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Revista
Portuguesa
de
Cardiologia
42
(2023)
677---678
www.revportcardiol.org
Revista
Portuguesa
de
Cardiologia
Portuguese
Journal
of
Cardiology
LETTER
TO
THE
EDITOR
Current
scenario
of
evidence-based
recommendations
in
sports
cardiology
Atual
cenário
das
recomendac ̧ões
em
cardiologia
desportiva
Sports
cardiology
is
a
growing
area
in
which
there
are
var-
ious
controversial
issues,
including
the
need
for
guidelines
to
standardize
the
assessment
of
individuals
with
cardio-
vascular
disease
(CVD)
and
the
eligibility
criteria
for
sports
participation.
The
2020
European
Society
of
Cardiology
(ESC)
guidelines
on
sports
cardiology
and
exercise
in
patients
with
CVD
1
were
received
with
great
enthusiasm
and
expectation,
since
they
contribute
to
better
risk
stratification
and
exer-
cise
prescription
in
the
presence
of
CVD
and
help
minimize
the
risk
of
adverse
events.
The
aim
of
this
study
was
to
analyze
the
classes
of
rec-
ommendation
and
levels
of
evidence
(LoE)
underlying
the
Figure
1
Distribution
of
classes
of
recommendations
in
the
2020
European
Society
of
Cardiology
(ESC)
guidelines
on
sports
cardi-
ology,
compared
with
other
ESC
clinical
guidelines
(non-ST
elevation
myocardial
infarction
(NSTEMI)
(2020),
cardiovascular
disease
(CVD)
prevention
(2021),
atrial
fibrillation
(AF)
(2020),
valvular
heart
disease
(VHD)
(2021),
and
heart
failure
(HF)
(2021).
2020
ESC
guidelines
on
sports
cardiology
and
to
compare
them
with
other
recent
ESC
guidelines
on
non-ST
eleva-
tion
myocardial
infarction
(NSTEMI)
(2020),
CVD
prevention
(2021),
atrial
fibrillation
(AF)
(2020),
valvular
heart
disease
(VHD)
(2021),
and
heart
failure
(HF)
(2021).
The
ESC
guidelines
on
sports
cardiology
propose
a
total
of
158
recommendations:
52
class
I
(recommended/indicated)
(33%);
43
class
IIa
(should
be
considered)
(27%);
32
class
IIb
(may
be
considered)
(20%);
and
31
class
III
(not
rec-
ommended)
(20%).
Compared
to
the
other
ESC
guidelines,
the
sports
cardiology
guidelines
have
fewer
class
I
and
more
class
IIb
or
III
recommendations
(
Figure
1
).
For
example,
the
mean
frequency
in
the
ESC
guidelines
on
NSTEMI,
CVD
pre-
vention,
AF,
VHD
and
HF
are
50%
for
class
I,
30%
for
class
IIa,
13%
for
class
IIb
and
6%
for
class
III.
The
majority
of
the
recommendations
on
sports
cardiology
(80%)
are
based
on
LoE
C
(consensus
experts’
opinion
and/or
small
studies,
retrospective
studies
or
registries),
13%
on
LoE
B
(single
randomized
clinical
trial
or
large
non-randomized
studies),
and
only
8%
on
LoE
A
(multiple
randomized
clinical
trials
or
https://doi.org/10.1016/j.repc.2022.10.015
0870-2551/©
2023
Published
by
Elsevier
Espa
̃
na,
S.L.U.
on
behalf
of
Sociedade
Portuguesa
de
Cardiologia.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(
http://creativecommons.org/licenses/by-nc-nd/4.0/
).
LETTER
TO
THE
EDITOR
Figure
2
Distribution
of
level
of
evidence
(LoE)
(A,
B
and
C)
in
the
2020
European
Society
of
Cardiology
(ESC)
guidelines
on
sports
cardiology,
compared
with
other
ESC
clinical
guidelines
(non-ST
elevation
myocardial
infarction
(NSTEMI)
(2020),
cardiovascular
disease
(CVD)
prevention
(2021),
atrial
fibrillation
(AF)
(2020),
valvular
heart
disease
(VHD)
(2021),
and
heart
failure
(HF)
(2021).
meta-analysis).
These
results
differ
from
the
other
ESC
guidelines
analyzed,
in
which
the
mean
frequencies
are
LoE
A
21%,
LoE
B
40%,
and
LoE
C
38%
(
Figure
2
).
These
results
confirm
the
current
scarcity
of
evidence
in
sports
cardiology
compared
to
other
areas
in
cardiol-
ogy,
especially
in
terms
of
randomized
clinical
trials,
most
evidence
being
based
on
expert
opinion,
small
studies,
retrospective
studies
or
registries.
However,
previous
data
showed
that
even
in
other
areas,
only
a
small
proportion
of
the
recommendations
in
major
cardiovascular
society
guide-
lines
were
supported
by
evidence
from
randomized
clinical
trials,
a
pattern
that
appears
to
persist
over
time.
2 --- 4
The
fact
that
sports
cardiology
is
an
emerging
subspe-
cialty
and
these
ESC
guidelines
are
the
first
in
this
field
worsens
their
limitations,
as
a
result
of
the
lack
of
evidence
on
the
natural
history
of
CVD
and
the
risk
of
sudden
car-
diac
death
during
intensive
exercise
and
competitive
sport.
In
this
setting,
it
is
difficult
to
formulate
specific
recom-
mendations
for
heterogeneous
scenarios,
populations
and
clinical
presentations.
These
guidelines
should
therefore
not
be
treated
simply
as
a
static
legal
document,
but
should
encourage
physicians
to
integrate
the
recommendations
with
their
clinical
experience
and
skills
in
sports
cardiol-
ogy.
Given
the
range
of
topics
that
remain
to
be
clarified,
the
ESC
guidelines
on
sports
cardiology
emphasize
sharing
the
decision-making
process
with
the
athlete/patient,
their
family,
and
other
health
and
exercise
professionals.
This
approach
is
mainly
proposed
in
more
controversial
cases
and
should
take
into
consideration
the
autonomy
and
prefer-
ences
of
each
individual,
who
should
provide
clear
informed
consent.
A
call
to
action
on
research
in
sports
cardiology
is
needed
to
overcome
the
multiple
gaps
in
evidence,
narrow
the
gray
zone
and
subjectivity
in
this
area,
improve
the
quality
of
evidence
and
support
future
recommendations.
Conflicts
of
interest
The
author
has
no
conflicts
of
interest
to
declare.
References
1.
Pelliccia
A,
Sharma
S,
Gati
S,
et
al.
2020
ESC
Guidelines
on
sports
cardiology
and
exercise
in
patients
with
cardiovascular
disease.
Eur
Heart
J.
2021;42:17---96.
2.
Caldeira
D,
Marques
A,
Almeida
J,
et
al.
Recommendations
and
levels
of
evidence
in
the
guidelines
of
the
European
Society
of
Cardiology:
current
scenario
and
time
trends.
Eur
Heart
J
Car-
diovasc
Pharmacother.
2020;6:122---4.
3.
Califf
AC,
Windecker
RMS,
et
al.
Levels
of
evidence
support-
ing
American
College
of
Cardiology/American
Heart
Association
and
European
Society
of
Cardiology
guidelines,
2008-2018.
JAMA.
2019;321:1069---80.
4.
van
Dijk
WB,
Grobbee
DE,
Vries
MC,
et
al.
A
systematic
break-
down
of
the
levels
of
evidence
supporting
the
European
Society
of
Cardiology
guidelines.
Eur
J
Prev
Cardiol.
2019;26:1944---52.
Hélder
Dores
a
,
b
a
Hospital
da
Luz,
Lisbon,
Portugal
b
NOVA
Medical
School,
Lisbon,
Portugal
E-mail
address:
heldores@hotmail.com
678

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