Acute effect of ultramarathon on systolic and diastolic cardiac function: Systematic review and meta-analysis

BACKGROUND

Ultramarathon running poses physiological challenges, impacting cardiac function. This systematic review and meta-analysis explore the acute effects of single-stage ultramarathon running on cardiac function.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations were followed. Searches covered Medline, Embase, CINAHL, SPORTDiscus, Web of Science, Central Cochrane, and Scopus. Random effects meta-analyses assessed left ventricular (LV) and right ventricular (RV) variables, expressed as mean differences (MD) with 95% confidence intervals (CI).

RESULTS

Among 6972 studies, 17 were included. Post-ultramarathon reductions were found in LV end-diastolic diameter (LVEDD) (-1.24; 95% CI = -1.77, -0.71 mm), LV end-diastolic volume (LVEDV) (-9.92; 95% CI = -15.25, -4.60 ml), LV stroke volume (LVSV) (-8.96 ml, 95% CI -13.20, -4.72 ml), LV ejection fraction (LVEF) (-3.71; 95% CI = -5.21, -2.22%), LV global longitudinal strain (LVGLS) (-1.48; 95% CI = -2.21, -0.76%), E/A (-0.30; 95% CI = -0.38, -0.22 cm/s), .E' (-1.35 cm/s, 95% CI -1.91, -0.79 cm/s), RV fractional area change (RVFAC) (-3.34, 95% CI = -5.84, -0.84%), tricuspid annular plane systolic excursion (TAPSE) (-0.12, 95% CI = -0.22, -0.02 cm), RV global longitudinal strain (RVGLS) (-1.73, 95% CI = -2.87, -0.59%), with increases in RV end-diastolic area (RVEDA) (1.89, 95% CI = 0.63, 3.14 cm2), RV Peak A' (1.32 cm/s, 95% CI 0.20, 2.44), and heart rate (18.24, 95% CI = 15.16, 21.32). No significant differences were observed in LV end-systolic diameter (LVESD), LV end-systolic volume (LVESV), RV end-diastolic diameter (RVEDD), RV Peak E', and RV Peak S'.

CONCLUSIONS

Evidence suggests immediate impairment of systolic and diastolic cardiac function post-ultramarathon running.

Cardiac autonomic regulation following a 246-km mountain ultra-marathon: An observational study

Physical exercise requires integrated autonomic and cardiovascular adjustments to maintain homeostasis. We aimed to observe acute posture-related changes in blood pressure, and apply a portable noninvasive monitor to measure the heart index for detecting arrhythmia among elite participants of a 246-km mountain ultra-marathon. Nine experienced ultra-marathoners (8 males and 1 female) participating in the Run Across Taiwan Ultra-marathon in 2018 were enrolled. The runners' Heart Spectrum Blood Pressure Monitor measurements were obtained in the standing and supine positions before and immediately after the race. Their high-sensitivity troponin T and N-terminal proB-type natriuretic peptide levels were analyzed 1 week before and immediately after the event. Heart rate was differed significantly in the immediate postrace assessment compared to the prerace assessment, in both the standing (P = .011; d = 1.19) and supine positions (P = .008; d = 1.35). Postural hypotension occurred in 4 (44.4%) individuals immediately postrace. In 3 out of 9 (33.3%) recruited finishers, the occurrence of premature ventricular complex signals in the standing position was detected; premature ventricular complex signal effect was observed in the supine position postrace in only 1 participant (11.1%). Premature ventricular complex signal was positively correlated with running speed (P = .037). Of the 6 individuals who completed the biochemical tests postrace, 2 (33.3%) had high-sensitivity troponin T and 6 (100%) had N-terminal proB-type natriuretic peptide values above the reference interval. A statistically significant increase was observed in both the high-sensitivity troponin T (P = .028; d = 1.97), and N-terminal proB-type natriuretic peptide (P = .028; d = 2.91) levels postrace compared to prerace. In conclusion, significant alterations in blood pressure and heart rate were observed in the standing position, and postexercise (postural) hypotension occurred among ultra-marathoners. The incidence of premature ventricular complexes was higher after the race than before.

Possible Mechanisms for Adverse Cardiac Events Caused by Exercise-Induced Hypertension in Long-Distance Middle-Aged Runners: A Review

Sudden cardiac death (SCD) is rare among athletes. However, hypertrophic cardiomyopathy is the leading cause of SCD among those <35 years of age. Meanwhile, coronary artery disease (CAD) is the primary SCD cause among those ≥35 years of age. CAD-induced plaque ruptures are believed to be a significant cause of cardiovascular diseases in middle-aged individuals who participate in extreme long-distance running activities such as marathons. A total of 1970 articles related to EIH were identified using search terms. Out of these, 1946 studies were excluded for reasons such as arterial hypertension, exercise-induced pulmonary hypertension, the absence of exercise stress testing (EST), and a lack of relevance to EIH. The study analyzed 24 studies related to both long-distance runners with exercise-induced hypertension (EIH) and the general public. Among these, 11 studies were quasi-experimentally designed studies used in randomized controlled trials (RCTs) on long-distance runners with EIH. Additionally, 12 studies utilized cohort designs, and one study with a quasi-experimental design was conducted among the general population. Recent studies suggest that an imbalance between oxygen demand and supply due to ventricular hypertrophy may be the actual cause of cardiovascular disease, regardless of CAD. Exercising excessively over an extended period can reduce endothelial function and increase arterial stiffness, which in turn increases afterload and leads to an excessive increase in blood pressure during exercise. Exercise-induced hypertension (EIH), which increases the morbidity rate of resting hypertension and is a risk factor for cardio-cerebro-vascular diseases, is more prevalent in middle-aged long-distance runners than in runners from other age groups, and it increases the prevalence of critical arrhythmias, such as atrial fibrillation or ventricular arrhythmias. EIH is associated with angiotensin II activity, and angiotensin II receptor blockers show promising effects in middle-aged runners. Further, guidelines for preventing excessive participation in races and restricting exercise intensity and frequency would be useful. This review identifies EIH as a potential risk factor for cardiovascular diseases and describes how EIH induces SCD.

Running Variability in Marathon-Evaluation of the Pacing Variables

Background and Objectives: Pacing analyses for increasingly popular long-distance running disciplines have been in researchers' spotlight for several years. In particular, assessing pacing variability in long-distance running was hardly achievable since runners must repeat long-running trials for several days. Potential solutions for these problems could be multi-stage long-distance running disciplines. Therefore, this study aimed to assess the long-distance running variability as well as the reliability, validity, and sensitivity of the variables often used for pacing analyses. Materials and Methods: This study collected the split times and finish times for 20 participants (17 men and three women; mean age 55.5 years ± 9.5 years) who completed the multiday marathon running race (five marathons in 5 days), held as part of the Bretzel Ultra Tri in Colmar, France, in 2021. Seven commonly used pacing variables were subsequently calculated: Coefficient of variation (CV), Change in mean speed (CS), Change in first lap speed (CSF), Absolute change in mean speed (ACS), Pace range (PR), Mid-race split (MRS), and First 32 km-10 km split (32-10). Results: Multi-stage marathon running showed low variability between days (Intraclass correlation coefficient (ICC) > 0.920), while only the CV, ACS, and PR variables proved to have moderate to good reliability (0.732 < ICC < 0.785). The same variables were also valid (r > 0.908), and sensitive enough to discern between runners of different performance levels (p < 0.05). Conclusions: Researchers and practitioners who aim to explore pacing in long-distance running should routinely utilize ACS, CV, and PR variables in their analyses. Other examined variables, CS, CSF, MRS, and 32-10, should be used cautiously. Future studies might try to confirm these results using different multi-stage event's data as well as by expanding sensitivity analysis to age and gender differences.

Exercise-Induced Fluid Retention, Cardiac Volume Overload, and Peripheral Edema in Ultra-Distance Cyclists

Introduction

Ultracyclists expose themselves to extreme physical challenges. This study aimed to elucidate the effects of ultracycling on electrolyte and fluid balance and investigate the potential occurrence of peripheral edema.

Methods

A total of 4 clinical visits were performed before, during, and after a 6-day bicycle ride in 13 ultracyclists (5 female, 8 male) including serial laboratory analyses of blood and urine, bioelectrical impedance, and echocardiography. Throughout the ride, participants continuously tracked fluid intake, measured extremity circumferences daily, and self-tested urinary electrolytes using a point-of-care testing device. Portrait photos were judged by 20 physicians for occurrence of facial and eyelid edema.

Results

Participants covered a mean distance of 1205 km and 19,417 vertical meters. From baseline to day 6, body weight remained stable (P = 0.479); however, body composition changed with increasing total body water (TBW) (+1.98 l ± 1.37, P = 0.003) and plasma volume (+18.86 % ± 10.7, P < 0.001). A significant increase in N-terminal pro brain natriuretic peptide (NT-proBNP) (+297.99 ng/l ± 190.42, P < 0.001) until day 6 indicates concomitant cardiac volume overload. Swelling of face and eyelids peaked on day 5 (both P ≤ 0.033). On recovery, changes partly resolved. Although urinary sodium concentration showed a nadir on day 4 (-32.18 mmol/l ± 23.88, P = 0.022), plasma osmolality (+5.69 mmosmol/kg ± 5.88, P = 0.004) and copeptin (+38.28 pg/ml ± 18.90, P < 0.001) increased steadily until day 6.

Conclusion

Ultracycling over multiple days induces extracellular volume expansion, peripheral edema, and cardiac volume overload. Renal sodium and water retention is likely contributing to this condition.

Reduced myocardial strain of interventricular septum among male amateur marathon runners: a cardiac magnetic resonance study

OBJECTIVES

To analyze the long-term effect of multiple marathons on cardiac structure and function in amateur marathon runners compared with healthy controls.

DESIGN

Cross-sectional study using male amateur marathon runners (n = 32) and age-matched cohort of male healthy controls (n = 12).

METHODS

A total of 32 male amateur marathon runners (age 44 ± 7 years) and 12 male healthy controls (age 42 ± 8 years) underwent cardiac magnetic resonance (CMR). The relevant parameters of cardiac structure and function were studied employing feature-tracking strain analysis.

RESULTS

Amateur marathon runners showed lower heart rates, body mass index and body surface area. The left ventricular (LV) mass index, LV end-diastolic volume index and right ventricular end-systolic volume index were significantly higher in amateur marathon runners compared with healthy controls. Furthermore, walls of interventricular septum (IVS) in amateur marathon runners were thicker than healthy controls. There was no significant difference between two groups in the global myocardial strain (MS) in LV. However, the segmental radial and circumferential strains of the LV were lower in amateur marathon runners compared to healthy controls, specifically in the 8th and 9th segments. Finally, we also found as the total running intensity increased, so did global longitudinal strain.

CONCLUSIONS

We reported higher wall thickness and lower regional radial and circumferential strain in the IVS region in amateur marathon runners, suggesting that prolonged and high-intensity exercise may cause cardiac remodeling. Further studies are needed to investigate whether this is an adaptive or maladaptive change in amateur marathon runners.

Relationship between echocardiographic characteristics and cardiac biomarkers during long-distance trail running

Background

Even if the beneficial cardiovascular effects of moderate exercise are recognized, effects of prolonged and intense exercise are still debated. This study aims to detect cardiovascular changes associated with long endurance running by assessing the relationship between echocardiographic parameters and cardiac biomarkers during long-distance trail running.

Methods

We performed a prospective observational study that included 20 participants who were all amateur runners (median age of 41 years old, still alive after a 7-year clinical follow-up) from 80-km trail running. All the participants underwent an echocardiographic examination and venous blood sampling before the race, at the intermediate refreshment checkpoints of the race (21st and 53rd km), and within 10 min after arrival.

Results

Mitral E/A velocity ratio and mitral TDI e’ wave were significantly decreased at the 21st km to arrival (p < 0.05). Mitral S wave and global longitudinal strain (GLS) were significantly decreased from the 53rd km to arrival (p < 0.05 for 53rd and 80th km). As compared to baseline, T-troponin and NT-proBNP were significantly increased at the 21st km in all the participants, but T-troponin values were systematically increased above the significative threshold. Diastolic echocardiographic abnormalities were mainly observed among participants with highest NT-proBNP (> 77 ng.l^–1) values at the 21st km. As compared to baseline, mitral e’ wave was significantly decreased (–35%) in participants with highest values of NT-proBNP. Similarly, GLS was also depressed among participants with highest troponin values at the 53rd km (p = 0.01 for 53rd km and p = 0.04 for arrival).

Conclusion

During the long-distance trail running, the early LV decrease in diastolic echocardiographic parameters is associated with increase in NT pro-BNP blood levels, and the decrease in LV systolic echocardiographic parameters later is associated with increase in T-troponin blood levels.

Study of the kinetics of the determinants of performance during a mountain ultra marathon: Multidisciplinary protocol of the first Trail Scientifique de Clécy 2021 (Preprint)

Background

The growing interest of the scientific community in trail running has highlighted the acute effects of practice at the time of these races on isolated aspects of physiological and structural systems; biological, physiological, cognitive, and muscular functions; and the psychological state of athletes. However, no integrative study has been conducted under these conditions with so many participants and monitoring of pre-, per-, and postrace variables for up to 10 days over a distance close to 100 miles.

Objective

The aim of this study was to evaluate the kinetics of the performance parameters during a 156 km trail run and 6000 m of elevation gain in pre-, per-, and postrace conditions. The general hypothesis is based on significant alterations in the psychological, physiological, mechanical, biological, and cognitive parameters.

Methods

The Trail Scientifique de Clécy took place on November 11, 2021. This prospective experimental study provides a comprehensive exploration of the constraints and adaptations of psychophysiological and sociological variables assessed in real race conditions during a trail running of 156 km on hilly ground and 6000 m of elevation gain (D+). The study protocol allowed for repeatability of study measurements under the same experimental conditions during the race, with the race being divided into 6 identical loops of 26 km and 1000 m D+. Measurements were conducted the day before and the morning of the race, at the end of each lap, after a pit stop, and up to 10 days after the race. A total of 55 participants were included, 43 (78%) men and 12 (22%) women, who were experienced in ultra–trail-running events and with no contraindications to the practice of this sport.

Results

The launch of the study was authorized on October 26, 2021, under the trial number 21-0166 after a favorable opinion from the Comité de Protection des Personnes Ouest III (21.09.61/SIRIPH 2G 21.01586.000009). Of the 55 runners enrolled, 41 (75%) completed the race and 14 (25%) dropped out for various reasons, including gastric problems, hypothermia, fatigue, and musculoskeletal injuries. All the measurements for each team were completed in full. The race times (ie, excluding the measurements) ranged from 17.8206 hours for the first runner to 35.9225 hours for the last runner. The average time to complete all measurements for each lap was 64 (SD 3) minutes.

Conclusions

The Trail Scientifique de Clécy, by its protocol, allowed for a multidisciplinary approach to the discipline. This approach will allow for the explanation of the studied parameters in relation to each other and observation of the systems of dependence and independence. The initial results are expected in June 2022.

International Registered Report Identifier (IRRID)

RR1-10.2196/38027

mTOR signaling-related microRNAs as cardiac hypertrophy modulators in high-volume endurance training

Aerobic exercise training (ET) promotes cardiovascular adaptations, including physiological left ventricular hypertrophy (LVH). However, the molecular mechanisms that underlying these changes are unclear. The study aimed to elucidate specific miRNAs and target genes involved with the Akt/mTOR signaling in high-volume ET-induced LVH. Eight-week-old female Wistar rats were assigned to three groups: sedentary control (SC), trained protocol 1 (P1), and trained protocol 2 (P2). P1 consisted of 60 minutes/day of swimming, 5x/week, for 10 weeks. P2 consisted of the same protocol as P1 until the 8^th week; in the 9^th week, rats trained 2x/day, and in the 10^th week, trained 3x/day. Subsequently, structure and molecular parameters were evaluated in the heart. Trained groups demonstrate higher values to VO₂ peak, exercise tolerance, and LVH in a volume-dependent manner. The miRNA-26a-5p levels were higher in P1 and P2 compared to SC group (150±15%, d=1.8; 148±16%, d=1.7; and 100±7%, respectively, P < 0.05). In contrast, miRNA-16-5p levels were lower in P1 and P2 compared to SC group (69±5%, d=2.3, P < 0.01; 37±4%, d=5.6, P < 0.001 and 100±6%, respectively). Additionally, miRNA-16-5p knockdown and miRNA-26a-5p overexpression significantly promoted cardiomyocyte hypertrophy in neonatal rat cardiomyocytes. Both miRNAs were selected, using Diana Tolls bioinformatics website, for acting in the mTOR signaling pathway. The protein expression of Akt, mTOR, p70^S6k, and 4E-BP1 were greater in P1 and even more pronounced in P2. Nonetheless, GSK3β protein expression was lower in trained groups. Together, these molecular changes may contribute to a pronounced physiological LVH observed in high-volume aerobic training.

Long distance running - Can bioprofiling predict success in endurance athletes?

The TransEuropeFootRace (TEFR) was one of the most extreme multistage competitions worldwide. The ultramarathon took the runners over a distance of 4487 km, from Bari, Italy, to the North Cape, Norway, in 64 days. The participating ultra-long-distance runners had to complete almost two marathons per day (~70 km). The race was accompanied by a research team analysing adaptations of different organ systems of the human body that were exposed to a chronic lack of regeneration time. Here, we analyzed runner's urine using mass spectrometric profiling of thousands of low-molecular weight compounds. The results indicated that pre-race molecular factors can predict finishers and separate them from nonfinishers already before the race. These observations were related to the training volume as finishers ran about twice as many kilometers per week before TEFR than nonfinishers, thus apparently achieving a higher performance level and resistance against overuse. While this hypothesis needs to be validated in future long-distance races, the bioprofiling experiments suggest that the competition readiness of the runners is measurable and might be adjustable.

Myocardial Injury and Overload among Amateur Marathoners as Indicated by Changes in Concentrations of Cardiovascular Biomarkers

Marathons continue to grow in popularity among amateurs. However, the impact of intensive exercise on the amateur's cardiovascular system has not yet been studied. Analysis of the influence of the marathon on kinetics of biomarkers reflecting cardiac injury and overload may bring new insights into this issue. We investigated the effect of running a marathon on the concentrations of high sensitivity cardiac troponin I (hs-cTnI), heart-type fatty acid binding protein (H-FABP), N-terminal proatrial natriuretic peptide (NT-proANP), B-type natriuretic peptide (BNP), growth differentiation factor 15 (GDF-15) and galectin 3 (Gal-3) in the population of male amateur runners. The study included 35 amateur marathoners and followed 3 stages: S1-two weeks prior to the marathon, S2-at the finish line and S3-two weeks after. Blood samples were collected at each stage and analyzed for biomarkers and laboratory parameters. Concentrations of all studied biomarkers were significantly higher at S2, whereas at S3 did not differ significantly compared to S1. Running a marathon by an amateur causes an acute rise in biomarkers of cardiac injury and stress. Whether repetitive bouts of intensive exercise elicit long-term adverse cardiovascular effects in amateur marathoners needs further research.