Effect of aging and physical activity on left ventricular compliance

Physical activity lowers all-cause and cardio-cerebrovascular mortality in adults with coronary heart disease

BACKGROUND

The health outcomes and their adherence to guideline-based secondary prevention physical activity in US patients with coronary heart disease (CHD), together with the association between physical activity (PA) and mortality risk, were investigated.

METHODS

Data on CHD patients (aged 18 to 85 years) was acquired from the US National Health and Nutrition Examination Survey (NHANES) 1999-2018. The patients were divided into four groups according to the level and frequency of PA, namely, a) sedentary (n = 1178), b) moderate PA (moderate, n = 270), c) vigorous PA once or twice per week (vigorous ≤2×, n = 206), and d) vigorous PA three or more times per week (vigorous >2×, n = 598). Logistic analysis was used to determine the relationship between PA and all-cause or cardio-cerebrovascular mortality in CHD patients.

RESULTS

A total of 2252 patients with CHD were enrolled, of whom 47.69% reported adequate PA. During the investigation, there were 296 (13.14%) cardio-cerebrovascular and 724 (32.15%) all-cause deaths. The incidence of all-cause or cardio-cerebrovascular death was lowest in the vigorous ≤2× group. Patients who undertook vigorous PA ≤ 2× showed the lowest risk of all-cause (odds ratio 0.32; 95% confidence interval 0.22-0.47; P < 0.01) or cardio-cerebrovascular death (odds ratio 0.43; 95% confidence interval 0.25-0.73; P < 0.01) relative to those in the sedentary group. More frequent vigorous PA did not lead to improved benefits.

CONCLUSIONS

Vigorous PA once or twice per week was more effective for reducing all-cause and cardio-cerebrovascular mortality compared with patients performing no or a moderate level of PA in US adults with CHD.

Impact of 12-Month Late-in-Life Exercise Training on Cardiopulmonary Reserve, Static Cardiac Structure, and Function: A Randomized Clinical Trial

OBJECTIVE

Although the cardiac benefits of maintaining a lifelong exercise routine are undisputed, to what extent late-in-life exercise training can ameliorate cardiac aging remains unclear. We examined the impact of a 12-month exercise training program on cardiac reserve, static cardiac structure, and cardiac function in older adults.

DESIGN

This study was a single-center, randomized trial using Zelen design. Participants in the center-based exercise (CBE) group underwent an individualized multicomponent exercise training program.

SETTING AND PARTICIPANTS

In total, 120 community-dwelling older adults aged 65-85 years were evenly divided into a CBE group and a control group.

METHODS

The primary outcome indicator was absolute change in peak oxygen uptake (peakVO2) per kilogram from baseline to 12 months. The secondary outcome indicators were the absolute changes in other cardiopulmonary exercise test indices and cardiac magnetic resonance parameters. This study has been registered at the Chinese Clinical Trial Registry Network (ChiCTR2400081824).

RESULTS

In total, 47 older adults in the control group and 49 in the CBE group ultimately completed the 12-month follow-up and were analyzed. Of all participants, 52 (46.4%) were men, and the mean age was 71.22 ± 4.55 years. The absolute change in peakVO2/kg was significantly different between the CBE and control groups by +3.32 mL/kg/min (95% CI 2.10-4.53; P < .001), and a sex-related difference was observed. Additionally, the right ventricular peak filling and ejection rate improved to a greater degree in the CBE than control group (+65.57 mL/s, P = .006; +56.39 mL/s, P = .026, respectively).

CONCLUSIONS AND IMPLICATIONS

A 12-month exercise training program started later in life was effective in improving cardiopulmonary reserve, and men showed a better response to training than women. The right ventricular function increased after late-in-life exercise training.

Impaired longitudinal systolic-diastolic coupling and cardiac response to exercise in patients with hypertrophic cardiomyopathy

BACKGROUND

In patients with hypertrophic cardiomyopathy (HCM), impaired augmentation of stroke volume and diastolic dysfunction contribute to exercise intolerance. Systolic-diastolic (S-D) coupling characterizes how systolic contraction of the left ventricle (LV) primes efficient elastic recoil during early diastole. Impaired S-D coupling may contribute to the impaired cardiac response to exercise in patients with HCM.

METHODS

Patients with HCM (n = 25, age = 47 ± 9 years) and healthy adults (n = 115, age = 49 ± 10 years) underwent a cardiopulmonary exercise testing (CPET) and echocardiogram. S-D coupling was defined as the ratio of LV longitudinal excursion of the mitral annulus during early diastole (EDexc) and systole (Sexc) and compared between groups. Peak oxygen uptake (peak V̇O2) (Douglas bags), cardiac index (C2H2 rebreathe), and stroke volume index (SVi) were assessed during CPET. Linear regression was performed between S-D coupling and peak V̇O2, peak cardiac index, and peak SVi.

RESULTS

S-D coupling was lower in HCM (Controls: 0.63 ± 0.08, HCM: 0.56 ± 0.10, p < 0.001). Peak V̇O2 and stroke volume reserve were lower in patients with HCM (Peak VO2 Controls: 28.5 ± 5.5, HCM: 23.7 ± 7.2 mL/kg/min, p < 0.001, SV reserve: Controls 39 ± 16, HCM 30 ± 18 mL, p = 0.008). In patients with HCM, S-D coupling was associated with peak V̇O2 (r = 0.47, p = 0.018), peak cardiac index (r = 0.60, p = 0.002), and peak SVi (r = 0.63, p < 0.001).

CONCLUSION

Systolic-diastolic coupling was impaired in patients with HCM and was associated with fitness and the cardiac response to exercise. Inefficient S-D coupling may link insufficient stroke volume generation, diastolic dysfunction, and exercise intolerance in HCM.

Effects of aging and endurance exercise training on cardiorespiratory fitness and cardiac structure and function in healthy midlife and older women

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in women in developed societies. Unfavorable structural and functional adaptations within the heart and central blood vessels with sedentary aging in women can act as the substrate for the development of debilitating CVD conditions such as heart failure with preserved ejection fraction (HFpEF). The large decline in cardiorespiratory fitness, as indicated by maximal or peak oxygen uptake (V̇o2max and V̇o2peak, respectively), that occurs in women as they age significantly affects their health and chronic disease status, as well as the risk of cardiovascular and all-cause mortality. Midlife and older women who have performed structured endurance exercise training for several years or decades of their adult lives exhibit a V̇o2max and cardiac and vascular structure and function that are on par or even superior to much younger sedentary women. Therefore, regular endurance exercise training appears to be an effective preventative strategy for mitigating the adverse physiological cardiovascular adaptations associated with sedentary aging in women. Herein, we narratively describe the aging and short- and long-term endurance exercise training adaptations in V̇o2max, cardiac structure, and left ventricular systolic and diastolic function at rest and exercise in midlife and older women. The role of circulating estrogens on cardiac structure and function is described for consideration in the timing of exercise interventions to maximize beneficial adaptations. Current research gaps and potential areas for future investigation to advance our understanding in this critical knowledge area are highlighted.

Understanding Exercise Capacity: From Elite Athlete to HFpEF

Exercise capacity is a spectrum that reflects an individual's functional capacity and the dynamic nature of cardiac remodelling along with respiratory and skeletal muscle systems. The relationship of increasing physical activity, increased cardiac mass and volumes, and improved cardiorespiratory fitness (CRF) is well established in the endurance athlete. However, less emphasis has been placed on the other end of the spectrum, which includes individuals with a more sedentary lifestyle and small hearts who are at increased risk of functional disability and poor clinical outcomes. Reduced CRF is an independent predictor of all-cause mortality and cardiovascular events determined by multiple inter-related exogenous and endogenous factors. In this review, we explore the relationship of physical activity, cardiac remodelling, and CRF across the exercise spectrum, emphasising the critical role of cardiac size in determining exercise capacity. In contrast to the large compliant left ventricle of the endurance athlete, an individual with a lifetime of physical inactivity is likely to have a small, stiff heart with reduced cardiac reserve. We propose that this might contribute to the development of heart failure with preserved ejection fraction in certain individuals, and is key to understanding the link between low CRF and increased risk of heart failure.

Randomized Controlled Trial of Moderate- and High-Intensity Exercise Training in Patients With Hypertrophic Cardiomyopathy: Effects on Fitness and Cardiovascular Response to Exercise

Background Moderate intensity exercise training (MIT) is safe and effective for patients with hypertrophic cardiomyopathy, yet the efficacy of high intensity training (HIT) remains unknown. This study aimed to compare the efficacy of HIT compared with MIT in patients with hypertrophic cardiomyopathy. Methods and Results Patients with hypertrophic cardiomyopathy were randomized to either 5 months of MIT, or 1 month of MIT followed by 4 months of progressive HIT. Peak oxygen uptake (V˙O2; Douglas bags), cardiac output (acetylene rebreathing), and arteriovenous oxygen difference (Fick equation) were measured before and after training. Left ventricular outflow gradient and volumes were measured by echocardiography. Fifteen patients completed training (MIT, n=8, age 52±7 years; HIT, n=7, age 42±8 years). Both HIT and MIT improved peak V˙O2 by 1.3 mL/kg per min (P=0.009). HIT (+1.5 mL/kg per min) had a slightly greater effect than MIT (+1.1 mL/kg per min) but with no statistical difference (group×exercise P=0.628). A greater augmentation of arteriovenous oxygen difference occurred with exercise (Δ1.6 mL/100 mL P=0.005). HIT increased left ventricular end-diastolic volume (+17 mL, group×exercise P=0.015) compared with MIT. No serious arrhythmias or adverse cardiac events occurred. Conclusions This randomized trial of exercise training in patients with hypertrophic cardiomyopathy demonstrated that both HIT and MIT improved fitness without clear superiority of either. Although the study was underpowered for safety outcomes, no serious adverse events occurred. Exercise training resulted in salutary peripheral and cardiac adaptations. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03335332.

Atrial Septal Defect: Larger Right Ventricular Dimensions and Atrial Volumes as Early as in the First Month After Birth-a Case-Control Study Including 716 Neonates

Atrial septal defect (ASD) is characterized by a left-to-right shunt causing dilatation of the right atrium and right ventricle as well as pulmonary hyperperfusion. The detection of ASDs often occurs late in childhood or adulthood. Little is known about cardiac structure and function in neonates with ASD.We analyzed neonatal echocardiograms from the Copenhagen Baby Heart Study, a multicenter, population-based cohort study of 27,595 neonates. We included 716 neonates with secundum-type ASDs and matched them 1:1 on sex and age at examination with neonates without ASD from the same birth cohort. Neonates with an ASD (median age 11 days, 52% female) had larger right ventricular (RV) dimensions than matched controls (RV longitudinal dimension end-diastole: 27.7 mm vs. 26.7 mm, p < 0.001; RV basal dimension end-diastole: 14.9 mm vs. 13.8 mm, p < 0.001; and RV outflow tract diameter 13.6 mm vs. 12.4 mm, p < 0.001). Atrial volumes were larger in neonates with ASD compared to controls (right atrial end-systolic volume: 2.9 ml vs. 2.1 ml, p < 0.001; and left atrial end-systolic volume 2.0 ml vs. 1.8 ml, p < 0.001). Tricuspid annular plane systolic excursion was larger in neonates with ASD than in controls (10.2 mm vs. 9.6 mm, p < 0.001). Left ventricular dimensions and function did not differ between neonates with ASD and controls. In conclusion, ASDs were associated with altered cardiac dimensions already in the neonatal period, with larger right ventricular dimensions and larger atrial volumes at echocardiography within the first 30 days after birth.ClinicalTrials.gov Identifier: NCT02753348 (April 27, 2016).

Bidirectional Association Between Frailty and Cardiac Structure and Function: The Atherosclerosis Risk in Communities Study

Background Frailty and heart failure frequently coexist in late life. Limited data exist regarding the longitudinal associations of frailty and subclinical cardiac dysfunction. We aim to quantify the association of frailty with longitudinal changes in cardiac function and of cardiac function with progression in frailty status in older adults. Methods and Results Participants in the Atherosclerosis Risk in Communities cohort underwent frailty assessments at Visit 5 (V5; 2011-2013), V6 (2016-2017), and V7 (2018-2019), and echocardiographic assessments at V5 and V7. We assessed the association between frailty status at V5 and changes in frailty status from V5 to V7 and changes in cardiac function over 6 years. We then evaluated the association of cardiac function measured at Visit 5 with progression in frailty status over 4 years. Multivariable regression models adjusted for demographics and comorbidities. Among 2574 participants free of heart failure at V5 and V7 (age 74±4 years at V5 and 81±4 years at V7), 3% (n=83) were frail. Frailty at V5 was associated with greater left atrial volume index and E/e' ratio at V5 and 7. Participants who transitioned from robust at V5 to frail at V7 demonstrated greater increases in left ventricular mass index, left atrial volume index, and E/e' over the same period. Among 1648 robust participants at Visit 5, greater left ventricular mass index and mean wall thickness, lower tissue Doppler imaging e', and higher E/e' ratio at Visit 5 were associated with progression in frailty status. Conclusions Among robust, older adults free of heart failure, progression in frailty and subclinical left ventricular remodeling and diastolic dysfunction are interrelated.

Effect of Aging on Intraventricular Kinetic Energy and Energy Dissipation

In recent years, analysis of kinetic energy (KE) and the rate of kinetic energy dissipation (KED) or energy loss (EL) within the cardiac chambers, obtained by cardiac imaging techniques, has gained increasing attention. Thus, there is a need to clarify the effect of physiological variables, specifically aging, on these energetic measures. To elucidate this aspect, we reviewed the literature on this topic. Overall, cardiac magnetic resonance and echocardiographic studies published so far indicate that aging affects the energetics of left and right intraventricular blood flow, although not all energy measures during the cardiac cycle seem to be affected by age in the same way. Current studies, however, have limitations. Additional large, multicenter investigations are needed to test the effect of physiological variables on intraventricular KE and KED/EL measures.

Potential mechanisms linking high-volume exercise with coronary artery calcification

Recent studies have found an association between high volumes of physical activity and increased levels of coronary artery calcification (CAC) among older male endurance athletes, yet the underlying mechanisms have remained largely elusive. Potential mechanisms include greater exposure to inflammatory cytokines, reactive oxygen species and oxidised low-density lipoproteins, as acute strenuous physical activity has been found to enhance their systemic release. Other possibilities include post-exercise elevations in circulating parathyroid hormone, which can modify the amount and morphology of calcific plaque, and long-term exposure to non-laminar blood flow within the coronary arteries during vigorous physical activity, particularly in individuals with pre-existing atherosclerosis. Further, although the association has only been identified in men, the role of testosterone in this process remains unclear. This brief review discusses the association between high-volume endurance exercise and CAC in older men, elaborates on the potential mechanisms underlying the increased calcification, and provides clinical implications and recommendations for those at risk.

The effect of physical activity level on the severity of diastolic dysfunction

BACKGROUND

Diastolic dysfunction (DD) is a risk factor for cardiovascular events in patients undergoing non-cardiac surgeries. Investigators aimed to assess the effect of physical activity level on the diastolic function of the left ventricle (LV) in patients attending the preoperative visit.

METHODS

This analytic cross-sectional study was conducted on 228 patients referred to Poursina hospital from November 2021 to March 2022. To define the physical activity level, we used the short form of the International Physical Activity Questionnaire (IPAQ). We categorized patients into inactive, minimally active, and health-enhancing physical activity groups. We also divided participants into three groups based on their daily sitting time. Also, echocardiographic parameters were calculated. The diastolic function of LV was evaluated, and its grading was defined from mild (grade1) to severe (grade 3).

RESULTS

Results showed that patients with DD had significantly higher age and lower levels of education (P < 0.001 and P = 0.005, respectively). After assessing echocardiographic parameters, we found that E/e', TR Velocity, left atrial volume index, and pulmonary artery pressure had a statistically significant inverse relationship with physical activity level (P < 0.001 for all). Comparing physical activity level of subgroups showed that in HEPA (health-enhancing physical activity), the chance of developing grade 2 or 3 DD was reduced by 97% compared to the inactive group (OR = 0.03, P < 0.001). Still, there was no significant difference between the inactive and minimally active groups (P = 0.223).

CONCLUSIONS

This study showed an inverse relationship between physical activity level and DD of the LV in a sample of 228 individuals attending the Anesthesia Clinic, independent of potentially confounding variables.Therefore, due to lower rate of DD in patients who are physically active, we can expect lower occurrence rate of cardiovascular events during surgery.

NT-proBNP point-of-care measurement as a screening tool for heart failure and CVD risk in type 2 diabetes with hypertension

AIMS

We used N-terminal pro-B-type natriuretic peptide (NT-proBNP) point-of-care testing (POCT) for heart failure risk stratification of individuals with type 2 diabetes for >10 years and hypertension.

METHODS

Overall 259 participants aged 50 years or older with type 2 diabetes (duration of >10 years), hypertension, and no overt cardiovascular disease (CVD) were recruited at two study centers. Patients' data were acquired and NT-proBNP levels were measured using the CARDIAC proBNP+ test (Roche) and the cobas h232 instrument (Roche). Participants were clustered into two groups according to their NT-proBNP concentration value: with NT-proBNP <125 pg/ml and with NT-proBNP ≥125 pg/ml.

RESULTS

Mean age of the participants was 66.1 ± 9.2 years, 55.2 % were female, 60.6 % (n = 157) had a NT-proBNP <125 pg/ml and 39.4 % (n = 102 ≥ 125 pg/ml). Differences were observed among those with low and high NT-proBNP in mean age (63.4 ± 8.8 years vs. 70.1 ± 8.2 years, p < 0.001), diabetes duration (15.4 ± 5.9 years vs. 17.9 ± 7.3 years, p = 0.003), and estimated glomerular filtration rate (eGFR) (86 ± 16 ml/min/1.73 m² vs. 76 ± 20 ml/min/1.73 m², p < 0.001).

CONCLUSIONS

NT-proBNP POCT is practical and can be pragmatically targeted for screening people with type 2 diabetes and hypertension for heart failure risk stratification in routine clinical practice.

Reduced cardiovascular reserve capacity in long-term allogeneic stem cell transplant survivors

Premature cardiovascular mortality is increased in long-term allogeneic stem cell transplant (allo-SCT) survivors, but little information exists regarding subclinical cardiovascular dysfunction in this population. We compared peak oxygen uptake ([Formula: see text]O_2peak), a prognostic cardiovascular marker, and its determinants between long-term allo-SCT survivors and non-cancer controls. Fourteen allo-SCT survivors (mean ± SD, 44 ± 15 years, 50% male, median time since allo-SCT: 6.5 years [range 2-20]) and 14 age- and sex-matched controls (46 ± 13 years, 50% male) underwent cardiopulmonary exercise testing to quantify [Formula: see text]O_2peak. Resting echocardiography (left-ventricular ejection fraction and strain), exercise cardiac MRI (peak cardiac and stroke volume index [CI_peak, SVI_peak]), biochemistry (hemoglobin, troponin-I, B-natriuretic peptide), dual-energy x-ray absorptiometry (lean [LM] and fat [FM] mass, percent body fat [%BF]) and Fick-principal calculation (arteriovenous oxygen difference) were also performed. Survivors exhibited impaired [Formula: see text]O_2peak as compared with controls (25.9 ± 5.1 vs. 33.7 ± 6.5 ml kg^-1 min^-1, p = 0.002), which coincided with reduced CI_peak (6.6 ± 0.8 vs. 8.6 ± 1.9 L min^-1 m^-2; p = 0.001) secondary to reduced SVI_peak (48 ± 4 vs. 61 ± 8 ml m^-2; p < 0.001) rather than chronotropic impairment, and higher %BF (difference, 7.9%, p = 0.007) due to greater FM (5.8 kg; p = 0.069) and lower LM (4.3 kg, p = 0.25). All other measures were similar between groups. Despite comparable resting cardiac function and biomarker profiles, survivors exhibited reduced [Formula: see text]O_2peak and exercise cardiac function and increased %BF relative to controls. These results highlight potential therapeutic avenues and the utility of exercise-based cardiovascular assessment in unmasking cardiovascular dysfunction in allo-SCT survivors.

Cardiac remodeling in well-healed burn survivors after 6 months of unsupervised progressive exercise training

Aerobic exercise is important in the rehabilitation of individuals with prior burn injuries, but no studies have examined whether adult burn survivors demonstrate cardiac remodeling to long-term aerobic exercise training. In this study, we tested the hypothesis that 6 months of progressive exercise training improves cardiac magnetic resonance imaging-based measures of cardiac structure and function in well-healed burn survivors. Secondary analyses explored relations between burn surface area and changes in cardiac structure in the cohort of burn survivors. V̇o2peak assessments and cardiac magnetic resonance imaging were performed at baseline and following 6 months of progressive exercise training from 19 well-healed burn survivors and 10 nonburned control participants. V̇o2peak increased following 6 months of training in both groups (Control: Δ5.5 ± 5.8 mL/kg/min; Burn Survivors: Δ3.2 ± 3.6 mL/kg/min, main effect of training, P < 0.001). Left ventricle (LV) mass (Control: Δ1.7 ± 3.1 g/m2; Burn survivors: Δ1.8 ± 2.7 g/m2), stroke volume (Control: Δ5.8 ± 5.2 mL/m2; Burn Survivors: Δ2.8 ± 4.2 mL/m2), and ejection fraction (Control: Δ2.4 ± 4.0%; Burn Survivors: Δ2.2 ± 4.3%) similarly increased following 6 months of exercise training in both cohorts (main effect of training P < 0.05 for all indexes). LV end-diastolic volume increased in the control group (Δ6.5 ± 4.5 mL/m2) but not in the cohort of burn survivors (Δ1.9 ± 2.7 mL/m2, interaction, P = 0.040). Multiple linear regression analyses revealed that burn surface area had little to no effect on changes in ventricular mass or end-diastolic volumes in response to exercise training. Our findings provide initial evidence of physiological cardiac remodeling, which is not impacted by burn size, in response to exercise training in individuals with well-healed burn injuries.NEW & NOTEWORTHY Aerobic exercise is important in the rehabilitation of individuals with prior burn injuries, but no studies have examined whether adult burn survivors demonstrate cardiac remodeling to long-term aerobic exercise training. In this study, we tested the hypothesis that 6 months of progressive exercise training would improve cardiac magnetic resonance imaging-based measures of cardiac structure and function in well-healed burn survivors. Our findings highlight the ability of exercise training to modify cardiac structure and function in well-healed burn survivors and nonburned sedentary controls alike.

Analysis of health-related, skill-related physical strength, and physique by blood pressure levels of Korean seniors

In Korea, the prevalence rate of hypertension among people aged over 30 is on an upward trend, which increased from 26.2% in 2008 to 28.3% in 2018. This hovers above the global morbidity rate of hypertension. As hypertension is the cause of cerebrovascular or cardiovascular diseases, early treatment and management are critical. Also, while there has been numerous research conducted on exercise intervention, the number of studies done on hypertension and physical fitness falls far below. To identify the relationship between health and physical fitness depending on the blood pressure levels of Korean seniors, the physical fitness test results of the National Fitness Award 100 conducted in 2017 were used, and blood pressure level, physique, and physical fitness data of 17,110 elderly population aged above 65 were analyzed. IBM Statistics SPSS 25.0 was used to process the collected data. Due to the gender difference in blood pressure levels, physique, and physical strength, the analysis was conducted by each gender, and the analysis of variance (ANOVA) was performed to identify the differences in physique and physical strength depending on the blood pressure level. Also, Tukey's HDS test was conducted if such differences were found. All analyzes were tested at the significance level (α) of 0.05. As a result of comparing the physique factors by blood pressure level, only males showed a significant difference between groups in terms of height(p = .019), and higher blood pressure implied greater height. Also, for both genders, those with high blood pressure appeared to have greater body weight(p < .001), body fat percentage(p < .001), BMI(p < .001), waist circumference(p < .001), and waist-to-height ratio(p < .001),. In addition, as the result of comparing health-related physical strength and skill-related physical strength by blood pressure level, males showed a significant difference only in muscular strength(p = .026) and flexibility(p < .001), while females showed a significant difference between groups in terms of cardiovascular endurance(p < .001), muscular strength(p = .025), muscular endurance(p < .001), balance, and motor coordination except for flexibility. Holistically, males only showed a significant difference in muscular strength and flexibility while females appeared to have a significant difference between groups in all categories except flexibility, which can be considered that physical fitness factors influence the blood pressure of females more than males.

Left Ventricular Diastolic Response to Isometric Handgrip Exercise in Physically Active and Sedentary Individuals

Aims: This study aims to investigate the diastolic left ventricular (LV) response to isometric handgrip exercise among healthy middle-aged men with high physical activity levels, versus matched sedentary individuals. Methods: Two groups of 10 men aged 41−51 years were studied. Men in the first group had high weekly self-reported physical activity levels (>3000 METs × min/week). In comparison, men in the second group reported low physical activity levels (<300 METs × min/week). An isometric handgrip exercise (IHE) stress echocardiography test was performed in all of them. Results: Both groups showed a similar and statistically significant increase in heart rate, systolic, diastolic, and mean arterial pressure following IHE. The group of active men under study did not show a statistically significant change in the ratio of early diastolic mitral valve inflow velocity to early diastolic lateral wall tissue velocity (E/e’ ratio) in response to IHE. Conversely, the inactive participants’ E/e’ ratio was higher at peak activity in the isometric handgrip exercise. Conclusions: Apparently, healthy middle-aged men with high levels of physical activity seem to have an improved lusitropic cardiac function compared to men with low levels of physical activity, as observed by the different diastolic LV responses induced by isometric handgrip exercise.

Effect of E-OJ-01 on Left Ventricular Ejection Fraction and Myocardial Oxygen Consumption: A Randomized, Double-Blind, Placebo-Controlled Study

Purpose

E-OJ-01 (Oxyjun^TM), a proprietary, standardized aqueous extract of Terminalia arjuna (TA) bark, has previously shown promising cardiovascular health benefits in healthy young athletic adults and is now being tested to determine its ability to support left ventricular ejection fraction and associated parameters in a diverse population.

Participants and Methods

Healthy adults aged 30-70 years (n=72) were included in the study to investigate the effect of 400 mg/day of E-OJ-01 when administered for 8 weeks on myocardial pumping capacity, primarily left ventricular ejection fraction (LVEF). The secondary endpoints were improvement in diastolic filling (E/A) ratio, rate pressure product (RPP), and fatigue severity scale (FSS) score. The effect of the intervention on blood lipids and gamma-glutamyltransferase (GGT) levels was also explored. The safety of the intervention was evaluated by monitoring adverse events, vitals (heart rate (HR), blood pressure (BP), and body temperature (BT)), and liver (serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT)) and kidney function (serum creatinine).

Results

E-OJ-01 increased the LVEF by 6.28% (percentage change) from the baseline compared with 0.24% (percentage change) in the placebo group (p<0.05). It reduced fatigue (22.52%), RPP (1.54%), and GGT levels (5.90%) from the baseline. No adverse events related to the intervention were observed during the study.

Conclusion

The study showed that E-OJ-01 could improve cardiac pumping capacity by significantly increasing LVEF and reducing fatigue in a diverse, healthy population.

Certainties and Uncertainties of Cardiac Magnetic Resonance Imaging in Athletes

Prolonged and intensive exercise induces remodeling of all four cardiac chambers, a physiological process which is coined as the “athlete’s heart”. This cardiac adaptation, however, shows overlapping features with non-ischemic cardiomyopathies, such as dilated, arrhythmogenic and hypertrophic cardiomyopathy, also associated with athlete’s sudden cardiac death. Cardiac magnetic resonance (CMR) is a well-suited, highly reproducible imaging modality that can help differentiate athlete’s heart from cardiomyopathy. CMR allows accurate characterization of the morphology and function of cardiac chambers, providing full coverage of the ventricles. Moreover, it permits an in-depth understanding of the myocardial changes through specific techniques such as mapping or late gadolinium enhancement. In this narrative review, we will focus on the certainties and uncertainties of the role of CMR in sports cardiology. The main aspects of physiological adaptation due to regular and intensive sports activity and the application of CMR in highly trained athletes will be summarized.

Heart Failure With Preserved Ejection Fraction as an Exercise Deficiency Syndrome: JACC Focus Seminar 2/4

Across differing spectrums of cardiac function and cardiac pathologies, there are strong associations between measures of cardiorespiratory fitness and burden of symptoms, quality of life, and prognosis. In this part 2 of a 4-part series, we contend that there is a strong association among physical activity, cardiorespiratory fitness, and cardiac function. We argue that a chronic lack of exercise is a major risk factor for heart failure with preserved ejection fraction in some patients. In support of this hypothesis, increasing physical activity is associated with greater cardiac mass, greater stroke volumes, greater cardiac output and peak oxygen consumption, and fewer clinical events. Conversely, physical inactivity results in cardiac atrophy, reduced output, reduced chamber size, and decreased ability to augment cardiac performance with exercise. Moreover, physical inactivity is a strong predictor of heart failure risk and death. In sum, exercise deficiency should be considered part of the broad heart failure with preserved ejection fraction phenotype.

Kinetic energy of left ventricular blood flow across heart failure phenotypes and in subclinical diastolic dysfunction

BACKGROUND

Kinetic energy (KE) of intracardiac blood flow reflects myocardial work spent on accelerating blood and provides a mechanistic window into diastolic filling dynamics. Diastolic dysfunction may represent an early stage in the development of heart failure (HF). Here we evaluated the hemodynamic effects of impaired diastolic function in subjects with and without HF, testing the hypothesis that left ventricular KE differs between controls, subjects with subclinical diastolic dysfunction (SDD), and HF patients.

METHODS

We studied 77 subjects (16 controls, 20 subjects with SDD, 16 HFpEF, 9 HFmrEF, and 16 HFrEF patients, age- and sex-matched at the group level). Cardiac magnetic resonance at 1.5T included intracardiac 4D flow and cine imaging. Left ventricular KE was calculated as 0.5*m*v².

RESULTS

Systolic KE was similar between groups (p>0.4), also after indexing to stroke volume (p=0.25), and was primarily driven by ventricular emptying rate (p<0.0001, R²=0.52). Diastolic KE was higher in heart failure patients than controls (p<0.05) but similar between SDD and HFpEF (p>0.18), correlating with inflow conditions (E-wave velocity, p<0.0001, R²=0.24) and end-diastolic volume (p=0.0003, R²=0.17) but not with average e' (p=0.07).

CONCLUSIONS

Diastolic KE differs between controls and heart failure, suggesting more work is spent filling the failing ventricle, while systolic KE does not differentiate between well-matched groups with normal ejection fraction even in the presence of relaxation abnormalities and heart failure. Mechanistically, KE reflects the acceleration imparted on the blood and is driven by variations in ventricular emptying and filling rates, volumes, and heart rate, regardless of underlying pathology.

Strenuous Endurance Exercise and the Heart: Physiological versus Pathological Adaptations

Although the benefits of regular physical activity on cardiovascular health are well established, the effects of strenuous endurance exercise (SEE) have been a matter of debate since ancient times. In this article, we aim to provide a balanced overview of what is known about SEE and the heart-from epidemiological evidence to recent cardiac imaging findings. Lifelong SEE is overall cardioprotective, with endurance master athletes showing in fact a youthful heart. Yet, some lines of research remain open, such as the need to elucidate the time-course and potential relevance of transient declines in heart function (or increases in biomarkers of cardiac injury) with SEE. The underlying mechanisms and clinical relevance of SEE-associated atrial fibrillation, myocardial fibrosis, or high coronary artery calcium scores also remain to be elucidated. © 2022 American Physiological Society. Compr Physiol 12:1-19, 2022.

Aging and Heart Failure with Preserved Ejection Fraction

Heart failure is a clinical syndrome characterized by the inability of the cardiovascular system to provide adequate cardiac output at normal filling pressures. This results in a clinical syndrome characterized by dyspnea, edema, and decreased exertional tolerance. Heart failure with preserved ejection fraction (HFpEF) is an increasingly common disease, and the incidence of HFpEF increases with age. There are a variety of factors which contribute to the development of HFpEF, including the presence of hypertension, diabetes, obesity, and other pro-inflammatory states. These comorbid conditions result in changes at the biochemical and cell signaling level which ultimately lead to a disease with a great deal of phenotypic heterogeneity. In general, the physiologic dysfunction of HFpEF is characterized by vascular stiffness, increased cardiac filling pressures, pulmonary hypertension, and impaired volume management. The normal and abnormal processes associated with aging serve as an accelerant in this process, resulting in the hypothesis that HFpEF represents a form of presbycardia. In this article, we aim to review the processes importance of aging in the development of HFpEF by examining the disease and its causes from the biochemical to physiologic level. © 2022 American Physiological Society. Compr Physiol 12: 1-10, 2022.

Independent and joint association of N-terminal pro-B-type natriuretic peptide and left ventricular mass index with heart failure risk in elderly diabetic patients with right ventricular pacing

Background

Elevated levels of N-terminal pro-B natriuretic peptide (NT-proBNP) and left ventricular hypertrophy (LVH) are independent risk factors for heart failure (HF). In addition, right ventricular pacing (RVP) is an effective treatment strategy for bradyarrhythmia, but long-term RVP is associated with HF. However, there is limited evidence on the independent and combined association of NT-proBNP and left ventricular mass index (LVMI) with HF risk in elderly diabetic patients with long-term RVP.

Methods

Between January 2017 and January 2018, a total of 224 elderly diabetic patients with RVP at Fuwai Hospital were consecutively included in the study, with a 5-year follow-up period. The study endpoint was the first HF readmission during follow-up. This study aimed to explore the independent and joint relationship of NT-proBNP and LVMI with HF readmission in elderly diabetic patients with long-term RVP, using a multivariate Cox proportional hazards regression model.

Results

A total of 224 (11.56%) elderly diabetic patients with RVP were included in the study. During the 5-year follow-up period, a total of 46 (20.54%) patients suffered HF readmission events. Multivariate Cox proportional hazards regression analysis showed that higher levels of NT-proBNP and LVMI were independent risk factors for HF readmission [NT-proBNP: hazard risk (HR) = 1.05, 95% confidence interval (CI): 1.01–1.10; LVMI: HR = 1.14, 95% CI: 1.02–1.27]. The optimal cut-off point of NT-proBNP was determined to be 330 pg/ml by receiver operating characteristic (ROC) curve analysis. Patients with NT-proBNP &gt; 330 pg/ml and LVH had a higher risk of HF readmission compared to those with NT-proBNP ≤ 330 pg/ml and non-LVH (39.02% vs. 6.17%; HR = 7.72, 95% CI: 1.34–9.31, P &lt; 0.001).

Conclusion

In elderly diabetic patients with long-term RVP, NT-proBNP and LVMI were associated with the risk of HF readmission. Elevated NT-proBNP combined with LVH resulted in a significantly higher risk of HF readmission.

Mechanisms of Exercise-Induced Cardiac Remodeling Differ Between Young and Aged Hearts

Aging induces physiological and molecular changes in the heart that increase the risk for heart disease. Several of these changes are targetable by exercise. We hypothesize that the mechanisms by which exercise improves cardiac function in the aged heart differ from those in the young exercised heart.

A normal pattern of mitral inflow predicts a better prognosis following cardiovascular events in early advanced-age patients

Although a mitral inflow pattern usually changes from a normal pattern to an abnormal relaxation pattern as part of the aging process in healthy people, some early advanced-age individuals maintain a normal pattern. We investigated whether a normal pattern of mitral inflow predicts a better prognosis following cardiovascular (CV) events in early advanced-age patients. We enrolled 425 patients aged 60-65 years with 0.6 < E/A < 1.5. Patients were divided according to their mitral inflow pattern, i.e., a normal pattern group (E/A ≥ 1.0, n = 77) and an abnormal relaxation pattern group (E/A < 1, n = 348), and were evaluated the relationship with CV events. Multivariate regression analysis found that the normal inflow pattern was associated with odds ratios of 0.859 for body mass index (BMI; 95% confidence interval [CI]: 0.778-0.937), 0.529 for hypertension (0.303-0.924), and 0.325 for heart rate (0.228-0.463). During the follow-up period (4.9 ± 1.8 years), the adjusted-hazard ratio was significantly lower in the normal pattern group (HR: 0.119, 95% CI 0.016-0.910). Kaplan-Meier curves showed a higher event-free rate for the normal pattern group than for the abnormal relaxation pattern group (p = 0.0292). Normal inflow pattern in early advanced-age patients predicts a better prognosis following CV events.

Systolic and diastolic function during cycling at the respiratory threshold between elderly and young healthy individuals

The hemodynamic consequences of aging have been extensively investigated during maximal incremental exercise. However, less is known about the effects of aging on hemodynamics during submaximal steady-state exercise. The aim of the present investigation was to compare the hemodynamics of healthy elderly and young subjects during an exercise bout conducted at the gas threshold (GET) intensity. Two groups of healthy, physically active subjects were studied: the elderly group—EG (n = 11; > 60 years old) and the young group—YG (n = 13; < 35 years old). Both groups performed a 5-min rectangular exercise test at the GET intensity. Hemodynamics were measured using echocardiography. The main finding was that stroke volume responses were higher in the YG than the EG (72.5 ± 16.7 vs. 52.4 ± 8.4 ml, respectively). The increased stroke volume capacity in the YG was the consequence of a greater capacity to increase cardiac preload and contractility and, to a lesser extent, to reduce systemic vascular resistance. Importantly, the atrial contribution to ventricular diastolic filling was substantially higher in the YG when compared to the EG.

Hemodynamic force analysis is not ready for clinical trials on HFpEF

Hemodynamic force analysis has been proposed as a novel tool for early detection of subclinical systolic dysfunction in heart failure with preserved ejection fraction (HFpEF). Here we investigated the ability of hemodynamic forces to discriminate between healthy subjects and heart failure patients with varying degrees of systolic dysfunction. We studied 34 controls, 16 HFpEF patients, and 25 heart failure patients with mid-range (HFmrEF) or reduced ejection fraction (HFrEF) using cardiac magnetic resonance with acquisition of cine images and 4D flow at 1.5 T. The Navier-Stokes equation was used to compute global left ventricular hemodynamic forces over the entire cardiac cycle. Forces were analyzed for systole, diastole, and the entire heartbeat, with and without normalization to left ventricular volume. Volume-normalized hemodynamic forces demonstrated significant positive correlation with EF (r² = 0.47, p < 0.0001) and were found significantly lower in heart failure with reduced ejection fraction compared to controls (p < 0.0001 for systole and diastole). No difference was seen between controls and HFpEF (p > 0.34). Non-normalized forces displayed no differences between controls and HFpEF (p > 0.24 for all analyses) and did not correlate with EF (p = 0.36). Left ventricular hemodynamic force analysis, whether indexed to LV volumes or not, is not ready for clinical trials on HFpEF assessment.

The Aging Athlete: Paradigm of Healthy Aging

The Exercise Boom of the 1970's resulted in the adoption of habitual exercise in a significant portion of the population. Many of these individuals are defying the cultural norms by remaining physically active and competing at a high level in their later years. The juxtaposition between masters athletes and non-exercisers demonstrate the importance of remaining physically active throughout the lifespan on physiological systems related to healthspan (years of healthy living). This includes ~50% improved maximal aerobic capacity (VO₂max) and enhanced skeletal muscle health (size, function, as well as metabolic and communicative properties) compared to non-exercisers at a similar age. By taking a reductionist approach to VO₂max and skeletal muscle health, we can gain insight into how aging and habitual exercise affects the aging process. Collectively, this review provides a physiological basis for the elite performances seen in masters athletes, as well as the health implications of lifelong exercise with a focus on VO₂max, skeletal muscle metabolic fitness, whole muscle size and function, single muscle fiber physiology, and communicative properties of skeletal muscle. This review has significant public health implications due to the potent health benefits of habitual exercise across the lifespan.

Exercise-Induced Cardiac Fatigue in Recreational Ultramarathon Runners at Moderate Altitude: Insights From Myocardial Deformation Analysis

Background

Controversy exists on the actual occurrence of exercise-induced cardiac fatigue (EICF) with ultraendurance exercise, as well as on whether factors such as age or training status might predispose to this condition. The present study aimed to assess the occurrence of EICF among recreational ultramarathon runners, as well as to determine potential predictive factors.

Methods

Nineteen male recreational runners (42 ± 12yrs) participated in a 55-km trial race at moderate altitude (1,800–2,500 m). Participants were evaluated before and after the race using Doppler echocardiography and myocardial deformation analysis. EICF was determined as a reduction >5% of either left ventricular global longitudinal strain (LVGLS) or right ventricular free wall strain (RVFWS). Demographical (age, body mass index), training (training experience, volume and intensity), competition (finishing time, relative intensity) and biochemical variables (blood lactate, creatine kinase [CK] and CK-MB) were assessed as predictors of EICF.

Results

A significant reduction in LVGLS (20.1 ± 2.1% at baseline vs. 18.8 ± 2.4% at post-race, p = 0.026), but not in RVFWS (27.4 ± 7.0 vs. 24.6 ± 5.3%, p = 0.187), was observed after the race. EICF was present in 47 and 71% of the participants attending to the decrease in LVGLS and RVFWS, respectively. No associations were found between any of the analyzed variables and EICF except for age, which was associated with the magnitude of decrement of RVFWS (r = 0.58, p = 0.030).

Conclusions

Ultramarathon running at moderate altitude seems to induce EICF in a considerable proportion of recreational athletes.

The Clinical Impact of Advanced Age on the Postoperative Outcomes of Patients Undergoing Gastrectomy for Gastric Cancer: Analysis Across US Hospitals Between 2011–2017

Purpose

This study systematically evaluated the implications of advanced age on post-surgical outcomes following gastrectomy for gastric cancer using a national database.

Materials and Methods

The 2011–2017 National Inpatient Sample was used to isolate patients who underwent gastrectomy for gastric cancer. From this, the population was stratified into those belonging to the younger age cohort (18–59 years), sexagenarians, septuagenarians, and octogenarians. The younger cohort and each advanced age category were compared in terms of the following endpoints: mortality following surgery, length of hospital stay, charges, and surgical complications.

Results

This study included a total of 5,213 patients: 1,366 sexagenarians, 1,490 septuagenarians, 743 octogenarians, and 1,614 under 60 years of age. Between the younger cohort and sexagenarians, there was no difference in mortality (2.27 vs. 1.67%; P=0.30; odds ratio [OR], 1.36; 95% confidence interval [CI], 0.81–2.30), length of stay (11.0 vs. 11.1 days; P=0.86), or charges ($123,557 vs. $124,425; P=0.79). Compared to the younger cohort, septuagenarians had higher rates of in-hospital mortality (4.30% vs. 1.67%; P<0.01; OR, 2.64; 95% CI, 1.67–4.16), length of stay (12.1 vs. 11.1 days; P<0.01), and charges ($139,200 vs. $124,425; P<0.01). In the multivariate analysis, septuagenarians had higher mortality (P=0.01; adjusted odds ratio [aOR], 2.01; 95% CI, 1.18–3.43). Similarly, compared to the younger cohort, octogenarians had a higher rate of mortality (7.67% vs. 1.67%; P<0.001; OR, 4.88; 95% CI, 3.06–7.79), length of stay (12.3 vs. 11.1 days; P<0.01), and charges ($131,330 vs. $124,425; P<0.01). In the multivariate analysis, octogenarians had higher mortality (P<0.001; aOR, 4.03; 95% CI, 2.28–7.11).

Conclusions

Advanced age (>70 years) is an independent risk factor for postoperative death in patients with gastric cancer undergoing gastrectomy.

Exercise in Octogenarians: How Much Is Too Little?

The global population is rapidly aging, with predictions of many more people living beyond 85 years. Age-related physiological adaptations predispose to decrements in physical function and functional capacity, the rate of which can be accelerated by chronic disease and prolonged physical inactivity. Decrements in physical function exacerbate the risk of chronic disease, disability, dependency, and frailty with advancing age. Regular exercise positively influences health status, physical function, and disease risk in adults of all ages. Herein, we review the role of structured exercise training in the oldest old on cardiorespiratory fitness and muscular strength and power, attributes critical for physical function, mobility, and independent living. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Increased Expression of N2BA Titin Corresponds to More Compliant Myofibrils in Athlete's Heart

Long-term exercise induces physiological cardiac adaptation, a condition referred to as athlete’s heart. Exercise tolerance is known to be associated with decreased cardiac passive stiffness. Passive stiffness of the heart muscle is determined by the giant elastic protein titin. The adult cardiac muscle contains two titin isoforms: the more compliant N2BA and the stiffer N2B. Titin-based passive stiffness may be controlled by altering the expression of the different isoforms or via post-translational modifications such as phosphorylation. Currently, there is very limited knowledge about titin’s role in cardiac adaptation during long-term exercise. Our aim was to determine the N2BA/N2B ratio and post-translational phosphorylation of titin in the left ventricle and to correlate the changes with the structure and transverse stiffness of cardiac sarcomeres in a rat model of an athlete’s heart. The athlete’s heart was induced by a 12-week-long swim-based training. In the exercised myocardium the N2BA/N2B ratio was significantly increased, Ser11878 of the PEVK domain was hypophosphorlyated, and the sarcomeric transverse elastic modulus was reduced. Thus, the reduced passive stiffness in the athlete’s heart is likely caused by a shift towards the expression of the longer cardiac titin isoform and a phosphorylation-induced softening of the PEVK domain which is manifested in a mechanical rearrangement locally, within the cardiac sarcomere.

Cell therapy rescues aging-induced beta-1 adrenergic receptor and GRK2 dysfunction in the coronary microcirculation

Our past study showed that coronary arterioles isolated from adipose-derived stromal vascular fraction (SVF)-treated rats showed amelioration of the age-related decrease in vasodilation to beta-adrenergic receptor (β-AR) agonist and improved β-AR-dependent coronary flow and microvascular function in a model of advanced age. We hypothesized that intravenously (i.v.) injected SVF improves coronary microvascular function in aged rats by re-establishing the equilibrium of the negative regulators of the internal adrenergic signaling cascade, G-protein receptor kinase 2 (GRK2) and G-alpha inhibitory (Gαi) proteins, back to youthful levels. Female Fischer-344 rats aged young (3 months, n = 24), old (24 months, n = 26), and old animals that received 1 × 10⁷ green fluorescent protein (GFP+) SVF cells (O + SVF, n = 11) 4 weeks prior to sacrifice were utilized. Overnight urine was collected prior to sacrifice for catecholamine measurements. Cardiac samples were used for western blotting while coronary arterioles were isolated for pressure myography studies, immunofluorescence staining, and RNA sequencing. Coronary microvascular levels of the β1 adrenergic receptor are decreased with advancing age, but this decreased expression was rescued by SVF treatment. Aging led to a decrease in phosphorylated GRK2 in cardiomyocytes vs. young control with restoration of phosphorylation status by SVF. In vessels, there was no change in genetic transcription (RNAseq) or protein expression (immunofluorescence); however, inhibition of GRK2 (paroxetine) led to improved vasodilation to norepinephrine in the old control (OC) and O + SVF, indicating greater GRK2 functional inhibition of β1-AR in aging. SVF works to improve adrenergic-mediated vasodilation by restoring the β1-AR population and mitigating signal cascade inhibitors to improve vasodilation.

Characteristics of the athlete's heart in aged hypertensive and normotensive subjects

BACKGROUND

Both hypertension and age-related impairment of the cardiac condition are known to be improved by regular physical training. As relatively few studies have been reported about the older, hypertensive patients, the aim of this study was to establish cardiac benefits of active lifestyle in these subjects.

METHODS

Two-dimensionally guided M-mode, Doppler- and tissue Doppler echocardiography was performed in 199 normo- and hypertensive, active and sedentary older (age>60 yrs.) men (111) and women (88). Results were compared either by ANOVA, or by Kruskall-Wallis test.

RESULTS

The left ventricular muscle index (LVMI), which is higher in young active than in sedentary persons, proved to be smaller in the active than sedentary older subjects: men normotensives: actives 83 vs. sedentary ones 98, hypertensives: actives 88 vs. sedentary ones 107, women normotensives: actives 77 vs. sedentary ones 89 g/m3. Diastolic function was better in the active groups demonstrated both by the ratio of the early to atrial peak blood flow velocities (men: normotensives: actives 1.03 vs. sedentary ones 0.76, women normotensives: actives 1.21 vs. sedentary ones 0.9, hypertensives: actives 1.04 vs. sedentary ones 0.88). The tissue Doppler results were also better in the active groups; the difference between the active and sedentary groups was more marked in the normotensive male groups than in the hypertensive ones.

CONCLUSIONS

Active lifestyle prevents age-related pathological LV hypertrophy, and attenuates the LV diastolic dysfunction.

One-Year Committed Exercise Training Reverses Abnormal Left Ventricular Myocardial Stiffness in Patients With Stage B Heart Failure With Preserved Ejection Fraction

BACKGROUND

Individuals with left ventricular (LV) hypertrophy and elevated cardiac biomarkers in middle age are at increased risk for the development of heart failure with preserved ejection fraction. Prolonged exercise training reverses the LV stiffening associated with healthy but sedentary aging; however, whether it can also normalize LV myocardial stiffness in patients at high risk for heart failure with preserved ejection fraction is unknown. In a prospective, randomized controlled trial, we hypothesized that 1-year prolonged exercise training would reduce LV myocardial stiffness in patients with LV hypertrophy.

METHODS

Forty-six patients with LV hypertrophy (LV septum >11 mm) and elevated cardiac biomarkers (N-terminal pro-B-type natriuretic peptide [>40 pg/mL] or high-sensitivity troponin T [>0.6 pg/mL]) were randomly assigned to either 1 year of high-intensity exercise training (n=30) or attention control (n=16). Right-heart catheterization and 3-dimensional echocardiography were performed while preload was manipulated using both lower body negative pressure and rapid saline infusion to define the LV end-diastolic pressure-volume relationship. A constant representing LV myocardial stiffness was calculated from the following: P=S×[Exp {a (V-V₀)}-1], where "P" is transmural pressure (pulmonary capillary wedge pressure - right atrial pressure), "S" is the pressure asymptote of the curve, "V" is the LV end-diastolic volume index, "V₀" is equilibrium volume, and "a" is the constant that characterizes LV myocardial stiffness.

RESULTS

Thirty-one participants (exercise group [n=20]: 54±6 years, 65% male; and controls (n=11): 51±6 years, 55% male) completed the study. One year of exercise training increased max by 21% (baseline 26.0±5.3 to 1 year later 31.3±5.8 mL·min^-1·kg^-1, P<0.0001, interaction P=0.0004), whereas there was no significant change in max in controls (baseline 24.6±3.4 to 1 year later 24.2±4.1 mL·min^-1·kg^-1, P=0.986). LV myocardial stiffness was reduced (right and downward shift in the end-diastolic pressure-volume relationship; LV myocardial stiffness: baseline 0.062±0.020 to 1 year later 0.031±0.009), whereas there was no significant change in controls (baseline 0.061±0.033 to 1 year later 0.066±0.031, interaction P=0.001).

CONCLUSIONS

In patients with LV hypertrophy and elevated cardiac biomarkers (stage B heart failure with preserved ejection fraction), 1 year of exercise training reduced LV myocardial stiffness. Thus, exercise training may provide protection against the future risk of heart failure with preserved ejection fraction in such patients. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03476785.

Associations of dietary markers with brain volume and connectivity: A systematic review of MRI studies

The high prevalence of unhealthy dietary patterns and related brain disorders, such as dementia, emphasizes the importance of research that examines the effect of dietary factors on brain health. Identifying markers of brain health, such as volume and connectivity, that relate to diet is an important first step towards understanding the lifestyle determinants of healthy brain ageing. We conducted a systematic review of 52 studies (total n = 21,221 healthy participants aged 26-80 years, 55 % female) that assessed with a range of MRI measurements, which brain areas, connections, and cerebrovascular factors were associated with dietary markers. We report associations between regional brain measures and dietary health. Collectively, lower diet quality was related to reduced brain volume and connectivity, especially in white and grey matter of the frontal, temporal and parietal lobe, cingulate, entorhinal cortex and the hippocampus. Associations were also observed in connecting fibre pathways and in particular the default-mode, sensorimotor and attention networks. However, there were also some inconsistencies in research methods and findings. We recommend that future research use more comprehensive and consistent dietary measures, more representative samples, and examine the role of key subcortical regions previously highlighted in relevant animal work.

The heart of the ageing endurance athlete: the role of chronic coronary stress

Moderate physical exercise is associated with an irrefutable reduction in cardiac morbidity and mortality. The current guidelines recommend at least 150 min of moderate exercise or 75 min of vigorous exercise per week. Endurance athletes perform exercise at a level that is 10- to 20-fold greater than these recommendations. These athletes reveal several structural and functional cardiac adaptations including increased cardiac size, enhanced ventricular filling, and augmentation of stroke volume even at the highest heart rates. The long-term effects of endurance exercise on the heart are unknown. Endurance exercise is associated with a transient increase in serum concentrations of biomarkers of cardiac damage and ventricular dysfunction which improves within 72 h. Over the past decade, there have been emerging studies reporting attenuated mortality benefit amongst individuals who perform the highest volume of exercise. Studies in lifelong male athletes aged above 40 years old show a higher prevalence of high coronary artery calcium scores (>300 Agatston units), a higher coronary plaque burden, and myocardial fibrosis compatible with subclinical myocardial infarction compared with relatively sedentary healthy controls, raising speculation that lifelong intense exercise imposes chronic coronary stress on the heart. This review article will provide a critical analysis of the existing data.

Effect of maternal age on cardiac adaptation in pregnancy

OBJECTIVE

To compare longitudinal maternal hemodynamic changes throughout gestation between different age groups.

METHODS

This was a prospective longitudinal study assessing maternal hemodynamics using a bioreactance technique at 11 + 0 to 13 + 6, 19 + 0 to 24 + 0, 30 + 0 to 34 + 0 and 35 + 0 to 37 + 0 weeks' gestation. Women were divided into four groups according to maternal age at the first visit at 11 + 0 to 13 + 6 weeks: Group 1, < 25.0 years; Group 2, 25.0-30.0 years; Group 3, 30.1-34.9 years; and Group 4, ≥ 35.0 years. A multilevel linear mixed-effects model was performed to compare the repeat measurements of hemodynamic variables, correcting for demographics, medical and obstetric history, pregnancy complications, maternal age and gestational-age window.

RESULTS

The study population included 254 women in Group 1, 442 in Group 2, 618 in Group 3 and 475 in Group 4. Younger women (Group 1) had the highest cardiac output (CO) and lowest peripheral vascular resistance (PVR), and older women (Group 4) had the lowest CO and highest PVR throughout pregnancy. The higher CO seen in younger women was achieved through an increase in heart rate alone and not with a concomitant rise in stroke volume. Although the youngest age group demonstrated an apparently more favorable hemodynamic profile, it had the highest incidence of a small-for-gestational-age neonate. There was no significant difference between the groups in the incidence of pre-eclampsia.

CONCLUSION

Age-specific differences in maternal hemodynamic adaptation do not explain the differences in the incidence of a small-for-gestational-age neonate between age groups. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

A Randomized Crossover Trial on the Acute Cardiovascular Demands During Flywheel Exercise

In a randomized crossover trial, we examined whether age plays a role in the mean arterial pressure (MAP) response during a vigorous flywheel exercise of varying load. We hypothesized that the magnitude of increase in the MAP during the flywheel exercise would increase in proportion to advancing age, thereby imposing a significant challenge to the cardiovascular system. A total of 30 participants of both sexes (age range from 20-55 y, 37% women) underwent a detailed medical examination, and their maximal oxygen uptake was determined. They performed a squat exercise (2 sets × 7 repetitions) on a flywheel ergometer at three randomly assigned moments of inertia set at 0.025, 0.05, and 0.075 kg m², while the cardiovascular response was continuously recorded via a Task force monitor. Compared to the resting values, robust rises in the MAP were observed during all three flywheel loads, reaching the highest value of 179 ± 4 mmHg (p = 0.001) during the highest load. In parallel, the cardiac index (cardiac output normalized by the body surface area) was two-fold greater during all the flywheel loads compared to rest, and at a high load, exclusively, the total peripheral resistance increased by 11% (p = 0.001). The rise in heart rate compensated for a load-dependent drop in the stroke index (stroke volume normalized by the body surface area). In our study population, no correlations were observed between the relative increase in the MAP and the participants' age for the three flywheel loads. The present findings suggest that the larger moments of inertia impose a substantial burden to the cardiovascular system, without apparent associated age-differences of the relative magnitude of MAP rise throughout the exercise.

Patient-specific parameter estimation: Coupling a heart model and experimental data

This study develops a hemodynamic model involving the atrium, ventricle, veins, and arteries that can be calibrated to experimental results. It is a Windkessel model that incorporates an unsteady Bernoulli effect in the blood flow to the atrium. The model is represented by ordinary differential equations in terms of blood volumes in the compartments as state variables and it demonstrates the use of conductance instead of resistance to capture the effect of a non-leaking heart valve. The experimental results are blood volume data from 20 young (half of which are women) and 20 elderly (half of which are women) subjects during rest, inotropic stress (dobutamine), and chronotropic stress (glycopyrrolate). The model is calibrated to conform with data and physiological findings in 4 different levels. First, an optimization routine is devised to find model parameter values that give good fit between the model volume curves and blood volume data in the atrium and ventricle. Patient-specific information are used to get initial parameter values as a starting point of the optimization. Also, model pressure curves must show realistic behavior. Second, parametric bootstrapping is performed to establish the reliability of the optimal parameters. Third, statistical tests comparing mean optimal parameter values from young vs elderly subjects and women vs men are examined to support and present age and sex related differences in heart functions. Lastly, statistical tests comparing mean optimal parameter values from resting condition vs pharmacological stress are studied to verify and quantify the effects of dobutamine and glycopyrrolate to the cardiovascular system.

Current Insights in the Age-related Decline in Sports Performance of the Older Athlete

The higher performance level of master athletes compared to non-athletes is often associated with better health throughout life. However, even the physical performance of master athletes declines with age, and this decline accelerates from about the age of 70 years onwards. A progressive loss of muscle mass, declines in force- and power-generating capacity, decreased flexibility, and the concomitant decline in specific tension characterize the muscular changes underlying performance declines. In the cardiovascular system, declines in stroke volume and cardiac output, and cardiac and vascular stiffness contribute to decreasing performance. Recent studies have shown that long-term endurance exercise in master athletes does not only have positive effects, but is associated with an increased incidence of atrial fibrillation, atherosclerotic plaques, and aortic dilation, and even more so in men than in women. Recently, larger longitudinal datasets were analysed and showed that the age-related decline in performance was similar in longitudinal and cross-sectional data. In conclusion, regular physical activity enhances the exercise capacity, and hence quality of life in old age, but it is not without risks.

Nutrition for Older Athletes: Focus on Sex-Differences

Regular physical exercise and a healthy diet are major determinants of a healthy lifespan. Although aging is associated with declining endurance performance and muscle function, these components can favorably be modified by regular physical activity and especially by exercise training at all ages in both sexes. In addition, age-related changes in body composition and metabolism, which affect even highly trained masters athletes, can in part be compensated for by higher exercise metabolic efficiency in active individuals. Accordingly, masters athletes are often considered as a role model for healthy aging and their physical capacities are an impressive example of what is possible in aging individuals. In the present review, we first discuss physiological changes, performance and trainability of older athletes with a focus on sex differences. Second, we describe the most important hormonal alterations occurring during aging pertaining regulation of appetite, glucose homeostasis and energy expenditure and the modulatory role of exercise training. The third part highlights nutritional aspects that may support health and physical performance for older athletes. Key nutrition-related concerns include the need for adequate energy and protein intake for preventing low bone and muscle mass and a higher demand for specific nutrients (e.g., vitamin D and probiotics) that may reduce the infection burden in masters athletes. Fourth, we present important research findings on the association between exercise, nutrition and the microbiota, which represents a rapidly developing field in sports nutrition.

Lifelong Endurance Exercise as a Countermeasure Against Age-Related [Formula: see text] Decline: Physiological Overview and Insights from Masters Athletes

Maximum oxygen consumption ([Formula: see text]) is not only an indicator of endurance performance, but also a strong predictor of cardiovascular disease and mortality. This physiological parameter is known to decrease with aging. In turn, physical exercise might attenuate the rate of aging-related decline in [Formula: see text], which in light of the global population aging is of major clinical relevance, especially at advanced ages. In this narrative review, we summarize the evidence available from masters athletes about the role of lifelong endurance exercise on aging-related [Formula: see text] decline, with examples of the highest [Formula: see text] values reported in the scientific literature for athletes across different ages (e.g., 35 ml·kg^-1·min^-1 in a centenarian cyclist). These data suggest that a linear decrease in [Formula: see text] might be possible if physical exercise loads are kept consistently high through the entire life span, with [Formula: see text] values remaining higher than those of the general population across all ages. We also summarize the main physiological changes that occur with inactive aging at different system levels-pulmonary and cardiovascular function, blood O₂ carrying capacity, skeletal muscle capillary density and oxidative capacity-and negatively influence [Formula: see text], and review how lifelong exercise can attenuate or even prevent most-but apparently not all (e.g., maximum heart rate decline)-of them. In summary, although aging seems to be invariably associated with a progressive decline in [Formula: see text], maintaining high levels of physical exercise along the life span slows the multi-systemic deterioration that is commonly observed in inactive individuals, thereby attenuating age-related [Formula: see text] decline.

Aerobic Versus Resistance Training Effects on Ventricular-Arterial Coupling and Vascular Function in the STRRIDE-AT/RT Trial

Background: The goal was studying the differential effects of aerobic training (AT) vs. resistance training (RT) on cardiac and peripheral arterial capacity on cardiopulmonary (CP) and peripheral vascular (PV) function in sedentary and obese adults.

Methods: In a prospective randomized controlled trial, we studied the effects of 6 months of AT vs. RT in 21 subjects. Testing included cardiac and vascular ultrasoundography and serial CP for ventricular-arterial coupling (Ees/Ea), strain-based variables, brachial artery flow-mediated dilation (BAFMD), and peak VO₂ (pVO_2; mL/kg/min) and peak O₂-pulse (O₂p; mL/beat).

Results: Within the AT group (n = 11), there were significant increases in rVO₂ of 4.2 mL/kg/min (SD 0.93) (p = 0.001); O₂p of 1.9 mL/beat (SD 1.3) (p = 0.008) and the brachial artery post-hyperemia peak diameter 0.18 mm (SD 0.08) (p = 0.05). Within the RT group (n = 10) there was a significant increase in left ventricular end diastolic volume 7.0 mL (SD 9.8; p = 0.05) and percent flow-mediated dilation (1.8%) (SD 0.47) (p = 0.004). Comparing the AT and RT groups, post exercise, rVO₂ 2.97, (SD 1.22), (p = 0.03), O₂p 0.01 (SD 1.3), (p = 0.01), peak hyperemic blood flow volume (1.77 mL) (SD 140.69) (p = 0.009), were higher in AT, but LVEDP 115 mL (SD 7.0) (p = 0.05) and Ees/Ea 0.68 mmHg/ml (SD 0.60) p = 0.03 were higher in RT.

Discussion: The differential effects of AT and RT in this hypothesis generating study have important implications for exercise modality and clinical endpoints.

Sex differences in the prognosis of patients with hypertrophic cardiomyopathy

We investigated sex-related differences in the prognosis of patients with hypertrophic cardiomyopathy (HCM) using the Korea National Health Insurance Service database. From 2010 to 2016, 9524 patients diagnosed with HCM and had more than 1-year follow-up period were analyzed. The primary endpoint was the composite of cardiovascular death or new-onset heart failure (HF) admission. Propensity score-matching analysis was performed to adjust for different baseline characteristics. With a 4.4-years’ median follow-up interval (range 2.0–6.6 years) and male predominance (77.6%), women with HCM were older (52.6 ± 9.7 vs. 51.4 ± 9.1, p < 0.001), had lower incomes, more comorbidities based on Charlson comorbidity index. Women with HCM had a higher incidence of the primary endpoint than men (incidence rate: 34.15 vs. 22.83 per 1000 person-years, log-rank p < 0.001). Multivariable Cox analysis showed that female sex was a poor prognostic factor for the primary endpoint (HR 1.43, 95% CI 1.24–1.64, p < 0.001). This was mainly driven by a higher incidence of new-onset HF admission (HR 1.55, 95% CI 1.34–1.80). However, there was no difference in the incidence of cardiovascular death between the sexes. This result was concordant in the propensity score-matched cohort. In conclusion, women with HCM have worse prognosis, which was mainly driven by a higher new-onset HF admission.

Ten-year follow-up of cardiac function and neural regulation in a group of amateur half-marathon runners

OBJECTIVE

In the last years, a debate exists about type, intensity and frequency of physical exercise that is really indicated to protect healthy subjects from cardiovascular disease. Regular physical training has been associated with an improved cardiovascular risk profile, but it has also been demonstrated that strenuous and uncontrolled physical exercise could be dangerous, in terms of increased cardiovascular morbidity and mortality. In the present study, we evaluated a group of 35 amateur half-marathon runners, who were likewise studied 10 years before (B). The results of B suggested that an increased cardiac sympathetic modulation could potentially represent a negative prognostic factor. The aim of this follow-up was to assess the medium-long-term effects of moderate to vigorous physical training on the cardiovascular neural control, cardiac function and occurrence of cardiovascular diseases.

METHODS

Each enrolled subject underwent: (1) an interview and physical examination to ascertain the presence of cardiovascular disease; (2) standing test to evaluate the cardiovascular neural control by means of heart rate variability (HRV), arterial blood pressure (AP) variability and baroreflex sensitivity (BRS); (3) transthoracic echocardiography to evaluate cardiac function.

RESULTS

At 10-year follow-up (FU), in this group of middle-aged athletes the occurrence of cardiovascular diseases was low, not unlike that of the overall population. The results of HRV analysis showed a decreased sympathetic and increased vagal modulation directed to the heart, compared with B. In addition, HRV, AP variability and BRS indices showed a physiological response to active standing. Finally, athletes had normal echocardiographic measures.

CONCLUSION

We conclude that in our group of athletes a regular moderate-vigorous physical training through the 10 years was quite beneficial as the prevalence of sympathetic cardiac modulation observed at B was not accompanied by increased cardiovascular risk, on the contrary a slight prevalence of vagal indices was observed at FU.

Sex Differences in Cardiovascular Aging and Heart Failure

PURPOSE OF THE REVIEW

This review summarizes sex-related changes in the heart and vasculature that occur with aging, both in the presence and absence of cardiovascular disease (CVD).

RECENT FINDINGS

In the presence of CVD risk factors and/or overt CVD, sex-specific changes in the number of cardiomyocytes, extent of the myocardial extracellular matrix, and myocellular hypertrophy promote unique patterns of LV remodeling in men and women. In addition, age- and sex-specific vascular stiffening is also well established, driven by changes in endothelial dysfunction, elastin-collagen content, microvascular dysfunction, and neurohormonal signaling. Together, these changes in LV chamber geometry and morphology, coupled with heightened vascular stiffness, appear to drive both age-related increases in systolic function and declines in diastolic function, particularly in postmenopausal women. Accordingly, estrogen has been implicated as a key mediator, given its direct vasodilating properties, association with nitric oxide excretion, and involvement in myocellular Ca2+ handling, mitochondrial energy production, and oxidative stress. The culmination of the abovementioned sex-specific cardiac and vascular changes across the lifespan provides important insight into heart failure development, particularly of the preserved ejection fraction variety, while offering promise for future preventive strategies and therapeutic approaches.