Sports activity and cardiovascular pathologies

Aortic stenosis

For acquired aortic stenosis (SA), the considerations made for the congenital form are generally valid (see previous article). It is important to remember that, with the exception of forms with rheumatic aetiology, adult aortic stenosis is not infrequently the expression of a degenerative-calcific process affecting a congenitally malformed aortic valve.

Aortic insufficiency

Also in aortic insufficiency (IA), in analogy to mitral insufficiency, different etiologies can be recognized: congenital (as in some bicuspid valves), rheumatic, from infective endocarditis, secondary to Marfan etc.
The general considerations made for mitral insufficiency are also valid for aortic insufficiency, remembering however that in the hemodynamically significant forms, usually symptomatic, relative coronary insufficiency can occur during exercise.
Nevertheless, stress hemodynamics in aortic insufficiency may appear, at least in theory, favorable in relation to the fact that the shortening of diastole and the reduction of peripheral resistance (dynamic effort) tend to reduce the volume of regurgitating blood.
For practical purposes, aortic insufficiency can be defined as mild in the presence of normal size of the left ventricle, normal ventricular function at rest and exertion (investigations with radionuclides and / or exertional ECHO), and the absence of peripheral signs of aortic regurgitation (elevated pressure differential, rapid pulse, etc.); moderate when the peripheral signs of AI are appreciable but the left ventricular size is only slightly increased and the ventricular function at rest and during exercise is normal; severe in other cases.

INDICATIONS
In cases with moderate and severe AI no competitive sporting activity will be allowed.
In cases with mild AI, minimal effort activities will be allowed. However, careful monitoring of left ventricular size and function over time is indicated, reducing the length of the eligibility period to six months.
In selected cases, eligibility may also be granted for medium-high effort activities, after careful control of the behavior of the left ventricular function under stress.

Particular attention should then be paid to subjects, especially those of young age, undergoing cardiac surgery and as such wearers of a valve prosthesis; in case of anticoagulant therapy it will be necessary to ban sports with the possibility of trauma or falls to avoid the risk of hematomas.

Let us now examine those situations in which the detection of instrumental clinical signs, or the appearance of some symptoms, impose precise diagnostic problems. In essence, it is a question of establishing whether we are dealing with a real organic pathology or whether we are dealing with signs and / or disorders of a functional nature, that is, benign. Will be taken into consideration:
- the detection of high blood pressure;
- the detection of a heart murmur;
- electrocardiographic anomalies.
Normal blood pressure in adults means a pressure below 140/90 mmHg; we can speak of stable arterial hypertension when values equal to or greater than 160/95 mmHg are found during at least two visits. "Borderline" hypertension is higher than P.A. normal, but less than 160/95 mmHg; labile hypertension that with values sometimes above, sometimes below 140/90 mmHg.

Arterial hypertension is a disease that affects 10 to 20% of the population; in the vast majority of cases (95%) it is of the so-called "essential" type, ie primitive; in the remaining cases it is secondary to other pathologies, mostly of renovascular and endocrine origin. It should be remembered that arterial hypertension is one of the main predisposing factors to myocardial infarction.
The finding of elevated blood pressure values in the young subject requires the stopping of the sporting activity and a complete etiological screening. Excluding the presence of aortic coarctation, arterial malformations and endocrine imbalances, if arterial hypertension is stable, appropriate therapeutic intervention is necessary, and subsequent execution of maximal stress tests (under both dietary and pharmacological therapy); the values stressors under stress should not exceed 220 mmHg for systolic BP and 105 mmHg for diastolic blood pressure.
Recommended activities are tennis, alpine skiing not at high altitude, flat cycling and non-competitive swimming etc .; all sports involving isometric strength are excluded.
A separate discussion should be made about "systolic arterial hypertension in the framework of the so-called cardiac hyperkinetic syndrome, frequently observed in young subjects, which involves, in addition to elevation of blood pressure, symptoms such as tachycardia, palpitations, breathing difficulties, dizziness, chest pains Not infrequently the subjects affected by this syndrome have a good physical capacity to work, but they can be excluded from sporting fitness due to the abnormal blood pressure values. In reality, it is proven that sporting activity is effectively one of the therapeutic measures that can be implemented with normalization of blood pressure values. According to the cases and any associated tachycardia, beta-blocking drugs will be associated, which cause a reduction in sympathetic stimulation of the heart and blockage. norepinephrine stimulation of beta-receptors.

See also: Physical activity and hypertension

Heart murmurs

A heart murmur does not necessarily have a pathological significance; Frequently encountered in infancy, functional, ie innocent, murmurs are relatively easily differentiated from organic, ie pathological, murmurs.
Heart murmurs consist of:

- a series of acoustic vibrations that can be caused by structural anomalies that obstruct the normal flow;
- an increased flow through normal structures (overflow);
- an inversion of the flow itself, situations in which a pressure gradient occurs between the heart chambers involved

Of the heart murmur, the following characteristics should be evaluated:

- the phase of the cardiac cycle in which it is located;
- the intensity, expressed in degrees from 1 to 6;
- the hearing venue;
- frequency and quality of sound.

A murmur is usually heard when the blood stream becomes swirling.
Murmurs can be systolic, diastolic and continuous, depending on the time they occupy in the cardiac cycle.
Systolic ejection murmurs due to organic valve stenosis are usually protomesosystolic with a mid-systolic (diamond shape) acme or later if the obstructive gradient is important. Those due to hyperinflow (eg that of the atrial defect) are at a protosystolic acme. Regurgitation systolic murmurs are due to atrioventricular valve insufficiency, or to a defect of the interventricular septum.
Atrial ejection and ventricular filling diastolic murmurs are due to stenosis of both organic and functional atrioventricular valves from overflow. Diastolic regurgitation murmurs are due to insufficiency of the aortic and pulmonary semilunars caused by intrinsic organic alterations of the valve leaflets or by dilation of the root of the respective vessels.
The continuous murmur is a noise that begins with the systole and continues beyond the second tone in all or part of the diastole. It originates from a flow that goes from a high resistance area to a low resistance area without interruption between systole and diastole. It is generally due to aorto-pulmonary communications, arteriovenous fistulas, changes in the flow pattern in arteries or veins.
The listening seat distinguishes murmurs into mitral, aortic, pulmonary, tricuspid, axillary, jugular, interscapulo-vertebral.
The discovery of a heart murmur in a subject who practices sports is a "not uncommon occurrence. Systolic, aortic and pulmonary murmurs, of a so-called elective nature, are to be considered devoid of pathological significance, which are the expression of an increased systolic volume expelled with increased speed through a normal valve system.
As situations at the origin of functional heart murmurs, the pectus excavatum and straight back syndrome, both of which involve a reduction in the thoracic sagittal diameter and a cardiac approach to the chest wall, should be remembered, facilitating the auscultation of any minimal heart murmurs.
In the context of murmurs and heart noises detectable during a systematic examination of a sportsman, the click and murmur referable to mitral valve prolapse deserve particular attention.

Curated by: Lorenzo Boscariol