Flavio D’ascenzi

Aims: We aimed to evaluate the real-world use of contemporary international ECG interpretation criteria in athletes, and to compare practices, clinical decision-making, and perceived barriers between specialist and nonspecialist professionals across Europe. Methods and results: Two sets of structured questionnaires were developed and distributed to either sports cardiologists or nonspecialist professionals. Knowledge of international guidelines, experience in ECG interpretation, and confidence levels in clinical decision-making across various clinical scenarios were evaluated. An open-ended questionnaire was also developed to explore aspects of ECG interpretation, medicolegal issues, relevant legal frameworks across European countries, and personal thoughts on possible future revisions to the documents. The questionnaires were revised and edited by expert sports cardiologists, affiliated with EAPC. Data were analysed both quantitatively and qualitatively. A total of 242 participants across Europe were included; 66% were male and 57% worked in public hospitals. Nonspecialists demonstrated uncertainty in standard definitions, classification systems, and key applications of ECG criteria. These findings highlight variability in preparticipation screening (PPS) practices and areas of uncertainty in clinical decision-making, alongside concerns regarding access to specialist services. Notably, 25% of specialists favoured a flexible interpretative approach beyond current standard criteria. The majority supported the need for updated guidance and improved description of specific ECG indices, including ventricular ectopy (83%), QRS fragmentation (83%), and low-amplitude QRS complexes (78%), alongside recognition of the potential role of artificial intelligence–based models. Gaps in knowledge, training, and practice were identified, and both groups emphasized medicolegal and pathway challenges. Conclusion: This international survey provides a contemporary real-world overview of ECG interpretation and PPS practice in athletes across Europe and revealed substantial heterogeneity in access to services, training, interpretation uncertainty, referral pathways, and medico-legal frameworks.

Aims: Immune checkpoint inhibitors (ICIs) may cause cardiotoxicity, mainly myocarditis, with potential life-threatening consequences. To date, large-scale prospective data on cardiac imaging after ICI are still lacking. Thus, our primary aim was to assess the diagnostic value of speckle tracking echocardiography (STE) for ICI-related cardiotoxicity according to current international recommendations, while our secondary aims were to assess the prognostic value of STE for adverse clinical outcome and evaluate the agreement between STE and CMR in patients with ICI-related myocarditis. Methods and results: In this prospective study, cancer patients referred for cardiologic evaluation before ICIs initiation were enrolled. Patients with known cardiac dysfunction (LV ejection fraction < 40%) were excluded. All patients underwent clinical, biohumoral and echocardiographic evaluation completed by STE at baseline and at ∼6 months after immunotherapy. Patients with suspected myocarditis underwent CMR. Then, over a longer follow up, the clinical events were registered: all-cause or cardiovascular death, acute myocarditis, acute heart failure, pulmonary embolisms, acute coronary syndromes, atrial or ventricular arrhythmias, extra-cardiac toxicity. We enrolled 122 patients (65 ± 14 years) referred for ICIs. Over 7 ± 6 months follow up, mean LV GLS showed a slight reduction after therapy with ICI (−20 ± 4% at baseline vs. −18 ± 7%), although remaining within the normal ranges. During 22 ± 17 months of follow up, 65 patients developed events. Among ICI-related myocarditis, 4 patients showed a significant reduction of GLS with a regional distribution similar to regional myocardial injury at CMR (97 ± 7% agreement), the fifth had a minimal involvement of the right ventricle, with normal LV GLS. Conclusion: Our results suggest that multimodality imaging combining different techniques may optimize the subclinical diagnosis of cardiotoxicity and the overall management of cancer patients undergoing ICIs.

Atrial fibrillation (AF) represents an important challenge in sports cardiology, with implications for diagnosis, treatment, and eligibility for competitive and recreational exercise. Regular physical activity provides substantial cardiovascular benefits and is generally associated with a lower risk of AF, whereas long-term exposure to high-volume endurance exercise has been associated with a higher AF prevalence, particularly among male master athletes. However, this relationship should not be interpreted according to a simple cause-and-effect model. Exercise-related atrial remodelling, autonomic changes, inflammation, and hemodynamic stress may contribute to arrhythmogenesis, but their clinical expression likely depends on individual clinical, structural, autonomic, and genetic susceptibility. AF in athletes therefore requires a comprehensive diagnostic evaluation aimed at characterizing the arrhythmia, identifying modifiable risk factors, and excluding underlying cardiovascular disease. Management should consider symptoms, arrhythmic burden, type of sport, performance expectations, thromboembolic and bleeding risks, and the underlying substrate. Anticoagulation should follow established thromboembolic risk assessment while considering sport-specific traumatic and bleeding risks. Rhythm control is particularly relevant in athletes, in whom long-term antiarrhythmic drug therapy may be limited by tolerability and effects on exercise performance; catheter ablation represents an important therapeutic option in appropriately selected individuals. Return-to-play decisions should consider arrhythmia control, cardiac substrate, and sport-specific demands. AF should not automatically lead to restriction from physical activity; exercise should instead be individually prescribed to preserve its cardiovascular benefits while minimizing conditions potentially promoting AF development or recurrence.

Regular physical activity offers numerous benefits to children's health and well-being and is essential for reducing cardiovascular risk in children with cardiovascular disease. Despite increasing evidence supporting its benefits, many young patients remain insufficiently active because of concerns regarding exercise related risks, limited expertise. This clinical consensus statement provides practical guidance for the prescription of exercise and physical activity in children and adolescents aged 6 to 17 years with cardiovascular disease. The document aims to bridge the gap between evidence supporting the benefits of physical activity and its implementation in daily clinical practice, promoting safe participation in sport and exercise across a broad spectrum of cardiovascular conditions. This consensus statement outlines an individualised, patient-centred approach to exercise prescription based on clinical assessment, cardiovascular risk stratification, and the FITT principle: frequency, intensity, time, and type. Specific recommendations are provided for congenital and acquired heart disease, cardiomyopathies, arrhythmias, pulmonary hypertension, cardio-oncology patients, and children with physical disabilities or syndromes. The document emphasises the importance of multidisciplinary care, periodic follow up, exercise testing when indicated, and tailored programs adapted to the child’s clinical condition, developmental stage, and personal preferences. The overarching goal is to encourage safe and enjoyable participation in physical activity, improve quality of life and functional capacity, and foster lifelong healthy behaviours in children with cardiovascular disease.

Heart failure with preserved ejection fraction (HFpEF) represents an increasingly prevalent clinical syndrome, driven by population ageing and the growing burden of cardiometabolic comorbidities, and is associated with significant morbidity and mortality. Due to its heterogeneous pathophysiology and the frequent absence of overt structural abnormalities, early diagnosis and accurate risk stratification remain challenging. In the current era of emerging disease-modifying therapies, the identification of sensitive imaging markers able to detect early myocardial dysfunction and refine patient characterization has become increasingly important. Speckle-tracking echocardiography has emerged as a valuable tool for the comprehensive evaluation of HFpEF, allowing the assessment of subclinical myocardial impairment beyond conventional parameters. Left ventricular global longitudinal strain (LV-GLS) identifies subtle systolic dysfunction despite preserved left ventricular ejection fraction (LVEF) and provides incremental diagnostic and prognostic information. Accordingly, LV-GLS has been incorporated into contemporary diagnostic algorithms and may represent a promising marker for monitoring disease progression and therapeutic response. Beyond the left ventricle (LV), left atrial (LA) strain has gained increasing relevance as a marker of atrial myopathy and elevated filling pressures. Left atrial reservoir strain (LARS) detects early atrial dysfunction before overt structural remodelling, improves the identification of HFpEF in patients with unexplained dyspnoea, and provides additional prognostic information, including prediction of atrial fibrillation and thromboembolic risk. Moreover, right ventricular free-wall longitudinal strain (RV-FWLS) allows early recognition of right ventricular involvement and has shown important prognostic implications, particularly in relation to pulmonary vascular dysfunction and exercise intolerance. Overall, a multi-chamber strain-based approach may improve HFpEF diagnosis, phenotyping, and risk stratification, supporting a transition toward a more personalized management strategy. Further prospective studies are needed to define the role of strain imaging in guiding therapeutic decisions and monitoring treatment response.

Long-term exposure to high-intensity endurance exercise induces significant physiological cardiovascular remodelling. However, recent evidence suggests that prolonged exercise in athletes, particularly those exposed to decades of intensive training, may be associated with features of cardiovascular ‘wear and tear’. These include electrical changes such as an increased risk of sinus node dysfunction and atrial fibrillation as well as structural abnormalities such as focal non-ischaemic fibrosis and coronary artery calcification, more frequently observed in middle-aged and older endurance athletes. These observations suggest that long-term high-intensity exercise may have deleterious cardiovascular effects in susceptible individuals, although the available data are primarily derived from male Caucasian athletes. While the clinical significance of these potentially maladaptive changes at the individual level remains uncertain, at a population level, high intensities and volumes of physical activity are consistently associated with reduced cardiovascular and all-cause mortality compared with sedentary behaviour, although the incremental survival benefit may plateau at very high exercise volumes. This review critically appraises the available evidence on chronic adverse cardiovascular adaptations associated with intense endurance exercise, highlighting unresolved controversies, sex- and ethnicity-related knowledge gaps, and the need to balance potential risks against the well-established survival benefits of lifelong physical activity.

Background: It is known that mitral valve surgery produces an early reduction in hemodynamic overload after the procedure. However, the reduction in left ventricular (LV) ejection fraction (EF) may persist over the long term. Speckle-tracking echocardiography (STE) provides more sensitive indices of cardiac performance in MR. Myocardial work (MW) evaluates LV performance by considering the effect of LV afterload. The aim of this study was to describe the acute and late postoperative changes in cardiac function and hemodynamics using STE and MW indices in patients with primary MR and to find echocardiographic predictors of postoperative symptom improvement. Methods: Consecutive patients with severe MR and preserved LV EF undergoing mitral valve repair or replacement were prospectively enrolled. Exclusion criteria were atrial fibrillation, previous cardiac surgery, and concomitant aortic or coronary surgery. Patients underwent clinical, biohumoral and echocardiographic evaluation before surgery and within one week after surgery during the hospitalization period. Then, 32 of them underwent a new echocardiographic exam, completed by MW, at long-term follow-up. Results: Overall, 42 patients were enrolled (mean age 65 ± 12 years, 50% male, mean LV EF 59 ± 4%). After intervention, 48% of patients showed a reduction in LV EF (n = 20), while most patients showed reductions in STE and MW parameters across all chambers. Particularly, the global work index (GWI) was reduced in 79% of patients (n = 33). After a mean long-term follow-up of 26 ± 5 months, all STE parameters significantly improved in >70% of patients (n = 22), while LV EF maintained its initial reduction. A baseline value of LV GLS > −17.7% identified patients with persistence of symptoms at long-term follow-up (AUC 0.68, p = 0.02). Conclusions: After an initial decline, LV function detected by GLS improved over the long term after mitral valve surgery, paralleling a reduction in symptoms. STE indices might provide additional value for the long-term follow-up of patients undergoing mitral valve repair/replacement.

This expert opinion paper focuses on the clinical implementation, execution, and interpretation of cardiopulmonary exercise testing (CPET), providing comprehensive insights into its recognized prognostic, diagnostic, and prescriptive value in everyday clinical practice. A practical guide offers step-by-step instructions on conducting and interpreting CPET, emphasizing the importance of high-quality testing for the benefit of patients, healthy individuals, and athletes. The approach considers test objectives, how to adapt procedures for different medical inquiries and reporting. A systematic method for interpreting CPET data is outlined, covering aerobic/exercise capacity evaluations with subsequent analyses of ventilatory, cardiovascular, cardiorespiratory gas-exchange, and muscular-metabolic responses to exercise. Special attention is given to post-exercise recovery and other novel parameters for informed clinical decision-making. The outcomes emphasize the need for better implementation of CPET for prognostic evaluations and in diagnostic pathways. Barriers to its adoption are discussed, including logistical challenges or resource constraints, and strategies for integrating CPET into routine care pathways are proposed. The statement provides further details on how to utilize CPET outcomes to tailor exercise prescription based on identified functional limitations and adjust exercise intensity using different physiological and pathological thresholds for both patients and athletes. Finally, the latest advancements in CPET are explored, including novel portable systems and integration with transcutaneous blood-gas monitoring, imaging, and (non-)invasive haemodynamic measures, also addressing the potential for smaller clinics, improving accessibility in clinical practice. This expert opinion statement aims to offer a roadmap for making CPET a more standardized and accessible tool in clinical care.

Patients with cancer usually report limitations of their functional capacity, which may range from subclinical impairment of cardiopulmonary exercise reserve to poor quality of life with physical, cognitive, or psychosocial consequences. Exercise training is a potent multi-targeted approach to control pre-existing and new risk factors. Preliminary evidence shows that it is associated with a lower risk of cancer therapy-related cardiotoxicity and increased self-reported well-being in patients with cancer. Current evidence demonstrates that supervised exercise therapy, including high-intensity interval training, is safe and well-tolerated and reduces risk in subjects with cancer in the pre-, active-, and post-treatment settings. The present consensus document will discuss the role of exercise training in cardio-oncology, focusing on patients with cardiovascular diseases induced by cancer treatment and on those who received cardiotoxic therapies.