Cardiac performance after an endurance open water swimming race

The Acute Impact of Endurance Exercise on Right Ventricular Structure and Function: A Systematic Review and Meta-analysis

There have been many studies since the late 1980s investigating the effect of endurance exercise on the left ventricle. More recently, attention has shifted to the right heart, with suggestions that endurance exercise may have a detrimental effect on the right ventricle. This systematic review and meta-analysis summarizes and critiques 26 studies, including 649 athletes, examining the acute impact of endurance exercise on the right ventricle. We also present a subanalysis contrasting ultraendurance with endurance exercise. Finally, we identify areas for future research, such as the influence of sex, ethnicity, and age.

Exploratory assessment of right ventricular structure and function during prolonged endurance cycling exercise

BACKGROUND

A reduction in right ventricular (RV) function during recovery from prolonged endurance exercise has been documented alongside RV dilatation. A relative elevation in pulmonary artery pressure and therefore RV afterload during exercise has been implicated in this post-exercise dysfunction but has not yet been demonstrated. The current study aimed to assess RV structure and function and pulmonary artery pressure before, during and after a 6-h cycling exercise bout.

METHODS

Eight ultra-endurance athletes were recruited for this study. Participants were assessed prior to exercise supine and seated, during exercise at 2, 4 and 6 h whilst cycling seated at 75% maximum heart rate, and post-exercise in the supine position. Standard 2D, Doppler and speckle tracking echocardiography were used to determine indices of RV size, systolic and diastolic function.

RESULTS

Heart rate and RV functional parameters increased from baseline during exercise, however RV structural parameters and indices of RV systolic and diastolic function were unchanged between in-exercise assessment points. Neither pulmonary artery pressures (26 ± 9 mmHg vs 17 ± 10 mmHg, P > 0.05) nor RV wall stress (7.1 ± 3.0 vs 6.2 ± 2.4, P > 0.05) were significantly elevated during exercise. Despite this, post-exercise measurements revealed RV dilation (increased RVD1 and 3), and reduced RV global strain (- 21.2 ± 3.5 vs - 23.8 ± 2.3, P = 0.0168) and diastolic tissue velocity (13.8 ± 2.5 vs 17.1 ± 3.4, P = 0.019) vs pre-exercise values.

CONCLUSION

A 6 h cycling exercise bout at 75% maximum heart rate did not alter RV structure, systolic or diastolic function assessments during exercise. Pulmonary artery pressures are not elevated beyond normal limits and therefore RV afterload is unchanged throughout exercise. Despite this, there is some evidence of RV dilation and altered function in post-exercise measurements.

Exercise-Induced Cardiac Fatigue in Soldiers Assessed by Echocardiography

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.

Cardiac and Pulmonary Vascular Remodeling in Endurance Open Water Swimmers Assessed by Cardiac Magnetic Resonance: Impact of Sex and Sport Discipline

Background: The cardiac response to endurance exercise has been studied previously, and recent reports have described the extension of this remodeling to the pulmonary vasculature. However, these reports have focused primarily on land-based sports and few data are available on exercise-induced cardio-pulmonary adaptation in swimming. Nor has the impact of sex on this exercise-induced cardio-pulmonary remodeling been studied in depth. The main aim of our study was to evaluate cardiac and pulmonary circulation remodeling in endurance swimmers. Among the secondary objectives, we evaluate the impact of sex and endurance sport discipline on this cardio-pulmonary remodeling promoted by exercise training.

Methods:Resting cardiovascular magnetic resonance imaging was performed in 30 healthy well-trained endurance swimmers (83.3% male) and in 19 terrestrial endurance athletes (79% male) to assess biventricular dimensions and function. Pulmonary artery dimensions and flow as well as estimates of pulmonary vascular resistance (PVR) were also evaluated.

Results:In relation to the reference parameters for the non-athletic population, male endurance swimmers had larger biventricular and pulmonary artery size (7.4 ± 1.0 vs. 5.9 ± 1.1 cm², p < 0.001) with lower biventricular ejection fraction (EF) (left ventricular (LV) EF: 58 ± 4.4 vs. 67 ± 4.5 %, p < 0.001; right ventricular (RV) EF: 60 ± 4 vs. 66 ± 6 %, p < 0.001), LV end-diastolic volume (EDV): 106 ± 11 vs. 80 ± 9 ml/m², p < 0.001; RV EDV: 101 ± 14 vs. 83 ± 12 ml/m², p < 0.001). Significantly larger LV volume and lower LV EF were also observed in female swimmers (LV EF: 60 ± 5.3 vs. 67 ± 4.6 %, p = 0.003; LV EDV: 90 ± 17.6 vs. 75± 8.7 ml/m², p = 0.002). Compared to terrestrial endurance athletes, swimmers showed increased LV indexed mass (75.0 ± 12.8 vs. 61.5 ± 10.0 g/m², p < 0.001). The two groups of endurance athletes had similar pulmonary artery remodeling.

Conclusions: Cardiac response to endurance swimming training implies an adaptation of both ventricular and pulmonary vasculature, as in the case of terrestrial endurance athletes. Cardio-pulmonary remodeling seems to be less extensive in female than in male swimmers.

Biochemical markers after the Norseman Extreme Triathlon

Prolonged exercise is known to cause changes in common biomarkers. Occasionally, competition athletes need medical assistance and hospitalisation during prolonged exercise events. To aid clinicians treating patients and medical teams in such events we have studied common biomarkers after at The Norseman Xtreme Triathlon (Norseman), an Ironman distance triathlon with an accumulated climb of 5200 m, and an Olympic triathlon for comparison. Blood samples were collected before, immediately after, and the day following the Norseman Xtreme Triatlon (n = 98) and Oslo Olympic Triathlon (n = 15). Increased levels of clinical significance were seen at the finish line of the Norseman in white blood cells count (WBC) (14.2 [13.5–14.9] 109/L, p < 0.001), creatinine kinase (CK) (2450 [1620–3950] U/L, p < 0.001) and NT-proBNP (576 [331–856] ng/L, p < 0.001). The following day there were clinically significant changes in CRP (39 [27–56] mg/L, p < 0.001) and Aspartate Aminotransferase (AST) (142 [99–191] U/L, p < 0.001). In comparison, after the Olympic triathlon distance, there were statistically significant, but less clinically important, changes in WBC (7.8 [6.7–9.6] 109/L, p < 0.001), CK (303 [182–393] U/L, p < 0.001) and NT-proBNP (77 [49–88] ng/L, p < 0.01) immediately after the race, and in CRP (2 [1–3] mg/L, p < 0.001) and AST (31 [26–41] U/L, p < 0.01) the following day. Subclinical changes were also observed in Hemoglobin, Thrombocytes, K+, Ca2+, Mg2+, Creatinine, Alanine Aminotransferase and Thyroxine after the Norseman. In conclusion, there were significant changes in biomarkers used in a clinical setting after the Norseman. Of largest clinical importance were clinically significant increased WBC, CRP, AST, CK and NT-proBNP after the Norseman. This is important to be aware of when athletes engaging in prolonged exercise events receive medical assistance or are hospitalised.

Cardiac adaptation to endurance exercise training: Differential impact of swimming and running

Objectives: High-intensity training has been associated with bi-ventricular and bi-atrial remodelling and a potentially increased risk of arrhythmias. Most of the evidence is based on endurance disciplines mainly involving the lower part of the body, while few data is available on upper body disciplines. The purpose of this study was to compare chronic cardiac remodelling induced by running and swimming as well as the acute response of ventricular and atrial performance after an upper-body and a lower-body endurance race. Methods: Standard and speckle tracking echocardiographic assessment of left ventricle, right ventricle and both atria was performed at baseline and immediately after a 9.5 km open-water swimming race in 26 healthy men and before and after a 35 km-trail-running race in 21 male runners. Results: No significant differences were observed in baseline ventricular dimensions. However, both right ventricular and atrial systolic deformation were greater in runners. This group also showed slightly larger atrial volumes as compared to swimmers. After the race, right ventricular dilatation was observed in both groups, but only runners showed a decrease in right ventricular deformation and a decrease in atrial volumes and deformation. Significant increases in atrial deformation without reduction in atrial volumes were observed only in swimmers after the race. Conclusions: Right ventricular and atrial remodelling is different depending on the endurance training discipline. Long-distance running races induce a greater impairment in right ventricular performance and atrial function compared to endurance swimming competitions.

Factors Related to Cardiac Troponin T Increase after Participation in a 100 Km Ultra-Marathon

BACKGROUND

Intensive and prolonged exercise leads to a rise of troponin concentration in blood. The mechanism responsible for troponin release during exercise remains ill-defined. The study aim was to search for risk factors of troponin increase after a prolonged endurance competition.

METHODS

The study included a group of 18 amateurs, healthy volunteers (median age 41.5 years, interquartile range - IQR 36-53 years, 83% male) who participated in a 100 km running ultra-marathon. Information on demographic characteristics, pre- and post-race heart rate, blood pressure, body composition and glucose, lactate (L), troponin T (hs-TnT) and C reactive protein (hs-CRP) concentration were obtained. Additionally, data on L and glucose levels every 9.2 km and fluid/food intakes during the race were collected.

RESULTS

There was a significant hs-TnT increase after the race exceeding upper reference values in 66% of runners (from 5 IQR 3-7 ng/L to 14 IQR 12-26 ng/L, p < 0.0001). None of the baseline parameters predicted a post-race hs-TnT increase. The only factors, correlating with changes of hs-TnT were mean L concentration during the race (rho = 0.52, p = 0.03) and change of hs-CRP concentration (rho = 0.59, p = 0.01).

CONCLUSIONS

Participation in a 100 km ultra-marathon leads to a modest, but significant hs-TnT increase in the majority of runners. Among analysed parameters only mean lactate concentration during the race and change in hs-CRP correlated with troponin change.

How to interpret right ventricular remodeling in athletes

Long-lasting athletic training induces an overload on the heart that leads to structural, functional, and electrical adaptive changes known as the "athlete's heart." The amount of this heart remodeling has been traditionally considered balanced between the left and the right heart chambers. However, during intense exercise, the right heart is exposed to a disproportional afterload and wall stress which over a long period of time could lead to more pronounced exercise-induced changes. Highly trained athletes, especially those involved in endurance sport disciplines, can develop marked right ventricular (RV) remodeling that could raise the suspicion of an underlying RV pathology including arrhythmogenic cardiomyopathy (ACM). The distinction between physiological and pathological RV remodeling is essential as ACM is a common cause of sudden cardiac death in athletes, and high-intensity exercise training has demonstrated to accelerate its phenotypic expression and worsen its prognosis. The distinction between physiological and pathological RV remodeling is essential since ACM is a common cause of sudden cardiac death in athletes, and high-intensity exercise training has demonstrated to accelerate the phenotypic expression and worsen the prognosis. This article outlines the physiological adaptation of the RV to acute exercise, the subsequent physiological structural and functional changes induced by athletic training and provides useful tips of how to differentiate between physiological RV remodeling and a cardiomyopathy phenotype.