Рекомендации кардиологов по отбору и отсеву спортсменов

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Рекомендации кардиологов по отбору и отсеву спортсменов.

Task Force 1: Classification of Sport
[Изображения доступны только зарегистрированным пользователям]

Наиболее безопасны боулинг, керлинг, гольф, йога.
Остальные градируются по нагрузкам: динамические и/или статические.

Causes of Sudden Death in Athletes
The cardiovascular causes of sudden death in young athletes have been well documented in forensic databases (5–9). These deaths occur in both sexes (although more commonly in males, by 9:1); in minorities, prominently including African-Americans and in a wide range of individual and team sports. In the United States, among people <35 years old, genetic heart diseases predominate, with hypertrophic cardiomyopathy being the most common, accounting for at least one-third of the mortality in autopsy-based athlete study populations (5–7). Congenital coronary anomalies (usually those of wrong sinus origin) are second in frequency, occurring in ≈15% to 20% of cases. Other less common diseases, each responsible for ≈5% or fewer of these sudden deaths, include myocarditis, aortic valve stenosis, aortic dissection/rupture (including cases of the Marfan phenotype), atherosclerotic coronary artery disease, ion channelopathies, and arrhythmogenic right ventricular cardiomyopathy. In addition, commotio cordis (i.e., sudden death caused by blunt, nonpenetrating chest blows, associated with structurally normal hearts) is more common as a cause of sudden death in young athletes than many of the aforementioned structural cardiovascular diseases (10).
Regional variations in the causes of sudden death may exist (6–9). Notable among these, arrhythmogenic right ventricular cardiomyopathy has been reported as the most common cause of sudden death in young athletes based on reports from the Veneto region of Italy (8), whereas this disease is a much less frequent cause of sudden death in U.S. athletes (6). In most athletes, sudden death occurs in the setting of ventricular fibrillation, with the notable exception of aortic dilation that leads to dissection and rupture. For older athletes (>35 years of age), atherosclerotic coronary artery disease is the predominant cause of sudden death (7), but this occurs less frequently in younger participants.

Journal of the American College of Cardiology Volume 66, Issue 21, December 2015
Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Preamble, Principles, and General Considerations
A Scientific Statement From the American Heart Association and American College of Cardiology
Barry J. Maron, Douglas P. Zipes and Richard J. Kovacs
[Ссылки доступны только зарегистрированным пользователям ]

Наиболее частые кардиологические причины смерти спортсменов.
Мужчины погибают чаще женщин (9 к 1).
На первом месте гипертрофическая кардиомиопатия, 1/3 всех случаев. Коронарные аномалии на 2 месте (15%-20%). Далее: миокардиты, аортальный стеноз, диссекция аорты, ИБС, каналопатии (от себя: включая проблемы с QT), аритмогенная дисплазия правого желудочка.
Наиболее часто смерть начинается с фибрилляции желудочков.

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This is an update to the Bethesda #36 report (2005) addressing eligibility and disqualification criteria for competitive athletes with cardiovascular conditions. As with previous reports, its emphasis is toward student athletes of high school and college age (12–25 years). There is a preamble and 15 Task Forces, each with unique titles and authors. The following is a list of the 15 Task Forces, and a few points to remember for each:

Task Force 1: Classification of Sport: Dynamic, Static, and Impact. All sports are classified in terms of their dynamic and static natures, impact, and respective intensities (low, medium, high).
Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes. Data from the Veneto region of Italy that support the utility of electrocardiography (ECG) screening among all competitive athletes have not been reproduced in other settings. The current recommendations stress the utility of a standardized history and physical examination for purposes of screening competitive athletes. ECG screening in small cohorts of young people may be considered in addition to a comprehensive history and physical examination, but should not necessarily be limited to athletes and should be done only with close physician supervision and sufficient quality control.
Task Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis. Specific recommendations are made, including participation of hypertrophic cardiomyopathy (HCM) genotype-positive athletes without left ventricular hypertrophy, counseling against the placement of prophylactic implantable cardioverter-defibrillators (ICDs) in athletes with HCM for the sole purpose of athletic participation, and assuring that athletes with probable or definitive myocarditis defer returning to athletic participation until evidence that active inflammation has resolved.
Task Force 4: Congenital Heart Disease (CHD). Recommendations are based on categories of CHD including:
Simple shunts (atrial septal defect, ventricular septal defect, patent ductus arteriosus)
Pulmonic and aortic stenosis, and aortic coarctation
Increased pulmonary vascular resistance in CHD
Cyanotic CHD, including tetralogy of Fallot
Transposition of the great arteries (D-loop, L-loop)
Ebstein’s anomaly
Coronary artery anomalies
Task Force 5: Valvular Heart Disease. Recommendations are based on categories of valve disease including:
Aortic stenosis, aortic regurgitation, bicuspid aortic valve
Mitral stenosis, mitral regurgitation
Athletes having undergone surgical intervention for valve disease
Task Force 6: Hypertension. Recommendations include careful assessment of blood pressure prior to beginning athletic training (Class I); allowable athletic participation for athletes with stage 1 hypertension in the absence of target organ damage (Class I); and restriction from participation, particularly from high static sports (e.g., weight lifting, boxing, wrestling) of athletes with stage 2 hypertension (blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥100 mm Hg) even in the absence of target organ damage.
Task Force 7: Aortic Diseases, Including Marfan Syndrome. Recommendations include indexing the observed aorta diameter to an expected aorta size (Devereux RB, et al. Am J Cardiol 2012;110:1189-94), and separately addressing athletes with Marfan syndrome, bicuspid aortopathy, and family history of aortic disease.
Task Force 8: Coronary Artery Disease. Recommendations include performance of maximal exercise testing in competitive athletes with known atherosclerotic coronary artery disease for assessment of inducible ischemia and exercise-induced electrical instability (Class I), and assessment of left ventricular systolic function among athletes with known coronary artery disease (Class I).
Task Force 9: Arrhythmias and Conduction Defects. Recommendations are based on the following categories:
Sinus bradycardia
First- and second-degree heart block; right bundle branch block, left bundle branch block, and complete heart block
Supraventricular tachycardia, atrial fibrillation and flutter, atrioventricular nodal re-entrant tachycardia
Premature ventricular contractions, nonsustained ventricular tachycardia (VT), sustained monomorphic and sustained polymorphic VT
Athletes with an ICD
Task Force 10: The Cardiac Channelopathies. Recommendations include evaluation by a heart rhythm specialist or genetic cardiologist with experience and expertise in channelopathies (Class I); and restriction from all competitive sports of any symptomatic competitive athlete with suspected or diagnosed cardiac channelopathy until a comprehensive evaluation has been completed, a treatment program has been implemented, and the athlete is asymptomatic on treatment for 3 months (Class I).
Task Force 11: Drugs and Performance Enhancing Substances. As a condition of participation in athletic activities, performance-enhancing drugs and supplements should be prohibited by schools, universities, and other sponsoring/participating organizations.
Task Force 12: Emergency Action Plans, Resuscitation, CPR, and AEDs. Schools and organizations hosting athletic events should have an emergency action plan (Class I); coaches and athletic trainers should be trained to implement timely cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) placement (Class I); and an AED should be available to a cardiac arrest victim within 5 minutes in all settings, including competition, training, and practice (Class I).
Task Force 13: Commotio Cordis. Defined as sudden cardiac death triggered by a relatively innocent blow to the precordium, commotion cordis is a rare event; focus should be on recognition and timely intervention, including CPR and defibrillation.
Task Force 14: Sickle Cell Trait. Recognized as a nontraumatic risk of sports participation, recognition of sickle cell trait is not a justification for disqualification from athletic participation (Class I). Preventative strategies (adequate rest, hydration) should be performed to minimize the likelihood of a cardiac event in an athlete with sickle cell trait (Class I).
Task Force 15: Legal Aspects of Medical Eligibility and Disqualification Recommendations. A physician’s general legal duty is to conform to accepted, customary, or reasonable medical practice in providing medical recommendations for sports participation that are consistent with an athlete’s short- and long-term best medical interests; a physician’s best medical judgment should not be compromised by an athlete’s desire to participate and in so doing assume medically unreasonable risk, or by the team’s desire for the athlete’s talents.

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Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes.

Recommendations
The guidelines presented here are those of the AHA/American College of Cardiology 2014 initiative (1).

1. It is recommended that the AHA’s 14-point screening guidelines and those of other societies, such as the American Academy of Pediatrics’ Preparticipation Physical Evaluation, be used by examiners as part of a comprehensive history taking and physical examination to detect or raise suspicion of genetic/congenital cardiovascular abnormalities (Class I; Level of Evidence C).

2. It is recommended that standardization of the questionnaire forms used as guides for examiners of high school and college athletes in the United States be pursued (Class I; Level of Evidence C).

3. Screening with 12-lead ECGs (or echocardiograms) in association with comprehensive history-taking and physical examination to identify or raise suspicion of genetic/congenital and other cardiovascular abnormalities may be considered in relatively small cohorts of young healthy people 12 to 25 years of age, not necessarily limited to competitive athletes (e.g., in high schools, colleges/universities or local communities). Close physician involvement and sufficient quality control is mandatory. If undertaken, such initiatives should recognize the known and anticipated limitations of the 12-lead ECG as a population screening test, including the expected frequency of false-positive and false-negative test results, as well as the cost required to support these initiatives over time (Class IIb; Level of Evidence C).

4. Mandatory and universal mass screening with 12-lead ECGs in large general populations of young healthy people 12 to 25 years of age (including on a national basis in the United States) to identify genetic/congenital and other cardiovascular abnormalities is not recommended for athletes and nonathletes alike (Class III, no evidence of benefit; Level of Evidence C).

5. Consideration for large-scale, general population, and universal cardiovascular screening in the age group 12 to 25 years with history taking and physical examination alone is not recommended (including on a national basis in the United States) (Class III, no evidence of benefit; Level of Evidence C).

Резюме.
Для предварительного отбора вполне достаточно обычного осмотра из 14 пунктов и стандартизированного опросника.
ЭКГ иногда может потребоваться в дополнение.
Массовый скрининг ЭКГ в популяции от 12 до 25 лет не нужен.
Специальные большие шкалы для осмотра и опроса не нужны.

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Task Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis.

Hypertrophic Cardiomyopathy
Recommendations
1. Participation in competitive athletics for asymptomatic, genotype-positive HCM patients without evidence of LV hypertrophy by 2-dimensional echocardiography and CMR is reasonable, particularly in the absence of a family history of HCM-related sudden death (Class IIa; Level of Evidence C).

2. Athletes with a probable or unequivocal clinical expression and diagnosis of HCM (ie, with the disease phenotype of LV hypertrophy) should not participate in most competitive sports, with the exception of those of low intensity (class IA sports) (see “Classification of Sport” [22]). This recommendation is independent of age, sex, magnitude of LV hypertrophy, particular sarcomere mutation, presence or absence of LV outflow obstruction (at rest or with physiological exercise), absence of prior cardiac symptoms, presence or absence of late gadolinium enhancement (fibrosis) on CMR, and whether major interventions such as surgical myectomy or alcohol ablation have been performed previously (Class III; Level of Evidence C).

3. Pharmacological agents (e.g., β-blockers) to control cardiac-related symptoms or ventricular tachyarrhythmias should not be administered for the sole purpose of permitting participation in high-intensity sports. Notably, such drugs may also be inconsistent with maximal physical performance in most sports (Class III; Level of Evidence C).

4. Prophylactic ICDs should not be placed in athlete-patients with HCM for the sole or primary purpose of permitting participation in high-intensity sports competition because of the possibility of device-related complications. ICD indications for competitive athletes with HCM should not differ from those in nonathlete patients with HCM (Class III; Level of Evidence B).

LV Noncompaction
Recommendations
1. Until more clinical information is available, participation in competitive sports may be considered for asymptomatic patients with a diagnosis of LVNC and normal systolic function, without important ventricular tachyarrhythmias on ambulatory monitoring or exercise testing, and specifically with no prior history of unexplained syncope (Class IIb; Level of Evidence C).

2. Athletes with an unequivocal diagnosis of LVNC and impaired systolic function or important atrial or ventricular tachyarrhythmias on ambulatory monitoring or exercise testing (or with a history of syncope) should not participate in competitive sports, with the possible exception of low-intensity class 1A sports, at least until more clinical information is available (Class III; Level of Evidence C).

Other Myocardial Diseases
Recommendations
1. Symptomatic athletes with DCM, primary nonhypertrophied restrictive cardiomyopathy, and infiltrative cardiac myopathies should not participate in most competitive sports, with the possible exception of low-intensity (class 1A sports) in selected cases, at least until more information is available (Class III; Level of Evidence C).

Myocarditis
Recommendations
1. Before returning to competitive sports, athletes who initially present with an acute clinical syndrome consistent with myocarditis should undergo a resting echocardiogram, 24-hour Holter monitoring, and an exercise ECG no less than 3 to 6 months after the initial illness (Class I; Level of Evidence C).

2. It is reasonable that athletes resume training and competition if all of the following criteria are met (Class IIa; Level of Evidence C):

a. Ventricular systolic function has returned to the normal range.

b. Serum markers of myocardial injury, inflammation, and heart failure have normalized.

c. Clinically relevant arrhythmias such as frequent or complex repetitive forms of ventricular or supraventricular ectopic activity are absent on Holter monitor and graded exercise ECGs.

At present, it is unresolved whether resolution of myocarditis-related LGE should be required to permit return to competitive sports.

3. Athletes with probable or definite myocarditis should not participate in competitive sports while active inflammation is present. This recommendation is independent of age, gender, and LV function (Class III; Level of Evidence C).

Arrhythmogenic Right Ventricular Cardiomyopathy
Recommendations
1. Athletes with a definite diagnosis of ARVC should not participate in most competitive sports, with the possible exception of low-intensity class 1A sports (Class III; Level of Evidence C).

2. Athletes with a borderline diagnosis of ARVC should not participate in most competitive sports, with the possible exception of low-intensity class 1A sports (Class III; Level of Evidence C).

3. Athletes with a possible diagnosis of ARVC should not participate in most competitive sports, with the possible exception of low-intensity class 1A sports (Class III; Level of Evidence C).

4. Prophylactic ICD placement in athlete-patients with ARVC for the sole or primary purpose of permitting participation in high-intensity sports competition is not recommended because of the possibility of device-related complications (Class III; Level of Evidence C).

Pericarditis
Recommendations
1. Athletes with pericarditis, regardless of its pathogenesis, should not participate in competitive sports during the acute phase. Such athletes can return to full activity when there is complete absence of evidence for active disease, including effusion by echocardiography, and when serum markers of inflammation have normalized. For pericarditis associated with evidence of myocardial involvement, eligibility should also be based on the course of myocarditis. Chronic pericardial disease that results in constriction disqualifies the person from all competitive sports (Class III; Level of Evidence C).

Резюме.
Гипертрофическая кардиомиопатия.
Генетические положительные, но без клинических проявлений, нормальной ЭхоКг и без плохого анамнеза могут быть допущены.
Люди с вероятным или установленным клиническим диагнозом не должны участвовать в большинстве соревновательных видов спорта, за исключением видов спорта с низкой интенсивностью (спорт класса IA), независимо от пола, возраста, выраженности гипертрофии.
Лекарства, например, бетаблокаторы, не должны использоваться с целью разрешить участие.
ИКД не имплантируют только ради участия в соревнованиях. Показания к ИКД такие же как у всех остальных.

Некомпактный миокард
Если без симптомов и анамнеза, то ситуация малоизучена и можно допустить.
Если есть симптомы и анамнез, то не допускать, за возможным исключением класса низкой интенсивности 1A.

Другие заболевания миокарда - не должны участвовать в спорте, за возможным исключением класса низкой интенсивности 1A.

Миокардит
Перед тем как вернуться к соревнованиям нужны ЭхоКг, ЭКГ с нагрузкой и Холтер в течение 3-6 месяцев как до заболевания.
Спортсмены с вероятным или установленным не участвуют, независимо от возраста, пола и функции ЛЖ.

Аритмогенная дисплазия правого желудочка
Вероятный, возможный и пограничный диагноз = противопоказание к спорту, за возможным исключением класса низкой интенсивности 1A (гольф, боулинг). ИКД не имплантируют ради цели участия в соревнованиях.

Перикардит
Во время острой фазы нельзя, если хронизируется - нельзя.
Возврат возможен при полном выздоровлении.

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Task Force 4: Congenital Heart Disease

Atrial Septal Defect
ASD: Untreated
Recommendations
1. It is recommended that athletes with small defects (<6 mm), normal right-sided heart volume, and no pulmonary hypertension should be allowed to participate in all sports (Class I; Level of Evidence C).
2. It is recommended that athletes with a large ASD and no pulmonary hypertension should be allowed to participate in all sports (Class I; Level of Evidence C).
3. Athletes with an ASD and pulmonary hypertension may be considered for participation in low-intensity class IA sports (Class I; Level of Evidence C).
4. Athletes with associated pulmonary vascular obstructive disease who have cyanosis and a large right-to-left shunt should be restricted from participation in all competitive sports, with the possible exception of class IA sports (Class III; Level of Evidence C).
ASD: After Surgical Repair or Closure by Interventional Catheterization
Recommendations
1. Three to 6 months after operation or intervention, athletes without pulmonary hypertension, myocardial dysfunction, or arrhythmias may participate in all sports (Class I; Level of Evidence C).
2. After operation or intervention, patients with pulmonary hypertension, arrhythmias, or myocardial dysfunction may be considered for participation in low-intensity class IA sports (Class IIb; Level of Evidence C).

Ventricular Septal Defect
VSD: Untreated
Recommendations
1. An athlete with a small or restrictive VSD with normal heart size and no pulmonary hypertension can participate in all sports (Class I; Level of Evidence C).
2. An athlete with a large, hemodynamically significant VSD and pulmonary hypertension may consider participation in only low-intensity class IA sports (Class IIb; Level of Evidence C).
VSD: After Surgical Repair or Closure by Interventional Catheterization
Recommendations
1. At 3 to 6 months after repair, asymptomatic athletes with no or a small residual defect and no evidence of pulmonary hypertension, ventricular or atrial tachyarrhythmia, or myocardial dysfunction can participate in all competitive sports (Class I; Level of Evidence C).
2. Athletes with persistent pulmonary hypertension should be allowed to participate in class IA sports only (Class I; Level of Evidence B).
3. Athletes with symptomatic atrial or ventricular tachyarrhythmias or second- or third-degree atrioventricular block should not participate in competitive sports until further evaluation by an electrophysiologist (Class III; Level of Evidence C).
4. Athletes with mild to moderate pulmonary hypertension or ventricular dysfunction should not participate in competitive sports, with the possible exception of low-intensity class IA sports (Class III; Level of Evidence C).

Patent Ductus Arteriosus
PDA: Untreated
Recommendations
1. Athletes with a small PDA, normal pulmonary artery pressure, and normal left-sided heart chamber dimension can participate in all competitive sports (Class I; Level of Evidence C).
2. Athletes with a moderate or large PDA and persistent pulmonary hypertension should be allowed to participate in class IA sports only (Class I; Level of Evidence B).
3. Athletes with a moderate or large PDA that causes left ventricular (LV) enlargement should not participate in competitive sports until surgical or interventional catheterization closure (Class III; Level of Evidence C).
PDA: Treated (After Surgical Repair or Closure by Interventional Catheterization)
Recommendations
1. After recovery from catheter or surgical PDA closure, athletes with no evidence of pulmonary hypertension can participate in all competitive sports (Class I; Level of Evidence C).
2. Athletes with residual pulmonary artery hypertension should be restricted from participation in all competitive sports, with the possible exception of class IA sports (Class I; Level of Evidence B).

Pulmonary Valve Stenosis
Recommendations
1. Athletes with mild PS and normal RV function can participate in all competitive sports. Annual reevaluation is also recommended (Class I; Level of Evidence B).
2. Athletes treated by operation or balloon valvuloplasty who have achieved adequate relief of PS (gradient <40 mm Hg by Doppler) can participate in all competitive sports (Class I; Level of Evidence B).
3. Athletes with moderate or severe PS can consider participation only in low-intensity class IA and IB sports (Class IIb; Level of Evidence B).
4. Athletes with severe pulmonary insufficiency as demonstrated by marked RV enlargement can consider participation in low-intensity class IA and IB sports (Class IIb; Level of Evidence B).

Aortic Valve Stenosis
Recommendations
1. Athletes with mild AS can participate in all competitive sports (Class I; Level of Evidence B).
2. Athletes with severe AS can participate only in low-intensity class IA sports (Class I; Level of Evidence B).
3. Athletes with moderate AS may be considered for participation in low static or low to moderate dynamic sports (class IA, IB, and IIA) (Class IIb; Level of Evidence B).
4. Athletes with severe AS should be restricted from all competitive sports, with the possible exception of low-intensity (class IA) sports (Class III; Level of Evidence B).
AS After Surgery or Balloon Dilation
Recommendations
1. Athletes with residual AS may be considered for participation in sports according to the above recommendations based on severity (Class IIb; Level of Evidence C).
2. Athletes with significant (moderate or severe) aortic valve insufficiency may participate in sports according to the recommendation of Task Force 5 in this document (8).

Coarctation of the Aorta
Coarctation of the Aorta: Untreated
Recommendations
1. Athletes with coarctation and without significant ascending aortic dilation (z score ≤3.0; a score of 3.0 equals 3 standard deviations from the mean for patient size) with a normal exercise test and a resting systolic blood pressure gradient <20 mm Hg between the upper and lower limbs and a peak systolic blood pressure not exceeding the 95th percentile of predicted with exercise can participate in all competitive sports (Class I; Level of Evidence C).
2. Athletes with a systolic blood pressure arm/leg gradient >20 mm Hg or exercise-induced hypertension (a peak systolic blood pressure exceeding the 95th percentile of predicted with exercise) or with significant ascending aortic dilation (z score >3.0) may be considered for participation only in low-intensity class IA sports (Class IIb; Level of Evidence C).
Coarctation of the Aorta: Treated by Surgery or Balloon and Stent
Recommendations
1. Athletes who are >3 months past surgical repair or stent placement with <20 mm Hg arm/leg blood pressure gradient at rest, as well as (1) a normal exercise test with no significant dilation of the ascending aorta (z score <3.0), (2) no aneurysm at the site of coarctation intervention, and (3) no significant concomitant aortic valve disease, may be considered for participation in competitive sports, but with the exception of high-intensity static exercise (classes IIIA, IIIB, and IIIC), as well as sports that pose a danger of bodily collision (Class IIb; Level of Evidence C).
2. Athletes with evidence of significant aortic dilation or aneurysm formation (not yet at a size to need surgical repair) may be considered for participation only in low-intensity (classes IA and IB) sports (Class IIb; Level of Evidence C).

Elevated Pulmonary Vascular Resistance in CHD
Recommendations
1. Patients with mean pulmonary artery pressure of <25 mm Hg can participate in all competitive sports (Class I; Level of Evidence B).
2. Patients with moderate or severe pulmonary hypertension, with a mean pulmonary artery pressure >25 mm Hg, should be restricted from all competitive sports, with the possible exception of low-intensity (class IA) sports. Complete evaluation and exercise prescription (physician guidance on exercise training) should be obtained before athletic participation (Class III; Level of Evidence B).

Резюме.
Небольшие пороки (дефекты межпредсердной и межжелудочковой перегородок и открытый артериальный проток). Если маленькие и без симптомов и без нарушения функции, то можно во всех видах спорта. Если с нарушением функции и с симптомами, то спорт только класса низкой интенсивности 1A.
После операции через 3-6 месяцев, если нет симптомов и нарушения функции, то можно любым видом спорта. Если есть остаточные явления, то спорт только класса низкой интенсивности 1A.

Стеноз клапана легочной артерии. Если небольшой и без нарушения функции и если после операции или баллонирования с градиентом менее 40 мм рт.ст. то разрешены все виды спорта.
При средней и тяжелой степени можно рассмотреть возможность участия только в спортивных соревнованиях класса IA и IB с низкой интенсивностью.

Стеноз аортального клапана. Если легкая степень, то все виды, если тяжелая, то только 1А, если умеренная, то класс IA, IB и IIA. При тяжелой лучше без соревнований.
После операции/баллонирования в зависимости от тяжести остаточных явлений по принципу как без операции.

Коарктация аорты. При незначительной, если разница давления между руками и ногами менее 20 мм рт.ст и нормальный тест на нагрузку, то разрешены все виды. Если разница давления больше 20 мм рт.ст., при нагрузке гипертония и восходящая дилатация, то участие только в спортивных состязаниях класса низкой интенсивности IA.
После операции, если после 3 месяцев после операции разница давления рук и ног менее 20 мм рт.ст. и нормальный тест на нагрузку, то допустимы все виды. Если нет, то классы IA и IB.

Легочная гипертензия. При давлении в ЛА менее 25 мм рт.ст. допустимы любые виды, если давление выше, то нет.

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Task Force 6: Hypertension. Recommendations include careful assessment of blood pressure prior to beginning athletic training (Class I); allowable athletic participation for athletes with stage 1 hypertension in the absence of target organ damage (Class I); and restriction from participation, particularly from high static sports (e.g., weight lifting, boxing, wrestling) of athletes with stage 2 hypertension (blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥100 mm Hg) even in the absence of target organ damage.

Recommendations

1.
It is reasonable that the presence of stage 1 hypertension in the absence of target-organ damage should not limit the eligibility for any competitive sport. Once having begun a training program, the hypertensive athlete should have BP measured every 2 to 4 months (or more frequently, if indicated) to monitor the impact of exercise (Class I; Level of Evidence B).

2.
Before people begin training for competitive athletics, it is reasonable that they undergo careful assessment of BP, and those with initially high levels (>140 mm Hg systolic or >90 mm Hg diastolic) should have comprehensive out-of-office measurements to exclude errors in diagnosis. Ambulatory BP monitoring with proper cuff and bladder size would be the most precise means of measurement (Class I; Level of Evidence B).

3.
Those with prehypertension (BP of 120/80 mm Hg–139/89 mm Hg) should be encouraged to modify their lifestyles but should not be restricted from physical activity. Those with sustained hypertension should have screening echocardiography performed. Athletes with LVH beyond that seen with “athlete’s heart” should limit participation until BP is normalized by appropriate antihypertensive drug therapy (Class IIa; Level of Evidence B).
4.

It is reasonable that athletes with stage 2 hypertension (a systolic BP >160 mm Hg or a diastolic BP >100 mm Hg), even without evidence of target-organ damage, should be restricted, particularly from high static sports, such as weight lifting, boxing, and wrestling, until hypertension is controlled by either lifestyle modification or drug therapy (Class IIa; Level of Evidence B).

5.
When prescribing antihypertensive drugs, particularly diuretic agents, for competitive athletes, it is reasonable for clinicians to use drugs already registered with appropriate governing bodies and if necessary obtain a therapeutic exemption (Class IIa; Level of Evidence B).

6.
When hypertension coexists with another cardiovascular disease, it is reasonable that eligibility for participation in competitive athletics is based on the type and severity of the associated condition (Class IIa; Level of Evidence C).

Рекомендации

1. Наличие гипертонии 1 стадии при отсутствии поражения органов-мишеней не должно ограничивать право на участие в каком-либо соревновательном виде спорта. После начала тренировочной программы спортсмену-гипертонику следует измерять АД каждые 2–4 месяца (или чаще, если показано) для контроля воздействия упражнений (класс I; уровень доказательности B).

2. Прежде чем люди начнут тренироваться для участия в соревнованиях по легкой атлетике, разумно провести тщательную оценку АД, а лицам с исходно высоким уровнем (>140 мм рт.ст. систолическое или >90 мм рт.ст. диастолическое) следует провести всесторонние внеофисные измерения для исключения ошибок. в диагностике. Амбулаторный мониторинг АД с использованием манжеты и мочевого пузыря надлежащего размера будет наиболее точным средством измерения (класс I; уровень доказательности B).

3. Людей с предгипертензией (АД 120/80 мм рт. ст.–139/89 мм рт. ст.) следует поощрять к изменению образа жизни, но не ограничивать в физической активности. Людям с устойчивой артериальной гипертензией следует провести скрининговую эхокардиографию. Спортсменам с ГЛЖ выше, чем при «спортивном сердце», следует ограничить участие до тех пор, пока АД не нормализуется с помощью соответствующей антигипертензивной лекарственной терапии (класс IIa; уровень доказательности B).

4. Разумно, что спортсменам с артериальной гипертензией 2 стадии (систолическое АД >160 мм рт.ст. или диастолическое АД >100 мм рт.ст.), даже без признаков поражения органов-мишеней, следует ограничить, в частности, занятия спортом с высокой статической нагрузкой, например тяжелой атлетикой, боксом и борьбой до тех пор, пока артериальная гипертензия не будет контролироваться модификацией образа жизни или медикаментозной терапией (класс IIa; уровень доказательности B).

5. При назначении антигипертензивных препаратов, особенно диуретиков, соревнующимся спортсменам клиницистам целесообразно использовать препараты, уже зарегистрированные в соответствующих руководящих органах, и, при необходимости, получить терапевтическое разрешение (класс IIa; уровень доказательности B).

6. Когда гипертония сосуществует с другим сердечно-сосудистым заболеванием, право на участие в спортивных соревнованиях основывается на типе и тяжести ассоциированного состояния (класс IIa; уровень доказательности C).