Cardiovascular magnetic resonance with parametric mapping in long-term ultra-marathon runners

Acute effect of ultramarathon on systolic and diastolic cardiac function: Systematic review and meta-analysis

BACKGROUND

Ultramarathon running poses physiological challenges, impacting cardiac function. This systematic review and meta-analysis explore the acute effects of single-stage ultramarathon running on cardiac function.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations were followed. Searches covered Medline, Embase, CINAHL, SPORTDiscus, Web of Science, Central Cochrane, and Scopus. Random effects meta-analyses assessed left ventricular (LV) and right ventricular (RV) variables, expressed as mean differences (MD) with 95% confidence intervals (CI).

RESULTS

Among 6972 studies, 17 were included. Post-ultramarathon reductions were found in LV end-diastolic diameter (LVEDD) (-1.24; 95% CI = -1.77, -0.71 mm), LV end-diastolic volume (LVEDV) (-9.92; 95% CI = -15.25, -4.60 ml), LV stroke volume (LVSV) (-8.96 ml, 95% CI -13.20, -4.72 ml), LV ejection fraction (LVEF) (-3.71; 95% CI = -5.21, -2.22%), LV global longitudinal strain (LVGLS) (-1.48; 95% CI = -2.21, -0.76%), E/A (-0.30; 95% CI = -0.38, -0.22 cm/s), .E' (-1.35 cm/s, 95% CI -1.91, -0.79 cm/s), RV fractional area change (RVFAC) (-3.34, 95% CI = -5.84, -0.84%), tricuspid annular plane systolic excursion (TAPSE) (-0.12, 95% CI = -0.22, -0.02 cm), RV global longitudinal strain (RVGLS) (-1.73, 95% CI = -2.87, -0.59%), with increases in RV end-diastolic area (RVEDA) (1.89, 95% CI = 0.63, 3.14 cm2), RV Peak A' (1.32 cm/s, 95% CI 0.20, 2.44), and heart rate (18.24, 95% CI = 15.16, 21.32). No significant differences were observed in LV end-systolic diameter (LVESD), LV end-systolic volume (LVESV), RV end-diastolic diameter (RVEDD), RV Peak E', and RV Peak S'.

CONCLUSIONS

Evidence suggests immediate impairment of systolic and diastolic cardiac function post-ultramarathon running.

No adverse association between exercise exposure and diffuse myocardial fibrosis in male endurance athletes

The potential association between endurance exercise and myocardial fibrosis is controversial. Data on exercise exposure and diffuse myocardial fibrosis in endurance athletes are scarce and conflicting. We aimed to investigate the association between exercise exposure and markers of diffuse myocardial fibrosis by cardiovascular magnetic resonance imaging (CMR) in endurance athletes. We examined 27 healthy adult male competitive endurance athletes aged 41 ± 9 years and 16 healthy controls in a cross sectional study using 3 Tesla CMR including late gadolinium enhancement and T1 mapping. Athletes reported detailed exercise history from 12 years of age. Left ventricular total mass, cellular mass and extracellular mass were higher in athletes than controls (86 vs. 58 g/m2, 67 vs. 44 g/m2 and 19 vs. 13 g/m2, all p < 0.01). Extracellular volume (ECV) was lower (21.5% vs. 23.8%, p = 0.03) and native T1 time was shorter (1214 ms vs. 1268 ms, p < 0.01) in the athletes. Increasing exercise dose was independently associated with shorter native T1 time (regression coefficient - 24.1, p < 0.05), but expressed no association with ECV. Our results indicate that diffuse myocardial fibrosis has a low prevalence in healthy male endurance athletes and do not indicate an adverse dose-response relationship between exercise and diffuse myocardial fibrosis in healthy athletes.

CMR Mapping: The 4th-Era Revolution in Cardiac Imaging

Cardiac magnetic resonance (CMR) imaging has witnessed substantial progress with the advent of parametric mapping techniques, most notably T1 and T2 mapping. These advanced techniques provide valuable insights into a wide range of cardiac conditions, including ischemic heart disease, cardiomyopathies, inflammatory cardiomyopathies, heart valve disease, and athlete's heart. Mapping could be the first sign of myocardial injury and oftentimes precedes symptoms, changes in ejection fraction, and irreversible myocardial remodeling. The ability of parametric mapping to offer a quantitative assessment of myocardial tissue properties addresses the limitations of conventional CMR methods, which often rely on qualitative or semiquantitative data. However, challenges persist, especially in terms of standardization and reference value establishment, hindering the wider clinical adoption of parametric mapping. Future developments should prioritize the standardization of techniques to enhance their clinical applicability, ultimately optimizing patient care pathways and outcomes. In this review, we endeavor to provide insights into the potential contributions of CMR mapping techniques in enhancing the diagnostic processes across a range of cardiac conditions.

Cardiac magnetic resonance assessment of athletic myocardial fibrosis; Benign bystander or malignant marker?

The benefits of exercise are irrefutable with a well-established dose-dependent relationship between exercise intensity and reduction in cardiovascular disease. Differentiating the physiological adaptation to exercise, termed the "athlete's heart" from cardiomyopathies, has been advanced by the advent of more sophisticated imaging modalities such as cardiac magnetic resonance imaging (CMR). Myocardial fibrosis on CMR is a mutual finding amongst seemingly healthy endurance athletes and individuals with cardiomyopathy. As a substrate for arrhythmias, fibrosis is traditionally associated with increased cardiovascular risk. In this article, we discuss the aetiologies, distribution and potential implications of myocardial fibrosis in athletes.

High-mobility group box 1 protein, receptor for advanced glycation end products and nucleosomes increases after marathon

Background: Prolonged and strenuous exercise has been linked to potential exercise-induced myocardial damages. One potential key to unmask the discussed underlying mechanisms of this subclinical cardiac damage could be markers of immunogenic cell damage (ICD). We investigated the kinetics of high-mobility group box 1 protein (HMGB1), soluble receptor for advanced glycation end products (sRAGE), nucleosomes, high sensitive troponin T (hs-TnT) and high sensitive C-reactive protein (hs-CRP) before and up to 12 weeks post-race and described associations with routine laboratory markers and physiological covariates. Methods: In our prospective longitudinal study, 51 adults (82% males; 43 ± 9 years) were included. All participants underwent a cardiopulmonary evaluation 10-12 weeks pre-race. HMGB1, sRAGE, nucleosomes, hs-TnT and, hs-CRP were analysed 10-12 weeks prior, 1-2 weeks before, immediately, 24 h, 72 h, and 12 weeks post-race. Results: HMGB1, sRAGE, nucleosomes and hs-TnT increased significantly from pre- to immediately post-race (0.82-2.79 ng/mL; 1132-1388 pg/mL; 9.24-56.65 ng/mL; 6-27 ng/L; p < 0.001) and returned to baseline within 24-72 h. Hs-CRP increased significantly 24 h post-race (0.88-11.5 mg/L; p < 0.001). Change in sRAGE was positively associated with change in hs-TnT (rs = 0.352, p = 0.011). Longer marathon finishing time was significantly associated with decreased levels of sRAGE [-9.2 pg/mL (β = -9.2, SE = 2.2, p < 0.001)]. Conclusion: Prolonged and strenuous exercise increases markers of ICD immediately post-race, followed by a decrease within 72 h. An acute marathon event results in transient alterations of ICD, we assume that this is not solely driven by myocyte damages.

Hypertrophic cardiomyopathy or athlete's heart? A systematic review of novel cardiovascular magnetic resonance imaging parameters

Hypertrophic cardiomyopathy (HCM) is a common cause of sudden cardiac death in athletes. Cardiac Magnetic Resonance (CMR) imaging is considered an excellent tool to differentiate between HCM and athlete's heart. The aim of this systematic review was to highlight the novel CMR-derived parameters with significant discriminative capacity between the two conditions. A systematic search in the MEDLINE, EMBASE and Cochrane Reviews databases was performed. Eligible studies were considered the ones comparing novel CMR-derived parameters on athletes and HCM patients. Therefore, studies that only examined Cine-derived volumetric parameters were excluded. Particular attention was given to binary classification results from multi-variate regression models and ROC curve analyses. Bias assessment was performed with the Quality Assessment on Diagnostic Accuracy Studies. Five (5) studies were included in the systematic review, with a total of 284 athletes and 373 HCM patients. Several novel indices displayed discriminatory potential, such as native T1 mapping and T2 values, LV global longitudinal strain, late gadolinium enhancement and whole-LV fractal dimension. Diffusion tensor imaging enabled quantification of the secondary eigenvalue angle and fractional anisotropy in one study, which also proved capable of reliably detecting HCM in a mixed athlete/patient sample. Several novel CMR-derived parameters, most of which are currently under development, show promising results in discerning between athlete's heart and HCM. Prospective studies examining the discriminatory capacity of all promising modalities side-by-side will yield definitive answers on their relative importance; diagnostic models can incorporate the best performing variables for optimal results.

Role of cardiovascular magnetic resonance in the clinical evaluation of left ventricular hypertrophy: a 360° panorama

Left ventricular hypertrophy (LVH) is a frequent imaging finding in the general population. In order to identify the precise etiology, a comprehensive diagnostic approach should be adopted, including the prevalence of each entity that may cause LVH, family history, clinical, electrocardiographic and imaging findings. By providing a detailed evaluation of the myocardium, cardiovascular magnetic resonance (CMR) has assumed a central role in the differential diagnosis of left ventricular hypertrophy, with the technique of parametric imaging allowing more refined tissue characterization. This article aims to establish a parallel between pathophysiological features and imaging findings through the broad spectrum of LVH entities, emphasizing the role of CMR in the differential diagnosis.

Cardiac Magnetic Resonance Findings in Patients Recovered from COVID-19 Pneumonia and Presenting with Persistent Cardiac Symptoms: The TRICITY-CMR Trial

The prevalence and clinical consequences of coronavirus disease 2019 (COVID-19)-related non-ischemic cardiac injury are under investigation. The main purpose of this study was to determine the occurrence of non-ischemic cardiac injury using cardiac magnetic resonance (CMR) imaging in patients with persistent cardiac symptoms following recovery from COVID-19 pneumonia. We conducted a single-center, cross-sectional study. Between January 2021 and May 2021, we enrolled 121 patients with a recent COVID-19 infection and persistent cardiac symptoms. Study participants were divided into those who required hospitalization during the acute phase of SARS-CoV-2 infection (n = 58; 47.9%) and those non-hospitalized (n = 63; 52.1%). Non-ischemic cardiac injury (defined as the presence of late gadolinium enhancement (LGE) lesion and/or active myocarditis in CMR) was detected in over half of post-COVID-19 patients (n = 64; 52.9%). LGE lesions were present in 63 (52.1%) and active myocarditis in 10 (8.3%) post-COVID-19 study participants. The majority of LGE lesions were located in the left ventricle at inferior and inferolateral segments at the base. There were no significant differences in the occurrence of LGE lesions (35 (60.3%) vs. 28 (44.4%); p = 0.117) or active myocarditis (6 (10.3%) vs. 4 (6.3%); p = 0.517) between hospitalized and non-hospitalized post-COVID-19 patients. However, CMR imaging revealed lower right ventricular ejection fraction (RVEF; 49.5 (44; 54) vs. 53 (50; 58) %; p = 0.001) and more frequent presence of reduced RVEF (60.3% vs. 33.3%; p = 0.005) in the former subgroup. In conclusion, more than half of our patients presenting with cardiac symptoms after a recent recovery from COVID-19 pneumonia had CMR imaging abnormalities indicating non-ischemic cardiac injury. The most common finding was LGE, while active myocarditis was detected in the minority of patients. CMR imaging abnormalities were observed both in previously hospitalized and non-hospitalized post-COVID-19 patients. Further research is needed to determine the long-term cardiovascular consequences of COVID-19 infection and the optimal management of patients with suspected post-COVID-19 non-ischemic cardiac injury.

Certainties and Uncertainties of Cardiac Magnetic Resonance Imaging in Athletes

Prolonged and intensive exercise induces remodeling of all four cardiac chambers, a physiological process which is coined as the “athlete’s heart”. This cardiac adaptation, however, shows overlapping features with non-ischemic cardiomyopathies, such as dilated, arrhythmogenic and hypertrophic cardiomyopathy, also associated with athlete’s sudden cardiac death. Cardiac magnetic resonance (CMR) is a well-suited, highly reproducible imaging modality that can help differentiate athlete’s heart from cardiomyopathy. CMR allows accurate characterization of the morphology and function of cardiac chambers, providing full coverage of the ventricles. Moreover, it permits an in-depth understanding of the myocardial changes through specific techniques such as mapping or late gadolinium enhancement. In this narrative review, we will focus on the certainties and uncertainties of the role of CMR in sports cardiology. The main aspects of physiological adaptation due to regular and intensive sports activity and the application of CMR in highly trained athletes will be summarized.

Detection of myocardial fibrosis: Where we stand

Myocardial fibrosis, resulting from the disturbance of extracellular matrix homeostasis in response to different insults, is a common and important pathological remodeling process that is associated with adverse clinical outcomes, including arrhythmia, heart failure, or even sudden cardiac death. Over the past decades, multiple non-invasive detection methods have been developed. Laboratory biomarkers can aid in both detection and risk stratification by reflecting cellular and even molecular changes in fibrotic processes, yet more evidence that validates their detection accuracy is still warranted. Different non-invasive imaging techniques have been demonstrated to not only detect myocardial fibrosis but also provide information on prognosis and management. Cardiovascular magnetic resonance (CMR) is considered as the gold standard imaging technique to non-invasively identify and quantify myocardial fibrosis with its natural ability for tissue characterization. This review summarizes the current understanding of the non-invasive detection methods of myocardial fibrosis, with the focus on different techniques and clinical applications of CMR.

T2 mapping in myocardial disease: a comprehensive review

Cardiovascular magnetic resonance (CMR) is considered the gold standard imaging modality for myocardial tissue characterization. Elevated transverse relaxation time (T2) is specific for increased myocardial water content, increased free water, and is used as an index of myocardial edema. The strengths of quantitative T2 mapping lie in the accurate characterization of myocardial edema, and the early detection of reversible myocardial disease without the use of contrast agents or ionizing radiation. Quantitative T2 mapping overcomes the limitations of T2-weighted imaging for reliable assessment of diffuse myocardial edema and can be used to diagnose, stage, and monitor myocardial injury. Strong evidence supports the clinical use of T2 mapping in acute myocardial infarction, myocarditis, heart transplant rejection, and dilated cardiomyopathy. Accumulating data support the utility of T2 mapping for the assessment of other cardiomyopathies, rheumatologic conditions with cardiac involvement, and monitoring for cancer therapy-related cardiac injury. Importantly, elevated T2 relaxation time may be the first sign of myocardial injury in many diseases and oftentimes precedes symptoms, changes in ejection fraction, and irreversible myocardial remodeling. This comprehensive review discusses the technical considerations and clinical roles of myocardial T2 mapping with an emphasis on expanding the impact of this unique, noninvasive tissue parameter.

The Role of Cardiovascular Magnetic Resonance Imaging in the Assessment of Myocardial Fibrosis in Young and Veteran Athletes: Insights From a Meta-Analysis

Background: Cardiac magnetic resonance (CMR) combined with late gadolinium enhancement (LGE) has revealed a non-negligible increased incidence of myocardial fibrosis (MF) in athletes compared to healthy sedentary controls.

Objective: The aim of this systematic research and meta-analysis is to investigate and present our perspective regarding CMR indices in athletes compared to sedentary controls, including T1 values, myocardial extracellular volume (ECV) and positive LGE indicative of non-specific fibrosis, also to discuss the differences between young and veteran athletes.

Methods: The protocol included searching, up to October 2021, of MEDLINE, EMBASE, SPORTDiscus, Web of Science and Cochrane databases for original studies assessing fibrosis via CMR in athletes. A mean age of 40 years differentiated studies' athletic populations to veteran and young.

Results: The research yielded 14 studies including in total 1,312 individuals. There was a statistically significant difference in LGE fibrosis between the 118/759 athletes and 16/553 controls (Z = 5.2, P < 0.001, I² = 0%, P_I = 0.45). Notably, LGE fibrosis differed significantly between 546 (14.6%) veteran and 140 (25.7%) young athletes (P = 0.002). At 1.5T, T1 values differed between 117 athletes and 48 controls (P < 0.0001). A statistically significant difference was also shown at 3T (110 athletes vs. 41 controls, P = 0.0004), as well as when pooling both 1.5T and 3T populations (P < 0.00001). Mean ECV showed no statistically significant difference between these groups.

Conclusions: Based on currently available data, we reported that overall LGE based non-specific fibrosis and T1 values differ between athletes and sedentary controls, in contrast to ECV values. Age of athletes seems to have impact on the incidence of MF. Future prospective studies should focus on the investigation of the underlying pathophysiological mechanisms.

Right heart exercise-training-adaptation and remodelling in endurance athletes

Long-term sports training leads to myocardial adaptations, with remodelling of the heart chambers. However, while myocardial adaptations of the left heart are well described, remodelling of the right heart and its impact on the development of arrhythmias is still debated. To conduct a systematic review on right ventricle (RV) and right atrium (RA) structural and functional changes in athletes who participate in long-term endurance training. Systematic review. A systematic literature search was conducted. All the articles reporting right heart echocardiographic (ECHO) and cardiac magnetic resonance (CMR) parameters evaluated in endurance athletes and sedentary subjects were considered eligible. A multivariate analysis was conducted to investigate whether age, sex, body surface area (BSA), intensity of training are associated with RV ECHO, CMR parameters and RA ECHO parameters. A positive association between age and right atrium area (RAA) (P = 0.01) was found. This is a negative association to RV E/A (P = 0.004), and RV end diastolic diameter (RVED) longitudinal (P = 0.01). A positive association between BSA and RVED middle (P = 0.001), as well between BSA and RAA (P = 0.05) was found, along with a negative association with RV E/A (P = 0.002). A positive association between intensity of training and RV end systolic area (RVESA) (P = 0.03), RV end diastolic volume indexed (RVEDVI) (P = 0.01), RV end systolic volume indexed (RVESVI) (P = 0.01) was found, along with a negative association with ejection fraction (EF %) (P = 0.01). Endurance athletes demonstrated an association between RV remodelling and age, BSA and intensity of training.

Absence of cardiac damage induced by long-term intensive endurance exercise training: A cardiac magnetic resonance and exercise echocardiography analysis in masters athletes

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Endurance long-term high level of training induces significant cardiac remodelling involving all cardiac chambers, also known as ‘athletes-heart”.

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Both left and right ventricular longitudinal strain increases significantly at exercise.

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Cardiac extracellular volume is normal in master athletes and there is no evidence of cardiac fibrosis induced by long term endurance training in master athletes.

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There is no evidence of cardiac damage induced by intensive endurance training in healthy asymptomatic master athletes.

Objectives

It is under debate whether the long-term practice of intensive endurance exercise induces chronic cardiac damage such as myocardial fibrosis and ventricle contractile dysfunction. Multimodality analysis was performed to evaluate myocardial damage induced by long term intensive endurance training in master athletes.

Methods

Thirty-three asymptomatic endurance master athletes (47 ± 6 year-old, 9,6 ± 1,7 h training/week for 26 ± 6 years), were compared to 18 sedentary controls (49 ± 7 year-old). They underwent a CMR protocol including 4 chambers morphological and late gadolinium-enhancement (LGE) analysis, left (LV) and right ventricular (RV) T1 mapping and calculation of cardiac extracellular volume (ECV). A maximal exercise echocardiography with left and right ventricular longitudinal global strain (LGS) analysis was performed. Cardiac biomarkers of fibrosis (high sensitive cardiac Troponin T, N-Terminal pro brain natriuretic peptide, N-terminal propeptide of procollagen type I and N-terminal propeptide of procollagen type III) were analysed.

Results

Athletes had larger left and right atrial volume, LV and RV end diastolic volume and increased LV and RV mass compared to controls. LGE was not found in athletes. Native T1 values of LV and RV were not significantly different in athletes compared with controls. ECV was normal in both groups (21,5%± 1,6% [18.3 – 23%] in athletes, 22%± 2,2% [18.5 – 27%] in controls). LV and RV peak exercise LGS values were higher in athletes. Cardiac biomarkers levels were normal.

Conclusion

Despite significant physiological cardiac remodelling, consistent with previous descriptions of athlete's heart, there was no evidence of myocardial fibrosis or exercise left or right ventricular dysfunction or cardiac fibrosis in endurance athletes. Our results are not supporting the hypothesis of deleterious cardiac effects induced by long term and intensive endurance exercise training.

Alterations in Circulating MicroRNAs and the Relation of MicroRNAs to Maximal Oxygen Consumption and Intima-Media Thickness in Ultra-Marathon Runners

The impact of long-term training on cardiovascular disease (CVD) is not clear. Carotid intima-media thickness (CIMT) test is recommended as a useful measure to diagnose the early stages of atherosclerosis. MicroRNAs (miRNAs) are altered due to endurance exercise and can be promising biomarkers of pathophysiological changes. We aimed to evaluate the association of circulating miRNAs with physical fitness and markers of atherosclerosis in ultra-marathon runners. Ultra-marathon runners had 28-fold upregulation of miR-125a-5p expressions compared to control individuals (p = 0.002), whereas let-7e and miR-126 did not differ statistically between ultra-marathon runners and controls. In the ultra-marathon runners' group, negative correlations were observed between VO₂max/kg and relative expression of miR-125a-5p and miR-126 (r = -0.402, p = 0.028; r = -0.438, p = 0.032, respectively). Positive correlations were observed between CIMT and miR-125a-5p and miR-126 (r = 0.388, p = 0.050; r = 0.504, p = 0.023, respectively) in ultra-marathon runners. Individuals with the highest quartile of VO₂max/kg had 23-fold lower miR-126 expression in comparison to subgroups with lower VO₂max/kg (p = 0.017). Our results may indicate that both miRNAs may serve as a biomarker for early pathological changes leading to atherosclerosis burden in athletes. Furthermore, the association between miRNAs and traditional risk factors for CVD indicate a possible use of these molecules as early biomarkers of future cardiovascular health.

Endurance exercise and the risk of cardiovascular pathology in men: a comparison between lifelong and late-onset endurance training and a non-athletic lifestyle - rationale and design of the Master@Heart study, a prospective cohort trial

Introduction

Low and moderate endurance exercise is associated with better control of cardiovascular risk factors, a decreased risk of coronary artery disease and atrial fibrillation (AF). There is, however, a growing proportion of individuals regularly performing strenuous and prolonged endurance exercise in which the health benefits have been challenged. Higher doses of endurance exercise have been associated with a greater coronary atherosclerotic plaque burden, risk of AF and myocardial fibrosis (MF).

Methods and analysis

Master@Heart is a multicentre prospective cohort study aiming to assess the incidence of coronary atherosclerosis, AF and MF in lifelong endurance athletes compared to late-onset endurance athletes (initiation of regular endurance exercise after the age of 30 years) and healthy non-athletes.

The primary endpoint is the incidence of mixed coronary plaques. Secondary endpoints include coronary calcium scores, coronary stenosis >50%, the prevalence of calcified and soft plaques and AF and MF presence. Tertiary endpoints include ventricular arrhythmias, left and right ventricular function at rest and during exercise, arterial stiffness and carotid artery intima media thickness.

Two hundred male lifelong athletes, 200 late-onset athletes and 200 healthy non-athletes aged 45–70 will undergo comprehensive cardiovascular phenotyping using CT, coronary angiography, echocardiography, cardiac MRI, 12-lead ECG, exercise ECG and 24-hour Holter monitoring at baseline. Follow-up will include online tracking of sports activities, telephone calls to assess clinical events and a 7-day ECG recording after 1 year.

Ethics and dissemination

Local ethics committees approved the Master@Heart study. The trial was launched on 18 October 2018, recruitment is complete and inclusions are ongoing.

Trial registration number

NCT03711539.

Epicardial Adipose Tissue and Cardiovascular Risk Assessment in Ultra-Marathon Runners: A Pilot Study

Epicardial adipose tissue (EAT) volume is associated with cardiovascular disease (CVD). Data regarding the influence of extremely intensive training on CVD are scarce. We compared EAT volume among ultra-marathon runners and in the sedentary control group, and assessed the correlations between EAT and risk factors of coronary artery disease (CAD). EAT volume around three main coronary vessels and right ventricle (RV) was measured in 30 healthy amateur ultrarunners and 9 sex- and age-matched sedentary controls using cardiac magnetic resonance. In addition, body composition, lipid profile, interleukin-6 (IL-6) plasma concentration, and intima-media thickness (IMT) were measured as well. The EAT volume was lower in all measured locations in the ultrarunners' group compared to control group (p < 0.001 for all). Ultrarunners had lower BMI and fat percentage (FAT%) and more favorable lipid profile compared to the control group (p < 0.05 for all). Ultrarunners had lower rate of pathologically high levels of plasma IL-6 (>1 pg/mL) compared to the control group (17% vs. 56%, p < 0.05). IMT was similar in both groups. In the ultrarunners' group, there was a positive correlation between EAT surrounding left anterior descending artery, circumflex artery, and RV and FAT%, and between EAT around circumflex artery and LDL and non-HDL cholesterol (p < 0.05 for all). In summary, extremely intensive training may decrease the risk of cardiovascular events in adult population of amateur athletes by reducing the amount and pro-inflammatory activity of EAT. However, more research is needed to draw firm conclusions regarding the anti- and pro-inflammatory effects of intensive training.

Cardiovascular Magnetic Resonance Imaging and Heart Failure

Purpose of Review

The purpose of this review is to summarize the application of cardiac magnetic resonance (CMR) in the diagnostic and prognostic evaluation of patients with heart failure (HF).

Recent Findings

CMR is an important non-invasive imaging modality in the assessment of ventricular volumes and function and in the analysis of myocardial tissue characteristics. The information derived from CMR provides a comprehensive evaluation of HF. Its unique ability of tissue characterization not only helps to reveal the underlying etiologies of HF but also offers incremental prognostic information.

Summary

CMR is a useful non-invasive tool for the diagnosis and assessment of prognosis in patients suffering from heart failure.

Deformation Parameters of the Heart in Endurance Athletes and in Patients with Dilated Cardiomyopathy-A Cardiac Magnetic Resonance Study

A better understanding of the left ventricle (LV) and right ventricle (RV) functioning would help with the differentiation between athlete's heart and dilated cardiomyopathy (DCM). We aimed to analyse deformation parameters in endurance athletes relative to patients with DCM using cardiac magnetic resonance feature tracking (CMR-FT). The study included males of a similar age: 22 ultramarathon runners, 22 patients with DCM and 21 sedentary healthy controls (41 ± 9 years). The analysed parameters were peak LV global longitudinal, circumferential and radial strains (GLS, GCS and GRS, respectively); peak LV torsion; peak RV GLS. The peak LV GLS was similar in controls and athletes, but lower in DCM (p < 0.0001). Peak LV GCS and GRS decreased from controls to DCM (both p < 0.0001). The best value for differentiation between DCM and other groups was found for the LV ejection fraction (area under the curve (AUC) = 0.990, p = 0.0001, with 90.9% sensitivity and 100% specificity for ≤53%) and the peak LV GRS diastolic rate (AUC = 0.987, p = 0.0001, with 100% sensitivity and 88.4% specificity for >-1.27 s^-1). The peak LV GRS diastolic rate was the only independent predictor of DCM (p = 0.003). Distinctive deformation patterns that were typical for each of the analysed groups existed and can help to differentiate between athlete's heart, a nonathletic heart and a dilated cardiomyopathy.

Cardiac involvement in consecutive elite athletes recovered from Covid-19: A magnetic resonance study

Magnetic resonance (MR) studies suggested cardiac involvement post-Covid-19 in a significant subset of affected individuals, including athletes. This brings serious clinical concerns regarding the potential need for in-depth cardiac screening in athletes after Covid-19 before return to play. The aim of this study was to gain further insight into the relation between Covid-19 and cardiac involvement in professional athletes. This was a retrospective cohort study, in which 26 consecutive elite athletes (national team, Olympians, top national league players; median age 24 years, interquartile range [IQR] 21-27, 81% female) were included. At 1.5 T including balanced steady-state free precession cine imaging, T1 and T2-mapping using Myomaps software (Siemens), dark-blood T2-weighted images with fat suppression, and late gadolinium enhancement (LGE) with phase-sensitive inversion recovery sequence were used. The athletes had mainly asymptomatic or mild course of the disease (77%). They were scanned after a median of 32 days (IQR 22-62 days) from the diagnosis. MR data were reviewed by three independent observers, each with >10 years cardiac MR experience. Native T1, T2, extracellular volume, and T2 signal intensity ratio were calculated. Diagnosis of acute myocarditis was based on modified Lake Louise criteria. Statistical analyses used were Pearson correlation and Bland-Altman repeatability analysis. At the time of MR the athletes had no pathologic electrocardiogram abnormalities or elevated troponin levels. MR did not reveal any case of acute myocarditis. Cardiac abnormalities were found in five (19%) athletes, including four athletes presenting borderline signs of isolated myocardial edema and one athlete showing nonischemic LGE with pleural and pericardial effusion. Another athlete had signs of persistent lung congestion without cardiac involvement. We have shown that in a small group of elite athletes with mainly asymptomatic to mild Covid-19, lack of electrocardiographic changes, and normal troponin concentration 1-2 months after the diagnosis, there were no signs of acute myocarditis, but 19% of athletes had some abnormalities as assessed by cardiac MR. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 3.

MicroRNAs as Biomarkers of Systemic Changes in Response to Endurance Exercise-A Comprehensive Review

Endurance sports have an unarguably beneficial influence on cardiovascular health and general fitness. Regular physical activity is considered one of the most powerful tools in the prevention of cardiovascular disease. MicroRNAs are small particles that regulate the post-transcription gene expression. Previous studies have shown that miRNAs might be promising biomarkers of the systemic changes in response to exercise, before they can be detected by standard imaging or laboratory methods. In this review, we focused on four important physiological processes involved in adaptive changes to various endurance exercises (namely, cardiac hypertrophy, cardiac myocyte damage, fibrosis, and inflammation). Moreover, we discussed miRNAs’ correlation with cardiopulmonary fitness parameter (VO_2max). After a detailed literature search, we found that miR-1, miR-133, miR-21, and miR-155 are crucial in adaptive response to exercise.

Prevalence of Myocardial Fibrosis in Intensive Endurance Training Athletes: A Systematic Review and Meta-Analysis

Objective: To review the published literature reporting on the incidence of myocardial fibrosis (MF) in high-intensity endurance athletes measured by late gadolinium enhancement (LGE) with cardiac magnetic resonance imaging (CMR). Methods: Five databases (PubMed, Cochrane Controlled Trials Register, EMBASE, Web of Science, and SPORTDiscus) were searched to obtain case cohort studies published before November 10, 2019. From 96 abstracts or reports extracted, 18 full-text articles were reviewed. The incidence of LGE was reported as outcome measures. Subgroup analysis was performed by age (under or above 50 years). Pooled estimates were obtained using a fixed-effects model. Results: After a full-text assessment, 12 studies involving 1,359 participants were included for analysis. Among them, 163/772 participants in the endurance athletes group showed LGE positive, compared with 19/587 participants in the comparison group. The results of the meta-analysis suggested that the prevalence of LGE was higher in the athletes group with long-term endurance exercise (OR 7.20;95%CI: 4.51-11.49). In addition, the same conclusion was drawn after the stratification of age. Conclusions: The available evidence demonstrates that high-intensity endurance athletes is associated with an increased incidence of LGE positive.

Cardiac magnetic resonance in arrhythmogenic cardiomyopathies

Over the past few years, the approach to the 'arrhythmic patient' has profoundly changed. An early clinical presentation of arrhythmia is often accompanied by non-specific symptoms and followed by inconclusive electrocardiographic findings. In this scenario, cardiac magnetic resonance (CMR) has been established as a clinical tool of fundamental importance for a correct prognostic stratification of the arrhythmic patient. This technique provides a high-spatial-resolution tomographic evaluation of the heart, which allows studying accurately the ventricular volumes, identifying even segmental kinetic anomalies and properly detecting diffuse or focal tissue alterations through an excellent tissue characterization, while depicting different patterns of fibrosis distribution, myocardial edema or fatty substitution. Through these capabilities, CMR has a pivotal role for the adequate management of the arrhythmic patient, allowing the identification of those phenotypic manifestations characteristic of structural heart diseases. Therefore, CMR provides valuable information to reclassify the patient within the wide spectrum of potentially arrhythmogenic heart diseases, the definition of which remains the major determinants for both an adequate treatment and a poor prognosis. The purpose of this review study was to focus on the role of CMR in the evaluation of the main cardiac clinical entities associated with arrhythmogenic phenomena and to present a brief debate on the main pathophysiological mechanisms involved in the arrhythmogenesis process.

COVID-19 Myocardial Pathology Evaluated Through scrEening Cardiac Magnetic Resonance (COMPETE CMR)

Background

Myocarditis is a leading cause of sudden cardiac death among competitive athletes and may occur without antecedent symptoms. COVID-19-associated myocarditis has been well-described, but the prevalence of myocardial inflammation and fibrosis in young athletes after COVID-19 infection is unknown.

Objectives

This study sought to evaluate the prevalence and extent of cardiovascular involvement in collegiate athletes that had recently recovered from COVID-19.

Methods

We conducted a retrospective cohort analysis of collegiate varsity athletes with prior COVID-19 infection, all of whom underwent cardiac magnetic resonance (CMR) prior to resumption of competitive sports in August 2020.

Results

Twenty-two collegiate athletes with prior COVID-19 infection underwent CMR. The median time from SARS-CoV-2 infection to CMR was 52 days. The mean age was 20.2 years. Athletes represented 8 different varsity sports. This cohort was compared to 22 healthy controls and 22 tactical athlete controls. Most athletes experienced mild illness (N=17, 77%), while the remainder (23%) were asymptomatic. No athletes had abnormal troponin I, electrocardiograms, or LVEF < 50% on echocardiography. Late gadolinium enhancement was found in 9% of collegiate athletes and one athlete (5%) met formal criteria for myocarditis.

Conclusions

Our study suggests that the prevalence of myocardial inflammation or fibrosis after an asymptomatic or mild course of ambulatory COVID-19 among competitive athletes is modest (9%), but would be missed by ECG, Ti, and strain echocardiography. Future investigation is necessary to further phenotype cardiovascular manifestations of COVID-19 in order to better counsel athletes on return to sports participation.

COVID-19-associated myocarditis has been well-described, but the prevalence of myocardial inflammation and fibrosis in athletes after COVID-19 is unknown. We conducted a retrospective cohort analysis of 22 collegiate athletes with prior COVID-19 infection who underwent electrocardiography, troponin I, echocardiography with strain, and CMR. The median time from SARS-CoV-2 infection to CMR was 52 days. All athletes experienced mild illness or were asymptomatic. Late gadolinium enhancement was found in 9%. This suggests the prevalence of myocardial inflammation or fibrosis after an asymptomatic or mild course of COVID-19 among competitive athletes is modest, but would be missed without CMR screening.

Prospective long-term follow-up analysis of the cardiovascular system in marathon runners: study design of the Pro-MagIC study

Introduction

Prolonged strenuous exercise training may result in structural, functional and electrical cardiac remodelling, as well as vascular and myocardial injuries. However, the extent to which high-volume, intense exercise is associated with arrhythmias, myocardial fibrosis, coronary heart disease and pathological alterations of the vasculature remains unknown. In addition, there is no clear consensus on the clinical significance of these exercise-induced changes. Previous studies typically used cross-sectional designs and examined exercise-induced cardiovascular changes in small cohorts of athletes for up to 3–7 days of recovery. Long-term longitudinal studies investigating cardiovascular changes induced by prolonged strenuous exercise in large cohorts of athletes are needed to improve scientific understanding in this area.

Methods and analysis

In this prospective observational monocenter study, 277 participants of the Beer, Marathon, Genetics, Inflammation and the Cardiovascular System (Be-MaGIC) study (ClinicalTrials.gov: NCT00933218) will be invited to participate in this 10-year follow-up study. A minimum target sample size of 130 participants will be included in the study. Participating athletes will be examined via the following: anthropometry, resting electrocardiography and echocardiography, blood sampling, retinal vessel diameters, carotid sonography and cardiopulmonary exercise testing, including exercise electrocardiography.

Discussion

This longitudinal study will provide comprehensive data on physiological changes in the cardiovascular system and the development of pathologies after a 10-year period of prolonged and strenuous endurance exercise. Since the participants will have engaged in a wide range of training loads and competitive race events, this study will provide useful risk factor determinants and training load cut-off values. The primary endpoint is the association between the exercise-induced increase in cardiac troponin during the Munich marathon 2009 and the decline in right ventricular ejection fraction over the next 10 years.

Trial registration number

NCT04166903.

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.

Myocardial fibrosis in athletes-Current perspective

Several previous studies suggested that prolonged and extensive physical activity might lead to increased prevalence of myocardial fibrosis in athletes. The review summarizes these studies focusing on common patterns of myocardial fibrosis observed in athletes, their potential causes and significance. It also presents recent research on parametric imaging shedding new light on diffuse myocardial fibrosis in athletes. Finally, it reviews how these traditional and novel cardiac magnetic resonance (CMR) techniques can be incorporated in the diagnostic work up to differentiate athlete's heart from cardiomyopathies.