the absence of target organ damage or concomitant cardiac dysfunction should not restrict eligibility from most competitive masters sports.100 101 In general, because of the documented benefits of low- to moderate-intensity exercise in lowering blood pressure and improving other coronary risk factors, the engagement in regular forms of exercise may be of benefit to hypertensive subjects, although competitive resistance training should be discouraged for athletes with moderate to severe hypertension. After beginning a regular athletic training program, hypertensive athletes should have their blood pressure monitored at least every 2 months to assess the impact of exercise.

Athletes with moderate to severe systemic hypertension (stage 2, 160 to 179 mm Hg systolic or 100 to 109 mm Hg diastolic blood pressure; or stage 3, >=180 mm Hg systolic or >=110 mm Hg diastolic blood pressure)100 101 should be restricted, particularly from highly static competitive sports (such as weight lifting or gymnastics), until their blood pressure is controlled.101 These restrictions regarding hypertension seem appropriate, because competitive athletics involves more intense physical exertion than is required for routine cardiovascular conditioning. The present recommendations are offered, although at present there are no persuasive data available that definitively link strenuous exercise and the risk for sudden cardiac death or disease progression among hypertensive subjects. When hypertension coexists with coronary artery disease, eligibility for participation in masters competition will usually be based on the nature and severity of the coronary disease.

Congenital and Valvular Heart Disease Conditions
Hypertrophic cardiomyopathy is a heterogeneous and unpredictable primary cardiac disease for which there is increased risk for sudden cardiac death in some patients.95 96 102 For these reasons, and because of the lack of precision that prevails in stratifying risk for sudden death in hypertrophic cardiomyopathy59 95 96 103 (particularly in competitive athletes), we believe that older individuals with an unequivocal diagnosis of this condition should be advised against participation in intense masters sports and confine their competitive athletic activity to only low-intensity sports. Patients with documented dilated cardiomyopathy or arrhythmogenic right ventricular cardiomyopathy99 should be excluded from all competitive sports.59

The vast majority of athletes with mitral valve prolapse do not have complicating factors and will be able to participate fully in sports. Asymptomatic athletes with mitral valve prolapse and any of the following criteria should be restricted to low-intensity competitive sports (such as golf and bowling): (1) history of syncope, judged probably arrhythmogenic in origin; (2) family history of sudden death due to mitral valve prolapse; (3) repetitive supraventricular or complex ventricular tachyarrhythmias, particularly if exacerbated by exercise; (4) moderate to severe mitral regurgitation; and (5) prior embolic event. For other less common congenital and valvular heart diseases in the masters age group, the consensus guidelines of Bethesda Conference No. 26 should be followed.55

Myocarditis
Athletes judged to have myocarditis (with or without evidence of a dilated cardiomyopathy) may return to competition when there is no longer evidence of active infection, ie, ventricular function and cardiac dimensions have returned to normal, and clinically relevant arrhythmias (frequent or repetitive forms of ventricular ectopic activity or sustained supraventricular tachycardia) are absent on ambulatory ECG (Holter) recording or exercise testing. A prudent convalescent period of {approx}6 months is recommended before these athletes return to competitive sports.

Chagas Disease
Chagas is an infectious but noncontagious disease caused by the parasite Trypanosomal cruzi, typically transmitted by a mosquito bite and confined to rural, undeveloped areas in the tropics or subtropics or South America.104 In these endemic areas, Chagas disease still constitutes a major public health problem. For example, an estimated 5% of the population of Brazil is infected, which may include older individuals participating in sports. Diagnosis can be made by direct parasite identification or positive serological reaction.

In its chronic phase, Chagas presents a well-defined clinical profile affecting organs with muscarinic receptors, such as the heart (in the myocardium and conduction system), colon, and esophagus. About one third of affected individuals develop cardiac complications leading to heart failure or thromboembolism-related or sudden cardiac death, often much later in life. Cardiac involvement (often in the form of chronic myocarditis) can be suspected when atrial and ventricular arrhythmias or the characteristic ECG pattern of right bundle-branch block and left anterior hemiblock with or without echocardiographic demonstration of apical aneurysm are present.

In the presence of Chagas disease, sports competition can be unrestricted if no objective signs or symptoms of cardiac involvement are evident (and resting and exercise ECG or echocardiographic tests are normal). With evidence of cardiac involvement (with or without pacemaker implantation), all intense competitive sports activity is contraindicated. Fortunately, the incidence of new Chagas disease cases has decreased recently in some South American countries.

Cardioactive Drugs
Those masters athletes using cardioactive drugs should discuss their competitive sports interests and needs with their physician. It may or may not be possible to adjust drugs and dosages to achieve compatibility with this desired lifestyle. However, ß-adrenergic blocking agents can generally be expected to impair performance during participation in intense competitive sports.105

Implementation of Screening and Eligibility Recommendations

In contrast to the common practice for high school and college-aged student athletes,50 it is unrealistic to expect governing authorities or sponsors to provide medical evaluations for all (or even most) masters athletes because of the often loose affiliations between masters sports organizations and their athletes and a lack of resources to support organized systematic screening programs. These considerations are particularly relevant to certain individual sports such as road racing or marathon events, in which preparation and training for competition are usually medically unsupervised and left to the discretion of the athlete. The practical limitations of broad-based preparticipation screening for public running events is illustrated by the London Marathon, which has 40 000 participants annually.106

For all these reasons, it becomes largely unavoidable that the primary responsibility rests with the masters athlete to identify and initiate contact with an appropriate physician (primary care practitioner, subspecialist cardiologist, or an appropriately trained sports medicine specialist) for the purpose of a preparticipation cardiovascular evaluation to include blood pressure measurement and risk factor analysis (with exercise ECG testing, if indicated). Even in those circumstances in which important cardiovascular disease is excluded or regarded as unlikely, we encourage the entry (or reentry) into competitive athletics to occur with a gradual training program that progressively leads to more vigorous levels of physical exertion.

With regard to prevention of sudden death, it is recommended that both personnel trained in cardiopulmonary resuscitation and automatic external defibrillators be available at all sanctioned masters sports events.107 108 The relatively advanced ages of many masters athletes and the anticipated frequency of cardiovascular events in this age group make these recommendations particularly reasonable and relevant, especially with the recent development of easy-to-use, low-cost defibrillators targeted for use at locations where large numbers of high-risk people congregate.107 108

Conclusions

The recommendations developed in this document provide general cardiovascular screening guidelines for older individuals entering, resuming, or continuing in organized sports competition. Adequate cardiovascular evaluations are important for identification of underlying cardiovascular disease (typically ischemic heart disease) before initiation of training programs at moderate to intense levels. This recommendation is underscored by the fact that masters athletes are unique, given the physiology associated with advancing age, the possibility of unsuspected coronary artery disease, and their often abrupt entry (or reentry) into competitive training programs. Specific recommendations are presented for the identification and evaluation of cardiovascular disease, as well as guidelines for clearance and disqualification. Also, a major impetus of this consensus document is to create a focus on the expanding medical issues concerning older individuals (potentially with underlying cardiovascular disease) who are involved in intense competitive sports. The achievement of these objectives will require the support of various athletic and professional medical organizations, the physician community, and insurance companies, as well as that of masters athletes and their families. Implementation of the screening approaches described here can aid in identification of high-risk athletes who can then be referred to effective risk-reduction programs, which ultimately will enhance the safety of sports participation for older athletes.

Footnotes

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee in August 2000. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0198.

(Circulation. 2001;103:327-334.)

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S. Mohlenkamp, N. Lehmann, F. Breuckmann, M. Brocker-Preuss, K. Nassenstein, M. Halle, T. Budde, K. Mann, J. Barkhausen, G. Heusch, et al.
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