Heart health for tennis players

"The two fulcra of medicine are reason and observation. Observation is the clue to guide the physician in his thinking.” — Giorgio Baglivi.

“The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease.” — Thomas Edison.

Cardiovascular diseases (CVDs) are the No. 1 cause of death worldwide, according to the World Health Organisation. CVDs take the lives of 19.9 million people each year, an estimated 31% of all deaths. In the United States alone, nearly half (48%, 121.5 million in 2016) of all adults have some type of cardiovascular disease, according to the American Heart Association’s “Heart and Stroke Statistics-2019 Update,” published in the association’s journal Circulation .

The WHO reports that these diseases are triggered chiefly by tobacco smoking, an unhealthy diet, the harmful use of alcohol and physical inactivity.

Playing tennis provides one of the most enjoyable and successful ways to prevent cardiovascular diseases and to mitigate, or even reverse, the effects of CVDs for those already suffering from them.

I consulted Dr. Silvina Delgado, a leading cardiologist and a specialist in sports medicine in Argentina, to learn more about the benefits of tennis and how tennis players can maintain optimum heart health. Toward these ends, she has parlayed her two passions — medicine and tennis — to start the Cardio-Tennis Foundation For Life in her home city of Resistencia, Chaco. When the peripatetic Delgado isn’t educating or treating patients, she’s competing in national and international tournaments and currently ranks in the top top five in the world in the ITF women’s 40+ in singles and doubles.

How has being a cardiologist influenced your tennis game?

Although my profession is very stressful, I really like my job. I enjoy my speciality and make a difference in the lives of my patients by imparting my knowledge. My profession influenced my game by helping me become a more thinking, rational player. It also improved my concentration and made me understand that one must be very well-trained and prepared to achieve the maximum performance.

However, I always say that it is easier to practise medicine than to play tennis because when one studies and indicates to each case the corresponding treatment, the problem is already solved or controlled. On the other hand, when you play tennis, you never know how the match will end until the last point is played.

Tennis is a complex sport, where every day you can learn something new, where you never get bored, and where the outcome of a match depends on many factors. These factors include stroke and footwork technique, strategy and tactics, the style of opponents, the type of surface, physical preparation, the psychological part, and the climate.

How has being an elite tennis player benefited your cardiac patients?

I believe that being an elite tennis player has benefited my patients because I’m able to motivate them to exercise regularly. They know that beyond their work and family responsibilities, they can, with perseverance, become more physically active. Many times my patients and friends have told me that I am an inspiration for them, because of my successful sports career, for the energy I transmit when I play and for the way I speak in seminars, in my office and to the media.

Most importantly, I instruct patients to play the sport they like and discontinue their sedentary life. Once they understand the health benefits of physical activity, they’ll become healthier and happier.

What is the purpose of your Cardio-Tennis Foundation For Life in Argentina?

I have two main objectives. The first objective is to implement cardio-tennis as a new fun way to do physical activity for health. Specifically, we strive to correct cardiovascular risk factors and to do cardiac rehabilitation.

The second objective is to raise awareness among the population of the importance of cardio-protected spaces as well as cardio-protected events.

What are cardio-protected spaces and cardio-protected events?

They are cardio-protected events that you organise. Some examples are cardio-protected marathons, matches or tournaments of different cardio-protected sports, congresses and cardio-protected days.

What has your Cardio-Tennis Foundation accomplished?

We’ve achieved several very important things to improve the health of South Americans. Now our entire country knows about cardio-tennis and it’s also popular in the neighbouring countries of Paraguay, Peru, Chile, Brazil, Bolivia and Uruguay.

We are promoting two bills in our Argentina legislature to require cardio-protected spaces, cardio-protected events, training in cardiopulmonary resuscitation and the use of automated external defibrillators. We have given seminars to demonstrate cardio-tennis and multiple talks to publicise our objectives and educate Argentines.

Finally, we created the first cardio-protected city, Gancedo, which is located in the province of Chaco and famous for having one of the largest meteorites in the world. In addition, wherever we have cardio-tennis, we will perform an evaluation of athletes and conduct various programs such as Tennis Xpress, to motivate people to know and enjoy this exciting sport. In these cardio-protected places, we will show the importance of it by doing training in CPR, in the uses of AED and in cardiovascular rehabilitation.

What is the Tennis Xpress programme and how does it help the Argentine people?

It is a sports initiation programme for adults who want to learn to play tennis quickly, where they teach the concepts, rules and basic strokes of tennis allowing students to play singles and doubles matches between friends or acquaintances in a short time. There are few sessions, usually six, once a week. During the week following the instruction session, players practise what they have learned.

The Copenhagen City Heart Study, which used 20,000 healthy people and was published in 2018 by Peter Schnohr and colleagues, showed that playing tennis, compared to a sedentary lifestyle, extended one’s life expectancy by an average of 9.7 years. Even though correlation does not prove causation, why does playing tennis appear to be so beneficial and important for a healthy heart and life?

It has been clearly demonstrated that people who are physically active have at least a 30% lower risk of death during follow-up care compared to inactive people. Obviously, playing tennis is much more than leading an active life; it is an exciting sport. Tennis not only is fun, but it also brings many physiological, physical and psychological benefits. Furthermore, tennis can be played throughout one’s life, with different objectives: recreational, social, or competitive. So we can understand why more and more people want to enjoy it.

Referring specifically to cardiovascular health, I would like to emphasise that tennis can become a way out of a sedentary lifestyle, a way to make physical activity a new habit in life, and a way to reduce blood pressure, control blood sugar (pre-diabetes or diabetes), cholesterol (dyslipidemia), and other important indicators of heart health. In my case, tennis is my passion and my way of coping with the worst moments of my life. It also opened many social and professional doors for me.

At what age should recreational players and tournament players, who deal with much greater physical strain and mental stress, see a cardiologist for the first time?

You must consult a cardiologist when you notice something is wrong, whatever your age is. So it is very important to pay attention to certain warning signs, such as chest pain at rest or during exercise, palpitations and headaches, which are associated with high blood pressure. Generally, in the asymptomatic population, when you are 35 to 40 years old, you should have a cardiological examination because you may have cardiovascular risk factors, such as high cholesterol, diabetes, hypertension, smoking, genetic inheritance, stress, obesity and sedentary lifestyle. These risk factors are associated with a higher probability of cardiovascular events. The most known cardiovascular events are angina pectoris, acute myocardial infarction, sudden death and cerebrovascular accidents.

Every day we hear or read about someone with high blood pressure, high cholesterol or a cerebrovascular accident who died of a heart attack at work or home or a while playing a sport.

I would like to stress that, as the World Health Organisation reported, the main cause of death in the world is cardiovascular diseases. So prevention is always better than cure.

How often should recreational players and tournament players subsequently see a cardiologist?

There is no established frequency of cardiological examinations. Each case is evaluated on its merits and the patient is followed up accordingly. But it is imperative that patients respect the instructions they receive during the medical consultation and the follow-up guidelines given in each cardiological consultation.

In 1996, the British Lawn Tennis Association became the first elite sporting organisation in the UK to adopt cardiovascular screening of all their national junior athletes for conditions predisposing to sudden cardiac death (SCD). These adolescent players underwent 12-lead ECG and 2-dimensional echocardiography preceded by a full cardiovascular evaluation during the peak competitive season. Should serious junior tournament players undergo cardiovascular screening?

As a cardiologist and sports doctor, I have no doubt that young players should have an adequate cardiological physical examination with a blood pressure test, sports clinical history and, minimally, an electrocardiogram. In this way one can detect murmurs, altered pressure values or some finding in the electrocardiogram that can determine signs or criteria of risk that may predict or prefigure cardiovascular events during their sports practices. In these cases, more specific complementary tests should be indicated.

In this way one can make a difference in the lives of athletes and give their family peace of mind. In my city, Resistencia, Chaco, the Chaquena Federation of Tennis requires that junior tennis players obtain a medical certificate given by a cardiologist with the requirements previously mentioned.

Which on-court, or off-court, symptoms should prompt a player to have his/her heart checked by a cardiologist?

The symptoms that indicate a cardiological examination should be done include chest pain and/or pain in the upper limbs at rest or during exercise, headaches or neck pains associated with high blood pressure, shortness of breath (dyspnea), or agitation when walking, which was previously absent. Other symptoms are shortness of breath at night and the need to sit down (paroxysmal nocturnal dyspnea), palpitations, or rapid or slow heartbeat associated with dizziness, and loss of consciousness (syncope).

Should every tennis club, resort, and center have an Automated External Defibrillator (AED)? And, if so, why? (Note: In the U.S., the cost of a machine ranges from $1,200 to $2,000.)

Of course, this would be the right thing. Don’t forget that a cardio-protected space increases the survival rate of a cardiac arrest or sudden death by 70%, provided it is performed with resuscitation and electric shock within three minutes.

If a tennis player experiences sudden cardiac arrest while playing and the facility has no AED, what should onlookers do to help him/her?

First, the spectators must activate the emergency service and inform them that a cardiac arrest occurred and that they need an AED. Second, start cardiopulmonary resuscitation manoeuvres immediately until the emergency service arrives and then use the AED.

When should cardiopulmonary resuscitation — commonly called CPR — be used?

Cardiopulmonary resuscitation is an emergency procedure that can save lives. It can be performed by any person trained to do so, even if they are not health professionals. You must use CPR when a person is unconscious, is not breathing, and has no pulse.

For the precise method to use CPR, I will quote the July 2019 Harvard Heart Letter ’s article titled, “Hands-only CPR: A lifesaving technique within your reach: The simple version of cardiopulmonary resuscitation pushing hard and fast on the chest can double a person’s odds of surviving cardiac arrest.”

How to do hands-only CPR?

If someone suddenly collapses, shake them and yell “Are you okay?” If you don’t see what appears to be normal breathing, call Emergency. If you put your phone on speaker, the operator can talk you through what to do, but here are the basic steps:

1. Place the person on the floor.

2. Kneel beside the person.

3. Place the heel of one hand on the centre of the person’s chest. Place the heel of the other hand on top of the first hand and lace your fingers together.

4. Position your body so that your shoulders are directly over your hands. Keeping your arms straight, push down with your arms and hands, using your body weight to compress the person’s chest.

5. Push hard enough to press the chest down approximately two inches.

6. Continue pressing the chest at a rate of 100 to 120 compressions per minute. This rhythm corresponds to the beat of two songs popular in the late 1970s, “Stayin’ Alive” and “I Will Survive.” New York-Presbyterian Hospital created a curated list of more recent (as well as some older) songs with similar beats.

7. Continue hands-only CPR until emergency medical personnel arrive. If possible, enlist another person to take over for you after a few minutes because doing the compressions can be tiring.

When the temperature and humidity are very high, what should tennis players do to avoid a heart attack or heat stroke?

Playing sports when the temperature is high can cause dehydration, so sports medicine specialists recommend drinking plenty of water during the day. Due to the heat, some sports activities should be suspended, until the temperature falls a little, to avoid a complication that can be fatal. A heat stroke can occur from an increase in body temperature caused by prolonged exposure to the sun and/or exercising in hot, humid weather and/or with little ventilation, to the point that the body loses water and salts essential for its proper functioning.

The danger posed by extreme heat prompted the U.S. Open in 2018 to activate its protocol to protect players when the temperature hit 33 degrees Celsius (91.4 degrees Fahrenheit) and the humidity reached 70 percent. If one player requested it, they were allowed 10-minute rest breaks.

This was the first time in U.S. Open history that this policy was adopted for the men. The Australian Open already had a rule for extreme heat. So you can clearly see the importance of taking precautions in the heat.

What other suggestions do you have to prevent heat stroke in addition to adequate hydration?

First, tennis players should avoid alcoholic beverages and very sugary beverages because they dehydrate. Second, they should eat plenty of vegetables and fruits, not only for their great nutritional value, but because they contain a lot of water. Third, they should avoid eating heavy meals. Fourth, they should wear lightweight and light-coloured clothes because that will lower the body temperature by as much as four degrees, while heavy and dark clothes will increase the body temperature by as much as four degrees.

If players have either high blood pressure or low blood pressure, should they limit their tennis in any way or take any precautions?

Hypertensive (high blood pressure) patients should visit their cardiologist regularly and join a group of hypertensive patients who are being treated to control their blood pressure. These patients must comply strictly with the treatment indicated by a cardiologist. The most important precaution is that you should never start physical activity when you feel unwell or your blood pressure is high.

However, beyond these recommendations, it must be clear that being hypertensive is not a contraindication to physical activity. When performed correctly, physical activity is healthful, and it controls the cardiovascular risk factors.

Patients who have low blood pressure should hydrate well, should not play tennis when they are thirsty, and should drink water and other beverages when they play socially or competitively.

Should men and women tennis players take aspirin daily or weekly? And, why or why not?

Acetylsalicylic acid (popularly known as aspirin) is currently used as a secondary prevention measure to reduce the risk of new cardiovascular events in those who have already had a myocardial infarction or stroke.

However, the use of aspirin in primary prevention — in patients who have not experienced cardiovascular events — is under discussion. That is mainly due to the risk of haemorrhages and gastric ulcers caused by aspirin.

For my patients, whether or not they are athletes, I indicate aspirin as primary prevention for those from 50 to 59 years of age with a cardiovascular risk of 10% or more, as long as they have a low risk of haemorrhage, a life expectancy of at least 10 years, and are willing to take the drug daily. For patients from 60 and 69 years of age, I weigh the preventive benefit of daily aspirin against the risk of bleeding. However, in patients 70 or older and 50 or younger, I do not indicate aspirin as primary prevention.

“Most importantly, I instruct patients to play the sport they like and discontinue their sedentary life. Once they understand the health benefits of physical activity, they’ll become healthier and happier,” says Silvina Delgado.

Why is sleep extremely important for cardiovascular health and optimum sports performance?

Sleep is extremely important because it decreases blood levels of stress hormones, which lowers blood pressure and heart rate. The hormones released during sleep boost our immune system.

What are the recommended hours of sleep for each age for tennis players?

The WHO recommends that school-age children (6-13) should sleep between 9 and 11 hours. Teenagers (14-17 years) should sleep between 8 and 10 hours. Young adults (18-25 years) should sleep between 7 and 9 hours, and no less than 6 hours or more than 10-11 hours. Adults (26-64) should sleep between 7 and 9 hours.

What are the keys to getting a good night of sleep?

First, sleep in an optimal environment where there is a comfortable bed, and a clean, well-ventilated room. Second, acquire what is called, a hygiene of sleep, which includes going to bed every night at about the same time. Third, exercise at least three times a week, and at least 45 minutes each time to recover from mental and physical fatigue accumulated throughout the day. Fourth, try your best not to think about work or personal problems.

Can heart disease actually be reversed by playing tennis? And, if so, how?

Yes, of course. The benefits of physical activity for health are amply demonstrated for cardiovascular rehabilitation, secondary prevention and primary prevention.

My project is to implement Cardio-Tennis throughout Argentina and the nations that border it. It has three major goals. First, I want to educate and encourage people to get out of a sedentary lifestyle and become physically active to stay healthy. The second goal is to correct cardiovascular risk factors. And the third goal is to prevent another heart event and to do cardiac rehabilitation.

Why are people with diabetes at significantly greater risk for heart disease and stroke?

Diabetes mellitus is present in almost a third of patients with acute coronary syndrome, and it is considered an independent cardiovascular risk factor usually associated with hypertension, obesity, and dyslipidemia. The metabolic and haematological alterations characteristic of diabetics induce the early, rapid and severe progression of coronary disease.

For cardiologists, the prevention and optimal treatment of acute diabetic coronary syndrome continues to be a great challenge; and it has been clearly demonstrated that aggressive multi-factorial treatment reduces the morbidity and mortality of these patients. That’s why when we receive diabetic patients, we treat them intensely because they have a greater risk of suffering cardiovascular events, such as heart disease and stroke, than patients who are not diabetic.

Should diabetics play tennis?

Physical activity, and in this case tennis, clearly has many benefits for diabetic patients. Specifically, it decreases blood sugar and cholesterol, and it helps overweight and obese people lose weight. You can also take patients out of a sedentary life more easily by having them play a fun physical activity, such as tennis, a sport that can be enjoyed from age 5 to 95. Besides pharmacological treatment prescribed by cardiologists, it’s urgent and mandatory that patients implement physical activity.

Is there an association of allergy and cardiovascular disease?

It is estimated that allergies occur in up to 40% of the human population. Katarzyna Bergmann and Grazyna Sypniewska, both of the Department of Laboratory Medicine, Nicolaus Copernicus University Collegium Medicum in Bydgoszcz, Poland, wrote: “Both cardiovascular diseases and allergic diseases are characterised by excessive inflammatory processes. Recent studies suggest a link between allergy and an increased risk of cardiovascular disease, resulting from overactivity of the immune system in allergic diseases and increased synthesis of proinflammatory mediators, which has been well documented in the pathogenesis of atherosclerosis.”

The conclusion of their 2018 abstract stated: “The hypothesis of the relationship between allergies and CVD risk is a matter of controversy. It is possible that chronic allergic diseases, and thus long-lasting increased inflammation, reflected by increased levels of proinflammatory cytokines may contribute to pathological changes in the circulatory system. This problem requires further population studies.”

It has been demonstrated that all inflammatory processes contribute to the cause and development of atherosclerosis. That is why I agree and affirm that there is a relationship between allergy and an increased risk of cardiovascular disease, as a result of the hyperactivity of the immune system in allergic diseases and the increase in the synthesis of proinflammatory mediators.

Therefore, we as cardiologists, insist that all allergic processes of our patients must be treated by specialists. In addition, we prevent infections through anti-flu and anti-pneumococcal vaccines. We take, very seriously, everything that can generate inflammation in our patients.

What advice do you give to your heart patients who have allergies and play aerobic sports such as tennis?

Some patients suffer from allergies caused by climate change, especially air pollution. In these cases, different symptoms associated with episodes of bronchospasm and/or respiratory infections are observed, which limit or prevent the performance of sports activities until the problem is corrected.

My most important recommendation is to continue playing tennis weekly as long as possible because it is proven that physical activity reduces inflammation, impacts positively on cardiovascular risk factors, and increases immunity. I also advise my patients, when they have any symptoms, to be treated as soon as possible for any type of allergy or infection. Finally, when necessary, I request anti-flu and anti-pneumococcal vaccines.

What is the connection between gum disease and heart disease?

At recent cardiology conferences, it was stressed that the cardiologist not only must insist on the correction of cardiovascular risk factors, but also prescribe vaccines to patients and send all patients to the dentist, not only patients who have heart valve problems and therefore have a greater risk of suffering endocarditis or cardia infection.

Independent of the mechanisms by which dental inflammatory processes are related to coronary events, it is clearly demonstrated that everything producing inflammation is closely related to the cause and development of atherosclerosis, which is characterised by an atheromatous, or an abnormal fatty deposit in and a fibrosis of the inner layer of the arteries, and that increases the risk of cardiovascular events.

Which foods should tennis players eat and drink a lot to attain optimum heart health?

Nutrition is the fuel for any physical activity and the material for the constitution and repair of the organism. The proper choice of foods in optimal quantities at the right time will allow you to reach your maximum potential.

A healthy diet must meet the following requirements: First, it must be complete. It must provide all the nutrients that the body needs: carbohydrates, fats, proteins, vitamins, minerals and water.

Second, it has to be balanced. The nutrients must be distributed keeping a proportion between them. Thus, carbohydrates have to comprise between 55 percent and 60 percent of the total calories per day; fats, between 25 percent and 30 percent; and proteins, between 12 percent and 15 percent. In addition you have to drink 1.5-2 litres of water a day.

Third, it has to be enough. The amount of food has to be adequate to maintain one’s weight within the ranges of normality and, in children, achieve growth and proportional development.

Fourth, it has to be adapted to each person’s age, sex and size, along with the level of their physical activity and the state of their health.

Fifth, it must be varied. It must contain different foods from each of the groups — dairy, fruits, vegetables, cereals, legumes, meat and poultry and fish — not only because it will be pleasing to the palate, but because great variety will ensure the body receives all the necessary nutrients.

Which foods should tennis players avoid or at least consume sparingly?

Tennis players should avoid eating too much salt (hypertensive), fried food and sausages (dyslipidemia). Instead, they should try to eat a diet rich in fruits and vegetables. Pre-diabetic tennis players who are overweight or obese, and even more so, those who already have diabetes should avoid consuming excess complex carbohydrates. Nutritional experts also stress that we should not eat products containing trans fat and hydrogenated oils.

The main purpose of the Cardio-Tennis Foundation For Life in Argentina is to implement cardio-tennis as a new fun way to do physical activity for health.

Which foods have excess complex carbohydrates?

The carbohydrates in some foods — mainly those that contain simple sugars and highly refined cereals, such as white flour — break down easily and cause blood sugar levels to rise rapidly. A diet rich in foods that quickly raise the blood sugar level can increase the risk of developing health problems such as diabetes. These are what are known as: “harmful” carbohydrates (refined foods and sugar), which are easy to obtain, come in generous portions, are tasty and are not very filling. As a result, people tend to eat more than is necessary.

Some are not necessary at all. Soft drinks and sweets are “empty calories” that do not provide any type of nutrient. Soft drinks, cakes, sweets, frozen desserts and some fruit drinks usually have large amounts of added sugars. They also tend to have a lot of calories and offer little or no nutrition. Sugar-rich diets are often linked to obesity. Finally, an excess of foods with sugar can cause tooth decay because of the high sugar content that erodes tooth enamel along with the acidity of sweetened beverages.

How can tennis parents instil good nutrition habits in their children?

Make good carbohydrate choices. Buy whole grains, fruits, vegetables and low-fat dairy products. Limit foods with added sugar and encourage children to be active every day. And do not forget to always set a good example. Children will see their parents’ healthy habits and adopt them, and this will make them have a healthier lifestyle in childhood and for the rest of their lives.

Do you have any other advice about how to avoid foods that have little nutritional value and can harm one’s health?

Yes, here are some more tips. First, to find out if a food product has added sugar, look at the list of ingredients to see if it has sugar, corn syrup, or other sweeteners, such as dextrose, fructose, honey or molasses, among others. Avoid products that have sugar or other sweeteners at the top of the ingredient list.

Second, instead of choosing foods with sugar, eat healthier options, such as fruits, a naturally sweet carbohydrate food that also provides the fibres and vitamins that everyone, especially children, needs.

Third, one way to reduce the amount of added sugar is to prohibit soft drinks and other drinks sweetened with sugar. Instead of soft drinks or juices, which usually have both added sugar and carbonated drinks, serve skim milk, water, or 100% natural fruit juice.

Dr. Priyanaka Rohatgi, Nutritionist at Apollo Hospital in India, wrote, “We call it a toxic chemical because sugar is eight times more addictive than cocaine…. Sugar causes metabolic dysfunction, which leads to weight gain, obesity, decreased HDL (good cholesterol), increased LDL (bad cholesterol), elevated triglycerides, increased blood sugar, high uric acid, and high blood pressure. Should tennis players also limit their sugar intake?

We know that the American Heart Association recommends a maximum of six teaspoons of added sugar per day for women and nine teaspoons for men. Tennis players, specifically, have to limit foods containing simple sugars before and between matches. A food high in simple sugars, such as a regular soda, candy, chocolate, frozen yoghurt, or fruit juice, will cause a “hypoglycemic reaction,” leading to low energy levels within one hour of ingesting the food. Highly refined carbohydrates, such as fat-free cookies or desserts and donuts, will cause the same effect.

Therefore, try to limit the general consumption of these foods. If you have them, save them for after training, games, or at the end of a meal. Try to take them with other foods that have a large amount of nutrients that contain complex carbohydrates and protein.

The American Heart Association recommends no more than 1,500 milligrams of sodium per day. Research published in The Lancet (online, May 20, 2016) found that most of the world’s population consumes more than 3,000 milligrams of sodium daily. Should hypertensive tennis players monitor their salt intake in the same way that conscientious overweight and obese people count their food calories?

All hypertensive patients should control salt intake and perform physical activity as a first measure. If this is not enough, a drug or drug treatment is started to lower their blood pressure. At least 30% of people in the Americas suffer from hypertension, in large part due to excessive salt intake. As a result, thousands have suffered strokes, heart attacks, and sudden deaths, according to the Pan American Health Organisation and the World Health Organization.

Argentina’s motto is “Less salt, more life.” After Argentina became the second country in the world after South Africa to pass a comprehensive law to reduce salt consumption, the percentage of the national population that adds salt to food after cooking or sitting at the table was reduced from 25% in 2009 to 17% in 2013.

Why is resistance training — usually this means weight training — good for the heart?

Resistance training is good for the heart because it improves cardiorespiratory fitness, making lungs and heart work more efficiently. In addition, it helps reduce the pulsations per minute of the heart because when your musculature is strengthened, your heart becomes stronger, which allows it to pump more blood in each heartbeat. That, in turn, makes the heart beat fewer times per minute, and, therefore, the heart gets less tired.

It has been clearly demonstrated that resistance training has a positive impact on the main cardiovascular risk factors. Specifically, it improves blood pressure, lowers bad cholesterol (LDL) and increases good cholesterol (HDL), improves blood fluidity, lowers blood sugar, and burns fat, which helps overweight and obese patients control their weight.

Do you recommend estrogen therapy for women tennis players? Or does it actually increase a women’s risk of cardiovascular disease, such as heart attack or stroke?

It has been demonstrated that women who practice sports that demand a lot of effort and resistance, suffer from menstrual disorders more frequently than women who do not practice physical exercise. These menstrual disorders may be varied, possibly depending on multiple factors that can be interrelated and, as a result, can lead to modifications of the menstrual cycle.

These menstrual disorders can be of different types, so it is very important to determine the cause of them in case it is necessary to apply hormone therapy. The truth is that athletes have lower estrogen values than normal.

What are the benefits of estrogen?

Research scientists have discovered two benefits to estrogen. First, they have found a direct relationship between this hormone and a decrease in the risk of suffering Alzheimer’s disease. Second, they found a direct relation between estrogen and an increase in bone density in female athletes with amenorrhea, which is an abnormal absence or suppression of the menstrual flow.

The question of whether women with amenorrhea associated with exercise should follow hormone therapy has been debated for many years, and it has been suggested that estrogens are capable of increasing bone density. A new study, which was carried out in the Department of Obstetrics and Gynecology, of the University of Alberta, in Edmonton, has confirmed the results. Bone density increased significantly in eight runners with amenorrhea who took estrogen for 24 to 30 months.

Finally, it is important to know that estrogen protects against cardiovascular events, so it would be very important to keep them within the normal values (range).

Therefore, I believe that each case should be evaluated promptly and with the corresponding professionals specialised in endocrinology and gynaecology in order to determine whether or not to implement estrogen therapy in athletes. This decision takes into account the patient’s age, the sporting activity and the intensity, duration, and weekly impact of the sport.

All things considered, I would recommend estrogen in tennis players only if I determined there are low levels of estrogen with alterations of the menstrual cycle, and following consultation with the gynaecologist and/or the corresponding endocrinologist.

Tennis players should drink plenty of water and other beverages when they play socially or competitively.

If a person has had a heart attack, heart surgery, or another cardiac event, what’s the best way to prevent future heart problems? Should they continue to compete in tournaments, or even play tennis at all?

Tennis is defined as an acyclic, anaerobic sport of 10% to 30% with an aerobic recovery phase of 70% to 90%. It can also be defined as a sport of multiple sprints or spikes, so it’s important to evaluate what to play and when to play, according to each athlete and their personal goals.

The best way to prevent future cardiac problems is to join a cardiac rehabilitation programme in which the participants make changes to achieve a healthy lifestyle for the heart and to treat the risk factors of cardiovascular diseases. This program includes physical training, education about heart health, and counselling to reduce stress and to help you return to an active lifestyle.

Once they complete the different stages of the cardiac rehabilitation program, and the corresponding cardiological evaluations are made, if players are able to do so, they return to their usual sports practice in a progressive and controlled manner, until they feel increasingly better and safer. In principle, non-competitive activity is indicated by the stress that implies it, and friendly matches are gradually incorporated, always trying to make the goal recreational.

The cardiovascular risk factors are taken into account according to the patient’s age and background. But in general terms, we suggest that tennis is played in a non-competitive manner.

In my experience, I see many patients with periodic follow-up and adequate cardiological control who begin to play tennis with friends. They start playing doubles which is less intense and more fun. Then, if they feel good, they play singles.

Each case must be evaluated on its merits to determine whether the patient should play tournaments in the future or not. Many highly competitive players dismiss the medical indications and recommendations, and decide to risk their health by competing even in high-level tournaments.

If a person is overweight, what precautions should she take when she plays tennis? Should obese people play tennis, or does that endanger the heart?

Overweight people, after adequate medical control in which there are no alterations that show increased cardiovascular risk, can and should engage in physical activity of mild to moderate intensity at least 90 minutes a week.

In the case of tennis, they should in principle practice for a longer duration at a mild to moderate intensity as rallies and then gradually add different exercises that increase intensity to burn more calories. They should avoid as much as possible abrupt stops and jumps to decrease the impact of pounding on their joints.

Do you recommend that tennis players wear devices such as Fitbit which track exercise, sleep, weight, nutrition, female health, heart rate, and cardio-fitness level?

I recommend it for all those tennis players who want to do it, because it provides very useful parameters for cardiologists and for them. Monitoring these devices often becomes a motivation for them to improve their fitness and heart health. People see the positive results from their concrete actions in daily life; and, at the same time, heart patients are more committed to follow their treatment. The only disadvantage is that some tennis players feel uncomfortable using them.

When a cardiologist orders a specific cardiac workup which includes pertinent bloodwork, what are the most important blood indicators — besides cholesterol and C-reactive protein — that are used to evaluate heart health?

The most important blood indicators are: hematocrit, blood count, blood sugar (diabetes), renal function markers with urinalysis, all types of cholesterol (dyslipidemia), thyroid hormones (even more so if the patient reports episodes of palpitations or a history of arrhythmias), uric acid, and electrolyte values such as sodium and potassium. And nowadays, in cardiology and in sports medicine, importance is given to vitamin D, calcium, and magnesium.

Vitamin D deficiency is associated with cardiovascular and cancer mortality, according to two studies recently published in The British Medical Journal . Although the evidence is still insufficient to supplement the diet with vitamin D, the researchers stress that its eventual preventive effect deserves to be studied.

I remind you that vitamin D, produced by the human body in contact with sunlight or acquired through certain foods, is essential for the intestinal absorption of calcium and for the health of bones. In recent times, in addition, this vitamin has been proposed to treat various pathologies, from hypertension to diabetes. A genetic study published in The Lancet Diabetes & Endocrinology established a close link between vitamin D and hypertension.

In addition, according to the analysis of genetic variants related to the synthesis of vitamin D, performed in 140,000 people with European ancestry, for every 10% increase in the level of vitamin D, the risk of high blood pressure decreases by 8%.

“In view of the costs and adverse effects of anti-hypertensive drugs, the possibility of preventing or reducing hypertension with vitamin D supplements becomes very attractive,” wrote The Lancet Diabetes & Endocrinology . That is why cardiologists stress the importance of vitamin D.

There is also a meta-analysis led by Rajiv Chowdhury, a specialist in Public Health at the University of Cambridge, who noted that vitamin D3 can reduce cardiovascular mortality in older adults. All these studies notwithstanding, before implementing a general vitamin D supplementation, it is necessary to establish the optimal dose and the duration of the intervention.

What is the ejection fraction?

The definition of the ejection fraction, written by Dr. Richard L. Weiss, M.D. on behalf of Penn Medicine Cardiologist (Heart Specialist), is as follows:

“The amount of blood that is pumped out by the heart in one beat is called the ejection fraction. An ejection fraction reflects the strength of the heart muscle. The normal ejection fraction for the left ventricle is 50% to 60%. The heart muscle may be weakened from a heart attack, heart failure, or an infection. Any weakening of the heart muscle may lower the ejection fraction.”

Why is the ejection fraction an important indicator of heart function?

When the heart is not functioning efficiently, different organs — such as the kidney, brain and heart — suffer. This can occur when patients have had a heart attack, heart failure (ischemia), myocarditis, and valvular heart disease.

The ejection fraction is a very important parameter for cardiologists, because it is an indicator of cardiovascular prognosis and mortality. It is also a very useful tool to optimize the monitoring and treatment of our patients.

What is the normal resting heart rate for men and women? And what does an abnormally high resting heart rate indicate? Should that concern tennis players?

In general, the normal resting heart rate for men and women is 50 to 90 beats per minute. If the heart rate is high at rest, it can indicate several things: great physical effort, an adrenergic or stress state, alterations at the level of the thyroid gland, dehydration and/or heat stroke, anaemia, compensatory response to high blood pressure heart failure, fever and/or the ingestion of any drug that stimulates the adrenergic system.

The most important thing is to evaluate if the tennis player has symptoms; and do an electrocardiogram to find out if it is your normal accelerated rhythm (sinus tachycardia) or the alteration of the heart rhythm (arrhythmia).

Should an abnormally high resting heart rate concern tennis players?

I definitely believe that it should be a symptom or finding to take into account, and even more so, if it happens frequently associated with symptoms.

In these cases, tennis players should consult a cardiologist as soon as possible. The cardiologist will identify if it is something that is permanent, or if it is sometimes felt at certain times as palpitations or accelerations of the heart rate. In addition, if palpitations occur during physical effort and are accompanied by chest pain and/or sweating and/or dizziness, the physical activity should stop and the athlete should immediately go to a cardiologist.

should wear lightweight and light-coloured clothes because that will lower the body temperature by as much as four degrees, while heavy and dark clothes will increase the body temperature by as much as four degrees.

What is the normal heart rate recovery for men and women? And what does an abnormally high heart rate recovery indicate?

The heart rate of recovery is the difference between the heart rate while exercising and the heart rate two minutes after having stopped exercising. For example, if after a training exercise, your heart rate is 140 beats per minute; and two minutes later, your heart rate is 90 beats per minute, your heart rate of recovery is 50 beats per minute (140 minus 90).

Some studies have linked the recovery of heart rate with heart health. A 2017 study published in the Journal of the American Heart Association and titled “Heart Rate Recovery and Risk of Cardiovascular Events and All‐Cause Mortality: A Meta‐Analysis of Prospective Cohort Studies” concluded: “Attenuated HRR is associated with increased risk of cardiovascular events and all‐cause mortality, which supports the recommendation of recording HRR for risk assessment in clinical practice as a routine.”

Therefore, in general, the greater the HRR number, the healthier the heart is.

Should a lower HRR number concern tennis players?

Tennis has moments of high intensity, and maximum physical effort can severely stress the heart. Many times, during a tennis match, there is no strict control of the heart rate, so I recommend that the players listen to the alerts of their body. An alert that tennis players frequently refer to is the feeling that they take longer than before to recover between the points. This is very valuable information, especially on the senior (45-95 age divisions) circuit where risk factors increase and cardiovascular disorders are more common.

The American Heart Association suggests that asymptomatic men over 45 and asymptomatic women over 55 should consider having a treadmill stress test before beginning a lifestyle that incorporates vigorous exercise. Do you agree?

I completely agree because a treadmill stress test can detect or rule out a cardiovascular problem. A good test result will ensure that a patient can play sports safely. Furthermore, these are precisely the ages at which cardiovascular risk factors can manifest themselves.

The International Olympic Committee (IOC) recommends that athletes have an echocardiogram every two years. Do you agree with this rigorous screening strategy?

I agree that by observing the heart in a two-dimensional way and using Doppler ultrasound, we can diagnose heart diseases that can be treated in time without risking the athlete’s life. One of the most common problems is hypertrophic cardiomyopathy. It is associated with sudden death, so it is important to perform the echocardiogram.

“There is a one in four chance that you will develop atrial fibrillation at some point in your life,” wrote Marc Gillinov, M.D., a staff cardiac surgeon at Cleveland Clinic, and Steven Nissen, M.D., chairman of the Department of Cardiovascular Medicine at Cleveland Clinic, in their 2012 book, Heart 411 . What do you advise for tennis players who have suffered atrial fibrillation?

Atrial fibrillation is the most frequent cause of cardiological hospitalisations due to arrhythmias in clinical practice. It is 1.5 times more frequent in men than in women, and as one’s age increases, the frequency of arrhythmia increases.

I advise tennis players to always have regular cardiac examinations. The most important thing is to have blood pressure treated and controlled, because it is one of the most frequent factors associated with the development of arrhythmia. Tennis players should also be knowledgeable about the problems in the arteries of the heart (ischemic heart disease) and heart failure (impaired ability and function of the heart), among other things.

How strong is the connection between negative emotions — especially anger, anxiety, and depression — and coronary heart disease? Social tennis should, at least in theory, relieve stress. Tournament tennis, however, can prove stressful, especially in long, close matches on hot days. What coping skills or relaxation techniques do you recommend to reduce or relieve stress and thus improve heart health?

It has been clearly demonstrated that negative emotions like anger, anxiety and depression, are associated with more coronary events. So I consider it important to encourage social tennis because it should, at least in theory, relieve stress. This is why I consider the practice and dissemination of cardio-tennis important.

A tennis tournament can be stressful, so I think it’s important to work on visualisation, positive thoughts, and correct breathing in order to relax. These techniques will help you face each match situation in a positive way and enable you to clearly analyze the areas you need to improve. A positive attitude will also help you compete better while you enjoy every moment. All these relaxation techniques can reduce or relieve stress and thus improve the health of your heart.

William C. Roberts, M.D., Executive Director, Baylor Heart and Vascular Institute; Dean, A. Webb Roberts Center for Continuing Medical Education; and Editor-in-Chief, The American Journal of Cardiology , stated: “Statin drugs, in my view, are the best cardiovascular drugs ever created, in that they have the greatest potential to prevent atherosclerotic plaques and their complications, and they also have the greatest potential to arrest plaque formation, and therefore, to prevent additional atherosclerotic events. These drugs are to atherosclerosis what penicillin was to infectious diseases.” Do you agree? And what has your experience been with statin drugs?

I totally agree. They are the group of medicines, which we cardiologists use as primary and secondary prevention. These drugs have the greatest impact on the reduction of cathovascular mortality. I prescribe these drugs every day and with excellent results.

According to the website mendedhearts.org , “By launching precision medicine initiatives, health systems can essentially customize care. Using diagnostics, genome sequencing, and data analytics, doctors can tailor treatment regimens to the patient, sparing them side effects from a drug that doesn’t work for them.” How important is precision medicine in the field of cardiology?

It is very important to practice precision medicine as well as provide personalized attention and treatment of patients. If precision medicine can be implemented within an entire health system, the results would be really impressive in the population. That would massively reduce the cardiovascular diseases, which are the main cause of death in the world.

Jack Sock of the United States receives assistance for heat exhaustion at the U.S. Open in 2015. “Due to the heat, the sports activities should be suspended, until the temperature falls a little, to avoid a complication that can be fatal,” says Silvina.

Can tennis be harmful to someone’s health?

When people take tennis competition too seriously, it can be harmful to their health. To provide an example of this danger, I’d like to share an anecdote. At a tournament, a friend informed me that he could not play because of a muscle tear in his left leg. He also said he had some heart problems. He had undergone some heart tests, and a cardiologist in his province recommended that a study be done to look at the arteries of his heart (coronary angiography).

He showed me the studies and asked for my advice as a cardiologist and friend. I examined the studies, looked him in the eyes, touched his shoulder and said: “The best thing that could have happened is that I played this tournament and learned about your heart problem so I can advise you what to do.”

A few days later, my friend called to thank me for my advice, and he informed me that three stents had been placed in his coronary arteries.

I decided to tell you this story because it is so important for all tennis players. Luckily, we saw each other at the tournament. The story had a happy ending. But if he did not respect the indications and instead competed in the tournament, there was a very high risk of his suffering a serious cardiovascular event or even sudden death.

As a final message for the tennis players, I want to emphasise that you should never minimize chest pain, discomfort in the mouth or the stomach, dizziness or exhaustion disproportionate to the effort made.

If you have any of these symptoms, you should stop playing and immediately consult a cardiologist. Quick action can save your life.

What is telemedicine?

It is a very important tool that is used around the world to greatly help health professionals and patients. It consists of evaluating, diagnosing, and treating patients remotely using telecommunications technology.

How will telemedicine change the way cardiologists treat their patients?

In Argentina, telemedicine was implemented in some provinces with excellent results. From the cardiological point of view, it makes it possible to make diagnoses on time and with greater precision. That leads to the initiation of more effective treatments, enables physicians to make referrals at the most appropriate time, and often prevents serious cardiac events.

What do you tell noncompliant heart patients who do not show up for appointments and skip medication doses, lower doses, delay refills, or don’t fill a prescription?

When patients do not take their medication, it is an extremely serious problem. I always tell them that complying with the prescribed medication has to be their priority because that gives them a better quality of life and improves their prognosis.