2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease

Tai Chi training as a primary care plan for the prevention and management of hypertension: an opinion and positioning article

Hypertension is a prevalent chronic condition worldwide that can impact patients' quality of life. Oral antihypertensive drugs are widely used to manage high blood pressure, primarily by regulating the renin-angiotensin-aldosterone system. Nevertheless, limited efficacy and low compliance represent significant obstacles, arising primarily from dose, duration, and medication type restrictions. Furthermore, the prolonged use of antihypertensive medication may result in dependence and adverse effects, without any substantial improvement in achieving targeted blood pressure leves. As a result, research has focused on using exercise therapy to treat hypertension. Tai Chi, a widely-practiced Chinese health exercise, has evolved into a form of exercise therapy that might help alleviate the risk associated with hypertension. Therefore, this article aims to outline the role of Tai Chi in preventing and managing hypertension.

Online Personal Training in Patients With Marfan Syndrome: A Randomized Controlled Study of Its Impact on Quality of Life and Physical Capacity

BACKGROUND

Marfan syndrome (MFS) is a genetic disorder affecting the vascular and musculoskeletal systems. Limited knowledge exists regarding the exercise benefits for this population. This study aimed to explore the impact of a structured exercise program on the quality of life (QoL) and physical capabilities of patients with MFS.

METHODS AND RESULTS

This was a randomized, controlled, parallel-group trial. Patients with MFS were randomized in a 1:1 ratio to either a training group or a control group. The trial included a 3-month online supervised training program. Seventy patients with MFS were compared with healthy subjects. They were randomized into a training group (MFS-T) and a control group (MFS-C). The training consisted of 2 supervised online sessions weekly for 3 months. The primary outcome was QoL, assessed using the Medical Outcomes Study Short-Form 36 questionnaire. Baseline QoL in all dimensions was lower in patients with MFS. Their peak oxygen uptake was 25% lower, and muscle elasticity was diminished compared with healthy subjects. Postintervention, significant improvements were observed in the MFS-T group relative to the MFS-C group: QoL (+20.2±14.3 versus +0.7±0.5), peak oxygen uptake (+34% versus +14%), muscle elasticity index (11.5±8.2 versus +1.2±1.7), reduced blood pressures during isometric squats (systolic -19±30 versus 0±6; diastolic -27±39 versus +2±15), and reduced pulse wave velocity at rest (-1.20±1.89 versus -0.40±1.61) and postexercise (-0.42±0.45 versus +0.08±0.48). The aortic diameter remained stable in both groups (MFS-T-0.19±1.1 versus MFS-C+0.11±0.78). After training, QoL remained lower in MFS-T than in healthy subjects, but peak oxygen uptake, pulse wave velocity at rest, and postexercise were similar to those of healthy subjects.

CONCLUSIONS

The 3-month online training program significantly enhanced QoL and cardiovascular/muscular metrics in patients with MFS without affecting aortic root diameter, suggesting its potential as part of a management strategy for MFS.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04553094.

Living with Congenital Aortic Stenosis: Exercise Restriction, Patterns of Adherence, and Quality of Life

Modern consensus panel guidelines recommend restriction from most organized sports for patients with moderate or severe aortic stenosis (AS). However, there is little published data on how frequently physicians deviate from guidelines, how well patients adhere to exercise restrictions, or the effect of restriction on patient-reported quality of life. In this study, we surveyed 93 subjects with AS and their cardiologists regarding participation in organized sports, physical activity, weightlifting, and exercise restriction. Subjects completed the pediatric quality of life inventory (PedsQL) and the pediatric cardiac quality of life inventory (PCQLI). We found that subjects with severe AS (n = 3) were commonly, but not universally, restricted from organized sports (n = 2, 66%). Subjects with moderate AS (n = 40) were rarely restricted from organized sports (n = 6, 17%). No physician-specific characteristics were associated with increased likelihood of recommending exercise restriction. Subjects were more likely to be restricted if they were older (16 years vs. 13 years, p 0.02) and had moderate versus mild AS (p 0.013). PCQLI scores for teens and young adults with AS (age 13-25) were lower than a comparison group of patients with mild congenital heart disease. For all age groups, the PedsQL social functioning score was lower for subjects with exercise restriction (p 0.052). In summary, cardiologists apply consensus guidelines leniently when restricting patients with moderate/severe AS from organized sports and weightlifting. Patients with AS routinely adhere to exercise restriction recommendations. Children and young adults with AS and exercise restriction have lower QOL scores in the social functioning domain.

Iron deficiency in athletes: Prevalence and impact on VO2 peak

BACKGROUND

Iron is an important micronutrient in pathways of energy production, adequate nutrient intake and its balance is essential for optimal athletic performance. However, large studies elucidating the impact of iron deficiency on athletes' performance are sparse.

METHODS

Competitive athletes of any age who presented for preparticipation screening 04/2020-10/2021 were included in this study and stratified for iron deficiency (defined as ferritin level <20 µg/l with and without mild anemia [hemoglobin levels ≥11 g/dl]). Athletes with and without iron deficiency were compared and the impact of iron deficiency on athletic performance was investigated.

RESULTS

Overall, 1190 athletes (mean age 21.9 ± 11.6 years; 34.2% females) were included in this study. Among these, 19.7% had iron deficiency. Patients with iron deficiency were younger (18.1 ± 8.4 vs. 22.8 ± 12.1 years, P < 0.001), more often females (64.5% vs. 26.8%, P < 0.001), had lower VO2 peak value (43.4 [38.5/47.5] vs. 45.6 [39.1/50.6]ml/min/kg, P = 0.022) and lower proportion of athletes reaching VO2 peak of >50 ml/min/kg (8.5% vs. 16.1%, P = 0.003). Female sex (OR 4.35 [95% CI 3.13-5.88], P > 0.001) was independently associated with increased risk for iron deficiency. In contrast, the risk for iron deficiency decreased by every life year (OR 0.97 [95% CI 0.95-0.99], P = 0.003). Iron deficiency was independently associated with reduced VO2 peak (OR 0.94 [0.91-0.97], P < 0.001) and lower probability to reach VO2 peak >50 ml/min/kg (OR 0.42 [95% CI 0.25-0.69], P = 0.001).

CONCLUSIONS

Iron deficiency is common in athletes (predominantly in female and in young athletes). Iron deficiency was independently associated with reduced VO2 peak during exercise testing and lower probability to reach a VO2 peak >50 ml/min/kg.

Cardiorespiratory fitness, atrial fibrillation and stroke: a review of the evidence in 2024

INTRODUCTION

The body of evidence linking cardiorespiratory fitness (CRF) levels with the risk of atrial fibrillation (AF) and stroke - two interconnected cardiovascular conditions - is not entirely consistent. Furthermore, specific CRF thresholds beyond which the risk of AF or stroke might not decrease are not well defined.

AREAS COVERED

This review summarizes research evidence on the role of CRF in the development of AF and stroke including dose-response relationships in general population participants, explores the biological mechanisms through which CRF may exert its effects, assesses the potential implications for clinical care and population health, identifies gaps in the current evidence, and suggest directions for future research. MEDLINE and Embase were searched from inception until July 2024 to identify observational longitudinal and interventional studies as well as systematic reviews and meta-analyses related to these study designs.

EXPERT OPINION

In the general population, increasing levels of CRF, achieved through consistent physical activity, can significantly reduce the likelihood of developing AF and stroke. The findings also advocate for a tailored approach to exercise prescriptions, acknowledging the plateau in benefits for AF risk beyond certain CRF levels, while advocating for higher intensity or prolonged activity to further reduce stroke risk.

Exercise training in left ventricular assist device patients: Protocol of an individual participant data meta-analysis

AIMS

Although left ventricular assist device (LVAD) implantation improves prognosis of advanced heart failure patients still suffer from impaired exercise capacity and quality of life (QoL). Exercise training may improve both; however, the available evidence about exercise training effects in LVAD patients remains inconclusive due to small and monocentric randomized controlled trials. This study aims to aggregate the individual participant data (IPD) to perform meta-analysis on the safety and efficacy of exercise training on exercise capacity and QoL over standard care in LVAD patients.

METHODS

Randomized controlled trials comparing exercise training and standard care (no supervised training) will be identified through database searching. Corresponding authors of eligible randomized controlled trials will be invited to share IPD. All IPD will be checked, recalculated to validate findings in initial reports, merged in a single dataset and stored in a secured encrypted database server. The merged IPD will be screened for quality, risk of bias, and heterogeneity of the included trials. Random effects meta-analyses will be conducted using one-stage and two-stage approaches, in particular with a view to subgroup analyses.

RESULTS

Based on findings of the individual randomized trials, we expected to obtain superior effects of exercise training on submaximal exercise capacity and QoL and similar effects on maximal aerobic capacity when compared with standard care.

CONCLUSIONS

Our study will be the first to harmonize IPD in meta-analysis to demonstrate the effects of exercise training on exercise performance and QoL over standard care in LVAD patients.

PROSPERO REGISTRATION NUMBER

CRD42023480119.

Changes in Cardiopulmonary Capacity Parameters after Surgery: A Pilot Study Exploring the Link between Heart Function and Knee Surgery

Background: A knee injury in an athlete leads to periods of forced exercise interruption. Myocardial work (MW) assessed by echocardiographic and cardiopulmonary exercise testing (CPET) are two essential methods for evaluating athletes during the period following injury. However, compared to pre-surgery evaluations, the variations in cardiovascular parameters and functional capacity assessed by these methods after surgery remain unclear. Methods: We evaluated 22 non-professional athletes aged 18-52, involved in prevalently aerobic or alternate aerobic/anaerobic sports activities, who were affected by a knee pathology requiring surgical treatment. The evaluation was performed at rest using transthoracic echocardiography, including MW assessment, and during exercise using CPET. Each athlete underwent the following two evaluations: the first before surgery and the second after surgery (specifically at the end of the deconditioning period). Results: Resting heart rate (HR) increased significantly (from 63.3 ± 10.85 to 71.2 ± 12.52 beats per minute, p = 0.041), while resting diastolic and systolic blood pressure, forced vital capacity, and forced expiratory volume in the first second did not show significant changes. Regarding the echocardiographic data, global longitudinal strain decreased from -18.9 ± 1.8 to -19.3 ± 1.75; however, this reduction was not statistically significant (p = 0.161). However, the global work efficiency (GWE) increased significantly (from 93.0% ± 2.9 to 94.8% ± 2.6, p = 0.006) and global wasted work (GWW) reduced significantly (from 141.4 ± 74.07 to 98.0 ± 50.9, p = 0.007). Additionally, the patients were able to perform maximal CPET at both pre- and post-surgery evaluations, as demonstrated by the peak respiratory exchange ratio and HR. However, the improved myocardial contractility (increased GWE and decreased GWW) observed at rest did not translate into significant changes in exercise parameters, such as peak oxygen consumption and the mean ventilation/carbon dioxide slope. Conclusions: After surgery, the athletes were more deconditioned (as indicated by a higher resting HR) but exhibited better resting myocardial contractility (increased GWE and reduced GWW). Interestingly, no significant changes in exercise capacity parameters, as evaluated by CPET, were found after surgery, suggesting that the improved myocardial contractility was offset by a greater degree of muscular deconditioning.

Improving cardiovascular risk stratification through multivariate time-series analysis of cardiopulmonary exercise test data

Nowadays cardiorespiratory fitness (CRF) is assessed using summary indexes of cardiopulmonary exercise tests (CPETs). Yet, raw time-series CPET recordings may hold additional information with clinical relevance. Therefore, we investigated whether analysis of raw CPET data using dynamic time warping combined with k-medoids could identify distinct CRF phenogroups and improve cardiovascular (CV) risk stratification. CPET recordings from 1,399 participants (mean age, 56.4 years; 37.7% women) were separated into 5 groups with distinct patterns. Cluster 5 was associated with the worst CV profile with higher use of antihypertensive medication and a history of CV disease, while cluster 1 represented the most favorable CV profile. Clusters 4 (hazard ratio: 1.30; p = 0.033) and 5 (hazard ratio: 1.36; p = 0.0088) had a significantly higher risk of incident adverse events compared to clusters 1 and 2. The model evaluation in the external validation cohort revealed similar patterns. Therefore, an integrative CRF profiling might facilitate CV risk stratification and management.

Exercise-based cardiac rehabilitation for adults with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia, disrupts the heart's rhythm through numerous small re-entry circuits in the atrial tissue, leading to irregular atrial contractions. The condition poses significant health risks, including increased stroke risk, heart failure, and reduced quality of life. Given the complexity of AF and its growing incidence globally, exercise-based cardiac rehabilitation (ExCR) may provide additional benefits for people with AF or those undergoing routine treatment for the condition.

OBJECTIVES

To assess the benefits and harms of ExCR compared with non-exercise controls for people who currently have AF or who have been treated for AF.

SEARCH METHODS

We searched the following electronic databases: CENTRAL in the Cochrane Library, MEDLINE Ovid, Embase Ovid, PsycINFO Ovid, Web of Science Core Collection Thomson Reuters, CINAHL EBSCO, LILACS BIREME, and two clinical trial registers on 24 March 2024. We imposed no language restrictions.

SELECTION CRITERIA

We included randomised clinical trials (RCTs) that investigated ExCR interventions compared with any type of non-exercise control. We included adults 18 years of age or older with any subtype of AF or those who had received treatment for AF.

DATA COLLECTION AND ANALYSIS

Five review authors independently screened and extracted data in duplicate. We assessed risk of bias using Cochrane's RoB 1 tool as outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed clinical and statistical heterogeneity by visual inspection of the forest plots and by using standard Chi² and I² statistics. We performed meta-analyses using random-effects models for continuous and dichotomised outcomes. We calculated standardised mean differences where different scales were used for the same outcome. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 20 RCTs involving a total of 2039 participants with AF. All trials were conducted between 2006 and 2024, with a follow-up period ranging from eight weeks to five years. We assessed the certainty of evidence as moderate to very low. Five trials assessed comprehensive ExCR programmes, which included educational or psychological interventions, or both; the remaining 15 trials compared exercise-only cardiac rehabilitation with controls. The overall risk of bias in the included studies was mixed. Details on random sequence generation, allocation concealment, and use of intention-to-treat analysis were typically poorly reported. Evidence from nine trials (n = 1173) suggested little to no difference in mortality between ExCR and non-exercise controls (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.76 to 1.49; I² = 0%; 101 deaths; low-certainty evidence). Based on evidence from 10 trials (n = 825), ExCR may have little to no effect on SAEs (RR 1.30, 95% CI 0.63 to 2.67; I² = 0%; 28 events; low-certainty evidence). Evidence from four trials (n = 378) showed that ExCR likely reduced AF recurrence (measured via Holter monitoring) compared to controls (RR 0.70, 95% CI 0.56 to 0.88; I² = 2%; moderate-certainty evidence). ExCR may reduce AF symptom severity (mean difference (MD) -1.59, 95% CI -2.98 to -0.20; I² = 61%; n = 600; low-certainty evidence); likely reduces AF symptom burden (MD -1.61, 95% CI -2.76 to -0.45; I² = 0%; n = 317; moderate-certainty evidence); may reduce AF episode frequency (MD -1.29, 95% CI -2.50 to -0.07; I² = 75%; n = 368; low-certainty evidence); and likely reduces AF episode duration (MD -0.58, 95% CI -1.14 to -0.03; I² = 0%; n = 317; moderate-certainty evidence), measured via the AF Severity Scale (AFSS) questionnaire. Moderate-certainty evidence from six trials (n = 504) showed that ExCR likely improved the mental component summary measure in health-related quality of life (HRQoL) of the 36-item Short Form Health Survey (SF-36) (MD 2.66, 95% CI 1.22 to 4.11; I² = 2%), but the effect of ExCR on the physical component summary measure was very uncertain (MD 1.75, 95% CI -0.31 to 3.81; I² = 52%; very low-certainty evidence). ExCR also may improve individual components of HRQoL (general health, vitality, emotional role functioning, and mental health) and exercise capacity (peak oxygen uptake (VO2peak) and 6-minute walk test) following ExCR. The effects of ExCR on serious adverse events and exercise capacity were consistent across different models of ExCR delivery: centre compared to home-based, exercise dose, exercise only compared to comprehensive programmes, and aerobic training alone compared to aerobic plus resistance programmes. Using univariate meta-regression, there was evidence of significant association between location of trial and length of longest follow-up on exercise capacity.

AUTHORS' CONCLUSIONS

Due to few randomised participants and typically short-term follow-up, the impact of ExCR on all-cause mortality or serious adverse events for people with AF is uncertain. ExCR likely improves AF-specific measures including reduced AF recurrence, symptom burden, and episode duration, as well as the mental components of HRQoL. ExCR may improve AF symptom severity, episode frequency, and VO2peak. Future high-quality RCTs are needed to assess the benefits of ExCR for people with AF on patient-relevant outcomes including AF symptom severity and burden, AF recurrence, AF-specific quality of life, and clinical events such as mortality, readmissions, and serious adverse events. High-quality trials are needed to investigate how AF subtype and clinical setting (i.e. primary and secondary care) may influence ExCR effectiveness.

High-intensity interval training improves cardiovascular and physical health in patients with rheumatoid arthritis: a multicentre randomised controlled trial

OBJECTIVES

Patients with rheumatoid arthritis (RA) have substantially elevated risk for cardiovascular diseases, and low cardiorespiratory fitness (VO2max) is a major mediator. The aim of this assessor-blinded, two-armed multicentre randomised controlled trial was to evaluate the effects of high-intensity interval training (HIIT) and strength exercise on cardiovascular health, physical fitness and overall health in patients with RA.

METHODS

In total, 87 patients (86% female; aged 20-60 years) were randomly assigned to an intervention group (IG) or a control group (CG). The IG performed HIIT and strength exercise for 12 weeks. The CG was instructed to be physically active on a moderately intensive level, ≥150 min/week. Primary outcome was change in VO2max. Secondary outcomes were changes in anthropometry measures, muscle strength, overall health (Visual Analogue Scale (VAS)-Global), Patient Global Impression of Change (PGIC), pain and disease activity (Disease Activity Score in 28 joints (DAS28)).

RESULTS

There was a significant mean group difference of change on VO2max (3.71 mL/kg/min; 95% CI 2.16, 5.25) in favour of the IG. Significant mean group differences of change were also seen for O2-pulse (1.38; 95% CI 0.85 to 1.91), waist circumference (-2.6; 95% CI -5.09 to -0.18), 1-minute sit-to-stand (5.0; 95% CI 3.35 to 6.72), handgrip strength (28.5; 95% CI 3.80 to 52.8), overall health (-14.7; 95% CI -23.8 to -5.50) and PGIC (p<0.0001) in favour of the IG. No significant mean group differences of change were found for pain (-4.0; 95% CI -13.07 to 5.06), DAS28 (-0.25; 95% CI -0.60 to 0.10) and erythrocyte sedimentation rate (-0.64; 95% CI -3.23 to 1.90).

CONCLUSION

Supervised HIIT and strength exercise improved cardiovascular health, physical fitness and overall health without a deterioration in pain and disease activity and should be considered in patients with well-controlled RA.

TRIAL REGISTRATION NUMBER

NCT05768165.

Management of aortic disease in children with FBN1-related Marfan syndrome

Marfan syndrome (MFS) is a hereditary connective tissue disorder with an estimated prevalence of 1:5000-1:10 000 individuals. It is a pleiotropic disease characterized by specific ocular, cardiovascular, and skeletal features. The most common cardiovascular complication is aortic root dilatation which untreated can lead to life-threatening aortic root dissection, mainly occurring in adult patients. Prompt diagnosis, appropriate follow-up, and timely treatment can prevent aortic events. Currently there are no specific recommendations for treatment of children with MFS, and management is greatly based on adult guidelines. Furthermore, due to the scarcity of studies including children, there is a lack of uniform treatment across different centres. This consensus document aims at bridging these gaps of knowledge. This work is a joint collaboration between the paediatric subgroup of the European Network of Vascular Diseases (VASCERN, Heritable Thoracic Aortic Disease Working Group) and the Association for European Paediatric and Congenital Cardiology (AEPC). A group of experts from 12 different centres and 8 different countries participated in this effort. This document reviews four main subjects, namely, (i) imaging of the aorta at diagnosis and follow-up, (ii) recommendations on medical treatment, (iii) recommendations on surgical treatment, and (iv) recommendations on sport participation.

Machine learning-based model for worsening heart failure risk in Chinese chronic heart failure patients

AIMS

This study aims to develop and validate an optimal model for predicting worsening heart failure (WHF). Multiple machine learning (ML) algorithms were compared, and the results were interpreted using SHapley Additive exPlanations (SHAP). A clinical risk calculation tool was subsequently developed based on these findings.

METHODS AND RESULTS

This nested case-control study included 200 patients with chronic heart failure (CHF) from the China-Japan Friendship Hospital (September 2019 to December 2022). Sixty-five variables were collected, including basic information, physical and chemical examinations, and quality of life assessments. WHF occurrence within a 3-month follow-up was the outcome event. Variables were screened using LASSO regression, univariate analysis, and comparison of key variables in multiple ML models. Eighty per cent of the data was used for training and 20% for testing. The best models were identified by integrating nine ML algorithms and interpreted using SHAP, and to develop a final risk calculation tool. Among participants, 68 (34.0%) were female, with a mean age (standard deviation, SD) of 68.57 (12.80) years. During the follow-up, 60 participants (30%) developed WHF. N-terminal pro-brain natriuretic peptide (NT-proBNP), creatinine (Cr), uric acid (UA), haemoglobin (Hb), and emotional area score on the Minnesota Heart Failure Quality of Life Questionnaire were critical predictors of WHF occurrence. The random forest (RF) model was the best model to predict WHF with an area under the curve (AUC) (95% confidence interval, CI) of 0.842 (0.675-1.000), accuracy of 0.775, sensitivity of 0.900, specificity of 0.833, negative predictive value of 0.800, and positive predictive value of 0.600 for the test set. SHAP analysis highlighted NT-proBNP, UA, and Cr as significant predictors. An online risk predictor based on the RF model was developed for personalized WHF risk assessment.

CONCLUSIONS

This study identifies NT-proBNP, Cr, UA, Hb, and emotional area scores as crucial predictors of WHF in CHF patients. Among the nine ML algorithms assessed, the RF model showed the highest predictive accuracy. SHAP analysis further emphasized NT-proBNP, UA, and Cr as the most significant predictors. An online risk prediction tool based on the RF model was subsequently developed to enhance early and personalized WHF risk assessment in clinical settings.

Ethnicity and sudden cardiac death in athletes: insights from a large United Kingdom registry

AIMS

The relationship between ethnicity and causes of sudden cardiac death (SCD) in athletes is poorly understood.

OBJECTIVES

To investigate aetiology of SCD among different ethnicities in a large cohort of athletes.

METHODS AND RESULTS

Between 1994 and November 2022, 7880 cases of SCD were consecutively referred from all over the United Kingdom to our national cardiac pathology centre; 848 (11%) were athletes. All cases underwent detailed autopsy evaluation by expert cardiac pathologists. Clinical information was obtained from referring coroners. Most of athletes were white (n = 758; 89%). Black and Asian athletes were in number of 51 (6%) and 39 (5%), respectively. A structurally normal heart, indicative of sudden arrhythmic death syndrome (SADS) was the most common autopsy finding (n = 385; 45%), followed by myocardial diseases (n = 275; 32%), atherosclerotic coronary artery disease (CAD) (n = 58; 7%), and coronary artery anomalies (n = 29; 3%). In most of cases, death occurred during exercise (n = 737; 87%). Arrhythmogenic cardiomyopathy (ACM) was more common in black (n = 13; 25%) than in white (n = 109; 14%) and Asian (n = 3; 8%) athletes (P = 0.03 between black and white athletes; P = 0.04 between black and Asian athletes); in contrast, CAD was more common in Asians (n = 6; 15% vs. n = 51; 7% in whites vs. n = 1; 2%; in blacks, P = 0.02 between Asian and black athletes). Among white athletes, ACM was more common in individuals who died during exercise than in the ones who died at rest (P = 0.005). Such a difference was not observed in Asian and black athletes. In Asian athletes, CAD was the diagnosis at autopsy in 18% of individuals who died during exercise and in none of individuals who died at rest.

CONCLUSION

A structurally normal heart at autopsy and myocardial diseases are the most common findings in athletes who died suddenly. While ACM is more common in black athletes, atherosclerotic CAD is more common in Asian athletes, with a strong association with exercise-induced SCD. ACM appears to be a driver of exercise-induced SCD in white athletes, however this is not the case in black and Asian athletes.

Diving Deep into Arrhythmias: Unravelling the Impact of Underwater Environments on Premature Ventricular Complexes in Divers

This review examines the relationship between the physiological demands of diving and premature ventricular complexes (PVCs) in divers. In the general population, some individuals have a greater tendency to experience PVCs, often without awareness or a clear understanding of the triggering factors. With the increasing availability and popularity of both scuba and apnoea diving, more people, including those with a predisposition to PVCs, are engaging in these activities. The underwater environment, with its unique stressors, may increase the risk of arrhythmogenic events, particularly PVCs. Here, we review the prevalence, pathophysiology, and aggravating factors of PVCs in divers, emphasising the need for a comprehensive cardiovascular assessment. Evidence suggests a higher prevalence of PVCs in divers compared with the general population, influenced by factors such as age, dive depth, gas bubbles, cold water immersion, pre-existing cardiovascular diseases, and lifestyle factors. The change in environment during diving could potentially trigger an increased frequency of PVCs, especially in individuals with a pre-existing tendency. We discuss diagnostic strategies, management approaches, and preventive measures for divers with PVCs, noting that although guidelines for athletes can be adapted, individual assessment is crucial. Significant knowledge gaps are identified, highlighting the need for future research to develop evidence-based guidelines and understand the long-term significance of PVCs in divers. This work aims to evaluate potential contributing factors to PVCs in divers and identify individuals who may be at higher risk of experiencing major adverse cardiovascular events (MACEs). This work aims to improve diver safety by promoting collaboration between cardiologists and diving medicine specialists and by identifying key areas for future investigation in this field. This work aims to improve the safety and well-being of divers by understanding the cardiovascular challenges they face, including pressure changes, cold water immersion, and hypoxia. We seek to elucidate the relationship between these challenges and the occurrence of PVCs. By synthesising current evidence, identifying knowledge gaps, and proposing preliminary recommendations, we aim to encourage collaboration between cardiologists and diving medicine specialists to optimise the screening, management, and risk stratification of PVCs in the diving population.

The role of exercise training on cardiovascular risk factors and heart disease in patients with chronic kidney disease G3-G5 and G5D: a Clinical Consensus Statement of the European Association of Preventive Cardiology of the ESC and the European Association of Rehabilitation in Chronic Kidney Disease

Cardiovascular (CV) morbidity and mortality is high in patients with chronic kidney disease (CKD). Most patients reveal a high prevalence of CV risk factors such as diabetes or arterial hypertension and many have manifest cardiovascular disease (CVD), such as coronary artery disease and chronic heart failure with an increased risk of clinical events including sudden cardiac death. Diabetes mellitus and hypertension contribute to the development of CKD and the prevalence of CKD is in the range of 20-65% in diabetic and 30-50% in hypertensive patients. Therefore, prevention and optimal treatment of CV risk factors and comorbidities are key strategies to reduce CV risk and improve survival in CKD. Beyond common CV risk factors, patients with CKD are often physically inactive and have low physical function leading to subsequent frailty with muscle fatigue and weakness, sarcopenia and increased risk of falling. Consequently, the economic health burden of CKD is high, requiring feasible strategies to counteract this vicious cycle. Regular physical activity and exercise training (ET) have been shown to be effective in improving risk factors, reducing CVD and reducing frailty and falls. Nonetheless, combining ET and a healthy lifestyle with pharmacological treatment is not frequently applied in clinical practice. For that reason, this Clinical Consensus Statement reviews the current literature and provides evidence-based data regarding the role of ET in reducing CV and overall burden in patients with CKD. The aim is to increase awareness among cardiologists, nephrologists, and healthcare professionals of the potential of exercise therapy in order to encourage implementation of ET in clinical practice, eventually reducing CV risk and disease, as well as reducing frailty in patients with CKD G3-G5D.

Prevalence and determinants of low QRS voltages and QRS fragmentation in children and adolescents undergoing sports pre-participation screening

AIMS

Low QRS voltages (LQRSV) in limb leads and QRS fragmentation (FQRS) are possible electrocardiographic signs of myocardial fibrosis and cardiomyopathy, but they are not listed in current criteria for interpreting athlete's electrocardiogram (ECG). We investigated the prevalence and determinants of LQRSV and FQRS in a cohort of young apparently healthy athletes undergoing pre-participation screening (PPS).

METHODS AND RESULTS

We analysed a consecutive series of 2140 ECG obtained during PPS of young athletes (mean age 12.5 ± 2.6 years, 7-18-year-old, 49% males). The peak-to-peak QRS voltage was measured in all limb leads, and LQRSV were defined when maximum value was <0.5 mV. Fragmented QRS morphologies were grouped into five patterns. Lead aVR was not considered. Maximum peak-to-peak QRS voltage in limb leads was 1.4 ± 0.4 mV, similar between younger and older athletes, but significantly lower in females than males (1.35 ± 0.38 mV vs. 1.45 ± 0.42 mV; P < 0.001). There was a weak correlation between maximal QRS voltages and body mass index (BMI), but not with type of sport or training load. Only five (0.2%) individuals showed LQRSV. At least one fragmented QRS complex was identified in 831 (39%) individuals but excluding the rSr' pattern in V1-V2, only 10 (0.5%) showed FQRS in ≥2 contiguous leads. They were older than those without FQRS, but did not differ in terms of gender, BMI, type of sport, or training load.

CONCLUSION

Low QRS voltages in limb leads and FQRS in ≥2 contiguous leads excluding V1-V2 are rare in young apparently healthy athletes and are not related to the type and intensity of sport activity. Therefore, they may require additional testing to rule out an underlying disease particularly when other abnormalities are present.

Health, burnout and well-being of UK cardiology trainees: insights from the British Junior Cardiologists' Association Survey

BACKGROUND

Cardiology training is demanding and associated with high workloads. Poor lifestyle and health among clinicians may stretch workforces and impact patient care. It has not been established what impact training in cardiology has on the doctors undertaking it. We aimed to establish the prevalence of physical and mental illness, burnout and the ability to maintain a healthy lifestyle among cardiology trainees in the United Kingdom (UK).

METHODS

The 2023 British Junior Cardiologists' Association training survey included questions on ill health, burnout, healthy living and invited responders to complete screening questionnaires for depression (Patient Health Questionnaire 9; PHQ-9) and anxiety (Generalised Anxiety Disorder 7; GAD-7). Significant anxiety and depression were defined as scoring within the moderate or severe range (PHQ-9≥10; GAD-7≥10). Burnout was a self-reported outcome. Poisson regression was used to determine prevalence ratios (PR) between univariate predictors of anxiety, depression and burnout.

RESULTS

Of 398 responders, 212 consented to answer health and well-being questions. Prior physical and mental health conditions were reported by 9% and 7% of trainees, respectively. Significant depression and anxiety symptoms were reported by 25% and 18% of trainees, respectively. Burnout was reported by 76% of trainees. Less than full-time trainees reported greater anxiety (PR 2.92, 95% CI 1.39 to 6.16, p<0.01) and depression (PR 3.66, 95% CI 2.24 to 5.98, p<0.01), while trainees with dependents reported less burnout (PR 0.77, 95% CI 0.65 to 0.92, p<0.01). Exercise, good sleep quality and maintaining a healthy diet were associated with less burnout and depressive symptoms (p<0.05). Half of trainees reported training having a negative impact on well-being, driven by the amount of service provision, curriculum requirements and lack of training opportunities.

CONCLUSIONS

The prevalence of anxiety, depression and burnout is high among UK cardiology trainees. Further work should establish the impact of cardiology trainee health on the quality of patient care. Training bodies should consider how occupational factors may contribute to health.

Associations of fear of physical activity, coping style and self-reported exercise behavior in patients with chronic heart failure

AIMS

Fear of physical activity (PA) is discussed as a barrier to regular exercise in patients with heart failure (HF), but HF-specific theoretical concepts are lacking. This study examined associations of fear of PA, heart-focused anxiety and trait anxiety with clinical characteristics and self-reported PA in outpatients with chronic HF. It was also investigated whether personality-related coping styles for dealing with health threats impact fear of PA via symptom perception.

METHODS AND RESULTS

This cross-sectional study enrolled 185 HF outpatients from five hospitals (mean age 62 ± 11 years, mean ejection fraction 36.0 ± 12%, 24% women). Avoidance of PA, sports/exercise participation (yes/no) and the psychological characteristics were assessed by self-reports. Fear of PA was assessed by the Fear of Activity in Situations-Heart Failure (FActS-HF15) questionnaire. In multivariable regression analyses higher NYHA class (b = 0.26, p = 0.036) and a higher number of HF drugs including antidepressants (b = 0.25, p = 0.017) were independently associated with higher fear of PA, but not with heart-focused fear and trait anxiety. Of the three anxiety scores only increased fear of PA was independently associated with more avoidance behavior regarding PA (b = 0.45, SE = 0.06, p < 0.001) and with increased odds of no sports/exercise participation (OR = 1.34, 95% CI 1.03-1.74, p = 0.028). Attention towards cardiac symptoms and symptom distress were positively associated with fear of PA (p < 0.001), which explained higher fear of PA in patients with a vigilant (directing attention towards health threats) coping style (p = 0.004).

CONCLUSIONS

Fear of PA assessed by the FActS-HF15 is a specific type of anxiety in patients with HF. Attention towards and being distressed by HF symptoms appear to play a central role in fear of PA, particularly in vigilant patients who are used to direct their attention towards health threats. These findings provide approaches for tailored interventions to reduce fear of PA and to increase PA in patients with HF.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02898246.

Effect of exercise training in patients with chronotropic incompetence and heart failure with preserved ejection fraction: Training-HR study protocol

BACKGROUND

Chronotropic incompetence (ChI) is linked with diminished exercise capacity in heart failure with preserved ejection fraction (HFpEF). Although exercise training has shown potential for improving functional capacity, the exercise modality associated with greater functional and chronotropic response (ChR) is not well-known. Additionally, how the ChR from different exercise modalities mediates functional improvement remains to be determined. This study aimed to evaluate the effect of three different exercise programs over current guideline recommendations on peak oxygen consumption (peakVO2) in patients with ChI HFpEF phenotype.

METHODS AND RESULTS

In this randomized clinical trial, 80 stable symptomatic patients with HFpEF and ChI (NYHA class II-III/IV) are randomized (1:1:1:1) to receive: a) a 12-week program of supervised aerobic training (AT), b) AT and low to moderate-intensity strength training, c)AT and moderate to high-intensity strength training, or d) guideline-based physical activity and exercise recommendations. The primary endpoint is 12-week changes in peakVO2. The secondary endpoints are 12-week changes in ChR, 12-week changes in quality of life, and how ChR changes mediate changes in peakVO2. A mixed-effects model for repeated measures will be used to compare endpoint changes. The mean age is 75.1 ± 7.2 years, and most patients are women (57.5 %) in New York Heart Association functional class II (68.7 %). The mean peakVO2, percent of predicted peakVO2, and ChR are 11.8 ± 2.6 mL/kg/min, 67.2 ± 14.7 %, and 0.39 ± 0.16, respectively. No significant baseline clinical differences between arms are found.

CONCLUSIONS

Training-HR will evaluate the effects of different exercise-based therapies on peakVO2, ChR, and quality of life in patients with ChI HFpEF phenotype.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT05649787).

Atrial Adaptations in Athletes Heart

BACKGROUND

Intensive training efforts are associated with hemodynamic changes accompanied by increases in cardiac output and stroke volume related to higher peak oxygen consumption and better athletic performance during exercise. These hemodynamic changes induce an enlargement of cardiac chambers, but also of the atria and may result in an athletes' heart (AH). Data from large studies about atrial enlargement in AH are sparse.

METHODS

Competitive athletes aged ≥18 years, who presented for pre-participation screening 04/2020-10/2021 were included in this study and stratified for AH (defined as physiologically increased heart volume >13.0 in males and >12.0 mL/kg in females).

RESULTS

Overall, 646 athletes aged ≥18 years (median age 24.0 [20.0/31.0] years; 206 [31.9%] females) were included in our study 04/2020-10/2021; among these, 118 (18.3%) had an AH. The computed absolute heart volume was 969.4 (853.1/1083.0) mL in athletes with AH and 841.3 (707.4/966.3) mL in those without AH (p < 0.001). AH was associated with larger left ventricular mass (206.6 ± 39.0 vs. 182.7 ± 44.2 g, p < 0.001). LA area (15.4 [13.7/18.2] vs. 14.3 [12.0/16.3] cm2, p < 0.001) and RA area (15.8 [13.8/18.6] vs. 14.5 [12.3/17.0] cm2, p < 0.001) were enlarged in AH versus those athletes without AH. The logistic regressions confirmed an independent association of AH on LV mass (OR 1.05 [95% CI 1.04-1.06], p < 0.001). LA area (OR 1.29 [95% CI 1.19-1.39], p < 0.001) as well as RA area (OR 1.28 [95% CI 1.19-1.38], p < 0.001) were afflicted by AH.

CONCLUSION

An AH is accompanied by significant enlargement of the atria as well as increased cardiac muscle mass.

BEAT-IT: A de-novo cardiac screening programme in Maltese adolescents

AIMS

Sudden cardiac death (SCD) in young individuals is often unexpected, provoking substantial emotional stress for family and friends of the deceased. Cardiac screening may identify individuals who harbour disorders linked to SCD. The feasibility and diagnostic yield of a nationwide cardiac screening programme in adolescents has never been explored.

METHODS

All individuals eligible for cardiac screening (students aged 15 years) were systematically invited to enrol. Students were provided with a health questionnaire. ECGs were acquired at school. A physician led consultation was carried out on site. Participants with an abnormal screen were then referred for secondary evaluation to the nation's tertiary centre. Feasibility criteria included a) participation rate >60%, b) adherence to secondary evaluation >80%, and c) cost per individual screened equating to <€100. The diagnostic yield was also evaluated.

RESULTS

At the end of enrolment, 2708 students gave consent (mean 15 years, 50.4% male), equating to 67.9% of the eligible cohort. Overall, 109 participants (4.0%) were referred for further evaluation. An abnormal electrocardiogram (ECG) was the most common reason for referral (3.7%). Fifteen individuals (0.6%) were diagnosed with a cardiac condition. Nine (0.3%) had a condition linked to SCD (n = 1 Long-QT syndrome, n = 1 Hypertrophic Cardiomyopathy, n = 5 Wolff-Parkinson White, n = 2 coronary anomalies). The yield was similar in athletes and non-athletes (p = 0.324). The cost per cardiac individual screened equated to €51.15.

CONCLUSION

A nationwide systematic cardiac screening programme for adolescent athletes and non-athletes is feasible and cost-efficient, provided that responsible centres have the appropriate infrastructure.

Physical activity, long-term fine particulate matter exposure and type 2 diabetes incidence: A prospective cohort study

Background

Despite the adverse effects of ambient fine particulate matter (PM2.5) on type 2 diabetes and the beneficial role of physical activity (PA), the influence of PM2.5 on the relationship between PA and type 2 diabetes remains unclear.

Methods

In this prospective study with 71,689 participants, PA was assessed by a questionnaire and was categorized into quartiles for volume and three groups for intensity. Long-term PM2.5 exposure was calculated using 1-km resolution satellite-based PM2.5 estimates. PM2.5 exposure and PA's effect on type 2 diabetes were assessed by cohort-stratified Cox proportional hazards models, individually and in combination.

Results

In 488,166 person-years of follow-up, 5487 incident type 2 diabetes cases were observed. The association between PA and type 2 diabetes was modified by PM2.5. Compared with the lowest quartile of PA volume, the highest quartile was associated with reduced type 2 diabetes risk in low PM2.5 stratification (≤65.02 µg/m3) other than in high PM2.5 stratification (>65.02 µg/m3), with the hazard ratio (HR) of 0.75 (95% confidence interval [CI]: 0.66-0.85) and 1.10 (95% CI: 0.99-1.22), respectively. Similar results were observed for PA intensity. High PM2.5 exposure combined with the highest PA levels increased the risk of type 2 diabetes the most (HR = 1.79, 95% CI: 1.59-2.01 for PA volume; HR = 1.82, 95% CI: 1.64-2.02 for PA intensity).

Conclusion

PA could reduce type 2 diabetes risk in low-pollution areas, but high PM2.5 exposure may weaken or even reverse the protective effects of PA. Safety and health benefits of PA should be thoroughly assessed for long-term polluted residents.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of a digital intervention on physical activity in adults: A randomized controlled trial in a large-scale sample

Background

Physical inactivity is associated with health risks, contributing to various diseases and all-cause mortality. Despite recommendations for regular physical activity (PA), many adults remain inactive, influenced by socioeconomic and environmental factors. Digital interventions, particularly web-based PA programs, offer promising possibilities to promote PA across populations. These programs vary in their effectiveness, reflecting differences in design, user engagement, and behavior change techniques employed.

Objective

This study evaluates the effectiveness of the 12-week multimodal web-based TKFitnessCoach. The PA online program is part of the TK-HealthCoach. This study investigates the program's impact on self-reported PA levels, goal attainment, healthrelated quality of life, body weight, and eating behavior, comparing an interactive personalized web-based intervention and non-interactive web-based health information.

Methods

In a randomized controlled trial (RCT), participants were allocated to either the intervention group (IG), receiving access to the interactive TK-FitnessCoach, or the control group (CG) that was provided a static website with evidence-based information on PA. The study targeted a German-speaking adult population interested in improving health behavior. Data was assessed at T0 (beginning of the study), T1 (postintervention), T2, 6 months, and T3, 12 months follow-ups, focusing on self-reported PA at T3 and on various secondary outcomes.

Results

We achieved equally distributed sociodemographics in both the IG and the CG with a mean age of 42.8 (IG), resp. 43.1 years (CG), and female participants of 76.1 % (IG), resp. 74.7 % (CG). PA at baseline was 277.9 min/week in the IG and 273.3 min/week in the CG. Both, the IG (n = 1153 in the Intention-to-treat (ITT) dataset) and CG (n = 1177 in the ITT dataset) exhibited significant increases in PA over time (IG(T3-T0) = 72.92 min/week; CG(T3-T0) = 74.12 min/week).However, the study did not find significant differences in the effectiveness of the interactive TK-FitnessCoach compared to the non-interactive control in terms of improving PA and related health outcomes. The intensity of using the TK-FitnessCoach was not associated with PA.

Conclusions

Both programs were effective in promoting PA among adults, with no significant differences observed between the two RCT groups. This highlights the potential of digital interventions in addressing physical inactivity, suggesting that the effectiveness of such programs may not solely depend on their interactivity but also on the quality and relevance of the information provided. Further research is needed to explore optimization strategies for such interventions, especially for persons with low PA, including user engagement, behavior change techniques, and the integration of objective PA tracking methods.

Trial registration

German Clinical Trials Register DRKS00020249; https://drks.de/search/en/trial/DRKS00020249.

What is the most appropriate age for the first cardiac screening of athletes?

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.

Exercise related versus non exercise related out of hospital cardiac arrest - A retrospective single-center study

Background

Physical activity prevents cardiovascular disease, but it may also trigger acute cardiac events like sudden cardiac death in patients with underlying heart disease. The chance of surviving an out-of-hospital cardiac arrest remains low, despite improving medical treatment and rescue chain. Prior studies signaled increased survival in exercise related out-of-hospital cardiac arrest.

Objective

The aim of this study was to evaluate the differences between exercise related out-of-hospital cardiac arrest and out-of-hospital cardiac arrest during daily activity in an urban setting.

Methods

Retrospective analysis of all out-of-hospital cardiac arrests from 2014 to 2021 treated at a cardiac arrest center of a tertiary hospital. The primary outcome was survival to discharge. Secondary outcomes included differences in pre-hospital care, in-hospital treatment, hypoxic ischemic encephalopathy, and laboratory parameters.

Results

478 OHCA patients were reviewed of which 432 patients (exercise related 36 (8.4%) vs. daily activity 396 (91.6%)) were included in the analysis. Patients suffering an exercise related arrest were younger (57 vs 65 years, p = 0.002) and mostly male (88.9 vs 74.5%, p = 0.054).The exercise related cohort received bystander cardiopulmonary resuscitation (77.8 vs 53.4%, p = 0.005) to a higher extent and had a shorter no-flow time (1.5 vs 2 min, p = 0.049). Exercise related arrest patients more often presented with a shockable rhythm (80.6 vs 64.1%, p = 0.032).At hospital admission exercise related arrest patients had a higher initial pH (7.24 vs 7.19, p = 0.015). In the exercise related group, a cardiac cause was numerically more frequent compared to the daily activity group (80.6 vs 68.7%, p = 0.09). In both groups myocardial infarction (47.2 vs 43.2%) was the most common cause, but a primary arrhythmic event (33.3 vs 25.5%) was more often documented in exercise related arrest patients. Exercise related arrest was mostly related to endurance training (52.8%) followed by ball sports (19.4%) and occurred directly during exercise in 77.8% of cases. Patients suffering exercise related arrest had higher survival till discharge (66.7 vs 47.7%, p = 0.036).

Conclusion

Based on this observational data from a highly selected group of out-of-hospital cardiac arrest patients treated at a cardiac arrest center, patients suffering an exercise related out-of-hospital cardiac arrest, differed in substantial characteristics and in the first line response compared to daily activity out-of-hospital cardiac arrest patients. The better survival to discharge of the exercise related out-of-hospital cardiac arrest group might be driven by these beneficial differences. This study underlines the need for public awareness for the importance of a fast first response and a broad distribution of automated external defibrillators in public sport areas since most of the exercise related out-of-hospital cardiac arrest patients presented with a cardiac cause and an initial shockable rhythm.

Multicomponent versus aerobic exercise intervention: Effects on hemodynamic, physical fitness and quality of life in adult and elderly cardiovascular disease patients: A randomized controlled study

Objective

Cardiovascular diseases (CVDs) remain a leading cause of mortality globally, emphasizing the need for effective preventive measures. This study aimed to investigate the effects of a multicomponent compared to an aerobic training program on the hemodynamic parameters, physical fitness, psychophysical health status and quality of life (QoL) of adults and elderly with stabilized CVDs.

Methods

Thirty-three subjects (19M and 14F; age 69.5 ± 4.9 years; BMI 27.34 ± 4.95 kg/m2) suffering from CVDs voluntarily participated in this 10-week randomized controlled study and were allocated into three groups: multicomponent training group (MTG; 6M, 6F; cardiorespiratory, resistance, flexibility and breathing exercises; 60', 2d·wk-1), aerobic training group (ATG; 7M, 5F; aerobic-only training; 60', 2d·wk-1) or a wait-list control group (CG; 6M, 3F; no PA). Hemodynamic parameters were assessed through resting hearth rate (RHR) and peripheral-systolic and diastolic blood pressure (P-SBP/P-DBP). Physical fitness was assessed via a 30" chair stand test (30CST), timed up and go (TUG) test, handgrip strength (HGS) test, and 2' step test (TMST). The health status, QoL and enjoyment were evaluated with short form-12 (SF-12), world health organization quality of life-bref (WHOQoL-bref) and physical activity enjoyment scale (PACES), respectively.

Results

After the intervention, MTG showed significant improvements in hemodynamic parameters (95 % CI, RHR: 2.76 to 9.07; P-SBP: 3.28 to 13.71; P-DBP: 3.56 to 8.94; p < 0.001), physical fitness (95 % CI, 30CST: 4.42 to -1.90; TUG: 0.56 to 1.58; TMST: 35.24 to -18.58; Dominant HGS: 4.00 to -1.65; Undominant HGS: 2.87 to -0.79, p < 0.001) and enjoyment (PACES: 15.18 to -5.48, p < 0.001) compared to CG; ATG showed significant improvement in hemodynamic parameters (95 % CI, RHR: 1.76 to 8.07; P-SBP: 3.19 to 13.63; P-DBP: 4.47 to 9.85, p < 0.001), physical fitness (95 % CI, 30CST: 2.59 to -0.07; TUG: 0.03 to 1.05; Dominant HGS: 2.42 to -0.07, p < 0.05; TMST: 36.08 to -19.41, p < 0.001) and enjoyment (PACES: 14.68 to -4.98, p < 0.001) compared to CG. No significant changes were observed in QoL and SF-12 (p > 0.05). Significant differences between MTG and ATG were only found in physical fitness variables (95 % CI, 30CST: 3.21 to -0.45, p < 0.01; Dominant HGS: 0.00 to 3.00, p < 0.05).

Conclusions

Findings showed significant improvements in hemodynamic parameters and physical fitness suggesting the effectiveness of the multicomponent exercise program, similar to aerobic-only training, and greater efficacy for lower limb strength and dominant hand grip strength in adults and elderly with stabilized CVDs. Both exercise groups showed similar levels of enjoyment.

AMPK Attenuation of β-Adrenergic Receptor-Induced Cardiac Injury via Phosphorylation of β-Arrestin-1-ser330

BACKGROUND

β-adrenergic receptor (β-AR) overactivation is a major pathological cue associated with cardiac injury and diseases. AMPK (AMP-activated protein kinase), a conserved energy sensor, regulates energy metabolism and is cardioprotective. However, whether AMPK exerts cardioprotective effects via regulating the signaling pathway downstream of β-AR remains unclear.

METHODS

Using immunoprecipitation, mass spectrometry, site-specific mutation, in vitro kinase assay, and in vivo animal studies, we determined whether AMPK phosphorylates β-arrestin-1 at serine (Ser) 330. Wild-type mice and mice with site-specific mutagenesis (S330A knock-in [KI]/S330D KI) were subcutaneously injected with the β-AR agonist isoproterenol (5 mg/kg) to evaluate the causality between β-adrenergic insult and β-arrestin-1 Ser330 phosphorylation. Cardiac transcriptomics was used to identify changes in gene expression from β-arrestin-1-S330A/S330D mutation and β-adrenergic insult.

RESULTS

Metformin could decrease cAMP/PKA (protein kinase A) signaling induced by isoproterenol. AMPK bound to β-arrestin-1 and phosphorylated Ser330 with the highest phosphorylated mass spectrometry score. AMPK activation promoted β-arrestin-1 Ser330 phosphorylation in vitro and in vivo. Neonatal mouse cardiomyocytes overexpressing β-arrestin-1-S330D (active form) inhibited the β-AR/cAMP/PKA axis by increasing PDE (phosphodiesterase) 4 expression and activity. Cardiac transcriptomics revealed that the differentially expressed genes between isoproterenol-treated S330A KI and S330D KI mice were mainly involved in immune processes and inflammatory response. β-arrestin-1 Ser330 phosphorylation inhibited isoproterenol-induced reactive oxygen species production and NLRP3 (NOD-like receptor protein 3) inflammasome activation in neonatal mouse cardiomyocytes. In S330D KI mice, the β-AR-activated cAMP/PKA pathways were attenuated, leading to repressed inflammasome activation, reduced expression of proinflammatory cytokines, and mitigated macrophage infiltration. Compared with S330A KI mice, S330D KI mice showed diminished cardiac fibrosis and improved cardiac function upon isoproterenol exposure. However, the cardiac protection exerted by AMPK was abolished in S330A KI mice.

CONCLUSIONS

AMPK phosphorylation of β-arrestin-1 Ser330 potentiated PDE4 expression and activity, thereby inhibiting β-AR/cAMP/PKA activation. Subsequently, β-arrestin-1 Ser330 phosphorylation blocks β-AR-induced cardiac inflammasome activation and remodeling.

The Spectrum of Coronary Artery Disease in Elite Endurance Athletes-A Long-Standing Debate: State-of-the-Art Review

Physical activity is recommended for the prevention of primary and secondary cardiovascular (CV) disease as it is linked to a number of health benefits, especially CV. However, recent research suggests that high-volume, long-term endurance exercise may hasten rather than slow the coronary atherosclerosis progression. This contentious theory has generated a great discussion and is still a major source of doubt when it comes to the clinical treatment of coronary artery disease (CAD) in athletes. CAD is the primary cause of sudden cardiac death in athletes over 35 years. Thus, recent studies evaluated the prevalence of CAD in athletes and its clinical and prognostic implications. Indeed, many studies have shown a relationship between endurance sports and higher volumes of coronary calcified plaque as determined by computed tomography. However, the precise pathogenetic substrate for the existence of an increased coronary calcification burden among endurance athletes remains unclear. Moreover, the idea that coronary plaques in elite athletes present a benign morphology has been cast into doubt by some recent studies showing potential association with adverse cardiovascular events. This review aims to analyze the association between physical activity and CAD, explaining possible underlying mechanisms of atherosclerotic progression and non-ischemic coronary lesions, focusing primarily on clinical and prognostic implications, multimodal evaluation, and management of CAD in endurance athletes.

Obesity and cardiovascular disease: an ESC clinical consensus statement

The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.

Obesity and cardiovascular disease: an ESC clinical consensus statement

The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.

Validation of activity trackers to estimate energy expenditure in older adults with cardiovascular risk factors

OBJECTIVES

To compare different types of activity trackers recording physical activity energy expenditure (PAEE) and examine their criterion validity against indirect calorimetry (IC) as the gold standard in adults over 60 years of age with a special focus on women with cardiovascular risk.

DESIGN

Synchronous registrations of PAEE were performed with up to four different devices to determine criterion validity against IC while participants performed a protocol of simulated activities in a laboratory setting.

METHOD

Thirty-four participants (25 women, 9 men) with at least a light cardiac risk performed a protocol of simulated activities in a laboratory setting (daily living activities, cycle ergometer test). PAEE was simultaneously assessed by IC, two research-grade activity trackers (ActiGraph-wGT3X-BT and Actiheart-4) and two consumer-level activity trackers (OMRON pedometer and Fitbit Charge-3). Tracker-derived PAEE was compared with PAEE calculated from IC descriptively and by Bland-Altman plots.

RESULTS

The ActiGraph (0.7 ± 0.4 kcal/min), the Actiheart (1.1 ± 0.6 kcal/min) and the OMRON (0.8 ± 0.6 kcal/min) underestimated, while the Fitbit (3.4 ± 1.2 kcal/min) overestimated PAEE compared to IC-PAEE (2.0 ± 0.5 kcal/min). The Bland-Altman limits of agreement (LoA) against IC were +0.5/+2.2 kcal/min for the ActiGraph, -0.3/+2.1 kcal/min for the Actiheart, -3.7/+1.0 kcal/min for the Fitbit, and -0.5/+2.9 kcal/min for the OMRON. The magnitude of the deviation varied considerably depending on the activity (e.g. walking, cleaning, cycle ergometer test).

CONCLUSIONS

The research-grade activity trackers estimated PAEE with higher validity than the commercially available activity trackers. The partly very wide LoA have to be critically considered when assessing PAEE in the context of health service research, as individual Physical Activity behaviour may be under- or overestimated.

Exercise intensity prescription in cardiovascular rehabilitation: bridging the gap between best evidence and clinical practice

Optimizing endurance exercise intensity prescription is crucial to maximize the clinical benefits and minimize complications for individuals at risk for or with cardiovascular disease (CVD). However, standardization remains incomplete due to variations in clinical guidelines. This review provides a practical and updated guide for health professionals on how to prescribe endurance exercise intensity for cardiovascular rehabilitation (CR) populations, addressing international guidelines, practical applicability across diverse clinical settings and resource availabilities. In the context of CR, cardiopulmonary exercise test (CPET) is considered the gold standard assessment, and prescription based on ventilatory thresholds (VTs) is the preferable methodology. In settings where this approach isn't accessible, which is frequently the case in low-resource environments, approximating VTs involves combining objective assessments-ideally, exercise tests without gas exchange analyses, but at least alternative functional tests like the 6-minute walk test-with subjective methods for adjusting prescriptions, such as Borg's ratings of perceived exertion and the Talk Test. Therefore, enhancing exercise intensity prescription and offering personalized physical activity guidance to patients at risk for or with CVD rely on aligning workouts with individual physiological changes. A tailored prescription promotes a consistent and impactful exercise routine for enhancing health outcomes, considering patient preferences and motivations. Consequently, the selection and implementation of the best possible approach should consider available resources, with an ongoing emphasis on strategies to improve the delivery quality of exercise training in the context of FITT-VP prescription model (frequency, intensity, time, type, volume, and progression).

Exercise and brain health in patients with coronary artery disease: study protocol for the HEART-BRAIN randomized controlled trial

Introduction

Patients with coronary artery disease (CAD) have a higher risk of developing cognitive impairment and mental health disorders compared to the general population. Physical exercise might improve their brain health. The overall goal of the HEART-BRAIN randomized controlled trial (RCT) is to investigate the effects of different types of exercise on brain health outcomes in patients with CAD, and the underlying mechanisms.

Methods

This three-arm, single-blinded RCT will include 90 patients with CAD (50-75 years). Participants will be randomized into: (1) control group-usual care (n = 30), (2) aerobic high-intensity interval training (HIIT) (n = 30), or (3) HIIT combined with resistance exercise training (n = 30). The 12-week intervention includes 3 supervised sessions (45-min each) per week for the exercise groups. Outcomes will be assessed at baseline and post-intervention. The primary outcome is to determine changes in cerebral blood flow assessed by magnetic resonance imaging. Secondary outcomes include changes in brain vascularization, cognitive measures (i.e., general cognition, executive function and episodic memory), and cardiorespiratory fitness. Additional health-related outcomes, and several potential mediators and moderators will be investigated (i.e., brain structure and function, cardiovascular and brain-based biomarkers, hemodynamics, physical function, body composition, mental health, and lifestyle behavior).

Conclusion

The HEART-BRAIN RCT will provide novel insights on how exercise can impact brain health in patients with CAD and the potential mechanisms explaining the heart-brain connection, such as changes in cerebral blood flow. The results may have important clinical implications by increasing the evidence on the effectiveness of exercise-based strategies to delay cognitive decline in this high-risk population.

Clinical trial registration

ClinicalTrials.gov, identifier [NCT06214624].

Prevention and rehabilitation after heart transplantation: A clinical consensus statement of the European Association of Preventive Cardiology, Heart Failure Association of the ESC, and the European Cardio Thoracic Transplant Association, a section of ESOT

Little is known either about either physical activity patterns, or other lifestyle-related prevention measures in heart transplantation (HTx) recipients. The history of HTx started more than 50 years ago but there are still no guidelines or position papers highlighting the features of prevention and rehabilitation after HTx. The aims of this scientific statement are (i) to explain the importance of prevention and rehabilitation after HTx, and (ii) to promote the factors (modifiable/non-modifiable) that should be addressed after HTx to improve patients' physical capacity, quality of life and survival. All HTx team members have their role to play in the care of these patients and multidisciplinary prevention and rehabilitation programmes designed for transplant recipients. HTx recipients are clearly not healthy disease-free subjects yet they also significantly differ from heart failure patients or those who are supported with mechanical circulatory support. Therefore, prevention and rehabilitation after HTx both need to be specifically tailored to this patient population and be multidisciplinary in nature. Prevention and rehabilitation programmes should be initiated early after HTx and continued during the entire post-transplant journey. This clinical consensus.

Sport PRactice and its Effects on aortic size and valve function in bicuspid Aortic valve Disease: a cross-sectional report from the SPREAD study

OBJECTIVE

Concerns exist about the possible detrimental effects of exercise training on aortic size and valve function in individuals with bicuspid aortic valve (BAV). This multicentre international study aimed to determine the characteristics of aortic size and valve function in athletes versus non-athletes with BAV and athletes with tricuspid aortic valve (TAV).

METHODS

We enrolled competitive athletes with BAV and age- and sex-matched athletes with TAV and non-athletes with BAV. We assessed valve function, aortic size and biventricular measures using echocardiography. Individuals with established moderate-severe AV stenosis, regurgitation or significant aortic dilation were excluded from the study.

RESULTS

The study population comprised 504 participants: 186 competitive athletes with BAV (84% males; age 30±11 years), 193 competitive athletes with TAV and 125 non-athletes with BAV. The aortic annulus was greater in athletes with BAV than athletes with TAV and non-athletes with BAV (p<0.001). Both athletic and non-athletic individuals with BAV had greater sinuses of Valsalva, sino-tubular junction and ascending aorta diameters than athletes with TAV (p<0.001). However, no significant differences were found between athletes and non-athletes with BAV. Left ventricular index volumes and mass were greater in athletes with BAV than in the other two groups (p<0.001). Individuals with BAV (athletes and non-athletes) had greater mean gradients than TAV athletes.

CONCLUSION

This multicentre international study demonstrates no differences between athletes with BAV and non-athletes with BAV regarding aortic valve function or aortic dimensions. However, athletes with BAV have larger aortic diameters and a relatively worse valvular function than athletes with TAV.

Arrhythmogenic Mitral Valve Prolapse Revisited: A Not Uncommon Cause of Youthful Sudden Death in Athletes and Women

BACKGROUND

Sudden deaths (SD) in young people including competitive athletes, albeit uncommon, are usually attributable to genetic, congenital or acquired cardiovascular conditions. However, it is under-appreciated that mitral valve prolapse (MVP), a relatively common valvular heart disease, is associated with SD in this youthful population.

METHODS

Forty-three MVP-related SDs are identified from 2 large cardiovascular registries with pathologic, clinical, and demographic findings reported.

RESULTS

Events occurred in both genders, but females were unexpectedly common (49%); median age was 22 ± 8 years, and 29 (67%) were engaged in competitive sports, including 17 with preparticipation examination. Of the 43 MVP cases, 21 died suddenly during or just after vigorous exercise including 6 during organized sports. Sixteen (37%) had been evaluated by a cardiologist resulting in confirmed MVP diagnosis in 11.. Pathologic findings characteristic of MVP included: bileaflet myxomatous involvement in all cases; and areas of interstitial or replacement myocardial fibrosis in 79%, most evident in posterolateral left ventricular wall.

CONCLUSIONS

Arrhythmogenic myxomatous degeneration (MVP) is an under-recognized cause of SD in young people including competitive athletes, disproportionally affecting females and requiring requires a high index of clinical suspicion. Frequency of left ventricular fibrosis in these young people with MVP suggests a mechanism for ventricular tachyarrhythmias and SD, relevant to future risk stratification.

Cardiovascular magnetic resonance feature tracking derived strain analysis can predict return to training following exertional heatstroke

BACKGROUND

Exertional heatstroke (EHS) is increasingly common in young trained soldiers. However, prognostic markers in EHS patients remain unclear. The objective of this study was to evaluate cardiovascular magnetic resonance (CMR) feature tracking derived left ventricle (LV) strain as a biomarker for return to training (RTT) in trained soldiers with EHS.

METHODS

Trained soldiers (participants) with EHS underwent CMR cine sequences between June 2020 and August 2023. Two-dimensional (2D) LV strain parameters were derived. At 3 months after index CMR, the participants with persistent cardiac symptoms including chest pain, dyspnea, palpitations, syncope, and recurrent heat-related illness were defined as non-RTT. Multivariable logistic regression analysis was used to develop a predictive RTT model. The performance of different models was compared using the area under curve (AUC).

RESULTS

A total of 80 participants (median age, 21 years; interquartile range (IQR), 20-23 years) and 27 health controls (median age, 21 years; IQR, 20-22 years) were prospectively included. Of the 77 participants, 32 had persistent cardiac symptoms and were not able to RTT at 3 months follow-up after experiencing EHS. The 2D global longitudinal strain (GLS) was significantly impaired in EHS participants compared to the healthy control group (-15.8 ± 1.7% vs -16.9 ± 1.2%, P = 0.001), which also showed significant statistical differences between participants with RTT and non-RTT (-15.0 ± 3.5% vs -16.5 ± 1.4%, P < 0.001). 2D-GLS (≤ -15.0%) (odds ratio, 1.53; 95% confidence interval: 1.08, 2.17; P = 0.016) was an independent predictor for RTT even after adjusting known risk factors. 2D-GLS provided incremental prognostic value over the clinical model and conventional CMR parameters model (AUCs: 0.72 vs 0.88, P = 0.013; 0.79 vs 0.88, P = 0.023; respectively).

CONCLUSION

Two-dimensional global longitudinal strain (≤ -15.0%) is an incremental prognostic CMR biomarker to predict RTT in soldiers suffering from EHS.

Effects of concurrent training and N-acetylcysteine supplementation on cardiac remodeling and oxidative stress in middle-aged spontaneously hypertensive rats

BACKGROUND

This study evaluated the effects of concurrent isolated training (T) or training combined with the antioxidant N-acetylcysteine (NAC) on cardiac remodeling and oxidative stress in spontaneously hypertensive rats (SHR).

METHODS

Six-month-old male SHR were divided into sedentary (S, n = 12), concurrent training (T, n = 13), sedentary supplemented with NAC (SNAC, n = 13), and concurrent training with NAC supplementation (TNAC, n = 14) groups. T and TNAC rats were trained three times a week on a treadmill and ladder; NAC supplemented groups received 120 mg/kg/day NAC in rat chow for eight weeks. Myocardial antioxidant enzyme activity and lipid hydroperoxide concentration were assessed by spectrophotometry. Gene expression of NADPH oxidase subunits Nox2, Nox4, p22 phox, and p47 phox was evaluated by real time RT-PCR. Statistical analysis was performed using ANOVA and Bonferroni or Kruskal-Wallis and Dunn.

RESULTS

Echocardiogram showed concentric remodeling in TNAC, characterized by increased relative wall thickness (S 0.40 ± 0.04; T 0.39 ± 0.03; SNAC 0.40 ± 0.04; TNAC 0.43 ± 0.04 *; * p < 0.05 vs T and SNAC) and diastolic posterior wall thickness (S 1.50 ± 0.12; T 1.52 ± 0.10; SNAC 1.56 ± 0.12; TNAC 1.62 ± 0.14 * mm; * p < 0.05 vs T), with improved contractile function (posterior wall shortening velocity: S 39.4 ± 5.01; T 36.4 ± 2.96; SNAC 39.7 ± 3.44; TNAC 41.6 ± 3.57 * mm/s; * p < 0.05 vs T). Myocardial lipid hydroperoxide concentration was lower in NAC treated groups (S 210 ± 48; T 182 ± 43; SNAC 159 ± 33 *; TNAC 110 ± 23 *# nmol/g tissue; * p < 0.05 vs S, # p < 0.05 vs T and SNAC). Nox 2 and p22 phox expression was higher and p47 phox lower in T than S [S 1.37 (0.66-1.66); T 0.78 (0.61-1.04) *; SNAC 1.07 (1.01-1.38); TNAC 1.06 (1.01-1.15) arbitrary units; * p < 0.05 vs S]. NADPH oxidase subunits did not differ between TNAC, SNAC, and S groups.

CONCLUSION

N-acetylcysteine supplementation alone reduces oxidative stress in untreated spontaneously hypertensive rats. The combination of N-acetylcysteine and concurrent exercise further decreases oxidative stress. However, the lower oxidative stress does not translate into improved cardiac remodeling and function in untreated spontaneously hypertensive rats.

Myocardial Fibrosis in Young and Veteran Athletes: Evidence from a Systematic Review of the Current Literature

Background: Exercise is associated with several cardiac adaptations that can enhance one's cardiac output and allow one to sustain a higher level of oxygen demand for prolonged periods. However, adverse cardiac remodelling, such as myocardial fibrosis, has been identified in athletes engaging in long-term endurance exercise. Cardiac magnetic resonance (CMR) imaging is considered the noninvasive gold standard for its detection and quantification. This review seeks to highlight factors that contribute to the development of myocardial fibrosis in athletes and provide insights into the assessment and interpretation of myocardial fibrosis in athletes. Methods: A literature search was performed using the PubMed/Medline database and Google Scholar for publications that assessed myocardial fibrosis in athletes using CMR. Results: A total of 21 studies involving 1642 endurance athletes were included in the analysis, and myocardial fibrosis was found in 378 of 1595 athletes. A higher prevalence was seen in athletes with cardiac remodelling compared to control subjects (23.7 vs. 3.3%, p < 0.001). Similarly, we found that young endurance athletes had a significantly higher prevalence than veteran athletes (27.7 vs. 19.9%, p < 0.001), while male and female athletes were similar (19.7 vs. 16.4%, p = 0.207). Major myocardial fibrosis (nonischaemic and ischaemic patterns) was predominately observed in veteran athletes, particularly in males and infrequently in young athletes. The right ventricular insertion point was the most common fibrosis location, occurring in the majority of female (96%) and young athletes (84%). Myocardial native T1 values were significantly lower in athletes at 1.5 T (p < 0.001) and 3 T (p = 0.004), although they had similar extracellular volume values to those of control groups. Conclusions: The development of myocardial fibrosis in athletes appears to be a multifactorial process, with genetics, hormones, the exercise dose, and an adverse cardiovascular risk profile playing key roles. Major myocardial fibrosis is not a benign finding and warrants a comprehensive evaluation and follow-up regarding potential cardiac disease.

Exploring the acceptability of three time-matched exercise interventions for increasing fitness in women living with obesity: A mixed-methods evaluation of the EXOFFIT study

Background

The EXOFFIT study compared the effectiveness of three time-matched exercise interventions in women with obesity for improving cardiorespiratory fitness. To best inform future research, evaluation of the interventions' acceptability is needed. Previous research has been inconsistent with methods and reporting of acceptability. Thus, the theoretical framework of acceptability (TFA) can be utilized to ensure that all aspects of acceptability are evaluated. No study to date in women with obesity has utilized the TFA in conjunction with quantitative data (i.e., frequencies of themes) to highlight the aspects of interventions that may be most important for participants.

Objective

This study aimed to examine the acceptability of the EXOFFIT program and gain insight into the participants' experience of participation, their perspective on the acceptability of trial procedures and interventions and gather their feedback on program changes.

Methods

A mixed-methods approach was employed. Thirty-eight participants who completed the exercise interventions were interviewed and completed a self-reported exit questionnaire. Interviews were transcribed verbatim and analyzed in three phases: emergent themes were agreed upon, then mapped to the TFA constructs and the frequencies of each construct and theme were presented as counts. Data collected from the exit questionnaire were collated and reported using descriptive statistics.

Results

All seven TFA constructs were identified in the analysis. The EXOFFIT program was found to have a high level of acceptability, with affective attitude, perceived effectiveness and self-efficacy being the most reported constructs. The burden and opportunity costs associated with the program were mainly related to family commitments and support needed to participate. Any negative impact of participation was noted to be outweighed by the perceived benefits.

Conclusions

The results of this study will inform the development of future programs with women with obesity and support the consideration of the TFA constructs from the outset of study design.Clinical Trial Registration Number: ISRCTN13517067.

2024 SIAC guidelines on cardiorespiratory rehabilitation in pediatric patients with congenital heart disease

The 2024 Interamerican Society of Cardiology (SIAC) guidelines on cardiorespiratory rehabilitation (CRR) in pediatric patients with congenital heart disease aim to gather and evaluate all relevant evidence available on the topic to unify criteria and promote the implementation of CRR programs in this population in Latin America and other parts of the world. Currently, there is no unified CRR model for the pediatric population. Consequently, our goal was to create these CRR guidelines adapted to the characteristics of congenital heart disease and the physiology of this population, as well as to the realities of Latin America. These guidelines are designed to serve as a support for health care workers involved in the care of this patient group who wish to implement a CRR program in their workplace. The guidelines include an easily reproducible program model that can be implemented in any center. The members of this Task Force were selected by the SIAC on behalf of health care workers dedicated to the care of pediatric patients with congenital heart disease. To draft the document, the selected experts performed a thorough review of the published evidence.

Diagnosis and treatment of myocarditis and inflammatory cardiomyopathy. Consensus document of the SEC-Working Group on Myocarditis

Myocarditis is defined as myocardial inflammation and its etiology is highly diverse, including infectious agents, drugs, and autoimmune diseases. The clinical presentation also varies widely, extending beyond the classic clinical picture of acute chest pain, and includes cases of cardiomyopathy of unknown cause whose etiology may be inflammatory. Because certain patients may benefit from targeted treatments, the search for the etiology should begin when myocarditis is first suspected. There remain several areas of uncertainty in the diagnosis and treatment of this disease. Consequently, this consensus document aims to provide clear recommendations for its diagnosis and treatment. Hence, a diagnostic algorithm is proposed, specifying when non-invasive diagnosis with cardiac MR is appropriate vs a noninvasive approach with endomyocardial biopsy. In addition, more novel aspects are discussed, such as when to suspect an underlying genetic etiology. The recommendations cover the management of myocarditis and inflammatory cardiomyopathy, both for general complications and specific clinical entities.

Association of accelerometer-derived physical activity with all-cause and cause-specific mortality among individuals with cardiovascular diseases: A prospective cohort study

AIMS

To investigate the association of accelerometer-measured intensity-specific physical activity (PA) with all-cause and cause-specific mortality among individuals with cardiovascular disease (CVD).

METHODS

In this prospective cohort study, 8,024 individuals with pre-existing CVD (mean age: 66.6 years, female: 34.1%) from the UK Biobank had their PA measured using wrist-worn accelerometers over a 7-day period in 2013-2015. All-cause, cancer, and CVD mortality was ascertained from death registries. Cox regression modelling and restricted cubic splines were used to assess the associations. Population-attributable fractions (PAFs) were used to estimate the proportion of preventable deaths if more PA were undertaken.

RESULTS

During an average of 6.8 years of follow-up, 691 deaths (273 from cancer and 219 from CVD) were recorded. An inverse non-linear association was found between PA duration and all-cause mortality risk, irrespective of PA intensity. The hazard ratio (HR) of all-cause mortality plateaued at 1800 minutes/week for light-intensity PA (LPA), 320 minutes/week for moderate-intensity PA (MPA) and 15 minutes/week for vigorous-intensity PA (VPA). The highest quartile of PA associated lower risks for all-cause mortality, with HRs of 0.63 (95% confidence interval [CI]: 0.51-0.79), 0.42 (0.33-0.54) and 0.47 (0.37-0.60) for LPA, MPA, and VPA, respectively. Similar associations were observed for cancer and CVD mortality. Additionally, the highest PAF were noted for VPA, followed by MPA.

CONCLUSION

We found an inverse non-linear association between all intensities of PA (LPA, MPA, VPA, and MVPA) and mortality risk in CVD patients using accelerometer-derived data, but with larger magnitude of the associations than that in previous studies based on self-reported PA.