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Lampert R, Chung EH, Ackerman MJ, Arroyo AR, Darden D, Deo R, Dolan J, Etheridge SP, Gray BR, Harmon KG, James CA, Kim JH, Krahn AD, La Gerche A, Link MS, MacIntyre C, Mont L, Salerno JC, Shah MJ. 2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play. Heart Rhythm 2024:S1547-5271(24)02560-8. [PMID: 38763377 DOI: 10.1016/j.hrthm.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/09/2024] [Indexed: 05/21/2024]
Abstract
Youth and adult participation in sports continues to increase, and athletes may be diagnosed with potentially arrhythmogenic cardiac conditions. This international multidisciplinary document is intended to guide electrophysiologists, sports cardiologists, and associated health care team members in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction. Expert, disease-specific risk assessment in the context of athlete symptoms and diagnoses is emphasized throughout the document. After appropriate risk assessment, management of arrhythmias geared toward return to play when possible is addressed. Other topics include shared decision-making and emergency action planning. The goal of this document is to provide evidence-based recommendations impacting all areas in the care of athletes with arrhythmic conditions. Areas in need of further study are also discussed.
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Affiliation(s)
- Rachel Lampert
- Yale University School of Medicine, New Haven, Connecticut
| | - Eugene H Chung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Rajat Deo
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joe Dolan
- University of Utah, Salt Lake City, Utah
| | | | - Belinda R Gray
- University of Sydney, Camperdown, New South Wales, Australia
| | | | | | | | - Andrew D Krahn
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Andre La Gerche
- Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | | | - Lluis Mont
- Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Jack C Salerno
- University of Washington School of Medicine, Seattle, Washington
| | - Maully J Shah
- Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania
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2
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Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Card Electrophysiol Clin 2024; 16:35-49. [PMID: 38280813 PMCID: PMC11207195 DOI: 10.1016/j.ccep.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
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3
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Epstein R, Liberman L, Silver ES. Long-Term Follow-Up of Second-Degree Heart Block in Children. Pediatr Cardiol 2023; 44:1529-1535. [PMID: 37658175 DOI: 10.1007/s00246-023-03195-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 05/20/2023] [Indexed: 09/03/2023]
Abstract
Little is known about the outcomes of children with second-degree heart block. We aimed to determine whether children with structurally normal hearts and Mobitz 1, 2:1 block or Mobitz 2 are at increased risk for progressing to complete heart block (CHB) or requiring a pacemaker (PM) at long-term follow-up. We searched our institutional electrophysiology database for children with potentially concerning second-degree block on ambulatory rhythm monitoring between 2009 and 2021, defined as frequent episodes of Mobitz 1 or 2:1 block, episodes of Mobitz 1 or 2:1 block with additional evidence of conduction disease (i.e. first-degree heart block, bundle branch block), or episodes of Mobitz 2. Ambulatory rhythm monitor, ECG, and demographic data were reviewed. The primary composite outcome was CHB on follow-up rhythm monitor or PM placement. 20 patients were in the final analysis. Six (30%) patients either developed CHB but do not have a PM (4 = 20%) or have a PM (2 = 10%). Median follow-up was 5.8 years (IQR 4.4-7.0). Patients with CHB or PM were more likely to have second-degree block at maximum sinus rate (67% vs. 0%, p = 0.003), a below normal average heart rate (67% vs. 14%, p = 0.04), and 2:1 block on initial ECG (50% vs. 0%, p = 0.02). In this study of children with potentially concerning second-degree block, 30% of patients progressed to CHB or required a PM. Second-degree block at maximum sinus rate, a low average heart, and 2:1 block on initial ECG were associated with increased risk of disease progression.
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Affiliation(s)
- Rebecca Epstein
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, 3959 Broadway, New York, NY, 10032, USA.
| | - Leonardo Liberman
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, 3959 Broadway, New York, NY, 10032, USA
| | - Eric S Silver
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, 3959 Broadway, New York, NY, 10032, USA
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Carstensen H, Nissen SD, Saljic A, Hesselkilde EM, van Hunnik A, Hohl M, Sattler SM, Fløgstad C, Hopster-Iversen C, Verheule S, Böhm M, Schotten U, Jespersen T, Buhl R. Long-Term Training Increases Atrial Fibrillation Sustainability in Standardbred Racehorses. J Cardiovasc Transl Res 2023; 16:1205-1219. [PMID: 37014465 PMCID: PMC10615936 DOI: 10.1007/s12265-023-10378-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/14/2023] [Indexed: 04/05/2023]
Abstract
Atrial fibrillation (AF) is more prevalent in athletes, and currently, the mechanisms are not fully understood. Atrial fibrillation inducibility and stability was investigated in trained and untrained Standardbred racehorses. The horses underwent echocardiography for evaluation of atrial size. High-density mapping during AF was performed, and the presence of structural remodeling, as well as the expression of inflammatory and pro-inflammatory markers in the atria, was studied. Atrial fibrillation sustained significantly longer after tachypacing in the trained horses, whereas no difference in AF inducibility was found. The untrained horses displayed a significant difference in the AF complexity when comparing right and left atria, whereas such difference was not observed in the trained animals. No evidence of increased structural remodeling or inflammation could be identified. Left atrial dimensions were not significantly increased. The increased AF sustainability in trained horses was not related to fibrosis or inflammation as seen in other animal exercise models.
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Affiliation(s)
- Helena Carstensen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark
| | - Sarah Dalgas Nissen
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.
| | - Arnela Saljic
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Eva Melis Hesselkilde
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Arne van Hunnik
- Department of Physiology, Maastricht University, Maastricht, Netherlands
| | - Mathias Hohl
- Department of Internal Medicine III, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Stefan Michael Sattler
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Cecilie Fløgstad
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark
| | - Charlotte Hopster-Iversen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark
| | - Sander Verheule
- Department of Physiology, Maastricht University, Maastricht, Netherlands
| | - Michael Böhm
- Department of Internal Medicine III, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, Maastricht, Netherlands
| | - Thomas Jespersen
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Rikke Buhl
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark
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5
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Graziano F, Mastella G, Merkely B, Vago H, Corrado D, Zorzi A. Ventricular arrhythmias recorded on 12-lead ambulatory electrocardiogram monitoring in healthy volunteer athletes and controls: what is common and what is not. Europace 2023; 25:euad255. [PMID: 37589170 PMCID: PMC10469403 DOI: 10.1093/europace/euad255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 07/29/2023] [Accepted: 08/14/2023] [Indexed: 08/18/2023] Open
Abstract
AIMS Premature ventricular beats (PVBs) in athletes are often benign, but sometimes they may be a sign of an underlying disease. We evaluated the prevalence, burden, and morphology of PVBs in healthy voluntary athletes and controls with the main purpose of defining if certain PVB patterns are 'common' and 'training related' and, as such, are more likely benign. METHODS AND RESULTS We studied 433 healthy competitive athletes [median age 27 (18-43) years, 74% males] and 261 age- and sex-matched sedentary subjects who volunteered to undergo 12-lead 24 h ambulatory electrocardiogram (ECG) monitoring (24H ECG), with a training session in athletes. Ventricular arrhythmias (VAs) were evaluated in terms of their number, complexity [i.e. couplet, triplet, or non-sustained ventricular tachycardia (NSVT)], exercise inducibility, and morphology. Eighty-six percent of athletes and controls exhibited a total of ≤10 PVBs/24 h, and >90% did not show any couplets, triplets, or runs of NSVT > 3 beats. An higher number of PVBs correlated with increasing age (P < 0.01) but not with sex and level of training. The most frequent morphologies among the 36 athletes with >50 PVBs were the infundibular (44%) and fascicular (22%) ones. In a comparison between athletes and sedentary individuals, and male and female athletes, no statistically significant differences were found in PVBs morphologies. CONCLUSION The prevalence and complexity of VAs at 24H ECG did not differ between athletes and sedentary controls and were not related to the type and amount of sport or sex. Age was the only variable associated with an increased PVB burden. Thus, no PVB pattern in the athlete can be considered 'common' or 'training related'.
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Affiliation(s)
- Francesca Graziano
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
- Department of Sports Medicine, Semmelweis University, Budapest, Hungary
| | - Giulio Mastella
- Klinikum Rechts der Isar-Innere Medizin I, Technische Universität München, Munchen, Germany
| | - Bela Merkely
- Department of Sports Medicine, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Hajnalka Vago
- Department of Sports Medicine, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
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Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Cardiol Clin 2023; 41:35-49. [PMID: 36368810 PMCID: PMC10292923 DOI: 10.1016/j.ccl.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
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7
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Graziano F, Juhasz V, Brunetti G, Cipriani A, Szabo L, Merkely B, Corrado D, D’Ascenzi F, Vago H, Zorzi A. May Strenuous Endurance Sports Activity Damage the Cardiovascular System of Healthy Athletes? A Narrative Review. J Cardiovasc Dev Dis 2022; 9:jcdd9100347. [PMID: 36286299 PMCID: PMC9604467 DOI: 10.3390/jcdd9100347] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 11/18/2022] Open
Abstract
The positive effects of physical activity are countless, not only on the cardiovascular system but on health in general. However, some studies suggest a U-shape relationship between exercise volume and effects on the cardiovascular system. On the basis of this perspective, moderate-dose exercise would be beneficial compared to a sedentary lifestyle, while very high-dose physical activity would paradoxically be detrimental. We reviewed the available evidence on the potential adverse effects of very intense, prolonged exercise on the cardiovascular system, both acute and chronic, in healthy athletes without pre-existing cardiovascular conditions. We found that endurance sports activities may cause reversible electrocardiographic changes, ventricular dysfunction, and troponin elevation with complete recovery within a few days. The theory that repeated bouts of acute stress on the heart may lead to chronic myocardial damage remains to be demonstrated. However, male veteran athletes with a long sports career show an increased prevalence of cardiovascular abnormalities such as electrical conduction delay, atrial fibrillation, myocardial fibrosis, and coronary calcifications compared to non-athletes. It must be underlined that the cause-effect relationship between such abnormalities and the exercise and, most importantly, the prognostic relevance of such findings remains to be established.
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Affiliation(s)
- Francesca Graziano
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 35122 Padova, Italy
| | - Vencel Juhasz
- Heart and Vascular Center of Semmelweis University, Hataror Rd. 18, 1122 Budapest, Hungary
| | - Giulia Brunetti
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 35122 Padova, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 35122 Padova, Italy
| | - Liliana Szabo
- Heart and Vascular Center of Semmelweis University, Hataror Rd. 18, 1122 Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center of Semmelweis University, Hataror Rd. 18, 1122 Budapest, Hungary
- Department of Sports Medicine, Semmelweis University, Gaal Jozsef Str. 9-11, 1122 Budapest, Hungary
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 35122 Padova, Italy
| | - Flavio D’Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Hajnalka Vago
- Heart and Vascular Center of Semmelweis University, Hataror Rd. 18, 1122 Budapest, Hungary
- Department of Sports Medicine, Semmelweis University, Gaal Jozsef Str. 9-11, 1122 Budapest, Hungary
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 35122 Padova, Italy
- Correspondence: ; Tel.: +39-049-8212322
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Sampognaro JR, Barth AS, Jun JC, Chrispin J, Berger RD, Love CJ, Eddy C, Calkins H. Prolonged asystole during REM sleep: A case report and review of the literature. Heart Rhythm O2 2022; 3:613-619. [PMID: 36340493 PMCID: PMC9626887 DOI: 10.1016/j.hroo.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- James R. Sampognaro
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andreas S. Barth
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan C. Jun
- Division of Pulmonary and Critical Care, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan Chrispin
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ronald D. Berger
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles J. Love
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Courtney Eddy
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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9
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Nissen SD, Weis R, Krag-Andersen EK, Hesselkilde EM, Isaksen JL, Carstensen H, Kanters JK, Linz D, Sanders P, Hopster-Iversen C, Jespersen T, Pehrson S, Buhl R. Electrocardiographic characteristics of trained and untrained standardbred racehorses. J Vet Intern Med 2022; 36:1119-1130. [PMID: 35488721 PMCID: PMC9151491 DOI: 10.1111/jvim.16427] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 04/01/2022] [Accepted: 04/02/2022] [Indexed: 11/28/2022] Open
Abstract
Background Long‐term exercise induces cardiac remodeling that potentially influences the electrical properties of the heart. Hypothesis/objectives We assessed whether training alters cardiac conduction in Standardbred racehorses. Animals Two hundred one trained and 52 untrained Standardbred horses. Methods Cross‐sectional study. Resting ECG recordings were analyzed to assess heart rate (HR) along with standard ECG parameters and for identification of atrial and ventricular arrhythmias. An electrophysiological study was performed in 13 horses assessing the effect of training on sinoatrial (SA) and atrioventricular (AV) nodal function by sinus node recovery time (SNRT) and His signal recordings. Age and sex adjustments were implemented in multiple and logistic regression models for comparison. Results Resting HR in beats per minute (bpm) was lower in trained vs untrained horses (mean, 30.8 ± 2.6 bpm vs 32.9 ± 4.2 bpm; P = .001). Trained horses more often displayed second‐degree atrioventricular block (2AVB; odds ratio, 2.59; P = .04). No difference in SNRT was found between groups (n = 13). Mean P‐A, A‐H, and H‐V intervals were 71 ± 20, 209 ± 41, and 134 ± 41 ms, respectively (n = 7). We did not detect a training effect on AV‐nodal conduction intervals. His signals were present in 1 horse during 2AVB with varying H‐V interval preceding a blocked beat. Conclusions and Clinical Importance We identified decreased HR and increased frequency of 2AVB in trained horses. In 5 of 7 horses, His signal recordings had variable H‐V intervals within each individual horse, providing novel insight into AV conduction in horses.
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Affiliation(s)
- Sarah D Nissen
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rikke Weis
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Elisabeth K Krag-Andersen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Eva M Hesselkilde
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas L Isaksen
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Helena Carstensen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Jørgen K Kanters
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dominik Linz
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Cardiology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands.,Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Charlotte Hopster-Iversen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Thomas Jespersen
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Steen Pehrson
- Department of Cardiology 2142, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Rikke Buhl
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
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Heidbuchel H, Adami PE, Antz M, Braunschweig F, Delise P, Scherr D, Solberg EE, Wilhelm M, Pelliccia A. Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions: Part 1: Supraventricular arrhythmias. A position statement of the Section of Sports Cardiology and Exercise from the European Association of Preventive Cardiology (EAPC) and the European Heart Rhythm Association (EHRA), both associations of the European Society of Cardiology. Eur J Prev Cardiol 2021; 28:1539-1551. [PMID: 32597206 DOI: 10.1177/2047487320925635] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 01/02/2023]
Abstract
Symptoms attributable to arrhythmias are frequently encountered in clinical practice. Cardiologists and sport physicians are required to identify high-risk individuals harbouring such conditions and provide appropriate advice regarding participation in regular exercise programmes and competitive sport. The three aspects that need to be considered are: (a) the risk of life-threatening arrhythmias by participating in sports; (b) control of symptoms due to arrhythmias that are not life-threatening but may hamper performance and/or reduce the quality of life; and (c) the impact of sports on the natural progression of the underlying arrhythmogenic condition. In many cases, there is no unequivocal answer to each aspect and therefore an open discussion with the athlete is necessary, in order to reach a balanced decision. In 2006 the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology published recommendations for participation in leisure-time physical activity and competitive sport in individuals with arrhythmias and potentially arrhythmogenic conditions. More than a decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of these conditions. The present document presents a combined effort by the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology and the European Heart Rhythm Association to offer a comprehensive overview of the most updated recommendations for practising cardiologists and sport physicians managing athletes with supraventricular arrhythmias, and provides pragmatic advice for safe participation in recreational physical activities, as well as competitive sport at amateur and professional level. A companion text on recommendations in athletes with ventricular arrhythmias, inherited arrhythmogenic conditions, pacemakers and implantable defibrillators is published as Part 2 in Europace.
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Affiliation(s)
- Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp, Belgium
| | - Paolo E Adami
- Italian National Olympic Committee, Institute of Sport Medicine and Science, Italy
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Germany
| | | | | | - Daniel Scherr
- Department of Medicine, Medical University of Graz, Austria
| | | | | | - Antonio Pelliccia
- Italian National Olympic Committee, Institute of Sport Medicine and Science, Italy
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11
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Cussen A, Harding A. Improvement of atrioventricular block with weight restoration in an adolescent with anorexia nervosa. J Paediatr Child Health 2021; 57:2001-2004. [PMID: 33600018 DOI: 10.1111/jpc.15393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/21/2021] [Accepted: 01/29/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Alexandra Cussen
- Department of Paediatrics, Austin Health, Melbourne, Victoria, Australia
| | - Anton Harding
- Department of Paediatrics, Austin Health, Melbourne, Victoria, Australia.,Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Women's and Children's Clinical Institute, Epworth Hospital, Melbourne, Victoria, Australia
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12
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Heidbuchel H, Arbelo E, D'Ascenzi F, Borjesson M, Boveda S, Castelletti S, Miljoen H, Mont L, Niebauer J, Papadakis M, Pelliccia A, Saenen J, Sanz de la Garza M, Schwartz PJ, Sharma S, Zeppenfeld K, Corrado D. Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators. Europace 2021; 23:147-148. [PMID: 32596731 DOI: 10.1093/europace/euaa106] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.
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Affiliation(s)
- Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp, University Antwerp, Wilrijkstraat 10, 2650 Antwerp, Belgium
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Flavio D'Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Mats Borjesson
- Centre for Health and Performance (CHP), Department of Food, Nutrition and Sport Sciences, Gothenburg University, Sweden.,Department of Neuroscience and Physiology, Gothenburg University, Gothenburg, Sweden
| | - Serge Boveda
- Cardiology Department, Clinique Pasteur, 45 Avenue de Lombez, 31076 Toulouse, France
| | - Silvia Castelletti
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Laboratory of Cardiovascular Genetics, Milan, Italy
| | - Hielko Miljoen
- Department of Cardiology, University Hospital Antwerp, University Antwerp, Wilrijkstraat 10, 2650 Antwerp, Belgium
| | - Lluis Mont
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Josef Niebauer
- Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Michael Papadakis
- Cardiology Clinical Academic Group, St. George's University of London, London, UK.,St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Antonio Pelliccia
- National Institute of Sports Medicine, Italian National Olympic Committee, Via dei Campi Sportivi 46, Rome, Italy
| | - Johan Saenen
- Department of Cardiology, University Hospital Antwerp, University Antwerp, Wilrijkstraat 10, 2650 Antwerp, Belgium
| | | | - Peter J Schwartz
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Laboratory of Cardiovascular Genetics, Milan, Italy
| | - Sanjay Sharma
- Cardiology Clinical Academic Group, St. George's University of London, London, UK.,St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Domenico Corrado
- Department of Cardiology, University of Padova, Padova, Italy.,Department of Pathology, University of Padova, Padova, Italy
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13
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Regulation of sinus node pacemaking and atrioventricular node conduction by HCN channels in health and disease. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2021; 166:61-85. [PMID: 34197836 DOI: 10.1016/j.pbiomolbio.2021.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/02/2021] [Accepted: 06/14/2021] [Indexed: 12/19/2022]
Abstract
The funny current, If, was first recorded in the heart 40 or more years ago by Dario DiFrancesco and others. Since then, we have learnt that If plays an important role in pacemaking in the sinus node, the innate pacemaker of the heart, and more recently evidence has accumulated to show that If may play an important role in action potential conduction through the atrioventricular (AV) node. Evidence has also accumulated to show that regulation of the transcription and translation of the underlying Hcn genes plays an important role in the regulation of sinus node pacemaking and AV node conduction under normal physiological conditions - in athletes, during the circadian rhythm, in pregnancy, and during postnatal development - as well as pathological states - ageing, heart failure, pulmonary hypertension, diabetes and atrial fibrillation. There may be yet more pathological conditions involving changes in the expression of the Hcn genes. Here, we review the role of If and the underlying HCN channels in physiological and pathological changes of the sinus and AV nodes and we begin to explore the signalling pathways (microRNAs, transcription factors, GIRK4, the autonomic nervous system and inflammation) involved in this regulation. This review is dedicated to Dario DiFrancesco on his retirement.
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14
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Mesirca P, Nakao S, Nissen SD, Forte G, Anderson C, Trussell T, Li J, Cox C, Zi M, Logantha S, Yaar S, Cartensen H, Bidaud I, Stuart L, Soattin L, Morris GM, da Costa Martins PA, Cartwright EJ, Oceandy D, Mangoni ME, Jespersen T, Buhl R, Dobrzynski H, Boyett MR, D'Souza A. Intrinsic Electrical Remodeling Underlies Atrioventricular Block in Athletes. Circ Res 2021; 129:e1-e20. [PMID: 33849278 DOI: 10.1161/circresaha.119.316386] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Pietro Mesirca
- IGF, Université de Montpellier, CNRS, INSERM, France (P.M., I.B., M.E.M.)
| | - Shu Nakao
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
- Department of Biomedical Sciences, Ritsumeikan University, Japan (S.N.)
| | - Sarah Dalgas Nissen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences (S.D.N., H.C., R.B.), University of Copenhagen, Denmark
| | - Gabriella Forte
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Cali Anderson
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Tariq Trussell
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Jue Li
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Charlotte Cox
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Min Zi
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Sunil Logantha
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, United Kingdom (S.L.)
| | - Sana Yaar
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Helena Cartensen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences (S.D.N., H.C., R.B.), University of Copenhagen, Denmark
| | - Isabelle Bidaud
- IGF, Université de Montpellier, CNRS, INSERM, France (P.M., I.B., M.E.M.)
| | - Luke Stuart
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | | | - Gwilym M Morris
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | | | - Elizabeth J Cartwright
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Delvac Oceandy
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Matteo E Mangoni
- IGF, Université de Montpellier, CNRS, INSERM, France (P.M., I.B., M.E.M.)
| | - Thomas Jespersen
- Department of Biomedical Sciences (T.J., M.R.B.), University of Copenhagen, Denmark
| | - Rikke Buhl
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences (S.D.N., H.C., R.B.), University of Copenhagen, Denmark
| | - Halina Dobrzynski
- Department of Anatomy, Jagiellonian University Medical College, Poland (H.D.)
| | - Mark R Boyett
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
- Department of Biomedical Sciences (T.J., M.R.B.), University of Copenhagen, Denmark
| | - Alicia D'Souza
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
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15
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Osteraas N. Neurologic complications of brady-arrhythmias. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:163-174. [PMID: 33632435 DOI: 10.1016/b978-0-12-819814-8.00006-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Brady-arrhythmias are responsible for both overt as well as subtle neurologic signs and symptoms, from the seemingly benign and nonspecific symptoms associated with presyncope, to sudden focal neurologic deficits. A brief background on nodal and infra-nodal brady-arrhythmias is provided, followed by extensive discussion regarding neurologic complications of brady-arrhythmias. The multiple mechanisms of and associations between Brady-arrhythmias and transient ischemic attacks and ischemic stroke are discussed. Controversial associations between brady-arrhythmias and neurologic disease are discussed as well, such as potential roles of brady-arrhythmias in cognitive impairment and sequelae of chronotropic incompetence; and the contribution of brady-arrhythmias to syncope and associated injuries to the nervous system. The chapter is written to stand on its own, with guidance toward other pertinent sections of this text where appropriate for further reading.
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Affiliation(s)
- Nicholas Osteraas
- Department of Neurologic Sciences, Rush University, Chicago, IL, United States.
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16
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Benchimol-Barbosa PR, Nasario Junior O, Nadal J. Assessing Dynamic Atrioventricular Conduction Time to RR-interval Coupling in Athletes and Sedentary Subjects. Arq Bras Cardiol 2020; 115:71-77. [PMID: 32401843 PMCID: PMC8384324 DOI: 10.36660/abc.20190281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/01/2019] [Indexed: 11/18/2022] Open
Abstract
Background Atrioventricular conduction time ( AVCT ) is influenced by autonomic input and subject to physiological remodeling. Objective To evaluate beat-by-beat AVCT and RR-interval variability in athletes and healthy sedentary subjects. Methods Twenty adults, including 10 healthy sedentary (Controls) and 10 elite long-distance runners (Athletes), age, weight and height-adjusted, underwent maximal metabolic equivalent (MET) assessment, and 15-min supine resting ECG recording seven days later. The interval between P-wave and R-wave peaks defined the AVCT . Mean (M) and standard deviation (SD) of consecutive RR-intervals (RR) and coupled AVCT were calculated, as well as regression lines of RR vs. AVCT (RR-AVCT) . Concordant AV conduction was defined as positive RR-AVCT slope and discordant otherwise. A multivariate linear regression model was developed to explain MET based on AVCT and RR-interval variability parameters. Significance-level: 5 %. Results In Athletes, M-RR and SD-RR values were higher than in Controls, whereas M-AVCT and SD-AVCT were not. RR-AVCT slopes were, respectively, 0.038 ± 0.022 and 0.0034 ± 0.017 (p < 0.05). Using a cut-off value of 0.0044 (AUC 0.92 ± 0.07; p < 0.001), RR-AVCT slope showed 100% specificity and 80% sensitivity. In a multivariate model, SD-RR and RR-AVCT slope were independent explanatory variables of MET (F-ratio: 17.2; p < 0.001), showing 100% specificity and 90% sensitivity (AUC 0.99 ± 0.02; p < 0.001). Conclusion In elite runners, AVCT to RR -interval dynamic coupling shows spontaneous discordant AV conduction, characterized by negative AVCT vs. RR -interval regression line slope. RR -intervals standard deviation and AVCT vs. RR -interval regression line slope are independent explanatory variables of MET (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).
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Affiliation(s)
| | - Olivassé Nasario Junior
- Instituto Alberto Luiz Coimbra de Pós-Graduação e Pesquisa de Engenharia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Jurandir Nadal
- Instituto Alberto Luiz Coimbra de Pós-Graduação e Pesquisa de Engenharia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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17
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Beirne E, Saklani P, Latchem D. 256 Syncope in an Endurance Athlete with 9 Second Ventricular Pauses - not What You Expect - A Case Report. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Clarke JD, Ul Haq F, Ranjan S, Zarich S. Demonstrating synchronization of isorhythmic dissociation with stress testing. Clin Case Rep 2020; 8:232-234. [PMID: 31998529 PMCID: PMC6982486 DOI: 10.1002/ccr3.2591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/04/2019] [Accepted: 11/14/2019] [Indexed: 11/05/2022] Open
Abstract
There are a variety of causes of atrial and ventricular dyssynchrony. The mechanism underlying the arrhythmia is usually a guide to further management. This case highlights the key distinguishing features of more benign etiologies.
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Affiliation(s)
| | - Faheem Ul Haq
- Department of CardiologyYale‐New Haven Health/Bridgeport HospitalBridgeportCTUSA
| | - Saurabh Ranjan
- Department of CardiologyYale‐New Haven Health/Bridgeport HospitalBridgeportCTUSA
| | - Stuart Zarich
- Department of CardiologyYale‐New Haven Health/Bridgeport HospitalBridgeportCTUSA
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19
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Corrado D, Drezner JA, D'Ascenzi F, Zorzi A. How to evaluate premature ventricular beats in the athlete: critical review and proposal of a diagnostic algorithm. Br J Sports Med 2019; 54:1142-1148. [PMID: 31481389 PMCID: PMC7513269 DOI: 10.1136/bjsports-2018-100529] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2019] [Indexed: 12/31/2022]
Abstract
Although premature ventricular beats (PVBs) in young people and athletes are usually benign, they may rarely mark underlying heart disease and risk of sudden cardiac death during sport. This review addresses the prevalence, clinical meaning and diagnostic/prognostic assessment of PVBs in the athlete. The article focuses on the characteristics of PVBs, such as the morphological pattern of the ectopic QRS and the response to exercise, which accurately stratify risk. We propose an algorithm to help the sport and exercise physician manage the athlete with PVBs. We also address (1) which athletes need more indepth investigation, including cardiac MRI to exclude an underlying pathological myocardial substrate, and (2) which athletes can remain eligible to competitive sports and who needs to be excluded.
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Affiliation(s)
- Domenico Corrado
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Jonathan A Drezner
- Stadium Sports Medicine Center, University of Washington, Seattle, Washington, USA
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
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20
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D’Souza A, Trussell T, Morris GM, Dobrzynski H, Boyett MR. Supraventricular Arrhythmias in Athletes: Basic Mechanisms and New Directions. Physiology (Bethesda) 2019; 34:314-326. [DOI: 10.1152/physiol.00009.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Athletes are prone to supraventricular rhythm disturbances including sinus bradycardia, heart block, and atrial fibrillation. Mechanistically, this is attributed to high vagal tone and cardiac electrical and structural remodeling. Here, we consider the supporting evidence for these three pro-arrhythmic mechanisms in athletic human cohorts and animal models, featuring current controversies, emerging data, and future directions of relevance to the translational research agenda.
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Affiliation(s)
- Alicia D’Souza
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Tariq Trussell
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Gwilym M. Morris
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Halina Dobrzynski
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Mark R. Boyett
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
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21
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Heart Rhythm 2019; 16:e128-e226. [DOI: 10.1016/j.hrthm.2018.10.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Indexed: 12/13/2022]
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22
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2019; 140:e382-e482. [DOI: 10.1161/cir.0000000000000628] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | - Kenneth A. Ellenbogen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- ACC/AHA Representative
| | - Michael R. Gold
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- HRS Representative
| | | | | | - José A. Joglar
- ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | | | | | | | | | | | | | - Cara N. Pellegrini
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information
- HRS Representative
- Dr. Pellegrini contributed to this article in her personal capacity. The views expressed are her own and do not necessarily represent the views of the US Department of Veterans Affairs or the US government
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. J Am Coll Cardiol 2019; 74:e51-e156. [DOI: 10.1016/j.jacc.2018.10.044] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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24
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary. J Am Coll Cardiol 2019; 74:932-987. [DOI: 10.1016/j.jacc.2018.10.043] [Citation(s) in RCA: 144] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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25
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Bonikowske AR, Barout A, Fortin-Gamero S, Lara MIB, Kapa S, Allison TG. Frequency and characteristics of exercise-induced second-degree atrioventricular block in patients undergoing stress testing. J Electrocardiol 2019; 54:54-60. [DOI: 10.1016/j.jelectrocard.2019.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/19/2019] [Accepted: 03/13/2019] [Indexed: 12/25/2022]
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26
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: Executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Heart Rhythm 2018; 16:e227-e279. [PMID: 30412777 DOI: 10.1016/j.hrthm.2018.10.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Indexed: 12/22/2022]
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Circulation 2018; 140:e333-e381. [PMID: 30586771 DOI: 10.1161/cir.0000000000000627] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | | | | | | | - Kenneth A Ellenbogen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information.,ACC/AHA Representative
| | - Michael R Gold
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information.,HRS Representative
| | | | | | - José A Joglar
- ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | | | | | | | | | | | | | - Cara N Pellegrini
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information.,HRS Representative.,Dr. Pellegrini contributed to this article in her personal capacity. The views expressed are her own and do not necessarily represent the views of the US Department of Veterans Affairs or the US government
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Zorzi A, Mastella G, Cipriani A, Berton G, Del Monte A, Gusella B, Nese A, Portolan L, Sciacca F, Tikvina S, Tollot S, Trovato D, Iliceto S, Schiavon M, Corrado D. Burden of ventricular arrhythmias at 12-lead 24-hour ambulatory ECG monitoring in middle-aged endurance athletes versus sedentary controls. Eur J Prev Cardiol 2018; 25:2003-2011. [DOI: 10.1177/2047487318797396] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Whether prolonged and intense exercise increases the incidence of ventricular arrhythmias in middle-aged athletes remains to be established. Design Prospective, case-control. Methods We studied 134 healthy competitive athletes >30 years old (median age 45 (39–51) years, 83% males) who had been engaged in 9 ± 2 h per week of endurance sports activity (running, cycling, triathlon) for 13 ± 4 consecutive years. One hundred and thirty-four age- and gender-matched individuals served as controls. Both groups underwent 12-lead 24-h ambulatory electrocardiogram monitoring, which included a training session in athletes. Ventricular arrhythmias were evaluated in terms of number, complexity (i.e. couplet, triplet or non-sustained ventricular tachycardia), exercise-inducibility and morphology. Results Thirty-five (26%) athletes and 31 (23%) controls showed >10 isolated premature ventricular beats or ≥1 complex ventricular arrhythmia ( p = 0.53). Athletes with ventricular arrhythmias were older (median 48 versus 43 years old, p = 0.03) but did not differ with regard to hours of training and years of activity compared with athletes without ventricular arrhythmias. Ten (7%) athletes and six (5%) controls showed >500 premature ventricular beats/24 h ( p = 0.30): the most common ventricular arrhythmia morphologies were infundibular (six athletes and five controls) and fascicular (two athletes and one control). Conclusions The prevalence of ventricular arrhythmias at 24-hour ambulatory electrocardiogram monitoring did not differ between middle-aged athletes and sedentary controls and was unrelated to the amount and duration of exercise. These findings do not support the hypothesis that endurance sports activity increases the burden of ventricular arrhythmias. Among individuals with frequent premature ventricular beats, the predominant ectopic QRS morphologies were consistent with the idiopathic and benign nature of the arrhythmia.
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Affiliation(s)
- Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Giulio Mastella
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Giampaolo Berton
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Alvise Del Monte
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Beatrice Gusella
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Alberto Nese
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Leonardo Portolan
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Federico Sciacca
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Suada Tikvina
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Saverio Tollot
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Domenico Trovato
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Maurizio Schiavon
- Physical Activity and Sports Medicine Unit, AULSS 6 Euganea, Padova, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
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29
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Zorzi A, De Lazzari M, Mastella G, Niero A, Trovato D, Cipriani A, Peruzza F, Portolan L, Berton G, Sciacca F, Tollot S, Palermo C, Bellu R, D'ascenzi F, Muraru D, Badano LP, Iliceto S, Schiavon M, Perazzolo Marra M, Corrado D. Ventricular Arrhythmias in Young Competitive Athletes: Prevalence, Determinants, and Underlying Substrate. J Am Heart Assoc 2018; 7:e009171. [PMID: 29886418 PMCID: PMC6220536 DOI: 10.1161/jaha.118.009171] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/03/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Whether ventricular arrhythmias (VAs) represent a feature of the adaptive changes of the athlete's heart remains elusive. We aimed to assess the prevalence, determinants, and underlying substrates of VAs in young competitive athletes. METHOD AND RESULTS We studied 288 competitive athletes (age range, 16-35 years; median age, 21 years) and 144 sedentary individuals matched for age and sex who underwent 12-lead 24-hour ambulatory electrocardiographic monitoring. VAs were evaluated in terms of number, complexity (ie, couplet, triplet, or nonsustained ventricular tachycardia), exercise inducibility, and morphologic features. Twenty-eight athletes (10%) and 13 sedentary individuals (11%) showed >10 isolated premature ventricular beats (PVBs) or ≥1 complex VA (P=0.81). Athletes with >10 isolated PVBs or ≥1 complex VA were older (median age, 26 versus 20 years; P=0.008) but did not differ with regard to type of sport, hours of training, and years of activity compared with the remaining athletes. All athletes with >10 isolated PVBs or ≥1 complex VA had a normal echocardiographic examination; 17 of them showing >500 isolated PVBs, exercise-induced PVBs, and/or complex VA underwent additional cardiac magnetic resonance, which demonstrated nonischemic left ventricular late gadolinium enhancement in 3 athletes with right bundle branch block PVBs morphologic features. CONCLUSIONS The prevalence of >10 isolated PVBs or ≥1 complex VA at 24-hour ambulatory electrocardiographic monitoring did not differ between young competitive athletes and sedentary individuals and was unrelated to type, intensity, and years of sports practice. An underlying myocardial substrate was uncommon and distinctively associated with right bundle branch block VA morphologic features.
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Affiliation(s)
- Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Manuel De Lazzari
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Giulio Mastella
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Alice Niero
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Domenico Trovato
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Francesco Peruzza
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Leonardo Portolan
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Giampaolo Berton
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Federco Sciacca
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Saverio Tollot
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Chiara Palermo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Roberto Bellu
- Division of Cardiology, Policlinico Abano Terme, Padova, Italy
| | - Flavio D'ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Italy
| | - Denisa Muraru
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Luigi Paolo Badano
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
| | - Maurizio Schiavon
- Physical Activity and Sports Medicine Unit, AULSS 6 Euganea, Padova, Italy
| | | | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy
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30
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Drago F, Battipaglia I, Di Mambro C. Neonatal and Pediatric Arrhythmias: Clinical and Electrocardiographic Aspects. Card Electrophysiol Clin 2018; 10:397-412. [PMID: 29784491 DOI: 10.1016/j.ccep.2018.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Arrhythmias have acquired a specific identity in pediatric cardiology, but for pediatric cardiologists it has always been difficult to recognize and treat them. Changes in anatomy and physiology result in electrocardiogram features that differ from the normal adult pattern and vary according to the age of the child. Sinus arrhythmia, ectopic atrial rhythm, "wandering pacemaker," and junctional rhythm can be normal characteristics in children (15%-25% of healthy children can have these rhythms on the electrocardiogram). Tachyarrhythmias and bradyarrhythmias must be treated according to the severity of symptoms, and the patient's age and weight.
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Affiliation(s)
- Fabrizio Drago
- Paediatric Cardiology and Cardiac Arrhythmias Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Piazza Sant'Onofrio 4, Rome 00165, Italy.
| | - Irma Battipaglia
- Paediatric Cardiology and Cardiac Arrhythmias Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Piazza Sant'Onofrio 4, Rome 00165, Italy
| | - Corrado Di Mambro
- Paediatric Cardiology and Cardiac Arrhythmias Unit, Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Piazza Sant'Onofrio 4, Rome 00165, Italy
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31
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Sanders RA, Kurosawa TA, Sist MD. Ambulatory electrocardiographic evaluation of the occurrence of arrhythmias in healthy Salukis. J Am Vet Med Assoc 2018; 252:966-969. [DOI: 10.2460/javma.252.8.966] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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32
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Tobon DP, Falk TH. Adaptive Spectro-Temporal Filtering for Electrocardiogram Signal Enhancement. IEEE J Biomed Health Inform 2018; 22:421-428. [DOI: 10.1109/jbhi.2016.2638120] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
INTRODUCTION Premature ventricular beats (PVBs) in competitive athletes are incidentally found during pre-participation ECG screening. Their clinical significance remains debatable with several studies suggesting they are a benign reflection of athlete's heart, and others proposing they may indicate underlying structural heart disease and heightened risk for sudden cardiac death (SCD). Areas covered: Effective management of athletes with PVBs may best be accomplished using an algorithmic approach for risk stratification with a goal of differentiating benign PVBs from those reflective of underlying cardiomyopathies. Current AHA/ACC consensus recommendations provide a platform for determining optimal medical and invasive therapeutic strategies for symptom control and management of long-term complications without erroneously restricting an athlete's ability to play. Utilizing a shared decision-making model is an optimal method for managing expectations and guiding exercise recommendations. Expert commentary: Though pre-participation ECG screening as the standard of care for competitive athletes remains controversial in the United States, a 12-lead ECG is often the first indication of underlying structural heart disease in athletes with PVBs and can therefore identify athletes at greater risk of SCD. Advancements in non-invasive imaging continue to improve in diagnostic potential and prognostication. Invasive therapies provide a curative strategy for refractory PVBs and PVB-induced cardiomyopathy.
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Affiliation(s)
- Tamanna K Singh
- a Cardiovascular Performance Program, Division of Cardiology , Massachusetts General Hospital , Boston , MA , USA
| | - Aaron L Baggish
- a Cardiovascular Performance Program, Division of Cardiology , Massachusetts General Hospital , Boston , MA , USA
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34
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Affiliation(s)
- Andrew D'Silva
- Clinical Cardiology and Academic Group, St George's University of London,, London, UK
| | - Sanjay Sharma
- Clinical Cardiology and Academic Group, St George's University of London,, London, UK
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35
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Flannery MD, Kalman JM, Sanders P, La Gerche A. State of the Art Review: Atrial Fibrillation in Athletes. Heart Lung Circ 2017; 26:983-989. [DOI: 10.1016/j.hlc.2017.05.132] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 05/16/2017] [Accepted: 05/19/2017] [Indexed: 01/27/2023]
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36
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37
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Heidbüchel H, Panhuyzen-Goedkoop N, Corrado D, Hoffmann E, Biffi A, Delise P, Blomstrom-Lundqvist C, Vanhees L, Ivarhoff P, Dorwarth U, Pelliccia A. Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions Part I: Supraventricular arrhythmias and pacemakers. ACTA ACUST UNITED AC 2016; 13:475-84. [PMID: 16874135 DOI: 10.1097/01.hjr.0000216543.54066.72] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This document by the Study Group on Sports Cardiology of the European Society of Cardiology extends on previous recommendations for sports participation for competitive athletes by also incorporating guidelines for those who want to perform recreational physical activity. For different supraventricular arrhythmias and arrhythmogenic conditions, a description of the relationship between the condition and physical activity is given, stressing how arrhythmias can be influenced by exertion or can be a reflection of the (patho)physiological cardiac adaptation to sports participation itself. The following topics are covered in this text: sinus bradycardia; atrioventricular nodal conduction disturbances; pacemakers; atrial premature beats; paroxysmal supraventricular tachycardia without pre-excitation; pre-excitation, asymptomatic or with associated arrhythmias (i.e. Wolff-Parkinson-White syndrome); atrial fibrillation; and atrial flutter. A related document discusses ventricular arrhythmias, channelopathies and implantable cardioverter defibrillators.
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Affiliation(s)
- Hein Heidbüchel
- Department of Cardiology-Electrophysiology, University Hospital Gasthuisberg, Leuven, Belgium.
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38
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Quintana DS, Alvares GA, Heathers JAJ. Guidelines for Reporting Articles on Psychiatry and Heart rate variability (GRAPH): recommendations to advance research communication. Transl Psychiatry 2016; 6:e803. [PMID: 27163204 PMCID: PMC5070064 DOI: 10.1038/tp.2016.73] [Citation(s) in RCA: 232] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 03/18/2016] [Accepted: 03/23/2016] [Indexed: 12/11/2022] Open
Abstract
The number of publications investigating heart rate variability (HRV) in psychiatry and the behavioral sciences has increased markedly in the last decade. In addition to the significant debates surrounding ideal methods to collect and interpret measures of HRV, standardized reporting of methodology in this field is lacking. Commonly cited recommendations were designed well before recent calls to improve research communication and reproducibility across disciplines. In an effort to standardize reporting, we propose the Guidelines for Reporting Articles on Psychiatry and Heart rate variability (GRAPH), a checklist with four domains: participant selection, interbeat interval collection, data preparation and HRV calculation. This paper provides an overview of these four domains and why their standardized reporting is necessary to suitably evaluate HRV research in psychiatry and related disciplines. Adherence to these communication guidelines will help expedite the translation of HRV research into a potential psychiatric biomarker by improving interpretation, reproducibility and future meta-analyses.
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Affiliation(s)
- D S Quintana
- Division of Mental Health and Addiction, NORMENT, KG Jebsen Centre for Psychosis Research, University of Oslo, Oslo University Hospital, Oslo, Norway,Division of Mental Health and Addiction, NORMENT, KG Jebsen Centre for Psychosis Research, University of Oslo, Oslo University Hospital, Building 49, Oslo University Hospital, Ullevål, Kirkeveien 166, PO Box 4956, Nydalen, Oslo N-0424, Norway. E-mail:
| | - G A Alvares
- Telethon Kids Institute, University of Western Australia, Perth, WA, Australia,Cooperative Research Centre for Living with Autism (Autism CRC), Brisbane, QLD, Australia
| | - J A J Heathers
- School of Psychology, University of Sydney, Sydney, NSW, Australia,Department of Cardiology and Intensive Therapy, Poznań University of Medical Sciences, Poznań, Poland
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39
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Senturk T, Xu H, Puppala K, Krishnan B, Sakaguchi S, Chen LY, Karim R, Dickinson O, Benditt DG. Cardiac pauses in competitive athletes: a systematic review examining the basis of current practice recommendations. Europace 2015; 18:1873-1879. [PMID: 26590379 DOI: 10.1093/europace/euv373] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/14/2015] [Indexed: 11/15/2022] Open
Abstract
AIMS It is generally recommended that individuals aspiring to competitive sports should undergo pre-participation cardiovascular assessment, particularly including arrhythmia risk evaluation. In regard to bradyarrhythmias, the 36th Bethesda Conference suggested that asymptomatic cardiac pauses ≤3 s are 'probably of no significance', whereas longer 'symptomatic' pauses may be abnormal. This study focused on assessing the evidence for the '3 s' threshold. METHODS A systematic literature search was undertaken including Embase (1980-) and Ovid Medline (1950-). The following MeSH terms were used in the database searches: Cardiac.mp & pause.mp. Additionally, pertinent publications found by review of citation lists of identified publications were examined. Individuals with reversible causes of bradyarrhythmia (e.g. drugs) were excluded. RESULTS The study population comprised 194 individuals with cardiac pauses of 1.35-30 s. In 120 athletes, specific records for pause durations were provided, but it was not always clear whether pauses occurred at rest. Among these 120 athletes, 106 had pauses ≤3 s, of whom 92 were asymptomatic and 14 were symptomatic. Fourteen athletes had pauses >3 s, of whom nine were asymptomatic and five were symptomatic. There were no deaths during follow-up (7.46 ± 5.1 years). With respect to symptoms, the ≤3 s threshold had a low-positive predictive value (35.7%) and low sensitivity (26.3%), but good negative predictive value (86.7%) and specificity (91%). CONCLUSION While the evidence is not incontrovertible, the 3 s pause threshold does not adequately discriminate between potentially asymptomatic and symptomatic competitive athletes, and alone should not be used to exclude potential competitors.
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Affiliation(s)
- Tunay Senturk
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA.,The Department of Cardiology, University of Uludag Medical School, Bursa, Turkey
| | - Hai Xu
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA
| | - Krishna Puppala
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA
| | - Balaji Krishnan
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA
| | - Scott Sakaguchi
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA
| | - Lin Y Chen
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA
| | - Rehan Karim
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Oana Dickinson
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA
| | - David G Benditt
- Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA
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Simula S, Laitinen T, Laitinen TM, Tarkiainen T, Hartikainen JEK, Hartikainen P. Effects of Three Months Fingolimod Therapy on Heart Rate. J Neuroimmune Pharmacol 2015; 10:651-4. [PMID: 26092537 DOI: 10.1007/s11481-015-9619-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 06/09/2015] [Indexed: 11/29/2022]
Abstract
Fingolimod is a novel disease-modifying drug for relapsing-remitting multiple sclerosis (RRMS). Fingolimod initiation associates with a decrease in heart rate (HR). However, the long-term effects of fingolimod on HR are not known. The aim of this study was prospectively investigate the effect of 3-month fingolimod therapy on HR. Twenty-seven RRMS patients underwent 24-h ambulatory electrocardiogram recording 20 ± 16 days before (baseline) and at the day of fingolimod initiation (1 day). Twenty-four patients completed 3 months follow-up (3 months). The average HR over 24-h and the average HR for daytime and nighttime were assessed at baseline, 1 day and 3 months. Fingolimod initiation resulted in slowing of HR from 82 ± 11 1/min at baseline to 63 ± 9.5 1/min at 5 h after the initiation of the therapy. The average HR during 24-h was lower at 1d (66 ± 7.8 1/min;p < 0.001) and also at 3 months (69 ± 8.3 1/min;p < 0.001) as compared to baseline (74 ± 10 1/min). The average daytime HR at 1 day (68 ± 8.4 1/min) was lower as compared to baseline (78 ± 11 1/min, p < 0.001), whereas no difference was found between the average daytime HR at baseline and at 3 months (79 ± 10 1/min). The average nighttime HR at 1 day (59 ± 8.8 1/min;p < 0.001) and at 3 months (60 ± 9.2 1/min;p < 0.05) both were lower than at baseline (64 ± 9.9 1/min). In conclusion, fingolimod resulted in HR decrease reaching the nadir at 5 h after the first dose. HR remained lower after 3 months fingolimod treatment as compared to baseline. Particularly, HR at daytime recovered whereas the nighttime HR showed not recovery as compared to the day of fingolimod initiation.
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Affiliation(s)
- Sakari Simula
- Department of Neurology, Mikkeli Central Hospital, Porrassalmenkatu 35-37, 50100, Mikkeli, Finland.
| | - Tomi Laitinen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Tiina M Laitinen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Tuula Tarkiainen
- Department of Clinical Physiology and Nuclear Medicine, Mikkeli Central Hospital, Mikkeli, Finland
| | - Juha E K Hartikainen
- Heart Center, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Päivi Hartikainen
- Neuro Center, Department of Neurology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
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41
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Long-term follow-up of early repolarization pattern in elite athletes. Am J Med 2015; 128:192.e1-9. [PMID: 24979742 DOI: 10.1016/j.amjmed.2014.06.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/04/2014] [Accepted: 06/04/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early repolarization pattern (ERP) is considered a benign variant of the electrocardiogram (ECG), more frequent in athletes. However, prospective studies suggested that ERP is associated with an increased risk of sudden cardiac death (SCD). The purpose of this study is to determine the prevalence, clinical characteristics, and long-term outcome of ERP in elite athletes during professional activity and after retirement. METHODS AND RESULTS A cohort of 299 white elite athletes recruited between 1960 and 1999 was retrospectively analyzed. Athletes were eligible if they had participated for at least 6 consecutive months in high competition and retired for a minimum of 5 years before inclusion. Clinical data and ECG were abstracted from the clinical records using a questionnaire, and outcomes after a mean follow-up of 24 years were registered. Among the 299 athletes, 66% were men with a mean age of 20 (SD 6.4) years. ERP was found in 31.4% of participants, and it was located in lateral ECG leads in 57.4% of cases, in inferior leads in 6.4%, and in both leads in the remaining 36.2%. After retirement, ERP still persisted in 53.4% of athletes. Predictive factors for the persistence were: left ventricular hypertrophy signs at the baseline ECG (odds ratio [OR] 4.35; 95% confidence interval [CI], 1.43-13.24; P = .010), sinus bradycardia after retirement (OR 2.56; 95% CI, 1.09-5.99; P = .031), and presence of ERP during the sportive career (OR 20.35; 95% CI, 8.54-48.51; P < .001). After a mean follow-up of 24 years, no episodes of SCD occurred. CONCLUSIONS A third of elite athletes presented ERP, and this persisted in 53.4% of cases after retirement. After a long follow-up period, no difference in outcome of SCD was seen.
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42
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Vanoli E, Pentimalli F, Botto G. Vagomimetic effects of fingolimod: physiology and clinical implications. CNS Neurosci Ther 2014; 20:496-502. [PMID: 24836740 PMCID: PMC4204275 DOI: 10.1111/cns.12283] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 04/17/2014] [Accepted: 04/20/2014] [Indexed: 01/01/2023] Open
Abstract
Fingolimod is a sphingosine 1-phosphate (S1P) receptor modulator approved to treat relapsing-remitting multiple sclerosis (MS). Initiation of treatment with fingolimod has been found to produce transient bradycardia and/or slowing of atrioventricular impulse conduction in a small proportion of patients. This effect is thought to be due to the interaction of fingolimod with S1P receptors on the surface membrane of atrial myocytes causing a vagomimetic effect, similar to the action of acetylcholine on muscarinic receptors. As a precaution, patients are under electrocardiogram (ECG) monitoring for 6 h after receiving their first dose. Fingolimod is contraindicated in patients with overt or concealed cardiac diseases. However, the Fingolimod Initiation and caRdiac Safety Trial (FIRST), which was designed specifically to investigate the cardiac profile of fingolimod, did not show an increased risk of clinically relevant cardiac events with fingolimod. This review examines the electrophysiology and pathophysiology of cardiac impulse formation in the context of fingolimod. It concludes that these vagomimetic effects should be considered benign and should not prevent the effective use of fingolimod in the treatment of patients with MS.
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Affiliation(s)
- Emilio Vanoli
- Cardiology Section, Department of Molecular Medicine, University of Pavia, Pavia, Italy; Cardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Italy
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Guccione J, Piantedosi D, Di Loria A, Veneziano V, Ciaramella P. Long-term Electrocardiography Recording with Holter Monitoring in 15 Donkeys. J Equine Vet Sci 2014. [DOI: 10.1016/j.jevs.2013.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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McClaskey D, Lee D, Buch E. Outcomes among Athletes with Arrhythmias and Electrocardiographic Abnormalities: Implications for ECG Interpretation. Sports Med 2013; 43:979-91. [DOI: 10.1007/s40279-013-0074-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Guntheroth W, Chun L, Patton KK, Matsushita MM, Page RL, Raskind WH. Wenckebach periodicity at rest that normalizes with tachycardia in a family with a NKX2.5 mutation. Am J Cardiol 2012; 110:1646-50. [PMID: 22920929 DOI: 10.1016/j.amjcard.2012.07.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 07/13/2012] [Accepted: 07/13/2012] [Indexed: 10/28/2022]
Abstract
A family with asymptomatic Wenckebach atrioventricular block (Wenckebach periodicity [WP]) has been followed at the investigators' institution for >4 decades. In contrast to all reported cases of WP (except in top-ranking athletes) family members have WP at rest that promptly converts to regular sinus tachycardia with exercise. They also have mild apical noncompaction that has been quite stable. Because of apparent autosomal dominant inheritance of the structural and arrhythmia disorders, deoxyribonucleic acid was obtained from 4 affected family members in 2 generations for sequence analysis of the cardiac transcription factor gene NKX2.5. A novel frame-shift mutation (c.959delC) was identified that would result in premature truncation of the protein at residue 293, with loss of the C-terminal 31 amino acids. The responsiveness of WP to exercise, the long-term stability of the WP rhythm, and the mild asymptomatic structural features expand the phenotypic presentation of diseases related to mutations in NKX2.5. In addition, the physiology of WP is reviewed in these subjects and in highly conditioned athletes. In conclusion, the investigators report familial stable WP and ventricular noncompaction caused by a mutation in NKX2.5.
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Bradiarritmias y bloqueos de la conducción. Rev Esp Cardiol 2012; 65:656-67. [DOI: 10.1016/j.recesp.2012.01.025] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 01/20/2012] [Indexed: 11/19/2022]
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Abstract
Athletes may present with palpitations, syncope, or arrest resulting in the diagnosis of arrhythmia, or screening may result in diagnosis of conditions with predisposition to arrhythmia. This chapter focuses on 3 common arrhythmic conditions in athletes-atrial fibrillation, premature ventricular contractions (PVCs), and the athlete with an implanted device. (1) Atrial fibrillation: most studies show that atrial fibrillation is more common in competitive athletes, particularly those participating in long-term endurance sports. Postulated mechanisms include morphologic changes such as atrial dilatation, autonomic changes such as increased vagal tone, or inflammatory changes due to sports participation. Treatment options include long-term antiarrhythmic agents, "pill in the pocket" medications, or radiofrequency ablation, a highly successful procedure in athletes. (2) Premature ventricular contractions: data conflict on whether the incidence of PVCs is increased in highly trained individuals. Very frequent PVCs in athletes, however, can be a manifestation of underlying heart disease, and athletes presenting with PVCs should undergo evaluation. In the absence of underlying heart disease, PVCs do not carry a poor prognosis, and US guidelines do not recommend restriction from sports. (3) Implanted devices: the safety of sports for the athlete with an implanted device is unknown, and current guidelines recommend against participation in vigorous competitive sports, based on postulated risks including failure to defibrillate and risk of injury. Many athletes with defibrillators and pacemakers do participate in sports. Ongoing research will better delineate the risks of sports for the athlete with an implanted device.
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Abstract
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.
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Affiliation(s)
- Thomas Rowland
- Department of Pediatrics, Baystate Medical Center, Springfield, Massachusetts 01199, USA.
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Naud P, Guasch E, Nattel S. Physiological versus pathological cardiac electrical remodelling: potential basis and relevance to clinical management. J Physiol 2010; 588:4855-6. [PMID: 21173087 PMCID: PMC3020321 DOI: 10.1113/jphysiol.2010.202556] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Patrice Naud
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal.
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Holty JEC, Guilleminault C. REM-related bradyarrhythmia syndrome. Sleep Med Rev 2010; 15:143-51. [PMID: 21055981 DOI: 10.1016/j.smrv.2010.09.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 08/22/2010] [Accepted: 09/07/2010] [Indexed: 02/02/2023]
Abstract
Cardiac arrhythmias during sleep are relatively common and include a diverse etiology, from benign sinus bradycardia to potentially fatal ventricular arrhythmias. Predisposing factors include obstructive sleep apnea and cardiac disease. Rapid eye movement (REM)-related bradyarrhythmia syndrome (including sinus arrest and complete atrioventricular block with ventricular asystole) in the absence of an underlying cardiac or physiologic sleep disorder was first described in the early 1980s. Although uncertain, the underlying pathophysiology likely reflects abnormal autonomic neural-cardiac inputs during REM sleep. The autonomic nervous system (ANS) is a known key modulator of heart rate fluctuations and rhythm during sleep and nocturnal heart rate reflects a balance between the sympathetic-parasympathetic systems. Whether the primary trigger for REM-related bradyarrhythmias reflects abnormal centrally mediated control of the ANS during REM sleep or anomalous baroreflex parasympathetic influences is unknown. This review focuses on the salient features of the REM-related bradyarrhythmia syndrome and explores potential mechanisms with a particular assessment of the relationship between the ANS and nocturnal heart rate fluctuations.
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Affiliation(s)
- Jon-Erik C Holty
- VA Palo Alto Health Care System, Department of Medicine, Pulmonary, Critical Care and Sleep Medicine, 3801 Miranda Ave (111P), Palo Alto, CA 94304, USA.
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