Left atrial function in elite athletes: A meta-analysis of two-dimensional speckle tracking echocardiographic studies

Investigation of left atrial mechanical function and left ventricular systolic and diastolic parameters in athletes performing resistance exercise and combined exercise

Some individuals who go to fitness centers for various purposes perform resistance exercise (RE) alone, while others engage in combined exercise (CE) by including cardio exercises along with RE. Studying the effects of these two different training methods on left ventricular (LV) systolic and diastolic parameters and left atrial mechanical function is an important step toward understanding the effects of different types of exercise on cardiac function. This knowledge has significant implications for public health, as it can inform the development of targeted and effective exercise programs that prioritize cardiovascular health and reduce the risk of adverse outcomes. Therefore, the primary aim of this study is to comprehensively investigate the LV systolic and diastolic parameters of athletes who engage in RE and CE using ECHO, to contribute to the growing body of literature on the cardiovascular effects of different types of exercise. Forty-two amateur athletes aged between 17 and 52 were included in our study. The participants consisted of the RE (n = 26) group who did only resistance exercise during the weekly exercise period, and the CE group (n = 16) who also did cardio exercise with resistance exercises. After determining sports age (year), weekly exercise frequency (day), and training volume (min) in addition to demographic information of RE and CE groups, left ventricular systolic and diastolic parameters and left atrial functions were determined by ECHO. Findings from our study revealed that parameters including the left ventricular end-diastolic diameter (LVEDD) (p = .008), left ventricular end-diastolic volume (LVEDV) (p = .020), stroke volume index (SV-I) (p = .048), conduit volume (CV-I) (p = .001), and aortic strain (AS) (p = .017) were notably higher in the RE group compared to the CE group. Also left atrial active emptying volüme (LAAEV) of CE was higher than the RE group (p = .031). In conclusion, the cardiac parameters of the RE group showed more athlete's heart characteristics than the CE group. These results may help to optimize the cardiovascular benefits of exercise routines while minimizing the potential risks associated with improper training.

Targeting left atrial dysfunction: A new way to prevent cardiovascular disease?

Clinical and biochemical factorsassociated with worsening of left atrial function, as assessed by speckle tracking echocardiography (i.e. left atrial reservoir strain = LARS) in a population-based cohortover a five-year period of follow-up.

Physical activity and the heart: from well-established cardiovascular benefits to possible adverse effects

The favorable effects of physical activity on the cardiovascular system have been well described in scientific literature. Physical activity reduces cardiovascular morbidity and mortality in both healthy subjects and in patients with cardiovascular disease. However, different intensity levels of physical activity have a different impact on the cardiovascular system. Some data support the hypothesis of a "physical activity paradox": repetitive exposure to vigorous physical activity may induce biological effects that counteract the benefits of moderate intensity levels of physical activity. In this review, we report the main effects of acute and chronic physical activity on the cardiovascular system and we summarize the biochemical mechanisms that may explain these effects.

Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023

Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.

The athlete's heart: insights from echocardiography

The manifestations of the athlete's heart can create diagnostic challenges during an echocardiographic assessment. The classifications of the morphological and functional changes induced by sport participation are often beyond 'normal limits' making it imperative to identify any overlap between pathology and normal physiology. The phenotype of the athlete's heart is not exclusive to one chamber or function. Therefore, in this narrative review, we consider the effects of sporting discipline and training volume on the holistic athlete's heart, as well as demographic factors including ethnicity, body size, sex, and age.

Influence of exercise training on the left atrium: implications for atrial fibrillation, heart failure, and stroke

The left atrium (LA) plays a critical role in receiving pulmonary venous return and modulating left ventricular (LV) filling. With the onset of exercise, LA function contributes to the augmentation in stroke volume. Due to the growing focus on atrial imaging, there is now evidence that structural remodeling and dysfunction of the LA is associated with adverse outcomes including incident cardiovascular disease. In patients with established disease, pathological changes in atrial structure and function are associated with exercise intolerance, increased hospital admissions and mortality, independent of left ventricular function. Exercise training is widely recommended in patients with cardiovascular disease to improve patient outcomes and maintain functional capacity. There are widely documented changes in LV function with exercise, yet less attention has been given to the LA. In this review, we first describe LA physiology at rest and during exercise, before exploring its association with cardiac disease outcomes including atrial fibrillation, heart failure, and stroke. The adaptation of the LA to short- and longer-term exercise training is evaluated through review of longitudinal studies of exercise training in healthy participants free of cardiovascular disease and athletes. We then consider the changes in LA structure and function among patients with established disease, where adverse atrial remodeling may be implicated in the disease process. Finally, we consider important future directions for assessment of atrial structure and function using novel imaging modalities, in response to acute and chronic exercise.

Echocardiography and strain analysis in Malaysian elite athletes versus young healthy adults

Background

Athletes have changes that can mimic pathological cardiomyopathy.

Methods

Echocardiographic study of 50 male, female athletes (MA, FA) and non-athletes (MNA, FNA) age 18 to 30 years. These athletes participate in sports with predominantly endurance component. All participants exhibit no known medical illnesses or symptoms.

Results

MA have thicker wall (IVSd) than MNA. No MA have IVSd > 1.2 cm and no FA have IVSd > 1.0 cm. Left ventricle internal dimension (LVIDd), left ventricle end diastolic volume index (LVEDVi) is bigger in athletes. None have LVIDd > 5.8 cm. Right ventricle fractional area change (FAC) is lower in athletes. (MA vs MNA, p = 0.013, FA vs FNA, p = 0.025). Athletes have higher septal and lateral e' (Septal e'; MA 13.57 ± 2.66 cm/s vs MNA 11.46 ± 2.93 cm/s, p < 0.001, Lateral e'; MA 17.17 ± 3.07 cm/s vs MNA 14.82 ± 3.14 cm/s, p < 0.001), (Septal e'; FA 13.46 ± 2.32 cm/s vs FNA 12.16 ± 2.05 cm/s, p = 0.04, Lateral e'; FA 16.92 ± 2.97 cm/s vs FNA 15.44 ± 2.29 cm/s, p = 0.006).No difference in Global longitudinal (GLS), Right ventricle free wall (RVFWS) and Global circumferential strain (GCS). Left atrial reservoir (LArS) and left atrial booster strain (LAbS) is smaller in athletes. (LArS, MA 44.12 ± 9.55% vs MNA 52.95 ± 11.17%, p < 0.001 LArS, FA 48.07 ± 10.06% vs FNA 53.64 ± 8.99%, p = 0.004), (LAbS, MA 11.59 ± 5.13% vs MNA 17.35 ± 5.27%, p < 0.001 LAbS FA 11.77 ± 4.65% vs FNA 15.30 ± 4.19%, p < 0.001).

Conclusion

Malaysian athletes have thicker wall and bigger left ventricle than controls. No athletes have IVSd > 1.2 cm and/or LVIDd > 5.8 cm. There is no difference in GLS, RVFWS and GCS but athletes have smaller LArS and LAbS.

Left Ventricular, Left Atrial and Right Ventricular Strain Modifications after Maximal Exercise in Elite Ski-Mountaineering Athletes: A Feasibility Speckle Tracking Study

Eleven world elite ski-mountaineering (Ski-Mo) athletes were evaluated for pronounced echocardiographic physiological remodeling as the primary aim of our feasibility speckle tracking study. In this context, sports-related cardiac remodeling was analyzed by performing two-dimensional echocardiography, including speckle tracking analysis of the left atrium (LA), right ventricle (RV) and left ventricular (LV) global longitudinal strain (LV-GLS) at rest and post-peak performance. The feasibility echocardiographic speckle tracking analysis was performed on eleven elite Ski-Mo athletes, which were obtained in 2022 during the annual medical examination. The obtained data of the professional Ski-Mo athletes (11 athletes, age: 18-26 years) were compared for different echocardiographic parameters at rest and post-exercise. Significant differences were found for LV-GLS mean (p = 0.0036) and phasic LA conduit strain pattern at rest and post-exercise (p = 0.0033). Furthermore, negative correlation between LV mass and LV-GLS (p = 0.0195, r = -0.69) and LV mass Index and LV-GLS (p = 0.0253, r = -0.66) at rest were elucidated. This descriptive reporting provided, for the first time, a sport-specific dynamic remodeling of an entire elite national team of the Ski-Mo athlete's left heart and elucidated differences in the dynamic deformation pattern of the left heart.

Left atrial function in young strength athletes: four-dimensional automatic quantitation study

Athletes might suffer from potentially fatal heart disease, which has always been a concern in cardiovascular medicine. The changes in left atrial (LA) size and function are related to the occurrence of arrhythmia. In the present study, four-dimensional automatic quantitation (4D LAQ) was used to explore the changes in LA function of young strength athletes. Eighty professional young strength athletes and sixty healthy young adults matched in age were selected for the study. The LA volumes and strains were automatically analyzed by 4D LAQ. The receiver operating characteristic (ROC) curves were used to evaluate the diagnostic value of strain in athletes' LA function. Pearson correlation analysis was performed to assess the potential association between conventional echocardiographic indexes and 4D parameters related to athletes' LA function. Compared to the control group, LA longitudinal and circumferential strain in the athlete group decreased, while LA volume increased (P < 0.05). However, LA strain was similar among 45 male and 35 female strength athletes (P > 0.05), while male athletes presented with a higher LA volume when compared to female controls (P < 0.05). ROC curve analysis showed that LA contraction longitudinal strain (LASct) was the best predictor in evaluating athletes' LA function. Athletes' heart rate and left ventricular mass index were significantly correlated with 4D LA function parameters.4D LAQ can be used for early detection of the changes in LA function in young strength athletes. There was no significant difference in LA strain between male and female athletes. The LASct was the most effective index for evaluating athletes' LA function.

Age impacts left atrial functional remodeling in athletes

Aim

Age-associated changes in cardiac filling and function are well known in the general population. Yet, the effect of aging on left atrial (LA) function, and its interaction with left ventricular (LV) adaptation, remain less described when combined with high-intensity chronic training. We aimed to analyze the effects of aging on LA and LV functions in trained athletes.

Methods and results

Ninety-five healthy highly-trained athletes referred for resting echocardiography were included. Two groups of athletes were retrospectively defined based on age: young athletes aged <35 years (n = 54), and master athletes aged ≥35 years (n = 41). All subjects were questioned about their sports practice. Echocardiographic analysis of LV systolic and diastolic functions (2D-echo, 3D-echo, and Doppler), as well as LA 2D dimensions and phasic deformations assessed by speckle tracking, were analyzed. Master athletes (mean age = 46.3 ± 8.3 years, mean duration of sustained training = 13.7 ± 8.9 years) exhibited significantly stiffer LV and LA with reduced LV early diastolic functional parameters (ratio E/A, peak e’, and ratio e’/a’), LA reservoir and conduit strain, whereas LA volume, LA contractile strain and LV peak a’ were higher, compared to young athletes. Multivariate regression analysis confirmed that age was predictive of peak e’, LA reservoir strain and LA conduit strain, independently of training variables. LA phasic strains were strongly associated with LV diastolic function.

Conclusions

Regardless of chronic sports practice, master athletes exhibited age-related changes in LA function closely coupled to LV diastolic properties, which led to LV filling shifts to late diastole.

Left atrial disease and left atrial reverse remodeling across different stages of heart failure development and progression: a new target for prevention and treatment

The left atrium is a dynamic chamber with peculiar characteristics. Stressors and disease mechanisms may deeply modify its structure and function, leading to left atrial remodelling and disease. Left atrial disease is a predictor of poor outcomes. It may be a consequence of left ventricular systolic and diastolic dysfunction and neurohormonal and inflammatory activation and/or actively contribute to the progression and clinical course of heart failure through multiple mechanisms such as left ventricular filling and development of atrial fibrillation and subsequent embolic events. There is growing evidence that therapy may improve left atrial function and reverse left atrial remodelling. Whether this translates into changes in patient's prognosis is still unknown.

In this review we report current data about changes in left atrial size and function across different stages of development and progression of heart failure. At each stage, drug therapies, lifestyle interventions and procedures have been associated with improvement in left atrial structure and function, namely a reduction in left atrial volume and/or an improvement in left atrial strain function, a process that can be defined as left atrial reverse remodelling and, in some cases, this has been associated with improvement in clinical outcomes. Further evidence is still needed mainly with respect of the possible role of left atrial reverse remodelling as an independent mechanism affecting the patient's clinical course and as regards better standardization of clinically meaningful changes in left atrial measurements. Summarizing current evidence, this review may be the basis for further studies.

Acute Left Atrial Response to Different Eccentric Resistance Exercise Loads in Patients with Heart Failure with Middle Range Ejection Fraction: A Pilot Study

In this study, we aimed to assess acute changes occurring on atrial function following single bouts of eccentric resistance exercise (ECC-RE) performed at two different loads. Twenty-five patients with chronic heart failure with middle range ejection fraction (HFmrEF) participated in three experimental sessions in a randomized order and on separate days: two sessions of ECC RE at 20% (ECC-20) of one-repetition maximum (1-RM) and 50% (ECC-50) 1-RM, and one session of control, without exercise. Each session lasted three minutes. Before and immediately after the sessions, patients underwent echocardiography and blood pressure and heart rate measurement. Peak atrial longitudinal strain (PALS) and peak atrial contractile strain (PACS) significantly increased after both ECC-20 (+16.3%) and ECC-50 (+18.1%) compared to control (between sessions p = 0.022). Peak atrial contractile strain (PACS) significantly increased after ECC-50 (+28.4%) compared to ECC-20 (+17.0%) and control (between sessions p = 0.034). The ratio of transmitral and annular velocities (E/E') increased significantly after ECC-20 (+10.4%) and ECC-50 (+19.0%) compared to control (between groups p = 0.003). EF, left ventricular longitudinal strain, and stroke volume did not change after ECC-RE sessions compared to control. Cardiac output increased significantly after ECC-20 and ECC-50 compared to control, (between groups p = 0.025). In conclusion, both ECC-RE sessions were well tolerated, and LA functional reserve was properly mobilized in response to ECC-RE in patients with HFmrEF. Cardiac output increased at the cost of an increased LV filling pressure, but no detrimental changes of LV function occurred.

The Added Value of Atrial Strain Assessment in Clinical Practice

Speckle tracking echocardiography has emerged as a sensitive tool to analyze myocardial function with improved diagnostic accuracy and prognostic value. Left atrial strain assessment has become a novel imaging method in cardiology with superior prognostic value compared to conventional left atrial volume indices. Left atrial function is divided into three phases, reservoir function being the most important. This review summarizes the added value of speckle tracking echocardiography derived left atrial strain assessment in clinical practice. Recently published data suggest the prognostic value of left atrial reservoir function in heart failure, atrial fibrillation, stroke and valvular heart disease. Furthermore, left atrial reservoir strain proved to be a predictor of cardiovascular morbidity and mortality in the general population. Thus, routine assessment of left atrial function can be an optimal strategy to improve cardiovascular risk prediction and supplement the current risk prediction models.

Cardiac remodeling in ambitious endurance-trained amateur athletes older than 50 years–an observational study

Background

Data on cardiac remodeling in veteran athletes are conflicting but of clinical importance.

Methods

Sixty-nine clinically stable and healthy individuals >50 years were identified (median 55 (IQR 52–64), 26% female). Echocardiographic features were identified in individuals, who have performed endurance sports at 70% of their maximum heart rate for at least 1 hour 3 times/ week over the previous 5 years.

Results

Median training time in all participants was 6 hours per week. Therefore, based on these 6 hours of weekly training, participants were grouped into 45 ambitious endurance-trained amateur athletes (EAA) and 24 recreationally active endurance-trained athletes (RAP) training ≥6 hours (6–10) and <6 hours (3.5–5), respectively. Left ventricular (LV) diameters were slightly larger in EAA than in RAP (27 mm/m² (25–28) vs. 25 mm/m² (24–27), p = 0.023) and EAA showed preserved diastolic function (p = 0.028) with lower E/E’ ratio (7 (6–9) vs. 9 (7–10), p = 0.039). Interventricular septal thickness and relative wall thickness ratio were similar. Global right ventricular and LV strain were similar, but left atrial (LA) reservoir strain was higher in EAA than in RAP (27% (22–34) vs. 20% (15–29), p = 0.002).

Conclusions

Endurance training in healthy athletes >50 years is not associated with chamber dilatation or LV hypertrophy. A weekly training duration of ≥6 hours seems beneficial to preserve diastolic function associated with an increased LA reservoir function.

Left atrial function in male veteran endurance athletes with paroxysmal atrial fibrillation

Aims

To assess left atrial (LA) function in sinus rhythm in veteran athletes with a history of paroxysmal atrial fibrillation (AF) exposed to prolonged endurance exercise compared with veteran athletes without AF and controls with and without paroxysmal AF from a non-athletic population.

Methods and results

Three hundred and two male participants from four groups, veteran recreational skiers with paroxysmal AF (n = 62), veteran skiers without AF (n = 89), and controls from a non-athletic population with (n = 62) and without paroxysmal AF (n = 89) underwent an echocardiographic examination in sinus rhythm to evaluate LA anatomy and function. The skiers (mean age 70.8±6.7 years) reported an average exposure to regular endurance exercise for 40–50 years. LA maximum and minimum volumes were larger in skiers (P < 0.001). LA volumes differed within the athletic and non-athletic groups with larger volumes in the AF groups ( P < 0.001). We observed a considerable overlap in LA volumes among non-athletes with AF and athletes without AF. LA reservoir strain (33.6% ± 4.8% vs. 28.3% ± 6.7% P < 0.001) and contractile strain (18.3% ± 4.0% vs. 15.0% ± 5.2% P < 0.001) were lower in both AF groups regardless of athletic status. LA reservoir strain was superior to volumetric measurements at identifying participants with AF (area under the curve 0.740 ±0.041).

Conclusion

Male veteran athletes had significantly larger LA volumes than non-athletes. In contrast, LA strain values were similar in athletes and non-athletes with paroxysmal AF, and significantly lower than in subjects without AF.

Central Hemodynamic Adjustments during Post-Exercise Hypotension in Hypertensive Patients with Ischemic Heart Disease: Concurrent Circuit Exercise versus High-Intensity Interval Exercise. A Preliminary Study

Concurrent aerobic plus resistance exercise (RAE) and high-intensity interval exercise (HIIE) are both effective at inducing post-exercise hypotension (PEH) in patients with hypertension. However, central hemodynamic changes associated with PEH in hypertensive subjects with underlying ischemic heart disease (IHD) have been poorly investigated. The study aim was to compare the acute effects produced by these two exercise modalities on left ventricular diastolic function and left atrial function. Twenty untrained male patients with a history of hypertension and IHD under stable pharmacological therapy were enrolled. Each patient underwent three exercise sessions: RAE, HIIE and a control session without exercise, each lasting 45 min. An echocardiography examination was performed before and between 30 min and 40 min from the end of the exercise sessions. Following the exercise sessions, BP values decreased in a similar way in RAE and HIIE and were unchanged after the control session. Compared to pre-session, the ratio between early filling velocity (E) and mitral annulus early diastolic velocity (E’). E/E’ increased after HIIE and remained unchanged after both RAE and control sessions (between-sessions p 0.002). Peak atrial longitudinal strain (PALS) increased slightly after RAE (+1.4 ± 1.1%), decreased after HIIE (−4.6 ± 2.4%) and was unchanged after the control session (between-sessions p 0.03). Peak atrial contraction strain (PACS) was mildly increased after RAE, was reduced after HIIE and was unchanged after the control session. Atrial volume was unchanged after both exercise sessions. Left ventricular and left atrial stiffness increased significantly after HIIE, but remained unchanged after the RAE and control sessions. Stroke volume and cardiac output increased after RAE, decreased after HIIE, and were unchanged after the control session. In conclusion, single session of RAE and HIIE brought about similar PEH in hypertensive subjects with IHD, while they evoked different central hemodynamic adjustments. Given its neutral effects on diastolic and atrial functions, RAE seems more suitable for reducing blood pressure in hypertensive patients with IHD.

Imaging of the left atrium: pathophysiology insights and clinical utility

Left atrial imaging and detailed knowledge of its pathophysiology, especially in the context of heart failure, have become an increasingly important clinical and research focus. This development has been accelerated by the growth of non-invasive imaging modalities, advanced image processing techniques, such as strain imaging, and the parallel emergence of catheter-based left atrial interventions like pulmonary vein ablation, left atrial appendage occlusion, and others. In this review, we focus on novel imaging methods for the left atrium, their pathophysiological background, and their clinical relevance for various cardiac conditions and diseases.

Atrial structure and function in middle-aged, physically-active males and females: A cardiac magnetic resonance study

Recent studies have reported on an association between endurance sport, atrial enlargement and the development of lone atrial fibrillation in younger, male cohorts. The atrial morphology and function of middle‐aged, physically‐active males and females have not been well studied. We hypothesized that middle‐aged males would demonstrate larger left atrium (LA) and right atrium (RA) volumes compared to females, but atrial function would not differ. LA and RA volume and function were evaluated at rest in healthy adults, using a standardized 3.0Tesla cardiac magnetic resonance protocol. Physical activity, medical history, and maximal oxygen consumption (V˙O2peak) were also assessed. Physically‐active, middle‐aged men (n = 60; 54 ± 5 years old) and women (n = 30; 54 ± 5 years old) completed this study. Males had a higher body mass index, systolic blood pressure, and V˙O2peak than females (p < .05 for all), despite similar reported physical activity levels. Absolute and BSA and height‐indexed LA and RA maximum volumes were higher in males relative to females, despite no differences in ejection fractions (p < .05 for all). In multivariable regression, male sex p < .001) and V˙O2peak (p = .004) were predictors of LA volume (model R² = 0.252), whereas V˙O2peak (p < .001), male sex (p = .03), and RV EF (p < .05) were predictors of RA volume (model R² = 0.377). While middle‐aged males exhibited larger atrial volumes relative to females, larger, prospective studies are needed to explore the magnitude of physiologic atrial remodeling and functional adaptations in relation to phenotypic factors.

Differing mechanisms of atrial fibrillation in athletes and non-athletes: alterations in atrial structure and function

AIMS

Atrial fibrillation (AF) is more common in athletes and may be associated with adverse left atrial (LA) remodelling. We compared LA structure and function in athletes and non-athletes with and without AF.

METHODS AND RESULTS

Individuals (144) were recruited from four groups (each n = 36): (i) endurance athletes with paroxysmal AF, (ii) endurance athletes without AF, (iii) non-athletes with paroxysmal AF, and (iv) non-athletic healthy controls. Detailed echocardiograms were performed. Athletes had 35% larger LA volumes and 51% larger left ventricular (LV) volumes vs. non-athletes. Non-athletes with AF had increased LA size compared with controls. LA/LV volume ratios were similar in both athlete groups and non-athlete controls, but LA volumes were differentially increased in non-athletes with AF. Diastolic function was impaired in non-athletes with AF vs. non-athletes without, while athletes with and without AF had normal diastolic function. Compared with non-AF athletes, athletes with AF had increased LA minimum volumes (22.6 ± 5.6 vs. 19.2 ± 6.7 mL/m2, P = 0.033), with reduced LA emptying fraction (0.49 ± 0.06 vs. 0.55 ± 0.12, P = 0.02), and LA expansion index (1.0 ± 0.3 vs. 1.2 ± 0.5, P = 0.03). LA reservoir and contractile strain were decreased in athletes and similar to non-athletes with AF.

CONCLUSION

Functional associations differed between athletes and non-athletes with AF, suggesting different pathophysiological mechanisms. Diastolic dysfunction and reduced strain defined non-athletes with AF. Athletes had low atrial strain and those with AF had enlarged LA volumes and reduced atrial emptying, but preserved LV diastolic parameters. Thus, AF in athletes may be triggered by an atrial myopathy from exercise-induced haemodynamic stretch consequent to increased cardiac output.

Worldwide prevalence of early repolarization pattern in general population and physically active individuals: A meta-analysis

BACKGROUND

The early repolarization pattern (ERP) has recently been associated with cardiac events such as ventricular arrhythmias and sudden cardiac death. However, estimates of the prevalence of ERP vary widely, especially between the general population and physically active individuals. We performed this systematic review and meta-analysis to quantitatively evaluate the worldwide prevalence of ERP in the general population and physically active individuals.

METHODS

We thoroughly searched the PubMed, EMBASE, Web of science, the Cochrane Library, and Scopus databases for relevant studies published until December 20, 2020. Studies in which prevalence was presented or could be estimated from eligible data were included. The pooled prevalence was analyzed using a random-effect model.

RESULTS

Finally, we included 29 studies (182,135 subjects) in the general population and 14 studies (8087 subjects) in the physically active individuals. The worldwide pooled prevalence of ERP in the general population was 11.6% (95% confidence interval [CI]: 10.0%-13.3%). The incidence of ERP was 17.0% and 6.2% in men and women, respectively. The prevalence was 20.9% in blacks, 13.4% in Asians, and 10.1% in Caucasians. Additionally, the prevalence of ERP in physically active individuals was 33.9% (95% CI: 25.3%-42.6%).

CONCLUSION

A significant difference in the worldwide prevalence of ERP is revealed in this study. The ERP is highly prevalent in men, blacks, and physically active individuals.

The beneficial effect of low-intensity exercise on cardiac performance assessed by two-dimensional speckle tracking echocardiography

BACKGROUND

Regular physical activity is associated with cardiovascular health; however, intensive exercise can have harmful effects on the heart. Two-dimensional (2D) speckle tracking echocardiography (STE) is a well-established diagnostic tool to evaluate subclinical myocardial dysfunction and has been widely used in athletes in recent years. This study is designed to evaluate whether low-intensity exercise has beneficial effects on myocardial performance. We aimed to evaluate systolic and diastolic functions of myocardium derived from STE in sports practitioners in a low-intensity exercise training program.

METHOD

Eighty-four sports practitioners and eighty-two sedentary healthy controls were prospectively included in our study. In addition to standard 2D echocardiographic measurements, left ventricular (LV) global longitudinal strain (GLS), right ventricular (RV) GLS, RV-free wall strain (FWS), left atrium (LA) strain, and strain rate were analyzed.

RESULTS

Mean LV GLS was significantly higher in sports practitioners compared with sedentary population (-19.21 ± 2.61% vs -18.37 ± 2.75%, P = .044). RV GLS was significantly higher in sports practitioners than sedentary population (-21.82 ± 4.86% vs -20.04 ± 4.62%, P = .016). Longitudinal strain and strain rate of LA conduit phase were significantly higher in sports practitioners than sedentary participants (-23.60 ± 6.83% vs -20.20 ± 6.64%, P = .001; -2.45 ± 0.81 L/s vs -2.10 ± 0.89 L/s, P = .010; respectively). Also, LA conduit phase strain/contraction phase strain and conduit phase strain rate/contraction phase strain rate ratios were higher in sports practitioners (1.88 ± 0.93 vs 1.48 ± 0.63, P = .001; 1.42 ± 0.65 vs 1.16 ± 0.53, P = .005; respectively).

CONCLUSION

The findings in the current study suggest that regular low-intensity exercise may have a beneficial effect on both systolic and diastolic functions of the myocardium.

The impact of demographic, anthropometric and athletic characteristics on left atrial size in athletes

The structural adaptations of the “athlete's heart” include left atrial (LA) enlargement. A literature search was performed based on PubMed listings up to November 2, 2019 using “athletes AND left atrium,” “athletes AND LA,” “sports AND left atrium,” “sports AND LA,” “exercise AND left atrium,” and “exercise AND LA” as the search terms. Eligible studies included those reporting the influence of demographic, anthropometric and athletic characteristics on LA size in athletes. A total of 58 studies were included in this review article. Although LA volume has been reported to be greater in males compared to females when indexed for body surface area (BSA), there was no difference between sexes. The positive association between LA size and age in athletes may reflect the increase in body size with maturation in nonadult athletes and the training age of endurance athletic activity in adult athletes. Caucasian and black athletes have been demonstrated to exhibit similar LA enlargement. The positive association of LA size with lean body mass (LBM) possibly accounts for the relationship of LA size with BSA. LA enlargement has been reported only in endurance‐trained, but not in strength‐trained athletes. LA size appears to increase with an increase in both the volume and intensity of endurance training. LA size correlates independently with the training age of endurance athletes. The athlete's characteristics that independently determine LA size include LBM, endurance training, and training age.

Evaluation of the left atrial function by two-dimensional speckle-tracking echocardiography in diabetic patients with obesity

Obesity and diabetes are risk factors for atrial cardiomyopathy and are, thus, deemed public health concerns. However, the effects of obesity on the left atrial (LA) function in patients with diabetes have not been determined yet. We sought to evaluate the effects of obesity on the LA function in patients with type 2 diabetes. Ninety-six consecutive patients with type 2 diabetes without significant coronary artery stenosis in selective coronary angiography were included in this cross-sectional study. Two-dimensional speckle-tracking echocardiography (2DSTE)-derived longitudinal LA myocardial deformation markers were compared between 42 obese and 54 nonobese patients. The longitudinal strain and the longitudinal strain rate of the LA myocardium during the reservoir phase and the contraction phase were reduced in the obese patients with diabetes compared with the nonobese patients with diabetes in the unadjusted analysis. In the adjusted analysis, longitudinal strain and the longitudinal strain rate during the contraction phase and the longitudinal strain rate during the reservoir phase were decreased in the obese patients with diabetes. The reservoir and contraction functions of the LA as evaluated by 2DSTE were decreased in our obese patients with diabetes compared with our nonobese patients with diabetes.

Left atrial function in elite athletes: A meta-analysis of two-dimensional speckle tracking echocardiographic studies

BACKGROUND

We sought to investigate left atrial (LA) volume, function, and strain in elite athletes by a meta-analysis including echocardiographic studies that provided volumetric and strain analysis of LA phasic function.

METHODS

The OVID-MEDLINE, PubMed, and Cochrane CENTRAL databases were searched for English-language articles without time restriction up to February 2018 through focused and high sensitive search strategies. Studies were identified by crossing the following search terms: "athletes," "left atrial size," "left atrial volume," "atrial function," "atrial strain," "atrial strain rate," "echocardiography," "2D speckle echocardiography."

RESULTS

Meta-analysis included 403 athletes and 314 active but not trained healthy controls from 9 studies. Pooled data showed that average LA volume index was higher in athletes than in healthy controls (28.0 ± 1.0 vs 20.7 ± 0.8 mL/m2 , P < 0.001). Global LA longitudinal strain, showing LA reservoir function, was lower in the athletes than in healthy controls with borderline significance (37.0 ± 1.2 vs 38.3 ± 1.5%, P = 0.044). Late diastolic LA strain rate, resembling LA contractile function, was also lower in elite athletes than in control group (-1.56 ± 0.08 vs -1.74 ± 0.09 seconds -1, P = 0.007).

CONCLUSIONS

Our meta-analysis shows that LA volume is higher, while LA reservoir and contractile functions are impaired in elite athletes during active training compared to untrained controls. Whether these changes persist during deconditioning periods remains to be determined. These alterations may be related to the higher risk of arrhythmias, in particular atrial fibrillation, reported among middle/old aged athletes.