The athlete's heart: is big beautiful?

Exercise-induced arterial hypertension - an independent factor for hypertrophy and a ticking clock for cardiac fatigue or atrial fibrillation in athletes?

Background : Exercise-induced arterial hypertension (EIAH) leads to myocardial hypertrophy and is associated with a poor prognosis. EIAH might be related to the "cardiac fatigue" caused by endurance training. The goal of this study was to examine whether there is any relationship between EIAH and left ventricular hypertrophy in Ironman-triathletes.

METHODS

We used echocardiography and spiroergometry to determine the left ventricular mass (LVM), the aerobic/anaerobic thresholds and the steady-state blood pressure of 51 healthy male triathletes. The main inclusion criterion was the participation in at least one middle or long distance triathlon.

RESULTS

When comparing triathletes with LVM <220g  and athletes with LVM >220g there was a significant difference between blood pressure values (BP) at the anaerobic threshold (185.2± 21.5 mmHg vs. 198.8 ±22.3 mmHg, p=0.037). The spiroergometric results were: maximum oxygen uptake (relative VO 2max) 57.3 ±7.5ml/min/kg vs. 59.8±9.5ml/min/kg (p=ns). Cut-point analysis for the relationship of BP >170 mmHg at the aerobic threshold and the probability of LVM >220g showed a sensitivity of 95.8%, a specificity of 33.3%, with a positive predictive value of 56.8 %, a good negative predictive value of 90%. The probability of LVM >220g increased with higher BP during exercise (OR: 1.027, 95% CI 1.002-1.052, p= 0.034) or with higher training volume (OR: 1.23, 95% CI 1.04 -1.47, p = 0.019). Echocardiography showed predominantly concentric remodelling, followed by concentric hypertrophy.

CONCLUSION

Significant left ventricular hypertrophy with LVM >220g is associated with higher arterial blood pressure at the aerobic or anaerobic threshold. The endurance athletes with EIAH may require a therapeutic intervention to at least prevent extensive stiffening of the heart muscle and exercise-induced cardiac fatigue.

The effect of exercise training on left ventricular function in young elite athletes

BACKGROUND

Regular training, in particular endurance exercise, induces structural myocardial adaptation, so-called "athlete's heart". In addition to the 2D standard echo parameters, assessment of myocardial function is currently possible by deformation parameters (strain, rotation and twist). Aim of study is to assess the role of rotation and twist parameters for better characterize the heart performance in trained elite young athletes from different kind of sports. Eventually, verify early on any possible impact due to the regular sport activity not revealed by the standard parameters.

METHODS

50 young athletes (16 cyclists, 17 soccer players, 17 basket players) regularly trained at least three times a week for at least 9 months a year and 10 young controls (mean age 18.5 ± 0.5 years) were evaluated either by to 2D echocardiography or by a Speckle Tracking (ST) multi-layer approach to calculate Left Ventricle (LV) endocardial and epicardial rotation, twist, circumferential strain (CS) and longitudinal strain (LS). Data were compared by ANOVA test.

RESULTS

All the found values were within the normal range. Left Ventricle Diastolic Diameter (LVDD 51.7 ± 2.6 mm), Cardiac Mass index (CMi 114.5 ± 18.5 g/m²), epi-CS, epi-LS, epicardial apex rotation and the Endo/Epi twist were significantly higher only in cyclists. In all the groups, a physiological difference of the Endo/Epi basal circumferential strain and twist values have been found. A weak but not significant relationship between the Endo and twist values and LVDD (r² = 0.44, p = .005) and CMi was also reported in cyclists.

CONCLUSIONS

Progressive increase of apical LV twist may represent an important component of myocardial remodelling. This aspect is particularly evident in the young cyclists group where the CMi and the LVDD are higher. ST multilayer approach completes the LV performance evaluation in young trained athletes showing values similar to adults.

[Sudden cardiac death in young athletes]

Cardiovascular diseases are the cause of death in up to 90% of athletes. The most frequent cause of death in young athletes is a sudden cardiac death (SCD). Causes of SCD among athletes are strongly correlated with age. In young athletes (< 35 years), the leading causes are congenital cardiac diseases, particularly hypertrophic cardiomyopathy and congenital coronary artery anomalies. By contrast, most of deaths in older athletes (< 35 years) are due to coronary artery disease. Although there is no possibility to decrease the risk of SCD to "zero", especially in sport competitions, clear recommendations, if available, for cardiovascular evaluation before athletic participation and side effects of sports activities, would minimize the frequency of SCD. If a specific condition of the cardiovascular system is diagnosed, it is necessary to establish the risk of SCD associated with a continual involvement in physical activities and competitive sports, and to define clearly disqualification criteria for each individual athlete.

Is the 'athlete's heart' arrhythmogenic? Implications for sudden cardiac death

Whether the ventricular hypertrophic response to athletic training can predispose to fatal ventricular dysrhythmias via mechanisms similar to that of pathological hypertrophy is controversial. This review examines current information regarding the metabolic and electrophysiological differences between the myocardial hypertrophy of heart disease and that associated with athletic training. In animal studies, the biochemical and metabolic profile of physiological hypertrophy from exercise training can largely be differentiated from that of pathological hypertrophy, but it is not clear if the former might represent an early stage in the spectrum of the latter. Information as to whether the electrical remodelling of the athlete's heart mimics that of patients with heart disease, and therefore serves as a substrate for ventricular dysrhythmias, is conflicting. If ventricular remodelling associated with athletic training can trigger fatal dysrhythmias, such cases are extraordinarily rare and thereby impossible to investigate by any standard experimental approach. Greater insight into this issue may come from a better understanding of the electrical responses to both acute bouts of exercise and chronic training in young athletes.

Hypertrophic cardiomyopathy in childhood

Hypertrophic cardiomyopathy has important differences in children compared with adults, particularly with regard to the range of causes and the outcomes in infants. Survival is highly dependent on etiology, particularly in the youngest patients, and pursuit of the specific cause is therefore necessary. The clinical utility of defining the genotype in children with familial hypertrophic cardiomyopathy exceeds that at other ages and has a highly favorable cost/benefit ratio. Although most of the available information concerning treatment and prevention of sudden death is derived in adults, management of children requires consideration of the differences in age-specific risk/benefit ratios.

Supernormal functional reserve of apical segments in elite soccer players: an ultrasound speckle tracking handgrip stress study

Background

Ultrasound speckle tracking from grey scale images allows the assessment of regional strain derived from 2D regardless of angle intonation, and it is highly reproducible. The study aimed to evaluate regional left ventricular functional reserve in elite soccer players.

Methods

50 subjects (25 elite athletes and 25 sedentary controls), aged 26 ± 3.5, were submitted to an echo exam, at rest and after the Hand Grip (HG) test. Both standard echo parameters and strain were evaluated.

Results

Ejection fraction was similar in athletes and controls both at rest (athletes 58 ± 2 vs controls 57 ± 4 p ns) and after HG (athletes 60 ± 2 vs controls 58 ± 3 p ns). Basal (septal and anterior) segments showed similar strain values in athletes and controls both at rest (athletes S% -19.9 ± 4.2; controls S% -18.8 ± 4.9 p = ns) and after HG (athletes S% -20.99 ± 2.8; controls S% -19.46 ± 4.4 p = ns). Medium-apical segments showed similar strain values at rest (athletes S% -17.31 ± 2.3; controls S% -20.00 ± 5.3 p = ns), but higher values in athletes after HG (athletes S% -24.47 ± 2.8; controls S% -20.47 ± 5.4 p < 0.05)

Conclusion

In athletes with physiological myocardial hypertrophy, a brief isometric effort produces enhancement of the strain in medium-apical left ventricular segments, suggesting the presence of a higher regional function reserve which can be elicited with an inotropic challenge and suitable methods of radial function quantification such as 2D-derived strain.

The role of echocardiography in the differential diagnosis between training induced myocardial hypertrophy versus cardiomyopathy

Increased myocardial mass due to regular high-volume intense exercise training (so-called athlete's heart) is not uncommon. Although directly correlated with the extent of training loads, myocardial hypertrophy is not present exclusively in well-trained or elite athletes. Athlete's heart is considered a physiological phenomenon with no known harmful consequences. However, extreme forms of myocardial hypertrophy due to endurance training resemble a structural heart disease such as hypertrophic cardiomyopathy, a condition associated with substantially increased risk of cardiac event. Endurance sports such as rowing and road cycling, rather than strength/power training, are most commonly associated with left ventricular (LV) wall thickness compatible with hypertrophic cardiomyopathy. The differentiation between physiological and maladaptive cardiac hypertrophy in athletes is undoubtedly important, since untreated cardiac abnormality often possesses a real threat of premature death due to heart failure during intense physical exertion. Luckily, the distinction from pathological hypertrophy is usually straightforward using transthoracic echocardiography, as endurance athletes, in addition to moderately and proportionally thickened LV walls with normal acoustic density, tend to possess increased LV diameter. In more uncertain cases, a detailed evaluation of myocardial function using (tissue) Doppler and contrast echocardiography is effective. When a doubt still remains, knowledge of an athlete's working capacity may be useful in evaluating whether the insidious cardiac pathology is absent. In such cases cardiopulmonary exercise testing typically resolves the dilemma: indices of aerobic capacity are markedly higher in healthy endurance athletes compared to patients. Other characteristics such as a decrease of LV mass due to training cessation are also discussed in the article. Key pointsTransthoracic echocardiography is still the most common relevant differentiation technique applied to distinguish athlete's heart from the cardiomyopathy.Conventional echocardiographic criteria such as left ventricular chamber size and diastolic function parameters are to be regarded first when making differential diagnosis between substantially increased wall thickness in athlete's heart (i.e. physiological adaptation) versus a disease (usually hypertrophic cardiomyopathy).When conventional echocardiographic parameters fail to diagnose the nature of myocardial hypertrophy, other differentiation criteria such as aerobic fitness, cardiac performance in response to physical exertion, and changes in echocardiographic parameters due to detraining, must be taken into consideration.Tissue Doppler, contrast and three-dimensional imaging are state-of-the-art echocardiographic techniques which have recently appeared in the differential diagnostics.

Akt1 Is Required for Physiological Cardiac Growth

Background— Postnatal growth of the heart chiefly involves nonproliferative cardiomyocyte enlargement. Cardiac hypertrophy exists in a “physiological” form that is an adaptive response to long-term exercise training and as a “pathological” form that often is a maladaptive response to provocative stimuli such as hypertension and aortic valvular stenosis. A signaling cascade that includes the protein kinase Akt regulates the growth and survival of many cell types, but the precise role of Akt1 in either form of cardiac hypertrophy is unknown.

Methods and Results— To evaluate the role of Akt1 in physiological cardiac growth, akt1 −/− adult murine cardiac myocytes (AMCMs) were treated with IGF-1, and akt1 −/− mice were subjected to exercise training. akt1 −/− AMCMs were resistant to insulin-like growth factor-1–stimulated protein synthesis. The akt1 −/− mice were found to be resistant to swimming training–induced cardiac hypertrophy. To evaluate the role of Akt in pathological cardiac growth, akt1 −/− AMCMs were treated with endothelin-1, and akt1 −/− mice were subjected to pressure overload by transverse aortic constriction. Surprisingly, akt1 −/− AMCMs were sensitized to endothelin-1–induced protein synthesis, and akt1 −/− mice developed an exacerbated form of cardiac hypertrophy in response to transverse aortic constriction.

Conclusions— These results establish Akt1 as a pivotal regulatory switch that promotes physiological cardiac hypertrophy while antagonizing pathological hypertrophy.

Multi-tasking RGS proteins in the heart: the next therapeutic target?

Regulator of G-protein-signaling (RGS) proteins play a key role in the regulation of G-protein-coupled receptor (GPCR) signaling. The characteristic hallmark of RGS proteins is a conserved approximately 120-aa RGS region that confers on these proteins the ability to serve as GTPase-activating proteins (GAPs) for G(alpha) proteins. Most RGS proteins can serve as GAPs for multiple isoforms of G(alpha) and therefore have the potential to influence many cellular signaling pathways. However, RGS proteins can be highly regulated and can demonstrate extreme specificity for a particular signaling pathway. RGS proteins can be regulated by altering their GAP activity or subcellular localization; such regulation is achieved by phosphorylation, palmitoylation, and interaction with protein and lipid-binding partners. Many RGS proteins have GAP-independent functions that influence GPCR and non-GPCR-mediated signaling, such as effector regulation or action as an effector. Hence, RGS proteins should be considered multifunctional signaling regulators. GPCR-mediated signaling is critical for normal function in the cardiovascular system and is currently the primary target for the pharmacological treatment of disease. Alterations in RGS protein levels, in particular RGS2 and RGS4, produce cardiovascular phenotypes. Thus, because of the importance of GPCR-signaling pathways and the profound influence of RGS proteins on these pathways, RGS proteins are regulators of cardiovascular physiology and potentially novel drug targets as well.

RGS4 reduces contractile dysfunction and hypertrophic gene induction in Galpha q overexpressing mice

The intrinsic GTPase activity of Galpha q is low, and RGS proteins which activate GTPase are expressed in the heart; however, their functional relevance in vivo is unknown. Transgenic mice with cardiac-specific overexpression of Galpha q in myocardium exhibit cardiac hypertrophy, enhanced PKC xi membrane translocation, embryonic gene expression, and depressed cardiac contractility. We recently reported that transgenic mice with cardiac-specific expression of RGS4, a Galpha q and Galpha i GTPase activator, exhibit decreased left ventricular hypertrophy and ANF induction in response to pressure overload. To test the hypothesis that RGS4 can act as a Galpha q-specific GTPase activating protein (GAP) in the in vivo heart, dual transgenic Galpha q-40xRGS4 mice were generated to determine if RGS4 co-expression would ameliorate the Galpha q-40 phenotype. At age 4 weeks, percent fractional shortening was normalized in dual transgenic mice as was left ventricular internal dimension and posterior and septal wall thicknesses. PKC xi membrane translocation and ANF and alpha -skeletal actin mRNA levels were also normalized. Compound transgenic mice eventually developed depressed cardiac contractility that was evident by 9 weeks of age. These studies establish for the first time a role for RGS4 as a GAP for Galpha q in the in vivo heart, and demonstrate that its regulated expression can have pathophysiologic consequences.

RGS4 causes increased mortality and reduced cardiac hypertrophy in response to pressure overload

RGS family members are GTPase-activating proteins (GAPs) for heterotrimeric G proteins. There is evidence that altered RGS gene expression may contribute to the pathogenesis of cardiac hypertrophy and failure. We investigated the ability of RGS4 to modulate cardiac physiology using a transgenic mouse model. Overexpression of RGS4 in postnatal ventricular tissue did not affect cardiac morphology or basal cardiac function, but markedly compromised the ability of the heart to adapt to transverse aortic constriction (TAC). In contrast to wild-type mice, the transgenic animals developed significantly reduced ventricular hypertrophy in response to pressure overload and also did not exhibit induction of the cardiac "fetal" gene program. TAC of the transgenic mice caused a rapid decompensation in most animals characterized by left ventricular dilatation, depressed systolic function, and increased postoperative mortality when compared with nontransgenic littermates. These results implicate RGS proteins as a crucial component of the signaling pathway involved in both the cardiac response to acute ventricular pressure overload and the cardiac hypertrophic program.

The impact of scalar variable and process on athlete-control comparisons of cardiac dimensions

PURPOSE

This study compared linear left ventricular dimensions and mass (LVM), before and after normalizing for body dimensions via allometric and ratio-standard scaling.

METHODS

Height (HT; m), body mass (BM; kg), body surface area (BSA; m2), and fat-free mass (FFM; kg) were measured in elite male weight lifters (N = 11) and age-matched controls (N = 45). Septum (ST), posterior wall (PWT), and internal dimension in diastole (LVIDd) were measured from M-mode echocardiographic traces and used to calculate LVM. Via multivariate allometric scaling, common group power function exponents were identified for all cardiac dimensions related to all body size scalars. t-tests were used to compare group differences in absolute and scaled data.

RESULTS

BM, FFM, and BSA, as well as absolute LVM (262 +/- 54 vs 206 +/- 39) and ST (11 +/- 1 vs 9 +/- 1), were greater in the athletes (P < 0.05). All exponents conformed to dimensionality theory within 95% confidence limits. Fat-free mass presented the highest multiple R value and the least residual sum of squares of any scalar variable. If FFM was used to scale, no difference in LVM remained (P > 0.05).

CONCLUSIONS

Data suggest that any group effect on cardiac dimensions is substantially altered by the scaling procedure. The choice of the most appropriate variable and process for partitioning out any effect of body dimensions on cardiac dimensions in similar studies requires attention.

Modeling the influence of body size and composition on M-mode echocardiographic dimensions

The purpose of this study was to determine the optimal index for normalizing left ventricular (LV) echocardiographic dimensions for differences in body size. M-mode echocardiograms defined LV internal dimension at end diastole (LVIDD) and LV wall thickness (LVWT) in 107 adults (59 male, 48 female). Allometric relations were assessed between cardiac dimensions (Y) and body size variables (X) of fat-free mass (FFM), height (H), body surface area (BSA), and fat mass (FM). Further to confirmation of homogeneity of regression slopes, size exponents common to both genders were fitted by a log-linear model: ln Y = ln a + c.gender + b.ln X, where a is the proportionality coefficient, b is the size exponent, and c is the gender coefficient. For LVIDD, mean body size exponents (95% confidence interval) were FFM0.35 (0.22-0.47), H0.68 (0.32-1.03), and BSA0.44 (0.26-0.62). For LVWT, the derived exponents were FFM0.43 (0.20-0.65), H0.65 (0-1.3), and BSA0.56 (0.23-0.89). Body fatness (expressed by FM) had no influence on LV dimensions, with exponents not different from zero (P > 0.05). The root-mean-squares error from the separate regression models indicated that the FFM index was the optimal solution. Indexation of LV dimensions by H was associated with the greatest error. Because the 95% confidence interval for the FFM exponents included 0.33, we recommend that linear LV dimensions be indexed by the cube root of FFM. In the absence of FFM data, the root of BSA was found to be the best surrogate index.

The power athlete

A number of normal daily and athletic activities require isometric or static exercise. Sports such as weight lifting and other high-resistance activities are used by power athletes to gain strength and skeletal muscle bulk. Static exercise, the predominant activity used in power training, significantly increases blood pressure, heart rate, myocardial contractility, and cardiac output. These changes occur in response to central neural irradiation, called central command, as well as a reflex originating from statically contracting muscle. Studies have demonstrated that blood pressure appears to be the regulated variable, presumably because the increased pressure provides blood flow into muscles whose arterial inflow is reduced as a result of increases in intramuscular pressure created by contraction. Thus, static exercise is characterized by a pressure load on the heart and can be differentiated from the hemodynamic response to dynamic (isotonic) exercise, which involves a volume load to the heart. Physical training with static exercise (i.e., power training) leads to concentric cardiac (particularly left ventricular) hypertrophy, whereas training with dynamic exercise leads to eccentric hypertrophy. The magnitude of cardiac hypertrophy is much less in athletes training with static than dynamic exercise. Neither systolic nor diastolic function is altered by the hypertrophic process associated with static exercise training. Many of the energy requirements for static exercise, particularly during more severe levels of exercise, are met by anaerobic glycolysis because the contracting muscle becomes comes deprived of blood flow. Power athletes, training with repetitive static exercise, derive little benefit from an increase in oxygen transport capacity, so that maximal oxygen consumption is increased only minimally or not at all. Peripheral cardiovascular adaptations also can occur in response to training with static exercise. Although the studies are controversial, these adaptations include modest decreases in resting blood pressure, reduced increases in blood pressure and sympathetic nerve activity during a given workload, enhanced baroreflex function, increases in muscle capillary-to-fiber ratio, possible improvements in lipid and lipoprotein profiles, and increases in glucose and insulin responsiveness. Some of these adaptations can occur in cardiac or hypertensive patients with no concomitant cardiovascular complications. In both healthy individuals and those with cardiovascular disease, the manner in which resistance training is performed may dictate the extent to which these adjustments take place. Specifically, training that involves frequent repetitions of moderate weight (and hence contains dynamic components) seems to produce the most beneficial results.

Evaluation of elite British cyclists: the role of the squad medical

OBJECTIVE

To describe and report results from the procedures and protocols used by the British Cycling Federation during the squad medicals of its elite cyclists.

METHODS

Screening of over 500 elite riders has been done by doctors, dentists, physiotherapists, opticians, and dietitians since 1990. A questionnaire provided additional information on musculoskeletal problems.

RESULTS

523 riders have been examined and 92 (17.5%) have been referred for further assessment or treatment. Most of these riders were sent either to their own general practitioner or to the British Olympic Medical Centre. The questionnaire was completed by 81% of riders. Low back pain was the most common problem that riders encountered (60%), and knee pain the second most common (33%). Four riders failed the eye examination, and a further 11 were classed as borderline. Twenty one per cent of riders undergoing dental examination needed further dental treatment.

CONCLUSIONS

The squad medical is an important and useful strategy for evaluating elite British cyclists. It shows that a structured system can help early diagnosis and treatment to provide injury-free cyclists at the start of a competitive season. The results from the questionnaire confirm previously unsubstantiated opinions about the incidence of musculoskeletal injuries in cyclists.