Prevalence and upper limit of cardiac hypertrophy in professional cyclists

Impact of endurance exercise on the heart of cyclists: A systematic review and meta-analysis

OBJECTIVE

To compare heart structure and function in endurance athletes relative to participants of other sports and non-athletic controls in units relative to body size. A secondary objective was to assess the association between endurance cycling and cardiac abnormalities.

PATIENTS AND METHODS

Five electronic databases (CINAHL, Cochrane Library, Medline, Scopus, and SPORTdiscus) were searched from the earliest record to 14 December 2019 to identify studies investigating cardiovascular structure and function in cyclists. Of the 4865 unique articles identified, 70 met inclusion criteria and of these, 22 articles presented 10 cardiovascular parameters in units relative to body size for meta-analysis and five presented data relating to incidence of cardiac abnormalities. Qualitative analysis was performed on remaining data. The overall quality of evidence was assessed using GRADE. Odds ratios were calculated to compare the incidence of cardiac abnormality.

RESULTS

Heart structure was significantly larger in cyclists compared to non-athletic controls for left ventricular: mass; end-diastolic volume, interventricular septal diameter and internal diameter; posterior wall thickness, and end-systolic internal diameter. Compared to high static and high dynamic sports (e.g., kayaking and canoeing), low-to-moderate static and moderate-to-high dynamic sports (e.g., running and swimming) and moderate-to-high static and low-to-moderate dynamic sports (e.g., bodybuilding and wrestling), endurance cyclists end-diastolic left ventricular internal diameter was consistently larger (mean difference 1.2-3.2 mm/m²). Cardiac abnormalities were higher in cyclists compared to controls (odds ratio: 1.5, 95%CI 1.2-1.8), but the types of cardiac abnormalities in cyclists were not different to other athletes.

CONCLUSION

Endurance cycling is associated with a larger heart relative to body size and an increased incidence of cardiac abnormalities relative to controls.

Myocardial Adaptations to Recreational Marathon Training Among Middle-Aged Men

Background—

Myocardial adaptations to exercise have been well documented among competitive athletes. To what degree cardiac remodeling occurs among recreational exercisers is unknown. We sought to evaluate the effect of recreational marathon training on myocardial structure and function comprehensively.

Methods and Results—

Male runners (n=45; age, 48±7 years; 64% with ≥1 cardiovascular risk factor) participated in a structured marathon-training program. Echocardiography, cardiopulmonary exercise testing, and laboratory evaluation were performed pre and post training to quantify changes in myocardial structure and function, cardiorespiratory fitness, and traditional cardiac risk parameters. Completion of an 18-week running program (25±9 miles/wk) led to increased cardiorespiratory fitness (peak oxygen consumption, 44.6±5.2 versus 46.3±5.4 mL/kg per minute; P <0.001). In this setting, there was a significant structural cardiac remodeling characterized by dilation of the left ventricle (end-diastolic volume, 156±26 versus 172±28 mL, P <0.001), right ventricle (end-diastolic area=27.0±4.8 versus 28.6±4.3 cm 2 ; P =0.02), and left atrium (end-diastolic volume, 65±19 versus 72±19; P =0.02). Functional adaptations included increases in both early (E′=12.4±2.5 versus 13.2±2.0 cm/s; P =0.007) and late (A′=11.5±1.9 versus 12.2±2.1 cm/s; P =0.02) left ventricular diastolic velocities. Myocardial remodeling was accompanied by beneficial changes in cardiovascular risk factors, including body mass index (27.0±2.7 versus 26.7±2.6 kg/m 2 ; P <0.001), total cholesterol (199±33 versus 192±29 mg/dL; P =0.01), low-density lipoprotein (120±29 versus 114±26 mg/dL; P =0.01), and triglycerides (100±52 versus 85±36 mg/dL; P =0.02).

Conclusions—

Among middle-aged men, recreational marathon training is associated with biventricular dilation, enhanced left ventricular diastolic function, and favorable changes in nonmyocardial determinants of cardiovascular risk. Recreational marathon training may, therefore, serve as an effective strategy for decreasing incident cardiovascular disease.

Cardiac dimensions over 5 years in highly trained long-distance runners and sprinters

AIMS

We assessed the changes in cardiac morphology between elite endurance-trained runners (n = 42) and elite sprinters (n = 34) over a 5-year period. In addition, we studied the relationship between heart size and maximum oxygen consumption (VO2 max).

METHODS

At the beginning of 5 consecutive seasons, all athletes underwent an incremental running test to determine VO2 max and a color-coded pulsed Doppler examination to determine baseline echocardiographic variables. We hypothesized that cardiac morphology had reached its upper limit in elite athletes, and showed only minor changes during 5 years of regular training.

RESULTS

Although all echocardiographic variables remained stable in nearly all sprinters studied, in the endurance runners (who presented higher cardiac cavity dimensions compared with sprinters), variations in heart morphology became evident from the third season, and were within established physiological limits.

CONCLUSION

Only 6 (17%) endurance runners and 3 (9%) sprinters showed a left ventricular internal diameter of > 60 mm (the threshold pathological value) at end diastole at some point during the observational period. Moreover, no statistically significant association was detected between changes in VO2 max and changes in heart size. After 5 years of intense training, the changes of the echocardiographic variables examined remained different between endurance runners and sprinters.

Left ventricular hypertrophy in athletes

Participation in regular intensive exercise is associated with a modest increase in left ventricular wall thickness (LVWT) and cavity size. The magnitude of these physiological changes is predominantly determined by a variety of demographic factors which include age, gender, size, ethnicity, and sporting discipline. A small minority of male athletes participating in sporting disciplines involving intensive isotonic and isometric exercise may exhibit substantial increases in cardiac size that overlap with the phenotypic manifestation of the cardiomyopathies. The most challenging clinical dilemma incorporates the differentiation between physiological left ventricular hypertrophy (LVH) (athlete's heart) and hypertrophic cardiomyopathy (HCM), which is recognized as the commonest cause of non-traumatic exercise related sudden cardiac death in young (<35 years old) athletes. This review aims to highlight the distribution and physiological upper limits of LVWT in athletes, determinants of LVH in athletes, and echocardiographic methods of differentiating athlete's heart from HCM.

Myocardial blood flow and adenosine A2A receptor density in endurance athletes and untrained men

Previous human studies have shown divergent results concerning the effects of exercise training on myocardial blood flow (MBF) at rest or during adenosine-induced hyperaemia in humans. We studied whether these responses are related to alterations in adenosine A2A receptor (A2AR) density in the left-ventricular (LV) myocardium, size and work output of the athlete's heart, or to fitness level. MBF at baseline and during intravenous adenosine infusion, and A2AR density at baseline were measured using positron emission tomography, and by a novel A(2A)R tracer in 10 healthy male endurance athletes (ET) and 10 healthy untrained (UT) men. Structural LV parameters were measured with echocardiography. LV mass index was 71% higher in ET than UT (193 +/- 18 g m(-2) versus 114 +/- 13 g m(-2), respectively). MBF per gram of tissue was significantly lower in the ET than UT at baseline, but this was only partly explained by reduced LV work load since MBF corrected for LV work was higher in ET than UT, as well as total MBF. The MBF during adenosine-induced hyperaemia was reduced in ET compared to UT, and the fitter the athlete was, the lower was adenosine-induced MBF. A2AR density was not different between the groups and was not coupled to resting or adenosine-mediated MBF. The novel findings of the present study show that the adaptations in the heart of highly trained endurance athletes lead to relative myocardial 'overperfusion' at rest. On the other hand hyperaemic perfusion is reduced, but is not explained by A2AR density.

The Tour de France: a physiological review

On 5 July 2003, the Tour de France (TDF) has celebrated 100th running. Instead of a chimney sweep competing during his free time (as in 1903), the recent winner is a highly trained, professional cyclist whose entire life-style has been dedicated to reach his pinnacle during this event. The TDF has been held successfully for 100 years, but the application of the physiologic sciences to the sport is a relatively recent phenomenon. Although some historical reports help to understand the unique physiological characteristics of this race, scientific studies were not available in Sports Science/Applied Physiology journals until the 1990s. The aim of this article is to review the history of the TDF. Special emphasis is placed on the last decade where classic physiology has been integrated into applied scientific cycling data.

Physiologic limits of left ventricular hypertrophy in elite junior athletes: relevance to differential diagnosis of athlete's heart and hypertrophic cardiomyopathy

OBJECTIVES

The present study was undertaken to define physiologic limits of left ventricular hypertrophy in elite adolescent athletes.

BACKGROUND

Systematic sports training may cause increased left ventricular wall thickness (LVWT), creating uncertainty regarding the differential diagnosis of athlete's heart from hypertrophic cardiomyopathy (HCM). This distinction is crucial because HCM is responsible for about one-third of all sudden deaths in young athletes. Echocardiographic data defining athlete's heart are limited largely to adults, with little information specifically in adolescent athletes (14 to 18 years old), for whom the risk of sudden death from HCM is highest.

METHODS

Seven hundred and twenty elite adolescent athletes (75% male) aged 15.7 +/- 1.4 years participating in ball, racket, and endurance sports and 250 healthy sedentary controls of similar age, gender, and body surface area underwent echocardiography.

RESULTS

Compared with controls, athletes had greater absolute LVWT (9.5 +/- 1.7 mm vs. 8.4 +/- 1.4 mm; p < 0.0001). Maximal LVWT exceeded predicted upper limits in 38 athletes (5%); however, no female athlete had a LVWT >11 mm and only three trained male athletes had absolute LVWT >12 mm (0.4%). Each of the 38 athletes with a LVWT exceeding predicted limits also showed enlarged left ventricular cavity dimension (54.4 +/- 2.1 mm; range 52 to 60 mm).

CONCLUSIONS

Trained adolescent athletes demonstrated greater absolute LVWT compared with nonathletes. Only a small proportion of athletes exhibited a LVWT exceeding upper limits, very rarely >12 mm, and then always with chamber enlargement. Hypertrophic cardiomyopathy should be considered strongly in any trained adolescent male athlete with LVWT >12 mm (females >11 mm) and nondilated left ventricle.

Physiology of professional road cycling

Professional road cycling is an extreme endurance sport. Approximately 30000 to 35000 km are cycled each year in training and competition and some races, such as the Tour de France last 21 days (approximately 100 hours of competition) during which professional cyclists (PC) must cover >3500 km. In some phases of such a demanding sport, on the other hand, exercise intensity is surprisingly high, since PC must complete prolonged periods of exercise (i.e. time trials, high mountain ascents) at high percentages (approximately 90%) of maximal oxygen uptake (VO2max) [above the anaerobic threshold (AT)]. Although numerous studies have analysed the physiological responses of elite, amateur level road cyclists during the last 2 decades, their findings might not be directly extrapolated to professional cycling. Several studies have recently shown that PC exhibit some remarkable physiological responses and adaptations such as: an efficient respiratory system (i.e. lack of 'tachypnoeic shift' at high exercise intensities); a considerable reliance on fat metabolism even at high power outputs; or several neuromuscular adaptations (i.e. a great resistance to fatigue of slow motor units). This article extensively reviews the different responses and adaptations (cardiopulmonary system, metabolism, neuromuscular factors or endocrine system) to this sport. A special emphasis is placed on the evaluation of performance both in the laboratory (i.e. the controversial Conconi test, distinction between climbing and time trial ability, etc.) and during actual competitions such as the Tour de France.

Left ventricular mass index and sports: the influence of different sports activities and arterial blood pressure

BACKGROUND

The mechanisms by which endurance training produces physiological hypertrophy have been thoroughly investigated but not with young athletes. The aim of our study was to investigate arterial blood pressure exercise responses in young athletes who started heavy training by the age of 11, participating in metabolically different sports (cycling, kayaking, and soccer) and to analyse the influence that arterial blood pressure at maximum exercise and VO(2) max could have on the development of cardiac mass in these subjects.

SUBJECTS AND METHODS

We studied a group of well trained normotensive male subjects, comprising 37 cyclists, 15 soccer players and 12 canoeists (mean age, 16+/-1 years). Evaluation included a clinical history and physical examination, M-mode and two-dimensional echocardiography, 12-lead resting electrocardiogram and a graded exercise test with direct determination of VO(2) max. Systolic and diastolic blood pressure were measured at rest and maximum exercise. Determination of the left ventricular mass index (LVMI) was performed using Devereux's formula with correction for the body surface area.

RESULTS

Cyclists showed values of LVMI in g m(-2) significantly higher than those of other subjects (123 vs. 92 and 113). Canoeists showed the maximal arterial blood pressure at maximum exercise in mmHg (190 vs. 172 and 170) and cyclists showed the maximal VO(2) ml kg(-1) min(-1) uptake (57.6 vs. 48.5 and 53.3). A linear correlation was found between LVMI and VO(2) max (r=0.4727, P<0.001) and this correlation was also significant with systolic blood pressure at maximum exercise (r=0.2909, P<0.01). No differences in LVMI were found when comparing those subjects who presented systolic blood pressure at maximum exercise equal or greater than 195 mmHg with those who presented less than this value.

CONCLUSIONS

It can be concluded that VO(2) max is the variable that better correlates with the LVMI. Athletes who reach greater systolic blood pressures at peak exercise have a tendency to develop greater LVMI. In comparison with soccer players and canoeists, cyclists are the sportsmen who develop a greater LVMI and VO(2) max.

The athlete's heart. A meta-analysis of cardiac structure and function

BACKGROUND

It has been postulated that depending on the type of exercise performed, 2 different morphological forms of athlete's heart may be distinguished: a strength-trained heart and an endurance-trained heart. Individual studies have not tested this hypothesis satisfactorily.

METHODS AND RESULTS

The hypothesis of divergent cardiac adaptations in endurance-trained and strength-trained athletes was tested by applying meta-analytical techniques with the assumption of a random study effects model incorporating all published echocardiographic data on structure and function of male athletes engaged in purely dynamic (running) or static (weight lifting, power lifting, bodybuilding, throwing, wrestling) sports and combined dynamic and static sports (cycling and rowing). The analysis encompassed 59 studies and 1451 athletes. The overall mean relative left ventricular wall thickness of control subjects (0.36 mm) was significantly smaller than that of endurance-trained athletes (0.39 mm, P=0.001), combined endurance- and strength-trained athletes (0.40 mm, P=0.001), or strength-trained athletes (0.44 mm, P<0.001). There was a significant difference between the 3 groups of athletes and control subjects with respect to left ventricular internal diameter (P<0. 001), posterior wall thickness (P<0.001), and interventricular septum thickness (P<0.001). In addition, endurance-trained athletes and strength-trained athletes differed significantly with respect to mean relative wall thickness (0.39 versus 0.44, P=0.006) and interventricular septum thickness (10.5 versus 11.8 mm, P=0.005) and showed a trend toward a difference with respect to posterior wall thickness (10.3 versus 11.0 mm, P=0.078) and left ventricular internal diameter (53.7 versus 52.1 mm, P=0.055). With respect to cardiac function, there were no significant differences between athletes and control subjects in left ventricular ejection fraction, fractional shortening, and E/A ratio.

CONCLUSIONS

Results of this meta-analysis regarding athlete's heart confirm the hypothesis of divergent cardiac adaptations in dynamic and static sports. Overall, athlete's heart demonstrated normal systolic and diastolic cardiac functions.

Heart dimensions may influence the occurrence of the heart rate deflection point in highly trained cyclists

OBJECTIVES

To determine whether the heart rate (HR) response to exercise in 21 highly trained cyclists (mean (SD) age 25 (3) years) was related to their heart dimensions.

METHODS

Before performing an incremental exercise test involving a ramp protocol with workload increases of 25 W/min, each subject underwent echocardiographic evaluation of the following variables: left ventricular end diastolic internal diameter (LVIDd), left ventricular posterior wall thickness at end diastole (LVPWTd), interventricular septal wall thickness at end diastole (IVSTd), left ventricular mass index (LVMI), left atrial dimension (LAD), longitudinal left atrial (LLAD) and right atrial (LRAD) dimensions, and the ratio of early to late (E/A) diastolic flow velocity.

RESULTS

The HR response showed a deflection point (HRd) at about 85% VO2MAX in 66.7% of subjects (D group; n = 14) and was linear in 33.3% (NoD group; n = 7). Several echocardiographic variables (LVMI, LAD, LLAD, LRAD) indicative of heart dimensions were similar in each group. However, mean LPWTd (p<0.01) and IVSTd (p<0.05) values were significantly higher in the D group. Finally, no significant difference between groups was found with respect to the E/A.

CONCLUSIONS

The HR response is curvilinear during incremental exercise in a considerable number of highly trained endurance athletes-that is, top level cyclists. The departure of HR increase from linearity may predominantly occur in athletes with thicker heart walls.

Left ventricular morphology and function in endurance-trained female athletes

In this study, we investigated resting left ventricular dimensions and function in trained female rowers, canoeists and cyclists. In male populations, such athletes have demonstrated the largest left ventricular wall thicknesses and cavity dimensions. Echocardiograms were analysed from 24 athletes (rowers and canoeists, n = 12; cyclists, n = 12) and 21 age-matched controls to measure left ventricular end-diastolic dimension and volume, and septal (ST) and posterior wall (PWT) thicknesses. Left ventricular mass was calculated from M-mode data. Systolic and diastolic function were calculated from M-mode and Doppler echocardiography, respectively. Height, body mass, body surface area and fat-free mass were determined anthropometrically. The athletes were well matched with the controls for all anthropometric variables except fat-free mass (rowers and canoeists 49.7+/-3.6 kg, cyclists 48.0+/-3.8 kg, controls 45.0+/-5.4 kg; P < 0.05). The left ventricular end-diastolic dimension, mass and volume, and septal and posterior wall thicknesses, were all significantly greater in the athletes than the controls (P < 0.05). These differences persisted (except for left ventricular end-diastolic dimension) even after allometric adjustment for group differences in fat-free mass. Stroke volume was larger (rowers and canoeists 102+/-13 ml, cyclists 103+/-16 ml, controls 80+/-15 ml; P < 0.05) in both groups of athletes but all other functional data were similar between groups. As in male athletes, female rowers, canoeists and cyclists displayed significantly larger left ventricular cavity dimensions and wall thicknesses than controls.

Mechanics of left ventricular systolic and diastolic function in physiologic hypertrophy of the athlete's heart

As a result of a number of factors, there is tremendous diversity in the pattern of cardiac mechanics encountered in athletes. Nevertheless, several trends can be identified, and several conclusions are possible. Hypertrophy of a mild to moderate degree and out of proportion to body size is a common finding. Some athletes experience ventricular dilation with appropriate hypertrophy and preservation of the ventricular mass-to-volume ratio, whereas others manifest concentric hypertrophy with an increased mass-to-volume ratio. The functional changes that are encountered appear to be secondary to the structural alterations, and there is no evidence of altered myocardial systolic or diastolic properties. Some athletes with hypertrophy have reduced wall stress when they are evaluated at rest, and velocity of shortening is augmented because of the reduced afterload. As a result of adaptation to a high-output state, some athletes appear preload reduced when evaluated at rest. Although velocity of shortening is not affected by preload status, fractional shortening is inversely related to preload. The magnitude of systolic shortening is therefore the net result of altered preload and afterload and cannot be understood without assessing both of these parameters. When the various determinants of systolic shortening are included, contractility appears to be normal. There have been several reports of depressed contractility immediately after extreme exertion. Although the mechanism remains uncertain, several intriguing possibilities have been proposed.

Impact of different sports and training on cardiac structure and function

There is overwhelming evidence, particularly from echocardiography, that the heart of competitive athletes may differ from that of nonathletes, matched for age, gender, and body size. A larger left ventricular mass has been shown in athletes performing predominantly dynamic aerobic and anaerobic sports, in athletes engaged in static training, and in players of ball sports. Enlargement of the left ventricular internal diameter was most pronounced and reached about 10% in athletes performing predominantly dynamic sports; mainly strength training athletes had a lesser increase of the internal dimension, which was limited to 2.5%. Also the left ventricular wall appeared to be thickened in all types of athletes compared with controls. In sports with high dynamic and low static demands, wall thickness was proportionate or slightly disproportionate to the size of the internal diameter so that relative wall thickness was not different from controls or slightly increased (predominantly eccentric hypertrophy). In strength athletes, the disproportionate increase of wall thickness averaged about 12% (predominantly concentric hypertrophy). In sports with high dynamic and high static demands and requiring prolonged training, such as cycling, the increases of absolute and relative wall thickness reached 29% and 19% and were more pronounced than in runners (mixed hypertrophy). A plausible interpretation of these results is that the development of so-called eccentric or concentric left ventricular hypertrophy according to the type of sports cannot be regarded as an absolute or dichotomous concept because training regimens and sports activities are not exclusively dynamic or static and because the load on the heart is not purely of the volume or the pressure type. Most studies agree that left ventricular systolic and diastolic function is normal in the athlete at rest, whereas diastolic function seems to be enhanced in the exercising endurance athlete. The consistency of the results of studies on athletes in the competitive and the resting season, of training of sedentary subjects, and of spinal cord-injured patients suggests that variations in physical activity can alter left ventricular structure; genetic factors do not seem to be involved in the size of the left ventricular internal diameter but have to be taken into account to interpret wall thickness.

Echocardiographic criteria of physiological left ventricular hypertrophy in combined strength- and endurance-trained athletes

In combined strength- and endurance-trained athletes who are showing both unusual large body dimensions as well as a high physical fitness, the dimensions of the 'athlete's heart' are expected to reach physiological limits. Therefore we investigated 75 male and 77 female competitive rowers by means of doppler-echocardiography. The absolute "critical" heart weight of 500 g was exceeded by 61% of the male and 10% of the female rowers. Maximal values of the left ventricular (LV) muscle mass were measured at 170 (men) and 133 (women) g.m-2 body surface area, respectively. The LV end-diastolic internal diameter was measured to be above the upper clinical limit of 55 mm in 55% of the male and 17% of the female rowers. A LV wall thickness of 13 and 12 mm was only exceeded by 3 male and 1 female athlete, respectively (maximal values: 14 and 12.5 mm). The LV wall/internal diameter ratio did not exceed 48-50%. The systolic LV function as well as ECG and blood pressure did not reveal any pathological finding, the diastolic LV function was always measured within the normal range. The LV wall thicknesses, internal diameter and hypertrophic index (relation between wall thickness and internal diameter) of the rowers were significantly higher than those of 62 non-endurance trained athletes (pairwise matched according to the body dimensions) and similar to 28 male 'pure' endurance athletes (pairwise matched according to the absolute heart volume). In conclusion, upper limits of echocardiographic volume measurements that are considered critical may be clearly exceeded by healthy strength-endurance trained athletes with simultaneously high body dimensions. The clinical limits, however, are still valid in subjects with a body mass up to approximately 70 kg. The LV wall thickness only exceptionally exceed the clinical limits. A specific influence of the strength elements in training on the LV hypertrophy had not be found.

The athlete's heart: is big beautiful?

Development of the concept of "athlete's heart" is traced through early clinical and radiographic studies to modern echocardiography and magnetic resonance imaging. It is noted that the lower limits of criteria for the diagnosis of a "pathological" enlargement of the heart have frequently been revised in an upward direction, as the prevalence of large hearts has been recognised in both endurance and power sports competitors who are in good health. Belief that hypertrophic cardiomyopathy is the commonest cause of sports related death in young adults is traced to weak diagnostic criteria and frequent republication of a very small group of cases. Although the existence of a congenital myocardial dystrophy is now well established, this condition is extremely rare, and has no particular predilection for athletes. Genetically based screening tests may become available in the future, but the exclusion of young adults from sports participation on echocardiographic criteria appears costly and ineffective. For most people, the development of a large heart is not a pathological sign--rather, it is a desirable outcome that will enhance performance on the sports field, and will allow longer independence in old age.