Electrocardiographic manifestations in female team handball players: analyzing ECG changes in athletes

Introduction

Long-term intense training leads to structural, functional, and electrical remodeling of the heart. How different sports affect the heart has not been fully investigated, particularly for female athletes. The aim of the present study was to investigate the morphology of 12-lead resting electrocardiogram (ECG) in elite female handball players compared to non-athlete female subjects. Potential changes will be explored to see if they could be explained by differences in cardiac dimensions and exercise hours.

Materials and methods

A cross-sectional study of 33 elite female team handball players compared to 33 sex and age-matched, non-athletic controls (age range 18-26 years) was performed. All participants underwent a resting 12-lead ECG and an echocardiographic examination. ECG variables for left ventricular hypertrophy and durations were evaluated and adjusted for cardiac dimensions and exercise hours using ANCOVA analysis. A linear regression analysis was used to describe relation between echocardiographic and ECG measures and exercise hours.

Results

The female handball players had larger cardiac dimensions and significantly lower heart rate and QTc duration (Bazett's formula) as well as increased QRS and QT durations compared to controls. The 12-lead sum of voltage and the 12-lead sum of voltage ∗ QRS were significantly higher among handball players. Changes in ECG variables reflecting the left ventricle could in part be explained by left ventricular size and exercise hours. Correlation with exercise hours were moderately strong in most of the echocardiographic measures reflecting left ventricular (LV), left ventricular mass (LVM), left atrium (LA) and right atrium (RA) size. Poor to fair correlations were seen in the majority of ECG measures.

Conclusions

Female team handball players had altered ECGs, longer QRS and QT durations, higher 12-lead sum of voltage and 12-lead sum of voltage ∗ QRS as well as shorter QTc (Bazett's formula) duration compared to non-athletic controls. These findings could only partly be explained by differences in left ventricular size. Despite larger atrial size in the athletes, no differences in P-wave amplitude and duration were found on ECG. This suggest that both structural, and to some degree electrical remodeling, occur in the female team handball players' heart and highlight that a normal ECG does not rule out structural adaptations. The present study adds knowledge to the field of sports cardiology regarding how the heart in female team handball players adapts to this type of sport.

Associations among Periodontitis, Calcified Carotid Artery Atheromas, and Risk of Myocardial Infarction

Cardiovascular disease is a common cause of morbidity and premature mortality. Cardiovascular disease can be prevented when risk factors are identified early. Calcified carotid artery atheromas (CCAAs), detected in panoramic radiographs, and periodontitis have both been associated with increased risk of cardiovascular disease. This case-control study aimed to 1) investigate associations between periodontitis and CCAA detected in panoramic radiographs and 2) determine the risk of future myocardial infarctions due to CCAA combined with periodontitis. We evaluated 1,482 participants (738 cases and 744 controls) with periodontitis and CCAAs recruited from the PAROKRANK study (Periodontitis and Its Relation to Coronary Artery Disease). Participants were examined with panoramic radiographs, including the carotid regions. Associations between myocardial infarction and periodontitis combined with CCAA were evaluated in 696 cases and 696 age-, sex-, and residential area–matched controls. Periodontitis was evaluated radiographically (as degree of bone loss) and with a clinical periodontal disease index score (from clinical and radiographic assessments). We found associations between CCAA and clinical periodontal disease index score among cases (odds ratio [OR], 1.51; 95% CI, 1.09 to 2.10; P = 0.02) and controls (OR, 1.70; 95% CI, 1.22 to 2.38; P < 0.01), although not between CCAA and the degree of bone loss. In a multivariable model, myocardial infarction was associated with CCAA combined with periodontitis, as assessed by degree of bone loss (OR, 1.75; 95% CI, 1.11 to 2.74; P = 0.01). When the cohort was stratified by sex, only men showed a significant association between myocardial infarction and CCAA combined with periodontitis. Participants with clinically diagnosed periodontitis exhibited CCAA in panoramic radiographs more often than those without periodontitis, irrespective of the presence of a recent myocardial infarction. Participants with combined periodontitis and CCAA had a higher risk of having had myocardial infarction as compared with participants with either condition alone. These findings implied that patients in dental care might benefit from dentists assessing panoramic radiographs for CCAA—particularly, patients with periodontitis who have not received any preventive measures for cardiovascular disease.

Invasive Dental Treatment and Risk for a First Myocardial Infarction

Invasive dental treatment is suggested to be associated with an increased risk for the development of cardiovascular events. We tested the hypothesis that the incidence of a first myocardial infarction (MI) within 4 wk after invasive dental treatments is increased. A registry-based case-control study within nationwide health care and population registries in Sweden was performed. The case patients included 51,880 individuals with a first fatal or nonfatal MI between January 2011 and December 2013. For each case, 5 control subjects, free from prior MI and matched for age, sex, and geographic area of residence, were randomly selected from the national population registry through risk set sampling with replacement, resulting in 246,978 control subjects. Information on dental treatments was obtained from the Dental Health Register, and the procedures were categorized into invasive dental treatments or other dental treatments. Conditional logistic regression was used to estimate odds ratios (ORs) for MI with corresponding 95% confidence intervals (CIs). In addition to the matching variables, adjustments were made for the following confounders: diabetes, previous cardiovascular disease (CVD), CVD drug treatment, education, and income. The mean age for case patients and controls subjects was 72.6 ± 13.0 y and 72.3 ± 13.0 y, respectively. Case patients more often had previous CVD (49% vs. 23%; P < 0.001) and diabetes (19% vs. 11%; P < 0.001) and received more treatment with CVD drugs (68% vs. 56%; P < 0.001) than control subjects. There was no association between invasive dental treatments during the 4 wk preceding the MI index date (crude OR = 0.99; 95% CI, 0.92 to 1.06; adjusted for confounders OR = 0.98; 95% CI, 0.91 to 1.06). This study did not support the hypothesis of an increased incidence of MI after recent invasive dental treatment.

Severe Periodontitis Is Associated with Myocardial Infarction in Females

The aim of the present study was to test the hypothesis that there is a sex difference in the association between periodontitis (PD) and a first myocardial infarction (MI). The analysis in the case-control study was based on 785 patients (147 females and 638 males) with a first MI and 792 matched controls (147 females and 645 males), screened for cardiovascular risk factors and subjected to a panoramic dental X-ray. Periodontal status was defined by alveolar bone loss and diagnosed as no PD (≥80% remaining alveolar bone), mild to moderate PD (66% to 79%), or severe PD (<66%). Logistic regression was used when analyzing PD as a risk factor for MI, adjusting for age, smoking, diabetes, education, and marital status. The mean age was 64 ± 7 y for females and 62 ± 8 y for males. Severe PD was more common in female patients than female controls (14 vs. 4%, P = 0.005), with an increased risk for severe PD among female patients with a first MI (odds ratio [OR] = 3.92, 95% confidence interval [CI] =1.53 to 10.00, P = 0.005), which remained (OR = 3.72, 95% CI = 1.24 to 11.16, P = 0.005) after adjustments. Male patients had more severe PD (7% vs. 4%; P = 0.005) than male controls and an increased risk for severe PD (OR = 1.88, 95% CI = 1.14 to 3.11, P = 0.005), but this association did not remain following adjustment (OR = 1.67, 95% CI = 0.97 to 2.84, NS). Severe PD was associated with MI in both females and males. After adjustments for relevant confounders, this association did, however, remain only in females. These data underline the importance of considering poor dental health when evaluating cardiovascular risk, especially in females.

Perioperative hemodynamic measurements with an implantable monitoring system (Chronicle) in a patient with severe heart failure undergoing non-cardiac surgery

A 53-year-old male patient with severe chronic heart failure due to ischemic cardiomyopathy (LVEF 25%) awaiting heart transplantation was admitted for resection of a bladder tumor. The patient underwent implantation of a Chronicle implantable hemodynamic monitor (IHM) two years before. Thus, perioperative monitoring of heart rate, right ventricular systolic, diastolic and pulse pressure, dP/dt and estimated pulmonary artery diastolic pressure through a lead implanted in the right ventricle was performed. In the postoperative period the patient developed low-output syndrome requiring catecholamine treatment. The patient was weaned from mechanical ventilation uneventfully the same day. However, he developed symptomatic and hemodynamic worsening of heart failure shortly after reduction of inotropes and required prolonged medical treatment with catecholamines. Patients with cardiac disease are known to be at increased risk for cardiovascular complications after noncardiac surgery. Therefore, it has been suggested that such patients could potentially benefit from perioperative invasive hemodynamic monitoring. For the first time, we report a case of perioperative continuous hemodynamic monitoring with a long term-implanted device in a potential heart transplant patient.

Central hemodynamic responses during serial exercise tests in heart failure patients using implantable hemodynamic monitors

INTRODUCTION

Exercise testing is commonly used in patients with congestive heart failure for diagnostic and prognostic purposes. Such testing may be even more valuable if invasive hemodynamics are acquired. However, this will make the test more complex and expensive and only provides information from isolated moments. We studied serial exercise tests in heart failure patients with implanted hemodynamic monitors allowing recording of central hemodynamics.

METHODS

Twenty-one NYHA Class II-III heart failure patients underwent maximal exercise tests and submaximal bike or 6-min hall walk tests to quantify their hemodynamic responses and to study the feasibility of conducting exercise tests in patients with such devices.

RESULTS

Patients were followed for 2-3 years with serial exercise tests. During maximal tests (n=70), heart rate increased by 52+/-19 bpm while S(v)O(2) decreased by 35+/-10% saturation units. RV systolic and diastolic pressure increased 29+/-11 and 11+/-6 mmHg, respectively, while pulmonary artery diastolic pressure increased 21+/-8 mmHg. Submaximal bike (n=196) and hall walk tests (n=172) resulted in S(v)O(2) changes of 80 and 91% of the maximal tests, while RV pressures ranged from 72 to 79% of maximal responses.

CONCLUSIONS

An added potential value of implantable hemodynamic monitors in heart failure patients may be to quantitatively determine the true hemodynamic profile during standard non-invasive clinical exercise tests and to compare that to hemodynamic effects of regular exercise during daily living. It would be of interest to study whether such information could improve the ability to predict changes in a patient's clinical condition and to improve tailoring patient management.

[Biventricular pacing as a new therapeutic method in heart failure. An alternative for patients with intraventricular conduction disorders]

Patients with severe heart failure often have interventricular conduction disturbances indicated by wide QRS complexes. The resulting uncoordinated contraction pattern leads to impaired systolic and diastolic function which might be overcome by a new technique, biventricular pacing. The first Swedish clinical trial is reported, an open study where 13 out of 16 patients improved in terms of functional class, walking test and quality of life after six months of treatment. The number of hospital days was markedly reduced after pacemaker implantation.

Continuous ambulatory haemodynamic monitoring with an implantable system. The feasibility of a new technique

AIMS

This study evaluates the feasibility and safety of a completely implantable system for long-term ambulatory monitoring of important haemodynamic parameters in patients with severe cardiopulmonary disease.

METHODS

The design of the implantable monitoring system is similar to a conventional single lead pacemaker. A lead with incorporated biosensors for the continuous recording of pressure and oxygen saturation signals is positioned in the right ventricle and connected to a monitor and memory device subcutaneously implanted like an ordinary pacemaker can.

RESULTS

Five patients with implanted haemodynamic monitoring systems have been followed for from 7 to 16 months. Continuous measurements of activity, heart rate, mixed venous oxygen saturation and estimated pulmonary artery diastolic pressure were registered with variable resolution during daily living and predefined provocations. The memory covered a maximum of 3 weeks at low resolution. The monitored parameters showed an adequate and significant response to various haemodynamic situations. Except for the demand of recalibration of two oxygen sensors, there were no technical problems and the quality of data were excellent.

CONCLUSION

Long-term ambulatory haemodynamic monitoring is feasible and potentially useful for the management of patients with severe cardiopulmonary disease.

Long-term recording of cardiac output via an implantable haemodynamic monitoring device

Long-term monitoring of central haemodynamics with implanted monitoring systems might be valuable in managing heart failure patients. Such systems offer an opportunity for repeated 'semi-invasive' cardiac output determinations according to the Fick principle. Five patients, four with chronic heart failure and one with chronic pulmonary disease, underwent supine exercise testing during cardiac catheterization at 0, 2, 6 and 11 months after implantation of a right ventricular mixed venous oxygen saturation sensor connected to an implantable haemodynamic monitor. The monitor provided a continuous measure of oxygen saturation via a radio-telemetry link to a metabolic cart capable of measurement of breath-by-breath oxygen consumption. Cardiac output was computed using oxygen consumption, mixed venous oxygen saturation, arterial oxygen saturation by pulse oximetry and haemoglobin oxygen capacity. Biosensor-derived oxygen saturation compared to blood samples from the pulmonary artery showed an excellent correlation over time, r2 = 0.94 (implant), r2 = 0.91 (6-11 months). There was a strong correlation between semi-invasive-determined cardiac output using the biosensor and the invasive technique, which persisted over the entire follow-up period. Repeated semi-invasive cardiac output measurements using an implanted haemodynamic monitoring system in chronic heart failure patients is feasible and the data may be of value for optimizing therapy.

Purification and properties of cyclostome carbonic anhydrase from erythrocytes of hagfish

1. Carbonic anhydrase (carbonate hydro-lyase, EC 4.2.1.1) has been purified from erythrocytes of hagfish (Myxine glutinosa). A single form with low specific CO2 hydration activity was isolated. The purified carbonic anhydrase appeared homogeneous judging from polyacrylamide gel electrophoresis and gel filtration experiments. The protein has a molecular weight of about 29 000, corresponding to about 260 amino acid residues. This molecular weight is in accordance with other vertebrate carbonic anhydrases with the exception of the elasmobranch enzymes, which have Mr 36 000--39 000. 2. The molecular weight obtained for hagfish carbonic anhydrase indicates that a carbonic anhydrase with Mr approx. 29 000 is the ancestral type of the vertebrate enzyme rather than, as in sharks, a heavier carbonic anhydrase molecule. 3. The circular dichroism spectrum may indicate a somewhat different structural arrangement of aromatic amino acid residues in this enzyme than in the mammalian carbonic anhydrases. 4. The enzyme is strongly inhibited by acetazolamide and also to a lesser extent by monovalent anions. 5. Zn2+, which is essential for activity, appears, contrary to other characterized carbonic anhydrases, less strongly bound in the active site of the enzyme.