Novel echocardiographic techniques for the evaluation of athletes' heart: A focus on speckle-tracking echocardiography

A First Diastolic Function Evaluation in the Personalized Exercise Prescription Program for Solid Organs Transplanted Subjects: Is Atrial Strain Useful?

Background/Objectives: Solid organ transplant recipients (OTR) have been recently involved in exercise prescription programs in order to reduce the high prevalence of cardiovascular diseases. The normal systolic and diastolic cardiac function is fundamental to personalizing the prescription. Diastolic dysfunction can be associated to a higher risk of cardiovascular events and left atrial (LA) strain is an emerging parameter in the evaluation of diastolic compromising, especially in subjects with preserved ejection fraction. Left atrial (LA) strain has never been explored in this category. The study aimed to evaluate the contribution of the LA strain in the assessment of diastolic function of OTR and its potential contribution in the exercise program. Methods: 54 solid OTR (liver and kidney transplants) regularly trained for at least 12 months in a home-based, partially supervised model at moderate intensity estimated by cardiopulmonary exercise test, underwent a complete echocardiographic analysis. The measured variables included left ventricle systolic function (ejection fraction, EF), diastolic function (E/A and E/E'), LA indexed volumes, LA peak atrial longitudinal strain (PALS) and LA peak atrial contraction strain (PACS). The data were compared to those of 44 healthy subjects (HS). Results: The OTR showed an overweight condition (BMI: 25.79 ± 2.92 vs. 22.25 ± 2.95; p < 0.01). Both groups showed a preserved systolic function (EF: OTR 63.1 ± 3.5% vs. HS 66.9 ± 6.1; p < 0.001), while diastolic standard parameters were significantly different (E/A, 1.01 ± 0.4 vs. 1.96 ± 0.74; p < 0.001; E/E', 9.2 ± 2.7 vs. 6.9 ± 1.3; p < 0.001, in OTR and HS respectively) despite being normal. LA strain was significantly lower in OTR vs. HS (4C PALS, 33.7 ± 9.7 vs. 45.4 ± 14.19; p < 0.001; 4C PACS, 15.9 ± 6.7 vs. 11.6 ± 7.5; p = 0.006; 2C PALS, 35.3 ± 11.1 vs. 47.6 ± 14.9; p < 0.001; 2C PALS, 17.4 ± 4.9 vs. 13.2 ± 14.97; p = 0.001; in OTR and HS respectively). A specific correlation of two- and four-chamber PACs and PALs with BMI has been observed (R for 4C PALS -0.406 ** and 2C PALS -0.276 *). Conclusions: These findings suggest that the coexistence of increased bodyweight in asymptomatic OTR patients can exacerbate the impairment of LA strains. LA strain detection could be useful in the development of a personalized exercise program for OTRs, especially for asymptomatic subjects and those with elevated cardiovascular risk profile, to potentially manage the exercise program in the long term. Larger studies will confirm the role via an eventual structured clinical score index.

Cardiac functional adaptation to resistance and endurance exercise training: a randomized crossover study

Few training studies have assessed the impact of different modes of exercise on changes in cardiac function. This study investigated changes in left ventricular (LV) systolic and diastolic function following endurance (END) and resistance (RES) training in healthy participants. Sixty-four individuals participated in a randomized crossover design trial, involving 12 wk of END and RES training, separated by a 12-wk washout. Echocardiograms assessed systolic function [ejection fraction (EF) and global longitudinal strain (GLS)], diastolic function [mitral valve early velocity (E), tissue Doppler velocity (e'), their ratio (E/e')], and left atrial volume indexed to body surface area (LA ESVi). LV mass (LVM) increased with both RES (Δ5.3 ± 11.9, P = 0.001) and END (Δ7.5 ± 13.9, P < 0.001). Once adjusted for lean body mass (LVMi), changes remained significant following END. E/e' improved following END (Δ-0.35 ± 0.98, P = 0.011) not RES (Δ0.35 ± 1.11, P =0.157; P = 0.001 between modes). LA ESVi increased with END (Δ2.0 ± 6.1, P = 0.019) but not RES (Δ1.7 ± 5.7, P = 0.113). EF and GLS were not impacted significantly by either mode of training. Adaptation in LVM and LA volumes, as well as diastolic function, was exercise mode specific. Twelve weeks of intensive END increased LVM, LA volumes, and increased diastolic function. Following RES, LVM increased, although this was attenuated after accounting for changes in lean body mass. There were no changes in systolic function following either mode of exercise training.NEW & NOTEWORTHY Different types of exercise training induce distinct physiological adaptations however few exercise training studies have assessed the impact of different modes of exercise on cardiac function. This study investigated changes in left ventricular systolic and diastolic function following exercise training. Participants completed both endurance and resistance training separated by a 12-wk washout period so each participant is their own control. We present adaptations in cardiac structure and diastolic function are exercise mode specific.

Cardiac imaging in athlete's heart: current status and future prospects

BACKGROUND

Physical activity contributes to changes in cardiac morphology, which are known as "athlete's heart". Therefore, these modifications can be characterized using different imaging modalities such as echocardiography, including Doppler (flow Doppler and Doppler myocardial imaging) and speckle-tracking, along with cardiac magnetic resonance, and cardiac computed tomography.

MAIN TEXT

Echocardiography is the most common method for assessing cardiac structure and function in athletes due to its availability, repeatability, versatility, and low cost. It allows the measurement of parameters like left ventricular wall thickness, cavity dimensions, and mass. Left ventricular myocardial strain can be measured by tissue Doppler (using the pulse wave Doppler principle) or speckle tracking echocardiography (using the two-dimensional grayscale B-mode images), which provide information on the deformation of the myocardium. Cardiac magnetic resonance provides a comprehensive evaluation of cardiac morphology and function with superior accuracy compared to echocardiography. With the addition of contrast agents, myocardial state can be characterized. Thus, it is particularly effective in differentiating an athlete's heart from pathological conditions, however, is less accessible and more expensive compared to other techniques. Coronary computed tomography is used to assess coronary artery anatomy and identify anomalies or diseases, but its use is limited due to radiation exposure and cost, making it less suitable for young athletes. A novel approach, hemodynamic forces analysis, uses feature tracking to quantify intraventricular pressure gradients responsible for blood flow. Hemodynamic forces analysis has the potential for studying blood flow within the heart and assessing cardiac function.

CONCLUSIONS

In conclusion, each diagnostic technique has its own advantages and limitations for assessing cardiac adaptations in athletes. Examining and comparing the cardiac adaptations resulting from physical activity with the structural cardiac changes identified through different diagnostic modalities is a pivotal focus in the field of sports medicine.

Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023

Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.

Echocardiography and strain analysis in Malaysian elite athletes versus young healthy adults

Background

Athletes have changes that can mimic pathological cardiomyopathy.

Methods

Echocardiographic study of 50 male, female athletes (MA, FA) and non-athletes (MNA, FNA) age 18 to 30 years. These athletes participate in sports with predominantly endurance component. All participants exhibit no known medical illnesses or symptoms.

Results

MA have thicker wall (IVSd) than MNA. No MA have IVSd > 1.2 cm and no FA have IVSd > 1.0 cm. Left ventricle internal dimension (LVIDd), left ventricle end diastolic volume index (LVEDVi) is bigger in athletes. None have LVIDd > 5.8 cm. Right ventricle fractional area change (FAC) is lower in athletes. (MA vs MNA, p = 0.013, FA vs FNA, p = 0.025). Athletes have higher septal and lateral e' (Septal e'; MA 13.57 ± 2.66 cm/s vs MNA 11.46 ± 2.93 cm/s, p < 0.001, Lateral e'; MA 17.17 ± 3.07 cm/s vs MNA 14.82 ± 3.14 cm/s, p < 0.001), (Septal e'; FA 13.46 ± 2.32 cm/s vs FNA 12.16 ± 2.05 cm/s, p = 0.04, Lateral e'; FA 16.92 ± 2.97 cm/s vs FNA 15.44 ± 2.29 cm/s, p = 0.006).No difference in Global longitudinal (GLS), Right ventricle free wall (RVFWS) and Global circumferential strain (GCS). Left atrial reservoir (LArS) and left atrial booster strain (LAbS) is smaller in athletes. (LArS, MA 44.12 ± 9.55% vs MNA 52.95 ± 11.17%, p < 0.001 LArS, FA 48.07 ± 10.06% vs FNA 53.64 ± 8.99%, p = 0.004), (LAbS, MA 11.59 ± 5.13% vs MNA 17.35 ± 5.27%, p < 0.001 LAbS FA 11.77 ± 4.65% vs FNA 15.30 ± 4.19%, p < 0.001).

Conclusion

Malaysian athletes have thicker wall and bigger left ventricle than controls. No athletes have IVSd > 1.2 cm and/or LVIDd > 5.8 cm. There is no difference in GLS, RVFWS and GCS but athletes have smaller LArS and LAbS.

Concentric and Eccentric Remodelling of the Left Ventricle and Its Association to Function in the Male Athletes Heart: An Exploratory Study

AIMS

To compare (1) conventional left ventricular (LV) functional parameters, (2) LV peak strain and strain rate and (3) LV temporal strain and strain rate curves in age, ethnicity and sport-matched athletes with concentric, eccentric and normal LV geometry.

METHODS

Forty-five male athletes were categorised according to LV geometry including concentric remodelling/hypertrophy (CON), eccentric hypertrophy (ECC) or normal (NORM). Athletes were evaluated using conventional echocardiography and myocardial speck tracking, allowing the assessment of myocardial strain and strain rate; as well as twist mechanics.

RESULTS

Concentric remodelling was associated with an increased ejection fraction (EF) compared to normal geometry athletes (64% (48-78%) and 56% (50-65%), respectively; p < 0.04). No differences in peak myocardial strain or strain rate were present between LV geometry groups including global longitudinal strain (GLS; CON -16.9% (-14.9-20.6%); ECC -17.9% (-13.0-22.1%); NORM -16.9% (-12.8-19.4%)), global circumferential strain (GCS; CON -18.1% (-13.5-24.5%); ECC -18.7% (-15.6-22.4%); NORM -18.0% (-13.5-19.7%)), global radial strain (GRS; CON 42.2% (30.3-70.5%); ECC 50.0% (39.2-60.0%); NORM 40.6 (29.9-57.0%)) and twist (CON 14.9° (3.7-25.3°); ECC 12.5° (6.3-20.8°); NORM 13.2° (8.8-24.2°)). Concentric and eccentric remodelling was associated with alterations in temporal myocardial strain and strain rate as compared to normal geometry athletes.

CONCLUSION

Physiological concentric and eccentric remodelling in the athletes heart is generally associated with normal LV function; with concentric remodelling associated with an increased EF. Physiological concentric and eccentric remodelling in the athletes heart has no effect on peak myocardial strain but superior deformation and untwisting is unmasked when assessing the temporal distribution.

Left Ventricular, Left Atrial and Right Ventricular Strain Modifications after Maximal Exercise in Elite Ski-Mountaineering Athletes: A Feasibility Speckle Tracking Study

Eleven world elite ski-mountaineering (Ski-Mo) athletes were evaluated for pronounced echocardiographic physiological remodeling as the primary aim of our feasibility speckle tracking study. In this context, sports-related cardiac remodeling was analyzed by performing two-dimensional echocardiography, including speckle tracking analysis of the left atrium (LA), right ventricle (RV) and left ventricular (LV) global longitudinal strain (LV-GLS) at rest and post-peak performance. The feasibility echocardiographic speckle tracking analysis was performed on eleven elite Ski-Mo athletes, which were obtained in 2022 during the annual medical examination. The obtained data of the professional Ski-Mo athletes (11 athletes, age: 18-26 years) were compared for different echocardiographic parameters at rest and post-exercise. Significant differences were found for LV-GLS mean (p = 0.0036) and phasic LA conduit strain pattern at rest and post-exercise (p = 0.0033). Furthermore, negative correlation between LV mass and LV-GLS (p = 0.0195, r = -0.69) and LV mass Index and LV-GLS (p = 0.0253, r = -0.66) at rest were elucidated. This descriptive reporting provided, for the first time, a sport-specific dynamic remodeling of an entire elite national team of the Ski-Mo athlete's left heart and elucidated differences in the dynamic deformation pattern of the left heart.

Difference in cardiac remodeling between female athletes and pregnant women: a case control study

OBJECTIVES

The aim of this study was to detect possible differences in reversible cardiac remodeling occurring in sport training and twin pregnancy.

BACKGROUND

cardiac remodeling occurs in athletes and pregnant women due to training and fetal requirements, respectively. These changes could be apparently similar.

METHODS

21 female elite athletes (23.2 ± 5.3 years), 25 women with twin pregnancies (35.4 ± 5.7 years) and 25 healthy competitive female athletes (controls), age-matched with pregnant women (34.9 ± 7.9 years), were enrolled. This latter group was included to minimize the effect of age on cardiac remodeling. All women evaluated through anamnestic collection, physical examination, 12 leads ECG, standard echocardiogram and strain analysis. Sphericity (SI) and apical conicity (ACI) indexes were also calculated.

RESULTS

Pregnant women showed higher LA dimension (p < 0.001) compared to both groups of athletes. LV e RV GLS were significantly different in pregnant women compared to female athletes (p = 0.02 and 0.03, respectively). RV GLS was also different between pregnant women and controls (p = 0.02). Pregnant women showed significantly higher S' wave compared to female athletes (p = 0.02) but not controls. Parameters of diastolic function were significantly higher in athletes (p = 0.08 for IVRT and p < 0.001 for E/A,). SI was lower in athletes in both diastole (p = 0.01) and systole (p < 0.001), while ACIs was lower in pregnant women (p = 0.04).

CONCLUSIONS

Cardiac remodeling of athletes and pregnant women could be similar at first sight but different in LV shape and in GLS, highlighting a profound difference in longitudinal deformation between athletes and pregnant women. This difference seems not to be related with age. These findings suggest that an initial maternal cardiovascular maladaptation could occur in the third trimester of twin pregnancies.

The Acute Effects of an Ultramarathon on Atrial Function and Supraventricular Arrhythmias in Master Athletes

BACKGROUND

Endurance sports practice has significantly increased over the last decades, with a growing proportion of master athletes. However, concerns exist regarding the potential proarrhythmic effects induced by ultra-endurance sports. This study aimed to analyse the acute effects of an ultramarathon race on atrial remodelling and supraventricular arrhythmias in a population of master athletes.

METHODS

Master athletes participating in an ultramarathon (50 km, 600 m of elevation gain) with no history of heart disease were recruited. A single-lead ECG was recorded continuously from the day before to the end of the race. Echocardiography and 12-lead resting ECG were performed before and immediately at the end of the race.

RESULTS

The study sample consisted of 68 healthy non-professional master athletes. Compared with baseline, P wave voltage was higher after the race (p < 0.0001), and more athletes developed ECG criteria for right atrial enlargement (p < 0.0001). Most of the athletes (97%) had ≥1 premature atrial beats (PAB) during the 24-h monitoring, also organised in triplets (17%) and non-sustained supraventricular tachycardias (NSSVTs) (19%). In contrast, exercise-induced PABs, triplets, and NSSVTs were rare. One athlete developed acute atrial fibrillation during the race. After the race, no significant differences were found in biatrial dimensions. Biatrial function, estimated by peak atrial longitudinal and contraction strains, were normal both before and after the race.

CONCLUSIONS

In master athletes running an ultramarathon, acute exercise-induced atrial dysfunction was not detected, and exercise-induced supraventricular arrhythmias were uncommon. These results did not confirm the hypothesis of an acute atrial dysfunction induced by ultra-endurance exercise.

Athlete’s Heart in Elite Biathlon, Nordic Cross—Country and Ski-Mountaineering Athletes: Cardiac Adaptions Determined Using Echocardiographic Data

Twelve world elite Biathlon (Bia), ten Nordic Cross Country (NCC) and ten ski-mountaineering (Ski-Mo) athletes were evaluated for pronounced echocardiographic physiological cardiac remodeling as a primary aim of our descriptive preliminary report. In this context, sports-related cardiac remodeling was analyzed by performing two-dimensional echocardiography including speckle tracking analysis as left ventricular global longitudinal strain (LV-GLS). A multicenter retrospective analysis of echocardiographic data was performed in 32 elite world winter sports athletes, which were obtained between 2020 and 2021 during the annual medical examination. The matched data of the elite world winter sports athletes (14 women, 18 male athletes, age: 18–35 years) were compared for different echocardiographic parameters. Significant differences could be revealed for left ventricular systolic function (LV-EF, p = 0.0001), left ventricular mass index (LV Mass index, p = 0.0078), left atrial remodeling by left atrial volume index (LAVI, p = 0.0052), and LV-GLS (p = 0.0003) between the three professional winter sports disciplines. This report provides new evidence that resting measures of cardiac structure and function in elite winter sport professionals can identify sport specific remodeling of the left heart, against the background of training schedule and training frequency.

The Role of Multimodality Imaging in Athlete's Heart Diagnosis: Current Status and Future Directions

“Athlete’s heart” is a spectrum of morphological and functional changes which occur in the heart of people who practice physical activity. When athlete’s heart occurs with its most marked expression, it may overlap with a differential diagnosis with certain structural cardiac diseases, including cardiomyopathies, valvular diseases, aortopathies, myocarditis, and coronary artery anomalies. Identifying the underlying cardiac is essential to reduce the potential for sudden cardiac death. For this purpose, a spectrum of imaging modalities, including rest and exercise stress echocardiography, speckle tracking echocardiography, cardiac magnetic resonance, computed tomography, and nuclear scintigraphy, can be undertaken. The objective of this review article is to provide to the clinician a practical step-by-step approach, aiming at distinguishing between extreme physiology and structural cardiac disease during the athlete’s cardiovascular evaluation.

Novel insights into the athlete's heart: is myocardial work the new champion of systolic function?

Aims

We sought to investigate the correlation between speckle-tracking echocardiography (STE)-derived myocardial work (MW) and invasively measured contractility in a rat model of athlete's heart. We also assessed MW in elite athletes and explored its association with cardiopulmonary exercise test (CPET)-derived aerobic capacity.

Methods and results

Sixteen rats underwent a 12-week swim training program and were compared to controls (n = 16). STE was performed to assess global longitudinal strain (GLS), which was followed by invasive pressure-volume analysis to measure contractility [slope of end-systolic pressure–volume relationship (ESPVR)]. Global MW index (GMWI) was calculated from GLS curves and left ventricular (LV) pressure recordings. In the human investigations, 20 elite swimmers and 20 healthy sedentary controls were enrolled. GMWI was calculated through the simultaneous evaluation of GLS and non-invasively approximated LV pressure curves at rest. All subjects underwent CPET to determine peak oxygen uptake (VO₂/kg). Exercised rats exhibited higher values of GLS, GMWI, and ESPVR than controls (−20.9 ± 1.7 vs. −17.6 ± 1.9%, 2745 ± 280 vs. 2119 ± 272 mmHg·%, 3.72 ± 0.72 vs. 2.61 ± 0.40 mmHg/μL, all P_Exercise < 0.001). GMWI correlated robustly with ESPVR (r = 0.764, P < 0.001). In humans, regular exercise training was associated with decreased GLS (−17.6 ± 1.5 vs. −18.8 ± 0.9%, P_Exercise = 0.002) but increased values of GMWI at rest (1899 ± 136 vs. 1755 ± 234 mmHg·%, P_Exercise = 0.025). GMWI exhibited a positive correlation with VO₂/kg (r = 0.527, P < 0.001).

Conclusions

GMWI precisely reflected LV contractility in a rat model of exercise-induced LV hypertrophy and captured the supernormal systolic performance in human athletes even at rest. Our findings endorse the utilization of MW analysis in the evaluation of the athlete’s heart.

Left atrial enlargement in competitive athletes and atrial electrophysiology

INTRODUCTION AND OBJECTIVES

There are scarce data on left atrial (LA) enlargement and electrophysiological features in athletes.

METHODS

Multicenter observational study in competitive athletes and controls. LA enlargement was defined as LA volume indexed to body surface area ≥ 34mL/m². We analyzed its relationship with atrial electrocardiography parameters.

RESULTS

We included 356 participants, 308 athletes (mean age: 36.4±11.6 years) and 48 controls (mean age: 49.3±16.1 years). Compared with controls, athletes had a higher mean LA volume index (29.8±8.6 vs 25.6±8.0mL/m², P=.006) and a higher prevalence of LA enlargement (113 [36.7%] vs 5 [10.4%], P <.001), but there were no relevant differences in P-wave duration (106.3±12.5ms vs 108.2±7.7ms; P=.31), the prevalence of interatrial block (40 [13.0%] vs 4 [8.3%]; P=.36), or morphology-voltage-P-wave duration score (1.8±0.84 vs 1.5±0.8; P=.71). Competitive training was independently associated with LA enlargement (OR, 14.7; 95%CI, 4.7-44.0; P <.001) but not with P-wave duration (OR, 1.02; 95%CI, 0.99-1.04), IAB (OR, 1.4; 95%CI, 0.7-3.1), or with morphology-voltage-P-wave duration score (OR, 1.4; 95%CI, 0.9-2.2).

CONCLUSIONS

LA enlargement is common in adult competitive athletes but is not accompanied by a significant modification in electrocardiographic parameters.

Differing mechanisms of atrial fibrillation in athletes and non-athletes: alterations in atrial structure and function

AIMS

Atrial fibrillation (AF) is more common in athletes and may be associated with adverse left atrial (LA) remodelling. We compared LA structure and function in athletes and non-athletes with and without AF.

METHODS AND RESULTS

Individuals (144) were recruited from four groups (each n = 36): (i) endurance athletes with paroxysmal AF, (ii) endurance athletes without AF, (iii) non-athletes with paroxysmal AF, and (iv) non-athletic healthy controls. Detailed echocardiograms were performed. Athletes had 35% larger LA volumes and 51% larger left ventricular (LV) volumes vs. non-athletes. Non-athletes with AF had increased LA size compared with controls. LA/LV volume ratios were similar in both athlete groups and non-athlete controls, but LA volumes were differentially increased in non-athletes with AF. Diastolic function was impaired in non-athletes with AF vs. non-athletes without, while athletes with and without AF had normal diastolic function. Compared with non-AF athletes, athletes with AF had increased LA minimum volumes (22.6 ± 5.6 vs. 19.2 ± 6.7 mL/m2, P = 0.033), with reduced LA emptying fraction (0.49 ± 0.06 vs. 0.55 ± 0.12, P = 0.02), and LA expansion index (1.0 ± 0.3 vs. 1.2 ± 0.5, P = 0.03). LA reservoir and contractile strain were decreased in athletes and similar to non-athletes with AF.

CONCLUSION

Functional associations differed between athletes and non-athletes with AF, suggesting different pathophysiological mechanisms. Diastolic dysfunction and reduced strain defined non-athletes with AF. Athletes had low atrial strain and those with AF had enlarged LA volumes and reduced atrial emptying, but preserved LV diastolic parameters. Thus, AF in athletes may be triggered by an atrial myopathy from exercise-induced haemodynamic stretch consequent to increased cardiac output.

Strain echocardiography to describe left ventricular function pre- and postexercise in elite basketball athletes: A feasibility study

BACKGROUND

Elite athletes show structural cardiac changes as an adaptation to exercise. Studies examining strain in athletes have largely analyzed images at rest only. There is little data available regarding the change in strain with exercise. Our objectives were: to investigate the feasibility of strain analysis in athletes at peak exercise, to determine the normal range of left ventricular (LV) global longitudinal strain (GLS) within this population postexercise, to describe how LV GLS changes with exercise, and to determine whether any clinical characteristics correlate with the change in GLS that occurs with exercise.

METHODS

We conducted a cross-sectional study on elite athletes who participated in the 2016-2018 National Basketball Association Draft Combines. Echocardiograms were obtained at rest and after completing a treadmill stress test to maximal exertion or completion of Bruce protocol. Primary outcomes included GLS obtained at rest and peak exercise. Secondary outcome was the change in GLS between rest and exercise. Univariate relationships between various clinical characteristics and our secondary outcome were analyzed.

RESULTS

Our final cohort (n = 111) was all male and 92/111 (82.9%) were African American. Mean GLS magnitude increased in response to exercise (-17.6 ± 1.8 vs -19.2 ± 2.6, P < .0001). Lower resting heart rates (r = .22, P = .02) and lower heart rates at peak exercise (r = .21, P = .03) correlated with the increase in LV GLS from exercise.

CONCLUSIONS

Strain imaging is technically feasible to obtain among elite basketball athletes at peak exercise. Normative strain response to exercise from this study may help identify abnormal responses to exercise in athletes.

Echocardiographic evaluation of the Athlete's heart

Cardiac response to prolonged, intense exercise induces phenotypic and physiologic adaptive changes that improve myocardial ability to meet oxygen demands. These adaptations, termed "athletes' heart," have been extensively studied. The importance of this entity arises from the increasing numbers of athletes as well as the drive for physical fitness in the general population leading to adaptive cardiac changes that need to be differentiated from life-threatening cardiovascular diseases. A number of pathologic entities may share phenotypic changes with the athletes' heart such as hypertrophic cardiomyopathy, dilated cardiomyopathy, Marfan's syndrome, and arrhythmogenic right ventricular cardiomyopathy. Cardiologists need to be cognizant of these overlapping findings to appropriately diagnose diseases and prevent catastrophic outcomes especially in young and healthy individuals who may not show any symptoms until they engage in intense exercise. It is equally important to recognize and distinguish normal, exercise-adaptive cardiac changes to provide accurate screening and guidance to young elite athletes. Echocardiography is a valuable modality that allows comprehensive initial evaluation of cardiac structures, function, and response to exercise. Several different echocardiographic techniques including M-Mode, 2D echo, Doppler, tissue Doppler, color tissue Doppler, and speckle tracking have been used in the evaluation of cardiac adaptation to exercise. The following discussion is a review of literature that has expanded our knowledge of the athlete's heart.

Changes in left ventricular and atrial mechanics and function after dialysis in patients with end-stage renal disease

Background

Hemodialysis (HD) can influence end-stage renal disease (ESRD) patients' circulatory system. The present study aimed to evaluate the effect of volume depletion on left ventricular (LV) and left atrial (LA) function and determine the volume-independent parameters before and after HD in patients with ESRD.

Methods

Between January 2018 and January 2019, we recruited long-term HD patients (n=40, 51.0±16.4 years), excluding those with structural cardiac disease. Echocardiographic parameters, including LV and LA volumes, flow Doppler, pulsed tissue Doppler, and speckle tracking echocardiography (STE) before and after HD (within 24 h), were examined, and the values were compared.

Results

Following HD, alteration in LV end-systolic volume was not detected, whereas LV end-diastolic volume (90.18±23.91 vs. 84.21±23.54 mL, P=0.036) and LV ejection fraction (LVEF; 64.63%±6.56% vs. 62.84%±6.56%, P=0.049) decreased. Peak early diastolic trans-mitral flow velocity (E-wave; 82.22±20.13 vs. 72.43±18.32 cm/s, P<0.001), peak early diastolic tissue Doppler velocity (e'; 6.45±1.88 vs. 5.77±1.63 cm/s, P<0.001) at the septal side of the mitral annulus, the ratio of early to late Doppler velocities of diastolic mitral inflow (0.90±0.27 vs. 0.79±0.23, P<0.001), and the average E/e' ratio (12.54±4.08 vs. 11.28±4.52, P=0.049) decreased significantly. No significant difference was found in peak blood flow velocity at the mitral valve during late diastole and e' at the lateral side of the mitral annulus after HD. LA volume index (35.55±12.61 vs. 30.22±9.80 mL/m², P<0.001), tricuspid regurgitation velocity (260.11±36.54 vs. 242.37±32.22 cm/s, P=0.002), and pulmonary artery systolic pressure (33.63±11.29 vs. 29.94±7.80 mmHg, P=0.006) significantly decreased. LV global longitudinal systolic strain (GLS) of 4-chamber view (-24.37%±3.02% vs. -23.38%±3.33%, P=0.019), rather than global circumferential systolic strain, exhibited significant change after HD. Significant changes were also found in LV longitudinal early diastolic strain rate (LSRe; 1.17±0.25 vs. 1.05±0.24 s^-1, P<0.001) and early diastolic global radial velocity (Ve; 2.62±0.59 vs. 2.25±0.67 cm/s, P=0.011) after HD, but not in other strain rates and global radial velocity measurements. LA maximal volume (35.55±12.61 vs. 30.22±9.80 mL/m², P<0.001), LA total emptying fraction (54.19%±10.39% vs. 49.63%±11.05%, P=0.009), and LA passive emptying fraction (32.23%±12.86% vs. 26.81%±9.28%, P=0.004) decreased significantly after HD, while LA minimal volume, the volume at the onset of atrial systole, and LA active emptying fraction after HD were not significantly different.

Conclusions

Most indices of systolic (LVEF and GLS of 4-chamber view) and early diastolic function (E-wave, e', LSRe, global radial Ve, and LA passive emptying fraction) were preload dependent. Late diastolic indices, including LV late diastolic global longitudinal strain rate, late diastolic global radial velocity, and LA active emptying fraction, did not change with volume depletion.

Analysis of left ventricular rotational deformation by 2D speckle tracking echocardiography: a feasibility study in athletes

2D speckle tracking echocardiography (2DSTE) is established to analyse left ventricular (LV) longitudinal function. The analysis of LV rotational deformation is challenging and requires standardization of image acquisition as well as postprocessing analysis. The aim of this study was to test the feasibility to analyse LV rotational deformation using 2DSTE by introducing a novel algorithm for the detection of artefacts. The study was performed in 20 healthy subjects serving as a control group and in 53 competitive sportsmen. Circumferential, radial strain (CS, RS) and LV rotation were analysed by 2DSTE in parasternal short axis views. The stepwise algorithm to exclude potential artefacts starts with the visual estimation of the image quality with respect to complete visualization of all myocardial segments during the entire cardiac cycle followed by the exclusion of data sets in participants with conduction abnormalities. The next step is the optimization of tracking areas and a cross-check of implausible strain waveforms in multiple acquired comparable cineloops. The last step is the exclusion of strain curves with persisting implausible waveforms if standardization failures and incorrect LV wall tracking are fixed. Plausible physiological strain curves were observed in 89% (n = 65/73) of all subjects. In controls all implausible waveforms could be verified as artefacts. The algorithm was applied in 53 professional athletes to test and confirm its feasibility. Abnormal CS waveforms were documented in 25 athletes, verified as artefacts due to tracking failures in 22 athletes and due to incorrect image acquisition in 3 athletes. CS artefacts were mostly located in the basal posterior and lateral LV segments. (endocardial: 6%, n = 4/70; p < 0.05) and basal posterior (endocardial: 8%, n = 5/70; p < 0.05) segments were highly susceptible to artefacts. 2DSTE of parasternal short axis views to analyse circumferential and radial deformation as well as LV rotation is feasible in athletes. The proposed algorithm helps to avoid artefacts and might contribute to standardization of this technique. 2DSTE might provide an interesting diagnostic tool for the detection of viral myocarditis, e.g. in athletes.

The acute effects of an ultramarathon on biventricular function and ventricular arrhythmias in master athletes

AIMS

Endurance sports practice has significantly increased over the last decades, with a growing proportion of participants older than 40 years. Although the benefits of moderate regular exercise are well known, concerns exist regarding the potential negative effects induced by extreme endurance sport. The aim of this study was to analyse the acute effects of an ultramarathon race on the electrocardiogram (ECG), biventricular function, and ventricular arrhythmias in a population of master athletes.

METHODS AND RESULTS

Master athletes participating in an ultramarathon (50 km, 600 m of elevation gain) with no history of heart disease were recruited. A single-lead ECG was recorded continuously from the day before to the end of the race. Echocardiography and 12-lead resting ECG were performed before and at the end of the race. The study sample consisted of 68 healthy non-professional master athletes. Compared with baseline, R-wave amplitude in V1 and QTc duration were higher after the race (P < 0.001). Exercise-induced isolated premature ventricular beats were observed in 7% of athletes; none showed non-sustained ventricular tachycardia before or during the race. Left ventricular ejection fraction, global longitudinal strain (GLS), and twisting did not significantly differ before and after the race. After the race, no significant differences were found in right ventricular inflow and outflow tract dimensions, fractional area change, s', and free wall GLS.

CONCLUSION 

In master endurance athletes running an ultra-marathon, exercise-induced ventricular dysfunction, or relevant ventricular arrhythmias was not detected. These results did not confirm the hypothesis of a detrimental acute effect of strenuous exercise on the heart.

Assessment of left ventricular systolic function by non-invasive pressure-strain loop area in young male strength athletes

Background

The health of athletes has been recognized as a worldwide public concern with more reported sudden cardiac deaths (SCD). Therefore, early detection of abnormal heart function in athletes can help reduce the risk of exercise. A novel valid non-invasive method to evaluate left ventricular (LV) myocardial work (MW) using LV pressure-strain loop (PSL), was used in this paper to explore LV systolic function in young male strength athletes.

Methods

Thirty-six professional young male strength athletes (the athlete group) and 32 healthy, age-matched young men (the control group) were involved in the study. The LVMW parameters were calculated as the area of PSL by two-dimensional speckle tracking echocardiography (2D-STE) and peak systolic LV pressure. The differences between two groups of data and the predictive efficacy of MW parameters for LV systolic function were analyzed.

Results

The athlete group had significantly higher values of global wasted myocardial work (GWW) and peak strain dispersion (PSD) than did the control group (P<0.05). Global myocardial work index (GWI), global constructive myocardial work (GCW) and global longitudinal strain (GLS) were lower in the athlete group than that in the control group, although statistical significance was not reached (P>0.05). Due to the proportion of GWW and GCW, statistically significant reduction was found in global myocardial work efficiency (GWE) in the athlete group. Conventional echocardiography parameters were well correlated with GWW and GWE (P<0.05). The best predictor of LV myocardial contractile performance in the athletes using receiver operating characteristic curve (ROC) was GWE, with the area under ROC (AUC) of 0.733, sensitivity of 83.3% and specificity of 59.4%.

Conclusions

Subclinical changes have appeared in the hearts of young male strength athletes after long-term intensive exercise and LVMW parameters by PSL play an important role in the evaluation of athlete’s LV contractile performance.

A Vegan Athlete's Heart-Is It Different? Morphology and Function in Echocardiography

Plant-based diets are a growing trend, including among athletes. This study compares the differences in physical performance and heart morphology and function between vegan and omnivorous amateur runners. A study group and a matched control group were recruited comprising N = 30 participants each. Eight members of the study group were excluded, leaving N = 22 participants. Members of both groups were of similar age and trained with similar frequency and intensity. Vegans displayed a higher VO2max (54.08 vs. 50.10 mL/kg/min, p < 0.05), which correlated positively with carbohydrate intake (ρ = 0.52) and negatively with MUFA (monounsaturated fatty acids) intake (ρ = −0.43). The vegans presented a more eccentric form of remodelling with greater left ventricular end diastolic diameter (LVEDd, 2.93 vs. 2.81 cm/m², p = 0.04) and a lower relative wall thickness (RWT, 0.39 vs. 0.42, p = 0.04) and left ventricular mass (LVM, 190 vs. 210 g, p = 0.01). The left ventricular mass index (LVMI) was similar (108 vs. 115 g/m², p = NS). Longitudinal strain was higher in the vegan group (−20.5 vs. −19.6%, p = 0.04), suggesting better systolic function. Higher E-wave velocities (87 vs. 78 cm/s, p = 0.001) and E/e′ ratios (6.32 vs. 5.6, p = 0.03) may suggest better diastolic function in the vegan group. The results demonstrate that following a plant-based diet does not impair amateur athletes’ performance and influences both morphological and functional heart remodelling. The lower RWT and better LV systolic and diastolic function are most likely positive echocardiographic findings.

Aerobic Training Protects Cardiac Function During Advancing Age: A Meta-Analysis of Four Decades of Controlled Studies

Background

In contrast to younger athletes, there is comparatively less literature examining cardiac structure and function in older athletes. However, a progressive accumulation of studies during the past four decades offers a body of literature worthy of systematic scrutiny.

Objectives

We conducted a systematic review, meta-analysis and meta-regression of controlled echocardiography studies comparing left ventricular (LV) structure and function in aerobically trained older athletes (> 45 years) with age-matched untrained controls, in addition to investigating the influence of chronological age.

Methods

Electronic databases were searched from inception to January 2018 before conducting a random-effects meta-analysis to calculate pooled differences in means, effect size and 95% confidence intervals (CIs). Study heterogeneity was reported using Cochran’s Q and I² statistic.

Results

Overall, 32 studies (644 athletes; 582 controls) were included. Athletes had greater LV end-diastolic diameter (3.65 mm, 95% CI 2.66–4.64), interventricular septal thickness (1.23 mm, 95% CI 0.85–1.60), posterior wall thickness (1.20 mm, 95% CI 0.83–1.56), LV mass (72 g, 95% CI 46–98), LV mass index (28.17 g·m², 95% CI 19.84–36.49) and stroke volume (13.59 mL, 95% CI 7.20–19.98) (all p < 0.01). Athletes had superior global diastolic function [ratio of early (E) to late (A) mitral inflow velocity (E/A) 0.18, 95% CI 0.13–0.24, p < 0.01; ratio of early (e′) to late (a′) diastolic annular tissue velocity (e′/a′) 0.23, 95% CI 0.06–0.40, p = 0.01], lower A (−8.20 cm·s⁻¹, 95% CI −11.90 to −4.51, p < 0.01) and a′ (−0.72 cm·s⁻¹, 95% CI −1.31 to −0.12, p = 0.02), and more rapid e′ (0.96 cm·s⁻¹, 95% CI 0.05–1.86, p = 0.04). Meta-regression for chronological age identified that athlete–control differences, in the main, are maintained during advancing age.

Conclusions

Athletic older men have larger cardiac dimensions and enjoy more favourable cardiac function than healthy, non-athletic counterparts. Notably, the athlete groups maintain these effects during chronological ageing.

Electronic supplementary material

The online version of this article (10.1007/s40279-018-1004-3) contains supplementary material, which is available to authorized users.

Left ventricular hypertrophy in athletes: How to differentiate between hypertensive heart disease and athlete’s heart

Athlete’s heart is typically accompanied by a remodelling of the cardiac chambers induced by exercise. However, although competitive athletes are commonly considered healthy, they can be affected by cardiac disorders characterised by an increase in left ventricular mass and wall thickness, such as hypertension. Unfortunately, training-induced increase in left ventricular mass, wall thickness, and atrial and ventricular dilatation observed in competitive athletes may mimic the pathological remodelling of pathological hypertrophy. As a consequence, distinguishing between athlete’s heart and hypertension can sometimes be challenging. The present review aimed to focus on the differential diagnosis between hypertensive heart disease and athlete’s heart, providing clinical information useful to distinguish between physiological and pathological remodelling.

Cardiac adaptations in elite female football- and volleyball-athletes do not impact left ventricular global strain values: a speckle tracking echocardiography study

Cardiac adaptations to exercise on an elite level have been well studied. Strain analysis by speckle tracking echocardiography has emerged as a tool for sports cardiologists to assess the nature of hypertrophy in athletes' hearts. In prior studies, strain values generally did not change in physiological adaptations to exercise but were reduced in pathological hypertrophy. However, research in this field has focused almost solely on male athletes. Purpose of the present study is to investigate strain values in the hearts of female elite athletes in football and volleyball. In this cross-sectional study echocardiography was performed on 19 female elite football-players, 16 female elite volleyball-players and 16 physically inactive controls. Conventional echocardiographic data was documented as well as left ventricular longitudinal, radial and circumferential strain values gained by speckle tracking echocardiography. The hearts of the female athletes had a thicker septal wall, a larger overall mass and larger atria than the hearts in the control group. Global longitudinal, radial and circumferential strain values did not differ between the athletes and controls or between sporting disciplines. No correlation between septal wall thickness and global strain values could be documented. Cardiac adaptations to elite level exercise in female volleyball and football players do not influence global strain values. This has been documented for male athletes of several disciplines. The present study adds to the very limited control-group comparisons of left ventricular strain values in elite female athletes. The findings indicate that global strain values can be used when assessing the cardiac health in female athletes.

The difference in referencing in Web of Science, Scopus, and Google Scholar

AIMS

How often a medical article is cited is important for many people because it is used to calculate different variables such as the h-index and the journal impact factor. The aim of this analysis was to assess how the citation count varies between Web of Science (WoS), Scopus, and Google Scholar in the current literature.

METHODS

We included the top 50 cited articles of four journals ESC Heart Failure; Journal of cachexia, sarcopenia and muscle; European Journal of Preventive Cardiology; and European Journal of Heart Failure in our analysis that were published between 1 January 2016 and 10 October 2019. We recorded the number of citations of these articles according to WoS, Scopus, and Google Scholar on 10 October 2019.

RESULTS

The top 50 articles in ESC Heart Failure were on average cited 12 (WoS), 13 (Scopus), and 17 times (Google Scholar); in Journal of cachexia, sarcopenia and muscle 37 (WoS), 43 (Scopus), and 60 times (Google Scholar); in European Journal of Preventive Cardiology 41 (WoS), 56 (Scopus), and 67 times (Google Scholar); and in European Journal of Heart Failure 76 (WoS), 108 (Scopus), and 230 times (Google Scholar). On average, the top 50 articles in all four journals were cited 41 (WoS), 52 (Scopus, 26% higher citations count than WoS, range 8-42% in the different journals), and 93 times (Google Scholar, 116% higher citation count than WoS, range 42-203%).

CONCLUSION

Scopus and Google Scholar on average have a higher citation count than WoS, whereas the difference is much larger between Google Scholar and WoS.

Superior cardiac mechanics without structural adaptations in pre-adolescent soccer players

AIMS

This study aimed to evaluate left ventricular structure, function and mechanics, in highly-trained, pre-adolescent soccer players compared with age- and sex-matched controls.

DESIGN

The study design was a prospective, cross-sectional comparison of left ventricular structure, function and mechanics.

METHODS

Twenty-two male soccer players from two professional youth soccer academies (age: 12.0 ± 0.3 years) and 22 recreationally active controls (age: 11.7 ± 0.3 years) were recruited. Two-dimensional conventional and speckle tracking echocardiography were used to quantify left ventricular structure, function and peak/temporal values for left ventricular strain and twist, respectively.

RESULTS

End-diastolic volume index was larger in soccer players (51 ± 8 mm/(m²)^1.5 vs. 45 ± 6 mm/(m²)^1.5; p = 0.007) and concentricity was lower in soccer players (4.3 ± 0.7 g/(mL)^0.667 vs. 4.9 ± 1.0 g/(mL)^0.667; p = 0.017), without differences in mean wall thickness between groups (6.0 ± 0.4 mm vs. 6.1 ± 0.5 mm; p = 0.754). Peak circumferential strain at the base (-22.2% ± 2.5% vs. -20.5% ± 2.5%; p = 0.029) and papillary muscle levels (-20.1% ± 1.5% vs. -18.3% ± 2.5%; p = 0.007) were greater in soccer players. Peak left ventricular twist was larger in soccer players (16.92° ± 7.55° vs. 12.34° ± 4.99°; p = 0.035) and longitudinal early diastolic strain rate was greater in soccer players (2.22 ± 0.40 s^-1 vs. 2.02 ± 0.46 s^-1; p = 0.025).

CONCLUSIONS

Highly-trained soccer players demonstrated augmented cardiac mechanics with greater circumferential strains, twist and faster diastolic lengthening in the absence of differences in wall thickness between soccer players and controls.

Diagnostic Differentiation Between Arrhythmogenic Cardiomyopathy and Athlete's Heart by Using Imaging

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an important cause of sudden cardiac death (SCD) in youth and athletes. In the last decade, several studies focused on right ventricular (RV) remodeling in athletes and revealed that features of the physiological adaptation of the right heart to training, such as RV dilation, may overlap with those of ARVC. Therefore, a careful multiparametric evaluation is required for differential diagnosis in order to avoid false diagnosis of ARVC or, in contrast, fail to identify the risk of causing SCD. This review summarizes physiological adaptation of the RV to exercise and describes features that could help distinguishing between athlete's heart and ARVC.

The developing athlete's heart: a cohort study in young athletes transitioning through adolescence

Background

Athlete's heart is a term used to describe physiological changes in the hearts of athletes, but its early development has not been described in longitudinal studies. This study aims to improve our understanding of the effects of endurance training on the developing heart.

Methods

Cardiac morphology and function in 48 cross-country skiers were assessed at age 12 years (12.1 ± 0.2 years) and then again at age 15 years (15.3 ± 0.3 years). Echocardiography was performed in all subjects including two-dimensional speckle-tracking strain echocardiography and three-dimensional echocardiography. All participants underwent cardiopulmonary exercise testing at both ages 12 and 15 years to assess maximal oxygen uptake and exercise capacity.

Results

Thirty-one (65%) were still active endurance athletes at age 15 years and 17 (35%) were not. The active endurance athletes had greater indexed maximal oxygen uptake (62 ± 8 vs. 57 ± 6 mL/kg/min, P < 0.05) at follow-up. There were no differences in cardiac morphology at baseline. At follow-up the active endurance athletes had greater three-dimensional indexed left ventricular end-diastolic (84 ± 11 mL/m2 vs. 79 ± 10 mL/m2, P < 0.05) and end-systolic volumes (36 ± 6 mL/m2 vs. 32 ± 3 mL/m2, P < 0.05). Relative wall thickness fell in the active endurance athletes, but not in those who had quit (–0.05 ΔmL/m2 vs. 0.00 mL/m2, P = 0.01). Four active endurance athletes had relative wall thickness above the upper reference values at baseline; all had normalised at follow-up.

Conclusion

After an initial concentric remodelling in the pre-adolescent athletes, those who continued their endurance training developed eccentric changes with chamber dilatation and little change in wall thickness. Those who ceased endurance training maintained a comparable wall thickness, but did not develop chamber dilatation.

Left atrial function in elite athletes: A meta-analysis of two-dimensional speckle tracking echocardiographic studies

BACKGROUND

We sought to investigate left atrial (LA) volume, function, and strain in elite athletes by a meta-analysis including echocardiographic studies that provided volumetric and strain analysis of LA phasic function.

METHODS

The OVID-MEDLINE, PubMed, and Cochrane CENTRAL databases were searched for English-language articles without time restriction up to February 2018 through focused and high sensitive search strategies. Studies were identified by crossing the following search terms: "athletes," "left atrial size," "left atrial volume," "atrial function," "atrial strain," "atrial strain rate," "echocardiography," "2D speckle echocardiography."

RESULTS

Meta-analysis included 403 athletes and 314 active but not trained healthy controls from 9 studies. Pooled data showed that average LA volume index was higher in athletes than in healthy controls (28.0 ± 1.0 vs 20.7 ± 0.8 mL/m2 , P < 0.001). Global LA longitudinal strain, showing LA reservoir function, was lower in the athletes than in healthy controls with borderline significance (37.0 ± 1.2 vs 38.3 ± 1.5%, P = 0.044). Late diastolic LA strain rate, resembling LA contractile function, was also lower in elite athletes than in control group (-1.56 ± 0.08 vs -1.74 ± 0.09 seconds -1, P = 0.007).

CONCLUSIONS

Our meta-analysis shows that LA volume is higher, while LA reservoir and contractile functions are impaired in elite athletes during active training compared to untrained controls. Whether these changes persist during deconditioning periods remains to be determined. These alterations may be related to the higher risk of arrhythmias, in particular atrial fibrillation, reported among middle/old aged athletes.

Impact of 24 weeks of supervised endurance versus resistance exercise training on left ventricular mechanics in healthy untrained humans

In addition to the well-known cardiac structural adaptation to exercise training, little work has examined changes in left ventricle (LV) mechanics. With new regional and global indexes available we sought to determine the effect of 24-wk endurance versus resistance training on LV mechanics. Twenty-three male subjects were randomly allocated to a 24-wk endurance or resistance training program. Pre- and posttraining two-dimensional echocardiographic images were acquired. Global LV mechanics [strain (ε)] were recorded in longitudinal, circumferential, and radial planes. Rotation was assessed at apical and basal levels. In addition, longitudinal ε-volume loops, across the cardiac cycle, were constructed from simultaneous LV ε (longitudinal and transverse strain) and volume measurements across the cardiac cycle as a novel measure of LV mechanics. Marginal differences in ε and rotation data were found between groups. After training, we found no change in global peak ε data. Peak basal rotation significantly increased after training, with changes in the endurance group (−2.2 ± 1.9° to −4.5 ± 3.3°) and the resistance group (−2.9 ± 3.0° to −3.4 ± 2.9°). LV ε-volume loops revealed a modest rightward shift in both groups. Although most global and regional indexes of LV mechanics were not significantly altered, 24 wk of intense supervised exercise training increased basal rotation. Further studies that assess LV mechanics in larger cohorts of subjects and those with cardiovascular disease and risk factors may reveal important training impacts.

NEW & NOTEWORTHY This study builds on previous work by our group and presents a comprehensive assessment of cardiac mechanics after dichotomous exercise training programs. We highlight novel findings in addition to the inclusion of strain-volume loops, which shed light on subtle differences in longitudinal and transverse contribution to volume change throughout the cardiac cycle. Our findings suggest that training has an impact on basal rotation and possibly strain-volume loops.

Circumferential strain rate to detect lipopolysaccharide-induced cardiac dysfunction: a speckle tracking echocardiography study

Background

Lipopolysaccharide (LPS)-induced myocardial dysfunction is a widely used indicator to study septic cardiomyopathy (SC). This study investigated the efficiency of strain rate imaging (SRI) in detecting LPS-induced myocardial dysfunction.

Methods

A total of 30 mice were randomly assigned to saline group (n=10), 10 mg/kg LPS group (n=10) and 20 mg/kg LPS group (n=10). Then at baseline, 6 and 20 h after LPS injection, 2-D and M-mode echocardiography were conducted with GE Vivid 7 ultrasound (il3L linear probe, 10.0-14.0 MHz) and Echopac PC software. Ejection fraction (EF) and fractional shortening (FS) were measured with M-mode tracings. Serum biochemical examination was then performed to evaluate sepsis-induced myocardial injury.

Results

In LPS 20 mg/kg group, at 6 h after LPS injection, SRI found significantly decreased early diastolic strain rate (SRe, 1.76±1.05 vs. 3.18±0.83 unit/s, P<0.05), but M-mode echo found no change in EF and FS. In 10 mg/kg LPS group, compared with those at 6 h after LPS injection, SRI found a decline in SRe (1.57±0.75 vs. 3.18±0.83 unit/s, P<0.05), and M-mode tracings found an elevation in EF (71.31%±11.68% vs. 55.36%±7.42%, P<0.05) and FS (35.67%±8.79% vs. 25.43%±4.32%, P<0.05) at 20 h. Furthermore, LPS elevated the levels of serum creatine kinase-MB (CK-MB) and cardiac troponin-T (cTnT) at 20 h.

Conclusions

SRI is useful to early assess LPS-induced cardiac deformation in mice. circumferential strain rate (SRcirc) is a sensitive indicator for LPS-induced myocardial injury in severe sepsis.

Resting heart rate in late adolescence and long term risk of cardiovascular disease in Swedish men

AIM

To investigate the association of resting heart rate (RHR) measured in late adolescence with the long term risk of myocardial infarction (MI), ischemic stroke (IS), heart failure (HF), atrial fibrillation (AF), cardiovascular- and all-cause death.

METHODS AND RESULTS

We followed a cohort of Swedish men enrolled for conscription in 1968-2005 (n = 1,008,485; mean age = 18.3 years) until December 2014. Outcomes were collected from the national inpatient - (IPR), outpatient - (OPR) and cause of death registries. Cox proportional hazard models were used to analyze the longitudinal association between RHR and outcomes while adjusting for potential confounders. While we found no independent association between RHR and risk of IS or MI when comparing the highest with the lowest quintile of the RHR distribution, but a positive association persisted between RHR and incident HF (Hazard ratio (HR) = 1.39 [95% confidence interval (CI) = 1.29-1.49]) after adjustment for body mass index (BMI) and blood pressure (BP). In similarly adjusted models, an inverse association was found for AF while there were weaker associations with death from cardiovascular disease (CVD) and all causes (adjusted HR = 1.12 [CI = 1.04-1.21] and 1.20 [CI = 1.17-1.24]). After further adjustment for cardiorespiratory fitness (CRF), the associations persisted for HF (HR = 1.26 [1.17-1.35] for any diagnostic position and HR = 1.43 [1.28-1.60] for HF as a main diagnosis) and for all-cause death (HR 1.09 [1.05-1.12]) but not for CVD death.

CONCLUSION

Adolescent RHR is associated with future risk of HF and death, independently of BP, BMI and CRF, but not with CVD death, MI or IS, suggesting a causal pathway between elevated heart rate and myocardial dysfunction.

Athlete's Heart and Left Heart Disease

Physical activity comprises all muscular activities that require energy expenditure. Regular sequence of structured and organized exercise with the specific purpose of improving wellness and athletic performance is defined as a sports activity.Exercise can be performed at various levels of intensity and duration. According to the social context and pathways, it can be recreational, occupational, and competitive. Therefore, the training burden varies inherently and the heart adaptation is challenging.Although a general agreement on the fact that sports practice leads to metabolic, functional and physical benefits, there is evidence that some athletes may be subjected to adverse outcomes. Sudden cardiac death can occur in apparently healthy individuals with unrecognized cardiovascular disease.Thus, panels of experts in sports medicine have promoted important pre-participation screening programmes aimed at determining sports eligibility and differentiating between physiological remodeling and cardiac disease.In this review, the most important pathophysiological and diagnostic issues are discussed.

Speckle Tracking Echocardiography for the Assessment of the Athlete's Heart: Is It Ready for Daily Practice?

PURPOSE OF REVIEW

To describe the use of speckle tracking echocardiography (STE) in the biventricular assessment of athletes' heart (AH). Can STE aid differential diagnosis during pre-participation cardiac screening (PCS) of athletes?

RECENT FINDINGS

Data from recent patient, population and athlete studies suggest potential discriminatory value of STE, alongside standard echocardiographic measurements, in the early detection of clinically relevant systolic dysfunction. STE can also contribute to subsequent prognosis and risk stratification. Despite some heterogeneity in STE data in athletes, left ventricular global longitudinal strain (GLS) and right ventricular longitudinal strain (RV ɛ) indices can add to differential diagnostic protocols in PCS. STE should be used in addition to standard echocardiographic tools and be conducted by an experienced operator with significant knowledge of the AH. Other indices, including left ventricular circumferential strain and twist, may provide insight, but further research in clinical and athletic populations is warranted. This review also raises the potential role for STE measures performed during exercise as well as in serial follow-up as a method to improve diagnostic yield.

Left Ventricular Speckle Tracking-Derived Cardiac Strain and Cardiac Twist Mechanics in Athletes: A Systematic Review and Meta-Analysis of Controlled Studies

Background

The athlete’s heart is associated with physiological remodeling as a consequence of repetitive cardiac loading. The effect of exercise training on left ventricular (LV) cardiac strain and twist mechanics are equivocal, and no meta-analysis has been conducted to date.

Objective

The objective of this systematic review and meta-analysis was to review the literature pertaining to the effect of different forms of athletic training on cardiac strain and twist mechanics and determine the influence of traditional and contemporary sporting classifications on cardiac strain and twist mechanics.

Methods

We searched PubMed/MEDLINE, Web of Science, and ScienceDirect for controlled studies of aged-matched male participants aged 18–45 years that used two-dimensional (2D) speckle tracking with a defined athlete sporting discipline and a control group not engaged in training programs. Data were extracted independently by two reviewers. Random-effects meta-analyses, subgroup analyses, and meta-regressions were conducted.

Results

Our review included 13 studies with 945 participants (controls n = 355; athletes n = 590). Meta-analyses showed no athlete–control differences in LV strain or twist mechanics. However, moderator analyses showed greater LV twist in high-static low-dynamic athletes (d = –0.76, 95% confidence interval [CI] –1.32 to –0.20; p < 0.01) than in controls. Peak untwisting velocity (PUV) was greater in high-static low-dynamic athletes (d = –0.43, 95% CI –0.84 to –0.03; p < 0.05) but less than controls in high-static high-dynamic athletes (d = 0.79, 95% CI 0.002–1.58; p = 0.05). Elite endurance athletes had significantly less twist and apical rotation than controls (d = 0.68, 95% CI 0.19–1.16, p < 0.01; d = 0.64, 95% CI 0.27–1.00, p = 0.001, respectively) but no differences in basal rotation. Meta-regressions showed LV mass index was positively associated with global longitudinal (b = 0.01, 95% CI 0.002–0.02; p < 0.05), whereas systolic blood pressure was negatively associated with PUV (b = –0.06, 95% CI –0.13 to –0.001; p = 0.05).

Conclusion

Echocardiographic 2D speckle tracking can identify subtle physiological differences in adaptations to cardiac strain and twist mechanics between athletes and healthy controls. Differences in speckle tracking echocardiography-derived parameters can be identified using suitable sporting categorizations.

Left ventricular longitudinal strain in soccer referees

Along the years, the analysis of soccer referees perfomance has interested the experts and we can find several types of studies in literature using in particular cardiac imaging. The aim of this retrospective study was to observe relationship between VO2max uptake and some conventional and not-conventional echocardiographic parameters. In order to perform this evaluation, we have enrolled 20 referees, belonging to Italian Soccer Referees' Association and we have investigated cardiovascular profile of them. We found a strong direct relationship between VO2max and global longitudinal strain of left ventricle assessed by means of speckle tracking echocardiographic analysis (R2=0.8464). The most common classic echocardiographic indexes have showed mild relations (respectively, VO2max vs EF: R2=0.4444; VO2max vs LV indexed mass: R2=0.2268). Therefore, our study suggests that longitudinal strain could be proposed as a specific echocardiographic parameter to evaluate the soccer referees performance.

Morphological changes and myocardial function assessed by traditional and novel echocardiographic methods in preadolescent athlete’s heart

Background

Athlete’s heart is a term used to describe the morphological and functional changes in the hearts of athletes. Recent studies suggest that these changes may occur even in preadolescent athletes. This study aims to improve our understanding of the changes occurring in the preadolescent athlete’s heart.

Design and methods

Cardiac morphology and function in 76 preadolescent cross-country skiers (aged 12.1 ± 0.2 years) were compared with 25 age-matched non-competing preadolescents. Echocardiography was performed in all subjects, including 2D speckle-tracking strain echocardiography and 3D echocardiography. All participants underwent cardiopulmonary exercise testing to assess oxygen uptake and exercise capacity.

Results

Athletes had greater indexed VO2 max (62 ± 7 vs. 44 ± 5 mL/kg per min, p < 0.001), indexed left ventricular end-diastolic volume (79 ± 7 vs. 68 ± 7 mL/m2, p < 0.001), left ventricular mass (69 ± 12 vs. 57 ± 13 g/m2, p < 0.001), indexed right ventricular basal diameter (28.3 ± 3.0 vs. 25.4 ± 3.5 mm/m2, p < 0.001) and right atrial area (10.6 ± 1.4 vs. 9.7 ± 1.2 cm2/m2, p < 0.01). There was no difference in left ventricular ejection fraction, global longitudinal strain, and global circumferential strain and right ventricular fractional area change between the groups. Controls had higher right ventricular global longitudinal strain (−28.1 ± 3.5 vs. −31.1 ± 3.3%, p < 0.01). VO2 max was highly correlated to left ventricular end-diastolic volume ( r = 0.76, p < 0.001).

Conclusion

Athletes had greater left ventricular mass and greater left and right ventricular chamber dimensions compared with controls, while left ventricular function did not differ. Interestingly, right ventricular deformation was significantly lower compared with controls. This supports the notion that there is physiological, adaptive remodelling in preadolescent athlete’s heart.