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

Analysis of over 1 million race records shows runners from East African countries as the fastest in 50-km ultra-marathons

The 50-km ultra-marathon is a popular race distance, slightly longer than the classic marathon distance. However, little is known about the country of affiliation and age of the fastest 50-km ultra-marathon runners and where the fastest races are typically held. Therefore, this study aimed to investigate a large dataset of race records for the 50-km distance race to identify the country of affiliation and the age of the fastest runners as well as the locations of the fastest races. A total of 1,398,845 50-km race records (men, n = 1,026,546; women, n = 372,299) were analyzed using both descriptive statistics and advanced regression techniques. This study revealed significant trends in the performance of 50-km ultra-marathoners. The fastest 50-km runners came from African countries, while the fastest races were found to occur in Europe and the Middle East. Runners from Ethiopia, Lesotho, Malawi, and Kenya were the fastest in this race distance. The fastest 50-km racecourses, providing ideal conditions for faster race times, are in Europe (Luxembourg, Belarus, and Lithuania) and the Middle East (Qatar and Jordan). Surprisingly, the fastest ultra-marathoners in the 50-km distance were found to fall into the age group of 20-24 years, challenging the conventional belief that peak ultra-marathon performance comes in older age groups. These findings contribute to a better understanding of the performance models in 50-km ultra-marathons and can serve as valuable insights for runners, coaches, and race organizers in optimizing training strategies and racecourse selection.

Aortic root/left ventricular diameters golden ratio in competitive athletes

BACKGROUND

The athlete's heart is a well-known phenomenon characterized by a harmonic remodelling that affects the cardiac chambers. However, whether mild-to-moderate aortic dilatation can be considered normal in athletes is debated. This study aimed to evaluate the ratio between left ventricular (LV) size and aortic dimensions, reporting the normal values of the ratio between the aortic root diameters at the level of the sinuses of Valsalva and LV diameters (AoD/LVEDD ratio) in a wide cohort of competitive athletes.

MATERIALS AND METHODS

Competitive athletes were compared with sedentary subjects and patients with aortic dilatation. 1901 subjects who underwent echocardiography from 2019 to 2022 were retrospectively enrolled: 993 athletes (74% males, mean age 26 ± 7 years), 410 sedentary (74.1% males, mean age 29 ± 11 years) and 498 patients with aortic dilatation (74.3% males, mean age 56 ± 7 years).

RESULTS

Patients with aortic dilatation had both an absolute (39.2 ± 2.4 mm) and indexed (19.4 ± 2.2 mm/m2) aortic diameter larger than athletes (30.6 ± 3.2 mm; 16.1 ± 1.5 mm/m2, p < 0.05) and sedentary subjects (30.5 ± 3.1 mm; 16.5 ± 1.6 mm/m2, p < 0.05), with no differences between athletes and sedentary subjects. The AoD/LVEDD ratio was lower in athletes (0.59 ± 0.06) compared to controls (0.65 ± 0.05, p < 0.05) and patients with aortic dilatation (0.81 ± 0.06, p < 0.05). The patients with aortopathy had the lowest LVEDD/AoD ratio, while competitive athletes had the highest, with values of 1.71 ± 0.16 in the latter (overall p value<0.001).

CONCLUSIONS

In this study, we reported the AoD/LVEDD and LVEDD/AoD ratio values in a cohort of healthy athletes, additional parameters that could help confirm the harmonic remodelling in the athlete's heart.

Insult of Ultraendurance Events on Blood Pressure: A Systematic Review and Meta-Analysis

The rise of ultraendurance sports in the past two decades warrants evaluation of the impact on the heart and vessels of a growing number of athletes participating. Blood pressure is a simple, inexpensive method to evaluate one dimension of an athlete's cardiovascular health. No systematic review or meta-analysis to date has chronicled and delineated the effects of ultraendurance races, such as ultramarathons, marathons, half-marathons, and Ironman triathlon events, specifically on heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and mean arterial pressure (MAP) measurements in supine and standing positions before and after the event. This meta-analysis reviews the effects of ultraendurance events on positional and calculated hemodynamic values. Data were extracted from 38 studies and analyzed using a random effects model with a total of 1,645 total blood pressure measurements. Of these, 326 values were obtained from a standing position, and 1,319 blood pressures were taken supine. Pre-race and post-race measurements were evaluated for clinical significance using established standards of hypotension and orthostasis. HR and calculated BP features, such as PP and MAP, were evaluated. Across all included studies, the mean supine post-race HR increased by 21±8 beats per minute (bpm) compared to pre-race values. The mean standing post-race HR increased by 23±14 bpm when compared with pre-race HR. Overall, there was a mean SBP decrease of 19±9 mmHg and a DBP decrease of 9±5 mmHg post-race versus pre-race values. MAP variations reflected SBP and DBP changes. The mean supine and standing pre-race blood pressures across studies were systolic (126±7; 124±14) and diastolic (76±6; 75±12), suggesting that some athletes may enter races with existing hypertension. The post-race increase in the mean HR and decline in mean blood pressure across examined studies suggest that during long-term events, ultramarathon athletes perform with relatively asymptomatic hypotension.

Exercise-Induced Arrhythmia or Munchausen Syndrome in a Marathon Runner?

A 36-year-old professional marathon runner reported sudden irregular palpitations occurring during competitions, with heart rates (HR) up to 230 bpm recorded on a sports HR monitor (HRM) over 4 years. These episodes subsided upon the cessation of exercise. Electrocardiograms, echocardiography, and cardiac magnetic resonance imaging results were borderline for athlete's heart. Because an electrophysiology study and standard exercise tests provoked no arrhythmia, doctors suspected Munchausen syndrome. Ultimately, an exercise test that simulated the physical effort of a competition provoked tachyarrhythmia consistent with the HRM readings. This case demonstrates the diagnostic difficulties related to exercise-induced arrhythmia and the diagnostic usefulness of sports HRMs.

Long-Term Sports Practice and Atrial Fibrillation: An Updated Review of a Complex Relationship

Atrial fibrillation (AF) is the most common sustained arrhythmia in clinical practice, and it is an enormous burden worldwide because of its high morbidity, disability and mortality. It is generally acknowledged that physical activity (PA) is strongly associated with a significant reduction in the risk of cardiovascular (CV) disease and all-cause mortality. Moreover, it has been observed that moderate and regular physical activity has the potential to reduce the risk of AF, in addition to improving overall well-being. Nevertheless, some studies have associated intense physical activity with an increased risk of AF. This paper aims to review the main related literature to investigate the association between PA and AF incidence and draw pathophysiological and epidemiological conclusions.

Effects of Long-Term Endurance Exercise on Cardiac Morphology, Function, and Injury Indicators among Amateur Marathon Runners

The purpose of this study was to investigate the effects of long-term endurance exercise on cardiac morphology and function, as well as injury indicators, among amateur marathon runners. We recruited 33 amateur runners who participated in a marathon. Participants were divided into experimental and control groups according to their National Athletic Grade. The experimental group included participants with a National Athletic Grade of 2 or better, and the control group included participants who did not have a National Athletic Grade. Cardiac morphology, function, and injury indicators were assessed before and after the participants' involvement in the Changsha International Marathon. All cardiac morphology and function indicators returned to pre-race levels at 24 h post-race, and left ventricular end-diastolic volume and left ventricular end-systolic volume indicators showed similar trends. Both stroke volume (SV) and percent fractional shortening (%FS) indicators showed similar trends in changes in the measurements before and after the race. SV showed no change between the pre-race and post-race periods. On the other hand, %FS showed a significant increase in the immediate post-race period, followed by restoration of its level at 24 h post-race. Among myocardial injury indicators, serum levels of cardiac troponin I, creatine kinase (CK), creatine kinase-MB (CK-MB), lactate dehydrogenase (LDH), aspartate aminotransferase (AST), and N-terminal pro-b-type natriuretic peptide (NT-proBNP) measured before the race, immediately after the race, and 24 h after the race displayed similar trends in changes among CK, CK-MB, LDH, and AST, while NT-proBNP levels did not change. We concluded that high-level amateur marathon runners had greater heart volumes, as well as wall and septal thicknesses, than low-level marathon runners, with differences in heart volume being the most pronounced. Long-term high-intensity endurance exercise caused some damage to the hearts of amateur runners. High-level runners showed better myocardial repair ability, and their levels of myocardial injury markers showed greater decreases at 24 h post-race, while low-level runners had poorer myocardial repair ability.

Multimodality Cardiac Imaging in Young and Veteran Athletes: Updates on Atrial Function Assessment, Arrhythmia Predisposition and Pathology Discrimination

Sports physicians and physiologists have aimed to assess exercise in young and master athletes so as to work out their conditioning levels and design training programs accordingly [...].

Running for Your Life: Metabolic Effects of a 160.9/230 km Non-Stop Ultramarathon Race on Body Composition, Inflammation, Heart Function, and Nutritional Parameters

Moderate endurance exercise leads to an improvement in cardiovascular performance, stress resilience, and blood function. However, the influence of chronic endurance exercise over several hours or days is still largely unclear. We examined the influence of a non-stop 160.9/230 km ultramarathon on body composition, stress/cardiac response, and nutrition parameters. Blood samples were drawn before (pre) and after the race (post) and analyzed for ghrelin, insulin, irisin, glucagon, cortisol, kynurenine, neopterin, and total antioxidant capacity. Additional measurements included heart function by echocardiography, nutrition questionnaires, and body impedance analyses. Of the 28 included ultra-runners (7f/21m), 16 participants dropped out during the race. The remaining 12 finishers (2f/10m) showed depletion of antioxidative capacities and increased inflammation/stress (neopterin/cortisol), while energy metabolism (insulin/glucagon/ghrelin) remained unchanged despite a high negative energy balance. Free fat mass, protein, and mineral content decreased and echocardiography revealed a lower stroke volume, left end diastolic volume, and ejection fraction post race. Optimizing nutrition (high-density protein-rich diet) during the race may attenuate the observed catabolic and inflammatory effects induced by ultramarathon running. As a rapidly growing discipline, new strategies for health prevention and extensive monitoring are needed to optimize the athletes’ performance.

May Strenuous Endurance Sports Activity Damage the Cardiovascular System of Healthy Athletes? A Narrative Review

The positive effects of physical activity are countless, not only on the cardiovascular system but on health in general. However, some studies suggest a U-shape relationship between exercise volume and effects on the cardiovascular system. On the basis of this perspective, moderate-dose exercise would be beneficial compared to a sedentary lifestyle, while very high-dose physical activity would paradoxically be detrimental. We reviewed the available evidence on the potential adverse effects of very intense, prolonged exercise on the cardiovascular system, both acute and chronic, in healthy athletes without pre-existing cardiovascular conditions. We found that endurance sports activities may cause reversible electrocardiographic changes, ventricular dysfunction, and troponin elevation with complete recovery within a few days. The theory that repeated bouts of acute stress on the heart may lead to chronic myocardial damage remains to be demonstrated. However, male veteran athletes with a long sports career show an increased prevalence of cardiovascular abnormalities such as electrical conduction delay, atrial fibrillation, myocardial fibrosis, and coronary calcifications compared to non-athletes. It must be underlined that the cause-effect relationship between such abnormalities and the exercise and, most importantly, the prognostic relevance of such findings remains to be established.

Exercise-Induced Atrial Remodeling in Female Amateur Marathon Runners Assessed by Three-Dimensional and Speckle Tracking Echocardiography

Endurance athletes have an increased risk of atrial remodeling and atrial arrhythmias. However, data regarding atrial adaptation to physical exercise in non-elite athletes are limited. Even less is known about atrial performance in women. We aimed to elucidate exercise-induced changes in atrial morphology and function in female amateur marathon runners using three-dimensional (3D) echocardiography and two-dimensional (2D) speckle tracking echocardiography (STE). The study group consisted of 27 female (40 ± 7 years) amateur athletes. Right (RA) and left atrial (LA) measures were assessed three times: 2–3 weeks before the marathon (stage 1), immediately after the run (stage 2), and 2 weeks after the competition (stage 3). Directly after the marathon, a remarkable RA dilatation, as assessed by RA maximal volume (RAVmax, 31.3 ± 6.8 vs. 35.0 ± 7.0 ml/m²; p = 0.008), with concomitant increase in RA contractile function [RA active emptying fraction (RA active EF), 27.7 ± 8.6 vs. 35.0 ± 12.1%; p = 0.014; RA peak atrial contraction strain (RA PACS) 13.8 ± 1.8 vs. 15.6 ± 2.5%; p = 0.016] was noticed. There were no significant changes in LA volumes between stages, while LA active EF (34.3 ± 6.4 vs. 39.4 ± 8.6%; p = 0.020), along with LA PACS (12.8 ± 2.1 vs. 14.9 ± 2.7%; p = 0.002), increased post race. After the race, an increase in right ventricular (RV) dimensions (RV end-diastolic volume index, 48.8 ± 11.0 vs. 60.0 ± 11.1 ml/m²; p = 0.001) and a decrease in RV function (RV ejection fraction, 54.9 ± 6.3 vs. 49.1 ± 6.3%; p = 0.006) were observed. The magnitude of post-race RV dilatation was correlated with peak RA longitudinal strain deterioration (r = −0.56, p = 0.032). The measured parameters did not differ between stages 1 and 3. In female amateur athletes, apart from RV enlargement and dysfunction, marathon running promotes transient biatrial remodeling, with more pronounced changes in the RA. Post-race RA dilatation and increment of the active contraction force of both atria are observed. However, RA reservoir function diminishes in those with post-race RV dilation.

Longitudinal Associations Between Cumulative Physical Activity and Change in Structure and Function of the Left Side of the Heart: The Tromsø Study 2007–2016

Background

Current knowledge about the relationship between physical activity (PA) and cardiac remodeling is mainly derived from cross-sectional studies of athletes, and there is a knowledge gap of this association in the general adult and elderly population. Therefore, we aimed to explore the longitudinal association between cumulative PA and change in cardiac structure and function in a general adult and elderly population.

Methods

This longitudinal study includes 594 participants from the sixth (Tromsø6, 2007–08) and seventh (Tromsø7, 2015–16) survey of the Tromsø Study. Cardiac structure and function were assessed by echocardiography at two time points, and PA was self-reported by questionnaire at both time points. PA volume was expressed as cumulative PA (Low, Moderate, and Hard) and the association with left atrial (LA) and left ventricular (LV) structure and function was assessed using ANCOVA.

Results

Overall, LA diameter index (LADi) increased significantly more in Hard compared to Moderate PA (+0.08 cm/m², 95% CI 0.01–0.15, p = 0.020) from Tromsø6 to Tromsø7. When stratified by sex or age, higher levels of cumulative PA were associated with increased LADi in males and in participants <65 years only. Indexed LV mass (LVMi) increased significantly more in Moderate than in Low PA (+3.9 g/m^2.7, 95% CI 0.23–7.57, p = 0.037). When stratified by sex or age, these changes in LVMi and indexed LV diameter (LVDi) were only significant in females. No significant associations were observed between cumulative PA and change in relative wall thickness, E/e' ratio, e' velocity, LV ejection fraction, and LADi/LVDi ratio.

Conclusion

Higher levels of cumulative PA were associated with increased LADi in males and participants <65 years, and with increased LVMi and LVDi in females. Despite cardiac chamber enlargement, the pump function of the heart did not change with higher levels of PA, and the atrioventricular ratio was unchanged. Our results indicate that cardiac chamber enlargement is a physiological response to PA.