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Title Page |
3 |
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Copyright Page |
4 |
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Contents |
5 |
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Contributors |
12 |
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Foreword |
15 |
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Preface |
16 |
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Part 1 The Cardiovascular System |
19 |
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Chapter 1 Anatomy and Physiology of the Heart |
21 |
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Introduction |
21 |
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Gross Cardiac Anatomy |
21 |
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Electrical Conduction in the Heart |
24 |
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Structure of the Cardiomyocyte |
26 |
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Cardiac Function |
27 |
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Intrinsic and Extrinsic Regulation of Cardiac Function |
28 |
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Conclusion |
30 |
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Chapter 2 The Vascular System |
31 |
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Introduction |
31 |
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The Circulatory Systems |
31 |
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The Systemic Circulation |
31 |
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The Lymphatic System |
33 |
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Control of Blood Flow |
33 |
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Neural Regulation |
34 |
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Local Regulating Mechanisms |
35 |
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Nitric Oxide |
35 |
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Mechanisms that Mediate Vasodilator Function |
36 |
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Haemodynamics |
37 |
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Conclusion |
38 |
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Chapter 3 Energy Production Pathways During Exercise |
39 |
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Introduction |
39 |
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Primary Sources of Energy in the Human Body |
39 |
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Interacting Energy Systems During Exercise |
41 |
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Measurement of Energy Sources |
45 |
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Training Effect |
47 |
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Conclusion |
48 |
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References |
48 |
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Chapter 4 Cardiovascular Responses to Exercise |
50 |
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Introduction |
50 |
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Cardiovascular Responses to Aerobic Exercise |
50 |
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Cardiovascular Responses to Static Exercise |
58 |
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Conclusion |
59 |
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References |
60 |
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Chapter 5 The Athlete’s Heart: Impact of Age, Sex, Ethnicity and Sporting Discipline |
61 |
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Introduction |
61 |
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Electrical Remodelling in the Athlete’s Heart |
61 |
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Structural Remodelling in the Athlete’s Heart |
61 |
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The Influence of Age on the Athlete’s Heart |
62 |
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The Influence of Sex on the Athlete’s Heart |
64 |
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The Influence of Ethnicity on the Athlete’s Heart |
64 |
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Influence of Sporting Discipline on the Athlete’s Heart |
68 |
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Conclusion |
68 |
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References |
69 |
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Chapter 6 Physical Activity in the Prevention and Management of Atherosclerotic Disease |
71 |
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Introduction |
71 |
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Definitions Encompassing Physical Activity |
71 |
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Preventing CVD: The Continuum of Human Activity from Sedentary Behaviour to Moderate- to Vigorous-Intensity Physical Activity |
71 |
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Physical Activity within Rehabilitation and Secondary Prevention |
73 |
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Early Commencement of Exercise Rehabilitation |
74 |
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Reducing Risk of Exertion-Related Events |
75 |
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Post-surgery and Early Rehabilitation |
76 |
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Post-Angioplasty and Post-Myocardial Infarction |
77 |
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Conclusion |
77 |
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References |
78 |
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Part 2 Preventing Sudden Cardiac Death in Athletes |
81 |
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Chapter 7 Incidence and Aetiology of Sudden Cardiac Death in Athletes |
83 |
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Introduction |
83 |
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Developing a Numerator and Denominator |
83 |
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The Incidence of SCD |
85 |
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Are Athletes at Greater Risk of SCD than Non-athletes? |
89 |
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Relative Frequency of SCD |
89 |
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Aetiology of SCD |
89 |
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Conclusion |
90 |
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References |
90 |
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Chapter 8 Cardiovascular Screening for the Prevention of Sudden Cardiac Death in Athletes |
92 |
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Introduction |
92 |
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The Risk of Sudden Death in Athletes |
92 |
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Rationale for Screening Competitive Athletes |
93 |
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The Screening Programmes Implemented in Italy |
93 |
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Rationale for Including a 12-Lead ECG in the PPE |
94 |
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Efficacy of Screening to Identify Cardiac Disease Risk |
94 |
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Impact of the Screening Programme on Cardiac Mortality |
95 |
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Costs of Systematic Screening across Italy |
96 |
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Limitations of Screening Programmes |
97 |
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Conclusion |
98 |
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References |
98 |
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Chapter 9 Comparison of Pre-participation Evaluations for Assessing Cardiovascular Risk in Athletes |
100 |
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Introduction |
100 |
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American Heart Association (AHA) |
100 |
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Pre-participation Physical Evaluation Monograph 4th Edition (4th Monograph) |
101 |
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European Society of Cardiology (ESC) |
102 |
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International Olympic Committee (IOC) |
103 |
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Fédération Internationale de Football Association (FIFA) |
103 |
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Comparison of the Five Protocols |
103 |
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Considerations |
109 |
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Conclusion |
111 |
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Acknowledgements |
111 |
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References |
111 |
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Chapter 10 Normal Electrocardiographic Findings in Athletes |
113 |
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Introduction |
113 |
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Normal ECG Findings in Athletes |
113 |
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Sinus Bradycardia |
113 |
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Sinus Arrhythmia |
113 |
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Junctional Escape Rhythm |
114 |
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Ectopic Atrial Rhythm |
114 |
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First-Degree Atrioventricular Block |
114 |
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Second-Degree Atrioventricular Block (Mobitz Type I/Wenckebach Phenomenon) |
114 |
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Incomplete Right Bundle Branch Block |
115 |
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Early Repolarisation |
116 |
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QRS Voltage Criteria for Left Ventricular Hypertrophy |
118 |
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Repolarisation Findings in Relation to Age and Ethnicity |
118 |
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Criteria for Interpretation of the Athletes’ ECGs |
118 |
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Conclusion |
120 |
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References |
120 |
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Chapter 11 Abnormal Electrocardiographic Findings in Athletes: Recognising Changes Suggestive of Cardiomyopathy |
122 |
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Introduction |
122 |
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T-Wave Inversion |
124 |
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ST-Segment Depression |
126 |
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Pathological Q-Waves |
126 |
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Voltage Criterion for Left Ventricular Hypertrophy |
126 |
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Voltage Criterion for Right Ventricular Hypertrophy |
127 |
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Intraventricular Conduction Abnormalities and QRS Fragmentation |
127 |
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Voltage Criteria for QRS-Axis Deviation and Atrial Enlargement |
128 |
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Premature Ventricular Contraction |
130 |
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Other ECG Phenotypes Associated with Cardiomyopathy |
130 |
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Conclusion |
131 |
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References |
131 |
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Chapter 12 Abnormal Electrocardiographic Findings in Athletes: Recognising Changes Suggestive of Primary Electrical Disease |
132 |
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Introduction |
132 |
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Long QT Interval |
132 |
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Short QT Interval |
135 |
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Brugada Pattern |
135 |
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Wolff–Parkinson–White Pattern |
137 |
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Supraventricular Tachycardias |
140 |
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Premature Ventricular Contractions and Ventricular Arrhythmias |
140 |
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Sinus Bradycardia |
141 |
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Heart Block |
142 |
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Sudden Death Syndromes with a Normal ECG |
144 |
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Conclusion |
144 |
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References |
144 |
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Chapter 13 Effective Echocardiographic Assessment of the Athlete: Basic Examination to Advanced Imaging Techniques |
146 |
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Introduction |
146 |
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Stage 1: Pre-echocardiographic Information |
146 |
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Stage 2: Standard Echocardiographic Examination |
148 |
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Stage 3: Novel Echocardiographic Indices |
155 |
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Stage 4: The Role of Exercise |
161 |
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Conclusion |
162 |
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References |
162 |
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Chapter 14 Early Repolarisation in Athletes |
165 |
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Introduction |
165 |
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Early Repolarisation Syndrome |
165 |
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Defining ER |
165 |
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ER in the General Population |
166 |
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Prevalence of ER in Athletes |
167 |
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Prognosis of ER in Athletes |
168 |
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Conclusion |
169 |
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References |
169 |
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Chapter 15 Clinical (Laboratory) Exercise Testing |
171 |
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Introduction |
171 |
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Basic Principles |
171 |
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Methods |
172 |
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ECG Recording |
175 |
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ECG Interpretation |
178 |
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Conclusion |
179 |
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References |
180 |
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Chapter 16 The Role of Cardiovascular Magnetic Resonance in the Assessment of Athletes |
181 |
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Introduction |
181 |
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The Athletes Heart |
183 |
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Who Should Have a CMR? |
183 |
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Hypertrophic Cardiomyopathy |
183 |
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Other Causes of LVH |
185 |
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Myocarditis |
188 |
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Cardiac Sarcoid |
188 |
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Coronary Artery Disease |
190 |
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Future Directions |
190 |
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Conclusion |
191 |
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Acknowledgements |
191 |
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References |
191 |
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Chapter 17 Genetic Testing for Cardiovascular Conditions Predisposing to Sudden Death |
193 |
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Introduction |
193 |
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Genetics of Inherited CVD |
193 |
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Genetic Testing for Inherited CVD |
196 |
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Genetic Testing in Sudden Death Risk Assessment |
198 |
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Genetic Testing in the Athlete |
200 |
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Conclusion |
203 |
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References |
204 |
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Part 3 Cardiac Conditions Predisposing to Sudden Cardiac Death |
205 |
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Section 1 Introduction |
207 |
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Chapter 18 Causes of Sudden Cardiac Death in Sport: The Importance of Autopsy and Specialist Examination of the Heart |
209 |
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Introduction |
209 |
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Disorders of the Coronary Arteries |
209 |
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Disorders of the Heart Muscle |
212 |
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Cardiac Valve Disease |
216 |
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Morphologically Normal Heart |
216 |
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Conduction System |
217 |
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Aortic Dissection |
217 |
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Blunt Chest Trauma |
218 |
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Sickle?Cell Disease |
218 |
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Conclusion |
219 |
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References |
219 |
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Section 2 Inherited and Congenital Cardiovascular Pathologies |
221 |
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Chapter 19 Hypertrophic Cardiomyopathy |
223 |
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Introduction |
223 |
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Epidemiology |
223 |
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Genetics |
224 |
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Diagnosis |
224 |
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Electrocardiogram Abnormalities |
227 |
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Left Ventricular Outflow Tract Obstruction |
227 |
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Differentiation from Athlete’s Heart |
227 |
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Natural History and Clinical Course |
228 |
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Management Considerations |
229 |
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Conclusion |
233 |
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References |
233 |
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Chapter 20 Arrhythmogenic Right Ventricular Cardiomyopathy |
235 |
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Introduction |
235 |
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Pathophysiology and Natural History |
235 |
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Diagnosis |
237 |
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Prevention of ARVC?Related Sudden Death |
241 |
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Clinical Management of Athletes with ARVC |
244 |
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Acknowledgments |
247 |
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References |
247 |
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Chapter 21 Dilated Cardiomyopathy, Left Ventricular Hypertrabeculation and Noncompaction |
249 |
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Introduction |
249 |
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Dilated Cardiomyopathy |
249 |
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Left Ventricular Noncompaction |
252 |
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Conclusion |
256 |
|
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References |
256 |
|
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Chapter 22 Marfan Syndrome and Aortopathies |
258 |
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What is Marfan Syndrome? |
258 |
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Salient Features |
258 |
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Diagnosis |
259 |
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Cardiac Problems |
260 |
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Impact on Physical Activity |
260 |
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Guidelines |
261 |
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Medication Impact on Physical Activity |
262 |
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Problems Encountered by Patients |
262 |
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Who Should be Aware? |
263 |
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What Advice is Needed? |
263 |
|
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After Surgery |
263 |
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Other Aortopathies |
263 |
|
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Conclusion |
264 |
|
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References |
264 |
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|
Chapter 23 Valvular Disease |
265 |
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Basic Principles |
265 |
|
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Aortic Valvular Disease |
271 |
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Mitral Valvular Disease |
275 |
|
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Right Heart Valvular Disease |
278 |
|
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Prosthetic Valves |
278 |
|
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Conclusion |
279 |
|
|
References |
279 |
|
|
Chapter 24 Congenital Heart Disease |
281 |
|
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Introduction |
281 |
|
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Epidemiology of CHD |
281 |
|
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Aetiology of CHD |
281 |
|
|
CHD in the Athlete Population |
282 |
|
|
Mortality Risks of Sudden Cardiac Death in CHD |
282 |
|
|
Activity and Sports in CHD |
283 |
|
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Assessment Tools in CHD |
284 |
|
|
General Considerations in Athletes with CHD |
285 |
|
|
Athletic Performance and Complications in Common Specific Lesions |
288 |
|
|
Conclusion |
291 |
|
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References |
291 |
|
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Chapter 25 Congenital Coronary Artery Anomalies |
293 |
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Introduction |
293 |
|
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Anomalous Origin of a Coronary Artery from the Pulmonary Trunk |
293 |
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Anomalous Coronary Artery Origin from a Wrong Aortic Sinus |
294 |
|
|
Other CCAAs from the Aorta: Variants of Uncertain Significance |
295 |
|
|
In Vivo Diagnosis of CCAA Carrying a Risk of Sudden Death |
298 |
|
|
Risk Stratification and Clinical Management |
299 |
|
|
CCAA and Consensus Guidelines for Eligibility/Disqualification |
300 |
|
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Conclusion |
302 |
|
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Acknowledgement |
302 |
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References |
302 |
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Section 3 Ion Channelopathies, Accessory Pathways and Electrical Disease |
305 |
|
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26 Long QT Syndrome |
307 |
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Introduction |
307 |
|
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Clinical Presentation of Long QT Syndrome |
307 |
|
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Diagnostic Approach for an Athlete with Suspected Long QT Syndrome |
308 |
|
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Genetic Basis for Long QT Syndrome |
313 |
|
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Risk Stratification in Long QT Syndrome |
314 |
|
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Disease Management in Long QT Syndrome |
316 |
|
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Considerations in the Context of Exercise and Physical Activity |
317 |
|
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References |
319 |
|
|
27 Brugada Syndrome |
321 |
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Concept and Epidemiology |
321 |
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Genetic Basis |
321 |
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Clinical Presentation |
322 |
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Diagnostic Criteria |
326 |
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Risk Stratification |
327 |
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Management |
328 |
|
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Exercise Considerations |
329 |
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Conclusion |
331 |
|
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References |
331 |
|
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28 Wolff–Parkinson–White Syndrome |
333 |
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Introduction |
333 |
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Epidemiology |
333 |
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Aetiology |
333 |
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Genetics |
334 |
|
|
Associated Cardiac Abnormalities |
334 |
|
|
ECG Criteria for Diagnosis |
334 |
|
|
Clinical Presentation |
334 |
|
|
Risk assessment of WPW |
336 |
|
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Transcatheter Ablation |
338 |
|
|
Management Summary |
340 |
|
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References |
340 |
|
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29 Catecholaminergic Polymorphic Ventricular Tachycardia |
342 |
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Introduction |
342 |
|
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Genetics and Pathophysiology |
342 |
|
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Contribution to SCD |
343 |
|
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Evaluation of Suspected CPVT |
344 |
|
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Risk Stratification |
345 |
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Management |
345 |
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Future Directions |
347 |
|
|
References |
347 |
|
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30 Idiopathic Ventricular Tachycardia/Ventricular Fibrillation |
349 |
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Definitions |
349 |
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Idiopathic Ventricular Tachycardia |
349 |
|
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Idiopathic Ventricular Fibrillation |
355 |
|
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References |
356 |
|
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Section 4 Acquired Disorders |
359 |
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Chapter 31 Commotio Cordis |
361 |
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Introduction |
361 |
|
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Prevalence |
361 |
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|
Clinical Profile |
361 |
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Experimental Model |
362 |
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Prevention |
364 |
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Treatment |
364 |
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Conclusion |
364 |
|
|
References |
367 |
|
|
32 Myocarditis |
368 |
|
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Introduction |
368 |
|
|
Aetiology and Epidemiology |
368 |
|
|
Clinical Manifestations |
369 |
|
|
Pathophysiology |
373 |
|
|
Myocarditis and Athletics |
374 |
|
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Long?Term Sequelae |
374 |
|
|
Treatment |
374 |
|
|
Conclusion |
375 |
|
|
References |
375 |
|
|
Section 5 Other Causes of Sudden Death |
377 |
|
|
Chapter 33 Alternative Noncardiac Medical Causes of Sudden Death: Sickle-Cell Trait, Exertional Heatstroke, Exercise Rhabdomyolysis, Asthma and Extreme Environmental Conditions |
379 |
|
|
Introduction |
379 |
|
|
Sickle-Cell Trait |
379 |
|
|
Exertional Heatstroke |
383 |
|
|
Other, Less Frequent Causes of Noncardiac Sudden Death |
385 |
|
|
References |
386 |
|
|
Part 4 Cardiovascular Management |
389 |
|
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Chapter 34 Guidelines for Sports Practice in Athletes with Cardiovascular Disease |
391 |
|
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Cardiomyopathies, Myocarditis and Pericarditis |
392 |
|
|
Primary Electrical Disease |
395 |
|
|
Aortopathies, Coronary Artery Disease and Hypertension |
397 |
|
|
Valvular Heart Disease |
401 |
|
|
Congenital Heart Disease |
401 |
|
|
References |
401 |
|
|
Chapter 35 Management of the Symptomatic Athlete |
403 |
|
|
Introduction |
403 |
|
|
General Considerations |
403 |
|
|
Syncope |
404 |
|
|
Palpitations |
407 |
|
|
Chest Pain |
408 |
|
|
Exertional Fatigue and Performance Decline |
411 |
|
|
Conclusion |
411 |
|
|
References |
412 |
|
|
Chapter 36 Management of Abnormal Physical Examination Findings in Athletes |
413 |
|
|
Introduction |
413 |
|
|
General Inspection |
413 |
|
|
Examination of the Hands |
414 |
|
|
Assessment of Resting Blood Pressure |
415 |
|
|
Examination of the Face and Neck |
417 |
|
|
Examination of the Thorax |
417 |
|
|
Examination of the Heart |
418 |
|
|
Examination of the Lungs |
421 |
|
|
Examination of the Abdomen |
421 |
|
|
Examination of the Lower Limbs |
421 |
|
|
Conclusion |
422 |
|
|
References |
422 |
|
|
Chapter 37 Management of Atrial Fibrillation in Athletes |
424 |
|
|
Introduction |
424 |
|
|
Epidemiology and Relevance |
425 |
|
|
Clinical Presentation |
426 |
|
|
Pathology |
426 |
|
|
Therapeutic Approach |
427 |
|
|
Prevention |
430 |
|
|
Conclusion |
430 |
|
|
References |
431 |
|
|
Chapter 38 Implantable Cardioverter-Defibrillators in Athletes |
433 |
|
|
Introduction |
433 |
|
|
ICD Structure and Function |
433 |
|
|
Subcutaneous ICDs |
436 |
|
|
ICDs in Athletes: Underlying Diagnosis |
436 |
|
|
ICDs in Athletes: Implications for Return to Play |
439 |
|
|
How to Care for an Athlete with an ICD: Practical Considerations |
441 |
|
|
Medical Equipment that may Interfere with an ICD |
441 |
|
|
Conclusion |
442 |
|
|
References |
442 |
|
|
Chapter 39 Management of Hypertension in Athletes |
445 |
|
|
Introduction and Epidemiology |
445 |
|
|
Considerations Relating to Sports Participation and Blood Pressure in Athletes |
445 |
|
|
Definition and Classification of Arterial Hypertension in Athletes |
446 |
|
|
Challenges of Diagnosing Hypertension in Athletes |
446 |
|
|
How to Assess Blood Pressure in Athletes |
447 |
|
|
Definition of EIAH at the Peak of Exercise |
449 |
|
|
Definition of EIAH at Submaximal Exercise |
449 |
|
|
Abnormal Blood Pressure Response in Recovery |
449 |
|
|
Diagnostic Evaluation of the Hypertensive Athlete |
450 |
|
|
Drugs Associated with Hypertension in Athletes |
451 |
|
|
Hypertension in Paralympic Athletes with Spinal Cord Injuries |
451 |
|
|
Physical Examination of the Hypertensive Athlete |
452 |
|
|
Cardiovascular Risk Stratification of the Hypertensive Athlete |
452 |
|
|
Cardiovascular Risk Factors |
452 |
|
|
Target Organ Damage |
452 |
|
|
Aetiology Assessment: Primary versus Secondary Hypertension |
453 |
|
|
Management of Hypertension in Athletes |
453 |
|
|
Eligibility for Sports Participation in Hypertensive Athletes |
455 |
|
|
References |
456 |
|
|
Part 5 Conundrums in Sports Cardiology |
457 |
|
|
Chapter 40 Distinguishing Physiological Left Ventricular Hypertrophy from Hypertrophic Cardiomyopathy in Athletes |
459 |
|
|
Introduction |
459 |
|
|
Establishing the ‘Grey Zone’ |
459 |
|
|
History and Familial Evaluation |
461 |
|
|
Echocardiography |
461 |
|
|
Electrocardiography |
462 |
|
|
Cardiac Magnetic Resonance |
463 |
|
|
Cardiopulmonary Exercise Testing |
464 |
|
|
Ambulatory ECG Monitoring |
464 |
|
|
Genetics |
464 |
|
|
De?training |
465 |
|
|
Potential Role of Biomarkers |
465 |
|
|
Conclusion |
465 |
|
|
References |
466 |
|
|
Chapter 41 Screening for Cardiovascular Disease in the Older Athlete |
467 |
|
|
Introduction |
467 |
|
|
Risk–Benefit of Physical Activity |
467 |
|
|
Coronary Artery Disease: Pathogenesis |
468 |
|
|
SCD due to CAD in Senior Athletes |
468 |
|
|
Clinical Presentation of CAD |
469 |
|
|
Positive Effects of Physical Activity |
469 |
|
|
Evaluation of Older Individuals before Participation in Sports |
469 |
|
|
Conclusion |
473 |
|
|
References |
473 |
|
|
Chapter 42 Is Ultra-Endurance Exercise Damaging to the Right Ventricle? |
475 |
|
|
Introduction |
475 |
|
|
From Physiological to Pathological Remodelling in Athletes: the Atrial Example |
476 |
|
|
From Physiologic to Pathologic Remodelling in Athletes: and the Ventricles? |
477 |
|
|
Why is the Right Ventricle Affected? |
477 |
|
|
Genetic Predisposition? |
480 |
|
|
Doping? |
481 |
|
|
Who is at Risk? |
481 |
|
|
Conclusion |
484 |
|
|
References |
484 |
|
|
Chapter 43 Clinical Implications of Performance-Enhancing Drugs for Cardiovascular Health |
486 |
|
|
Introduction |
486 |
|
|
Anabolic Agents |
486 |
|
|
Peptide Hormones, Growth Factors and Related Substances |
489 |
|
|
Stimulants |
490 |
|
|
Beta-2 Agonists |
490 |
|
|
Masking Agents |
491 |
|
|
Conclusion |
491 |
|
|
References |
491 |
|
|
Chapter 44 Cardiovascular Concerns in the Paralympic Athlete |
493 |
|
|
Introduction |
493 |
|
|
Cardiovascular Concerns in Athletes with SCI |
493 |
|
|
Other Important Considerations for the Team Physician |
498 |
|
|
Conclusion |
500 |
|
|
References |
500 |
|
|
Part 6 Emergency Cardiac Care |
501 |
|
|
Chapter 45 Emergency Cardiac Care in the Athletic Setting: From School Sports to the Olympic Arena |
503 |
|
|
Introduction |
503 |
|
|
Epidemiology |
503 |
|
|
Planning |
504 |
|
|
Training |
504 |
|
|
Personnel |
504 |
|
|
Equipment |
505 |
|
|
Communications |
506 |
|
|
Onsite Emergency Cardiac Care Protocol |
507 |
|
|
Transport |
508 |
|
|
Definitive Cardiac Critical Care |
508 |
|
|
Post-SCA Debrief |
508 |
|
|
Conclusion |
509 |
|
|
References |
509 |
|
|
Part 7 Sports Cardiology Training |
511 |
|
|
Chapter 46 Recommendations for Sports Cardiology Training for the Sports Medicine Physician |
513 |
|
|
Introduction |
513 |
|
|
Sports Cardiology Curriculum |
514 |
|
|
Training Environment and Infrastructure |
516 |
|
|
Strategies for Learning and Assessment |
516 |
|
|
Conclusion |
519 |
|
|
References |
519 |
|
|
Index |
521 |
|
|
EULA |
530 |
|