Upper normal values of blood pressure response to exercise in Olympic athletes

Exaggerated Blood Pressure Response to Exercise Is a Risk of Future Hypertension Even in Healthy, Normotensive Young Individuals-Potential Preventive Strategies for This Phenomenon?

Physical activity and regular exercise are well known to reduce the risks of cerebrovascular and cardiovascular diseases, leading the American College of Sports Medicine to endorse the concept that "exercise is medicine". However, a single bout of exercise temporarily raises arterial blood pressure (BP) to meet the metabolic demands of working muscle, and this BP response is particularly exaggerated in older adults and patients with cardiovascular conditions, such as hypertension, resulting in an exaggerated BP response during exercise. This presents a paradox: while regular exercise is crucial for preventing these diseases, excessively high BP responses during exercise could increase the risk of vascular damage. The mechanisms underlying this exaggerated BP response during exercise remain unclear, and effective exercise regimens for these populations have yet to be established. Currently, low-intensity exercise is recommended; however, its efficacy in disease prevention is uncertain. Notably, even among healthy individuals, there is significant variation in the BP response to exercise. Some healthy individuals, despite having normal resting BP, exhibit an exaggerated BP response during physical activity. Importantly, these individuals are often unaware that their BP becomes excessively elevated during physical activity. Repeated exposure to these heightened BP responses through regular physical activity may increase their long-term risk of cardiovascular disease. How can we prevent disease development in these individuals while still ensuring the effectiveness of exercise? Some studies have shown that individuals with a family history of hypertension may experience this phenomenon even in children and adolescents. Additionally, left ventricular hypertrophy contributes to an exaggerated BP response to exercise, suggesting a possible genetic influence. Conversely, other reports indicate that factors such as arterial stiffness, obesity, and low exercise capacity also contribute to this exaggerated response. Our recent preliminary data suggest that the cognitive benefits of exercise may be diminished in individuals who exhibit an exaggerated BP response during exercise. This implies that individuals with an exaggerated BP response, despite having normal resting BP, may not fully benefit from exercise. In this perspective paper, we review the physiological aspects of this phenomenon and explore strategies to address it. Additionally, we discuss BP responses in athletes within this content. Our goal is to prevent disease while maximizing the benefits of exercise for healthy individuals with an exaggerated BP response, as well as for elderly and cardiovascular patients.

Determinants of supraventricular extra beats in elite athletes practicing different sporting disciplines

BACKGROUND

Supraventricular extra beats (SVEB) are frequently observed in athletes but data on significance, prognostic role and correlation with cardiac remodeling are contrasting. It is uncertain whether SVEB may indicate the development of more complex arrhythmias and the need for closer monitoring is undetermined. The aim was to assess the prevalence and clinical significance of BESV in Olympic athletes of different sporting disciplines, evaluating potential correlations with cardiac remodeling and clinical features.

METHODS

We enrolled athletes who participated at 2012-2022 Olympic Games, submitted to physical examination, blood tests, echocardiography and exercise tests, categorized into power, skills, endurance and mixed disciplines.

RESULTS

We studied 1492 elite athletes: 56% male individuals, mean age 25.8 ± 5.1 years; 29.5% practiced power, 12.3% skills, 21% endurance and 37.2% mixed disciplines. At exercise-stress tests, 6.2% had SVEB, mostly single beats. SVEB were not influenced by anthropometrics or blood test results. They were more common in male individuals (77.4 vs. 54.6%, P < 0.0001) and older athletes (27.1 ± 5.7 vs. 25.7 ± 5.1, P = 0.01). In male athletes with SVEB, higher left atrial volumes were observed (24.2 ± 7.3 vs. 22.2 ± 7.1 ml/m2, P = 0.03). No differences were found in terms of sporting discipline: despite larger left atrial dimensions in aerobic disciplines, SVEB rates were similar in different sporting disciplines (6.1% endurance, 6.3% mixed, 5.2% power and 8.7% skills; P = 0.435).

CONCLUSION

SVEB were more common in older, male athletes and associated with higher left atrial volume (especially in male individuals) regardless of sport practiced. Athletes with greater left atrial volume and SVEB are supposed to have higher risk, in middle age, of developing more complex arrhythmias.

Physical exercise in hypertensive heart disease: From the differential diagnosis to the complementary role of exercise

Arterial hypertension (AH) is one of the most common pathologic conditions and uncontrolled AH is a leading risk factor for cardiovascular disease and mortality. AH chronically causes myocardial and arterial remodelling with hemodynamic changes affecting the heart and other organs, with potentially irreversible consequences leading to poor outcomes. Therefore, a proper and early treatment of AH is crucial after the diagnosis. Beyond medical treatment, physical exercise also plays a therapeutic role in reducing blood pressure, given its potential effects on sympathetic tone, renin-angiotensin-aldosterone system, and endothelial function. International scientific societies recommend physical exercise among lifestyle modifications to treat AH in the first stages of the disease. Moreover, some studies have also shown its usefulness in addition to drugs to reduce blood pressure further. Therefore, an accurate, personalized exercise prescription is recommended to optimize the prevention and treatment of hypertension. On the other hand, uncontrolled AH in athletes requires proper risk stratification and careful evaluation to practice competitive sports safely. Moreover, the differential diagnosis between hypertensive heart disease and athlete's heart is sometimes challenging and requires a careful and comprehensive interpretation in order not to misinterpret the clinical findings. The present review aims to discuss the relationship between hypertensive heart disease and physical exercise, from diagnostic tools to prevention and treatment strategies.

Lack of cardiac remodelling in elite endurance athletes: an unexpected and not so rare finding

PURPOSE

Endurance elite athletes are expected to present a cardiac remodelling, characterized by eccentric hypertrophy (EH), may be associated with higher sportive performances. However, not all can present a cardiac remodelling. The study aimed to identify endurance athletes without cardiac remodelling characterizing their physiologic and clinical features.

METHODS

We studied 309 endurance athletes (cycling, rowing, canoeing, triathlon, athletics, long-distance swimming, cross-country skiing, mid-long distance track, pentathlon, biathlon, long-distance skating and Nordic-combined) examined during period of training, by clinical evaluation, ECG, echocardiogram and exercise-stress test. Sport career achievements (Olympic\World championship medals or national\world records) were recorded.

RESULTS

EH was found in most of athletes, (n = 126, 67% of males; n = 85, 68.5% of females). A significant proportion,, exhibited normal geometry (NG) ( n = 59, 31.3% in males; n = 39, 31.4% in females). At stress test, significant differences between EH and NG athletes were found in peak power (317.1 ± 71.2W in NG vs. 342.2 ± 60.6W in EH, p = 0.014 in males and 225.1 ± 38.7W in NG vs. 247.1 ± 37W in EH, p = 0.003 in females), rest heart rate (66.1 ± 13 in NG vs. 58.6 ± 11.6 in EH, p = 0.001 in males and 68 ± 13.2 in NG vs. 59.2 ± 11.2 in EH, p = 0.001 in females) with similar ventricular extrasystoles (p = 0.363 in males and p = 0.492 in females). However, no significant differences in athletic achievements were registered.

CONCLUSION

Our study demonstrates a relatively high prevalence of NG in endurance athletes, in addition to the expected EH. Athletes with NG perform worse in exercise-stress test and exhibit some less advantageous functional heart characteristics. However, the type of heart geometry is not associated with negative clinical findings.

Association between FT3 Levels and Exercise-Induced Cardiac Remodeling in Elite Athletes

BACKGROUND

Previous studies demonstrated that variations of fT3, even within the euthyroid range, can influence cardiac function. Our aim was to investigate whether thyroid hormones, even within the euthyroid range, are associated with the magnitude of exercise-induced cardiac remodeling in Olympic athletes.

METHODS

We evaluated 1342 Olympic athletes (mean age 25.6 ± 5.1) practicing different sporting disciplines (power, skills, endurance, and mixed). Athletes underwent blood testing (thyroid stimulating hormone, fT3, and fT4), echocardiography, and exercise-stress testing. Athletes taking thyroid hormones, affected by thyroiditis, or presenting TSH out of ranges were excluded.

RESULTS

The level of thyroid hormones varied according to the type of sporting discipline practiced: endurance athletes presented the lowest TSH (p < 0.0001), fT3 (p = 0.007), and fT4 (p < 0.0001) in comparison to the remaining ones. Resting heart rate (HR) was positively correlated to fT3 in athletes of different disciplines (power: p = 0.0002, R2 = 0.04; skill: p = 0.0009, R2 = 0.05; endurance: p = 0.007, R2 = 0.03; and mixed: p = 0.04, R2 = 0.01). The same results were seen for peak HR in the exercise-stress test in athletes engaged in power, skill, and endurance (respectively, p < 0.0001, R2 = 0.04; p = 0.01, R2 = 0.04; and p = 0.005, R2 = 0.02). Moreover, a positive correlation was observed with cardiac dimensions, i.e., interventricular septum (power: p < 0.0001, R2 = 0.11; skill: p = 0.02, R2 = 0.03; endurance: p = 0.002, R2 = 0.03; mixed: p < 0.0001, R2 = 0.04). Furthermore, fT3 was directly correlated with the left ventricle (LV) end-diastolic volume in skills (p = 0.04, R2 = 0.03), endurance (p = 0.04, R2 = 0.01), and mixed (p = 0.04, R2 = 0.01).

CONCLUSIONS

Thyroid hormones, even within the euthyroid range, are associated with cardiac adaptive response to exercise and may contribute to exercise-induced cardiac remodeling.

Left Ventricular Trabeculation: Arrhythmogenic and Clinical Significance in Elite Athletes

INTRODUCTION

Left ventricular (LV) trabeculations (LVTs) are common findings in athletes. Limited information exists regarding clinical significance, management, and outcome.

OBJECTIVES

The purpose of this study is to examine the prevalence and morphologic characteristics of LVTs in elite athletes, with a focus on clinical correlates and prognostic significance.

METHODS

We enrolled 1,492 Olympic elite athletes of different sports disciplines with electrocardiogram, echocardiogram, and exercise stress test. Individuals with a definite diagnosis of LV noncompaction (LVNC) were excluded; we focused on athletes with LVTs not meeting the criteria for LVNC.

RESULTS

Four hundred thirty-five (29.1%) athletes presented with LVTs, which were more frequent in male athletes (62.1% vs 53.5%, P = .002) and Black athletes compared with Caucasian (7.1% vs 2.4%, P < .0001) and endurance athletes (P = .0005). No differences were found with relation to either the site or extent of trabeculations. Endurance athletes showed a higher proportion of LVTs and larger LV volumes (end-diastolic and end-systolic, respectively, 91.5 ± 19.8 mL vs 79.3 ± 29.9 mL, P = .002; and 33.1 ± 10 mL vs 28.6 ± 11.7 mL, P = .007) and diastolic pattern with higher E wave (P = .01) and e' septal velocities (P = .02). Ventricular arrhythmias were found in 14% of LVTs versus 11.6% of athletes without LVTs (P = .22). Neither the location nor the LVTs' extension were correlated to ventricular arrhythmias. At 52 ± 32 months of follow-up, no differences in arrhythmic burden were observed (11.1% in LVT athletes vs 10.2%, P = .51).

CONCLUSIONS

Left ventricular trabeculations are quite common in athletes, mostly male, Black, and endurance, likely as the expression of adaptive remodeling. In the absence of associated clinical abnormalities, such as LV systolic and diastolic impairment, electrocardiogram repolarization abnormalities, or family evidence of cardiomyopathy, athletes with LVTs have benign clinical significance and should not require further investigation.

The athlete's heart: allometric considerations on published papers and relation to cardiovascular variables

To evaluate the morphology of the "athlete's heart", left ventricular (LV) wall thickness (WT) and end-diastolic internal diameter (LVIDd) at rest were addressed in publications on skiers, rowers, swimmers, cyclists, runners, weightlifters (n = 927), and untrained controls (n = 173) and related to the acute and maximal cardiovascular response to their respective disciplines. Dimensions of the heart at rest and functional variables established during the various sport disciplines were scaled to body weight for comparison among athletes independent of body mass. The two measures of LV were related (r = 0.8; P = 0.04) across athletic disciplines. With allometric scaling to body weight, LVIDd was similar between weightlifters and controls but 7%-15% larger in the other athletic groups, while WT was 9%-24% enlarged in all athletes. The LVIDd was related to stroke volume, oxygen pulse, maximal oxygen uptake, cardiac output, and blood volume (r =  ~ 0.9, P < 0.05), while there was no relationship between WT and these variables (P > 0.05). In conclusion, while cardiac enlargement is, in part, essential for the generation of the cardiac output and thus stroke volume needed for competitive endurance exercise, an enlarged WT seems important for the development of the wall tension required for establishing normal arterial pressure in the enlarged LVIDd.

Cardiovascular Effects of Chronic Hormone Therapy: Study on Olympic Female Athletes

Female physiology is regulated after puberty by the menstrual cycle, whose hormonal fluctuations create a multitude of effects on several systems, including the cardiovascular one. The use of hormone therapy (HT) is quite common in female athletes, and data on cardiovascular effects in this population are lacking. We sought to investigate the effects of HT in highly trained athletes to assess any difference associated with HT on cardiac remodeling, exercise capacity, and clinical correlates. We studied 380 female elite athletes (mean age 25.5 ± 4.8) competing in endurance and mixed sports; 67 athletes (18%) were in chronic HT therapy. All athletes underwent baseline electrocardiography, exercise electrocardiography stress test, transthoracic echocardiogram, and complete blood tests, including lipid profile and inflammation indexes. The echocardiographic study showed a characteristic left ventricular (LV) remodeling, defined by lower LV mass index (86.2 vs 92.5 g/m2, p <0.006), end-diastolic LV diameter (28.3 vs 29.4 mm/m2, p <0.004), and end-diastolic LV volume (61.82 vs 67.09 ml/m2, p <0.010) compared with controls, without changes in systolic function and diastolic relaxation/filling indexes. A lower burden of ventricular arrhythmias on exercise was observed in HT athletes (1.5% vs 8.6% in those without therapy, p = 0.040). Linear regression analysis showed that HT had an independent effect on LV end-diastolic diameter indexed (p = 0.014), LV end-diastolic volume indexed (p = 0.030), and LV mass indexed (p = 0.020). In conclusion, chronic treatment with HT in female athletes is associated with less cardiac remodeling, including a lower LV cavity, volume, and mass, with preserved systolic and diastolic function, and decreased burden of exercise-induced ventricular arrhythmias. HT, therefore, appears to be responsible for a more economic but equally efficient cardiac adaptation to intensive athletic conditioning.

Exercise-Induced Blood Pressure Dynamics: Insights from the General Population and the Athletic Cohort

Blood pressure (BP) dynamics during graded exercise testing provide important insights into cardiovascular health, particularly in athletes. These measurements, taken during intense physical exertion, complement and often enhance our understanding beyond traditional resting BP measurements. Historically, the challenge has been to distinguish 'normal' from 'exaggerated' BP responses in the athletic environment. While basic guidelines have served their purpose, they may not fully account for the complex nature of BP responses in today's athletes, as illuminated by contemporary research. This review critically evaluates existing guidelines in the context of athletic performance and cardiovascular health. Through a rigorous analysis of the current literature, we highlight the multifaceted nature of exercise-induced BP fluctuations in athletes, emphasising the myriad determinants that influence these responses, from specific training regimens to inherent physiological nuances. Our aim is to advocate a tailored, athlete-centred approach to BP assessment during exercise. Such a paradigm shift is intended to set the stage for evidence-based guidelines to improve athletic training, performance and overall cardiovascular well-being.

Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography

BACKGROUND

Central Illustration : Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography ESBPRE: exaggerated systolic blood pressure response to exercise; HR: heart rate; SBP: systolic blood pressure.

BACKGROUND

The association between exaggerated systolic blood pressure response to exercise (ESBPRE) and myocardial ischemia is controversial and little studied in patients with established or suspected chronic coronary syndrome.

OBJECTIVE

To verify the relationship between myocardial ischemia and ESBPRE in patients undergoing exercise stress echocardiography (ESE).

METHODS

This is a cross-sectional study with 14,367 patients undergoing ESE, from January 2000 to January 2022, divided into the following 2 groups: G1, composed of patients whose peak systolic pressure increased ≥ 90 mmHg (value corresponding to the 95th percentile of the study population), and G2, patients who did not demonstrate an exaggerated hypertensive response. The groups were compared using Student's t and chi-square tests. P values < 0.05 were considered significant. Logistic regression was also performed to identify independent risk factors for myocardial ischemia, ESBPRE, complaints of typical chest pain prior to the exam, and angina during the test.

RESULTS

Of the 14,367 patients, 1,500 (10.4%) developed ESBPRE, and 7,471 (52.0%) were female. The percentages of previous complaints of typical chest pain, angina during the test, and myocardial ischemia in patients with ESBPRE were 5.8%, 2.4% and 18.1%, compared to 7.4%, 3.9%, and 24.2%, in patients without ESBPRE, respectively (p = 0.021,p = 0.004, p < 0.001). In multivariate analysis, ESBPRE was independently associated with a lower probability of myocardial ischemia (odds ratio: 0.73; 95% confidence interval: 0.58 to 0.93; p = 0.009).

CONCLUSION

Exaggerated increase in systolic blood pressure during ESE may be a marker for excluding myocardial ischemia.

Comparative features of the morphometric correlates of blood pressure response to physical load of qualified athletes in some sports

Purpose: the purpose of this study was to establish morphometric parameters that correlate with the reactivity and recovery of blood pressure in response to a standard physical load in athletes of various game sports. Material & Methods: to achieve the set goal, 101 qualified male athletes engaged in game sports were examined. All examined represented 3 game sports: 13 – water polo (average age 27.3±6.3 years), 59 – volleyball (average age 21.1±2.5 years), 29 – handball (average age 20.9±2.8 years). The morphometric study was carried out by traditional methods and included the determination of body length (BL, cm), body weight (BW, kg), chest circumference (CC, cm) with calculation of chest excursion (CE, cm), hand dynamometry, vital lung capacity (VLC, ml). Body mass index (BMI, kg×m–2), vital index (VI, ml×kg–1) and Erismann index (IE, c.u.) were calculated separately. The Martine test (20 squats in 30 seconds) was performed according to the traditional method. Results: changes in SBP in response to load were the significantly greater in handball players compared to water polo players (p=0.025) and compared to volleyball players (p=0.022). Changes in SBP during 3 minutes of recovery are not related to morphometric parameters and obey the general mechanisms of changes in hemodynamic support under the influence of physical load. Changes in DBP during 3 minutes of recovery are related to chest circumference (CC, cm) and proportionality of its development (IE, c.u.) in volleyball and water polo players, and with BW (kg) in handball players. Changes in PBP during 3 minutes of recovery in handball players are not differentiated, in volleyball players they are related to the proportionality of chest development (IE, c.u.), and in water polo players to the BW (kg), CC (cm), mobility and proportionality of chest development (CE, cm and IE, c.u.). Conclusions: the obtained results confirm that changes in DBP and PBP in response to physical load and during the recovery period after it are related to the morphometric parameters of the body, which can characterize the mechanisms of hemodynamic maintenance recovery and be useful in the selection and the organization of recovery measures in certain sports sport.

Comparative features of the morphometric correlates of blood pressure response to physical load of qualified athletes in some sports

Purpose: the purpose of this study was to establish morphometric parameters that correlate with the reactivity and recovery of blood pressure in response to a standard physical load in athletes of various game sports. Material & Methods: to achieve the set goal, 101 qualified male athletes engaged in game sports were examined. All examined represented 3 game sports: 13 – water polo (average age 27.3±6.3 years), 59 – volleyball (average age 21.1±2.5 years), 29 – handball (average age 20.9±2.8 years). The morphometric study was carried out by traditional methods and included the determination of body length (BL, cm), body weight (BW, kg), chest circumference (CC, cm) with calculation of chest excursion (CE, cm), hand dynamometry, vital lung capacity (VLC, ml). Body mass index (BMI, kg×m–2), vital index (VI, ml×kg–1) and Erismann index (IE, c.u.) were calculated separately. The Martine test (20 squats in 30 seconds) was performed according to the traditional method. Results: changes in SBP in response to load were the significantly greater in handball players compared to water polo players (p=0.025) and compared to volleyball players (p=0.022). Changes in SBP during 3 minutes of recovery are not related to morphometric parameters and obey the general mechanisms of changes in hemodynamic support under the influence of physical load. Changes in DBP during 3 minutes of recovery are related to chest circumference (CC, cm) and proportionality of its development (IE, c.u.) in volleyball and water polo players, and with BW (kg) in handball players. Changes in PBP during 3 minutes of recovery in handball players are not differentiated, in volleyball players they are related to the proportionality of chest development (IE, c.u.), and in water polo players to the BW (kg), CC (cm), mobility and proportionality of chest development (CE, cm and IE, c.u.). Conclusions: the obtained results confirm that changes in DBP and PBP in response to physical load and during the recovery period after it are related to the morphometric parameters of the body, which can characterize the mechanisms of hemodynamic maintenance recovery and be useful in the selection and the organization of recovery measures in certain sports sport.

Hypertensive Response to Exercise in Athletes: Unremarkable Finding or Relevant Marker for Future Cardiovascular Complications?

Background. In the general population, hypertensive response to exercise (HRE) predicts new-onset resting hypertension or other cardiovascular diseases. Methods. PubMed was searched for English articles published between January 1st 2000 and April 30th 2020. Additional studies were identified via reference lists of included studies. 92 papers were selected for full text analysis, finally 30 studies were included. Results. The results from 5 follow-up studies suggested an association between HRE and the risk of developing hypertension, while 10 studies reported a link with adverse cardiovascular events in the general population. Another study showed an association between HRE and future hypertension in athletes after a follow-up of 7 years. HRE in athletes was associated with left ventricular hypertrophy in three studies. Two other studies showed a link between HRE and focal myocardial fibrosis in triathletes and myocardial injury, respectively. One study found lower Apoliprotein-1 serum levels in athletes with HRE leading to a higher risk for cardiovascular disease. Only in one study no association with cardiovascular dysfunction in athletes with HRE was found. Conclusions. Based on current evidence, HRE is not a normal finding in athletes. If detected, it should be interpreted as a risk factor for future cardiovascular complications. Future research should address the adequate follow-up and management of athletes with HRE.

The Athlete's Heart-Challenges and Controversies: JACC Focus Seminar 4/4

Regular exercise promotes structural, functional, and electrical remodeling of the heart, often referred to as the "athlete's heart," with intense endurance sports being associated with the greatest degree of cardiac remodeling. However, the extremes of exercise-induced cardiac remodeling are potentially associated with uncommon side effects. Atrial fibrillation is more common among endurance athletes and there is speculation that other arrhythmias may also be more prevalent. It is yet to be determined whether this arrhythmic susceptibility is a result of extreme exercise remodeling, genetic predisposition, or other factors. Gender may have the greatest influence on the cardiac response to exercise, but there has been far too little research directed at understanding differences in the sportsman's vs sportswoman's heart. Here in part 4 of a 4-part seminar series, the controversies and ambiguities regarding the athlete's heart, and in particular, its arrhythmic predisposition, genetic, and gender influences are reviewed in depth.

Systolic Blood Pressure Response to Exercise in Endurance Athletes in Relation to Oxygen Uptake, Work Rate and Normative Values

Work rate has a direct impact on the systolic blood pressure (SBP) during aerobic exercise, which may be challenging in the evaluation of the SBP response in athletes reaching high work rates. We aimed to investigate the exercise SBP response in endurance athletes in relation to oxygen uptake (VO2), work rate and to recent reference equations for exercise SBP in the general population. Endurance athletes with a left-ventricular end-diastolic diameter above the reference one performed a maximal bicycle cardiopulmonary exercise test. The increase in SBP during exercise was divided by the increase in VO2 (SBP/VO2 slope) and in Watts, respectively (SBP/W slope). The maximum SBP (SBPmax) and the SBP/W slope were compared to the predicted values. In total, 27 athletes (59% men) were included; mean age, 40 ± 10 years; mean VO2max, 50 ± 5 mL/kg/min. The mean SBP/VO2 slope was 29.8 ± 10.2 mm Hg/L/min, and the mean SBP/W slope was 0.27 ± 0.08 mm Hg/W. Compared to the predicted normative values, athletes had, on average, a 12.2 ± 17.6 mm Hg higher SBPmax and a 0.12 ± 0.08 mm Hg/W less steep SBP/W slope (p < 0.01 and p < 0.001, respectively). In conclusion, the higher SBPmax values and the less steep SBP/W slope highlight the importance of considering work rate when interpreting the SBP response in endurance athletes and suggest a need for specific normative values in athletes to help clinicians distinguish physiologically high maximal blood pressure from a pathological blood pressure response.

Blood Pressure Response and Pulse Arrival Time During Exercise Testing in Well-Trained Individuals

Introduction: There is a lack of data describing the blood pressure response (BPR) in well-trained individuals. In addition, continuous bio-signal measurements are increasingly investigated to overcome the limitations of intermittent cuff-based BP measurements during exercise testing. Thus, the present study aimed to assess the BPR in well-trained individuals during a cycle ergometer test with a particular focus on the systolic BP (SBP) and to investigate pulse arrival time (PAT) as a continuous surrogate for SBP during exercise testing.

Materials and Methods: Eighteen well-trained male cyclists were included (32.4 ± 9.4 years; maximal oxygen uptake 63 ± 10 ml/min/kg) and performed a stepwise lactate threshold test with 5-minute stages, followed by a continuous test to voluntary exhaustion with 1-min increments when cycling on an ergometer. BP was measured with a standard automated exercise BP cuff. PAT was measured continuously with a non-invasive physiological measurements device (IsenseU) and metabolic consumption was measured continuously during both tests.

Results: At lactate threshold (281 ± 56 W) and maximal intensity test (403 ± 61 W), SBP increased from resting values of 136 ± 9 mmHg to maximal values of 219 ± 21 mmHg and 231 ± 18 mmHg, respectively. Linear within-participant regression lines between PAT and SBP showed a mean r² of 0.81 ± 17.

Conclusion: In the present study focusing on the BPR in well-trained individuals, we observed a more exaggerated systolic BPR than in comparable recent studies. Future research should follow up on these findings to clarify the clinical implications of the high BPR in well-trained individuals. In addition, PAT showed strong intra-individual associations, indicating potential use as a surrogate SBP measurement during exercise testing.

Updated Blood Pressure Guidelines: Implications for Athletes

PURPOSE OF REVIEW

To review the prevalence, short- and long-term impact of exercise on blood pressure, and the evaluation and treatment of hypertension in competitive athletes.

RECENT FINDINGS

Due, in part, to inconsistencies in measurement and the definitions used, the true prevalence of hypertension is unknown as reports range from 0 to 83%. With recent changes in the blood pressure guidelines, the proportion of athletes that meet criteria for elevated blood pressure or stage 1 hypertension has increased dramatically with over one-third of collegiate and professional athletes meeting criteria for hypertension. Data consistently show that American-style football players, particularly linemen, display the highest rates of hypertension. These athletes typically have a larger body mass index, higher body fat percentage, and weight gain in serial follow-up. Many athletes with hypertension have traditional risk factors, and, to date, there is no evidence of a causal relationship between long-term sport participation and increased risk of developing hypertension. Many more athletes now meet criteria for hypertension, given the updated blood pressure guidelines. This should be taken as an opportunity for early intervention, as athletes are not immune to the development of cardiovascular risk factors and disease.

Acute Cardiorespiratory and Metabolic Responses to Incremental Cycling Exercise in Endurance- and Strength-Trained Athletes

The purpose of this study was to examine the acute effects of a progressive submaximal cycling exercise on selected cardiorespiratory and metabolic variables in endurance and strength trained athletes. The sample comprised 32 participants aged 22.0 ± 0.54 years who were assigned into three groups: an endurance trained group (END, triathletes, n = 10), a strength trained group (STR, bodybuilders, n = 10), and a control group (CON, recreationally active students, n = 12). The incremental cycling exercise was performed using a progressive protocol starting with a 3 min resting measurement and then a 50 W workload with subsequent constant increments of 50 W every 3 min until 200 W. The following cardiometabolic variables were evaluated: heart rate (HR), oxygen uptake (VO2), carbon dioxide production (VCO2), respiratory exchange ratio (RER), systolic and diastolic blood pressure (SBP and DBP), and blood lactate (BLa−). We found the between-group differences in metabolic variables (the average RER and BLa−) were statistically significant (Tukey’s HSD test: CON vs. STR, p < 0.01 and p < 0.05, respectively; CON vs. END, p < 0.001; END vs. STR, p < 0.001). RER and BLa− differences in all groups depended on the workload level (G-G-epsilon = 0.438; p < 0.004 and G-G-epsilon = 0.400; p < 0.001, respectively). There were no significant differences in cardiorespiratory variables between endurance- and strength-trained groups. In conclusion, this study demonstrated that acute cardiorespiratory responses at each of the four submaximal workloads were comparable in endurance- compared to strength-trained athletes, but significantly different compared to recreationally active men. However, there were significant differences in the metabolic responses of RER and BLa−. Based on our findings we recommend that endurance-trained athletes follow a concurrent training program, combined strength and endurance training, to improve neuromuscular parameters and thus optimize their economy of movement and endurance-specific muscle power capacity.

Differences between Elite Male and Female Badminton Athletes Regarding Heart Rate Variability, Arterial Stiffness, and Aerobic Capacity

Cardiovascular health and aerobic capacity play crucial roles in determining the performance of athletes in the highly competitive sport of badminton. Few studies have directly compared heart rate variability (HRV), arterial stiffness, and aerobic capacity between male and female athletes, especially among badminton athletes. This study investigated sex differences in HRV, arterial stiffness, and aerobic capacity in badminton athletes. Elite badminton athletes were recruited and divided into male (n = 20, 21.0 ± 1.8 years old) and female (n = 16, 21.2 ± 2.3 years old) groups. Both groups performed an incremental treadmill running test for the evaluation of maximal oxygen consumption (V.O2max), anaerobic threshold, and time to exhaustion. They started exercising at a treadmill speed of 2.7 km/h and an inclination of 10% gradient for 3 min, and the speed and inclination were gradually increased every 3 min until they were exhausted or fatigued volitionally. HRV was examined using the Polar heart rate monitor over a period of 5 min at rest in the supine position. Subsequently, the index of arterial stiffness was examined under the same condition. Our results revealed significant differences between the male and female athletes in V.O2max (men: 60.38 ± 8.98 mL/kg/min, women: 48.13 ± 7.72 mL/kg/min, p < 0.05), anaerobic threshold (men: 41.50 ± 7.26 mL/kg/min, women: 32.51 ± 6.19 mL/kg/min, p < 0.05), time to exhaustion (men: 902.15 ± 120.15 s, women: 780.56 ± 67.63 s, p < 0.05), systolic blood pressure (men: 125.27 ± 7.76 mmHg, women: 107.16 ± 11.09 mmHg, p < 0.05), and arterial stiffness index (men: 63.56 ± 12.55, women: 53.83 ± 8.03, p < 0.05). However, no significant differences in HRV measures were observed between the two groups. These findings suggested that the male badminton athletes demonstrated significantly higher aerobic capacity than did the female athletes, but there were no significant differences in HRV measures. The female athletes exhibited superior arterial function, compared with their male counterparts.

Blood pressure response to dynamic exercise testing in adolescent elite athletes, what is normal?

BACKGROUND

In general, only few studies are dedicated to blood pressure behavior under physical stress in children and adolescents. Even less is published about the blood pressure behavior of young high-performance athletes on the ergometer. For this reason, we evaluated the blood pressure behavior under stress compared to non-athletes in a large collective (n = 739) of young high-performance athletes (age 10-20 years, mean 15.8 years, male 442, female 297) of different sports. A complete echocardiographic examination was available in all athletes.

RESULT

Regardless of gender, the young competitive athletes achieved significantly higher maximum blood pressure values than investastigated populations from previous studies. Based on the data obtained, blood pressure percentiles are now defined explicitly for junior athletes across sports as well as age- and gender-dependent, which did not exist in this form of normal values for the special clientele of young competitive athletes. The echocardiographic examinations demonstrated stress-induced cardiac adaptation adaptations in the majority of athletes, which thus correlate with the comparatively higher stress blood pressures compared to non-athletes.

CONCLUSION

For the first time, blood pressure percentiles for exercise tests on the ergometer for age groups and gender in high performance athletes are defined based on a comparatively large collective of young competitive athletes. Upper limits were determined, in particular for systolic blood pressure under stress, and categorized according to gender and age. Performance diagnosticians and physicians are now enabled to make a more accurate assessment of the corresponding blood pressure regulation of young athletes under exercise conditions.

Extreme Hypoxia Causing Brady-Arrythmias During Apnea in Elite Breath-Hold Divers

Introduction: The cardiac electrical conduction system is very sensitive to hypoglycemia and hypoxia, and the consequence may be brady-arrythmias. Weddell seals endure brady-arrythmias during their dives when desaturating to 3.2 kPa and elite breath-hold-divers (BHD), who share metabolic and cardiovascular adaptions including bradycardia with diving mammals, endure similar desaturation during maximum apnea. We hypothesized that hypoxia causes brady-arrythmias during maximum apnea in elite BHD. Hence, this study aimed to define the arterial blood glucose (Glu), peripheral saturation (SAT), heart rhythm (HR), and mean arterial blood pressure (MAP) of elite BHD during maximum apneas.

Methods: HR was monitored with Direct-Current-Pads/ECG-lead-II and MAP and Glu from a radial arterial-catheter in nine BHD performing an immersed and head-down maximal static pool apnea after three warm-up apneas. SAT was monitored with a sensor on the neck of the subjects. On a separate day, a 12-lead-ECG-monitored maximum static apnea was repeated dry (n = 6).

Results: During pool apnea of maximum duration (385 ± 70 s), SAT decreased from 99.6 ± 0.5 to 58.5 ± 5.5% (∼PaO₂ 4.8 ± 1.5 kPa, P < 0.001), while Glu increased from 5.8 ± 0.2 to 6.2 ± 0.2 mmol/l (P = 0.009). MAP increased from 103 ± 4 to 155 ± 6 mm Hg (P < 0.005). HR decreased to 46 ± 10 from 86 ± 14 beats/minute (P < 0.001). HR and MAP were unchanged after 3–4 min of apnea. During dry apnea (378 ± 31 s), HR decreased from 55 ± 4 to 40 ± 3 beats/minute (P = 0.031). Atrioventricular dissociation and junctional rhythm were observed both during pool and dry apneas.

Conclusion: Our findings contrast with previous studies concluding that Glu decreases during apnea diving. We conclude during maximum apnea in elite BHD that (1) the diving reflex is maximized after 3–4 min, (2) increasing Glu may indicate lactate metabolism in accordance with our previous results, and (3) extreme hypoxia rather than hypoglycemia causes brady-arrythmias in elite BHD similar to diving mammals.

Left ventricular hypertrophy in athletes, a case-control analysis of interindividual variability

BACKGROUND

A variability in cardiac remodeling is observed in athletes regardless of age, sex, body size and sport participated. We sought to investigate whether other individual characteristics could affect the extent of Left ventricular hypertrophy (LVH).

METHODS

From 2120 consecutive Olympic athletes, those with LVH (defined as LV Wall thickness ≥ 13 mm) were matched 1:1 by age, gender, body surface area and type of sport with non-LVH Athletes. Clinical and Echocardiographic variables were compared.

RESULTS

48 athletes with LVH (2.3%) and 48 matched non-LVH athletes were identified. LVH Athletes had higher body weight (90 ± 18 vs 81 ± 11Kg; p = 0.006) body mass index (26 ± 2 vs 24 ± 2 Kg/m2; p < 0.001) and body fat percentage (15 ± 7% vs 12 ± 4%; p = 0.016) compared to non-LVH Athletes. They also had higher systolic (123 ± 1 vs 116 ± 11 mmHg; p = 0.002) and diastolic blood pressure (76 ± 8 vs 71 ± 9 mmHg; p = 0.002). On exercise testing, LVH Athletes reached a lower index workload (3.7 ± 0.9 vs 4.1 ± 0.8 W/Kg; p = 0.013) and a higher peak diastolic blood pressure (79 ± 10 vs 74 ± 11 mmHg; p = 0.012) than those without LVH. Binary logistic regression analysis showed that diastolic blood pressure (OR 1.052; 95% CI from 1.011 to 1.130; p = 0.020) and BMI (OR 1.220; 95% CI from 1.016 to 1.465; p = 0.033) had the strongest association with LVH as categorical variable.

CONCLUSIONS

Our study showed that increased blood pressure at rest and during exercise, together with larger body weight, body mass and fat percentage are associated with a higher degree of LVH, which is not associated with a greater physical performance and therefore possibly disproportionate to the sport activity.

Sex-Based Differences in Peak Exercise Blood Pressure Indexed to Oxygen Consumption Among Competitive Athletes

PURPOSE

Although exercise testing guidelines define cutoffs for an exaggerated exercise systolic blood pressure (SBP) response, SBPs above these cutoffs are not uncommon in athletes given their high exercise capacity. Alternately, guidelines also specify a normal SBP response that accounts for metabolic equivalents (METs; mean [SD] of 10 [2] mm Hg per MET or 3.5 mL/kg/min oxygen consumption [V˙o₂]). SBP and V˙o₂ increase less during exercise in females than males. It is not clear if sex-based differences in exercise V˙o₂ are related to differences in SBP or if current recommendations for normal increase in SBP per MET produce reasonable estimates using measured METs (ie, V˙o₂) in athletes. We therefore examined sex-based differences in exercise SBP indexed to V˙o₂ in athletes with the goal of defining normative values for exercise SBP that account for fitness and sex.

METHODS

Using prospectively collected data from a single sports cardiology program, normotensive athlete patients were identified who had no relevant cardiopulmonary disease and had undergone cardiopulmonary exercise testing with cycle ergometry or treadmill. The relationship between ΔSBP (peak - rest) and ΔV˙o₂ (peak - rest) was examined in the total cohort and compared between sexes.

FINDINGS

A total of 413 athletes (mean [SD] age, 35.5 [14] years; 38% female; mean [SD] peak V˙o₂, 46.0 [10.2] mL/kg/min, 127% [27%] predicted) met the inclusion criteria. The ΔSBP correlated with unadjusted ΔV˙o₂ (cycle: R² = 0.18, treadmill: R² = 0.12; P < 0.0001). Female athletes had lower mean (SD) peak SBP (cycle: 161 [15] vs 186 [24] mm Hg; treadmill: 165 [17] vs 180 [20] mm Hg; P < 0.05) than male athletes. Despite lower peak SBP, mean (SD) ΔSBP relative to unadjusted ΔV˙o₂ was higher in female than male athletes (cycle: 25.6 [7.2] vs 21.1 [7.3] mm Hg/L/min; treadmill: 21.6 [7.2] vs 17.0 [6.2] mm Hg/L/min; P < 0.05). When V˙o₂ was adjusted for body size and converted to METs, female and male athletes had similar mean (SD) ΔSBP /ΔMET (cycle: 6.0 [2.1] vs 5.8 [2.0] mm Hg/mL/kg/min; treadmill: 4.7 [1.8] vs 4.8 [1.7] mm Hg/mL/kg/min).

IMPLICATIONS

In this cohort of athletes without known cardiopulmonary disease, observed sex-based differences in peak exercise SBP were in part related to the differences in ΔV˙o₂ between male and female athletes. Despite lower peak SBP, ΔSBP/unadjusted ΔV˙o₂ was paradoxically higher in female athletes. Future work should define whether this finding reflects sex-based differences in the peripheral vascular response to exercise. In this athletic cohort, ΔSBP/ΔMET was similar between sexes and much lower than the ratio that has been proposed by guidelines to define a normal SBP response. Our observed ΔSBP/ΔMET, based on measured rather than estimated METs, provides a clinically useful estimate for normal peak SBP range in athletes.

Cardiorespiratory Fitness, Workload, and the Blood Pressure Response to Exercise Testing

ABSTRACT

We propose that for correct clinical interpretation of exaggerated exercise blood pressure (EEBP), both cardiorespiratory fitness and exercise workload must be considered. A key recommendation towards achieving the correct clinical interpretation of EEBP is that exercise BP should be measured during submaximal exercise with a fixed external workload.

Exercise blood pressure and cardiac structure: A systematic review and meta-analysis of cross-sectional studies

OBJECTIVES

A hypertensive response to exercise (HRE) is associated with cardiovascular disease and high blood pressure (BP). Sub-clinical changes to cardiac structure may underlie these associations, although this has not been systematically determined. Via systematic review and meta-analysis, we aimed to (1) assess the relationship between exercise BP and cardiac structure, and (2) determine if cardiac structure is altered in those with an HRE, across various study populations (including those with/without high BP at rest).

DESIGN AND METHODS

Three online databases were searched for cross-sectional studies reporting exercise BP, HRE and cardiac structural variables. Random-effects meta-analyses and meta-regressions were used to calculate pooled correlations between exercise BP and cardiac structure, and pooled mean differences and relative risk between those with/without an HRE.

RESULTS

Forty-nine studies, (n=23,707 total; aged 44±4 years; 63% male) were included. Exercise systolic BP was associated with increased left ventricular (LV) mass, LV mass index, relative wall thickness, posterior wall thickness and interventricular septal thickness (p<0.05 all). Those with an HRE had higher risk of LV hypertrophy (relative risk: 2.6 [1.85-3.70]), increased LV mass (47±7g), LV mass index (7±2g/m²), relative wall thickness (0.02±0.005), posterior wall thickness (0.78±0.20mm), interventricular septal thickness (0.78±0.17mm) and left atrial diameter (2±0.52mm) vs. those without an HRE (p<0.05 all). Results were broadly similar between studies with different population characteristics.

CONCLUSIONS

Exercise systolic BP is associated with cardiac structure, and those with an HRE show evidence towards adverse remodelling. Results were similar across different study populations, highlighting the hypertension-related cardiovascular risk associated with an HRE.

Sex differences in workload-indexed blood pressure response and vascular function among professional athletes and their utility for clinical exercise testing

Purpose

Sex differences in blood pressure (BP) regulation at rest have been attributed to differences in vascular function. Further, arterial stiffness predicts an exaggerated blood pressure response to exercise (BPR) in healthy young adults. However, the relationship of vascular function to the workload-indexed BPR and potential sex differences in athletes are unknown.

Methods

We examined 47 male (21.6 ± 1.7 years) and 25 female (21.1 ± 2 years) athletes in this single-center pilot study. We assessed vascular function at rest, including systolic blood pressure (SBP). Further, we determined the SBP/W slope, the SBP/MET slope, and the SBP/W ratio at peak exercise during cycling ergometry.

Results

Male athletes had a lower central diastolic blood pressure (57 ± 9.5 vs. 67 ± 9.5 mmHg, p < 0.001) but a higher central pulse pressure (37 ± 6.5 vs. 29 ± 4.7 mmHg, p < 0.001), maximum SBP (202 ± 20 vs. 177 ± 15 mmHg, p < 0.001), and ΔSBP (78 ± 19 vs. 58 ± 14 mmHg, p < 0.001) than females. Total vascular resistance (1293 ± 318 vs. 1218 ± 341 dyn*s/cm⁵, p = 0.369), pulse wave velocity (6.2 ± 0.85 vs. 5.9 ± 0.58 m/s, p = 0.079), BP at rest (125 ± 10/76 ± 7 vs. 120 ± 11/73.5 ± 8 mmHg, p > 0.05), and the SBP/MET slope (5.7 ± 1.8 vs. 5.1 ± 1.6 mmHg/MET, p = 0.158) were not different. The SBP/W slope (0.34 ± 0.12 vs. 0.53 ± 0.19 mmHg/W) and the peak SBP/W ratio (0.61 ± 0.12 vs. 0.95 ± 0.17 mmHg/W) were markedly lower in males than in females (p < 0.001).

Conclusion

Male athletes displayed a lower SBP/W slope and peak SBP/W ratio than females, whereas the SBP/MET slope was not different between the sexes. Vascular functional parameters were not able to predict the workload-indexed BPR in males and females.

Exercise blood pressure, cardiorespiratory fitness and mortality risk

OBJECTIVE

To assess the cardiorespiratory fitness (CRF) impact on the association between exercise blood pressure (BP) and mortality risk.

PATIENTS AND METHODS

We assessed CRF in 15,004 US Veterans (mean age 57.5 ± 11.2 years) who completed a standardized treadmill test between January 1, 1988 and July 28, 2017 and had no evidence of ischemia. They were classified as Unfit or Fit according to the age-specific metabolic equivalents (METs) achieved <50% (6.2 ± 1.6 METs; n = 8440) or ≥ 50% (10.5 ± 2.4 METs; n = 6264). To account for the impact of resting systolic BP (SBP) on outcomes, we calculated the difference (Peak SBP-Resting SBP) and termed it SBP-Reserve. We noted a significant increase in mortality associated with SBP-Reserve ≤52 mmHg and stratified the cohort accordingly (SBP-Reserve ≤52 mmHg and > 52 mmHg). We applied multivariable Cox models to estimate hazard ratios (HR) and 95% confidence interval (CIs) for outcomes.

RESULTS

Mortality risk was significantly elevated only in Unfit individuals with SBP-Reserve ≤52 mmHg compared to those with SBP-Reserve >52 mmHg (HR = 1.35; CI: 1.24-1.46; P < 0.001). We then assessed the CRF and SBP-Reserve interaction on mortality risk with Fit individuals with SBP-Reserve >52 mmHg serving as the referent. Mortality risk was 92% higher (HR = 1.92%; 95% CI: 1.77-2.09; P < 0.001) in Unfit individuals with SBP-Reserve ≤52 mmHg and 47% higher (HR = 1.47; 95% CI: 1.33-1.62; P < 0.001) in those with SBP-Reserve >52 mmHg.

CONCLUSION

Low CRF was associated with increased mortality risk regardless of peak exercise SBP. The risk was substantially higher in individuals unable to augment their exercise SBP >52 mmHg beyond resting levels.

Elevated peak systolic blood pressure in endurance-trained athletes: Physiology or pathology?

Blood pressure is a function of cardiac output and peripheral vascular resistance. During graded exercise testing (GXT), systolic blood pressure (SBP) is expected to increase gradually along with work rate, oxygen consumption, heart rate, and cardiac output. Individuals exposed to chronic endurance training attain a greater exercise SBP than in their untrained state and sedentary counterparts, but it is currently unknown what is considered a safe upper limit. This review discusses key studies examining blood pressure response in sedentary individuals and athletes. We highlight the physiological characteristics of highly fit individuals in terms of cardiovascular physiology and exercise blood pressure and review the state of the current literature regarding the safety of high SBP during exercise in this particular subgroup. Findings from this review indicate that a consensus on what is a normal SBP response to exercise in highly fit subjects and direct causation linking high GXT SBP to pathology is lacking. Consequently, applying GXT SBP guidelines developed for a "normal" population to endurance-trained individuals appears unsupported at this time. Lack of evidence for poor outcomes leads us to infer that elevated peak SBP in this subgroup could more likely reflect an adaptive response to training, rather than a pathological outcome. Future studies should track clinical outcomes of those achieving elevated SBP and develop athlete-specific guidelines.

Association of 25-hydroxy vitamin D level with the blood pressure response to a maximum exercise test among professional indoor athletes

Purpose

Low vitamin D levels have been associated with elevated blood pressure (BP) in the general population. However, whether there is an association of vitamin D insufficiency with BP changes during maximum exercise in athletes is currently unclear.

Methods

A total of 120 male professional indoor athletes (age 26 ± 5 years) were examined. BP was measured at rest and during a graded cycling test. We assessed the BP response (BPR) during maximum exercise and the respective load. BP and BPR (peak-baseline BP) were analysed with respect to 25-OH vitamin D levels, with levels < 30 ng/mL defining vitamin D insufficiency.

Results

35 athletes were classified as being vitamin D insufficient. BP was not different between sufficient and insufficient vitamin D groups (122 ± 10/75 ± 7 vs. 120 ± 12/77 ± 9 mmHg). At maximum exercise, however, systolic BP (198 ± 17 vs. 189 ± 19, p = 0.026) and the pulse pressure (118 ± 18 vs. 109 ± 21 mmHg, p = 0.021) were higher in the sufficient group; the BPR was not different between groups (76 ± 20/5 ± 6 vs. 69 ± 22/3 ± 6 mmHg, p = 0.103). Athletes with sufficient levels had a higher maximum power output (3.99 ± 0.82 vs. 3.58 ± 0.78 W/kg, p = 0.015) and achieved higher workloads (367 ± 78 vs. 333 ± 80 W, p = 0.003). The workload-adjusted BPR (maximum systolic BP/MPO) was not different between athletes with sufficient and insufficient vitamin D levels (51 ± 10 vs. 56 ± 14 mmHg × kg/W, p = 0.079).

Conclusion

Athletes with sufficient vitamin D achieved a higher maximum systolic BP and a higher maximum power output. The workload-adjusted BPR was not different between groups, which suggests that this finding reflects a better performance of athletes with sufficient vitamin D.

Workload-indexed blood pressure response to a maximum exercise test among professional indoor athletes

BACKGROUND

Exercise testing is performed regularly in professional athletes. However, the blood pressure response (BPR) to exercise is rarely investigated in this cohort, and normative upper thresholds are lacking. Recently, a workload-indexed BPR (increase in systolic blood pressure per increase in metabolic equivalent of task (SBP/MET slope)) was evaluated in a general population and was compared with mortality. We sought to evaluate the SBP/MET slope in professional athletes and compare it with performance.

DESIGN

This was a cross-sectional study.

METHODS

A total of 142 male professional indoor athletes (age 26 ± 5 years) were examined. Blood pressure was measured at rest and during a standardized, graded cycle ergometer test. We assessed the BPR during exercise, the workload, and the metabolic equivalent of task (MET). Athletes were divided into groups according to their SBP/MET slope quartiles (I <4.3; II 4.3-6.2; III >6.2-9; IV >9 mmHg/MET) and compared regarding systolic BP (sBP) and workload achieved.

RESULTS

Athletes in group I (n = 42) had the lowest maximum sBP (180 ± 13 mmHg) but achieved the highest relative workload (4.2 ± 1 W/kg). With increasing SBP/MET slope, the maximum sBP increased (II (n = 56): 195 ± 15 mmHg; III (n = 44): 216 ± 16 mmHg) and the workload achieved decreased (II: 3.9 ± 0.7 W/kg; III: 3.3 ± 0.5 W/kg). The differences in sBP between these groups were significant (p < 0.001). None of the athletes were assigned to group IV (>9 mmHg/MET).

CONCLUSION

Athletes in the lowest SBP/MET slope quartile displayed the lowest maximum sBP but achieved a higher workload than athletes classified into the other SBP/MET slope groups. This simple, novel metric might help to distinguish a normal from an exaggerated BPR to exercise, to identify athletes at risk of developing hypertension.

Hydrostatic pressure promotes endothelial tube formation through aquaporin 1 and Ras-ERK signaling

Vascular tubulogenesis is tightly linked with physiological and pathological events in the living body. Endothelial cells (ECs), which are constantly exposed to hemodynamic forces, play a key role in tubulogenesis. Hydrostatic pressure in particular has been shown to elicit biophysical and biochemical responses leading to EC-mediated tubulogenesis. However, the relationship between tubulogenesis and hydrostatic pressure remains to be elucidated. Here, we propose a specific mechanism through which hydrostatic pressure promotes tubulogenesis. We show that pressure exposure transiently activates the Ras/extracellular signal-regulated kinase (ERK) pathway in ECs, inducing endothelial tubulogenic responses. Water efflux through aquaporin 1 and activation of protein kinase C via specific G protein–coupled receptors are essential to the pressure-induced transient activation of the Ras/ERK pathway. Our approach could provide a basis for elucidating the mechanopathology of tubulogenesis-related diseases and the development of mechanotherapies for improving human health.

Yoshino et al. investigate the mechanism by which exposure to pressure promotes endothelial cells to form tubes and find that Aquaporin-mediated water efflux activates the Ras-ERK pathway via PKC and GPCR activation. These findings may be relevant to understand how blood pressure affects vascular tubulogenesis.

The influence of fitness on exercise blood pressure and its association with cardiac structure in adolescence

PURPOSE

Exaggerated exercise blood pressure (BP) is associated with altered cardiac structure and increased cardiovascular risk. Fitness modifies these associations, but the effect in healthy adolescents is unknown. We performed an observational study to determine the influence of fitness on post-exercise BP, and on its relationship with cardiac structure in adolescents.

METHODS

4835 adolescents from the Avon Longitudinal Study of Parents and Children, (15.4 (0.3) years, 49% male) completed a submaximal cycle test. Fitness was estimated as physical work capacity 170 adjusted for lean body mass and post-exercise BP measured immediately posttest. Cardiovascular structure and function, including left ventricular (LV) mass (n = 1589), left atrium (LA) size (n = 1466), cardiac output (CO, n = 1610), and total peripheral resistance (TPR, n = 1610) were measured at rest by echocardiography 2.4 (0.4) years later.

RESULTS

Post-exercise systolic BP increased stepwise by fitness tertile (131.2 mm Hg [130.4, 132.1]; 137.3 mm Hg [136.5, 138.0]; 142.3 mm Hg [141.5, 143.1]). Each 5 mm Hg of post-exercise systolic BP was associated with 2.46 g [1.91, 3.01] greater LV mass, 0.02 cm [0.02, 0.03] greater LA size, and 0.25 g/m^2.7 [0.14, 0.36] greater LV mass index. Adjustment for fitness abolished associations (0.29 g [-0.16, 0.74]; 0.01 cm [-0.001, 0.014] and 0.08 g/m^2.7 [-0.001, 0.002]). Similar associations between post-exercise systolic BP and each outcome were found between the lowest and highest fitness thirds. CO increased with fitness third (difference 0.06 L/min [-0.05, 0.17]; 0.23 L/min [0.12, 0.34]) while TPR decreased (difference -0.13 mm Hg·min/L [-0.84,0.59]; -1.08 mm Hg·min/L [-0.1.80, 0.35]).

CONCLUSIONS

Post-exercise systolic BP increased with fitness, which modified its association with cardiac structure. Higher CO, but lower TPR suggests a physiologically adapted cardiovascular system with greater fitness, highlighting the importance of fitness in adolescence.

Elite athletes as research model: vitamin D insufficiency associates with elevated central blood pressure in professional handball athletes

PURPOSE

Low vitamin D levels have been associated with elevated blood pressure in the general population. Prospective studies, however, have produced conflicting evidence about the blood pressure-lowering effects of vitamin D supplementation. Cardiorespiratory fitness may modulate the vitamin D-blood pressure association. We therefore examined this association in professional athletes, whose high training load serves as a biological control for physical fitness.

METHODS

50 male professional handball players (age 26 ± 5 years) were examined. We assessed the central aortic pressure parameters using transfer function-based analysis of oscillometrically obtained peripheral arterial waveforms. Serum 25-OH vitamin D concentrations were determined by chemiluminescent immunoassay. The threshold for insufficiency was set at values of < 30 ng/mL.

RESULTS

Central blood pressure (cBP) was 98 ± 7/60 ± 10 mmHg. The aortic pulse wave velocity (PWV) was 6.3 ± 1.0 m/s. Nine athletes (18%) displayed insufficient 25-OH vitamin D levels and had a significantly (p < 0.01) higher cBP compared with the 41 (82%) athletes with sufficient 25-OH vitamin D levels (106 ± 5/68 ± 8 vs. 97 ± 7/58 ± 9 mmHg). Central systolic blood pressure (cSBP) in vitamin D-sufficient athletes was significantly lower in comparison to the healthy reference population (97 mmHg vs. 103 mmHg, p < 0.001). This significance of difference was lost in vitamin D-insufficient athletes (106 mmHg vs. 103 mmHg, p = 0.12).

CONCLUSION

Significantly raised central systolic and diastolic blood pressure in vitamin D-insufficient elite athletes implicates vitamin D as a potential modifier of vascular functional health.

Brief recommendations for participation in competitive sports of athletes with arterial hypertension: Summary of a Position Statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC)

Owing to its undisputed multitude of beneficial effects, European Society of Cardiology guidelines advocate regular physical activity as a class IA recommendation for the prevention and treatment of cardiovascular disease. Nonetheless, competitive athletes with arterial hypertension may be exposed to an increased risk of cardiovascular events. Guidance to physicians will be given in this summary of our recently published recommendations for participation in competitive sports of athletes with arterial hypertension.

Cardiovascular risk profile in Olympic athletes: an unexpected and underestimated risk scenario

Background

Prevalence of cardiovascular (CV) risk factors has been poorly explored in subjects regularly engaged in high-intensity exercise programmes. Our aim was, therefore, to assess the prevalence and distribution of CV risk factors in a large population of competitive athletes, to derive the characteristics of athlete’s lifestyle associated with the best CV profile.

Methods

1058 Olympic athletes (656 males, 402 females), consecutively evaluated in the period 2014–2016, represent the study population. Prevalence and distribution of CV risk factors was assessed, in relation to age, body size and sport.

Findings

Dyslipidemia was the most common risk (32%), followed by increased waist circumference (25%), positive family history (18%), smoking habit (8%), hypertension (3.8%) and hyperglycaemia (0.3%). Large subset of athletes (418, 40%) had none or 1 (414, 39%) risk factor, while only a few (39, 3.7%) had 3/4 CV risk factors. The group without risks largely comprised endurance athletes (34%). Ageing was associated with higher total and low-density lipoprotein cholesterol, triglycerides (p<0.001) and glycaemia (p=0.002) and lower high-density lipoprotein cholesterol. On multivariate logistic regression analysis, age, BMI and body fat were identified as independent predictors of increased CV risk.

Interpretation

Dyslipidemia and increased waist circumference are common in elite athletes (32% and 25%, respectively). A large proportion (40%) of athletes, mostly endurance, are totally free from risk factors. Only a minority (3%) presents a high CV risk, largely expression of lifestyle and related to modifiable CV risk factors.

Ascending Aortic Dimensions in Former National Football League Athletes

BACKGROUND

Ascending aortic dimensions are slightly larger in young competitive athletes compared with sedentary controls, but rarely >40 mm. Whether this finding translates to aortic enlargement in older, former athletes is unknown.

METHODS AND RESULTS

This cross-sectional study involved a sample of 206 former National Football League (NFL) athletes compared with 759 male subjects from the DHS-2 (Dallas Heart Study-2; mean age of 57.1 and 53.6 years, respectively, P<0.0001; body surface area of 2.4 and 2.1 m², respectively, P<0.0001). Midascending aortic dimensions were obtained from computed tomographic scans performed as part of a NFL screening protocol or as part of the DHS. Compared with a population-based control group, former NFL athletes had significantly larger ascending aortic diameters (38±5 versus 34±4 mm; P<0.0001). A significantly higher proportion of former NFL athletes had an aorta of >40 mm (29.6% versus 8.6%; P<0.0001). After adjusting for age, race, body surface area, systolic blood pressure, history of hypertension, current smoking, diabetes mellitus, and lipid profile, the former NFL athletes still had significantly larger ascending aortas (P<0.0001). Former NFL athletes were twice as likely to have an aorta >40 mm after adjusting for the same parameters.

CONCLUSIONS

Ascending aortic dimensions were significantly larger in a sample of former NFL athletes after adjusting for their size, age, race, and cardiac risk factors. Whether this translates to an increased risk is unknown and requires further evaluation.

Prevalence and Management of Systemic Hypertension in Athletes

The aim of the present study was to evaluate the prevalence, determinants, and clinical management of systemic hypertension in a large cohort of competitive athletes: 2,040 consecutive athletes (aged 25 ± 6 years, 64% men) underwent clinical evaluation including blood test, electrocardiogram, exercise test, echocardiography, and ophthalmic evaluation. Sixty-five athletes (3%) were identified with hypertension (men = 57; 87%) including 5 with a secondary cause (thyroid dysfunction in 3, renal artery stenosis in 1, and drug induced in 1). The hypertensive athletes had greater left ventricular hypertrophy and showed more often a concentric pattern than normotensive ones. Moreover, they showed a mildly reduced physical performance and were characterized by a higher cardiovascular risk profile compared with normotensive athletes. Multivariate logistic regression analysis showed that family hypertension history (odds ratio 2.05; 95% confidence interval 1.21 to 3.49; p = 0.008) and body mass index (odds ratio 1.32; 95% confidence interval 1.23 to 1.40; p <0.001) were the strongest predictors of hypertension. Therapeutic intervention included successful lifestyle modification in 57 and required additional pharmacologic treatment in 3 with essential hypertension. Secondary hypertension was treated according to the underlying disorder. After a mean follow-up of 18 ± 6 months, all hypertensive athletes had achieved and maintained optimal control of the blood pressure, without restriction to sport participation. In conclusion, the prevalence of hypertension in athletes is low (3%) and largely related to family history and overweight. In the vast majority of hypertensives, lifestyle modifications were sufficient to achieve an optimal control of blood pressure values.