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Moliterno E, Rovere G, Giarletta L, Brancasi A, Larici AR, Savino G, Bianco M, Meduri A, Palmieri V, Natale L, Marano R. The role of coronary CT angiography in athletes. LA RADIOLOGIA MEDICA 2024; 129:1008-1024. [PMID: 38971947 DOI: 10.1007/s11547-024-01837-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 06/19/2024] [Indexed: 07/08/2024]
Abstract
The sudden death of a young or high-level athlete or adolescent during recreational sports is one of the events with the greatest impact on public opinion in modern society. Sudden cardiac death (SCD) is the principal medical cause of death in athletes and can be the first and last clinical presentation of underlying disease. To prevent such episodes, pre-participation screening has been introduced in many countries to guarantee cardiovascular safety during sports and has become a common target among medical sports/governing organizations. Different cardiac conditions may cause SCD, with incidence depending on definition, evaluation methods, and studied populations, and a prevalence and etiology changing according to the age of athletes, with CAD most frequent in master athletes, while coronary anomalies and non-ischemic causes prevalent in young. To detect silent underlying causes early would be of considerable clinical value. This review summarizes the pre-participation screening in athletes, the specialist agonistic suitability visit performed in Italy, the anatomical characteristics of malignant coronary anomalies, and finally, the role of coronary CT angiography in such arena. In particular, the anatomical conditions suggesting potential disqualification from sport, the post-treatment follow-up to reintegrate young athletes, the diagnostic workflow to rule-out CAD in master athletes, and their clinical management are analyzed.
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Affiliation(s)
- Eleonora Moliterno
- Department of Radiological and Haematological Sciences - Section of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Rovere
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168, Rome, Italy
| | - Lorenzo Giarletta
- Department of Radiological and Haematological Sciences - Section of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Brancasi
- Department of Radiological and Haematological Sciences - Section of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Rita Larici
- Department of Radiological and Haematological Sciences - Section of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168, Rome, Italy
| | - Giancarlo Savino
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168, Rome, Italy
| | - Massimiliano Bianco
- Sports Medicine Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Agostino Meduri
- Department of Radiological and Haematological Sciences - Section of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168, Rome, Italy
| | - Vincenzo Palmieri
- Sports Medicine Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luigi Natale
- Department of Radiological and Haematological Sciences - Section of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168, Rome, Italy
| | - Riccardo Marano
- Department of Radiological and Haematological Sciences - Section of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy.
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go Agostino Gemelli 8, 00168, Rome, Italy.
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Orchard J, Harmon KG, D'Ascenzi F, Meyer T, Pieles GE. What is the most appropriate age for the first cardiac screening of athletes? J Sci Med Sport 2024:S1440-2440(24)00210-X. [PMID: 38890019 DOI: 10.1016/j.jsams.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/20/2024] [Accepted: 05/28/2024] [Indexed: 06/20/2024]
Abstract
For sporting organisations that conduct screening of athletes, there are very few consistent guidelines on the age at which to start. Our review found the total rate of sudden cardiac arrest or death is very low between the ages of 8-11 years (less than 1/100,000/year), increasing to 1-2/100,000/year in both elite athletes and community athletes aged 12-15 years and then steadily increases with age. The conditions associated with sudden cardiac death in paediatric athletes and young adult athletes are very similar with some evidence that death from coronary artery abnormalities occurs more frequently in athletes 10-14 years old. The decision when to begin a screening program involves a complex interplay between requirements and usual practices in a country, the rules of different leagues and programs, the age of entry into an elite program, the underlying risk of the population and the resources available. Given the incidence of sudden cardiac arrest or death in young people, we recommend beginning cardiac screening no earlier than 12 years (not later than 16 years). The risk increases with age, therefore, starting a program at any point after age 12 has added value. Importantly, anyone with concerning symptoms (e.g. collapse on exercise) or family history of an inherited cardiac condition should see a physician irrespective of age. Finally, no screening program can capture all abnormalities, and it is essential for organisations to implement a cardiac emergency plan including training on recognition and response to sudden cardiac arrest and prompt access to resuscitation, including defibrillators.
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Affiliation(s)
- Jessica Orchard
- Sydney School of Public Health, The University of Sydney, Australia. https://twitter.com/jessicajorchard
| | | | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Sports Cardiology and Rehab Unit, University of Siena, Italy. https://twitter.com/FlavioDascenzi
| | - Tim Meyer
- Institute of Sports and Preventive Medicine, Saarland University, Germany. https://twitter.com/ProfTim_Meyer
| | - Guido E Pieles
- Department of Athlete Screening and Sports Cardiology, Aspetar Orthopaedic and Sports Medicine Hospital, Qatar; Institute of Sport, Exercise and Health, University College London, UK.
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3
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Miljoen H, Favere K, Van De Heyning C, Corteville B, Dausin C, Herbots L, Teulingkx T, Bekhuis Y, Lyssens M, Bogaert J, Heidbuchel H, Claessen G. Low rates of myocardial fibrosis and ventricular arrhythmias in recreational athletes after SARS-CoV-2 infection. Front Cardiovasc Med 2024; 11:1372028. [PMID: 38628312 PMCID: PMC11018940 DOI: 10.3389/fcvm.2024.1372028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/26/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction High rates of cardiac involvement were reported in the beginning of the coronavirus disease 2019 (COVID-19) pandemic. This led to anxiety in the athletic population. The current study was set up to assess the prevalence of myocardial fibrosis and ventricular arrhythmias in recreational athletes with the recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Methods Consecutive adult recreational athletes (≥18 years old, ≥4 h of mixed type or endurance sports/week) underwent systematic cardiac evaluation after a prior confirmed COVID-19 infection. Evaluation included clinical history, electrocardiogram (ECG), 5-day Holter monitoring, and cardiac magnetic resonance (CMR) imaging with simultaneous measurement of high-sensitive cardiac Troponin I. Data from asymptomatic or mildly symptomatic athletes (Group 1) were compared with those with moderate to severe symptoms (Groups 2-3). Furthermore, a comparison with a historical control group of athletes without COVID-19 (Master@Heart) was made. Results In total, 35 athletes (18 Group 1, 10 female, 36.9 ± 2.2 years, mean 143 ± 20 days following diagnosis) were evaluated. The baseline characteristics for the Group 1 and Groups 2-3 athletes were similar. None of the athletes showed overt myocarditis on CMR based on the updated Lake Louise criteria for diagnosis of myocarditis. The prevalence of non-ischemic late gadolinium enhancement [1 (6%) Group 1 vs. 2 (12%) Groups 2-3; p = 0.603] or ventricular arrhythmias [1 Group 1 athlete showed non-sustained ventricular tachycardia (vs. 0 in Groups 2-3: p = 1.000)] were not statistically different between the groups. When the male athletes were compared with the Master@Heart athletes, again no differences regarding these criteria were found. Conclusion In our series of recreational athletes with prior confirmed COVID-19, we found no evidence of ongoing myocarditis, and no more detection of fibrosis or ventricular arrhythmias than in a comparable athletic pre-COVID cohort. This points to a much lower cardiac involvement of COVID-19 in athletes than originally suggested.
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Affiliation(s)
- Hielko Miljoen
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Research Group Cardiovascular Diseases, Department GENCOR, University of Antwerp, Antwerp, Belgium
| | - Kasper Favere
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Research Group Cardiovascular Diseases, Department GENCOR, University of Antwerp, Antwerp, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Caroline Van De Heyning
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Research Group Cardiovascular Diseases, Department GENCOR, University of Antwerp, Antwerp, Belgium
| | - Ben Corteville
- Department of Cardiology, Jan Palfijn Hospital, Ghent, Belgium
| | - Christophe Dausin
- Exercise Physiology Research Group, Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Lieven Herbots
- Department of Cardiology, Hartcentrum, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Youri Bekhuis
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Cardiology, Leuven University Hospitals, Leuven, Belgium
- Department of Cardiovascular Sciences, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Malou Lyssens
- Exercise Physiology Research Group, Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Jan Bogaert
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Research Group Cardiovascular Diseases, Department GENCOR, University of Antwerp, Antwerp, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Guido Claessen
- Department of Cardiology, Hartcentrum, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
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Andresen K, Klæboe LG, Lie ØH, Broch K, Kvaslerud AB, Bosse G, Hopp E, de Lange C, Haugaa KH, Edvardsen T. No adverse association between exercise exposure and diffuse myocardial fibrosis in male endurance athletes. Sci Rep 2024; 14:6581. [PMID: 38503845 PMCID: PMC10951320 DOI: 10.1038/s41598-024-57233-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/15/2024] [Indexed: 03/21/2024] Open
Abstract
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.
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Affiliation(s)
- Kristoffer Andresen
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Nydalen, P. O. Box 4950, N-0424, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Gunnar Klæboe
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Nydalen, P. O. Box 4950, N-0424, Oslo, Norway
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
| | - Øyvind Haugen Lie
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Nydalen, P. O. Box 4950, N-0424, Oslo, Norway
| | - Kaspar Broch
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Nydalen, P. O. Box 4950, N-0424, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anette Borger Kvaslerud
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Nydalen, P. O. Box 4950, N-0424, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Gerhard Bosse
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Einar Hopp
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Charlotte de Lange
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Hermann Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Nydalen, P. O. Box 4950, N-0424, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Heart and Lung Diseases Unit, Department of Medicine, Karolinska University Hospital, Huddinge, Sweden
| | - Thor Edvardsen
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Nydalen, P. O. Box 4950, N-0424, Oslo, Norway.
- Faculty of Medicine, University of Oslo, Oslo, Norway.
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5
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Unnithan VB, Beaumont A, Rowland T, George K, Sculthorpe N, Lord RN, Bakhshi A, Oxborough D. Left Ventricular Responses during Exercise in Highly Trained Youth Athletes: Echocardiographic Insights on Function and Adaptation. J Cardiovasc Dev Dis 2022; 9:jcdd9120438. [PMID: 36547435 PMCID: PMC9787332 DOI: 10.3390/jcdd9120438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
There is an increase in the prevalence of elite youth sports academies, whose sole aim is to develop future elite athletes. This involves the exposure of the child and adolescent athlete to high-volume training during a period of volatile growth. The large amount of data in this area has been garnered from the resting echocardiographic left ventricular (LV) evaluation of the youth athlete; while this can provide some insight on the functional adaptations to training, it is unable to elucidate a comprehensive overview of the function of the youth athletes' LV during exercise. Consequently, there is a need to interrogate the LV responses in-exercise. This review outlines the feasibility and functional insight of capturing global indices of LV function (Stroke Index-SVIndex and Cardiac Index-QIndex), systolic and diastolic markers, and cardiac strain during submaximal and maximal exercise. Larger SVI and QI were noted in these highly trained young athletes compared to recreationally active peers during submaximal and maximal exercise. The mechanistic insights suggest that there are minimal functional systolic adaptions during exercise compared to their recreationally active peers. Diastolic function was superior during exercise in these young athletes, and this appears to be underpinned by enhanced determinants of pre-load.
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Affiliation(s)
- Viswanath B. Unnithan
- Sport and Physical Activity Research Institute, Division of Sport and Exercise, School of Health and Life Sciences, University of the West of Scotland, Hamilton G72 0LH, UK
- Correspondence: ; Tel.: +44-01698-894413
| | - Alexander Beaumont
- School of Science, Technology and Health, York St. John University, York YO31 7EX, UK
| | - Thomas Rowland
- Sport and Physical Activity Research Institute, Division of Sport and Exercise, School of Health and Life Sciences, University of the West of Scotland, Hamilton G72 0LH, UK
| | - Keith George
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK
| | - Nicholas Sculthorpe
- Sport and Physical Activity Research Institute, Division of Sport and Exercise, School of Health and Life Sciences, University of the West of Scotland, Hamilton G72 0LH, UK
| | - Rachel N. Lord
- Cardiff Centre for Exercise and Health, Cardiff Metropolitan University, Cardiff CF5 2YB, UK
| | | | - David Oxborough
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK
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Abstract
Exercise stress testing (EST) is indicated for diagnostic and prognostic purposes in the general population. In athletes, stress tests can also be useful to inform the risk of high-intensity training and competition, to assess athletic conditioning, and to refine training regimens. Many specific indications for EST are unique to athletes. Treadmill and cycle ergometer protocols each have their strengths and disadvantages; extensive protocol customization may be necessary to answer the clinical question at hand. A comprehensive understanding of the available tools for exercise testing, their strengths, and their limitations is crucial to providing cardiovascular care to athletic individuals.
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Affiliation(s)
- Gary Parizher
- Sports Cardiology Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael S Emery
- Sports Cardiology Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
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D’Ascenzi F, Baggiano A, Cavigli L, Mandoli GE, Andreini D, Marallo C, Valente S, Focardi M, Cameli M, Pontone G. The role of cardiac computed tomography in sports cardiology: back to the future! Eur Heart J Cardiovasc Imaging 2022; 23:e481-e493. [DOI: 10.1093/ehjci/jeac069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/15/2022] [Accepted: 03/21/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
In recent years, the role of pre-participation evaluation (PPE) in the prevention of sudden cardiac death in competitive athletes has become evident. Most physicians routinely supplement assessment by resting electrocardiogram with imaging techniques, such as echocardiography. The primary goal of imaging in the clinical assessment of competitive athletes is to exclude cardiovascular conditions associated with adverse outcomes. Cardiac computed tomography is emerging as an important technique for stratifying cardiovascular risk and assessing coronary artery disease (CAD), particularly in master athletes. Conversely, in young athletes, this technique has the best non-invasive coronary artery resolution and provides valuable details on coronary artery anatomy. Recent technical developments have brought about a dramatic reduction in radiation exposure, a major drawback of this diagnostic method; nowadays cardiac computed tomography may be performed at a dose of barely one millisievert. The present review provides a practical guide for the use of cardiac computed tomography in the PPE of competitive athletes, with a specific focus on its value for detecting congenital coronary anomalies and CAD in young and master athletes, respectively.
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Affiliation(s)
- Flavio D’Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, V.le M. Bracci 16, 53100 Siena, Italy
| | - Andrea Baggiano
- Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Luna Cavigli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, V.le M. Bracci 16, 53100 Siena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, V.le M. Bracci 16, 53100 Siena, Italy
| | - Daniele Andreini
- Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Carmine Marallo
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, V.le M. Bracci 16, 53100 Siena, Italy
| | - Serafina Valente
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, V.le M. Bracci 16, 53100 Siena, Italy
| | - Marta Focardi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, V.le M. Bracci 16, 53100 Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, V.le M. Bracci 16, 53100 Siena, Italy
| | - Gianluca Pontone
- Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Milan, Italy
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8
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Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Clin Electrophysiol 2022; 8:533-553. [PMID: 35450611 DOI: 10.1016/j.jacep.2021.12.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 01/21/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) encompasses a group of conditions characterized by right ventricular fibrofatty infiltration, with a predominant arrhythmic presentation. First described in the late 1970s and early 1980s, it is now frequently recognized to have biventricular involvement. The prevalence is ∼1:2,000 to 1:5,000, depending on geographic location, and it has a slight male predominance. The diagnosis of ARVC is determined on the basis of fulfillment of task force criteria incorporating electrophysiological parameters, cardiac imaging findings, genetic factors, and histopathologic features. Risk stratification of patients with ARVC aims to identify those who are at increased risk of sudden cardiac death or sustained ventricular tachycardia. Factors including age, sex, electrophysiological features, and cardiac imaging investigations all contribute to risk stratification. The current management of ARVC includes exercise restriction, β-blocker therapy, consideration for implantable cardioverter-defibrillator insertion, and catheter ablation. This review summarizes our current understanding of ARVC and provides clinicians with a practical approach to diagnosis and management.
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9
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Abstract
Hereditary diseases under the age of 35 are the most common underlying heart disease, leading to sudden cardiac death (SCD) in competitive sports, while in older people, atherosclerotic coronary artery disease (CAD) is the main cause. The following preventive measures are recommended: (a) The pre-participation cardiovascular screening, (b) the genetic testing, (c) the use of implantable cardioverter-defibrillator (ICD), (d) the prohibition of doping in sports, (e) the prevention of 'exercise-induced' cardiac complications, (f) the reduction of high-risk factors for CAD, and (g) the use of cardiopulmonary resuscitation. The cost-effectiveness of the electrocardiograms in the pre-participation screening programs remains questionable. Genetic testing is recommended in borderline cases and positive family history. Athletes with ICD can, under certain conditions, participate in competitive sports. Excessive endurance exercise appears to harm the endothelium, promotes inflammatory processes and leads to fibrosis in the myocardium, and calcium deposition in the coronary vessels. Cardiac arrest may be reversed if cardiopulmonary resuscitation is performed and a defibrillator is immediately used. Thus, equipping all fields with automatic external defibrillators are recommended.
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Affiliation(s)
- Asterios Deligiannis
- Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelia Kouidi
- Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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10
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Petek BJ, Tso JV, Churchill TW, Guseh JS, Loomer G, DiCarli M, Lewis GD, Weiner RB, Kim JH, Wasfy MM, Baggish AL. Normative cardiopulmonary exercise data for endurance athletes: the Cardiopulmonary Health and Endurance Exercise Registry (CHEER). Eur J Prev Cardiol 2021; 29:536-544. [PMID: 34487164 DOI: 10.1093/eurjpc/zwab150] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/05/2021] [Accepted: 08/24/2021] [Indexed: 11/14/2022]
Abstract
AIMS Accurate interpretation of cardiopulmonary exercise testing (CPET) relies on age, gender, and exercise modality-specific reference values. To date, clinically applicable CPET reference values derived from a source population of endurance athletes (EAs) have been lacking. The purpose of this study was to generate CPET reference values for use in the clinical assessment of EA. METHODS AND RESULTS Prospective data accrued during the clinical care of healthy EA were used to derive CPET reference values and to develop novel equations for V˙O2peak. The performance of these equations was compared to the contemporary standard of care equations and assessed in a discrete EA validation cohort. A total of 272 EA (age = 42 ± 15 years, female = 31%, V˙O2peak = 3.6 ± 0.83 L/min) met inclusion criteria and comprised the derivation cohort. V˙O2peak prediction equations derived from general population cohorts described a modest amount of V˙O2peak variability [R2 = 0.58-0.70, root mean square error (RMSE) = 0.46-0.54 L/min] but were mis-calibrated (calibration-in-the-large = 0.45-1.18 L/min) among EA leading to significant V˙O2peak underestimation. Newly derived, externally validated V˙O2peak prediction equations for EA that included age, sex, and height for both treadmill (R2 = 0.74, RMSE = 0.42 L/min) and cycle ergometer CPET (Cycle: R2 = 0.69, RMSE = 0.42 L/min) demonstrated improved accuracy. CONCLUSION Commonly used V˙O2peak prediction equations derived from general population cohorts perform poorly among competitive EA. Newly derived CPET reference values including novel V˙O2peak prediction equations may improve the clinical utility of CPET in this rapidly growing patient population.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jason V Tso
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute, 1462 Clifton Road, NE, Suite 502, Atlanta, GA 30322, USA
| | - Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - J Sawalla Guseh
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Garrett Loomer
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Milena DiCarli
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Gregory D Lewis
- Division of Cardiology, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Rory B Weiner
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan H Kim
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute, 1462 Clifton Road, NE, Suite 502, Atlanta, GA 30322, USA
| | - Meagan M Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
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11
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Hill L, Mountjoy M, Miller J, Burr J. Sink or swim: innovations in aquatic health. J Sports Med Phys Fitness 2021; 61:1104-1114. [PMID: 34137575 DOI: 10.23736/s0022-4707.21.12697-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since the first modern Olympic Games in 1896, the aquatic sports have expanded both in participation and innovation over the last century. Beginning with swimming, diving, water polo, and later additions of artistic swimming, open water swimming and high diving, the aquatics sports represent a core pillar of Olympic disciplines. The rapid expansion of aquatic disciplines necessitated the foundation of the Fédération Internationale de Natation (FINA) in 1908, to govern the development of aquatic sports. The amateur spectacle has been slowly replaced with an increased focus on health and performance by dedicated professional athletes and support teams, resulting in the development of new innovations. In the early years, innovations largely centered on technical equipment such as bathing suit and springboard design. In more recent years, research and innovation have shifted focus to health and its impact on performance, including but not limited to changes in training methods, nutrition, injury and illness reduction through surveillance and access to education for athletes, coaches, and support personnel. An increased awareness on factors that affect athlete health have also driven safety innovations including the development of Nutrition and Relative Energy Deficiency in Sport Clinical Assessment Tool, the Sport Mental Health Assessment and Recognition Tools and safeguarding from harassment and abuse through embedding athletes' right to safe sport in underpinning statutory documents. While the future of aquatic health innovations remains undefined, there are many potential opportunities for research and knowledge translation as the aquatic sports continue to evolve and adapt over time.
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Affiliation(s)
- Lee Hill
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada -
| | - Margo Mountjoy
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada.,Sports Medicine, FINA, Lausanne, Switzerland
| | - James Miller
- Sports Medicine, FINA, Lausanne, Switzerland.,Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jamie Burr
- Human Health and Nutritional Sciences, University of Guelph, Guelph, ON, Canada
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12
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Chung EH, Shantha G. My Approach to Sudden Death Risk Evaluation in Athletes, Who Should Play and Who Can Return to Play? CURRENT CARDIOVASCULAR RISK REPORTS 2021. [DOI: 10.1007/s12170-021-00675-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Brito D, Meester S, Yanamala N, Patel HB, Balcik BJ, Casaclang-Verzosa G, Seetharam K, Riveros D, Beto RJ, Balla S, Monseau AJ, Sengupta PP. High Prevalence of Pericardial Involvement in College Student Athletes Recovering From COVID-19. JACC Cardiovasc Imaging 2021; 14:541-555. [PMID: 33223496 PMCID: PMC7641597 DOI: 10.1016/j.jcmg.2020.10.023] [Citation(s) in RCA: 134] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study sought to explore the spectrum of cardiac abnormalities in student athletes who returned to university campus in July 2020 with uncomplicated coronavirus disease 2019 (COVID-19). BACKGROUND There is limited information on cardiovascular involvement in young individuals with mild or asymptomatic COVID-19. METHODS Screening echocardiograms were performed in 54 consecutive student athletes (mean age 19 years; 85% male) who had positive results of reverse transcription polymerase chain reaction nasal swab testing of the upper respiratory tract or immunoglobulin G antibodies against severe acute respiratory syndrome coronavirus type 2. Sequential cardiac magnetic resonance imaging was performed in 48 (89%) subjects. RESULTS A total of 16 (30%) athletes were asymptomatic, whereas 36 (66%) and 2 (4%) athletes reported mild and moderate COVID-19 related symptoms, respectively. For the 48 athletes completing both imaging studies, abnormal findings were identified in 27 (56.3%) individuals. This included 19 (39.5%) athletes with pericardial late enhancements with associated pericardial effusion. Of the individuals with pericardial enhancements, 6 (12.5%) had reduced global longitudinal strain and/or an increased native T1. One patient showed myocardial enhancement, and reduced left ventricular ejection fraction or reduced global longitudinal strain with or without increased native T1 values was also identified in an additional 7 (14.6%) individuals. Native T2 findings were normal in all subjects, and no specific imaging features of myocardial inflammation were identified. Hierarchical clustering of left ventricular regional strain identified 3 unique myopericardial phenotypes that showed significant association with the cardiac magnetic resonance findings (p = 0.03). CONCLUSIONS More than 1 in 3 previously healthy college athletes recovering from COVID-19 infection showed imaging features of a resolving pericardial inflammation. Although subtle changes in myocardial structure and function were identified, no athlete showed specific imaging features to suggest an ongoing myocarditis. Further studies are needed to understand the clinical implications and long-term evolution of these abnormalities in uncomplicated COVID-19.
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Affiliation(s)
- Daniel Brito
- Division of Cardiology, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
| | - Scott Meester
- Department of Emergency Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Naveena Yanamala
- Division of Cardiology, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
| | - Heenaben B Patel
- Division of Cardiology, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
| | - Brenden J Balcik
- Department of Emergency Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Grace Casaclang-Verzosa
- Division of Cardiology, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
| | - Karthik Seetharam
- Division of Cardiology, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
| | - Diego Riveros
- Department of Emergency Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Robert James Beto
- Division of Cardiology, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
| | - Sudarshan Balla
- Division of Cardiology, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
| | - Aaron J Monseau
- Department of Emergency Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Partho P Sengupta
- Division of Cardiology, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA.
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14
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Gaafar A, Gaafar A. Routine pre-employment echocardiography assessment in young adults: cost and benefits. Egypt Heart J 2021; 73:3. [PMID: 33409841 PMCID: PMC7788111 DOI: 10.1186/s43044-020-00131-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/26/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Conventional echocardiography is a safe, available, and accurate tool for cardiac structural and functional evaluation, but it should not cancel clinical assessment and history tacking, and indeed both are complementary. A pre-employment assessment is important for employees and community safety and suitability for a specific work requirement. RESULTS Aiming to assess the value of routine pre-employment echocardiography for the detection of cardiac abnormalities, we examined seven hundred ninety-five persons who were routinely referred to us for pre-employment conventional echocardiography. Only 9 persons had structural cardiac abnormalities (1.3%) and distributed as follows: two had bicuspid aortic valve with isolated aortic regurgitation, one of them had mild AR, and the other had moderate AR. Two cases had mitral valve prolapse, one of them had trivial MR, while the other had a flail anterior leaflet with severe MR. One patient had atrial septal defect 1.5 cm with mild pulmonary hypertension and right-sided chambers dilatation. One patient had dextrocardia (situs inversus totalis) without other cardiac problems. One had moderate pulmonary hypertension and modest right-sided chambers dilation. Two patients had left ventricular hypertrophy. Surprisingly, we did not detect rheumatic valvular heart disease. The money cost of echocardiography tests for those 795 persons was 198,750 Egyptian pounds (LE); their transportation cost was about 19.800LE. The total group time cost of the tests was 265 h, total time lost at the waiting room was 1590 h, total transportation time lose was 2385 h, so the total time cost was about 4000 h. Using psychological stress questionnaire, 33 participants (4.2%) had results suggestive of a low sense of psychological pressure due to echocardiography examination, 221 participants (27.8%) had results suggestive of a moderate feeling of stress, while 541 participants (68%) had results suggestive of a high sense of stress. CONCLUSION We recommend against routine echocardiography for cardiac assessment in pre-employment assessment and to do it only for persons with abnormal clinical or ECG findings.
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Affiliation(s)
- Ahmed Gaafar
- Cardiology Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Asmaa Gaafar
- Psychology Department, Faculty of Humanities, Al-Azhar University, Cairo, Egypt
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15
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Akkuş A, Belviranli M, Şap F, Okudan N. Assessment of Structure, Function, and Rhythm of the Heart with Echocardiography and Electrocardiography in Adolescent Swimmers. Pediatr Cardiol 2021; 42:182-188. [PMID: 32965565 DOI: 10.1007/s00246-020-02469-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/18/2020] [Indexed: 01/20/2023]
Abstract
The aim of this study was to evaluate the cardiac parameters by using electrocardiography and echocardiography in adolescent swimmers. Twenty-two adolescent swimmers and 22 gender- and age-matched sedentary controls admitted to our center between November 2018 and May 2019 were included in this study. In addition to demographical characteristics, participants were assessed via a 12-lead electrocardiography and two-dimensional echocardiography for cardiac function. On the echocardiography, end-systolic and end-diastolic interventricular septum, end-systolic and end-diastolic left ventricular posterior wall thicknesses, left atrial width, Tricuspid E, left ventricular mass and left ventricular mass index were higher in the swimmers when compared to the sedentary controls (P < 0.05). On the electrocardiography, Tp-e duration which reflects ventricular transmural repolarization, and Tp-e/QT and Tp-e/corrected QT ratios were higher in the swimmers than the sedentary controls (P < 0.05). In conclusion, swimming exercise in children leads to concentric thickening of left ventricle and induces an increase in Tp-e duration, and Tp-e/QT and Tp-e/corrected QT ratios, which are the novel markers for risk of ventricular arrhythmias.
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Affiliation(s)
- Abdullah Akkuş
- Department of Paediatrics, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Muaz Belviranli
- Division of Sports Physiology, Department of Physiology, Faculty of Medicine, Selçuk University, 42131, Konya, Turkey.
| | - Fatih Şap
- Division of Paediatric Cardiology, Department of Paediatrics, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Nilsel Okudan
- Division of Sports Physiology, Department of Physiology, Faculty of Medicine, Selçuk University, 42131, Konya, Turkey
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16
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D'Ascenzi F, Valentini F, Anselmi F, Cavigli L, Bandera F, Benfari G, D'Andrea A, Di Salvo G, Esposito R, Evola V, Malagoli A, Elena Mandoli G, Santoro C, Galderisi M, Mondillo S, Cameli M. Bicuspid aortic valve and sports: From the echocardiographic evaluation to the eligibility for sports competition. Scand J Med Sci Sports 2020; 31:510-520. [PMID: 33260267 DOI: 10.1111/sms.13895] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 10/23/2020] [Accepted: 11/27/2020] [Indexed: 12/19/2022]
Abstract
Bicuspid aortic valve (BAV) is the most common congenital heart defect in adults. Although a BAV may remain without clinical consequences for a lifetime, it can deteriorate in aortic valve stenosis and regurgitation and aortic dilatation. Unfortunately, the impact of regular training on patients with BAV and its natural course is not fully understood, although preliminary evidence suggests that the progression of valvular disease occurs primarily in an independent manner from sports practice. The current review aims to report how to perform a comprehensive echocardiographic examination in athletes with BAV and analyze the current literature on the influence of sports practice and how it impacts the aortic valve in athletes with BAV. The article also summarizes the current recommendations on sports eligibility and disqualification for competitive athletes with BAV.
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Affiliation(s)
- Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesca Valentini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesca Anselmi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Luna Cavigli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesco Bandera
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Giovanni Benfari
- Department of Medicine, Section of Cardiology, University of Verona, Verona, Italy
| | - Antonello D'Andrea
- Department of Cardiology, Umberto I° Hospital Nocera Inferiore, Salerno, Italy
| | | | - Roberta Esposito
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Vincenzo Evola
- Department of Clinical and Experimental Medicine, University of Palermo, Palermo, Italy
| | | | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Sergio Mondillo
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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17
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Valentini F, Anselmi F, Metra M, Cavigli L, Giacomin E, Focardi M, Cameli M, Mondillo S, D'Ascenzi F. Diagnostic and prognostic value of low QRS voltages in cardiomyopathies: old but gold. Eur J Prev Cardiol 2020; 29:1177-1187. [PMID: 33624098 DOI: 10.1093/eurjpc/zwaa027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/13/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023]
Abstract
The interpretation of 12-lead resting electrocardiogram (ECG) in patients with a definitive diagnosis or with the suspicion of a cardiomyopathy represents a cornerstone for the diagnostic work up and management of patients. Although low electrocardiographic QRS voltages (LQRSV) detected by 12-lead resting ECG have historically been acknowledged by physicians, in view of recent evidence on the demonstration of myocardial scar by cardiac magnetic resonance and its relevance as a cause of sudden cardiac death even in young individuals, a new interest has been raised about the utility of LQRSV in the clinical practice. Beyond their diagnostic value, LQRSV have also demonstrated a prognostic role in different cardiomyopathies. The present review summarizes the diagnostic and prognostic value of LQRSV in cardiomyopathies, reporting the new evidence, primarily based on advanced imaging studies, supporting the clinical utility of this parameter.
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Affiliation(s)
- Francesca Valentini
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, Cardiothoracic Department, Spedali Civili of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Francesca Anselmi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Marco Metra
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, Cardiothoracic Department, Spedali Civili of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Luna Cavigli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Elisa Giacomin
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Marta Focardi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Sergio Mondillo
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale M. Bracci, 16, 53100 Siena, Italy
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18
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Grubic N, Puskas J, Phelan D, Fournier A, Martin LJ, Johri AM. Shock to the Heart: Psychosocial Implications and Applications of Sudden Cardiac Death in the Young. Curr Cardiol Rep 2020; 22:168. [PMID: 33040200 PMCID: PMC7547819 DOI: 10.1007/s11886-020-01419-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Although rare, sudden cardiac death (SCD) in the young is a tragic event, having a dramatic impact upon all involved. The psychosocial burden associated with SCD can leave friends, families, and entire communities bereft. With only limited evidence to describe the volatile emotional reactions associated with a young SCD, there is an urgent need for care providers to better understand the psychological complexities and impacts faced by both at-risk individuals and those directly affected by these tragic events. RECENT FINDINGS Current knowledge of the psychosocial implications associated with SCD in the young has recently generated interest in the cardiovascular community, with the goal of addressing prevention strategies (screening), family bereavement, and the psychological impact of at-risk or surviving individuals. With the emergence of novel strategies aimed at reducing the public health impact of SCD in the young, further discussion regarding the psychosocial impact of SCD, encompassing prevention, survivorship, and the downstream communal effects of a young death is required. Support systems and intervention could assist in the management of the associated psychosocial burden, yet there is a lack of clinical guidelines to direct this form of care. There is an important need for multidisciplinary collaboration across subspecialties to provide support to grieving individuals and manage patient well-being throughout the screening process for SCD. This collaborative approach requires the integration of cardiovascular and psychological expertise where relevant.
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Affiliation(s)
- Nicholas Grubic
- Department of Public Health Sciences, Queen’s University, Kingston, Canada
- Department of Medicine, Queen’s University, Kingston, Canada
| | - Jake Puskas
- Department of Medicine, Queen’s University, Kingston, Canada
| | - Dermot Phelan
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC USA
| | - Anne Fournier
- Department of Pediatrics, University of Montréal, Montréal, Canada
| | - Luc J. Martin
- School of Kinesiology and Health Studies, Queen’s University, Kingston, Canada
| | - Amer M. Johri
- Department of Medicine, Queen’s University, Kingston, Canada
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19
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Characterisation of LV myocardial exercise function by 2-D strain deformation imaging in elite adolescent footballers. Eur J Appl Physiol 2020; 121:239-250. [PMID: 33030575 PMCID: PMC7815563 DOI: 10.1007/s00421-020-04510-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/19/2020] [Indexed: 12/15/2022]
Abstract
Purpose Few data exist on the descriptions of LV myocardial mechanics and reserve during dynamic exercise of adolescent athletes. The aim of this study was to describe the LV myocardial and cardiopulmonary changes during exercise using 2-D strain deformation imaging. Methods Elite adolescent male football players (n = 42) completed simultaneous cardiopulmonary exercise testing (CPET) and exercise echocardiography measurement of LV myocardial deformation by 2-D strain imaging. LV longitudinal and circumferential 2-D strain and strain rates were analyzed at each stage during incremental exercise to a work rate of 150 W. Additionally, exercise LV myocardial deformation and its relation to metabolic exercise parameters were evaluated at each exercise stage and in recovery using repeated measures ANOVA, linear regression and paired t tests. Results LV peak systolic baseline 2-D strain (longitudinal: − 15.4 ± 2.5%, circumferential: − 22.5 ± 3.1%) increased with each exercise stage, but longitudinal strain plateaued at 50 W (mean strain reserve − 7.8 ± 3.0) and did not significantly increase compared to subsequent exercise stages (P > 0.05), whilst circumferential strain (mean strain reserve − 11.6 ± 3.3) significantly increased (P < 0.05) throughout exercise up to 150 W as the dominant mechanism of exercise LV contractility increase. Regression analyses showed LV myocardial strain increased linearly relative to HR, VO2 and O2 pulse (P < 0.05) for circumferential deformation, but showed attenuation for longitudinal deformation. Conclusion This study describes LV myocardial deformation dynamics by 2-D strain and provides reference values for LV myocardial strain and strain rate during exercise in adolescent footballers. It found important differences between LV longitudinal and circumferential myocardial mechanics during exercise and introduces a methodology that can be used to quantify LV function and cardiac reserve during exercise in adolescent athletes.
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20
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Palumbo P, Cannizzaro E, Di Cesare A, Bruno F, Schicchi N, Giovagnoni A, Splendiani A, Barile A, Masciocchi C, Di Cesare E. Cardiac magnetic resonance in arrhythmogenic cardiomyopathies. Radiol Med 2020; 125:1087-1101. [PMID: 32978708 DOI: 10.1007/s11547-020-01289-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Pierpaolo Palumbo
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, AQ, Italy.
| | | | - Annamaria Di Cesare
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Federico Bruno
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, AQ, Italy
| | - Nicolò Schicchi
- Department of Radiology, Azienda Ospedaliero-Universitaria, Ospedali Riuniti Di Ancona, Ancona, Italy
| | - Andrea Giovagnoni
- Department of Radiology, Azienda Ospedaliero-Universitaria, Ospedali Riuniti Di Ancona, Ancona, Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, AQ, Italy
| | - Antonio Barile
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, AQ, Italy
| | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Via Vetoio 1, 67100, L'Aquila, AQ, Italy
| | - Ernesto Di Cesare
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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21
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(Sudden cardiac arrest/death during sports). COR ET VASA 2020. [DOI: 10.33678/cor.2020.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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22
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Domenech-Ximenos B, Sanz-de la Garza M, Prat-González S, Sepúlveda-Martínez A, Crispi F, Duran-Fernandez K, Perea RJ, Bijnens B, Sitges M. Prevalence and pattern of cardiovascular magnetic resonance late gadolinium enhancement in highly trained endurance athletes. J Cardiovasc Magn Reson 2020; 22:62. [PMID: 32878630 PMCID: PMC7469354 DOI: 10.1186/s12968-020-00660-w] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intensive endurance exercise may induce a broad spectrum of right ventricular (RV) adaptation/remodelling patterns. Late gadolinium enhancement (LGE) has also been described in cardiovascular magnetic resonance (CMR) of some endurance athletes and its clinical meaning remains controversial. Our aim was to characterize the features of contrast CMR and the observed patterns of the LGE distribution in a cohort of highly trained endurance athletes. METHODS Ninety-three highly trained endurance athletes (> 12 h training/week at least during the last 5 years; 36 ± 6 years old; 53% male) and 72 age and gender-matched controls underwent a resting contrast CMR. In a subgroup of 28 athletes, T1 mapping was also performed. RESULTS High endurance training load was associated with larger bi-ventricular and bi-atrial sizes and a slight reduction of biventricular ejection fraction, as compared to controls in both genders (p < 0.05). Focal LGE was significantly more prevalent in athletes than in healthy subjects (37.6% vs 2.8%; p < 0.001), with a typical pattern in the RV insertion points. In T1 mapping, those athletes who had focal LGE had higher extracellular volume (ECV) at the remote myocardium than those without (27 ± 2.2% vs 25.2 ± 2.1%; p < 0.05). CONCLUSIONS Highly trained endurance athletes showed a ten-fold increase in the prevalence of focal LGE as compared to control subjects, always confined to the hinge points. Additionally, those athletes with focal LGE demonstrated globally higher myocardial ECV values. This matrix remodelling and potential presence of myocardial fibrosis may be another feature of the athlete's heart, of which the clinical and prognostic significance remains to be determined.
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Affiliation(s)
- B Domenech-Ximenos
- Radiology Department, Hospital Clinic, Barcelona, Spain.
- Cardiovascular Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
| | - M Sanz-de la Garza
- Cardiovascular Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
| | - S Prat-González
- Cardiovascular Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - A Sepúlveda-Martínez
- Barcelona Center for Maternal-Fetal and Neonatal Medicine Hospital Clínic and Hospital Sant Joan de Deu, Barcelona University, CIBER-ER, Barcelona, Spain
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico - Universidad de Chile, Santiago de Chile, Chile
| | - F Crispi
- Barcelona Center for Maternal-Fetal and Neonatal Medicine Hospital Clínic and Hospital Sant Joan de Deu, Barcelona University, CIBER-ER, Barcelona, Spain
| | - K Duran-Fernandez
- Cardiovascular Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - R J Perea
- Radiology Department, Hospital Clinic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - B Bijnens
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- BCN Medtech, Universitat Pompeu Fabra, Barcelona, Spain
- ICREA, Barcelona, Spain
| | - M Sitges
- Cardiovascular Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
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23
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Baggish AL, Battle RW, Beaver TA, Border WL, Douglas PS, Kramer CM, Martinez MW, Mercandetti JH, Phelan D, Singh TK, Weiner RB, Williamson E. Recommendations on the Use of Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes: A Report from the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2020; 33:523-549. [PMID: 32362332 DOI: 10.1016/j.echo.2020.02.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Robert W Battle
- University of Virginia Health System, Charlottesville, Virginia
| | | | - William L Border
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Dermot Phelan
- Sanger Heart and Vascular Institute in Atrium Health, Charlotte, North Carolina
| | | | - Rory B Weiner
- Massachusetts General Hospital, Boston, Massachusetts
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24
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Millar LM, Fanton Z, Finocchiaro G, Sanchez-Fernandez G, Dhutia H, Malhotra A, Merghani A, Papadakis M, Behr ER, Bunce N, Oxborough D, Reed M, O'Driscoll J, Tome Esteban MT, D'Silva A, Carr-White G, Webb J, Sharma R, Sharma S. Differentiation between athlete’s heart and dilated cardiomyopathy in athletic individuals. Heart 2020; 106:1059-1065. [DOI: 10.1136/heartjnl-2019-316147] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/22/2020] [Accepted: 03/25/2020] [Indexed: 12/30/2022] Open
Abstract
ObjectiveDistinguishing early dilated cardiomyopathy (DCM) from physiological left ventricular (LV) dilatation with LV ejection fraction <55% in athletes (grey zone) is challenging. We evaluated the role of a cascade of investigations to differentiate these two entities.MethodsThirty-five asymptomatic active males with DCM, 25 male athletes in the ‘grey zone’ and 24 male athletes with normal LV ejection fraction underwent N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement, ECG and exercise echocardiography. Grey-zone athletes and patients with DCM underwent cardiovascular magnetic resonance (CMR) and Holter monitoring.ResultsLarger LV cavity dimensions and lower LV ejection fraction were the only differences between grey-zone and control athletes. None of the grey-zone athletes had abnormal NT-proBNP, increased ectopic burden/complex arrhythmias or pathological late gadolinium enhancement on CMR. These features were also absent in 71%, 71% and 50% of patients with DCM, respectively. 95% of grey-zone athletes and 60% of patients with DCM had normal ECG. During exercise echocardiography, 96% grey-zone athletes increased LV ejection fraction by >11% from baseline to peak exercise compared with 23% of patients with DCM (p<0.0001). Peak LV ejection fraction was >63% in 92% grey-zone athletes compared with 17% patients with DCM (p<0.0001). Failure to increase LV ejection fraction >11% from baseline to peak exercise or achieve a peak LV ejection fraction >63% had sensitivity of 77% and 83%, respectively, and specificity of 96% and 92%, respectively, for predicting DCM.ConclusionComprehensive assessment using a cascade of routine investigations revealed that exercise stress echocardiography has the greatest discriminatory value in differentiating between grey-zone athletes and asymptomatic patients with DCM. Our findings require validation in larger studies.
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25
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Bernardino G, Sanz de la Garza M, Domenech-Ximenos B, Prat-Gonzàlez S, Perea RJ, Blanco I, Burgos F, Sepulveda-Martinez A, Rodriguez-Lopez M, Crispi F, Butakoff C, González Ballester MA, De Craene M, Sitges M, Bijnens B. Three-dimensional regional bi-ventricular shape remodeling is associated with exercise capacity in endurance athletes. Eur J Appl Physiol 2020; 120:1227-1235. [PMID: 32130484 DOI: 10.1007/s00421-020-04335-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/25/2020] [Indexed: 12/30/2022]
Abstract
AIMS Endurance athletes develop cardiac remodeling to cope with increased cardiac output during exercise. This remodeling is both anatomical and functional and shows large interindividual variability. In this study, we quantify local geometric ventricular remodeling related to long-standing endurance training and assess its relationship with cardiovascular performance during exercise. METHODS We extracted 3D models of the biventricular shape from end-diastolic cine magnetic resonance images acquired from a cohort of 89 triathlon athletes and 77 healthy sedentary subjects. Additionally, the athletes underwent cardio-pulmonary exercise testing, together with an echocardiographic study at baseline and few minutes after maximal exercise. We used statistical shape analysis to identify regional bi-ventricular shape differences between athletes and non-athletes. RESULTS The ventricular shape was significantly different between athletes and controls (p < 1e-6). The observed regional remodeling in the right heart was mainly a shift of the right ventricle (RV) volume distribution towards the right ventricular infundibulum, increasing the overall right ventricular volume. In the left heart, there was an increment of left ventricular mass and a dilation of the left ventricle. Within athletes, the amount of such remodeling was independently associated to higher peak oxygen pulse (p < 0.001) and weakly with greater post-exercise RV free wall longitudinal strain (p = 0.03). CONCLUSIONS We were able to identify specific bi-ventricular regional remodeling induced by long-lasting endurance training. The amount of remodeling was associated with better cardiopulmonary performance during an exercise test.
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Affiliation(s)
- G Bernardino
- BCN Medtech, DTIC Universitat Pompeu Fabra, Barcelona, Spain. .,Medisys, Philips, Paris, France.
| | - M Sanz de la Garza
- Cardiovascular Institute, Hospital Clínic, IDIBAPS, Barcelona, Spain.,CIBERCV, Barcelona, Spain
| | - B Domenech-Ximenos
- Cardiovascular Institute, Hospital Clínic, IDIBAPS, Barcelona, Spain.,Radiology Department, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - S Prat-Gonzàlez
- Cardiovascular Institute, Hospital Clínic, IDIBAPS, Barcelona, Spain.,CIBERCV, Barcelona, Spain
| | - R J Perea
- Radiology Department, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - I Blanco
- ICR, IDIBAPS, University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Center on Respiratory Diseases, Madrid, Spain
| | - F Burgos
- ICR, IDIBAPS, University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Center on Respiratory Diseases, Madrid, Spain
| | - A Sepulveda-Martinez
- BCNatal, ICGON, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.,CIBER-ER, Barcelona, Spain.,Fetal Medicine Unit, Department of Obstetrics and Gynecology Hospital Clínico de la Universidad de Chile, Santiago de Chile, Chile
| | - M Rodriguez-Lopez
- BCNatal, ICGON, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.,CIBER-ER, Barcelona, Spain.,Pontificia Universidad Javeriana Cali, Cali, Colombia
| | - F Crispi
- BCNatal, ICGON, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.,CIBER-ER, Barcelona, Spain
| | | | | | | | - M Sitges
- Cardiovascular Institute, Hospital Clínic, IDIBAPS, Barcelona, Spain.,CIBERCV, Barcelona, Spain
| | - B Bijnens
- BCN Medtech, DTIC Universitat Pompeu Fabra, Barcelona, Spain.,ICREA, Barcelona, Spain
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26
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Echocardiographic Pulmonary to Left Atrial Ratio (ePLAR): A Comparison Study between Ironman Athletes, Age Matched Controls and A General Community Cohort. J Clin Med 2019; 8:jcm8101756. [PMID: 31652633 PMCID: PMC6832979 DOI: 10.3390/jcm8101756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/11/2019] [Accepted: 10/18/2019] [Indexed: 01/10/2023] Open
Abstract
Background: During exercise there is a proportionally lower rise in systemic and pulmonary pressures compared to cardiac output due to reduced vascular resistance. Invasive exercise data suggest that systemic vascular resistance reduces more than pulmonary vascular resistance. The aim of this study was the non-invasive assessment of exercise hemodynamics in ironman athletes, compared with an age matched control group and a larger general community cohort. Methods: 20 ironman athletes (40 ± 11 years, 17 male) were compared with 20 age matched non-athlete controls (43 ± 7 years, 10 male) and a general community cohort of 230 non-athletes individuals (66 ± 11 years, 155 male), at rest and after maximal-symptom limited treadmill exercise stress echocardiography. Left heart parameters (mitral E-wave, e’-wave and E/e’) and right heart parameters (tricuspid regurgitation maximum velocity and right ventricular systolic pressure), were used to calculate the echocardiographic Pulmonary to Left Atrial Ratio (ePLAR) value of the three groups. Results: Athletes exercised for 12.2 ± 0.53 min, age matched controls for 10.1 ± 2.8 min and general community cohort for 8.3 ± 2.6 min. Mitral E/e’ rose slightly for athletes (0.9 ± 1.8), age matched controls (0.6 ± 3.0) and non-athletes (0.4 ± 3.2). Right ventricular systolic pressure increased significantly more in athletes than in both non-athlete cohorts (35.6 ± 17 mmHg vs. 20.4 ± 10.8 mmHg and 18 ± 9.6 mmHg). The marker of trans-pulmonary gradient, ePLAR, rose significantly more in athletes than in both non-athlete groups (0.15 ± 0.1 m/s vs. 0.07 ± 0.1 m/s). Conclusions: Pulmonary pressures increased proportionally four-fold compared with systemic pressures in ironman athletes. This increase in pulmonary vascular resistance corresponded with a two-fold increase in ePLAR. These changes were exaggerated compared with both non-ironman cohorts. Such changes have been previously suggested to lead to right ventricle dysfunction, arrhythmias and sudden cardiac death.
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27
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Baggish AL. Prolonged Systole and Reduced Ejection Fraction among Competitive Athletes: Slow and Low but Able to Go. J Am Soc Echocardiogr 2019; 32:997-999. [DOI: 10.1016/j.echo.2019.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 05/28/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
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28
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Holdsworth DA, Parsons IT, Chamley R, Britton J, Pavitt C, Baksi AJ, Neubauer S, d’Arcy J, Nicol ED. Cardiac MRI improves cardiovascular risk stratification in hazardous occupations. J Cardiovasc Magn Reson 2019; 21:48. [PMID: 31352898 PMCID: PMC6661777 DOI: 10.1186/s12968-019-0544-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 05/21/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The benefit of cardiovascular magnetic resonance Imaging (CMR) in assessing occupational risk is unknown. Pilots undergo frequent medical assessment for occult disease, which threatens incapacitation or distraction during flight. ECG and examination anomalies often lead to lengthy restriction, pending full investigation. CMR provides a sensitive, specific assessment of cardiac anatomy, tissue characterisation, perfusion defects and myocardial viability. We sought to determine if CMR, when added to standard care, would alter occupational outcome. METHODS A retrospective review was conducted of all personnel attending the RAF Aviation Medicine Consultation Service (AMCS) for assessment of a cardiac anomaly, over a 2-year period. Those undergoing standard of care (history, examination, exercise ECG, 24 h-Holter and transthoracic echocardiography), and those undergoing a CMR in addition, were identified. The influence of CMR upon the final decision regarding flying restriction was determined by comparing the diagnosis reached with standard of care plus CMR vs. standard of care alone. RESULTS Of the ~ 8000 UK military aircrew, 558 personnel were seen for cardiovascular assessment. Fifty-two underwent CMR. A normal TTE did not reliably exclude abnormalities subsequently detected by CMR. Addition of CMR resulted in an upgraded occupational status in 62% of those investigated, with 37% returning to unrestricted duties. Only 8% of referrals were undiagnosed following CMR. All these were cases of borderline chamber dilatation and reduction in systolic function in whom diagnostic uncertainty remained between physiological exercise adaptation and early cardiomyopathy. CONCLUSIONS CMR increases the likelihood of a definitive diagnosis and of return to flying. This study supports early use of CMR in occupational assessment for high-hazard occupations.
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Affiliation(s)
- David A. Holdsworth
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, England
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Iain T. Parsons
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, England
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW36NP England
| | - Rebecca Chamley
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, England
- Royal Berkshire NHS Foundation Trust, Reading, England
| | - Joseph Britton
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, England
| | - Christopher Pavitt
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW36NP England
| | - A. John Baksi
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW36NP England
| | - Stefan Neubauer
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
- Division of Cardiovascular Medicine, University of Oxford, Oxford NIHR Biomedical Research Centre, Oxford, England
| | - Joanna d’Arcy
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, England
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Edward D. Nicol
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, England
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW36NP England
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29
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Tahir E, Scherz B, Starekova J, Muellerleile K, Fischer R, Schoennagel B, Warncke M, Stehning C, Cavus E, Bohnen S, Radunski UK, Blankenberg S, Simon P, Pressler A, Adam G, Patten M, Lund GK. Acute impact of an endurance race on cardiac function and biomarkers of myocardial injury in triathletes with and without myocardial fibrosis. Eur J Prev Cardiol 2019; 27:94-104. [PMID: 31242053 PMCID: PMC6923712 DOI: 10.1177/2047487319859975] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIMS The aim of this study was to investigate the occurrence of myocardial injury and cardiac dysfunction after an endurance race by biomarkers and cardiac magnetic resonance in triathletes with and without myocardial fibrosis. METHODS AND RESULTS Thirty asymptomatic male triathletes (45 ± 10 years) with over 10 training hours per week and 55 ± 8 ml/kg per minute maximal oxygen uptake during exercise testing were studied before (baseline) and 2.4 ± 1.1 hours post-race. Baseline cardiac magnetic resonance included cine, T1/T2, late gadolinium enhancement (LGE) and extracellular volume imaging. Post-race non-contrast cardiac magnetic resonance included cine and T1/T2 mapping. Non-ischaemic myocardial fibrosis was present in 10 triathletes (LGE+) whereas 20 had no fibrosis (LGE-). At baseline, LGE + triathletes had higher peak exercise systolic blood pressure with 222 ± 21 mmHg compared to LGE- triathletes (192 ± 30 mmHg, P < 0.01). Post-race troponin T and creatine kinase MB were similarly increased in both groups, but there was no change in T2 and T1 from baseline to post-race with 54 ± 3 ms versus 53 ± 3 ms (P = 0.797) and 989 ± 21 ms versus 989 ± 28 ms (P = 0.926), respectively. However, post-race left atrial ejection fraction was significantly lower in LGE + triathletes compared to LGE- triathletes (53 ± 6% vs. 59 ± 6%, P < 0.05). Furthermore, baseline atrial peak filling rates were lower in LGE - triathletes (121 ± 30 ml/s/m2) compared to LGE + triathletes (161 ± 34 ml/s/m2, P < 0.01). Post-race atrial peak filling rates increased in LGE- triathletes to 163 ± 46 ml/s/m2, P < 0.001), but not in LGE + triathletes (169 ± 50ml/s/m2, P = 0.747). CONCLUSION Despite post-race troponin T release, we did not find detectable myocardial oedema by cardiac magnetic resonance. However, the unfavourable blood pressure response during exercise testing seemed to be associated with post-race cardiac dysfunction, which could explain the occurrence of myocardial fibrosis in triathletes.
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Affiliation(s)
- Enver Tahir
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg-Eppendorf, Germany
| | - Benedikt Scherz
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg-Eppendorf, Germany
| | - Jitka Starekova
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg-Eppendorf, Germany
| | - Kai Muellerleile
- Department of General and Interventional Cardiology, University Heart Center, Germany
| | - Roland Fischer
- Department of Pediatric Hematology and Oncology, University Hospital Hamburg-Eppendorf, Germany.,UCSF, Benioff Children's Hospital Oakland, USA
| | - Björn Schoennagel
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg-Eppendorf, Germany
| | - Malte Warncke
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg-Eppendorf, Germany
| | | | - Ersin Cavus
- Department of General and Interventional Cardiology, University Heart Center, Germany
| | - Sebastian Bohnen
- Department of General and Interventional Cardiology, University Heart Center, Germany
| | - Ulf K Radunski
- Department of General and Interventional Cardiology, University Heart Center, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center, Germany
| | - Perikles Simon
- Department of Sports Medicine, Johannes Gutenberg University Mainz, Germany
| | - Axel Pressler
- Department of Prevention, Rehabilitation and Sports Medicine, Technische Universität München, Germany.,Center of Sports and Preventive Cardiology, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg-Eppendorf, Germany
| | | | - Gunnar K Lund
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg-Eppendorf, Germany
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30
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Edenfield KM, Reifsteck F, Carek S, Harmon KG, Asken BM, Dillon MC, Street J, Clugston JR. Echocardiographic measurements of left ventricular end-diastolic diameter and interventricular septal diameter in collegiate football athletes at preparticipation evaluation referenced to body surface area. BMJ Open Sport Exerc Med 2019; 5:e000488. [PMID: 31205743 PMCID: PMC6540318 DOI: 10.1136/bmjsem-2018-000488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2019] [Indexed: 11/21/2022] Open
Abstract
Background Are borderline echocardiogram structural measurements due to physiological adaptation or pathology in college football players? The normal reference data are very limited in this population. We report left ventricular end-diastolic diameter (LVEDD) and interventricular septal diameter (IVSD) echocardiogram findings in college football athletes. Methods and results A retrospective cohort review of preparticipation examination transthoracic echocardiogram measurements of LVEDD and IVSD from 375 American collegiate football athletes cleared for participation from the University of Florida in 2012–2017 and University of Georgia in 2010–2015 was performed. LVEDD and IVSD were analysed by field position (lineman, n=137; non-lineman, n=238), race (black, n=216; white, n=158) and body surface area (BSA) for associations. Values were compared with non-athlete norms, and collegiate football athlete-specific reference norm tables were created. Twenty-one (5.6%) athletes had LVEDD and 116 (31%) had IVSD measurements above the reference normal non-athlete values. Univariate analyses indicated that the lineman position and increasing BSA were associated with larger values for LVEDD and IVSD. Black race was associated with larger IVSD values, and white race was associated with larger LVEDD values. Player position correlated strongly with BSA (r>0.7); we created normal reference tables for LVEDD and IVSD, stratified by BSA group classification (low, average and high BSA). Proposed clinical cut-offs for normal and abnormal values are reported for raw echocardiograph metrics and BSA-indexed scores. Conclusions A significant number of collegiate football athletes had LVEDD and IVSD values above non-athlete norms. BSA-specific normal values help clinicians interpret results for football athletes.
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Affiliation(s)
- Katherine M Edenfield
- Community Health and Family Medicine, University of Florida, Gainesville, Florida, USA.,University Athletic Association, University of Florida, Gainesville, Florida, USA.,Student Health Care Center, University of Florida, Gainesville, Florida, USA
| | - Fred Reifsteck
- University Health Center, University of Georgia, Athens, Georgia, USA.,Athletic Association, University of Georgia, Athens, Georgia, USA
| | - Stephen Carek
- Community Health and Family Medicine, University of Florida, Gainesville, Florida, USA
| | - Kimberly G Harmon
- Family Medicine and Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Breton M Asken
- Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | | | - Joan Street
- Student Health Care Center, University of Florida, Gainesville, Florida, USA
| | - James R Clugston
- Community Health and Family Medicine, University of Florida, Gainesville, Florida, USA.,University Athletic Association, University of Florida, Gainesville, Florida, USA.,Student Health Care Center, University of Florida, Gainesville, Florida, USA
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31
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D'Ascenzi F, Anselmi F, Piu P, Fiorentini C, Carbone SF, Volterrani L, Focardi M, Bonifazi M, Mondillo S. Cardiac Magnetic Resonance Normal Reference Values of Biventricular Size and Function in Male Athlete's Heart. JACC Cardiovasc Imaging 2018; 12:1755-1765. [PMID: 30553678 DOI: 10.1016/j.jcmg.2018.09.021] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/27/2018] [Accepted: 09/18/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The aim of this meta-analysis was to derive normal reference values of biventricular size and function estimated by cardiac magnetic resonance (CMR) in competitive athletes. BACKGROUND Exercise-induced enlargement of cardiac chambers is commonly observed in competitive athletes. However, ventricular dilatation is also a common phenotypic expression of life-threatening cardiomyopathies. The use of CMR for the exclusion of pathology is growing. However, normal reference values have not been established for athletes. METHODS The authors conducted a systematic review of English-language studies in the MEDLINE, Scopus, and Cochrane databases investigating biventricular size and function by CMR in athletes. Athletes were divided into endurance, combined, and mixed groups according to the sport practiced. The potential impact of training volume was also evaluated. RESULTS Twenty-seven studies and 983 competitive athletes were included for CMR quantification of biventricular size and function. In this review, normal reference values are presented for biventricular size and function to be applied to male competitive athletes according to the disciplines practiced. A significant impact of training volume was demonstrated for the right ventricle: athletes practicing the largest number of training hours per week were those exhibiting the greatest degree of right ventricular remodeling. Notably, biventricular function was not significantly affected by training volume. CONCLUSIONS The present meta-analysis defines the normal limits of biventricular size and function estimated by CMR in competitive athletes. The authors suggest using these normal reference values as an alternative to standard upper limits derived from the general population when interpreting CMR images in athletes.
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Affiliation(s)
- Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.
| | - Francesca Anselmi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Pietro Piu
- Department of Medicine, Surgery, and Neuroscience, University of Siena, Siena, Italy
| | - Caterina Fiorentini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | | | - Luca Volterrani
- Unit of Diagnostic Imaging, University Hospital Santa Maria alle Scotte, Siena, Italy
| | - Marta Focardi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Marco Bonifazi
- Department of Medicine, Surgery, and Neuroscience, University of Siena, Siena, Italy
| | - Sergio Mondillo
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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32
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Chevalier L, Guy JM, Doutreleau S. [Place of the exercise stress test at the sportsman]. Ann Cardiol Angeiol (Paris) 2018; 67:361-364. [PMID: 30301545 DOI: 10.1016/j.ancard.2018.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/23/2018] [Indexed: 06/08/2023]
Abstract
Is the stress test still part of the useful examinations in the detection of risk heart disease in sports subjects? Should we continue to use it as a surveillance examination in coronary sports patients? Meta-analysis, considering a ST subshift of more than 1mm as a criterion for positivity, underline the low prevalence of abnormal examinations and a significant rate of false-positives. But for the diagnosis of coronary artery disease, it is mainly the evolution of the ST segment to effort or recovery and the occurrence of stress arrhythmias that detect true positivity. When coronary risk is more important (presence of risk factors, resumption of sport, intense and prolonged efforts), it seems lawful to recommend such a review on a regular basis among men over 40 years of age with two risk factors but Also among veterans taking up sport after a period of prolonged inactivity. For the asymptomatic coronary athlete the stress test remains at the centre of the final decision for the resumption of a sport in competition irrespective of the method of revascularization. Of course the stress test, even inevitable, remains flawed in the detection of coronary artery disease in the asymptomatic athlete. However, it provides additional information on the condition of being maximal, and attaching importance to arrhythmias, the tensional profile and the maximum power developed in addition to the ST segment's only study.
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Affiliation(s)
- L Chevalier
- Clinique du sport, 33370 Bordeaux-Mérignac, France
| | - J M Guy
- Center de réadaptation cardiorespiratoire de la loire, 33370 Saint-Priest-en-Jarez, France.
| | - S Doutreleau
- Service de médecine du sport et explorations fonctionnelles, CHU, 33370 Grenoble, France
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33
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Sudden Death and Ventricular Arrhythmias in Athletes: Screening, De-Training and the Role of Catheter Ablation. Heart Lung Circ 2018; 28:155-163. [PMID: 30554599 DOI: 10.1016/j.hlc.2018.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/05/2018] [Indexed: 01/29/2023]
Abstract
Athletes enjoy excellent health outcomes including greater longevity relative to non-athletic counterparts. Paradoxically, however, endurance athletic conditioning is associated with an increase in some arrhythmias. This review discusses the potential mechanisms for this paradox and strategies enabling early identification of potentially serious pathologies. Screening remains contentious due to the challenges of identifying relatively rare entities amongst a healthy cohort. The imperfect diagnostic accuracy of all current tests means that screening strategies have potential for harm through incorrect diagnoses as well as the potential for identification of important sub-clinical pathologies. Management of athletes at risk of ventricular arrhythmias and sudden cardiac death is similarly complex. There is much yet to learn about the specific patterns of ventricular arrhythmias in athletes, and the separation of benign from potentially life-threatening remains imperfect. There are some promising advances, however, such as specialised imaging modalities combined with improved electrophysiological diagnostics and therapeutics. Some unique clinical patterns are emerging to advance our understanding and management of athletes with ventricular arrhythmias, requiring specialised skillsets for evaluation and management.
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Abstract
INTRODUCTION Premature ventricular beats (PVBs) in competitive athletes are incidentally found during pre-participation ECG screening. Their clinical significance remains debatable with several studies suggesting they are a benign reflection of athlete's heart, and others proposing they may indicate underlying structural heart disease and heightened risk for sudden cardiac death (SCD). Areas covered: Effective management of athletes with PVBs may best be accomplished using an algorithmic approach for risk stratification with a goal of differentiating benign PVBs from those reflective of underlying cardiomyopathies. Current AHA/ACC consensus recommendations provide a platform for determining optimal medical and invasive therapeutic strategies for symptom control and management of long-term complications without erroneously restricting an athlete's ability to play. Utilizing a shared decision-making model is an optimal method for managing expectations and guiding exercise recommendations. Expert commentary: Though pre-participation ECG screening as the standard of care for competitive athletes remains controversial in the United States, a 12-lead ECG is often the first indication of underlying structural heart disease in athletes with PVBs and can therefore identify athletes at greater risk of SCD. Advancements in non-invasive imaging continue to improve in diagnostic potential and prognostication. Invasive therapies provide a curative strategy for refractory PVBs and PVB-induced cardiomyopathy.
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Affiliation(s)
- Tamanna K Singh
- a Cardiovascular Performance Program, Division of Cardiology , Massachusetts General Hospital , Boston , MA , USA
| | - Aaron L Baggish
- a Cardiovascular Performance Program, Division of Cardiology , Massachusetts General Hospital , Boston , MA , USA
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Tahir E, Starekova J, Muellerleile K, von Stritzky A, Münch J, Avanesov M, Weinrich JM, Stehning C, Bohnen S, Radunski UK, Freiwald E, Blankenberg S, Adam G, Pressler A, Patten M, Lund GK. Myocardial Fibrosis in Competitive Triathletes Detected by Contrast-Enhanced CMR Correlates With Exercise-Induced Hypertension and Competition History. JACC Cardiovasc Imaging 2017; 11:1260-1270. [PMID: 29248656 DOI: 10.1016/j.jcmg.2017.09.016] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/06/2017] [Accepted: 09/14/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVES This study analyzed the presence of myocardial fibrosis detected by late gadolinium-enhancement (LGE) cardiac magnetic resonance (CMR) in correlation with the performance of competitive triathletes objectified by an exercise test and individual competition history. BACKGROUND Myocardial fibrosis detected by LGE CMR has been reported to occur in 0% to 50% of asymptomatic athletes. However, the cause and mechanisms of myocardial fibrosis are unclear. METHODS Eighty-three asymptomatic triathletes undergoing >10 training h per week (43 ± 10 years of age; 65% male) and 36 sedentary controls were studied by using LGE and extracellular volume (ECV) CMR. Parameters of physical fitness were measured by spiroergometry. Triathletes reported their lifetime competition results. RESULTS LGE CMR revealed focal nonischemic myocardial fibrosis in 9 of 54 (17%) male triathletes (LGE+) but in none of the female triathletes (p < 0.05). LGE+ triathletes had higher peak exercise systolic blood pressure (213 ± 24 mm Hg) than LGE- triathletes (194 ± 26 mm Hg; p < 0.05). Furthermore, left ventricular mass index was higher in LGE+ triathletes (93 ± 7 g/m2) than in LGE- triathletes (84 ± 11 g/m2; p < 0.05). ECV in LGE- myocardium was higher in LGE+ triathletes (26.3 ± 1.8%) than in LGE- triathletes (24.4 ± 2.2%; p < 0.05). LGE+ triathletes completed longer cumulative distances in swimming and cycling races and participated more often in middle and Iron Man distances than LGE- triathletes. A cycling race distance of >1,880 km completed during competition had the highest accuracy to predict LGE, with an area under the curve value of 0.876 (p < 0.0001), resulting in high sensitivity (89%) and specificity (79%). Multivariate analysis identified peak exercise systolic blood pressure (p < 0.05) and the swimming race distance (p < 0.01) as independent predictors of LGE presence. CONCLUSIONS Myocardial fibrosis in asymptomatic triathletes seems to be associated with exercise-induced hypertension and the race distances. There appears to be a safe upper limit, beyond which exercise may result in myocardial fibrosis.
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Affiliation(s)
- Enver Tahir
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Jitka Starekova
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Kai Muellerleile
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
| | - Alexandra von Stritzky
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
| | - Julia Münch
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
| | - Maxim Avanesov
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Julius M Weinrich
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | | | - Sebastian Bohnen
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
| | - Ulf K Radunski
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
| | - Eric Freiwald
- Institute for Medical Biometry and Epidemiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Axel Pressler
- Department of Prevention, Rehabilitation, and Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Monica Patten
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
| | - Gunnar K Lund
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Hamburg Eppendorf, Hamburg, Germany.
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Pressler A. Female Athlete's Heart: Appropriate Scaling to Body Size May Resolve Diagnostic Conundrums. JACC Cardiovasc Imaging 2017; 10:1531-1532. [PMID: 29216978 DOI: 10.1016/j.jcmg.2017.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 09/13/2017] [Accepted: 09/21/2017] [Indexed: 11/29/2022]
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Affiliation(s)
- Andrew D'Silva
- Clinical Cardiology and Academic Group, St George's University of London,, London, UK
| | - Sanjay Sharma
- Clinical Cardiology and Academic Group, St George's University of London,, London, UK
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Authors' Reply. J Am Soc Echocardiogr 2017; 30:1043-1045. [DOI: 10.1016/j.echo.2017.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Indexed: 11/18/2022]
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Wijnberg I, Franklin S. The heart remains the core: cardiac causes of poor performance in horses compared to human athletes. COMPARATIVE EXERCISE PHYSIOLOGY 2017. [DOI: 10.3920/cep170012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cardiac remodelling occurs in response to exercise and is generally beneficial for athletic performance due to the increase in cardiac output. However, this remodelling also may lead to an increased prevalence of cardiac murmurs and arrhythmias. In most cases, these are not considered to be significant. However, in some cases, there may be potentially deleterious consequences. Whilst sudden cardiac death (SCD) is a rare occurrence, the consequences are catastrophic for both the horse and potentially the rider or driver. Furthermore, the sudden death of a horse in the public arena has negative connotations in regards to public perception of welfare during equestrian sports. Prediction of which individuals might be susceptible to potential deleterious effects of exercise is a focus of interest in both human and equine athletes but remains a challenge because many athletes experience cardiac murmurs and exercise-induced arrhythmias that are clinically irrelevant. This review summarises the effects of exercise on cardiac remodelling in the horse and the potential effects on athletic performance and SCD. The use of biomarkers and their future potential in the management of athletic horses is also reviewed.
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Affiliation(s)
- I.D. Wijnberg
- Department of Equine Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 114, 3584 CM, Utrecht, the Netherlands
| | - S.H. Franklin
- Equine Health and Performance Centre, School of Animal and Veterinary Science, University of Adelaide, SA 5005, Australia
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Grazioli G, Sanz de la Garza M, Vidal B, Montserrat S, Sarquella-Brugada G, Pi R, Til L, Gutierrez J, Brugada J, Sitges M. Prevention of sudden death in adolescent athletes: Incremental diagnostic value and cost-effectiveness of diagnostic tests. Eur J Prev Cardiol 2017; 24:1446-1454. [DOI: 10.1177/2047487317713328] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Gonzalo Grazioli
- Cardiovascular Institute, Hospital Clinic, University of Barcelona; IDIBAPS, Institute for Biomedical Research August Pi i Sunyer, Spain
| | - Maria Sanz de la Garza
- Cardiovascular Institute, Hospital Clinic, University of Barcelona; IDIBAPS, Institute for Biomedical Research August Pi i Sunyer, Spain
| | - Barbara Vidal
- Cardiovascular Institute, Hospital Clinic, University of Barcelona; IDIBAPS, Institute for Biomedical Research August Pi i Sunyer, Spain
| | - Silvia Montserrat
- Cardiovascular Institute, Hospital Clinic, University of Barcelona; IDIBAPS, Institute for Biomedical Research August Pi i Sunyer, Spain
| | - Georgia Sarquella-Brugada
- Department of Cardiology, Hospital Sant Joan de Deu, University of Barcelona, Esplugues de Llobregat, Spain
| | | | - Lluis Til
- GIRSANE, Consorci Sanitari de Terrassa-Centre d Alt Rendiment, Sant Cugat del Valles, Spain
| | | | - Josep Brugada
- Cardiovascular Institute, Hospital Clinic, University of Barcelona; IDIBAPS, Institute for Biomedical Research August Pi i Sunyer, Spain
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clinic, University of Barcelona; IDIBAPS, Institute for Biomedical Research August Pi i Sunyer, Spain
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Le TT, Bryant JA, Ting AE, Ho PY, Su B, Teo RCC, Gan JSJ, Chung YC, O'Regan DP, Cook SA, Chin CWL. Assessing exercise cardiac reserve using real-time cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2017. [PMID: 28110638 DOI: 10.1186/s12968-0170322-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Exercise cardiovascular magnetic resonance (ExCMR) has great potential for clinical use but its development has been limited by a lack of compatible equipment and robust real-time imaging techniques. We developed an exCMR protocol using an in-scanner cycle ergometer and assessed its performance in differentiating athletes from non-athletes. METHODS Free-breathing real-time CMR (1.5T Aera, Siemens) was performed in 11 athletes (5 males; median age 29 [IQR: 28-39] years) and 16 age- and sex-matched healthy volunteers (7 males; median age 26 [interquartile range (IQR): 25-33] years). All participants underwent an in-scanner exercise protocol on a CMR compatible cycle ergometer (Lode BV, the Netherlands), with an initial workload of 25W followed by 25W-increment every minute. In 20 individuals, exercise capacity was also evaluated by cardiopulmonary exercise test (CPET). Scan-rescan reproducibility was assessed in 10 individuals, at least 7 days apart. RESULTS The exCMR protocol demonstrated excellent scan-rescan (cardiac index (CI): 0.2 ± 0.5L/min/m2) and inter-observer (ventricular volumes: 1.2 ± 5.3mL) reproducibility. CI derived from exCMR and CPET had excellent correlation (r = 0.83, p < 0.001) and agreement (1.7 ± 1.8L/min/m2). Despite similar values at rest (P = 0.87), athletes had increased exercise CI compared to healthy individuals (at peak exercise: 12.2 [IQR: 10.2-13.5] L/min/m2 versus 8.9 [IQR: 7.5-10.1] L/min/m2, respectively; P < 0.001). Peak exercise CI, where image acquisition lasted 13-17 s, outperformed that at rest (c-statistics = 0.95 [95% confidence interval: 0.87-1.00] versus 0.48 [95% confidence interval: 0.23-0.72], respectively; P < 0.0001 for comparison) in differentiating athletes from healthy volunteers; and had similar performance as VO2max (c-statistics = 0.84 [95% confidence interval = 0.62-1.00]; P = 0.29 for comparison). CONCLUSIONS We have developed a novel in-scanner exCMR protocol using real-time CMR that is highly reproducible. It may now be developed for clinical use for physiological studies of the heart and circulation.
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Affiliation(s)
- Thu-Thao Le
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore.
| | - Jennifer Ann Bryant
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Alicia Er Ting
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Pei Yi Ho
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | - Boyang Su
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
| | | | | | | | | | - Stuart A Cook
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- National Heart and Lung Institute, Imperial College, London, UK
| | - Calvin Woon-Loong Chin
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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Le TT, Bryant JA, Ting AE, Ho PY, Su B, Teo RCC, Gan JSJ, Chung YC, O’Regan DP, Cook SA, Chin CWL. Assessing exercise cardiac reserve using real-time cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2017; 19:7. [PMID: 28110638 PMCID: PMC5256575 DOI: 10.1186/s12968-017-0322-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 01/06/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Exercise cardiovascular magnetic resonance (ExCMR) has great potential for clinical use but its development has been limited by a lack of compatible equipment and robust real-time imaging techniques. We developed an exCMR protocol using an in-scanner cycle ergometer and assessed its performance in differentiating athletes from non-athletes. METHODS Free-breathing real-time CMR (1.5T Aera, Siemens) was performed in 11 athletes (5 males; median age 29 [IQR: 28-39] years) and 16 age- and sex-matched healthy volunteers (7 males; median age 26 [interquartile range (IQR): 25-33] years). All participants underwent an in-scanner exercise protocol on a CMR compatible cycle ergometer (Lode BV, the Netherlands), with an initial workload of 25W followed by 25W-increment every minute. In 20 individuals, exercise capacity was also evaluated by cardiopulmonary exercise test (CPET). Scan-rescan reproducibility was assessed in 10 individuals, at least 7 days apart. RESULTS The exCMR protocol demonstrated excellent scan-rescan (cardiac index (CI): 0.2 ± 0.5L/min/m2) and inter-observer (ventricular volumes: 1.2 ± 5.3mL) reproducibility. CI derived from exCMR and CPET had excellent correlation (r = 0.83, p < 0.001) and agreement (1.7 ± 1.8L/min/m2). Despite similar values at rest (P = 0.87), athletes had increased exercise CI compared to healthy individuals (at peak exercise: 12.2 [IQR: 10.2-13.5] L/min/m2 versus 8.9 [IQR: 7.5-10.1] L/min/m2, respectively; P < 0.001). Peak exercise CI, where image acquisition lasted 13-17 s, outperformed that at rest (c-statistics = 0.95 [95% confidence interval: 0.87-1.00] versus 0.48 [95% confidence interval: 0.23-0.72], respectively; P < 0.0001 for comparison) in differentiating athletes from healthy volunteers; and had similar performance as VO2max (c-statistics = 0.84 [95% confidence interval = 0.62-1.00]; P = 0.29 for comparison). CONCLUSIONS We have developed a novel in-scanner exCMR protocol using real-time CMR that is highly reproducible. It may now be developed for clinical use for physiological studies of the heart and circulation.
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Affiliation(s)
- Thu-Thao Le
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609 Singapore
| | - Jennifer Ann Bryant
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609 Singapore
| | - Alicia Er Ting
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609 Singapore
| | - Pei Yi Ho
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609 Singapore
| | - Boyang Su
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609 Singapore
| | | | | | | | | | - Stuart A. Cook
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609 Singapore
- Duke-NUS Medical School, Singapore, Singapore
- National Heart and Lung Institute, Imperial College, London, UK
| | - Calvin Woon-Loong Chin
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, 169609 Singapore
- Duke-NUS Medical School, Singapore, Singapore
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Beaudry R, Haykowsky MJ, Baggish A, La Gerche A. A Modern Definition of the Athlete’s Heart—for Research and the Clinic. Cardiol Clin 2016; 34:507-514. [DOI: 10.1016/j.ccl.2016.06.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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La Gerche A, Calkins H. T-wave subtleties in screened athletes: sharpening the lead or whittling the pencil away? Eur Heart J 2016; 37:2528-30. [PMID: 26586782 DOI: 10.1093/eurheartj/ehv612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- André La Gerche
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia KU Leuven, Leuven, Belgium The Alfred Hospital, Melbourne, Australia
| | - Hugh Calkins
- Department of Medicine, Division of Cardiology, The Johns Hopkins University, Baltimore, MD, USA
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RV Remodeling in Olympic Athletes. JACC Cardiovasc Imaging 2016; 10:385-393. [PMID: 27544901 DOI: 10.1016/j.jcmg.2016.03.017] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/28/2016] [Accepted: 03/31/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to assess the impact of sex and different sports on right ventricular (RV) remodeling and compare the derived upper limits with widely used revised Task Force (TF) reference values. BACKGROUND Uncertainties exist regarding the extent and physiological determinants of RV remodeling in highly trained athletes. The issue is important, considering that in athletes RV size occasionally exceeds the cutoff limits proposed to diagnose arrhythmogenic RV cardiomyopathy. METHODS A total of 1,009 Olympic athletes (mean age 24 ± 6 years; n = 647 [64%] males) participating in skill, power, mixed, and endurance sport were evaluated by 2-dimensional echocardiography and Doppler/tissue Doppler imaging. The right ventricular outflow tract (RVOT) in parasternal long-axis (PLAX) and short-axis views, fractional area change, s' velocity, and morphological features were assessed. RESULTS Indexed RVOT PLAX was greater in females than in males (15.3 ± 2.2 mm/m2 vs. 14.4 ± 1.9 mm/m2; p < 0.001). Both RVOT PLAX and parasternal short-axis view were significantly different among skill, power, mixed, and endurance sports: 14.3 ± 2.1 mm/m2 versus 14.7 ± 1.9 mm/m2 versus 14.0 ± 1.8 mm/m2 versus 15.7 ± 2.2 mm/m2, respectively (p < 0.001); and 15.2 ± 2.7 mm/m2 versus 15.3 ± 2.4 mm/m2 versus 14.8 ± 2.1 mm/m2 versus 16.2 ± 2.5 mm/m2, respectively (p < 0.001). The 95th percentile for indexed RVOT PLAX and parasternal short-axis view was 18 mm/m2 and 20 mm/m2, respectively. Fractional area change and s' velocity did not differ among the groups (p = 0.34 for both). RV enlargement compatible with major and minor TF diagnostic criteria for arrhythmogenic RV cardiomyopathy was observed in 41 (4%) and 319 (32%) athletes. A rounded apex was described in 823 (81%) athletes, prominent trabeculations in 378 (37%) athletes, and a prominent/hyperreflective moderator band in 5 (0.5%) athletes. CONCLUSIONS RV remodeling occurs in Olympic athletes, with male sex and endurance practice playing the major impact. A significant subset (up to 32%) of athletes exceeds the normal TF limits; therefore, we recommend referring to the 95th percentiles here reported as referral values; alternatively, only major diagnostic TF criteria for arrhythmogenic RV cardiomyopathy may be appropriate.
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Right and Left Ventricular Function and Mass in Male Elite Master Athletes. Circulation 2016; 133:1927-35. [DOI: 10.1161/circulationaha.115.020975] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 03/07/2016] [Indexed: 11/16/2022]
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Kovacs R, Baggish AL. Cardiovascular adaptation in athletes. Trends Cardiovasc Med 2016; 26:46-52. [DOI: 10.1016/j.tcm.2015.04.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 03/24/2015] [Accepted: 04/03/2015] [Indexed: 11/29/2022]
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Szelid Z, Lux Á, Kolossváry M, Tóth A, Vágó H, Lendvai Z, Kiss L, Maurovich-Horvat P, Bagyura Z, Merkely B. Right Ventricular Adaptation Is Associated with the Glu298Asp Variant of the NOS3 Gene in Elite Athletes. PLoS One 2015; 10:e0141680. [PMID: 26517550 PMCID: PMC4627801 DOI: 10.1371/journal.pone.0141680] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 10/12/2015] [Indexed: 11/19/2022] Open
Abstract
Nitric oxide (NO), an important endogenous pulmonary vasodilator is synthetized by the endothelial NO synthase (NOS3). Reduced NO bioavailability and thus the Glu298Asp polymorphism of NOS3 may enhance right ventricular (RV) afterload and hypertrophic remodeling and influence athletic performance. To test this hypothesis world class level athletes (water polo players, kayakers, canoeists, rowers, swimmers, n = 126) with a VO2 maximum greater than 50ml/kg/min were compared with non-athletic volunteers (n = 155). Cardiopulmonary exercise tests and cardiac magnetic resonance imaging (cMRI) were performed to determine structural or functional changes. Genotype distribution of the NOS3 Glu298Asp polymorphism was not affected by gender or physical performance. Cardiac MRI showed increased stroke volume with eccentric hypertrophy in all athletes regardless of their genotype. However, the Asp allelic variant carriers had increased RV mass index (32±6g versus 27±6g, p<0.01) and larger RV stroke volume index (71±10ml versus 64±10ml, p<0.01) than athletes with a Glu/Glu genotype. Genotype was not significantly associated with athletic performance. In the non-athletic group no genotype related differences were detected. The association between the NOS3 Glu298Asp polymorphism and RV structure and dimension in elite athletes emphasizes the importance of NOS3 gene function and NO bioavailability in sport related cardiac adaptation.
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Affiliation(s)
- Zsolt Szelid
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
- * E-mail:
| | - Árpád Lux
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | - Márton Kolossváry
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Attila Tóth
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | - Hajnalka Vágó
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | | | - Loretta Kiss
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | - Pál Maurovich-Horvat
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsolt Bagyura
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | - Béla Merkely
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
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My patient wants to perform strenuous endurance exercise. What's the right advice? Int J Cardiol 2015; 197:248-53. [DOI: 10.1016/j.ijcard.2015.06.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/07/2015] [Accepted: 06/12/2015] [Indexed: 12/23/2022]
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Schnell F, Claessen G, La Gerche A, Bogaert J, Lentz PA, Claus P, Mabo P, Carré F, Heidbuchel H. Subepicardial delayed gadolinium enhancement in asymptomatic athletes: let sleeping dogs lie? Br J Sports Med 2015. [DOI: 10.1136/bjsports-2014-094546] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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