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Erevik CB, Kleiven Ø, Frøysa V, Bjørkavoll-Bergseth M, Chivulescu M, Klæboe LG, Dejgaard L, Auestad B, Skadberg Ø, Melberg T, Urheim S, Haugaa K, Edvardsen T, Ørn S. Myocardial inefficiency is an early indicator of exercise-induced myocardial fatigue. Front Cardiovasc Med 2023; 9:1081664. [PMID: 36712275 PMCID: PMC9874326 DOI: 10.3389/fcvm.2022.1081664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023] Open
Abstract
Background The effect of prolonged, high-intensity endurance exercise on myocardial function is unclear. This study aimed to determine the left ventricular (LV) response to increased exercise duration and intensity using novel echocardiographic tools to assess myocardial work and fatigue. Materials and methods LV function was assessed by echocardiography before, immediately, and 24 h after a cardiopulmonary exercise test (CPET) and a 91-km mountain bike leisure race. Cardiac Troponin I (cTnI) was used to assess myocyte stress. Results 59 healthy recreational athletes, 52 (43-59) years of age, 73% males, were included. The race was longer and of higher intensity generating higher cTnI levels compared with the CPET (p < 0.0001): Race/CPET: exercise duration: 230 (210, 245)/43 (40, 45) minutes, mean heart rate: 154 ± 10/132 ± 12 bpm, max cTnI: 77 (37, 128)/12 (7, 23) ng/L. Stroke volume and cardiac output were higher after the race than CPET (p < 0.005). The two exercises did not differ in post-exercise changes in LV ejection fraction (LVEF) or global longitudinal strain (GLS). There was an increase in global wasted work (p = 0.001) following the race and a persistent reduction in global constructive work 24 h after exercise (p = 0.003). Conclusion Increased exercise intensity and duration were associated with increased myocardial wasted work post-exercise, without alterations in LVEF and GLS from baseline values. These findings suggest that markers of myocardial inefficiency may precede reduction in global LV function as markers of myocardial fatigue.
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Affiliation(s)
- Christine Bjørkvik Erevik
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway,*Correspondence: Christine Bjørkvik Erevik,
| | - Øyunn Kleiven
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Vidar Frøysa
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | | | - Monica Chivulescu
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars Gunnar Klæboe
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars Dejgaard
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bjørn Auestad
- Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway,Research Department, Stavanger University Hospital, Stavanger, Norway
| | - Øyvind Skadberg
- Department of Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | - Tor Melberg
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Stig Urheim
- Department of Cardiology, Bergen University Hospital, Bergen, Norway
| | - Kristina Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Thor Edvardsen
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Stein Ørn
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
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2
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Charton M, Kervio G, Matelot D, Lachard T, Galli E, Donal E, Carré F, Le Douairon Lahaye S, Schnell F. Exercise-Induced Cardiac Fatigue in Soldiers Assessed by Echocardiography. Front Cardiovasc Med 2021; 8:785869. [PMID: 34988130 PMCID: PMC8720761 DOI: 10.3389/fcvm.2021.785869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/01/2021] [Indexed: 01/02/2023] Open
Abstract
Background: Echocardiographic signs of exercise-induced cardiac fatigue (EICF) have been described after strenuous endurance exercise. Nevertheless, few data are available on the effects of repeated strenuous exercise, especially when associated with other constraints as sleep deprivation or mental stress which occur during military selection boot camps. Furthermore, we aimed to study the influence of experience and training level on potential EICF signs.Methods: Two groups of trained soldiers were included, elite soldiers from the French Navy Special Forces (elite; n = 20) and non-elite officer cadets from a French military academy (non-elite; n = 38). All underwent echocardiography before and immediately after exposure to several days of uninterrupted intense exercise during their selection boot camps. Changes in myocardial morphology and function of the 4 cardiac chambers were assessed.Results: Exercise-induced decrease in right and left atrial and ventricular functions were demonstrated with 2D-strain parameters in both groups. Indeed, both atrial reservoir strain, RV and LV longitudinal strain and LV global constructive work were altered. Increase in LV mechanical dispersion assessed by 2D-strain and alteration of conventional parameters of diastolic function (increase in E/e' and decrease in e') were solely observed in the non-elite group. Conventional parameters of LV and RV systolic function (LVEF, RVFAC, TAPSE, s mitral, and tricuspid waves) were not modified.Conclusions: Alterations of myocardial functions are observed in soldiers after uninterrupted prolonged intense exercise performed during selection boot camps. These alterations occur both in elite and non-elite soldiers. 2D-strain is more sensitive to detect EICF than conventional echocardiographic parameters.
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Affiliation(s)
- Marion Charton
- Department of Cardiology, Pontchaillou Hospital, Rennes, France
| | | | - David Matelot
- LTSI, INSERM, U1099, University of Rennes 1, Rennes, France
| | - Thibault Lachard
- Department of Sport Medicine, Pontchaillou Hospital, Rennes, France
| | - Elena Galli
- Department of Cardiology, Pontchaillou Hospital, Rennes, France
- LTSI, INSERM, U1099, University of Rennes 1, Rennes, France
| | - Erwan Donal
- Department of Cardiology, Pontchaillou Hospital, Rennes, France
- LTSI, INSERM, U1099, University of Rennes 1, Rennes, France
| | - François Carré
- LTSI, INSERM, U1099, University of Rennes 1, Rennes, France
- Department of Sport Medicine, Pontchaillou Hospital, Rennes, France
| | | | - Frédéric Schnell
- LTSI, INSERM, U1099, University of Rennes 1, Rennes, France
- Department of Sport Medicine, Pontchaillou Hospital, Rennes, France
- *Correspondence: Frédéric Schnell
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3
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Pagourelias ED, Christou GA, Sotiriou PG, Anifanti MA, Koutlianos NA, Tsironi MP, Christou KA, Vassilikos VP, Deligiannis AP, Kouidi EJ. Impact of a 246 Km ultra-marathon running race on heart: Insights from advanced deformation analysis. Eur J Sport Sci 2021; 22:1287-1295. [PMID: 33980129 DOI: 10.1080/17461391.2021.1930194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Although previous studies suggest that prolonged intense exercise such as marathon running transitorily alters cardiac function, there is little information regarding ultramarathon races. Aim of this study was to investigate the acute impact of ultra-endurance exercise (UEE) on heart, applying advanced strain imaging. Echocardiographic assessment was performed the day before and at the finish line of "Spartathlon": A 246 Km ultra-marathon running race. 2D speckle-tracking echocardiography was performed in all four chambers, evaluating longitudinal strain (LS) for both ventricles and atria. Peak strain values and temporal parameters adjusted for heart rate were extracted from the derived curves. Out of 60 participants initially screened, 27 athletes (19 male, age 45 ± 7 years) finished the race in 33:34:27(28:50:38-35:07:07) hours. Absolute values of right (RV) and left ventricular (LV) LS (RVLS -22.9 ± 3.6 pre- to -21.2 ± 3.0% post-, p=0.04 and LVLS -20.9 ± 2.3 pre- to -18.8 ± 2.0 post-, p=0.009) slightly decreased post-race, whereas atrial strain did not change. RV and LV LS decrease was caused mainly by strain impairment of basal regions with apical preservation. Inter-chamber relationships assessed through RV/LV, LV/LA, RV/RA and RA/LA peak values' ratios remained unchanged from pre to post-race. Finally, UEE caused an extension of the systolic phase of cardiac cycle with concomitant diastole reduction (p<0.001 for all strain curves). Conclusively, ventricular LS strain as well as effective diastolic period slightly decreased, whereas atrial strain and inter-chamber relationships remained unchanged after running a 246-km-ultra-marathon race. These changes may be attributed to concomitant pre- and afterload alterations following UEE.
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Affiliation(s)
- Efstathios D Pagourelias
- Sports Medicine Laboratory, Department of Physical Education and Sports Science, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Third Cardiology Department, Hippokrateion University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios A Christou
- Sports Medicine Laboratory, Department of Physical Education and Sports Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiota G Sotiriou
- Sports Medicine Laboratory, Department of Physical Education and Sports Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria A Anifanti
- Sports Medicine Laboratory, Department of Physical Education and Sports Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos A Koutlianos
- Sports Medicine Laboratory, Department of Physical Education and Sports Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria P Tsironi
- Faculty of Human Movement and Quality of Life Sciences, Department of Nursing, University of Peloponnese, Sparta, Greece
| | - Konstantinos A Christou
- Sports Medicine Laboratory, Department of Physical Education and Sports Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasileios P Vassilikos
- Third Cardiology Department, Hippokrateion University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Asterios P Deligiannis
- Sports Medicine Laboratory, Department of Physical Education and Sports Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelia J Kouidi
- Sports Medicine Laboratory, Department of Physical Education and Sports Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
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4
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What are the Limiting Factors During an Ultra-Marathon? A Systematic Review of the Scientific Literature. J Hum Kinet 2020; 72:129-139. [PMID: 32269654 PMCID: PMC7126261 DOI: 10.2478/hukin-2019-0102] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This review aimed to analyse factors that limited performance in ultra-marathons and mountain ultra-marathons. A literature search in one database (PubMed) was conducted in February 2019. Quality of information of the articles was evaluated using the Oxford´s level of evidence and the Physiotherapy Evidence Database (PEDro) scale. The search strategy yielded 111 total citations from which 23 met the inclusion criteria. Twenty one of the 23 included studies had a level of evidence 2b (individual cohort study), while the 2 remaining studies had a level of evidence of 5 (expert opinion). Also, the mean score in the PEDro scale was 3.65 ± 1.61, with values ranging from 0 to 7. Participants were characterised as experienced or well-trained athletes in all of the studies. The total number of participants was 1002 (893 men, 86 women and 23 unknown). The findings of this review suggest that fatigue in ultra-endurance events is a multifactorial phenomenon that includes physiological, neuromuscular, biomechanical and cognitive factors. Improved exercise performance during ultra-endurance events seems to be related to higher VO2max values and maximal aerobic speed (especially during submaximal efforts sustained over a long time), lower oxygen cost of transport and greater running experience.
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5
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Lord RN, Utomi V, Oxborough DL, Curry BA, Brown M, George KP. Left ventricular function and mechanics following prolonged endurance exercise: an update and meta-analysis with insights from novel techniques. Eur J Appl Physiol 2018; 118:1291-1299. [PMID: 29869711 PMCID: PMC6028893 DOI: 10.1007/s00421-018-3906-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/26/2018] [Indexed: 11/24/2022]
Abstract
Background The cardiac consequences of undertaking endurance exercise are the topic of
recent debate. The purpose of this review is to provide an update on a growing
body of literature, focusing on left ventricular (LV) function following
prolonged endurance exercise over 2 h in duration which have employed novel
techniques, including myocardial speckle tracking, to provide a more
comprehensive global and regional assessment of LV mechanics. Methods Prospective studies were filtered independently following a pre-set criteria,
resulting in the inclusion of 27 studies in the analyses. A random-effects
meta-analysis was used to determine the weighted mean difference and 95%
confidence intervals (CI) of LV functional and mechanical data from
pre-to-post-exercise. Narrative commentary was also provided where volume of
available evidence precluded meta-analysis. Results A significant overall reduction in LV longitudinal strain (Ɛ) n = 22
(− 18 ± 1 to − 17 ± 1%; effect size (d) − 9:
− 1 to − 0.5%), strain rate n = 10 (SR;d − 0.9: − 0.1.3 to − 0.5 l/s) and twistn = 5 (11.9 ± 2.2 to 8.7 ± 2.2°,d − 1: − 1.6 to − 0.3°) was observed
following strenuous endurance exercise (range 120–1740 min) (P < 0.01). A smaller number of studies
(n = 4) also reported a non-significant
reduction in global circumferential and radial Ɛ (P > 0.05). Conclusion The meta-analysis and narrative commentary demonstrated that a reduction in LV
function and mechanics is evident following prolonged endurance exercise. The
mechanism(s) responsible for these changes are complex and likely
multi-factorial in nature and may be linked to right and left ventricular
interaction.
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Affiliation(s)
- Rachel N Lord
- Cardiff Centre for Exercise and Health, Cardiff Metropolitan University Cyncoed Campus, Cyncoed Road, Cardiff, CF236XD, UK.
| | - Victor Utomi
- Research Institure for Sport and Exercise Sciences, Tom Reilly Building, Liverpool John Moores University, Liverpool, UK
| | - David L Oxborough
- Research Institure for Sport and Exercise Sciences, Tom Reilly Building, Liverpool John Moores University, Liverpool, UK
| | - Bryony A Curry
- Cardiff Centre for Exercise and Health, Cardiff Metropolitan University Cyncoed Campus, Cyncoed Road, Cardiff, CF236XD, UK
| | - Megan Brown
- Cardiff Centre for Exercise and Health, Cardiff Metropolitan University Cyncoed Campus, Cyncoed Road, Cardiff, CF236XD, UK
| | - Keith P George
- Research Institure for Sport and Exercise Sciences, Tom Reilly Building, Liverpool John Moores University, Liverpool, UK
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6
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Knechtle B, Nikolaidis PT. Physiology and Pathophysiology in Ultra-Marathon Running. Front Physiol 2018; 9:634. [PMID: 29910741 PMCID: PMC5992463 DOI: 10.3389/fphys.2018.00634] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/11/2018] [Indexed: 12/31/2022] Open
Abstract
In this overview, we summarize the findings of the literature with regards to physiology and pathophysiology of ultra-marathon running. The number of ultra-marathon races and the number of official finishers considerably increased in the last decades especially due to the increased number of female and age-group runners. A typical ultra-marathoner is male, married, well-educated, and ~45 years old. Female ultra-marathoners account for ~20% of the total number of finishers. Ultra-marathoners are older and have a larger weekly training volume, but run more slowly during training compared to marathoners. Previous experience (e.g., number of finishes in ultra-marathon races and personal best marathon time) is the most important predictor variable for a successful ultra-marathon performance followed by specific anthropometric (e.g., low body mass index, BMI, and low body fat) and training (e.g., high volume and running speed during training) characteristics. Women are slower than men, but the sex difference in performance decreased in recent years to ~10–20% depending upon the length of the ultra-marathon. The fastest ultra-marathon race times are generally achieved at the age of 35–45 years or older for both women and men, and the age of peak performance increases with increasing race distance or duration. An ultra-marathon leads to an energy deficit resulting in a reduction of both body fat and skeletal muscle mass. An ultra-marathon in combination with other risk factors, such as extreme weather conditions (either heat or cold) or the country where the race is held, can lead to exercise-associated hyponatremia. An ultra-marathon can also lead to changes in biomarkers indicating a pathological process in specific organs or organ systems such as skeletal muscles, heart, liver, kidney, immune and endocrine system. These changes are usually temporary, depending on intensity and duration of the performance, and usually normalize after the race. In longer ultra-marathons, ~50–60% of the participants experience musculoskeletal problems. The most common injuries in ultra-marathoners involve the lower limb, such as the ankle and the knee. An ultra-marathon can lead to an increase in creatine-kinase to values of 100,000–200,000 U/l depending upon the fitness level of the athlete and the length of the race. Furthermore, an ultra-marathon can lead to changes in the heart as shown by changes in cardiac biomarkers, electro- and echocardiography. Ultra-marathoners often suffer from digestive problems and gastrointestinal bleeding after an ultra-marathon is not uncommon. Liver enzymes can also considerably increase during an ultra-marathon. An ultra-marathon often leads to a temporary reduction in renal function. Ultra-marathoners often suffer from upper respiratory infections after an ultra-marathon. Considering the increased number of participants in ultra-marathons, the findings of the present review would have practical applications for a large number of sports scientists and sports medicine practitioners working in this field.
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Affiliation(s)
- Beat Knechtle
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
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7
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Abstract
Zusammenfassung. Wir stellen die wichtigsten Erkenntnisse zu Organschädigungen durch einen Ultramarathon zusammen. Nach einem Ultramarathon können kardiale Biomarker wie CK, CK-MB, kardiales Troponin I (cTnI) und N-terminales pro-Brain Natriuretic Peptide (NT-pro BNP) erhöht sein. Bis 80 % und mehr der Finisher klagen über Verdauungsprobleme, die einer der Hauptgründe sind, einen Ultramarathon nicht zu finishen. Bis zu 90 % der Läufer, die einen Ultramarathon aufgeben, klagen über Übelkeit. Nach einem Ultramarathon steigen die Leberwerte oft an, schwerwiegende Konsequenzen bleiben meist aus. Risikofaktoren für eine Einschränkung der Nierenfunktion sind eine ausgeprägte Muskelschädigung mit Rhabdomyolyse, Dehydratation, Hypotonie, Hyperurikämie, Hyponatriämie, geringe Wettkampferfahrung sowie die Einnahme von NSARs. Ultraläufer leiden nach einem Ultramarathon oft an Infekten der oberen Atemwege.
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Affiliation(s)
- Beat Knechtle
- 1 Medbase St. Gallen
- 2 Institut für Hausarztmedizin, Universität Zürich
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8
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Stillman AE, Oudkerk M, Bluemke DA, de Boer MJ, Bremerich J, Garcia EV, Gutberlet M, van der Harst P, Hundley WG, Jerosch-Herold M, Kuijpers D, Kwong RY, Nagel E, Lerakis S, Oshinski J, Paul JF, Slart RHJA, Thourani V, Vliegenthart R, Wintersperger BJ. Imaging the myocardial ischemic cascade. Int J Cardiovasc Imaging 2018; 34:1249-1263. [PMID: 29556943 DOI: 10.1007/s10554-018-1330-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/05/2018] [Indexed: 01/25/2023]
Abstract
Non-invasive imaging plays a growing role in the diagnosis and management of ischemic heart disease from its earliest manifestations of endothelial dysfunction to myocardial infarction along the myocardial ischemic cascade. Experts representing the North American Society for Cardiovascular Imaging and the European Society of Cardiac Radiology have worked together to organize the role of non-invasive imaging along the framework of the ischemic cascade. The current status of non-invasive imaging for ischemic heart disease is reviewed along with the role of imaging for guiding surgical planning. The issue of cost effectiveness is also considered. Preclinical disease is primarily assessed through the coronary artery calcium score and used for risk assessment. Once the patient becomes symptomatic, other imaging tests including echocardiography, CCTA, SPECT, PET and CMR may be useful. CCTA appears to be a cost-effective gatekeeper. Post infarction CMR and PET are the preferred modalities. Imaging is increasingly used for surgical planning of patients who may require coronary artery bypass.
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Affiliation(s)
- Arthur E Stillman
- Department of Radiology and Imaging Sciences, Emory University, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA.
| | - Matthijs Oudkerk
- Center of Medical Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | - David A Bluemke
- Department of Radiology and Imaging Sciences, National Institute of Biomedical Imaging and Bioengineering, Bethesda, MD, USA
| | - Menko Jan de Boer
- Department of Cardiology, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Jens Bremerich
- Department of Radiology, University of Basel Hospital, Basel, Switzerland
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Matthias Gutberlet
- Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Pim van der Harst
- Department of Genetics, University Medical Center Groningen, Groningen, The Netherlands
| | - W Gregory Hundley
- Departments of Internal Medicine & Radiology, Wake Forest University, Winston-Salem, NC, USA
| | | | - Dirkjan Kuijpers
- Department of Radiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Raymond Y Kwong
- Department of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, DZHK Centre for Cardiovascular Imaging, University Hospital, Frankfurt/Main, Germany
| | | | - John Oshinski
- Department of Radiology and Imaging Sciences, Emory University, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA
| | | | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Vinod Thourani
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
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9
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Romero SA, Minson CT, Halliwill JR. The cardiovascular system after exercise. J Appl Physiol (1985) 2017; 122:925-932. [PMID: 28153943 DOI: 10.1152/japplphysiol.00802.2016] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 01/10/2017] [Accepted: 01/12/2017] [Indexed: 11/22/2022] Open
Abstract
Recovery from exercise refers to the time period between the end of a bout of exercise and the subsequent return to a resting or recovered state. It also refers to specific physiological processes or states occurring after exercise that are distinct from the physiology of either the exercising or the resting states. In this context, recovery of the cardiovascular system after exercise occurs across a period of minutes to hours, during which many characteristics of the system, even how it is controlled, change over time. Some of these changes may be necessary for long-term adaptation to exercise training, yet some can lead to cardiovascular instability during recovery. Furthermore, some of these changes may provide insight into when the cardiovascular system has recovered from prior training and is physiologically ready for additional training stress. This review focuses on the most consistently observed hemodynamic adjustments and the underlying causes that drive cardiovascular recovery and will highlight how they differ following resistance and aerobic exercise. Primary emphasis will be placed on the hypotensive effect of aerobic and resistance exercise and associated mechanisms that have clinical relevance, but if left unchecked, can progress to symptomatic hypotension and syncope. Finally, we focus on the practical application of this information to strategies to maximize the benefits of cardiovascular recovery, or minimize the vulnerabilities of this state. We will explore appropriate field measures, and discuss to what extent these can guide an athlete's training.
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Affiliation(s)
- Steven A Romero
- University of Texas Southwestern Medical Center, Dallas, Texas.,Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Texas; and
| | | | - John R Halliwill
- Department of Human Physiology, University of Oregon, Eugene, Oregon
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10
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Stewart GM, Yamada A, Haseler LJ, Kavanagh JJ, Chan J, Koerbin G, Wood C, Sabapathy S. Influence of exercise intensity and duration on functional and biochemical perturbations in the human heart. J Physiol 2016; 594:3031-44. [PMID: 26801350 PMCID: PMC4887693 DOI: 10.1113/jp271889] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 01/15/2016] [Indexed: 12/22/2022] Open
Abstract
KEY POINTS Strenuous endurance exercise induces transient functional and biochemical cardiac perturbations that persist for 24-48 h. The magnitude and time-course of exercise-induced reductions in ventricular function and increases in cardiac injury markers are influenced by the intensity and duration of exercise. In a human experimental model, exercise-induced reductions in ventricular strain and increases in cardiac troponin are greater, and persist for longer, when exercise is performed within the heavy- compared to moderate-intensity exercise domain, despite matching for total mechanical work. The results of the present study help us better understand the dose-response relationship between endurance exercise and acute cardiac stress/injury, a finding that has implications for the prescription of day-to-day endurance exercise regimes. ABSTRACT Strenuous endurance exercise induces transient cardiac perturbations with ambiguous health outcomes. The present study investigated the magnitude and time-course of exercise-induced functional and biochemical cardiac perturbations by manipulating the exercise intensity-duration matrix. Echocardiograph-derived left (LV) and right (RV) ventricular global longitudinal strain (GLS), and serum high-sensitivity cardiac troponin (hs-cTnI) concentration, were examined in 10 males (age: 27 ± 4 years; V̇O2, peak : 4.0 ± 0.8 l min(-1) ) before, throughout (50%, 75% and 100%), and during recovery (1, 3, 6 and 24 h) from two exercise trials. The two exercise trials consisted of 90 and 120 min of heavy- and moderate-intensity cycling, respectively, with total mechanical work matched. LVGLS decreased (P < 0.01) during the 90 min trial only, with reductions peaking at 1 h post (pre: -19.9 ± 0.6%; 1 h post: -18.5 ± 0.7%) and persisting for >24 h into recovery. RVGLS decreased (P < 0.05) during both exercise trials with reductions in the 90 min trial peaking at 1 h post (pre: -27.5 ± 0.7%; 1 h post: -25.1 ± 0.8%) and persisting for >24 h into recovery. Serum hs-cTnI increased (P < 0.01) during both exercise trials, with concentrations peaking at 3 h post but only exceeding cardio-healthy reference limits (14 ng l(-1) ) in the 90 min trial (pre: 4.2 ± 2.4 ng l(-1) ; 3 h post: 25.1 ± 7.9 ng l(-1) ). Exercise-induced reductions in ventricular strain and increases in cardiac injury markers persist for 24 h following exercise that is typical of day-to-day endurance exercise training; however, the magnitude and time-course of this response can be altered by manipulating the intensity-duration matrix.
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Affiliation(s)
- Glenn M Stewart
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Akira Yamada
- Department of Cardiology, Fujita Health University, Nagoya, Japan
| | - Luke J Haseler
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Justin J Kavanagh
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Jonathan Chan
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
- Cardiology Division, The Prince Charles Hospital, Brisbane, Australia
| | - Gus Koerbin
- Faculty of Education, Science, Technology and Maths, University of Canberra, Canberra, Australia
| | - Cameron Wood
- Pathology North, Royal North Shore Hospital, Sydney, Australia
| | - Surendran Sabapathy
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
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Lord R, George K, Somauroo J, Jain N, Reese K, Hoffman MD, Haddad F, Ashley E, Jones H, Oxborough D. Exploratory insights from the right-sided electrocardiogram following prolonged endurance exercise. Eur J Sport Sci 2016; 16:1014-22. [DOI: 10.1080/17461391.2016.1165292] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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12
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Oosthuyse T, Millen AME. Comparison of energy supplements during prolonged exercise for maintenance of cardiac function: carbohydrate only versus carbohydrate plus whey or casein hydrolysate. Appl Physiol Nutr Metab 2016; 41:674-83. [PMID: 27177231 DOI: 10.1139/apnm-2015-0491] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Cardiac function is often suppressed following prolonged strenuous exercise and this may occur partly because of an energy deficit. This study compared left ventricular (LV) function by 2-dimensional echocardiography and tissue Doppler imaging (TDI) before and after ∼2.5 h of cycling (2-h steady-state 60% peak aerobic power output plus 16 km time trial) in 8 male cyclists when they ingested either placebo, carbohydrate-only (CHO-only), carbohydrate-casein hydrolysate (CHO-casein), or carbohydrate-whey hydrolysate (CHO-whey). No treatment-by-time interactions occurred, but pre-to-postexercise time effects occurred selectively. Although diastolic function measured by pulsed-wave Doppler early-to-late (E/A) transmitral blood flow velocity was suppressed in all trials from pre- to postexercise (mean change post-pre exercise: -0.53 (95% CI -0.15 to -0.91)), TDI early-to-late (e'/a') tissue velocity was significantly suppressed pre- to postexercise only with placebo, CHO-only, and CHO-whey (septal and lateral wall e'/a' average change: -0.62 (95% CI -1.12 to -0.12); -0.69 (95% CI -1.19 to -0.20); and -0.79 (95% CI -1.28 to -0.29), respectively) but not with CHO-casein (-0.40 (95% CI -0.90 to 0.09)). LV contractility was, or tended to be, significantly reduced pre- to postexercise with placebo, CHO-only, and CHO-whey (systolic blood pressure/end systolic volume change, mm Hg·mL(-1): -0.8 (95% CI -1.2 to -0.4), p = 0.0003; -0.5 (95% CI -0.9 to -0.02), p = 0.035; and -0.4 (95% CI -0.8 to 0.04), p = 0.086, respectively), but not with CHO-casein (-0.3 (95% CI -0.8 to 0.1), p = 0.22). However, ejection fraction (EF) and ventricular-arterial coupling were significantly reduced pre- to postexercise only with placebo (placebo change: EF, -4.6 (95% CI -8.4 to -0.7)%; stroke volume/end systolic volume, -0.3 (95% CI -0.6 to -0.04)). Despite no treatment-by-time interactions, pre-to-postexercise time effects observed with specific beverages may be meaningful for athletes. Tentatively, the order of beverages with least-to-most variables displaying a time effect indicating suppression of LV function following exercise was CHO-casein < CHO-only and CHO-whey < placebo, and calls for further verification.
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Affiliation(s)
- Tanja Oosthuyse
- Exercise Laboratory, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa.,Exercise Laboratory, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Aletta M E Millen
- Exercise Laboratory, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa.,Exercise Laboratory, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
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13
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The right ventricle following ultra-endurance exercise: insights from novel echocardiography and 12-lead electrocardiography. Eur J Appl Physiol 2014; 115:71-80. [DOI: 10.1007/s00421-014-2995-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 09/01/2014] [Indexed: 01/26/2023]
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14
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Cardiac electrical conduction, autonomic activity and biomarker release during recovery from prolonged strenuous exercise in trained male cyclists. Eur J Appl Physiol 2013; 114:1-10. [DOI: 10.1007/s00421-013-2742-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 09/27/2013] [Indexed: 10/26/2022]
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15
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Chan-Dewar F, Gregson W, Whyte G, Gaze D, Waterhouse J, Wen J, George K. Do the effects of high intensity 40 km cycling upon left ventricular function and cardiac biomarker during recovery vary with time of day? J Sports Sci 2013; 31:414-23. [DOI: 10.1080/02640414.2012.735369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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16
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Canine left ventricle electromechanical behavior under different pacing modes. J Interv Card Electrophysiol 2012; 35:11-7. [DOI: 10.1007/s10840-010-9532-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 11/22/2010] [Indexed: 10/28/2022]
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17
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Shave R, Oxborough D. Exercise-induced cardiac injury: evidence from novel imaging techniques and highly sensitive cardiac troponin assays. Prog Cardiovasc Dis 2012; 54:407-15. [PMID: 22386291 DOI: 10.1016/j.pcad.2012.01.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Prolonged endurance exercise in humans has been associated with an acute impairment in diastolic and systolic cardiac function and the release of cardiac troponin. In this chapter, we review recent evidence from studies using novel echocardiographic parameters and highly sensitive cardiac troponin assays. We demonstrate that the mechanics of left and right ventricular functions are acutely impaired after completion of prolonged exercise and that this reduction in function is likely multifactorial in etiology. However, we highlight that exercise-induced cardiac troponin release is not a marker of exercise-induced pathology but likely a physiologic response to exercise. Finally, we discuss the potential link between prolonged exercise and the increased incidence of cardiac pathology in veteran athletes.
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MESH Headings
- Adaptation, Physiological
- Athletes
- Biomarkers/blood
- Diagnostic Imaging/methods
- Exercise
- Humans
- Physical Endurance
- Predictive Value of Tests
- Prognosis
- Troponin/blood
- Ventricular Dysfunction, Left/blood
- Ventricular Dysfunction, Left/diagnosis
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Right/blood
- Ventricular Dysfunction, Right/diagnosis
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function, Left
- Ventricular Function, Right
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Affiliation(s)
- Rob Shave
- Cardiff School of Sport, Cardiff Metropolitan University, Cyncoed Campus, Cardiff, UK.
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18
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Chan-Dewar F, Gregson W, Whyte G, King J, Gaze D, Carranza-García LE, Legaz-Arrese A, George K. Cardiac electromechanical delay is increased during recovery from 40 km cycling but is not mediated by exercise intensity. Scand J Med Sci Sports 2011; 23:224-31. [PMID: 22092882 DOI: 10.1111/j.1600-0838.2011.01376.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2011] [Indexed: 12/16/2022]
Abstract
Cardiac electrical-mechanical delay (cEMD), left ventricular (LV) function, and cardiac troponin I (cTnI) were assessed after 40 km cycle time trials completed at high (HIGH) and moderate (MOD) intensities in 12 cyclists. Echocardiograms and blood samples were collected before, 10, and 60 min after cycling. cEMD as assessed by time from QRS onset to peak systolic (S') tissue velocity was lengthened after both bouts of cycling but was not mediated by cycling intensity (HIGH: 174 ± 52 vs 198 ± 26 ms; MOD: 151 ± 40 vs 178 ± 52 ms, P < 0.05). Global LV systolic function was unaltered by exercise. cEMD from QRS to peak early (E') diastolic tissue velocity was also increased post-exercise (HIGH: 524 ± 95 vs 664 ± 68 ms; MOD: 495 ± 62 vs 604 ± 91 ms, P < 0.05). Indices of LV diastolic function was reduced after cycling but were not mediated by exercise intensity. cTnI was elevated in two participants after HIGH trial (0.06 ug/L; 0.04 ug/L) and one participant after MOD trial (0.02 ug/L). While cEMD is lengthened and LV diastolic function was reduced post-cycling, altering time-trial intensity had little impact upon cEMD, LV function, and cTnI release.
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Affiliation(s)
- F Chan-Dewar
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK.
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Oxborough D, Shave R, Warburton D, Williams K, Oxborough A, Charlesworth S, Foulds H, Hoffman MD, Birch K, George K. Dilatation and Dysfunction of the Right Ventricle Immediately After Ultraendurance Exercise. Circ Cardiovasc Imaging 2011; 4:253-63. [DOI: 10.1161/circimaging.110.961938] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Running an ultramarathon has been shown to have a transient negative effect on right ventricular (RV) and left ventricular (LV) function. Additionally, recent findings suggested that ultraendurance athletes may be more at risk of developing a RV cardiomyopathy. The standard echocardiographic assessment of RV function is problematic; however, the introduction of ultrasonic speckle tracking technology has the potential to yield a comprehensive evaluation of RV longitudinal function, providing new insights into this phenomenon. Thus, the primary aim of this exploratory study was to evaluate comprehensively RV structure and function after a 161-km ultramarathon and establish whether changes in the RV are associated with alterations in LV function.
Methods and Results—
Myocardial speckle tracking echocardiograms of the RV and LV were obtained before and immediately after a 161-km ultramarathon in 16 healthy adults. Standard echocardiography was used to determine RV size and function and LV eccentricity index. Speckle tracking was used to determine the temporal evaluation of indices of RV and LV function. RV size was significantly increased postrace (RV outflow, 32 to 35 mm,
P
=0.002; RV inflow, 42 to 45 mm,
P
=0.027) with an increase in LV eccentricity index (1.03 to 1.13,
P
=0.006). RV strain (ε) was significantly reduced postrace (−27% to −24%,
P
=0.004), but there was no change in the rates of ε. Peak ε in all planes of LV motion were reduced postrace (longitudinal, −18.3 to −16.3%,
P
=0.012; circumferential, −20.2% to −15.7%,
P
=0.001; radial, 53.4% to 40.3%,
P
=0.009). Changes in RV size and function correlated with diastolic strain rates in the LV.
Conclusions—
This exploratory study demonstrates RV dilatation and reduction in function after an ultramarathon. Further research is warranted to elucidate the mechanisms responsible for these findings. It is not clear what clinical impact might result from consecutive bouts of postexercise RV dysfunction.
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Affiliation(s)
- David Oxborough
- From the Faculty of Medicine and Health, University of Leeds, Leeds, UK (D.O.); Cardiff School of Sport, Cyncoed Campus, Cyncoed, Cardiff, Wales, UK (R.S.); Centre for Sport Medicine and Human Performance, Brunel University, Uxbridge, London, UK (R.S.); Cardiovascular Physiology and Rehabilitation Laboratory, Physical Activity and Chronic Disease Prevention Unit and Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada (D.W., S.C., H.F.); Research
| | - Robert Shave
- From the Faculty of Medicine and Health, University of Leeds, Leeds, UK (D.O.); Cardiff School of Sport, Cyncoed Campus, Cyncoed, Cardiff, Wales, UK (R.S.); Centre for Sport Medicine and Human Performance, Brunel University, Uxbridge, London, UK (R.S.); Cardiovascular Physiology and Rehabilitation Laboratory, Physical Activity and Chronic Disease Prevention Unit and Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada (D.W., S.C., H.F.); Research
| | - Darren Warburton
- From the Faculty of Medicine and Health, University of Leeds, Leeds, UK (D.O.); Cardiff School of Sport, Cyncoed Campus, Cyncoed, Cardiff, Wales, UK (R.S.); Centre for Sport Medicine and Human Performance, Brunel University, Uxbridge, London, UK (R.S.); Cardiovascular Physiology and Rehabilitation Laboratory, Physical Activity and Chronic Disease Prevention Unit and Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada (D.W., S.C., H.F.); Research
| | - Karen Williams
- From the Faculty of Medicine and Health, University of Leeds, Leeds, UK (D.O.); Cardiff School of Sport, Cyncoed Campus, Cyncoed, Cardiff, Wales, UK (R.S.); Centre for Sport Medicine and Human Performance, Brunel University, Uxbridge, London, UK (R.S.); Cardiovascular Physiology and Rehabilitation Laboratory, Physical Activity and Chronic Disease Prevention Unit and Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada (D.W., S.C., H.F.); Research
| | - Adele Oxborough
- From the Faculty of Medicine and Health, University of Leeds, Leeds, UK (D.O.); Cardiff School of Sport, Cyncoed Campus, Cyncoed, Cardiff, Wales, UK (R.S.); Centre for Sport Medicine and Human Performance, Brunel University, Uxbridge, London, UK (R.S.); Cardiovascular Physiology and Rehabilitation Laboratory, Physical Activity and Chronic Disease Prevention Unit and Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada (D.W., S.C., H.F.); Research
| | - Sarah Charlesworth
- From the Faculty of Medicine and Health, University of Leeds, Leeds, UK (D.O.); Cardiff School of Sport, Cyncoed Campus, Cyncoed, Cardiff, Wales, UK (R.S.); Centre for Sport Medicine and Human Performance, Brunel University, Uxbridge, London, UK (R.S.); Cardiovascular Physiology and Rehabilitation Laboratory, Physical Activity and Chronic Disease Prevention Unit and Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada (D.W., S.C., H.F.); Research
| | - Heather Foulds
- From the Faculty of Medicine and Health, University of Leeds, Leeds, UK (D.O.); Cardiff School of Sport, Cyncoed Campus, Cyncoed, Cardiff, Wales, UK (R.S.); Centre for Sport Medicine and Human Performance, Brunel University, Uxbridge, London, UK (R.S.); Cardiovascular Physiology and Rehabilitation Laboratory, Physical Activity and Chronic Disease Prevention Unit and Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada (D.W., S.C., H.F.); Research
| | - Martin D. Hoffman
- From the Faculty of Medicine and Health, University of Leeds, Leeds, UK (D.O.); Cardiff School of Sport, Cyncoed Campus, Cyncoed, Cardiff, Wales, UK (R.S.); Centre for Sport Medicine and Human Performance, Brunel University, Uxbridge, London, UK (R.S.); Cardiovascular Physiology and Rehabilitation Laboratory, Physical Activity and Chronic Disease Prevention Unit and Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada (D.W., S.C., H.F.); Research
| | - Karen Birch
- From the Faculty of Medicine and Health, University of Leeds, Leeds, UK (D.O.); Cardiff School of Sport, Cyncoed Campus, Cyncoed, Cardiff, Wales, UK (R.S.); Centre for Sport Medicine and Human Performance, Brunel University, Uxbridge, London, UK (R.S.); Cardiovascular Physiology and Rehabilitation Laboratory, Physical Activity and Chronic Disease Prevention Unit and Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada (D.W., S.C., H.F.); Research
| | - Keith George
- From the Faculty of Medicine and Health, University of Leeds, Leeds, UK (D.O.); Cardiff School of Sport, Cyncoed Campus, Cyncoed, Cardiff, Wales, UK (R.S.); Centre for Sport Medicine and Human Performance, Brunel University, Uxbridge, London, UK (R.S.); Cardiovascular Physiology and Rehabilitation Laboratory, Physical Activity and Chronic Disease Prevention Unit and Experimental Medicine Program, University of British Columbia, Vancouver, British Columbia, Canada (D.W., S.C., H.F.); Research
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20
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Sahlén A, Shahgaldi K, Aminoff A, Aagaard P, Manouras A, Winter R, Ehrenborg E, Braunschweig F. Effects of Prolonged Exercise on Left Ventricular Mechanical Synchrony in Long-Distance Runners: Importance of Previous Exposure to Endurance Races. J Am Soc Echocardiogr 2010; 23:977-84. [DOI: 10.1016/j.echo.2010.06.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Indexed: 11/26/2022]
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21
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Oxborough D, Whyte G, Wilson M, O'Hanlon R, Birch K, Shave R, Smith G, Godfrey R, Prasad S, George K. A Depression in Left Ventricular Diastolic Filling following Prolonged Strenuous Exercise is Associated with Changes in Left Atrial Mechanics. J Am Soc Echocardiogr 2010; 23:968-76. [DOI: 10.1016/j.echo.2010.06.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Indexed: 10/19/2022]
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