Exercise stress test in apparently healthy individuals - where to place the finish line? The Ferrari corporate wellness programme experience

Cardiopulmonary Exercise Testing Interpretation in Athletes: What the Cardiologist Should Know

The noninvasive assessment of oxygen consumption, carbon dioxide production, and ventilation during a cardiopulmonary exercise test (CPET) provides insight into the cardiovascular, pulmonary, and metabolic system's ability to respond to exercise. Exercise physiology has been shown to be distinct for competitive athletes and highly active persons (CAHAPs), thus creating more nuanced interpretations of CPET parameters. CPET in CAHAP is an important test that can be used for both diagnosis (provoking symptoms during a truly maximal test) and performance.

Regional Differences in Self-Reported Health, Physical Activity and Physical Fitness of Urban Senior Citizens in Austria

The aim of this study is to compare data on the health status, self-reported exercise and non-exercise physical activity as well as fitness parameters, such as grip strength, of people in retirement in two cities that are both considered urban centres according to the statistical office of the European Union (EUROSTAT), but differ by geographic location. Self-reported physical activity questionnaires and objective assessments of physical fitness indicators collected by sports scientists were used and examined for differences. A total of 210 people (66.3 years ± 2.3) in Salzburg (n = 90) and Vienna (n = 120) was analysed. While no differences were found in self-reported health, there were differences in self-reported exposure to self-reported exercise and non-exercise physical activity, with the Viennese population being more inactive than their more western comparison group. In addition, the objective indicators for muscle strength, balance and flexibility of the lower extremities differed significantly in favour of the more western Austrian population. We recommend assessing the situation of older people in Austria regarding their physical activity and fitness on a regional basis, even if they live in cities of the same category. Future projects should therefore aim to consider specific regional needs during development and incorporate both subjective and objective indicators when monitoring the success of such programs.

Do Androgenic Pattern, Insulin State and Growth Hormone Affect Cardiorespiratory Fitness and Strength in Young Women with PCOS?

In this study, cardiorespiratory fitness (CRF) and strength level were assessed in women with and without polycystic ovary syndrome (PCOS), matched for age, body composition, androgenic pattern and insulinemic pattern. Patients with and without PCOS were evaluated at the Endocrinology Unit and Sport Medicine Division to assess endocrinological (insulinemic, androgenic pattern and growth hormone), anthropometric (with DEXA) and functional parameters (with cardiopulmonary exercise test and handgrip test), as well as physical activity level (with the Global Physical Activity Questionnaire). A total of 31 patients with PCOS and 13 controls were included. No statistically significant differences were found between groups in terms of age, body mass index, body composition, androgenic pattern, insulin state, growth hormone and physical activity level. The PCOS group demonstrated significantly better cardiorespiratory fitness (VO₂max per kg (30.9 ± 7.6 vs. 24.8 ± 4.1 mL/kg/min; p = 0.010), VO₂max per kg of fat-free mass (52.4 ± 8.9 vs. 45.3 ± 6.2 mL/kg/min; p = 0.018)), strength levels (handgrip per kg (0.36 ± 0.09 vs. 0.30 ± 0.08; p = 0.009), handgrip per kg of fat-free mass (13.03 ± 2.32 vs. 11.50 ± 1.91; p = 0.001)) and exercise capacity (METs at test (14.4 ± 2.72 vs. 12.5 ± 1.72 METs; p = 0.019)). In this study, women with PCOS showed a better cardiorespiratory fitness and strength than the control group. The only determinant that could explain the differences observed seems to be the presence of the syndrome itself. These results suggest that PCOS per se does not limit exercise capacity and does not exclude good functional capacity.

Cardiovascular disease prevention in the worksite: Where are we?

The current guidelines of the European Society of Cardiology on cardiovascular (CV) disease prevention highlighted the importance of implementing coordinated set of action, including worksite, aimed at eliminating or minimizing the impact of CV disease and their related disabilities. Workplace wellness programs tend to focus on modifiable risk factors of non-communicable disease, such as nutrition, physical activity, and smoking cessation. However, nowadays, corporate wellness programs are still rare and incomplete, and usually received limited attention. This represents a big public health issue since company health and wellness interventions may provide an important opportunity to identify and manage CV risk. Given the increasing of employees' average age, a progressive shifting of retirement age and an increased number of chronic diseases, these preventive programs will increasingly represent key factors of both employee's health and economic strategies of companies in the near future.

Rehabilitation effects of circuit resistance training in coronary heart disease patients: A systematic review and meta-analysis

Background and Hypothesis

The rehabilitation effect of circuit resistance training in coronary heart disease (CHD) patients remains unclear. We perform this review to examine the rehabilitation effect of circuit resistance training in CHD patients and to provide a basis for the formulation of reasonable individual exercise prescriptions for CHD patients.

Methods

Randomized controlled trials (RCTs) were searched on PubMed, Web of Science, The Cochrane Library, Embase, Clinical Trials, and CNKI. About 1232 studies were identified. Nine RCTs were finally used for the present meta‐analysis to determine the rehabilitation effect of circuit resistance training in CHD patients, compared to aerobic training. Individuals enrolled for the studies were at a mean age of 60.5 years old and were all CHD patients. Following the PRISMA guidelines, we extracted basic information about the study and patient characteristics, as well as measurements (e.g., the peak oxygen uptake, the body mass index [BMI], the body fat percentage, the systolic blood pressure, the total cholesterol, and triglycerides). Subsequently, this meta‐analysis determined the overall effect by using standardized mean difference (SMD) and 95% confidence interval (CI).

Results

Compared with aerobic training, circuit resistance training significantly decrease the BMI and the body fat percentage.

Conclusions

As suggested from the present meta‐analysis of RCTs, circuit resistance training is effective in improving the BMI and the body fat percentage in CHD patients and may help delay the progression of CHD. CRT has the advantage of lower load in most cases with a similar effect.

Limited diagnostic value of questionnaire-based pre-participation screening algorithms: a "risk-exposed" approach to sports activity

BACKGROUND

Several pre-participation screening algorithms (PPSAs) have been proposed to assess sports eligibility in different populations. They are usually based on self-administered questionnaires, without further medical assessment if no risk factors are documented. The Med-Ex "Formula Benessere" worksite program includes a complete cardiovascular (CV) screening for all participants. The purpose of this study was to assess PPSAs accuracy in detecting medical and/or CV abnormalities in the general population, comparing the results with the date derived from Med-Ex program.

METHODS

The Med-Ex medical evaluation, consisting of medical history, physical examination (including body composition), resting electrocardiogram (ECG) and exercise stress test in 464 male subjects (38.4 aged) was analyzed and matched to several PPSAs - Physical Activity Readiness Questionnaire (PAR-Q) (2002-2020), American Heart Association (AHA)/American College of Sport Medicine (ACSM) (1998-2009-2014-2015), European Association of Cardiovascular Prevention and Rehabilitation (EACPR) (2011) - retrospectively simulated.

RESULTS

Five-hundred and 67 abnormalities were detected though Med-Ex medical evaluation, and one-fourth (24%) would have been undetected applying PPSA alone. In particular 28% of high blood pressure, 21% of impaired fasting glycaemia, 21% of high Body Mass Index (BMI) values and 19% of ECG abnormalities would have been missed, on average, by all PPSAs.

CONCLUSIONS

The simulation analysis model performed in this study allowed to highlight the limits of PPSAs in granting sport eligibility, compared to a medical-guided CV screening. These findings emphasize the importance of a more balanced approach to pre-participation screening that includes a thorough evaluation of the cost/benefit ratio.

Acceptability and Practicality of a Quick Musculoskeletal Examination into Sports Medicine Pre-Participation Evaluation

BACKGROUND

Child musculoskeletal (MSK) diseases are common and, even if often benign, sometimes can lead to significant impairment in the future health of children. Italian pre-participation evaluation (PPE), performed by a sports medicine physician, allows for the screening of a wide range of children every year. Therefore, this study aims to evaluate the feasibility and the acceptability of pGALS (pediatric Gait, Arms, Legs and Spine) screening, a simple pediatric MSK screening examination, when performed as part of a routine PPE.

METHODS

Consecutive school-aged children attending a sports medicine screening program were assessed with the addition of pGALS to the routine clinical examination. Practicability (time taken) and patient acceptability (discomfort caused) were recorded.

RESULTS

654 children (326 male, mean age 8.9 years) were evaluated through pGALS. The average time taken was 4.26 min (range 1.9-7.3 min). Acceptability of pGALS was deemed high: time taken was "adequate" (97% of parents) and caused little or no discomfort (94% of children). Abnormal MSK findings were common.

CONCLUSIONS

pGALS is a practical and acceptable tool to perform in sports medicine PPE, even if performed by a non-expert in MSK medicine. Although common, abnormal MSK findings need to be interpreted in the global clinical context and assessment.

Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility in athletes with heart disease: update 2020

Since 1989, SIC Sport and a FMSI, in partnership with leading Italian Cardiological Scientific Associations (ANCE, ANMCO and SIC) have produced Cardiological Guidelines for Completive Sports Eligibility for athletes with heart disease (COCIS -- 1989, 1995, 2003, 2009 and 2017). The English version of the Italian Cardiological Guidelines for Competitive Sports Eligibility for athletes with heart disease was published in 2013 in this Journal. This publication is an update with respect to the document previously published in English in 2013. It includes the principal innovations that have emerged over recent years, and is divided into five main chapters: arrhythmias, ion channel disorders, congenital heart diseases, acquired valve diseases, cardiomyopathies, myocarditis and pericarditis and ischemic heart disease. Wherever no new data have been introduced with respect to the 2013 publication, please refer to the previous version. This document is intended to complement recent European and American guidelines but an important difference should be noted. The European and American guidelines indicate good practice for people engaging in physical activity at various levels, not only at the competitive level. In contrast, the COCIS guidelines refer specifically to competitive athletes in various sports including those with high cardiovascular stress. This explains why Italian guidelines are more restrictive than European and USA ones. COCIS guidelines address 'sports doctors' who, in Italy, must certify fitness to participate in competitive sports. In Italy, this certificate is essential for participating in any competition.

Relationship Between Cardiorespiratory Fitness, Baseline Blood Pressure and Hypertensive Response to Exercise in the Ferrari Corporate Population

AIM

To evaluate the incidence and clinical significance of impaired cardiorespiratory fitness (CRF) and the association with baseline blood pressure (BP) levels and hypertensive response to exercise (HRE).

METHODS

A cross-sectional study was conducted on a total sample of 2058 individuals with a mean age of 38 ± 9 years, enrolled for the first time at the Ferrari corporate wellness program "Formula Benessere", including a maximal exercise stress testing (EST). BP and heart rate (HR) values were obtained from EST at rest, during exercise and recovery time. CRF was arbitrarily classified according to estimated VO_{2 max} in optimal, normal, mildly and moderately reduced.

RESULTS

One-hundred and thirty-nine individuals of 2058 (6.7%) showed a moderate CRF reduction assessed by EST. Subjects with elevated resting and/or exercise BP showed a worse CRF than those with normal BP levels, also after the adjustment for age, sex, body mass index, smoking habits, peak SBP and DBP. Seventy-seven individuals (3.7%) showed an HRE during EST, with normal baseline BP levels.

CONCLUSION

About 7% of a corporate population showed a significantly reduced CRF, assessed by EST. Individuals with lower levels of CRF have higher resting and/or peak exercising BP values after adjusting for co-variables. This study expands the role of EST outside of traditional ischemic CVD evaluation, towards the assessment of reduced CRF and HRE in the general population, as a possible not evaluated CV risk factor.

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators

This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.

Echocardiographic Screening of Anomalous Origin of Coronary Arteries in Athletes with a Focus on High Take-Off

Anomalous aortic origin of coronary arteries (AAOCA) represents a rare congenital heart disease. However, this disease is the second most common cause of sudden cardiac death in apparently healthy athletes. The aim of this systematic review is to analyze the feasibility and the detection rate of AAOCA by echocardiography in children and adults. A literature search was performed within the National Library of Medicine using the following keywords: coronary artery origin anomalies and echocardiography; then, the search was redefined by adding the keywords: athletes, children, and high take-off. Nine echocardiographic studies investigating AAOCA and a total of 33,592 children and adults (age range: 12–49 years) were included in this review. Of these, 6599 were athletes (12–49 years). All studies demonstrated a high feasibility and accuracy of echocardiography for the evaluation of coronary arteries origin as well as their proximal tracts. However, some limitations exist: the incidence of AAOCA varied from 0.09% to 0.39% (up to 0.76%) and was lower than described in computed tomography series (0.3–1.8%). Furthermore, echocardiographic views for the evaluation of AAOCA and the definition of “minor” defects (e.g., high take-off coronary arteries) have not been standardized. An echocardiographic protocol to diagnose the high take-off of coronary arteries is proposed in this article. In conclusion, the screening of AAOCA by echocardiography is feasible and accurate when appropriate examinations are performed; however, specific acoustic windows and definitions of defects other than AAOCA need to be standardized to improve sensitivity and specificity.

Female Athlete's Heart: Sex Effects on Electrical and Structural Remodeling

BACKGROUND

Most of our knowledge on training-induced cardiac remodeling is derived from men, with the paucity of data from women representing an important gap in knowledge. The aim of the study was to define the electrocardiographic and morphological features of female athlete's heart, with special attention to differences related to sex and sport.

METHODS

Seven hundred twenty Olympic athletes (360 females and 360 age- and sport-matched males, mean age: 23±5 years) were evaluated by clinical, resting, and exercise electrocardiography and echocardiography.

RESULTS

Anterior T-wave inversion was more common in females than males (P<0.05). Left ventricular (LV) wall thickness and LV mass were greater in men (P<0.001). Females had smaller absolute but greater indexed LV and right ventricular (RV) dimensions as compared to males. Most women had normal LV geometry (80.8%). A progressive increase in LV/RV dimensions was observed in women from those engaged in skill, power, to mixed and endurance disciplines, with the endurance ones demonstrating the greatest degree of RV dilatation. Women had a peculiar biventricular adaptation, with higher LV/RV (1.41±0.16 versus 1.36±0.15, P<0.0001) and lower RV inflow/outflow ratio (P<0.001), as compared to men.

CONCLUSIONS

Sex significantly affects cardiac remodeling in athletes, with females presenting a different electrical and structural remodeling. Women maintain a normal LV geometry, with relative larger increase of cavity dimensions compared with men. Type of sport has a relevant impact, with endurance athletes exhibiting the greatest degree of RV and LV dimensional remodeling. The present study confirms the need for a sex-based approach for interpreting the complex features of athlete's heart in women.

Uphill walking at iso-efficiency speeds

Uphill walking gait has been extensively studied, but the optimal uphill speed able to enhance the metabolic demand without increasing fatigability has so far received little attention. Therefore, the aim of this study was to assess the metabolic/kinematic demand at constant speed (6 km·h^-1 G0 level, G2 2% uphill, G7 7% uphill) and at iso-efficiency speeds (G2IES 5.2 km·h^-1 2% uphill and G7IES 3.9 km·h^-1 7% uphill). For this aim, physically active women (n:24, Age 33.40 ± 4.97 years, BMI 21.62 ± 2.06 kg/m^-2) after an 8-min warm-up were studied on a treadmill for 10' for every walking condition with a 5' rest in between. Average heart rate (AVG-HR), rating of perceived exertion (RPE) and kinematic variables (stance time, swing time, stride length, stride cycle, stride-length variability, stride-cycle variability and internal work) were studied. Modifications in stance time, stride length and stride cycle (p<0.005), and lower internal-work values (p<0.001) occurred in G7IES in comparison to the other conditions. Swing time was significantly modified only in G7IES compared to G0 and G7 (p<0.001 and p<0.005, respectively). Stride-length variability and stride-cycle variability were higher in G7IES compared to the other conditions (p<0.001). G7 induced the highest AVG-HR (p<0.005) and RPE (p<0.001) compared to the other conditions. This study demonstrates that by applying the equation for uphill walking gait, it is possible to maintain a similar metabolic demand and RPE at iso-efficiency speeds during uphill compared to level walking, inducing at the same time a modification of the kinematic parameters of walking gait performed at the same slope condition.

External Responsiveness of the SuperOpTM Device to Assess Recovery After Exercise: A Pilot Study

Post-exercise recovery is a complex process involving a return of performance and a physiological or perceptual feeling close to pre-exercise status. The hypothesis of this study is that the device investigated here is effective in evaluating the recovery state of professional cyclists in order to plan effective training. Ten professional male cyclists belonging to the same team were enrolled in this study. Participants performed a 7-day exercise program [D1, D4, and D7: low-intensity training; D2 and D5: passive recovery; D3: maximum oxygen consumption (VO2Max) test (for maximum mechanical power assessment only); and D6: constant load test]. During the week of monitoring, each morning before getting up, the device assessed each participant's so-called Organic Readiness {OR [arbitrary unit (a.u.)]}, based on blood pressure (BP), heart rate (HR), features of past exercise session, and following self-perceived condition. Based on its readings and algorithm, the device graphically displayed four different colors/values, indicating general exercise recommendations: green/3 = "you can train hard," yellow/2 = "you can train averagely," orange/1 = "you can train lightly," or red/0 = "you should recover passively." During the week of research, morning OR values and Bonferroni post-hoc comparisons showed significant differences between days and, namely, values (1) D2 (after low intensity training) was higher than D4 (after VO2Max test; P = 0.033 and d = 1.296) and (2) D3 and D6 (after passive recovery) were higher than D4 (after VO2Max test; P = 0.006 and d = 2.519) and D5 (after low intensity training; P = 0.033 and d = 1.341). The receiver operating characteristic analysis area under curve (AUC) recorded a result of 0.727 and could differentiate between D3 and D4 with a sensitivity and a specificity of 80%. Preliminarily, the device investigated is a sufficiently effective and sensitive/specific device to assess the recovery state of athletes in order to plan effective training.

Guidelines for Physical Activity-A Cross-Sectional Study to Assess Their Application in the General Population. Have We Achieved Our Goal?

National and international healthcare organizations propose guidelines for physical activity worldwide, defining its characteristics. These guidelines' practical applications are difficult to estimate, since they are not fully followed. The aim of the present cross-sectional observational study was to assess awareness about guidelines for physical activity and to evaluate their practical applications in a sample of the Italian population. In total, 310 participants completed an online survey (mean age 29.10 ± 4.44), assessing the habits, beliefs and health effects of physical activity. In total, 39.35% of respondents were inactive. In total, 6.91% of active respondents did not perform a warm-up phase at the beginning of each training session and 77.14% did not check their own heart rate during the training session. Approximately half of respondents reported erroneous beliefs about the type, frequency and volume of physical activity, compared to data proposed by the guidelines. The preventive effect of physical activity was clearly perceived for cardiovascular diseases, diabetes, metabolic syndrome and depression. Several subjects misinterpreted the preventive role of physical activity in colon and breast cancers, and in femur and vertebral fractures. Habits and beliefs about physical activity in the general population are far from the guidelines and recommendations. Therefore, it is necessary to strengthen the conscious practice of physical activity further.

Effectiveness of Workplace Yoga Interventions to Reduce Perceived Stress in Employees: A Systematic Review and Meta-Analysis

Work-related stress represents a relevant public health issue and solution strategies are mandatory. Yoga is a common approach to manage stress and its effectiveness has been extensively confirmed. Therefore, this study aims systematically to review the effectiveness of Yoga interventions carried out at workplace on work-related stress among employees and to assess their impact quantitatively. Springerlink, MEDLINE, PubMed, CINAHL, Web of Science, Scopus, Cochrane CENTRAL and PEDro databases were searched. Clinical trials comparing workplace Yoga interventions to control groups, and evaluating perceived stress as outcome measure, were assessed for eligibility. All forms and styles of Yoga were considered for the analysis. Out of 3392 initially identified, 6 studies were included in the meta-analysis; 266 participants practicing Yoga interventions at worksite were compared to 221 subjects in control group. Included studies showed "some concerns" about different domains of source of bias. Quantitative analysis showed an overall effect size of -0.67 [95% confidence interval (CI): -0.86, -0.49] in favor of Yoga intervention in reducing stress outcome measures. Hence, workplace Yoga interventions were more effective when compared to no treatment in work-related stress management. Further high-quality studies are needed to improve the validity of these results and to specify more characteristics of the Yoga intervention, such as style, volume, and frequency.

Syncope in the Young Adult and in the Athlete: Causes and Clinical Work-up to Exclude a Life-Threatening Cardiac Disease

Syncope is defined as a transient loss of consciousness due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery. It is usually a benign event, but sometimes it may represent the initial presentation of several cardiac disorders associated with sudden cardiac death during physical activity. A careful evaluation is essential particularly in young adults and in competitive athletes in order to exclude the presence of an underlying life-threatening cardiovascular disease. The present review analyzes the main non-cardiac and cardiac causes of syncope and the contribution of the available tools for differential diagnosis. Clinical work-up of the athlete with syncope occurring in extreme environments and management in terms of sports eligibility and disqualification are also discussed.

Low Dose Resistance Exercise: A Pilot Study Examining Effects on Blood Pressure and Augmentation Index Between Intensities

INTRODUCTION

The effects of resistance exercise on vascular function are unclear.

AIM

To investigate the acute haemodynamic (blood pressure and augmentation index) and rate of perceived exertion (RPE) response to two types of resistance exercises of equal workload-a set of unilateral 35% of one repetition maximum (1RM) quadriceps extension and a set of unilateral 70% 1RM quadriceps extension.

METHODS

Twenty two young healthy males completed both exercises on separate days. Heart rate, central and peripheral systolic and diastolic blood pressure (BP), augmentation pressure, augmentation index (AIx), augmentation index at a heart rate of 75 beats per minute (AIx75), and RPE were measured using applanation tonometry before exercise, immediately after exercise, 5 min after exercise and 15 min after exercise.

RESULTS

AIx75 was significantly lower 5 min after exercising at 35% of 1RM than 70% of 1RM. Systolic blood pressure was significantly lower at 5 min post exercise for both intensities. There was no significant difference in RPE between conditions or time points.

CONCLUSIONS

Results suggest that changes in blood pressure and augmentation index vary depending on the intensity of resistance exercise regardless of the volume of exercise carried out. Changes in AIx75 in response to resistance exercise may be independent of changes in BP.