CARDIAC DISEASE AND PRE - PARTICIPATION SCREENING IN BOXING Daniel Azimzadeh

1. CARDIAC DISEASE AND PRE-PARTICIPATION SCREENING IN BOXING Daniel Azimzadeh MBChB, School of Medicine, University of Liverpool1 Eligibility to compete with known Cardiac Disease - Boxing: Arrhythmias:Asymptomatic bradycardia, increasing on exertion, is deemed acceptable by Bethesda and ESC, but tachycardia requires treatment prior to participation. In addition, there is an absolute contraindication of pacemaker insertion due to risk of collision. There are discrepancies between ESC and Bethesda regarding atrial flutteror fibrillation, supraventricular & ventriculartachycardias,ventricular flutter or fibrillation and congenital third degree heart block in investigation, treatment and eligibility for sport participation. Congenital Cardiac Disease:Overall, Bethesda, ESC, ABAE, Canadian Professional Boxing Federation (CPBF) and World Series of Boxing (WSB) conditionally allow certain defects. However, EBA and World Boxing Council (WBC) regard any congenital cardiac defect as an absolute contraindication. The main inconsistencies between Bethesda and ESC comprise conditional approval of aortic coarctationand tetralogy repair. All sources agree that symptomatic atrial and ventricular septal defects, patent ductusarteriosusand untreated cyanotic heart diseaseare contraindications. Valvular Heart Disease:ESC and Bethesda disagree regarding participation in boxers with, mitral & aortic stenosis or regurgitation and tricuspid regurgitation, but both deem mild mitral regurgitation as acceptable. AIBA, WBC and EBA however do not accept any history of valvular heart disease or repair. Myocardial & Pericardial Disease:There is an unquestionable contraindication for any cardiomyopathy amongst ESC, Bethesda, AIBA, EBA, ABAE, WBC, WSB and Oriental & Pacific Boxing Federation . Furthermore, connective tissue diseases (Marfan and Ehlers-Danlos syndrome) and infiltrative diseases are also contraindicated by Bethesda. Finally, infective cardiac wall conditions (pericarditis and myocarditis) are only permissible after confirmed treatment. Coronary Artery Disease (CAD), and Hypertension:CAD universally debars boxers from participation with similar opinions on those who show cardiac risk factors with no actual disease. Furthermore, many organisations show a cautious approach to stage 1 hypertension (140/90mmHg), ranging from an absolute contraindication to referral for further investigation; ESC, AIBA, WSB and EBA allow participation providing medication control. Stage 2 hypertension (>160/100mmHg) and malignant hypertension is a concurrent contraindication. Eligibility to compete with known Cardiac Disease - Football: Bethesda and ESC recommendations for participation in football show few key differences. Firstly, in Bethesda (but not ESC) the presence of a pacemaker may be acceptable with the use of protected padding. Furthermore, Bethesda states post-surgical great artery transposition repair is acceptable but remains disallowed in ESC. Bethesda permits boxers and footballers to compete with mild mitral stenosis, whereas ESC only permits footballers. Finally, both Bethesda and ESC conditionally allow stage 2 hypertension in footballers, unlike in boxers. Boxing Pre-participation Screening for Cardiac Disease: World Amateur and Professional organisations: PPS in ABAE, AIBA and United States Amateur Boxing (USAB) require questionnaire and cardiac examination only. In contrast, WBC, USAB and AIBA require an additional ECG with discovered abnormalities or in older boxers. There are, however, no specified screening requirements for WBO and WBA. European Society of Cardiology (ESC):It is recommended that all athletes under 35 undergo PPS questionnaire, examination and ECG. If any abnormalities then echocardiogram is performed. This is adopted in Italy for all sports and by major sporting organisations in rest of Europe. US State Athletic Commissions (SAC):PPS in boxers is highly varied amongst US SAC (see figure below). Alarmingly, Michigan state requires no cardiac screening for competition and only four states offer a baseline physical examination & ECG and screening for older athletes. 70% of SAC request a baseline examination, although 23% require this only prior to a fight. In addition, only 17% SAC routinely require a baseline ECG. Only 47% specify routine baseline requirements for older boxers: (physical: 11%; ECG: 23%; advanced tests: 23%). Also, only 17% of SAC require PPS physical and ECG. Literature review: Cardiac-related issues in Boxing There is limited data with few observational studies and case reports. Of 15 boxers with ECGs recorded before and immediately after a bout, 3 boxers showed significant ventricular repolarisationabnormalities likely due to boxing related sympathetic over-activity. There are two case reports: a 32-year-old professional boxer with Myocardial Contusion (MC), and a 65-year-old retired boxer with pericardial constriction, chylous ascites and chylothorax. The risk of such events are a rarity due to glove padding. SCDin athletes (including boxers) from a French and American sample showed that HCM was the cause in 30% and 50% of the individuals respectively, but the proportion of boxers is unspecified. Similar French data compiled over 19 years, showed 1 boxer died from arrhythmogenic right ventricular cardiomyopathyduring exercise. Finally, a 6-year German epidemiological data analysis showed a 59 year-old-boxer with SCD of unknown aetiology. Introduction Discussion Eligibility to compete with known Cardiac Disease – Boxing Consensus guidelines for all sports have been published in USA (Bethesda 36th) and Europe (ESC). There are further guidelines from Boxing Organisations and Commissions around the world and even within specific US States. There is variation between these guidelines, but some are unanimous (HCM, some arrhythmias, congenital defects & valve disease). USA (Bethesda 36th) vs. European (ESC) Consensus Guidelines: There are many similarities with variation attributed to ‘cultural, social, and legal backgrounds’.It is recommended that a unified document should be publishedto alleviate confusion. Furthermore, differences between participation in boxing compared to football are limited; there are certain increased leniencies amongst the consensus documents to reflect the increased cardiac demand of boxing. Boxing Pre-participation Screening for Cardiac Disease: There are marked differences in PPS between World Amateur and Professional Organisations, ESC and US State Athletic Commissions. The ESC involves questionnaire, examination and ECG in all. Whilst most other organisations offer at least an examination, a boxer can compete in Michigan State without even this. Many states do not offer a baseline ECG or any additional screening for older boxers. The debate of whether a routine ECG is necessary for athlete screening is relevant. In Italy, a 26-year study demonstrated the inclusion of ECG led to an 89% reduction in SCD in athletes. This is contrary to the American Heart Association screening, based on questionnaire and examination alone. In boxing, there has been a call to introduce a routine ECG although the British Board of Boxing Control has no formal screening protocol. To contrast, the Football Association of England offers an ECG on all young participants, in spite of its lower cardiac exertion profile as a sport. Literature review: Cardiac-related issues in Boxing There is a low prevalence of SCD within boxing, although data is limited and therefore this conclusion cannot be confidently drawn. This may be due to the rarity of such events and its overshadowing neuropsychiatric and craniofacial issues, which is beyond the scope of this report. Boxers with certain cardiac conditions may be permitted or banned from participation, purely based on the region or organisation delivering the assessment; this variation also exists for PPS. Consequently, global criteria should be devised. Furthermore, there is a strong argument for the inclusion of a baseline ECG screening for all competitive boxers. A pilot study comprising a large sample of professional boxers undertaking ECG screening in addition to routine history and examination at baseline is recommended. Prof. John Somauroo, Sports Cardiologist, Countess of Chester NHS Trust Dr. Nigel Jones, Dr to British Boxing Board of Control and Liverpool FC • Sudden cardiac death (SCD) in athletes is usually unexpected in fit and asymptomatic individuals. Hypertrophic Cardiomyopathy (HCM) is the most common aetiology in under 35’s, with a wide range of other causes. The incidence of SCD ranges from 1:28,000 - 300,000 in studies from Italy, America and Canada. Identifying those at risk and removing them from sport participation can avoid potential fatalities; consequently, optimal screening, striking a balance between cost and effectiveness is essential. Pre-participation screening (PPS) guidelines markedly vary around the world. In Italy PPS is mandatory for all athletes in all sports, but this is not the case around the rest of Europe. First team elite footballers (soccer) in Europe are mandated by UEFA to have PPS. Athletes with documented cardiac disease may also be at risk of SCD and there are European guidelines for further investigation and eligibility to continue sports participation. • Boxing poses a high cardiac demand with boxers’ VO2max (maximum level of oxygen utilised during exercise) ranging from 55.8 to 63.8ml/kg/min. In addition, lactate levels are elevated, indicating the highly anaerobic nature of the sport, ultimately placing a greater requirement for cardiac output. Lactate levels have been demonstrated to rise up to 13.6±3.2mmol/l with just four 2-minute rounds, with a 1-minute break in between each round. This is up to twice that of footballers at 8.4mmol/l. • Aims: • In light of the potential for SCD and the cardiac demand for boxing in comparison to football, we propose the following objectives: • The cardiac conditions which constitute ineligibility of participation in boxing, and how it differs from football. • Current worldwide cardiac screening in boxing • A review of literature available with regards to SCD and cardiac disease in boxing. Methodology Alist of boxing regulatory bodies was established with published medical eligibility guidelines obtained. US State Athletic Commissions’ guidelines were compared with US National Athletic PPS guidelines and European consensus documents. PPS and eligibility to compete with specific cardiac diseases was tabulated for for comparison. A literature search was carried out using Medline and Ovid for any previous studies or case reports on SCD in boxing or cardiac disease as a consequential injury. Conclusion Results The comprehensive US overview (36th Bethesda Conference 2005) of eligibility for athletes to compete and management plans was compared with the European Society of Cardiology’s (ESC) consensus document (EHJ 2005). Additional guidelines from 8 boxing regulatory bodies were located (n=2 amateur & n=6 professional). The marked variation in opinion and eligibility criteria amongst various organisations and authors was documented. Acknowledgements