Invited editorial Unicuique suum: the proper discipline for the proper athlete Germana Panattoni*, Cinzia Crescenzi*, Roberta Della Bona and Leonardo Calo ` Arterial hypertension (AH) is the most relevant risk factor for cardiovascular disease. The prevalence was estimated to be 1.13 billion in 2015, with a prevalence of over 150 million in central and eastern Europe. 1 Clinical evidence showed that elevated blood pressure (BP) is associated with an increased risk of several car- diovascular events such as haemorrhagic stroke, myo- cardial infarction, ischaemic stroke, sudden death, heart failure, as well as end-stage renal disease. 2 Furthermore, despite increased knowledge of this serious health problem and its consequences, hyperten- sion remains highly prevalent, under-recognized and under-controlled. 3 European Society of Cardiology (ESC) guidelines recommend regular physical activity, with a class IA indication, in order to prevent or delay the onset of hypertension and to reduce cardiovascular risk. Indeed aerobic exercise has been proved to reduce BP by regulating sympathetic activity, arterial stiffness, oxidative stress and by correcting additional compo- nents of the metabolic syndrome. Nonetheless the reported prevalence of systemic hypertension in the athletic population is not as uncommon as expected (3%). 4 High BP represents, in fact, the most common abnormal finding during cardiac screening of athletes and could expose them to an increased risk of cardiovascular events. Therefore, the identification and the management of hypertensive individuals in the setting of pre-participa- tion screening are mandatory. In this issue of the European Journal of Preventive Cardiology, Niebauer et al. report some brief recom- mendations for participation in competitive sports of athletes with AH. 5 In athletes, as in the general adult population, hypertension is defined as systolic BP of 140 mmHg or greater and/or diastolic BP of 90 mmHg or greater, repeatedly measured in the office. 6 Children and ado- lescents have lower BP levels, with normal values of less than 120/80 mmHg. The use of out-of-office BP meas- urement with 24-hour ambulatory BP monitoring and/ or home BP monitoring is useful to confirm the diagnosis of hypertension, to detect white coat effect and masked hypertension, and monitor BP control. Pre-participation examination of competitive ath- letes with AH includes family and personal history, physical examination, cardiovascular risk profile, screening for potential secondary causes of hyperten- sion (i.e. medication or performance enhancing sub- stances such as erythropoietin and anabolic steroids) and 12-lead ECG. Eligibility for participation in com- petitive athletes with AH is based on the assessment of the cardiovascular risk profile estimated using the European SCORE system, 7 on the presence of target organ damage and/or associated clinical condition (Figure 1). In patients with low or moderate cardiovascular risk no restriction from competitive sport is required if BP values are normalized. In patients with a high risk or very high risk and adequate control of BP values, par- ticipation in all competitive sports is allowed, with the exclusion of power disciplines. Except in the presence of very high BP values (grade 3 hypertension), athletes with treated or untreated hypertension should not be exempted from regular exercise, especially aerobic exer- cise, which is considered beneficial as part of lifestyle changes to reduce BP. In all circumstances, if BP values are not well controlled, temporary restriction from competitive sport is recommended. Routinely, as a part of the medical programme, exercise testing is performed to assess cardiovascular adaptations during effort and exercise-induced arrhyth- mias. As a small percentage of athletes during exercise exceed upper BP limit values, without organ damage, it is not clear if these patients should be discouraged Division of Cardiology, Policlinico Casilino, Rome, Italy Corresponding author: Leonardo Calo `, Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy. Email: leonardo.calo@tin.it * The first two authors contributed equally to this work and should be regarded as co-first authors. European Journal of Preventive Cardiology 0(00) 1–4 ! The European Society of Cardiology 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/2047487319861230 journals.sagepub.com/home/cpr