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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sports cardiology is a growing area in which there are various controversial issues&#44; including the need for guidelines to standardize the assessment of individuals with cardiovascular disease &#40;CVD&#41; and the eligibility criteria for sports participation&#46; The 2020 European Society of Cardiology &#40;ESC&#41; guidelines on sports cardiology and exercise in patients with CVD<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> were received with great enthusiasm and expectation&#44; since they contribute to better risk stratification and exercise prescription in the presence of CVD and help minimize the risk of adverse events&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The aim of this study was to analyze the classes of recommendation and levels of evidence &#40;LoE&#41; underlying the 2020 ESC guidelines on sports cardiology and to compare them with other recent ESC guidelines on non-ST elevation myocardial infarction &#40;NSTEMI&#41; &#40;2020&#41;&#44; CVD prevention &#40;2021&#41;&#44; atrial fibrillation &#40;AF&#41; &#40;2020&#41;&#44; valvular heart disease &#40;VHD&#41; &#40;2021&#41;&#44; and heart failure &#40;HF&#41; &#40;2021&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The ESC guidelines on sports cardiology propose a total of 158 recommendations&#58; 52 class I &#40;recommended&#47;indicated&#41; &#40;33&#37;&#41;&#59; 43 class IIa &#40;should be considered&#41; &#40;27&#37;&#41;&#59; 32 class IIb &#40;may be considered&#41; &#40;20&#37;&#41;&#59; and 31 class III &#40;not recommended&#41; &#40;20&#37;&#41;&#46; Compared to the other ESC guidelines&#44; the sports cardiology guidelines have fewer class I and more class IIb or III recommendations &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; For example&#44; the mean frequency in the ESC guidelines on NSTEMI&#44; CVD prevention&#44; AF&#44; VHD and HF are 50&#37; for class I&#44; 30&#37; for class IIa&#44; 13&#37; for class IIb and 6&#37; for class III&#46; The majority of the recommendations on sports cardiology &#40;80&#37;&#41; are based on LoE C &#40;consensus experts&#8217; opinion and&#47;or small studies&#44; retrospective studies or registries&#41;&#44; 13&#37; on LoE B &#40;single randomized clinical trial or large non-randomized studies&#41;&#44; and only 8&#37; on LoE A &#40;multiple randomized clinical trials or meta-analysis&#41;&#46; These results differ from the other ESC guidelines analyzed&#44; in which the mean frequencies are LoE A 21&#37;&#44; LoE B 40&#37;&#44; and LoE C 38&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">These results confirm the current scarcity of evidence in sports cardiology compared to other areas in cardiology&#44; especially in terms of randomized clinical trials&#44; most evidence being based on expert opinion&#44; small studies&#44; retrospective studies or registries&#46; However&#44; previous data showed that even in other areas&#44; only a small proportion of the recommendations in major cardiovascular society guidelines were supported by evidence from randomized clinical trials&#44; a pattern that appears to persist over time&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The fact that sports cardiology is an emerging subspecialty and these ESC guidelines are the first in this field worsens their limitations&#44; as a result of the lack of evidence on the natural history of CVD and the risk of sudden cardiac death during intensive exercise and competitive sport&#46; In this setting&#44; it is difficult to formulate specific recommendations for heterogeneous scenarios&#44; populations and clinical presentations&#46; These guidelines should therefore not be treated simply as a static legal document&#44; but should encourage physicians to integrate the recommendations with their clinical experience and skills in sports cardiology&#46; Given the range of topics that remain to be clarified&#44; the ESC guidelines on sports cardiology emphasize sharing the decision-making process with the athlete&#47;patient&#44; their family&#44; and other health and exercise professionals&#46; This approach is mainly proposed in more controversial cases and should take into consideration the autonomy and preferences of each individual&#44; who should provide clear informed consent&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A call to action on research in sports cardiology is needed to overcome the multiple gaps in evidence&#44; narrow the gray zone and subjectivity in this area&#44; improve the quality of evidence and support future recommendations&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Letter to the Editor
Current scenario of evidence-based recommendations in sports cardiology
Atual cenário das recomendações em cardiologia desportiva
Hélder Doresa,b
a Hospital da Luz, Lisbon, Portugal
b NOVA Medical School, Lisbon, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sports cardiology is a growing area in which there are various controversial issues&#44; including the need for guidelines to standardize the assessment of individuals with cardiovascular disease &#40;CVD&#41; and the eligibility criteria for sports participation&#46; The 2020 European Society of Cardiology &#40;ESC&#41; guidelines on sports cardiology and exercise in patients with CVD<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> were received with great enthusiasm and expectation&#44; since they contribute to better risk stratification and exercise prescription in the presence of CVD and help minimize the risk of adverse events&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The aim of this study was to analyze the classes of recommendation and levels of evidence &#40;LoE&#41; underlying the 2020 ESC guidelines on sports cardiology and to compare them with other recent ESC guidelines on non-ST elevation myocardial infarction &#40;NSTEMI&#41; &#40;2020&#41;&#44; CVD prevention &#40;2021&#41;&#44; atrial fibrillation &#40;AF&#41; &#40;2020&#41;&#44; valvular heart disease &#40;VHD&#41; &#40;2021&#41;&#44; and heart failure &#40;HF&#41; &#40;2021&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The ESC guidelines on sports cardiology propose a total of 158 recommendations&#58; 52 class I &#40;recommended&#47;indicated&#41; &#40;33&#37;&#41;&#59; 43 class IIa &#40;should be considered&#41; &#40;27&#37;&#41;&#59; 32 class IIb &#40;may be considered&#41; &#40;20&#37;&#41;&#59; and 31 class III &#40;not recommended&#41; &#40;20&#37;&#41;&#46; Compared to the other ESC guidelines&#44; the sports cardiology guidelines have fewer class I and more class IIb or III recommendations &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; For example&#44; the mean frequency in the ESC guidelines on NSTEMI&#44; CVD prevention&#44; AF&#44; VHD and HF are 50&#37; for class I&#44; 30&#37; for class IIa&#44; 13&#37; for class IIb and 6&#37; for class III&#46; The majority of the recommendations on sports cardiology &#40;80&#37;&#41; are based on LoE C &#40;consensus experts&#8217; opinion and&#47;or small studies&#44; retrospective studies or registries&#41;&#44; 13&#37; on LoE B &#40;single randomized clinical trial or large non-randomized studies&#41;&#44; and only 8&#37; on LoE A &#40;multiple randomized clinical trials or meta-analysis&#41;&#46; These results differ from the other ESC guidelines analyzed&#44; in which the mean frequencies are LoE A 21&#37;&#44; LoE B 40&#37;&#44; and LoE C 38&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">These results confirm the current scarcity of evidence in sports cardiology compared to other areas in cardiology&#44; especially in terms of randomized clinical trials&#44; most evidence being based on expert opinion&#44; small studies&#44; retrospective studies or registries&#46; However&#44; previous data showed that even in other areas&#44; only a small proportion of the recommendations in major cardiovascular society guidelines were supported by evidence from randomized clinical trials&#44; a pattern that appears to persist over time&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The fact that sports cardiology is an emerging subspecialty and these ESC guidelines are the first in this field worsens their limitations&#44; as a result of the lack of evidence on the natural history of CVD and the risk of sudden cardiac death during intensive exercise and competitive sport&#46; In this setting&#44; it is difficult to formulate specific recommendations for heterogeneous scenarios&#44; populations and clinical presentations&#46; These guidelines should therefore not be treated simply as a static legal document&#44; but should encourage physicians to integrate the recommendations with their clinical experience and skills in sports cardiology&#46; Given the range of topics that remain to be clarified&#44; the ESC guidelines on sports cardiology emphasize sharing the decision-making process with the athlete&#47;patient&#44; their family&#44; and other health and exercise professionals&#46; This approach is mainly proposed in more controversial cases and should take into consideration the autonomy and preferences of each individual&#44; who should provide clear informed consent&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A call to action on research in sports cardiology is needed to overcome the multiple gaps in evidence&#44; narrow the gray zone and subjectivity in this area&#44; improve the quality of evidence and support future recommendations&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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