The paradox of exercise

Vigorous exercise and sports participation in individuals with hypertrophic cardiomyopathy

Historically, individuals with HCM have been restricted from vigorous competitive sports due to concerns for risk of sudden death. More recently, prospective data are emerging that individuals with HCM who participate in vigorous sports do not have increased arrhythmic risk compared to the less active, and series of athletes with HCM continuing to compete, while small, have not shown high risk. Guidelines are evolving, and while differences exist, all now recommend an individualized approach and shared decision-making for athletes with HCM wishing to return to play.

[Physical activity to reduce cardiovascular risk -Why deprive yourself ?]

Sports-related sudden death is an uncommon event, affecting mainly middle-aged men who practice leisure sports, and is related to unknown coronary artery disease. In athletes, cardiac causes are also predominant, with a greater proportion of structural and electrical heart disease. If first-aid resuscitation measures are initiated, survival easily exceeds 50%, and this is an excellent educational illustration of how to improve the prognosis of non-sport-related cardiac arrest. Prevention of a sport-related cardiovascular event remains difficult, and relies on clinical examination, questioning (including family history) and resting ECG in participants >35 years old. The non-contraindication visit is also an opportunity to pass on to the patient the rules of good sports "hygiene" and life-saving gestures in the event of sudden death during sport in one of the partners (and the importance of regularly educating oneself in life-saving gestures...).

Team Approach: Diagnosis, Management, and Prevention of Sudden Cardiac Arrest in the Athlete

» Sudden cardiac events during sports competition are rare but tragic occurrences that require a timely, comprehensive response by well-prepared athletic trainers and medical providers. This sequence should prioritize prompt emergency medical system activation, immediate initiation of cardiopulmonary resuscitation (CPR), automated early defibrillation (AED), and comprehensive advanced life support efforts.» Exercise-induced cardiac remodeling, referred to as the "athlete's heart," refers to a host of adaptive changes that increase cardiac chamber size and wall thickness to allow for greater pressures and volumes during exercise. This remodeling phenotype may overlap with other inherited cardiomyopathies and cardiac abnormalities, which can complicate clinical care. The long-term implications of this electrical and structural remodeling on cardiac function are unknown.» Although the best screening strategies to optimize primary prevention of sudden cardiac arrest is an evolving topic, the effectiveness of CPR and early defibrillation use in treating out-of-hospital sudden cardiac arrest has been well-established, despite their reported underuse.

Association between accelerometer-derived physical activity and incident cardiac arrest

AIMS

Studies on objectively measured physical activity (PA) have investigated acute cardiovascular outcomes but not cardiac arrest (CA). Our study aimed to investigate the dose-response relationship between accelerometer-measured PA and CA by intensity of PA.

METHODS AND RESULTS

This prospective cohort study included 98 893 UK Biobank participants whose PA data were measured using wrist-worn accelerometers. Total PA volume was measured using the average overall acceleration. Minutes per week of light PA (LPA), moderate PA (MPA), and vigorous PA (VPA) were recorded. The incident CA was identified using diagnostic codes linked to hospital encounters and death records. Cox proportional hazard models with restricted cubic splines were used to study the associations, including sex differences. During the follow-up period (median: 7.31 years; interquartile range: 6.78-7.82 years), 282 incident CAs (0.39 per 1000 person-years) occurred. Total PA was inversely related to CA risk. The CA risk decreased sharply until the time spent in MPA or VPA reached ∼360 min or 20 min per week, respectively, after which it was relatively flat. The LPA was not associated with CA risk. Subgroup analyses showed a more pronounced association between PA and a reduced risk of CA in women compared to men.

CONCLUSION

Accelerometer-measured PA, particularly MPA and VPA, was associated with a lower CA risk. Furthermore, a stronger association was observed in women than men.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Sudden cardiac arrest in athletes and strategies to optimize preparedness

Sudden cardiac arrest (SCA) is the leading cause of death in young athletes. Despite efforts to improve preparedness for cardiac emergencies, the incidence of out-of-hospital cardiac arrests in athletes remains high, and bystander awareness and readiness for SCA support are inadequate. Initiatives such as designing an emergency action plan (EAP) and mandating training in cardiopulmonary resuscitation (CPR) and automated external defibrillator use (AED) for team members and personnel can contribute to improved survival rates in SCA cases. This review provides an overview of SCA in athletes, focusing on identifying populations at the highest risk and evaluating the effectiveness of different screening practices in detecting conditions that may lead to SCA. We summarize current practices and recommendations for improving the response to SCA events, and we highlight the need for ongoing efforts to optimize preparedness through the implementation of EAPs and the training of individuals in CPR and AED use. Additionally, we propose a call to action to increase awareness and training in EAP development, CPR, and AED use for team members and personnel. To improve outcomes of SCA cases in athletes, it is crucial to enhance bystander awareness and preparedness for cardiac emergencies. Implementing EAPs and providing training in CPR and AED use for team members and personnel are essential steps toward improving survival rates in SCA cases.

Prevalence and pattern of focal and potential diffuse myocardial fibrosis in male and female marathon runners using contrast-enhanced cardiac magnetic resonance

OBJECTIVES

This study analyzed the prevalence and pattern of focal and potential diffuse myocardial fibrosis detected by late gadolinium enhancement (LGE) and extracellular volume (ECV) imaging in male and female marathon runners using cardiac magnetic resonance (CMR).

METHODS

Seventy-four marathon runners were studied including 55 males (44 ± 8 years) and 19 females (36 ± 7 years) and compared to 36 controls with similar age and sex using contrast-enhanced CMR, exercise testing, and blood samples.

RESULTS

Contrast-enhanced CMR revealed focal myocardial fibrosis in 8 of 74 runners (11%). The majority of runners were male (7 of 8, 88%). LGE was typically non-ischemic in 7 of 8 runners (88%) and ischemic in one runner. ECV was higher in remote myocardium without LGE in male runners (25.5 ± 2.3%) compared to male controls (24.0 ± 3.0%, p < 0.05), indicating the potential presence of diffuse myocardial fibrosis. LV mass was higher in LGE + males (86 ± 18 g/m2) compared to LGE- males (73 ± 14 g/m2, p < 0.05). Furthermore, LGE + males had lower weight (69 ± 9 vs 77 ± 9 kg, p < 0.05) and shorter best marathon finishing times (3.2 ± 0.3 h) compared to LGE- males (3.6 ± 0.4 h, p < 0.05) suggesting higher training load in these runners to accomplish the marathon in a short time.

CONCLUSION

The high frequency of non-ischemic myocardial fibrosis in LGE + male runners can be related to increased LV mass in these runners. Furthermore, a higher training load could explain the higher LV mass and could be one additional cofactor in the genesis of myocardial fibrosis in marathon runners.

KEY POINTS

• A high frequency of myocardial fibrosis was found in marathon runners. • Myocardial fibrosis occurred typically in male runners and was typically non-ischemic. • Higher training load could be one cofactor in the genesis of myocardial fibrosis in marathon runners.

Coronary Artery Tortuosity Found in a Marathon Runner

Coronary artery tortuosity (CAT) is an anatomical anomaly in which the coronary arteries contain kinks or coils. It is usually found incidentally in elderly patients with long-standing uncontrolled hypertension. This case illustrates a 58-year-old female marathon runner who was found to have CAT, originally presenting with chest pain, hypotension, presyncope, and a severe cramping sensation in her legs.

Vigorous Exercise in Patients With Hypertrophic Cardiomyopathy

Importance

Whether vigorous intensity exercise is associated with an increase in risk of ventricular arrhythmias in individuals with hypertrophic cardiomyopathy (HCM) is unknown.

Objective

To determine whether engagement in vigorous exercise is associated with increased risk for ventricular arrhythmias and/or mortality in individuals with HCM. The a priori hypothesis was that participants engaging in vigorous activity were not more likely to have an arrhythmic event or die than those who reported nonvigorous activity.

Design, Setting, and Participants

This was an investigator-initiated, prospective cohort study. Participants were enrolled from May 18, 2015, to April 25, 2019, with completion in February 28, 2022. Participants were categorized according to self-reported levels of physical activity: sedentary, moderate, or vigorous-intensity exercise. This was a multicenter, observational registry with recruitment at 42 high-volume HCM centers in the US and internationally; patients could also self-enroll through the central site. Individuals aged 8 to 60 years diagnosed with HCM or genotype positive without left ventricular hypertrophy (phenotype negative) without conditions precluding exercise were enrolled.

Exposures

Amount and intensity of physical activity.

Main Outcomes and Measures

The primary prespecified composite end point included death, resuscitated sudden cardiac arrest, arrhythmic syncope, and appropriate shock from an implantable cardioverter defibrillator. All outcome events were adjudicated by an events committee blinded to the patient's exercise category.

Results

Among the 1660 total participants (mean [SD] age, 39 [15] years; 996 male [60%]), 252 (15%) were classified as sedentary, and 709 (43%) participated in moderate exercise. Among the 699 individuals (42%) who participated in vigorous-intensity exercise, 259 (37%) participated competitively. A total of 77 individuals (4.6%) reached the composite end point. These individuals included 44 (4.6%) of those classified as nonvigorous and 33 (4.7%) of those classified as vigorous, with corresponding rates of 15.3 and 15.9 per 1000 person-years, respectively. In multivariate Cox regression analysis of the primary composite end point, individuals engaging in vigorous exercise did not experience a higher rate of events compared with the nonvigorous group with an adjusted hazard ratio of 1.01. The upper 95% 1-sided confidence level was 1.48, which was below the prespecified boundary of 1.5 for noninferiority.

Conclusions and Relevance

Results of this cohort study suggest that among individuals with HCM or those who are genotype positive/phenotype negative and are treated in experienced centers, those exercising vigorously did not experience a higher rate of death or life-threatening arrhythmias than those exercising moderately or those who were sedentary. These data may inform discussion between the patient and their expert clinician around exercise participation.

Impact of coronavirus disease (COVID-19) pandemic on physical activity of patients with cardiac implantable electronic devices—A remote monitoring study

Objectives

The study aims to investigate the impact of COVID-19 pandemic on physical activity and frequency of implantable cardioverter-defibrillator (ICD) therapies of patients with cardiac implantable electronic devices.

Methods and results

Physical activity, heart rate and ICD-therapies were assessed via routine remote monitoring over two years. We focussed on a 338-day period during COVID-19 pandemic that was divided in 6 time-intervals defined by public health interventions and compared to the previous regular year. Paired nonparametric longitudinal analysis was performed to detect differences between time-intervals. To model effects of age, sex and time we applied a nonparametric ANOVA-type-statistic. 147 patients with cardiac implantable electronic devices were analysed. Longitudinal analysis of physical activity in 2019 and 2020 showed a specific weekly and seasonal pattern. Physical activity was reduced during the pandemic (mean daily physical activity 2019: 12.4% vs. 2020: 11.5%; p<0.0001) with the strongest reductions (fold changes 0.885/0.889, p<0.0001/p<0.0001) during the two lockdown-periods. In older patients (>70 years), physical activity was decreased in every time-interval of the year 2020. In time-intervals of eased restrictions, physical activity of younger patients (≤70 years) was not different compared to 2019. No variation in mean heart rate, arrhythmia-burden and count of ICD-therapies was found.

Conclusion

Physical activity shows fluctuations dependent on days of the week and time of the year. During the pandemic, physical activity was reduced in patients with cardiac implantable electronic devices with the strongest reductions during lockdown-periods. Younger patients resumed former levels of physical activity in times of eased restrictions while older patients remained less active. Thus, activation of the elderly population is important to prevent long-term health impairments due to the pandemic.

Dietary-Lifestyle Patterns Associated with Bone Turnover Markers, and Bone Mineral Density in Adult Male Distance Amateur Runners—A Cross-Sectional Study

Background: Excessive mileage can be detrimental to bone mineral density among long-distance runners. The negative effects of mileage could be alleviated by appropriate nutrition. The purpose of this study was to analyse the dietary-lifestyle patterns in relation to bone mineral density and bone turnover markers among amateur marathoners. Methods: A total of 53 amateur male distance runners were divided into two clusters by k-means cluster analysis. Bone mineral density was measured by dual X-ray absorptiometry (DXA). Blood was drawn to analyse bone resorption marker C-terminal telopeptide (cTX) and bone formation marker amino-terminal propeptide of type I collagen (PINP). Food frequency intake and lifestyle information were measured by multicomponent questionnaire KomPAN^®. Yearly average mileage per month was taken from each participant. Results: There were two distinguished clusters: Less-healthy-more-active-low-Z-score (LessHA) (n = 33) and More-healthy-less-active-high-Z-score (MoreHLA) (n = 20). LessHA had a lower frequency intake of pro-healthy food groups, a lower number of meals during a typical day, and a higher mileage training than the group of athletes who followed the MoreHLA. Athletes following the LessHA pattern also had a lower Z-score in the lumbar spine and femoral bone and a lower PINP. Conclusion: The current study suggests that pro-healthy dietary patterns and lower mileage may favour higher bone mineral density in male amateur marathoners.

Global thrombosis test for assessing thrombotic status and efficacy of antithrombotic diet and other conditions

Because of the high mortality from myocardial infarction and stroke, there is a great demand for finding novel methods of diagnosis, prevention and treatment of these diseases. Most of the current tests measure important determinants of thrombosis such as platelet function, coagulation and fibrinolysis in isolation; therefore, a global test measuring the actual thrombotic status would be more useful in clinical conditions. We obtained considerable experience by using the global thrombosis test, which determines the actual thrombotic status by taking into account the measured platelet reactivity, coagulation and fibrinolytic activities. In animal experiments, we found significant correlation between the ex vivo global thrombosis test measurements and the in vivo thrombotic status. The published evidence for the benefit of an antithrombotic diet with regular physical exercise is also described.

There is a great concern in the general population how to detect the risk of thrombotic events and prevent the high mortality from stroke, myocardial infarction, sudden death and cancer-associated thrombosis. Our experience on antithrombotic fruits and vegetables intake and regular exercise assessed by the global thrombosis test suggested a potentially unique way of preventing these life-threatening diseases. In addition, global thrombosis testing may offer some benefit in detecting risk of thrombotic of forthcoming thrombotic events in cancer and COVID-19 virus-infected patients.

Between- versus within-person emotional and cognitive reactivity in relation to depressive symptoms

BACKGROUND

Theories connecting depression to emotional reactivity (ER) or cognitive reactivity (CR) have not clearly indicated whether ER and CR are between-person or within-person constructs. Most empirical tests of these theories have focused on either between- or within-person operationalizations of these constructs, but not both. Between- and within-person studies address qualitatively different questions and often generate very different results. Consequently, the goals of the current study were to examine the relation of depressive symptoms to both between- and within-person operationalizations of both ER and CR.

METHODS

Participants were 160 undergraduate students who completed daily diary measures (assessing stress, negative emotions, and negative cognitions) and measures of depressive symptoms. Multilevel modeling (MLM) enabled examination of depressive symptoms to the within- and between-person components of ER and CR.

RESULTS

Depressive symptoms were positively related to within-person ER and CR but not to between-person operationalizations of ER and CR.

LIMITATIONS

The sample only included college students and only assessed depressive symptoms, not clinical diagnoses of major depression.

CONCLUSIONS

Important implications emerge for theory, practice, and future research. We recommend distinguishing between-person from within-person dimensions of ER and CR in future research.

Sudden cardiac death in sports: could we save Pheidippides?

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.

Establishing a cardiac training group for patients with heart failure: the "HIP-in-Würzburg" study

Background

Exercise training in heart failure (HF) is recommended but not routinely offered, because of logistic and safety-related reasons. In 2020, the German Society for Prevention&Rehabilitation and the German Society for Cardiology requested establishing dedicated “HF training groups.” Here, we aimed to implement and evaluate the feasibility and safety of one of the first HF training groups in Germany.

Methods

Twelve patients (three women) with symptomatic HF (NYHA class II/III) and an ejection fraction ≤ 45% participated and were offered weekly, physician-supervised exercise training for 1 year. Patients received a wrist-worn pedometer (M430 Polar) and underwent the following assessments at baseline and after 4, 8 and 12 months: cardiopulmonary exercise test, 6-min walk test, echocardiography (blinded reading), and quality of life assessment (Kansas City Cardiomyopathy Questionnaire, KCCQ).

Results

All patients (median age [quartiles] 64 [49; 64] years) completed the study and participated in 76% of the offered 36 training sessions. The pedometer was worn ≥ 1000 min per day over 86% of the time. No cardiovascular events occurred during training. Across 12 months, NT-proBNP dropped from 986 pg/ml [455; 1937] to 483 pg/ml [247; 2322], and LVEF increased from 36% [29;41] to 41% [32;46]%, (p for trend = 0.01). We observed no changes in exercise capacity except for a subtle increase in peak VO₂% predicted, from 66.5 [49; 77] to 67 [52; 78]; p for trend = 0.03. The physical function and social limitation domains of the KCCQ improved from 60 [54; 82] to 71 [58; 95, and from 63 [39; 83] to 78 [64; 92]; p for trend = 0.04 and = 0.01, respectively. Positive trends were further seen for the clinical and overall summary scores.

Conclusion

This pilot study showed that the implementation of a supervised HF-exercise program is feasible, safe, and has the potential to improve both quality of life and surrogate markers of HF severity. This first exercise experiment should facilitate the design of risk-adopted training programs for patients with HF.

Dietary and Biological Assessment of the Omega-3 Status of Collegiate Athletes: A Cross-Sectional Analysis

Omega-3 fatty acids (ω-3 FA) are associated with cardiovascular health, brain function, reduction of inflammation, and several other physiological roles of importance to competitive athletes. The ω-3 FA status of National Collegiate Athletic Association (NCAA) Division I athletes has not been well-described. The purpose of this study was to evaluate the ω-3 FA status of NCAA Division I athletes using dietary and biological assessment methodology. Athletes from nine NCAA Division I institutions from throughout the U.S. (n = 1,528, 51% male, 34 sports represented, 19.9 ± 1.4 years of age) completed a food frequency questionnaire (FFQ) to assess ω-3 FA from diet and supplements. Omega-3 Index (O3i) was evaluated in a sub-set of these participants (n = 298, 55% male, 21 sports represented, 20.0 ± 1.3 years of age) using dried blood spot sampling. Only 6% (n = 93) of athletes achieved the Academy of Nutrition & Dietetics’ recommendation to consume 500 mg DHA+EPA per day. Use of ω-3 FA supplements was reported by 15% (n = 229) of participants. O3i was 4.33 ± 0.81%, with no participants meeting the O3i benchmark of 8% associated with the lowest risk of cardiovascular disease. Every additional weekly serving of fish or seafood was associated with an absolute O3i increase of 0.27%. Overall, sub-optimal ω-3 FA status was observed among a large, geographically diverse group of male and female NCAA Division I athletes. These findings may inform interventions aimed at improving ω-3 FA status of collegiate athletes. Further research on athlete-specific ω-3 FA requirements is needed.

Sport Participation in Patients with Implantable Cardioverter-Defibrillators

PURPOSE OF REVIEW

Athletes diagnosed with cardiovascular disease may receive implantable cardioverter defibrillators (ICDs). Until recently, there were no data describing the safety of return to play for athletes receiving an ICD, and consensus recommendations restricted ICD patients to competitive sports no more vigorous than bowling or golf.

RECENT FINDINGS

The ICD Sports Registry prospectively followed 440 athletes who continued sports participation after receiving an ICD, for up to 4 years. While many received shocks, both appropriate and inappropriate, during competition or practice, as well as during other physical activity or rest, there were no failures to defibrillate and no injuries related to arrhythmia or shock during sports. Recent subanalyses as described below have focused on how best to program the ICD, and on the younger subgroup including interscholastic athletes. Based on these data, the most recent consensus statement from the AHA/ACC on athletic eligibility now describes sports participation with an ICD as a IIB recommendation, "may be considered".

Mobility Difficulties, Physical Activity, and All-cause Mortality Risk in a Nationally representative Sample of Older Adults

Background

This study sought to determine the association between levels of physical activity and mobility difficulties and time to death while accounting for the effect of several confounders. We also examined the possible interaction between them and how various daily-life mobility difficulties could predict all-cause mortality.

Methods

A nationally representative sample of 2,074 noninstitutionalized adults aged 60 years and older was analyzed. Vital status over a 3-year follow-up period was ascertained through national registers or by asking participants' relatives. Kaplan-Meier survival curves were stratified by levels of physical activity and mobility difficulties. Unadjusted and adjusted Cox proportional hazards regression models (by age, gender, marital status, years of education, multimorbidity, tobacco and alcohol consumption, depression, and memory function) were calculated, and interactions between the predictors and the covariates were explored.

Results

There was a dose-gradient effect of physical activity on time to death, with high levels associated with a 51% lower risk of dying, compared with moderate physical activity. Each unit increase in mobility functioning was associated with a 2% drop in mortality. Difficulties in standing for long periods, getting where one wants to go or extending arms to reach objects, were also found to be strong predictors of all-cause mortality.

Conclusions

Our results confirm the importance of older adults practicing moderate-to-vigorous physical activity. The assessment of self-reported difficulties in daily-life mobility activities, such as standing for long periods or not being able to move around, could be used in health settings as a screening for mortality risk.

Sports-related sudden cardiac death due to myocardial diseases on a population from 1-35 years: a multicentre forensic study in Spain

This is a multicentre forensic study that identifies all sports-related sudden deaths (SRSDs) in young people, due to myocardial diseases (MDs) that occurred in a large area of Spain. The aim of the study is to assess the epidemiology, causes of death, and sport activities associated with these fatalities. This is a retrospective study based on forensic autopsies performed in the provinces of Biscay, Seville, Valencia and in the jurisdiction covered by the National Institute of Toxicology and Forensic Sciences in Madrid (Spain). The retrospective study encompasses from 2010 to 2017. All sudden cardiac deaths (SCDs) in persons 1-35 years old were selected. The total number of SCDs were divided into death occurred during exercise (SRSD) and death during rest, sleep or normal activities (non-SRSD). Each of these two groups was subdivided according to the cause of death into MD (primary cardiomyopathies and myocarditis) and non-MD. Clinic-pathological, toxicological and genetic characteristics of SRSD due to MD were analysed. Over the 8-year study period, we identified 645 cases of SCD in the young: 75 SRSD (11.6%) and 570 non-SRSD (88.4%). MD was diagnosed in 33 (44.0%) of the SRSD and in 112 (19.6%) of the non-SRSD cases. All cases of SRSD due to MD were males (mean age (24.0 ± 7.6) years) practicing recreational sports (85%). SRSDs were more frequent in arrhythmogenic cardiomyopathy (ACM) (37%) and hypertrophic cardiomyopathy (HCM) (24%), followed by myocarditis (15%) and idiopathic left ventricular hypertrophy (ILVH) (9%). Only in five cases of SRSD the MD responsible of death (HCM) had been diagnosed in life. Cardiovascular symptoms related to the disease were present in other seven patients (six of them with ACM). Postmortem genetic studies were performed in 15/28 (54%) primary cardiomyopathies with positive results in 12 (80%) cases. The most frequent sports disciplines were football (49%) followed by gymnastics (15%) and running (12%). In Spain, SRSD in young people due to MDs occurs in males who perform a recreational activity. Compared with control group we observed a strong association between MDs and exertion. One in three SRSDs are due to cardiomyopathy, especially ACM, which reinforces the need for preparticipation screening to detect these pathologies in recreational sport athletes. Further studies are warranted to understand the causes and circumstances of sudden death to facilitate the development of preventive strategies.

Acute Impact of Different Exercise Modalities on Arterial and Platelet Function

PURPOSE

Acute coronary syndromes and ischemic stroke are associated with arterial events involving platelets, the endothelium, and atherosclerosis. Although regular physical activity is associated with lower risk of cardiovascular events and mortality, risk is transiently increased during and immediately after participation in an acute bout of exercise. No previous study has investigated the acute impact of exercise on platelet activation and arterial function in the same participants; it is also unknown if responses are dependent on exercise modality. We hypothesized that commonly adopted, yet physiologically distinct, modalities of exercise ("aerobic" vs "resistance") have differing effects on in vivo platelet activation and conduit artery diameter.

METHODS

Eight apparently healthy middle-age (53.5 ± 1.6 yr) male subjects took part in four 30-min experimental interventions (aerobic exercise, resistance exercise, combined aerobic/resistance exercise, or no-exercise), in random order. Blood samples were collected, and the measurement of brachial artery diameter by ultrasound was performed before, immediately after, and 1 h after each intervention. Platelet activation was determined by the positive binding of antibodies to surface receptors exposed on activated platelets (anti-CD62P and PAC-1).

RESULTS

Brachial artery diameter increased immediately after all three exercise modalities (P < 0.001) and remained above preexercise levels 1 h after resistance exercise and after combined aerobic/resistance exercise. No changes were observed in markers of in vivo platelet activation with any experimental protocol.

CONCLUSIONS

These data suggest that postexercise enhancement in arterial function may mitigate the acute impact of exercise on platelet activation.

Lifestyle Modification and Medical Management of Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy is a heterogenous condition associated with a myriad of symptoms. Just as in other disease states, the aim of medical therapy is the alleviation of suffering, improvement of longevity, and the prevention of complications. This article focuses on the associated comorbidities seen in patients with hypertrophic cardiomyopathy, potential lifestyle interventions, and conventional medical treatments for symptomatic hypertrophic cardiomyopathy.

Prevention of thrombotic disorders by antithrombotic diet and exercise: evidence by using global thrombosis tests

Prevention of thrombotic disorders has priority over treatment. There are only two pathologically relevant tests which are suitable for measuring the overall thrombotic status both in experimental conditions and in humans. The Global Thrombosis Test (GTT) and the Global Parallel-Plate Thrombosis Test can detect the pathologically relevant global thrombotic status. These tests have been successfully used for monitoring the effect of antithrombotic drugs and for developing novel antithrombotic agents. By using GTT, varieties of fruits, vegetables, and regular physical exercise have been tested for the effect on global thrombotic status. This review discusses the published evidence for the benefit of diet of selected fruit and vegetable varieties and doing regular physical exercise on improving thrombotic status. Future clinical trials monitored by GTT or Global Parallel-Plate Thrombosis Test could decide on the effectiveness of an experimentally proven antithrombotic diet with regular physical exercise in the prevention of thrombotic diseases.

Sudden Cardiac Death During Sports Activities in the General Population

Regular exercise reduces cardiovascular and overall mortality. Participation in sports is an important determinant of cardiovascular health and fitness. Regular sports activity is associated with a smaller risk of sudden cardiac death (SCD). However, there is a small risk of sports-related SCD. Sports-related SCD accounts for approximately 5% of total SCD. SCD among athletes comprises only a fraction of all sports-related SCD. Sport-related SCD has a male predominance and an average age of affliction of 45 to 50 years. Survival is better than for other SCD. This review summarizes links between sports and SCD and discusses current knowledge and controversies.

Different times of day do not change heart rate variability recovery after light exercise in sedentary subjects: 24 hours Holter monitoring

Incidence of cardiovascular events follows a circadian rhythm with peak occurrence during morning. Disturbance of autonomic control caused by exercise had raised the question of the safety in morning exercise and its recovery. Furthermore, we sought to investigate whether light aerobic exercise performed at night would increase HR and decrease HRV during sleep. Therefore, the aim of this study was to test the hypothesis that morning exercise would delay HR and HRV recovery after light aerobic exercise, additionally, we tested the impact of late night light aerobic exercise on HR and HRV during sleep in sedentary subjects. Nine sedentary healthy men (age 24 ± 3 yr; height 180 ± 5 cm; weight 79 ± 8 kg; fat 12 ± 3%; mean±SD) performed 35 min of cycling exercise, at an intensity of first anaerobic threshold, at three times of day (7 a.m., 2 p.m. and 11 p.m.). R-R intervals were recorded during exercise and during short-time (60 min) and long-time recovery (24 hours) after cycling exercise. Exercise evoked increase in HR and decrease in HRV, and different times of day did not change the magnitude (p < 0.05 for time). Morning exercise did not delay exercise recovery, HR was similar to rest after 15 minutes recovery and HRV was similar to rest after 30 minutes recovery at morning, afternoon, and night. Low frequency power (LF) in normalized unites (n.u.) decreased during recovery when compared to exercise, but was still above resting values after 60 minutes of recovery. High frequency power (HF-n.u.) increased after exercise cessation (p < 0.05 for time) and was still below resting values after 60 minutes of recovery. The LF/HF ratio decreased after exercise cessation (p < 0.05 for time), but was still different to baseline levels after 60 minutes of recovery. In conclusion, morning exercise did not delay HR and HRV recovery after light aerobic cycling exercise in sedentary subjects. Additionally, exercise performed in the night did change autonomic control during the sleep. So, it seems that sedentary subjects can engage physical activity at any time of day without higher risk.

Trend of cardiovascular risk factors in the older Iranian population: 2002-2014

AIM

Current study aimed to investigate the sex-stratified secular trend of cardiovascular disease risk factors among an older population in Iran during a median follow-up period of 8.76 years.

METHODS

A total of 1490 participants (733 women) aged ≥60 years were evaluated in four study phases of 2002-2005, 2005-2008, 2008-2011 and 2011-2014. The trends of cardiovascular disease risk factors for each sex were estimated using generalized estimating equations.

RESULTS

The age-adjusted prevalence of diabetes, hypertension, central obesity, and chronic kidney disease at the baseline was 24%, 43%, 55%, and 32% in men and 31%, 57%, 60% and 53% in women, respectively, and had noticeable upward trend during the study period to reach 35%, 56%, 61% and 51% in men, and 42%, 71%, 74% and 67% in women, respectively. However, lipid profile parameters showed favorable trends. Despite the increasing trend in drug consumption, approximately 27% of women with diabetes and 37% of men with diabetes did not use antidiabetic medication, respectively; the results were 23% and 35% for hypertensive women and men, respectively. Among men, there was a decreasing trend towards low physical activity, from 40% at baseline to 26% at the most recent follow up. The prevalence of smoking remained steady throughout follow up.

CONCLUSIONS

Despite the benefits of lipid lowering, the status of other risk factor profiles are often suboptimal in both sexes. There remains much room for improvement in risk factors management, particularly for hypertension, smoking and adiposity status, and a need for an intervention. Geriatr Gerontol Int 2018; 18: 130-137.

Intensive Exercise Training Improves Cardiac Electrical Stability in Myocardial-Infarcted Rats

Background

Moderate exercise training has been shown to decrease sudden cardiac death post myocardial infarction. However, the effects of intensive exercise are still controversial.

Methods and Results

Fourteen myocardial‐infarcted rats were divided into sedentary (n=8) and intensive training groups (n=6) and 18 sham control rats to sedentary (n=10) and intensive training groups (n=8). Heart rate variability was obtained at weeks 1 and 8. The inducibility of ventricular tachycardia/fibrillation was assessed in a Langendorff system. Fast Fourier transforms were applied on the recorded ventricular tachycardia/fibrillations. Training reduces low to high frequency ratio of heart rate variability at week 8 compared with that at week 1 (P<0.05). In isolated hearts, the probability for ventricular tachycardia/fibrillation was decreased from 4.5±0.8% in sedentary controls to 1.56±0.2% in intensive training controls (P<0.05) and from 13.5±2.1% in the sedentary group to 5.4±1.2% in the intensive training group (P<0.01). Moreover, the pacing current required for ventricular fibrillation induction in the trained groups was increased following exercise (P<0.05). Fast Fourier transform analysis of ECG findings revealed an exercise‐induced ventricular fibrillation transition from a narrow, single‐peak spectrum at 17 Hz in sedentary controls to a broader range of peaks ranging from 13 to 22 Hz in the intensive training controls.

Conclusions

Intensive exercise in infarcted rats leads to reduced ventricular fibrillation propensity and is associated with normalization of refractoriness and intrinsic spatiotemporal electrical variations.

The exercise paradox may be solved by measuring the overall thrombotic state using native blood

While exercise is widely believed to prevent atherothrombotic diseases, it occasionally causes sudden death. This exercise paradox may be due to the inadequate testing of the thrombotic and thrombolytic status. A recently developed shear-induced thrombosis/endogenous fibrinolysis test performed with non-anticoagulated blood samples allows the assessment of the thrombotic state of an individual both at rest and after exercise. This sensitive and physiologically relevant test may help to solve the aforementioned exercise paradox.

[Sports cardiology : Overview of relevant clinical topics]

Physical activity is nowadays an established therapeutic principle concerning primary and secondary prevention of cardiovascular diseases; therefore, in internal sports medicine various aspects go beyond basic cardiological knowledge and require special medical expertise (sports cardiology). Acute cardiac risk is increased during physical activity; therefore, physical activity should be individually phased under consideration of the whole clinical situation. Physical training results in a functional adaptation of the cardiovascular system. Moreover, a structural adaptation can also be observed in competitive athletes but a differentiation between athlete's heart and cardiomyopathy is sometimes challenging. Preparticipation screening verifiably reduces the incidence of sudden cardiac death in athletes. Respective recommendations for the required diagnostics have been published and statutory health insurances are increasingly more willing to bear the incurred costs. Statistically, doping is more frequent in performance-orientated leisure time sports than in competitive sports. Drugs which are relevant for doping have partially irreversible cardiac side effects.

Association of regular physical activity with total and cause-specific mortality among middle-aged and older Chinese: a prospective cohort study

Association between physical activity and mortality has rarely been investigated among the Chinese population. Furthermore, the most appropriate amount of physical activity for longevity benefits remains unclear. We used data from the Dongfeng-Tongji cohort, including 24,606 middle-aged and older retired adults in 2008 and followed to 2013, to quantify linear and non-linear dose-response relationships between regular physical activity and mortality risks by Cox proportional hazards model. Compared with participants who did not engage in regular physical activity, those performing regular physical activity had significantly 46%, 56%, and 49% decreased risks of mortality from all causes, circulatory, and respiratory diseases, respectively. Each one-SD increase in regular physical activity was associated with 32% decrease of respiratory disease mortality. There were significant nonlinear dose-response associations between regular physical activity and mortality from all causes and circulatory diseases. Mortality risks decreased monotonically with increased regular physical activity amount, and appeared to reach a threshold at around 100 MET-hours/week. More mortality benefits were found among non-smokers than that among current and former smokers. Our results suggest that middle-aged and older Chinese adults can achieve mortality benefits from regular physical activity at the WHO recommended minimum, and the benefit threshold appears at approximately 100 MET hours/week.

Impact of commonly prescribed exercise interventions on platelet activation in physically inactive and overweight men

The exercise paradox infers that, despite the well‐established cardioprotective effects of repeated episodic exercise (training), the risk of acute atherothrombotic events may be transiently increased during and soon after an exercise bout. However, the acute impact of different exercise modalities on platelet function has not previously been addressed. We hypothesized that distinct modalities of exercise would have differing effects on in vivo platelet activation and reactivity to agonists which induce monocyte‐platelet aggregate (MPA) formation. Eight middle‐aged (53.5 ± 1.6 years) male participants took part in four 30 min experimental interventions (aerobic AE, resistance RE, combined aerobic/resistance exercise CARE, or no‐exercise NE), in random order. Blood samples were collected before, immediately after, and 1 h after each intervention, and incubated with one of three agonists of physiologically/clinically relevant pathways of platelet activation (thrombin receptor activating peptide‐6 TRAP, arachidonic acid AA, and cross‐linked collagen‐related peptide xCRP). In the presence of AA, TRAP, and xCRP, both RE and CARE evoked increases in MPAs immediately post‐exercise (P < 0.01), whereas only AA significantly increased MPAs immediately after AE (P < 0.01). These increases in platelet activation post‐exercise were transient, as responses approached pre‐exercise levels by 1 h. These are the first data to suggest that exercise involving a resistance component in humans may transiently increase platelet‐mediated thrombotic risk more than aerobic modalities.

Illicit drugs and cardiac arrhythmias in athletes

The current management of athletes with cardiac arrhythmias has become complicated by the widespread use of illicit drugs, which can be arrhythmogenic.

The World Anti-Doping Agency annually updates a list of prohibited substances and methods banned by the International Olympic Committee that includes different classes of substances namely, anabolic androgenic steroids, hormones and related substances, β2-agonists, diuretics, stimulants, narcotics, cannabinoids, glucocorticosteroids, alcohol, β-blockers and others. Almost all illicit drugs may cause, through a direct or indirect arrhythmogenic effect, a wide range of cardiac arrhythmias (focal or reentry type, supraventricular and/or ventricular) that can even be lethal and which are frequently sport activity related.

A large use of illicit drugs has been documented in competitive athletes, but the arrhythmogenic effect of specific substances is not precisely known. Precipitation of cardiac arrhythmias, particularly in the presence of a latent electrophysiologic substrate including some inherited cardiomyopathies, at risk of sudden death or due to long-term consumption of the substances, should raise the suspicion that illicit drugs may be a possible cause and lead cardiologists to investigate carefully this relationship and appropriately prevent the clinical consequences.

Martial Arts and Metabolic Diseases

Different forms of martial arts are practiced worldwide, each with various intensities of physical activity. These disciplines are potentially an effective exercise therapy for metabolic diseases. Tai chi is the most well-studied style of martial arts and has shown evidence of its effect on metabolic diseases; however, little evidence is available regarding the association between other styles of martial arts and metabolic health. To summarize and evaluate the effects of martial arts on metabolic diseases, eligible articles were searched by using Pubmed. To date, systematic reviews provide no definite conclusion on the effectiveness of tai chi for treating metabolic diseases because of a small numbers of subjects, short durations of clinical trials, and some biases involved in testing. However, there are several clinical studies on subjects with metabolic diseases, which show that tai chi improves obesity, glycemic control, blood pressure control, and lipid profiles. Currently, some limited evidence suggests that other martial arts, such as kung fu and karate, may be beneficial for body composition, glycemic control, and arterial stiffness. To clarify the effectiveness of martial arts for treating metabolic diseases, well-designed prospective studies, preferably with a larger number of subjects and of longer duration, are warranted.

Serum cardiac troponin I analysis to determine the excessiveness of exercise intensity: A novel equation

Physical exertion is often promoted because of its beneficial health effects. This only holds true, however, as long as the optimal exercise intensity is not exceeded. If physical exertion becomes too strenuous or prolonged, cardiac injury or dysfunction may occur. Consequently, a significant elevation of the serum concentration of the sensitive and specific cardiac biomarker troponin I can be observed. In this article, we present the derivation of a novel equation that can be used to evaluate to what extent the intensity of conducted endurance exercise was excessive, based on a post-exercise assessment of serum cardiac troponin I. This is convenient, as exercise intensity is difficult for an athlete to quantify accurately and the currently used heart rate indices can be affected by various physiological and environmental factors. Serum cardiac troponin I, on the other hand, is a post-hoc parameter that directly reflects the actual effects on the myocardium and may therefore be a promising alternative. To our knowledge, this is the first method to determine relative exercise intensity in retrospect. We therefore believe that this equation can serve as a potentially valuable tool to objectively evaluate the benefits or harmful effects of physical exertion.

Coronary artery disease in the military patient

Ischaemic heart disease is the most common cause of sudden death in the UK, and the most common cardiac cause of medical discharge from the Armed Forces. This paper reviews current evidence pertaining to the diagnosis and management of coronary artery disease from a military perspective, encompassing stable angina and acute coronary syndromes. Emphasis is placed on the limitations inherent in the management of acute coronary syndromes in the deployed environment. Occupational issues affecting patients with coronary artery disease are reviewed. Consideration is also given to the potential for coronary artery disease screening in the military, and the management of modifiable cardiovascular disease risk factors, to help decrease the prevalence of coronary artery disease in the military population.

The association of physical activity with all-cause, cardiovascular, and cancer mortalities among older adults

OBJECTIVE

To evaluate the association of physical activity with all-cause, cardiovascular, and cancer mortalities among older adults.

METHODS

A study sample consisting of 77,541 community-dwelling Taipei citizens aged ≥ 65 years was selected based on data obtained from the government-sponsored Annual Geriatric Health Examination Program between 2006 and 2010. Subjects were asked how many times they had physical activity for ≥ 30 min during the past 6 months. Mortality was determined by matching cohort identifications with national death files.

RESULTS

Compared to subjects with no physical activity, those who had 1-2 times of physical activity per week had a decreased risk of all-cause mortality [hazard ratio (HR): 0.77; 95% confidence interval (CI): 0.71-0.85). Subjects with 3-5 times of physical activity per week had a further decreased risk of all-cause mortality (HR: 0.64; 95% CI: 0.58-0.70). An inverse dose-response relationship was observed between physical activity and all-cause, cardiovascular, and cancer mortality. According to stratified analyses, physical activity was associated with a decreased risk of mortality in most subgroups.

CONCLUSIONS

Physical activity had an inverse association with all-cause, cardiovascular, and cancer mortality among older adults. Furthermore, most elderly people can benefit from an active lifestyle.

Sports-related sudden cardiac death in a competitive and a noncompetitive athlete population aged 12 to 49 years: data from an unselected nationwide study in Denmark

BACKGROUND

Preparticipation screening programs have been suggested to reduce the numbers of sports-related sudden cardiac deaths (SrSCD).

OBJECTIVE

The purpose of this study was to identify and characterize all SrSCD aged 12-49 years and to address the difference in incidence rates between competitive and noncompetitive athletes.

METHODS

All deaths among persons aged 12-49 years from 2007-2009 were included. Death certificates were reviewed. History of previous admissions to hospital was assessed, and discharge summaries and autopsy reports were read. Sudden cardiac deaths (SCDs) and SrSCD cases were identified.

RESULTS

In the 3-year period, there were 881 SCDs, of which we identified 44 SrSCD. In noncompetitive athletes aged 12-35 years, the incidence rate of SrSCD was 0.43 (95% confidence interval [CI] 0.16-0.94) per 100,000 athlete person-years vs 2.95 (95% CI 1.95-4.30) in noncompetitive athletes aged 36-49 years. In competitive athletes, the incidence rate of SrSCD was 0.47 (95% CI 0.10-1.14) and 6.64 (95% CI 2.86-13.1) per 100,000 athlete person-years in those aged 12-35 years and 36-49 years, respectively. The incidence rate of SCD in the general population was 10.7 (95% CI 10.0-11.5) per 100.000 person-years.

CONCLUSION

The incidence rates of SrSCD in noncompetitive and competitive athletes are not different. The study showed an increase in the incidence rate of SrSCD in persons aged 36-49 years in both noncompetitive and competitive athletes compared to those aged 12-35 years. Importantly, SCD in the general population is much more prevalent than is SrSCD in all age groups.

Exercise at 65 and beyond

Aging is characterized by increasing muscle loss, physical inactivity and frailty. Physical inactivity is known to be associated with increased incidence of obesity and many life-threatening chronic conditions. We know that exercise, through many factors including antiinflammatory effects and enhanced fitness, can help prevent and treat many chronic diseases as well as help maintain independent living. We set out to demonstrate the utility of regular exercise in this potentially vulnerable age group in both the treatment and prevention of chronic diseases. The benefits, risks and recommendations for physical activity are discussed with an emphasis on practical advice for safe exercise in the context of established international guidelines. These guidelines typically state that 150 min per week of moderate aerobic intensity exercise should be achieved with some additional whole-body strength training and balance work. Individual risk assessment should be undertaken in a way to enable safe exercise participation to achieve maximum benefit with minimum risk. The risk assessment, subsequent advice and prescription for exercise should be personalized to reflect individual fitness and functional levels as well as patient safety. Newer and potentially exciting benefits of exercise are discussed in the areas of neuroscience and inflammation where data are suggesting positive effects of exercise in maintaining memory and cognition as well as having beneficial antiinflammatory effects.