Cardiac remodelling in adolescent athletes – sex differences progress through adolescence

Background

Cardiac remodelling beyond reference values is well-known in adult athlete's heart. Male endurance athletes are more prone to develop cardiac chambers and wall thickness above reference values. Cardiac remodelling is also described in adolescent athletes, but considered to be moderate compared to adults. However, few studies evaluate adolescent athlete's heart by paediatric echocardiographic reference values. Current paediatric reference values are sex-unspecific and do not include exercise data. The impact of sex and exercise on remodelling in adolescent athlete's heart remains unclear.

Purpose

We aimed to study the development of cardiac remodelling and potential sex differences in adolescent athletes. We hypothesized that male adolescent athletes would display greater degree of remodelling compared to female adolescent athletes.

Methods

Male (M) and female (F) adolescent cross-country skiers were recruited in a longitudinal cohort study. They were examined with echocardiography at age 12, 15 and 18. Data on exercise was collected at all examinations. We evaluated echocardiographic parameters by paediatric reference values (Z-score: number of standard deviations above estimated mean in the given body surface area). Echocardiographic measures were considered above upper reference value if Z-score was ≥2.

Results

Seventy-six athletes were examined at age 12 (48 M, 28 F), 48 at age 15 (34 M, 14 F) and 34 at age 18 (23 M, 11 F). Although Z-scores were within reference values at age 12 (Table 1), a subset of athletes displayed Z-scores ≥2 for end-diastolic intraventricular septum diameter (IVSd, M 13/48=27%, F 5/28=18%) and left ventricular posterior wall thickness (LVPWd, M 6/48=13%, F 2/28=14%). The male group demonstrated enlarged left ventricular mass (LVM) from age 15 (Figure 1). Males had greater left ventricular end-diastolic volume (LV EDV) from age 12. Additional sex differences were evident from age 15 for IVSd, LVPWd and LVM (Table 1). There was no sex difference in exercise hours. Both groups had normal myocardial function through the study period.

Conclusion

Cardiac remodelling beyond reference values was observed in athletes of both sexes from early adolescent age. Sex differences were evident from age 12 with further progression. Pathological values for LVM were more frequent in males. These findings suggest that sex differences in exercise-induced cardiac remodelling is more prominent in adolescents than previously reported. Sex and exercise history should be considered in questions of pathology.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The South-Eastern Norway Regional Health AuthorityCentre for Children and Youth Sport, Norwegian School of Sport Sciences

Long-term cardiac adverse effects after modern Hodgkins lymphoma treatment

Background

Hodgkin's lymphoma (HL) frequently affects both children and young adults. Traditional treatment of HL is effective but associated with a life-time prevalence of cardiac disease exceeding 50%. Treatment protocols were modified in 1997 to reduce cardiotoxicity, primarily by reducing both radiation fields and doses.

Purpose

To assess the long-term impact of the modified treatment protocols on left ventricular cardiac function.

Methods

HL survivors (n=244) treated with anthracycline-based chemotherapy using modified treatment protocols in 3 centres in Norway between 1997 and 2007 were included in this cross-sectional study. Of these, 130 (53%) also received mediastinal radiotherapy. They were compared to controls recruited from the general population (n=58) matched for age, sex, and risk-factors. Echocardiography was performed in all subjects.

Results

The participants were on average 46±9 years old and had received treatment on average 17±3 years before examination. Echocardiographic parameters are shown in the table. Reduced left ventricular (LV) ejection fraction (EF) (<52%) was found in 19 HL-survivors and three controls (13% vs. 6%, p=0.24). Reduced LV global longitudinal strain (GLS) (> −18.0%) was found in 41 HL survivors and three controls (25% vs. 6%, p<0.05). There was no difference in prevalence of reduced GLS between HL survivors who received mediastinal radiotherapy and those who did not (26% vs. 24%, p=0.70).

Conclusion

While a minority of HL survivors did have a slight reduction in longitudinal deformation, the effect was small and importantly, we found no difference in EF between HL survivors treated with modified protocols and controls. Mediastinal radiotherapy did not seem to increase the prevalence of reduced cardiac function in HL survivors.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): South-Eastern Norway Regional Health Authority

Sex differences in athlete"s heart are evident from early adolescence

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority

OnBehalf

ProCardio Center for Innovation

Introduction

Athlete’s Heart (AH) is characterized by cardiac remodelling as a response to exercise, but data on sex differences in adolescent athletes is limited.

Purpose

To study the impact of sex on development of AH in adolescent athletes. We hypothesize that male adolescent athletes develop greater morphological changes than females, also when adjusted for body surface area (BSA).

Methods

We recruited 12-year-old cross-country skiers of both sexes in a longitudinal cohort study. We examined them with echocardiography at age 12, 15 and 18.

Results

We recruited 76 athletes (48 males and 28 females). We could follow 48 participants at age 15 (34 males and 14 females), and 34 participants at age 18 (23 males and 11 females). There were no sex differences in exercise hours at any time point. Adolescent males had greater indexed LV end-diastolic volume (LV EDVi) at all time points (Figure 1). Both sexes displayed LV enlargement already at age 12, and athletes of both sexes displayed LV EDVi close to or above upper reference values for the adult population. Only males increased their indexed LV mass (LVMI) from 12 to 18 years (LVM/BSA, Δg/m²; 33 ± 27 vs 4 ± 19, P = 0.006). Male adolescent athletes increased their LVMI by 7.4 grams more and LV EDVi by 4.0 ml more than female athletes did for every 1000 hours of exercise training. Cardiac function was within normal range in both sexes throughout the study period.

Conclusion

 Sex-related differences in cardiac adaptation to exercise are evident from early adolescence. Both sexes demonstrate cardiac remodelling, but adolescent male athletes display greater morphological changes compared to female athletes. Abstract Figure 1

431 Impact of endurance training versus non-endurance training on cardiac morphology and physical fitness in highly trained young athletes

Funding Acknowledgements

South-Eastern Norway Regional Health Authority

OnBehalf

Center for Cardiological Innovation

Background

Endurance exercise is closely correlated with physical fitness and the development of the athlete’s heart. The impact of changes in exercise-patterns in young athletes is poorly described.

Aims

This study aims to explore the impact of endurance training versus non-endurance training on cardiac morphology and physical fitness in young endurance athletes.

Methods

Forty-eight cross-country skiers were examined at age 12 (12.1 ± 0.2 years) and then again at age 15 (15.3 ± 0.3 years). Echocardiography, including 3D echocardiography, and cardiopulmonary exercise testing was performed in all participants. Self-reported data on weekly hours of endurance and weekly hours of non-endurance training was collected.

Results

At follow-up, thirty-one (65%) of the endurance athletes were still active and 17 (35%) were not. There was a moderate, positive correlation between weekly hours of endurance-only training and changes in VO2 max from baseline to follow-up (R = 0.55, p < 0.001), but no correlation was found for weekly hours of all types of training (Figure). Weekly hours of endurance-only training also showed moderate, positive correlations with changes in chamber dimensions, including indexed 3D left ventricular (LV) end-diastolic volume (R = 0.45, p < 0.01), 3D LV end-systolic volume (R = 0.35, p < 0.05), right ventricular (RV) end-diastolic area (R = 0.39, p < 0.01) and RV end-systolic area (R = 0.44, p < 0.01). No correlation was found for weekly hours of all types of training.

Conclusion

Only endurance training is sufficient to induce cardiac remodeling, including dilatation of both ventricles, in highly trained adolescent athletes.

Abstract 431 Figure.

P1507 Early and late morphological changes in the athlete"s heart: a longitudinal cohort study in young elite athletes

Funding Acknowledgements

South-Eastern Norway Regional Health Authority

OnBehalf

Center for Cardiological Innovation

Background

Recent studies have suggested an initial concentric remodelling in the early development of the athlete’s heart in endurance athletes. However, the development from the early to the fully developed endurance athlete’s heart has not been described in longitudinal studies.

Aims

This study aims to explore the morphological changes occurring in hearts of young endurance athletes transitioning through adolescence.

Methods

Forty-eight cross-country skiers were examined at age 12 (12.1 ± 0.2 years) and then again at age 15 (15.3 ± 0.3 years). Cardiopulmonary exercise test and echocardiography, including 3D acquisitions, was performed in all subjects at both baseline and follow-up.

Results

At follow-up, 31 (65%) of the endurance athletes were still active and 17 (35%) were not. No differences in cardiac morphology were identified at baseline. At 15 years of age, the active endurance athletes had greater VO2 max, 3D indexed left ventricular end-diastolic and end-systolic volumes (Table). Relative wall thickness (RWT) decreased in the active endurance athletes during follow-up (0.35 ± 0.05 to 0.31 ± 0.04, p < 0.001), but not in the former athletes. Four active endurance athletes had RWT above the upper reference values at baseline; at follow up, all had normalized.

Conclusion

After an early concentric remodeling in the 12 years old athletes, those who continued regular endurance training developed eccentric changes with chamber dilatation and a drop in RWT. In contrast, those who ceased endurance training maintained a comparable wall thickness, but did not develop chamber dilatation nor experience a drop in RWT.

Baseline Follow-up Active athletes (n = 31) Former athletes (n = 17) p-value Active athletes (n = 31) Former athletes (n = 17) p-value VO2 max, indexed 65 ± 7 63 ± 7 0.33 62 ± 8 57 ± 6 <0.05 Interventricular septum thickness, mm 7.9 ± 0.8 7.8 ± 1.0 0.54 8.1 ± 1.2 7.8 ± 0.9 0.41 LV end-diastolic diameter, mm/m2 2.1 ± 0.3 2.0 ± 0.3 0.60 3.0 ± 0.2 2.9 ± 0.2 0.34 LV poster wall thickness, mm 7.3 ± 0.9 6.8 ± 0.9 0.07 7.8 ± 1.2 8.1 ± 1.2 0.42 3D LV end-diastolic volume, mL/m2 76 ± 8 74 ± 8 0.89 84 ± 11 79 ± 10 <0.05 3D LV end-systolic volume, mL/m2 33 ± 4 33 ± 4 0.99 36 ± 6 32 ± 3 <0.05 3D LV ejection fraction, % 56 ± 3 56 ± 3 0.93 58 ± 3 59 ± 2 0.52 3D LV Mass/BSA, g/m2 69 ± 7 71 ± 4 0.57 76 ± 11 74 ± 6 0.19 Relative wall thickness 0.35 ± 0.05 0.33 ± 0.05 0.12 0.31 ± 0.04 0.33 ± 0.05 0.05 Data expressed as mean ± SD. P-values calculated using the Student"s paired t-test. Volumes are indexed to body surface area.

P6239Late adverse effects of residual platinum concentrations on cardiac function in testicular cancer survivors: a 30-year follow-up study

Background

Cisplatin-based chemotherapy (CBCT) is essential in the treatment of testicular cancer (TC), and platinum can be detected in TC survivors decades after cessation of treatment. CBCT has been implicated as a risk factor in cardiovascular morbidity and mortality.

Purpose

Our study aimed to assess the relationship between residual serum platinum concentrations and changes in cardiac function and morphology in TC survivors 30 years after CBCT.

Methods

Seventy TC survivors diagnosed and treated with CBCT (1980–1994) were recruited from the longitudinal Norwegian Cancer Study in Testicular Cancer Survivors. Serum platinum concentration was measured twenty years after CBCT. Patients were then allocated to either a high or low platinum concentration group. Echocardiography was performed in all subjects.

Results

The participants were on average 60±9 years old. There was a trend towards smaller left ventricular (LV) volumes in the high residual platinum concentration group (Table). No intergroup difference in cardiac function was found. Six (9%) participants had reduced EF (<52%) and 14 (20%) participants had reduced LV global longitudinal strain (> −18.0%), however, there was no intergroup difference. Neither cumulative cisplatin dose nor residual serum platinum concentration showed any correlation with LV or right ventricular functional parameters.

Table 1 Low residual Pt concentration >85 ng/L (n=35) High residual Pt concentration <85 ng/L (n=35) p-value Cumulative cisplatin dose, mg/m2 680±249 814±271 <0.05 Residual Pt concentration, ng/L 44±22 136±44 <0.001 3D LV end-diastolic volume, ml/m2 66±17 60±8 0.07 3D LV end-systolic volume, ml/m2 29±15 24±5 0.08 3D ejection fraction, % 57±9 59±6 0.24 LV global longitudinal strain, % −19.2±3.3 −20.0±2.0 0.26 LV global circumferential strain, % −21.1±4.2 −22.1±1.8 0.30 E/e' 10.6±4.4 9.2±2.2 0.10 TAPSE, mm 2.2±0.4 2.3±0.4 0.22 RV fractional area change, % 40±7 41±7 0.67 Data are presented as mean ± SD. The P-values were derived from the Student's t-test. LV, left ventricle; MV, mitral valve; Pt, platinum; RV, right ventricle; TAPSE, tricuspid annular plane systolic excursion.

Conclusion

Our 30-year follow-up study of testicular cancer patients could not demonstrate impact on cardiac function caused by cumulative cisplatin dose or residual serum platinum concentrations.

Acknowledgement/Funding

South-Eastern Norway Regional Health Authority

P606High intermodality variability in ejection fraction measured by echocardiography, cardiac magnetic resonance and single photon emission computed tomography in chronic coronary artery disease patients

Background

Clinical treatment strategies are often based on measurement of left ventricular ejection fraction (LVEF). There is limited evidence about variations in LVEF when measured by different imaging modalities.

Purpose

To investigate the intermodality variability of LVEF measured by two-dimensional echocardiography (2DE), three-dimensional echocardiography (3DE), cardiac magnetic resonance (CMR), and single photon emission computed tomography (SPECT) in patients with chronic coronary artery disease (CAD).

Methods

Patients from a multicenter study (DOPPLER-CIP – Determining optimal noninvasive parameters for the prediction of left ventricular remodeling in chronic ischemic patients) with chronic CAD were included. LVEF was measured by CMR and at least one additional modality. In each modality, LVEF was measured by a core laboratory independently of the other modalities. Measurements of LVEF by CMR were compared to 2DE, 3DE and SPECT using correlation and Bland-Altman plots.

Results

A total of 343 patients were included. Mean age was 63.9±8.3 years and 253 (74%) were males. Mean LVEF by CMR was 61.8±11.6%. Correlations between CMR LVEF and other modalities were moderate for 2DE and 3DE, and good for SPECT (Figure A-C). CMR had significantly greater correlation to SPECT, compared to 2DE and 3DE. Bland-Altman plots indicated relatively wide limits of agreement between all modalities, ranging from 31% to 42% (Figure, D-F). Mean absolute difference of LVEF between CMR and other modalities were 8.5% for 2DE, 9.0% for 3DE, and 8.3% for SPECT. The percentage of measurements that fell within a range of 5% difference compared to CMR LVEF was 41% for 2DE, 34% for 3DE and 37% for SPECT (all p>0.05).

Conclusions

In a multicenter study with chronic CAD patients, LVEF assessed by CMR had better correlation to SPECT, compared to 2DE and 3DE. However, there was considerable variability among all three modalities that were compared to CMR. Awareness of these variations are important in clinical management.