Hemodynamic and ECG responses to stress test in early adolescent athletes explain ethnicity-related cardiac differences

The athletes heart-from acute stimulus to chronic adaptation

INTRODUCTION

The complex phenomenon of the athlete's heart (AH) describes the chronic physiological structural and functional adaptation secondary to repeated exposure of an acute exercise stimulus.

SOURCES OF DATA

This narrative review is based on published evidence.

AREAS OF AGREEMENT

Highly trained athletic individuals frequently display cardiac parameters which are suggestive of an AH and can exceed the traditional 'normal' limits.

AREA OF CONTROVERSY

The physiological processes underpinning the extent of cardiac adaption and how this is closely linked to exercise type, but also sex, ethnicity, and body size.

GROWING POINTS

Since its seminal description by Morganroth and colleagues in 1975, our understanding of the AH has evolved in tandem with improvements in cardiac imaging techniques alongside the exploration of more diverse athletic populations. This narrative review aims to provide a balanced discussion of the multi-factorial nature of structure and function of the AH with specific reference to the unique physiological exercise stimuli.

AREAS TIMELY FOR DEVELOPING RESEARCH

Despite great interest in cardiac adaptations across a broad spectrum of athletic populations, future research designs should consider the use of new and novel imaging techniques to enhance our understanding of the acute cardiovascular responses which ultimately mediates such adaptations, especially in athletic populations underrepresented in the literature.

Racial Disparities in Sports Cardiology: A Review

Importance

Racial disparities in cardiovascular health, including sudden cardiac death (SCD), exist among both the general and athlete populations. Among competitive athletes, disparities in health outcomes potentially influenced by social determinants of health (SDOH) and structural racism remain inadequately understood. This narrative review centers on race in sports cardiology, addressing racial disparities in SCD risk, false-positive cardiac screening rates among athletes, and the prevalence of left ventricular hypertrophy, and encourages a reexamination of race-based practices in sports cardiology, such as the interpretation of screening 12-lead electrocardiogram findings.

Observations

Drawing from an array of sources, including epidemiological data and broader medical literature, this narrative review discusses racial disparities in sports cardiology and calls for a paradigm shift in approach that encompasses 3 key principles: race-conscious awareness, clinical inclusivity, and research-driven refinement of clinical practice. These proposed principles call for a shift away from race-based assumptions towards individualized, health-focused care in sports cardiology. This shift would include fostering awareness of sociopolitical constructs, diversifying the medical team workforce, and conducting diverse, evidence-based research to better understand disparities and address inequities in sports cardiology care.

Conclusions and Relevance

In sports cardiology, inadequate consideration of the impact of structural racism and SDOH on racial disparities in health outcomes among athletes has resulted in potential biases in current normative standards and in the clinical approach to the cardiovascular care of athletes. An evidence-based approach to successfully address disparities requires pivoting from outdated race-based practices to a race-conscious framework to better understand and improve health care outcomes for diverse athletic populations.

The athlete's heart: insights from echocardiography

The manifestations of the athlete's heart can create diagnostic challenges during an echocardiographic assessment. The classifications of the morphological and functional changes induced by sport participation are often beyond 'normal limits' making it imperative to identify any overlap between pathology and normal physiology. The phenotype of the athlete's heart is not exclusive to one chamber or function. Therefore, in this narrative review, we consider the effects of sporting discipline and training volume on the holistic athlete's heart, as well as demographic factors including ethnicity, body size, sex, and age.

Rationale and design of the PROspective ATHletic Heart (Pro@Heart) study: long-term assessment of the determinants of cardiac remodelling and its clinical consequences in endurance athletes

Background

Exercise-induced cardiac remodelling (EICR) results from the structural, functional and electrical adaptations to exercise. Despite similar sports participation, EICR varies and some athletes develop phenotypic features that overlap with cardiomyopathies. Training load and genotype may explain some of the variation; however, exercise ‘dose’ has lacked rigorous quantification. Few have investigated the association between EICR and genotype.

Objectives

(1) To identify the impact of training load and genotype on the variance of EICR in elite endurance athletes and (2) determine how EICR and its determinants are associated with physical performance, health benefits and cardiac pathology.

Methods

The Pro@Heart study is a multicentre prospective cohort trial. Three hundred elite endurance athletes aged 14–23 years will have comprehensive cardiovascular phenotyping using echocardiography, cardiac MRI, 12-lead ECG, exercise-ECG and 24-hour-Holter monitoring. Genotype will be determined using a custom cardiomyopathy gene panel and high-density single-nucleotide polymorphism arrays. Follow-up will include online tracking of training load. Cardiac phenotyping will be repeated at 2, 5, 10 and 20 years.

Results

The primary endpoint of the Pro@Heart study is the association of EICR with both training load and genotype. The latter will include rare variants in cardiomyopathy-associated genes and polygenic risk scores for cardiovascular traits. Secondary endpoints are the incidence of atrial and ventricular arrhythmias, physical performance and health benefits and their association with training load and genotype.

Conclusion

The Pro@Heart study is the first long-term cohort study to assess the impact of training load and genotype on EICR.

Trial registration number

NCT05164328; ACTRN12618000716268.

Electrical and Structural Adaption of Athlete’s Heart and the Impact on Training and Recovery Management in Professional Basketball Players: A Retrospective Observational Study

Introduction

We analyzed data of 27 professional basketball players to prove cardiac remodeling referring echocardiographic parameters, cardiopulmonary exercise testing (CPET), and 12-lead electrocardiogram (ECG) analyses. The aim of our study was to present different characteristics in the athletes, on the one hand signs of a high vagal tone in the 12-lead ECG as criteria of early repolarization (ER), furthermore echocardiographic remodeling parameters and finally the performance in CPET. Therefore, we divided the cohort into a group with signs of ER pattern in the 12-lead ECG and without these criteria and presented the differences in detail.

Materials and Methods

This was a single-center, retrospective study performed in 27 professional basketball players (age: 26.5 ± 7.5 years, male: 27, height: 197.2 ± 12 cm, weight: 100 ± 17 kg, BMI: 25.7 ± 3.4 kg/m2). All participants underwent a sports medicine checkup, ECG analysis, transthoracic echocardiographic examination, and a CPET on a cycle ergometer between 2015 and 2019 during their pre-season preparation time. All individuals were healthy people without cardiological advance anamnesis. After assessment, two groups were built based on electrocardiographic criteria of ER pattern and a group without these criteria and compared against each other for parameters of echocardiographic assessment, CPET, and 12-lead ECG analysis. Data were analyzed with Minitab statistic program (Minitab Inc., State College, PA, United States) and Graph Pad Prism 8.2.1 (279; Graph Pad Software, San Diego, CA, United States) using ANOVA testing with post-hoc testing and unpaired t-testing (p ≤ 0.05).

Retrospectively additional information was collected referring to the management of training sessions, recovery time, and nutrition by interviewing the athletic training staff in order to understand the principles for individual athlete’s training management and physiological and cardiopulmonary interactions.

Results

Comparing professional basketball players with ER pattern to those with no ER pattern, significant differences were found for CPET, echocardiographic, and ECG analysis (p < 0.05). Absolute and relativized peak oxygen uptake (VO2 peak; ER 4120 ± 750 ml/min (39 ± 5.4 ml/kg/min) vs. non-ER 3556 ± 393 ml/min (37.2 ± 5.3 ml/kg/min), p = 0.018) and maximum workload during CPET (ER 310 ± 51.5 Watt (2.94 ± 0.35 W/kg) vs. non-ER 271 ± 32 Watt (2.85 ± 0.49 W/kg), p = 0.026) was higher in athletes with an ER pattern. Furthermore, ER pattern athletes showed a higher enddiastolic left ventricular diameter (LVedd; ER 58.3 ± 7.9 mm vs. non-ER 53.6 ± 3.6 mm, p = 0.048) and a significantly enlarged left atrial (LA) endsystolic diameter (ER 23.33 ± 2.71 mm vs. non-ER 20.47 ± 2.29 mm, p = 0.006) as well as a significantly enlarged right atrial (RA) endsystolic diameter (ER 23.42 ± 2.15 mm vs. non-ER 20.93 ± 3.28 mm, p = 0.033). Significant differences between the two compared groups could be revealed for left ventricular mass Index (LVMI gr/m2; LVMI ER 113 gr/m2 ± 17.5 vs. LVMI non-ER 91.3 gr/m2 ± 15.1, p = 0.002), but no significant differences for the relative wall thickness were found (RWT; RWT ER 0.49 ± 0.11 vs. RWT non-ER 0.38 ± 0.06, p = 0.614).

Conclusion

Professional basketball players with criteria of ER pattern showed different results in CPET and cardiac remodeling as athletes with no ER pattern. These findings should encourage the athletic training staff to emphasize the quality of an individual training schedule for each athlete based on the cardiopulmonary pre-season sport medicine checkup. Nevertheless, echocardiographic findings, ER pattern, and performance in CPET have to be interpreted referring the sport-specific and athlete’s ethnical background.

Racial differences of early vascular aging in children and adolescents

The prevalence of non-communicable disease (NCDs) is rising globally, with a large burden recorded in sub-Saharan countries and populations of black race/ethnicity. Accelerated vascular deterioration, otherwise known as early vascular aging (EVA), is the underlying factor for highly prevalent NCDs such as hypertension. The etiology of EVA is multifactorial with a central component being arterial stiffness with subsequent development of hypertension and cardiovascular complications. Although arterial stiffness develops with increasing age, many children and adolescents are subjected to the premature development of arterial stiffness, due to genetic or epigenetic predispositions, lifestyle and behavioral risk factors, and early life programming. Race/ethnic differences in pediatric populations have also been reported with higher aortic stiffness in black (African American) compared with age-matched white (European American) counterparts independent of blood pressure, body mass index, or socioeconomic status. With known evidence of race/ethnic differences in EVA, the pathophysiological mechanisms underlying graded differences in the programming of EVA are still sparse and rarely explored. This educational review aims to address the early life determinants of EVA in children and adolescents with a particular focus on racial or ethnic differences.

Exercise electrocardiography combined with stress echocardiography for predicting myocardial ischemia in adults

Myocardial ischemia (MI) has the highest mortality rate in the world. Traditional noninvasive MI examinations include exercise electrocardiography tests (EETs) and stress echocardiography (SE). Treadmill and dobutamine tests are commonly used as stress protocols. In the present study, 278 patients with suspected MI were examined, 66 of whom were diagnosed with MI and 212 did not show evidence of MI by coronary angiography (CAG)/coronary CT angiography (CCTA). All patients underwent clinical EET and SE evaluations prior to CAG/CCTA. All groups were compared based on specific clinical parameters including age, sex, blood pressure, heart rate, blood oxygen saturation, underlying conditions and ejection fraction/fraction shortening. The data indicated superior diagnostic efficiency of the combined EET+SE method for the diagnosis of suspected MI compared with either EET or SE alone. The sensitivity/specificity/positive predictive value and negative predictive value for detecting MI were excellent compared with those of traditional examinations. The diagnostic efficiency of the combination analysis may reduce the prevalence of MI and medical costs. The present study provided novel insight for the development of methods that may be used for MI detection and prediction.

The Impact of Ethnicity on Cardiac Adaptation

Regular intensive exercise is associated with a plethora of electrical, structural and functional adaptations within the heart to promote a prolonged and sustained increase in cardiac output. Bradycardia, increased cardiac dimensions, enhanced ventricular filling, augmentation of stroke volume and high peak oxygen consumption are recognised features of the athlete's heart. The type and magnitude of these adaptations to physical exercise are governed by age, sex, ethnicity, sporting discipline and intensity of sport. Some athletes, particularly those of African or Afro-Caribbean (black) origin reveal changes that overlap with diseases implicated in sudden cardiac death. In such instances, erroneous interpretation has potentially serious consequences ranging from unfair disqualification to false reassurance. This article focuses on ethnic variation in the physiological cardiac adaption to exercise.