Determinants of LV mass in athletes: the impact of sport, constitutional traits and cardiovascular risk factors

The spectrum of eccentric left ventricular hypertrophy in endurance sports disciplines

Endurance sports disciplines largely differ in terms of specific training and event modalities, likely resulting in diverse morpho-functional cardiac changes. Our study aims to assess elite athletes engaged in different endurance disciplines and describe cardiac remodelling in each. We enrolled 282 Olympic athletes (58.5% males, mean age 26.7 ± 4.7) practising long-distance running (57, 20.2%), triathlon (18, 6.4%), canoeing/rowing (76, 26.9%), cycling (65, 23%), long-distance swimming (21, 7.4%), cross-country skiing & biathlon (45, 16%). athletes underwent ECG, echocardiogram and exercise stress-test. Eccentric LV hypertrophy (EH) was present in 73.8% of athletes, without gender differences (p = 0.847), varying greatly among disciplines (p = 0.0005). Triathlon (94.4%) and cycling (87.7%) showed the highest prevalence. The largest LV volumes were observed in triathlon-athletes and cyclists (LVEDVi: males, p = 0.009, females, p = 0.002). The lowest LV dimensions were found in rowing/canoeing (males: p < 0.0001; females: p < 0.0001). Long-distance runners and swimmer presented intermediate extent of LV remodelling. Positive correlation between hours of training and LVMi (p = 0.0004) and LVEDVi (p = 0.048) was observed among cyclists. Indeed, cyclists with the highest EH (i.e., lowest LVMi\LVEDVi ratio) achieved the highest workload at exercise stress-test (p = 0.045) and better athletic achievements. Among endurance athletes, cyclists and triathletes present the most marked extent of LV EH, while canoeists and rowers the lowest degree, with major increase in LV mass. Intra-group analysis showed an association between eccentric hypertrophy and superior exercise capacity and higher athletic performances that may be related to an increased stroke volume and cardiac output, which improve cardiovascular efficiency during endurance exercise. These findings could be useful both for clinicians in identifying potential health issues in athletes and for coaches when assessing athletes' training status.

Differences Between Olympic and National Athletes: Training and Experience Are the Keys to Success

OBJECTIVE

Olympic athletes (OAs) represent a unique subset of highly trained subjects achieving extraordinary performance. Differences between OAs and elite/national athletes (EAs), defined as athletes not qualified for the Olympics, are not investigated.

DESIGN

Therefore, we compared OAs with EAs enrolling 1472 athletes (63.6% OAs; 56.9%, men, mean age 25.8 ± 5.1 years) of power (24.7%), skills (12.5%), endurance (20.8%), and mixed (37.4%) disciplines performing clinical, anthropometric, echocardiographic, exercise stress, and blood test analysis.

RESULTS

Olympic athletes were older (power: 25.9 ± 4.6 vs 24.1 ± 4.7, P = 0.0002; skills: 28.6 ± 6.5 vs 25.2 ± 6.5, P = 0.0003; endurance: 27.2 ± 4.5 vs 23.7 ± 3.9, P = 0.001; mixed: 27.9 ± 4.7 vs 22.8 ± 4.4, P = 0.001) and trained for more hours (power: 26.1 ± 10.9 vs 19.9 ± 7.5, P < 0.0001; skills: 29.1 ± 9.4 vs 21 ± 9.4, P = 0.0004; endurance: 26.4 ± 8.7 vs 19.4 ± 8.5, P = 0.001; mixed: 28.4 ± 9.5 vs 22.2 ± 9.2, P = 0.001) compared with EAs. No morphological cardiac differences were observed. At the exercise test, the maximum watt reached was similar (except that in power, P = 0.004). Olympic athletes showed statistically significant lower serum calcium, lower thyroid stimulating hormone, and relatively higher total and low-density lipoprotein cholesterol.

CONCLUSIONS

Olympic athletes are older, have a larger body mass, and can sustain a larger training volume than elite athletes. However, no major differences in cardiac remodeling or clinical and laboratory parameters differentiate these 2 groups. Expertise and volume of training appear to represent the critical factors to translate from the national to the Olympic level.

Abnormal blood pressure response to exercise and ventricular arrhythmias: a suspicious association in athletes

INTRODUCTION

Abnormal blood pressure response to exercise (ABPR) in athletes is considered a risk for incident hypertension, conferring a higher cardiovascular risk profile. We sought to describe the clinical cardiovascular features of athletes with ABPR and, moreover, the relationship of ABPR with occurrence of exercise-induced ventricular ectopic beats (VEBs).

METHODS AND RESULTS

We enrolled 1460 elite athletes (56.1% male; mean age 25.8 ± 5.1 years old), engaged in skills, power, mixed and endurance sport, who underwent clinical examination, transthoracic echocardiogram (TTE) and exercise stress testing. ABPR was defined as >220/85 mmHg in males and >200/80 mmHg in females. ABPR was found in 8% ( n  = 117) of athletes, being older ( P  = 0.049) and presenting higher cardiovascular risk profile (obesity, P  = 0.007; glucose intolerance, P  = 0.043 and familiarity for cardiovascular disease, P  = 0.026). Athletes with ABPR had higher prevalence of exercise-induced VEBs (19.6% vs. 11.9% in normotensive athletes, P  = 0.015). Uncommon VEBs morphology was more frequent in athletes with ABPR (64.7% vs. 19% in the normotensive, P  = 0.0002). Finally, in those with ABPR and VEBs, TTE revealed greater left ventricular end-diastolic diameter indexed ( P  = 0-006), LVEDVi ( P  = 0.017) and LVMi ( P  = 0.04) compared to those without VEBs.

CONCLUSION

A not small group of elite athletes (8%) presented an exaggerated blood pressure response to exercise and exhibited higher cardiovascular risk profile compared to their normotensive counterparts. Moreover, athletes with ABPR showed higher prevalence of ventricular arrhythmias on effort and the combination of ABPR and ventricular arrhythmias was associated with more pronounced cardiac remodelling.

Differences in athlete's left ventricular morphology by sex and sports discipline categories in elite Japanese athletes

OBJECTIVES

The cardiac morphology of elite athletes is related to sports disciplines and race; however, no studies have examined the effects of sports discipline on East Asian athletes. Therefore, this study aimed to assess left ventricular (LV) remodeling using transthoracic echocardiography in elite Japanese athletes and establish standard values for the indicators of the cardiac morphology of elite athletes in East Asia, considering the influence of body size.

METHODS

We retrospectively evaluated 1,363 elite Japanese athletes who underwent electrocardiography and transthoracic echocardiography between January 2011 and December 2021. The athletes were assigned to four sports discipline categories (skill, power, mixed, and endurance). We evaluated the differences in LV volume and mass between the groups for each sex.

RESULTS

The LV end-diastolic volume (LVEDV) and LV mass indexed to the body surface area (BSA) in the endurance group (LVEDV/BSA: 72.3 ± 11.4 mL/m2 in males and 68.7 ± 11.0 mL/m2 in females, LV mass/BSA: 121.1 ± 19.1 g/m2 in males and 106.5 ± 18.0 g/m2 in females) were significantly larger than those of any other groups. Both values were affected by sex, BSA, and endurance sport type, whereas only LV mass was affected by age.

CONCLUSION

Cardiac remodeling is proportional to the sport type, with a significantly greater effect in athletes playing endurance sports. The remodeling is particularly evident in the left ventricle; however, the corresponding remodeling is also observed in other heart chambers. Cardiac remodeling in elite Japanese athletes is similar to that observed in elite athletes of other races, except for the changes in LV wall thickness.

The Effects of Endurance Training and High-Intensity Resistance Training on Pulse Wave Velocity and QT Dispersion

Objectives: This study aimed to examine the effects of endurance and high-intensity resistance training on arterial stiffness and ventricular repolarization in elite athletes. Methods: A total of 50 male athletes from different sports disciplines (volleyball, football, judo, and wrestling) and a sedentary group of 30 males participated in this study. Data collected from all participants included age, height, body weight, cardiovascular hemodynamic parameters, arterial stiffness parameters, and ECG measurements. Results: There was no significant age difference between the athlete group (20.42 ± 1.903 years) and the control group (20.97 ± 1.771 years) (p > 0.05). However, body mass index (BMI) values in the control group (24.83 ± 2.22 kg/m2) were significantly different from those in the athlete group (22.39 ± 2.663 kg/m2) (p < 0.05). Significant differences were found between the athlete and control groups in QT dispersion, systolic blood pressure, pulse pressure, and central pulse pressure values (p < 0.05), while similar results were obtained for arterial stiffness parameters (p > 0.05). Conclusions: The lack of a difference in pulse wave velocity and augmentation index (AIx) values between the athletes and the control group suggests that athletes do not bear additional risks regarding arterial stiffness. However, increased systolic blood pressure, pulse pressure, and central pulse pressure, among the hemodynamic parameters, indicate potential variations in vascular wall compliance and hemodynamic responses in the cardiovascular system. The increase in QT dispersion suggests that athletes may exhibit a heterogeneous repolarization process and an elevated risk of ventricular arrhythmias compared to the general population.

Aortic Dimension in Elite Athletes: Updated Systematic Review and Meta-Analysis

AIMS

To assess the presence and the extent of an "aortic remodeling" in elite athletes.

METHODS

A systematic review and meta-analysis of literature were conducted for studies (1981-2024) reporting echocardiographic aortic diameters of elite athletes compared to non-athlete healthy controls. Among the 5,494 studies retrieved, 21 (9,464 elite athletes vs. 2,637 non-athlete controls) fulfilled all eligibility criteria. Data were aggregated using a random effects model for estimating the pooled risk ratio and mean difference.

RESULTS

Absolute aortic diameters at the sinus of Valsalva (AoSV) were higher in overall elite athletes compared to non-athlete healthy controls (mean difference [MD] 1.69 [95% CI 1.01-2.37] mm; p <0.001) and if stratified to sex. This difference was maintained if AoSV was indexed to height (AoSV/h) (MD 0.04 [95% CI -0.00-0.08] mm/m; ES 2.18 [95% CI 1.10-3.26]; p<0.001). The analysis of AoSV/h according to sex was not performed for the paucity of studies. However, when indexed to body surface area (AoSV/BSA), no differences were found between the two groups (MD 0.04 [95% CI -0.25-0.34] mm/m2; p = 0.880), also according to sex. Above findings were not influenced by age.

CONCLUSIONS

Absolute AoSV was mildly larger in athletes compared to non-athlete healthy controls, even when indexed to height. However, no differences were evident when indexed by BSA, irrespective of sex, type of sport and age. Therefore, assessment of the aortic size in elite athletes should consider the proper normalization in order to avoid misdiagnosis of aortopathies.

PROSPERO REGISTRY ID

CRD42024561255.

Long-Term Evaluation of Lipid Profile Changes in Olympic Athletes

Dyslipidemia is a major contributor to the development of atherosclerotic cardiovascular disease. Despite high level of physical activity, athletes are not immune from dyslipidemia, but longitudinal data on the variation of lipids are currently lacking. We sought to assess lipid profile changes over time in Olympic athletes practicing different sports disciplines (power, skills, endurance, and mixed). We enrolled 957 consecutive athletes evaluated from London 2012 to Beijing 2022 Olympic Games. Dyslipidemia was defined as low-density lipoprotein (LDL) ≥115 mg/dl, high-density lipoprotein (HDL) <40 mg/dl for males, or HDL <50 mg/dl for females. Hypertriglyceridemia was defined as triglycerides >150 mg/dl. At the follow-up, a variation of ±40 mg/dl for LDL, ±6 mg/dl for HDL, and ±50 mg/dl for triglycerides was considered relevant. Athletes with follow-up <10 months or taking lower lipid agents were excluded. Follow-up was completed in 717 athletes (74.9%), with a mean duration of 55.6 months. Mean age was 27.2 ± 4.8 years old, 54.6% were male (n = 392). Overall, 19.8% (n = 142) athletes were dyslipidemic at both blood tests, being older, practicing nonendurance sports, and predominantly male. In 69.3% (n = 129) of those with elevated LDL at t0, altered values were confirmed at follow-up, while the same occurred in 36.5% (n = 15) with hypo-HDL and 5.3% (n = 1) in those with elevated triglycerides. Weight and fat mass percentage modifications did not affect lipid profile variation. LDL hypercholesterolemia tends to persist over time especially among male, older, and nonendurance athletes. LDL hypercholesterolemia detection in athletes should prompt early preventive intervention to reduce the risk of future development of atherosclerotic disease.

Association between FT3 Levels and Exercise-Induced Cardiac Remodeling in Elite Athletes

BACKGROUND

Previous studies demonstrated that variations of fT3, even within the euthyroid range, can influence cardiac function. Our aim was to investigate whether thyroid hormones, even within the euthyroid range, are associated with the magnitude of exercise-induced cardiac remodeling in Olympic athletes.

METHODS

We evaluated 1342 Olympic athletes (mean age 25.6 ± 5.1) practicing different sporting disciplines (power, skills, endurance, and mixed). Athletes underwent blood testing (thyroid stimulating hormone, fT3, and fT4), echocardiography, and exercise-stress testing. Athletes taking thyroid hormones, affected by thyroiditis, or presenting TSH out of ranges were excluded.

RESULTS

The level of thyroid hormones varied according to the type of sporting discipline practiced: endurance athletes presented the lowest TSH (p < 0.0001), fT3 (p = 0.007), and fT4 (p < 0.0001) in comparison to the remaining ones. Resting heart rate (HR) was positively correlated to fT3 in athletes of different disciplines (power: p = 0.0002, R2 = 0.04; skill: p = 0.0009, R2 = 0.05; endurance: p = 0.007, R2 = 0.03; and mixed: p = 0.04, R2 = 0.01). The same results were seen for peak HR in the exercise-stress test in athletes engaged in power, skill, and endurance (respectively, p < 0.0001, R2 = 0.04; p = 0.01, R2 = 0.04; and p = 0.005, R2 = 0.02). Moreover, a positive correlation was observed with cardiac dimensions, i.e., interventricular septum (power: p < 0.0001, R2 = 0.11; skill: p = 0.02, R2 = 0.03; endurance: p = 0.002, R2 = 0.03; mixed: p < 0.0001, R2 = 0.04). Furthermore, fT3 was directly correlated with the left ventricle (LV) end-diastolic volume in skills (p = 0.04, R2 = 0.03), endurance (p = 0.04, R2 = 0.01), and mixed (p = 0.04, R2 = 0.01).

CONCLUSIONS

Thyroid hormones, even within the euthyroid range, are associated with cardiac adaptive response to exercise and may contribute to exercise-induced cardiac remodeling.

Cardiac Adaptation in Power Athletes: Differential Impact of Judo and Weightlifting

Background: According to the ESC guidelines, sport disciplines are classified in relation to the predominant component (skill, power, mixed and endurance), including a wide range of disciplines with different isometric/isotonic exercises and exercise-induced heart remodeling. The aim of our study was to evaluate differences in morpho-functional cardiac adaptations in power athletes, comparing judokas with weightlifters. Methods: We enrolled 55 Olympic athletes (38 judokas, 17 weightlifters), aged 24.5 ± 3.8 years, 25 (45.4%) of whom were males, and they underwent a pre-participation evaluation, including a physical examination, ECG, transthoracic echocardiogram, and exercise stress test. Results: The judokas presented significant differences in cardiac adaptations, with larger left ventricle (LV) end-diastolic and end-systolic volumes indexed (LVEDVi, p = 0.002 and LVESVi, p = 0.004) and higher LVMass values indexed (p = 0.033), but similar LV wall thicknesses (p = 0.093) and LV ejection fractions (p = 0.981). Also, the left atrium (LA) dimension (p = 0.0002) and volume indexed (p < 0.0001) were higher in the judokas, as were the larger right ventricle (RV) areas. Finally, the judokas showed higher VO2max (p = 0.012), O2 pulse (p = 0.007), VE/O2 LT1 (p = 0.041) and VE/O2 LT2 (p = 0.036) values, with a lower resting heart rate (p = 0.031) and higher exercise capacity (p = 0.011). Conclusions: The judokas showed substantial differences in cardiac morpho-functional adaptations from the weightlifters, and, accordingly, judo should be more properly considered not a pure strength sport but more similar to mixed disciplines of the ESC classification.

The role of cardiac magnetic resonance in sports cardiology: results from a large cohort of athletes

BACKGROUND

Cardiac magnetic resonance (CMR) provides information on morpho-functional abnormalities and myocardial tissue characterisation. Appropriate indications for CMR in athletes are uncertain.

OBJECTIVE

To analyse the CMR performed at our Institute to evaluate variables associated with pathologic findings in a large cohort of athletes presenting with different clinical conditions.

METHODS

All the CMR performed at our Institute in athletes aged > 14 years were recruited. CMR indications were investigated. CMR was categorised as "positive" or "negative" based on the presence of morphological and/or functional abnormalities and/or the presence of late gadolinium enhancement (excluding the right ventricular insertion point), fat infiltration, or oedema. Variables associated with "positive" CMR were explored.

RESULTS

A total of 503 CMR were included in the analysis. "Negative" and "positive" CMR were 61% and 39%, respectively. Uncommon ventricular arrhythmias (VAs) were the most frequent indications for CMR, but the proportion of positive results was low (37%), and only polymorphic ventricular patterns were associated with positive CMR (p = 0.006). T-wave inversion at 12-lead ECG, particularly on lateral and inferolateral leads, was associated with positive CMR in 34% of athletes (p = 0.05). Echocardiography abnormalities resulted in a large proportion (58%) of positive CMR, mostly cardiomyopathies.

CONCLUSION

CMR is more efficient in identifying a pathologic cardiac substrate in athletes in case of VAs (i.e., polymorphic beats), abnormal ECG repolarisation (negative T-waves in inferolateral leads), and borderline echocardiographic findings (LV hypertrophy, mildly depressed LV function). On the other hand, CMR is associated with a large proportion of negative results. Therefore, a careful clinical selection is needed to indicate CMR in athletes appropriately.

The athlete's heart: insights from echocardiography

The manifestations of the athlete's heart can create diagnostic challenges during an echocardiographic assessment. The classifications of the morphological and functional changes induced by sport participation are often beyond 'normal limits' making it imperative to identify any overlap between pathology and normal physiology. The phenotype of the athlete's heart is not exclusive to one chamber or function. Therefore, in this narrative review, we consider the effects of sporting discipline and training volume on the holistic athlete's heart, as well as demographic factors including ethnicity, body size, sex, and age.