Blood Pressure and LV Remodeling Among American-Style Football Players

Concussion burden and later-life cardiovascular risk factors in former professional American-style football players

OBJECTIVE

Mid-life cardiovascular risk factors are associated with later cognitive decline. Whether repetitive head injury among professional athletes impacts cardiovascular risk is unknown. We investigated associations between concussion burden and postcareer hypertension, high cholesterol, and diabetes among former professional American-style football (ASF) players.

METHODS

In a cross-sectional study of 4080 professional ASF players conducted between January 2015 and March 2022, we used an mulitsymptom concussion symptom score (CSS) and the number of loss-of-consciousness (LOC) episodes as a single severe symptom to quantify football-related concussion exposure. Primary outcomes were hypertension, dyslipidemia, and diabetes, defined by current or recommended prescription medication use.

RESULTS

The prevalence of hypertension, high cholesterol, and diabetes among former players (52 ± 14 years of age) was 37%, 34%, and 9%. Concussion burden was significantly associated with hypertension (lowest vs. highest CSS quartile, odds ratio (OR) = 1.99; 95%CI: 1.33-2.98; p < 0.01) and high cholesterol (lowest vs. moderate CSS, OR = 1.46, 95%CI, 1.11-1.91; p < 0.01), but not diabetes. In fully adjusted models, the prevalence of multiple CVD was associated with CSS. These results were driven by younger former players (≤ 40 year of age) in which the odds of hypertension were over three times higher in those in the highest CSS quartile (OR = 3.29, 95%CI: 1.39-7.61; p = 0.01). Results were similar for LOC analyses.

INTERPRETATION

Prior concussion burden is associated with postcareer atherogenic cardiovascular risk profiles among former professional American football players.

Inter-season training effects on cardiovascular health in American-style football players

BACKGROUND

Recent studies on American-style football (ASF) athletes raised questions about the impact of training on the cardiovascular phenotype, particularly among linemen players who engage mostly in static exercise during competition and who exhibit concentric cardiac remodeling, often considered maladaptive. We aimed to examine the cardiovascular adaptation to the inter-season mixed-team training program among ASF players.

METHODS

A prospective, longitudinal, cohort study was conducted among competitive male ASF players from the University of Montreal before and after an inter-season training, which lasted 7 months. This program includes, for all players, combined dynamic and static exercises. Clinical and echocardiographic examinations were performed at both steps. Left atrial (LA) and ventricular (LV) morphological and functional changes were assessed using a multiparametric echocardiographic approach (2D and 3D-echo, Doppler, and speckle tracking). Two-way ANOVA was performed to analyze the impacts of time and field position (linemen versus non-linemen).

RESULTS

Fifty-nine players (20 linemen and 39 non-linemen) were included. At baseline, linemen had higher blood pressure (65% were prehypertensive and 10% were hypertensive), thicker LV walls, lower LV systolic and diastolic functions, lower LA-reservoir and conduit functions than non-linemen. After training, linemen significantly reduced weight (Δ-3.4%, P < 0.001) and systolic blood pressure (Δ-4.5%, P < 0.001), whereas non-linemen maintained their weight and significantly increased their systolic (Δ+4.2%, P = 0.037) and diastolic (Δ+16%, P < 0.001) blood pressure ). Mixed training was associated with significant increases in 2D-LA volume (P < 0.001), 3D-LV end-diastolic volume (P < 0.001), 3D-LV mass (P < 0.001), and an improvement in LV systolic function, independently of the field position. Non-linemen remodeled their LV in a more concentric fashion and showed reductions in LV diastolic and LA reservoir functions.

CONCLUSIONS

Our study underscored the influence of field position on cardiovascular adaptation among university-level ASF players, and emphasized the potential of inter-season training to modulate cardiovascular risk factors, particularly among linemen.

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.

Methodology for studying Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the International Olympic Committee (IOC) consensus on REDs

In the past decade, the study of relationships among nutrition, exercise and the effects on health and athletic performance, has substantially increased. The 2014 introduction of Relative Energy Deficiency in Sport (REDs) prompted sports scientists and clinicians to investigate these relationships in more populations and with more outcomes than had been previously pursued in mostly white, adolescent or young adult, female athletes. Much of the existing physiology and concepts, however, are either based on or extrapolated from limited studies, and the comparison of studies is hindered by the lack of standardised protocols. In this review, we have evaluated and outlined current best practice methodologies to study REDs in an attempt to guide future research.This includes an agreement on the definition of key terms, a summary of study designs with appropriate applications, descriptions of best practices for blood collection and assessment and a description of methods used to assess specific REDs sequelae, stratified as either Preferred, Used and Recommended or Potential Researchers can use the compiled information herein when planning studies to more consistently select the proper tools to investigate their domain of interest. Thus, the goal of this review is to standardise REDs research methods to strengthen future studies and improve REDs prevention, diagnosis and care.

Physiological and Biomechanical Monitoring in American Football Players: A Scoping Review

American football is the sport with the highest rates of concussion injuries. Biomedical engineering applications may support athletes in monitoring their injuries, evaluating the effectiveness of their equipment, and leading industrial research in this sport. This literature review aims to report on the applications of biomedical engineering research in American football, highlighting the main trends and gaps. The review followed the PRISMA guidelines and gathered a total of 1629 records from PubMed (n = 368), Web of Science (n = 665), and Scopus (n = 596). The records were analyzed, tabulated, and clustered in topics. In total, 112 studies were selected and divided by topic in the biomechanics of concussion (n = 55), biomechanics of footwear (n = 6), biomechanics of sport-related movements (n = 6), the aerodynamics of football and catch (n = 3), injury prediction (n = 8), heat monitoring of physiological parameters (n = 8), and monitoring of the training load (n = 25). The safety of players has fueled most of the research that has led to innovations in helmet and footwear design, as well as improvements in the understanding and prevention of injuries and heat monitoring. The other important motivator for research is the improvement of performance, which has led to the monitoring of training loads and catches, and studies on the aerodynamics of football. The main gaps found in the literature were regarding the monitoring of internal loads and the innovation of shoulder pads.

Cardiac structure and function of elite volleyball players across different playing positions

BACKGROUND

Volleyball is a popular Olympic sport but has been little studied. Volleyball players have very distinct roles based on their playing positions. The present study aimed to investigate and compare cardiac functions and structure in elite volleyball players across different playing positions.

METHODS

Left ventricular structure and function were measured using echocardiography in 60 male professional volleyball players (30.6±3.6 years) across five playing positions including libero, opposite players, outside hitters, middle blockers, and setters.

RESULTS

Significant differences in most echocardiographic variables were observed among different playing positions, including left ventricular (LV) internal dimension, posterior wall thickness, intact ventricular septum, stroke volume, cardiac output, end-diastolic volume, ejection fraction, and fractional shortening (all P<0.01). End-systolic volume was not different among positions (P=0.167). The opposite players demonstrated greater LV dimension and thickness as well as systolic function than players in other positions (P<0.05). Stroke volume in the setters was significantly lower than those of the opposite players and outside hitters (P<0.05). Regression analysis showed that the playing position independently predicted most of the echocardiographic variables (P<0.05).

CONCLUSIONS

LV adaptations in volleyball players vary widely according to their playing positions. The opposite players had the most pronounced LV adaptations compared with player in other positions.

Healthspan and chronic disease burden among young adult and middle-aged male former American-style professional football players

OBJECTIVE

To examine the relationships between age, healthspan and chronic illness among former professional American-style football (ASF) players.

METHODS

We compared age-specific race-standardised and body mass index-standardised prevalence ratios of arthritis, dementia/Alzheimer's disease, hypertension and diabetes among early adult and middle-aged (range 25-59 years) male former professional ASF players (n=2864) with a comparator cohort from the National Health and Nutrition Examination Survey and National Health Interview Survey, two representative samples of the US general population. Age was stratified into 25-29, 30-39, 40-49 and 50-59 years.

RESULTS

Arthritis and dementia/Alzheimer's disease were more prevalent among ASF players across all study age ranges (all p<0.001). In contrast, hypertension and diabetes were more prevalent among ASF players in the youngest age stratum only (p<0.001 and p<0.01, respectively). ASF players were less likely to demonstrate intact healthspan (ie, absence of chronic disease) than the general population across all age ranges.

CONCLUSION

These data suggest the emergence of a maladaptive early ageing phenotype among former professional ASF players characterised by premature burden of chronic disease and reduced healthspan. Additional study is needed to investigate these findings and their impact on morbidity and mortality in former ASF players and other athlete groups.

Interassociation Consensus Statement on Sports Nutrition Models for the Provision of Nutrition Services From Registered Dietitian Nutritionists in Collegiate Athletics

Collegiate athletic programs are increasingly adding nutrition services to interdisciplinary sports medicine and sports performance departments in response to scientific evidence highlighting nutrition's integral role in supporting athletic performance and overall health. Registered Dietitian Nutritionists (RDNs) specializing in sports dietetics (ie, sports RDNs) and credentialed Board-certified Specialists in Sports Dietetics (CSSDs) are the preferred nutrition service providers for these programs. Their extensive training and proficiency in medical nutrition therapy, education and behavioral counseling, food-service management, exercise physiology, physical performance, and administration, as defined by the "Standards of Practice and "Standards of Professional Performance" for Registered Dietitian Nutritionists in Sports Nutrition and Human Performance," make these practitioners uniquely qualified to deliver the breadth of care required in the collegiate setting. Therefore, this document, guided by a multidisciplinary panel, introduces 4 sports nutrition models through which any collegiate athletic program can deliver sports RDN-directed nutrition services. In each model, the most effective staffing and scope of service are indicated and reviewed. In addition, recommended organizational structures for sports RDNs are provided that best support the delivery of the model's nutrition services in a variety of collegiate athletic programs and organizational settings. Lastly, future research initiatives and nutrition interventions to help improve the standard of care through these sport nutrition models are explored.

Differentiating Physiology from Pathology: The Gray Zones of the Athlete's Heart

Routine vigorous exercise can lead to electrical, structural, and functional adaptations that can enhance exercise performance. There are several factors that determine the type and magnitude of exercise-induced cardiac remodeling (EICR) in trained athletes. In some athletes with pronounced cardiac remodeling, there can be an overlap in morphologic features with mild forms of cardiomyopathy creating gray zone scenarios whereby distinguishing health from disease can be difficult. An integrated clinical approach that factors athlete-specific characteristics (sex, size, sport, ethnicity, and training history) and findings from multimodality imaging are essential to help make this distinction.

Left ventricular function and mechanics in backs and forwards elite rugby union players

PURPOSE

The aim of the present study was to assess left ventricular (LV) morphological and regional functional adaptations in backs and forwards elite rugby union (RU) players.

METHODS

Thirty-nine elite male RU players and twenty sedentary controls have been examined using resting echocardiography. RU players were divided into two groups, forwards (n = 22) and backs (n = 17). Evaluations included tissue Doppler and 2D speckle tracking analysis to assess LV strains and twisting mechanics.

RESULTS

The elite RU players exhibited a LV remodeling characterized by an increase in LV mass indexed to body surface area (82.2 ± 13.2 vs. 99.9 ± 16.1 and 119.7 ± 13.4 g.m^-2, in controls, backs and forwards; P < 0.001). Compared to backs, forwards exhibited lower global longitudinal strain (19.9 ± 2.5 vs. 18.0 ± 1.6%; P < 0.05), lower early diastolic velocity (16.5 ± 1.8 vs. 15.0 ± 2.3 cm.s^-1; P < 0.05) and lower diastolic longitudinal strain rate (1.80 ± 0.34 vs. 1.54 ± 0.26 s^-1; P < 0.01), especially at the apex. LV twist and untwisting velocities were similar in RU players compared to controls, but with lower apical (-46.2 ± 22.1 vs. -28.2 ± 21.7 deg.s^-1; P < 0.01) and higher basal rotational velocities (33.9 ± 20.9 vs. 48.4 ± 20.7 deg.s^-1; P < 0.05).

CONCLUSION

RU players exhibited an increase in LV mass which was more pronounced in forwards. In forwards, LV global longitudinal strain was depressed, LV filling pressures were decreased and LV relaxation depressed at the apex.

Hypertension and Ventricular-Arterial Uncoupling in Collegiate American Football Athletes

Background

Ventricular–arterial (VA) coupling is defined as the ratio between arterial elastance (EA) and left ventricular elastance (ELV). VA uncoupling, as occurs in hypertensive heart disease, is associated with adverse outcomes. This study sought to determine the relationship between American football (AF)–associated hypertension and VA uncoupling.

Methods and Results

This was a multicenter, longitudinal, and repeated measures observational study of collegiate AF athletes across 3 years of AF participation. Of 200 freshman athletes initially enrolled, 142 (67 Black [47%]/75 White [53%], 58 linemen [41%]/84 nonlinemen [59%]) were prospectively studied with echocardiography and applanation tonometry. Primary echocardiographic VA coupling outcome measures were EA/ELV and ΔEA/ELV, with increased EA/ELV indicating VA uncoupling. Adjusting for race and player position, AF athletes demonstrated increased EA/ELV (mean [95% CI]Δ, 0.10 [0.04–0.15]; P=0.001) and systolic blood pressure (SBP) (mean [95% CI]Δ, 11.4 [8.3–14.5] mm Hg, P<0.001) over their collegiate AF careers. In combination with longitudinal VA uncoupling, hypertension prevalence (including both stage 1 and 2) increased from 54% at baseline to 77% (44% stage 2) at the end of the study period (P<0.001). In multivariable mixed‐effects linear regression analysis, higher SBP (β=0.021, P=0.02), lower E′ (β=−0.010, P=0.03), and worse global longitudinal strain (β=0.036, P<0.001) were associated with higher EA/ELV. Increased SBP (ΔSBP, β=0.029, P=0.02) and worsened global longitudinal strain (Δglobal longitudinal strain, β=0.045, P<0.001) also predicted increased ΔEA/ELV.

Conclusions

VA uncoupling is associated with pathologically increased SBP and subclinical impairments in left ventricular systolic function in collegiate AF athletes, indicating a key mechanism underlying maladaptive cardiovascular phenotypes observed in this population. Future studies analyzing whether targeted clinical interventions improve VA coupling and health outcomes are warranted.

Left ventricular hypertrophy in athletes, a case-control analysis of interindividual variability

BACKGROUND

A variability in cardiac remodeling is observed in athletes regardless of age, sex, body size and sport participated. We sought to investigate whether other individual characteristics could affect the extent of Left ventricular hypertrophy (LVH).

METHODS

From 2120 consecutive Olympic athletes, those with LVH (defined as LV Wall thickness ≥ 13 mm) were matched 1:1 by age, gender, body surface area and type of sport with non-LVH Athletes. Clinical and Echocardiographic variables were compared.

RESULTS

48 athletes with LVH (2.3%) and 48 matched non-LVH athletes were identified. LVH Athletes had higher body weight (90 ± 18 vs 81 ± 11Kg; p = 0.006) body mass index (26 ± 2 vs 24 ± 2 Kg/m2; p < 0.001) and body fat percentage (15 ± 7% vs 12 ± 4%; p = 0.016) compared to non-LVH Athletes. They also had higher systolic (123 ± 1 vs 116 ± 11 mmHg; p = 0.002) and diastolic blood pressure (76 ± 8 vs 71 ± 9 mmHg; p = 0.002). On exercise testing, LVH Athletes reached a lower index workload (3.7 ± 0.9 vs 4.1 ± 0.8 W/Kg; p = 0.013) and a higher peak diastolic blood pressure (79 ± 10 vs 74 ± 11 mmHg; p = 0.012) than those without LVH. Binary logistic regression analysis showed that diastolic blood pressure (OR 1.052; 95% CI from 1.011 to 1.130; p = 0.020) and BMI (OR 1.220; 95% CI from 1.016 to 1.465; p = 0.033) had the strongest association with LVH as categorical variable.

CONCLUSIONS

Our study showed that increased blood pressure at rest and during exercise, together with larger body weight, body mass and fat percentage are associated with a higher degree of LVH, which is not associated with a greater physical performance and therefore possibly disproportionate to the sport activity.

Association between race and maladaptive concentric left ventricular hypertrophy in American-style football athletes

OBJECTIVES

American-style football (ASF) athletes are at risk for the development of concentric left ventricular hypertrophy (C-LVH), an established cardiovascular risk factor in the general population. We sought to address whether black race is associated with acquired C-LVH in collegiate ASF athletes.

METHODS

Collegiate ASF athletes from two National Collegiate Athletic Association Division-I programmes were recruited as freshmen between 2014 and 2019 and analysed over 3 years. Demographics (neighbourhood family income) and repeated clinical characteristics and echocardiography were recorded longitudinally at multiple timepoints. A mixed-modelling approach was performed to evaluate acquired C-LVH in black versus white athletes controlling for playing position (linemen (LM) and non-linemen (NLM)), family income, body weight and blood pressure.

RESULTS

At baseline, black athletes (N=124) were more often NLM (72% vs 54%, p=0.005) and had lower median neighbourhood family income ($54 119 vs $63 146, p=0.006) compared with white athletes (N=125). While both black and white LM demonstrated similar increases in C-LVH over time, among NLM acquired C-LVH was more common in black versus white athletes (postseason year-1: N=14/89 (16%) vs N=2/68 (3%); postseason year-2: N=9/50 (18%) vs N=2/32 (6%); postseason year-3: N=8/33 (24%) vs N=1/13 (8%), p=0.005 change over time). In stratified models, black race was associated with acquired C-LVH in NLM (OR: 3.70, 95% CI 1.12 to 12.21, p=0.03) and LM was associated with acquired C-LVH in white athletes (OR: 3.40, 95% CI 1.03 to 11.27, p=0.048).

CONCLUSIONS

Independent of family income and changes in weight and blood pressure, black race was associated with acquired C-LVH among collegiate ASF NLM and LM was associated with acquired C-LVH in white athletes.

Season-Long Heart-Rate Variability Tracking Reveals Autonomic Imbalance in American College Football Players

PURPOSE

To track cardiac-autonomic functioning, indexed by heart-rate variability, in American college football players throughout a competitive period.

METHODS

Resting heart rate (RHR) and the natural logarithm root mean square of successive differences (LnRMSSD) were obtained throughout preseason and ∼3 times weekly leading up to the national championship among 8 linemen and 12 nonlinemen. Seated 1-minute recordings were performed via mobile device and standardized for time of day and proximity to training.

RESULTS

Relative to preseason, linemen exhibited suppressed LnRMSSD during camp-style preparation for the playoffs (P = .041, effect size [ES] = -1.01), the week of the national semifinal (P < .001, ES = -1.27), and the week of the national championship (P = .005, ES = -1.16). As a combined group, increases in RHR (P < .001) were observed at the same time points (nonlinemen ES = 0.48-0.59, linemen ES = 1.03-1.10). For all linemen, RHR trended upward (positive slopes, R2 = .02-.77) while LnRMSSD trended downward (negative slopes, R2 = .02-.62) throughout the season. Preseason to postseason changes in RHR (r = .50, P = .025) and LnRMSSD (r = -.68, P < .001) were associated with body mass.

CONCLUSIONS

Heart-rate variability tracking revealed progressive autonomic imbalance in the lineman position group, with individual players showing suppressed values by midseason. Attenuated parasympathetic activation is a hallmark of impaired recovery and may contribute to cardiovascular maladaptations reported to occur in linemen following a competitive season. Thus, a descending pattern may serve as an easily identifiable red flag requiring attention from performance and medical staff.

Sport disciplines and cardiac remodeling in elite university athletes competing in 2017 Taipei Summer Universiade

Cardiac remodeling is common in the athletes. Little data is available regarding the cardiac remodeling on the recently proposed 4 sport disciplines among the elite university athletes.A total of 7639 athletes participated in the 2017 Taipei Summer Universiade. Cardiac evaluation via history, ECG, and echocardiography were performed in 826 athletes who signed up for Check Up Your Heart. Athletes were grouped into one of 4 sport disciplines Skill, Power, Mixed, and Endurance.After excluding 66 participants with missing demographic data, 13 missing echocardiographic data, and 24 inadequate echocardiographic images, a total number of 723 university athletes (mean age 23 ± 3 years, 419 males) from 99 countries engaging in 25 different sporting events were analyzed. Electrocardiograms showed that Endurance group had a slower heart rate and higher percentage of left ventricular (LV) hypertrophy (39%). Echocardiograms showed there were significant differences in LV mass index (P < .001), LV geometry (P < .001), left atrial (LA) dilatation (P = .026), right ventricular (RV) dilatation (P < .001), right atrial (RA) dilatation (P < .0001), and tricuspid annular plane systolic excurse (P = .006). LV ejection fraction, LV strain, RV strain, and LV diastolic function showed no difference in 4 sport disciplines.Eccentric LV hypertrophy was the most common type of cardiac remodeling in the university athletes participated in 2017 Taipei Summer Universiade. Adaptive changes in chamber size were more commonly seen in Endurance sport. RA dilatation was the most sensitive to hemodynamic demand, followed by RV dilatation, LA dilatation, and LV dilatation.

Weight Gain, Hypertension, and the Emergence of a Maladaptive Cardiovascular Phenotype Among US Football Players

Importance

Former US football athletes are at increased risk of cardiovascular (CV) morbidity and mortality compared with the general population and other professional athletes. However, responsible maladaptive CV phenotypes have not been fully characterized.

Objective

To address the emergence and progression of multiple independent factors associated with CV risk across serial years of collegiate US football participation.

Design, Setting, and Participants

Collegiate US football athletes from 2 National Collegiate Athletic Association Division I programs were recruited as freshmen between June 2014 and June 2017 and analyzed at multiple points throughout 3 complete years of collegiate US football participation (until January 2019). Excluded athletes were those who did not complete any season of US football training because of injury, illness, or leaving the team. Factors associated with CV risk assessed clinically, by transthoracic echocardiography, and by vascular applanation tonometry were recorded.

Exposures

The exposure of interest was seasonal US football exposure, including training, competition, and the training environment.

Main Outcomes and Measures

Primary outcome measures were left ventricular mass index and geometry (cardiac structure), early diastolic myocardial relaxation velocity (E'; diastolic function), and pulse-wave velocity (arterial stiffness).

Results

Of 186 individuals recruited as freshmen, 126 athletes were included in analyzed data. Collegiate US football athletes (62 white individuals [49%]; 63 black individuals [50%]; 77 nonlinemen [61%]; 49 linemen [39%]; 126 male individuals [100%]) weighed a mean (SD) of 101.1 (21.0) kg, with a mean systolic blood pressure of 129.1 (11.6) mm Hg at baseline of the freshman season. Adjusting for race, height, and player position, there were significant increases in weight (mean [SE] Δ, 4.74 [0.6] kg; P < .001), systolic blood pressure (mean [SE] Δ, 11.6 [1.6] mm Hg; P < .001), and pulse-wave velocity (mean [SE] Δ, 0.24 [0.09] m/s; P = .007), and significant declines in E' (mean [SE] Δ, -1.7 [0.3] cm/s; P < .001) across 3 years of US football participation. Weight gain was associated with both arterial stiffening (increased pulse-wave velocity, β = 0.01 [SE, 0.004]; P = .003) and the development of concentric left ventricular hypertrophy (odds ratio, 1.09 [95% CI, 1.05-1.14]; P < .001); increased systolic blood pressure was also associated with arterial stiffening (β = 0.01 [SE, 0.003]; P = .007) and the development of concentric left ventricular hypertrophy (odds ratio, 1.04 [95% CI, 1.01-1.07]; P = .02).

Conclusions and Relevance

Collegiate US football athletes who gain weight and develop increased systolic blood pressure levels are at risk for the development of a pathologic CV phenotype characterized by concentric left ventricular hypertrophy, arterial stiffening, and reduced left ventricular diastolic function. Future work aimed at optimizing CV health in this population, who are young but uniquely at risk, is warranted.

Nonsteroidal Anti-inflammatory Drugs and Cardiovascular Risk in American Football

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with adverse cardiovascular outcomes and reportedly overused in American-style football (ASF). However, assessment of ASF NSAID use in the context of cardiovascular risk has not been performed. We sought to characterize NSAID use patterns and the association with cardiovascular risk in a diverse cohort of high school and collegiate ASF athletes.

METHODS

A total of 226 ASF athletes, 60 endurance athletes, and 63 nonathletic controls were studied pre- and postseason with echocardiography, vascular applanation tonometry, and clinical data assessment. Qualitative NSAID use throughout the season was recorded at postseason.

RESULTS

ASF athletes gained weight (Δ0.86 ± 3.9 kg, P < 0.001), increased systolic blood pressure (SBP, Δ3.1 ± 12 mm Hg, P < 0.001) and pulse wave velocity (Δ0.2 ± 0.6 m·s, P < 0.001), and decreased E' (Δ-1.4 ± 2.8 cm·s, P < 0.001) across one athletic season. Seventy-seven percent (n = 173) of ASF athletes reported that sport-specific NSAID use began in middle school. ASF NSAID use was more frequent with "weekly" (n = 42.19%) and "daily" (n = 32.14%) use compared with endurance athletes (P < 0.001) and controls (P = 0.02). ASF NSAID use increased in parallel with postseason SBP and weights. "Daily" ASF NSAID users demonstrated the highest postseason SBP (137 ± 13 vs 128 ± 13 mm Hg, P = 0.002) and weight (109.0 ± 18.6 vs 95.8 ± 20.5 kg, P = 0.002) compared with "never/rare" users. Adjusting for player position, SBP, pulse wave velocity, and E', increased weight (odds ratio = 1.04, 95% confidence interval = 1.0-1.08, P = 0.037) was associated with more frequent NSAID use.

CONCLUSIONS

Habitual NSAID use commonly begins during adolescence, before full physical maturation, and is associated with cardiovascular risk, particularly increased weight, in ASF athletes. NSAID use frequency should be considered when risk stratifying high-risk ASF athletes.

Recommendations for exercise and screening for safe athletic participation in hypertensive youth

Physical activity is an important component of ideal cardiovascular health. Current guidelines recommend that youth with hypertension participate in competitive sports once hypertensive target organ effects and risks have been assessed and that children with hypertension receive treatment to lower BP below stage 2 thresholds (e.g., < 140/90 mmHg or < 95th percentile + 12 mmHg) before participating in competitive sports. Despite these recommendations, pediatricians and pediatric subspecialists continue to struggle with how best to counsel their patients regarding appropriate forms of physical activity, the impact of exercise on blood pressure, and how best to screen for cardiovascular conditions that place youth at risk for sudden cardiac death. This review provides a summary of our current knowledge regarding the safety and utility of exercise in the management of high blood pressure in youth. We review determinants of blood pressure during exercise, the impact of blood pressure on cardiovascular health and structure, mechanisms for assessing cardiometabolic fitness (e.g., exercise stress test), contraindications to athletic participation, and how best to plan for athletic participation among hypertensive youth. Greater knowledge in these areas may offer clarity to providers faced with the challenge of prescribing exercise recommendations for hypertensive youth.

Cardiovascular Care of Masters Athletes

Masters athletes (MA), men and woman older than 35 years who participate in competitive athletics, is a rapidly growing population that is increasingly encountered in clinical cardiovascular practice. Although the high levels of exercise typically performed by MA confer numerous health advantages, no amount of exercise confers complete immunity from cardiovascular disease. The review was written to cover the clinical management of MA with cardiovascular disease. Focus is dedicated to four of the most common clinical scenarios including atrial fibrillation, myocardial fibrosis, coronary artery disease, and dilation of the ascending aorta.

Left Ventricular Longitudinal Strain as a Marker for Point of No Return in Hypertensive Heart Failure Treatment

BACKGROUND

There are currently no therapies that can improve prognosis in cases of heart failure (HF) with preserved ejection fraction (EF). We hypothesized that there is a point of no return after which no response to treatment is noted and that for the prevention of hypertensive HF this point may be determined by left ventricle (LV) strain, in the prevention of hypertensive HF. Here an angiotensin-converting enzyme inhibitor (ACE-I) was initiated based on myocardial strain imaging and its effects were determined in an animal model.

METHODS

Thirty-two male Dahl salt-sensitive rats, age 6 weeks, were divided into six experimental groups and compared with low-salt (n = 8) and high-salt control groups (n = 8). In the early treatment group, ACE-I was administered from the age of 6 weeks (n = 4); in the longitudinal strain (LS) group, at 10-12 weeks when LS impairment was >-21% (n = 4); in the circumferential strain (CS) group, at 16-18 weeks when CS impairment was >-18% (n = 4); and in the EF group, at 20 weeks when EF was <55% (n = 4). Subsequently, all rats were sacrificed at 23 weeks age, the LV and lung weight were measured, and pathologic analyses were performed.

RESULTS

At 23 weeks of age, the lung and LV weights increased in the high-salt control, EF, and CS groups, whereas the lung and LV weights in the LS and early groups were similar to those in the low-salt control group. The percentage of area of subendocardial fibrosis was >6% in the high-salt control, EF, and CS groups and <3% in the LS, early, and low-salt groups. Serial echocardiography demonstrated LS improvement in the LS group; however, the CS and EF groups showed no differences.

CONCLUSIONS

Heart failure-related lung congestion was prevented when ACE-I was administered soon after LS impairment, accompanied by suppression of cardiac hypertrophy and fibrosis, thereby suggesting that the point of no return of myocardial remodeling due to hypertension was present after LS but before CS impairment.

The Football Players' Health Study at Harvard University: Design and objectives

The Football Players Health Study at Harvard University (FPHS) is a unique transdisciplinary, strategic initiative addressing the challenges of former players’ health after having participated in American style football (ASF). The whole player focused FPHS is designed to deepen understanding of the benefits and risks of participation in ASF, identify risks that are potentially reversible or preventable, and develop interventions or approaches to improve the health and wellbeing of former players. We are recruiting and following a cohort of former professional ASF players who played since 1960 (current n = 3785). At baseline, participants complete a self‐administered standardized questionnaire, including initial reporting of exposure history and physician‐diagnosed health conditions. Additional arms of the initiative are addressing targeted studies, including promising primary, secondary, and tertiary interventions; extensive in‐person clinical phenotyping, and legal and ethical concerns of the play. This paper describes the components of the FPHS studies undertaken and completed thus far, as well as those studies currently underway or planned for the near future. We present our initiatives herein as a potential paradigm of one way to proceed (acknowledging that it is not the only way). We share what we have learned so that it may be useful to others, particularly in regard to trying to make professional sports meet the needs of multiple stakeholders ranging from players to owners, to fans, and possibly even to parents making decisions for their children.

Echocardiographic measurements of left ventricular end-diastolic diameter and interventricular septal diameter in collegiate football athletes at preparticipation evaluation referenced to body surface area

Background

Are borderline echocardiogram structural measurements due to physiological adaptation or pathology in college football players? The normal reference data are very limited in this population. We report left ventricular end-diastolic diameter (LVEDD) and interventricular septal diameter (IVSD) echocardiogram findings in college football athletes.

Methods and results

A retrospective cohort review of preparticipation examination transthoracic echocardiogram measurements of LVEDD and IVSD from 375 American collegiate football athletes cleared for participation from the University of Florida in 2012–2017 and University of Georgia in 2010–2015 was performed.

LVEDD and IVSD were analysed by field position (lineman, n=137; non-lineman, n=238), race (black, n=216; white, n=158) and body surface area (BSA) for associations. Values were compared with non-athlete norms, and collegiate football athlete-specific reference norm tables were created.

Twenty-one (5.6%) athletes had LVEDD and 116 (31%) had IVSD measurements above the reference normal non-athlete values. Univariate analyses indicated that the lineman position and increasing BSA were associated with larger values for LVEDD and IVSD. Black race was associated with larger IVSD values, and white race was associated with larger LVEDD values. Player position correlated strongly with BSA (r>0.7); we created normal reference tables for LVEDD and IVSD, stratified by BSA group classification (low, average and high BSA). Proposed clinical cut-offs for normal and abnormal values are reported for raw echocardiograph metrics and BSA-indexed scores.

Conclusions

A significant number of collegiate football athletes had LVEDD and IVSD values above non-athlete norms. BSA-specific normal values help clinicians interpret results for football athletes.

Temporal Changes in Cardiovascular Remodeling Associated with Football Participation

PURPOSE

American-style football (ASF) participation rates in the United States are highest among high school (HS) athletes. This study sought to compare the cardiovascular response to HS versus collegiate ASF participation.

METHODS

The ASF participants (HS, n = 61; collegiate, n = 87) were studied at preseason and postseason time points with echocardiography and applanation tonometry. Primary outcome variables included: left ventricular (LV) mass index, LV diastolic function (early relaxation velocity [E']), and arterial stiffness (pulse wave velocity [PWV]).

RESULTS

High school (17.1 ± 0.4 yr) and collegiate ASF participants (18 ± 0.4 yr) experienced similar LV hypertrophy (ΔLV mass HS = 10.5 ± 10 vs collegiate = 11.2 ± 13.6 g·m, P = 0.97). Among HS participants, increases in LV mass were associated with stable diastolic tissue velocities (ΔE' = -0.3 ± 2.9 cm·s, P = 0.40) and vascular function (ΔPWV = -0.1 ± 0.6 m·s, P = 0.13). In contrast, collegiate participants demonstrated a higher burden of concentric LV hypertrophy (21/87, 24% vs 7/61, 11%, P = 0.026) with concomitant reductions in diastolic tissue velocities (ΔE': -2.0 ± 2.7 cm·s, P < 0.001) and increased arterial stiffness (ΔPWV: Δ0.2 ± 0.6 m·s, P = 0.003), changes that were influenced by linemen who had the highest post-season weight (124 ± 10 kg) and systolic blood pressure ([SBP], 138.8 ± 11 mm Hg). In multivariable analyses adjusting for age and ethnicity, body mass was an independent predictor of post-season PWV (β estimate = 0.01, P = 0.04) and E' (β estimate = -0.04, P = 0.05), whereas SBP was an independent predictor of postseason LV mass index (β estimate = 0.18, P = 0.01) and PWV (β estimate = 0.01, P = 0.007).

CONCLUSIONS

The transition from HS to college represents an important physiologic temporal data point after which differential ASF cardiovascular phenotypes manifest. Future work aimed to clarify underlying mechanisms, and the long-term clinical implications of these findings is warranted.

Weight Gain and Health Affliction Among Former National Football League Players

BACKGROUND

Professional American-style football players are among the largest athletes across contemporary sporting disciplines. Weight gain during football participation is common, but the health implications of this early-life weight gain remain incompletely understood. We sought to define weight trajectories of former professional American-style football athletes and to establish their relationship with 5 common health afflictions (cardiovascular disease, cardiometabolic disease, neurocognitive impairment, sleep apnea, and chronic pain).

METHODS

A health survey was distributed to former National Football League (NFL) players. Former players reported body weight at 4 time points (high school, college, professional, and time of survey response) as well as maximal retirement weight. Logistic regression was used to assess associations between weight gain during football participation and health affliction.

RESULTS

In this cohort of former NFL players (n = 3,506, age 53 ± 14 years), mean weight increase from high school to time of survey response was 40 ± 36 pounds, with the majority of weight gain occurring during periods of football participation (high-school-to-college and college-to-professional). The prevalence of health afflictions ranged from 9% (cardiovascular disease) to 28% (chronic pain). Weight gain during football participation was independently associated with risk of multiple later-life health afflictions in models adjusted for football exposure, lifestyle variables, and post-career weight gain.

CONCLUSIONS

Early-life weight gain among American-style football athletes is common and is associated with risk of adverse health profiles during later-life. These findings establish football-associated weight gain as a key predictor of post-career health and raise important questions about the central role of targeted weight gain in this population.

Characterization of the dynamic changes in left ventricular morphology and function induced by exercise training and detraining

BACKGROUND

Although exercise-induced cardiac hypertrophy has been intensively investigated, its development and regression dynamics have not been comprehensively described. In the current study, we aimed to characterize the effects of regular exercise training and detraining on left ventricular (LV) morphology and function.

METHODS

Rats were divided into exercised (n = 12) and control (n = 12) groups. Exercised rats swam 200 min/day for 12 weeks. After completion of the training protocol, rats remained sedentary for 8 weeks (detraining period). Echocardiographic follow-up was performed regularly to obtain LV long- and short-axis recordings for speckle-tracking echocardiography analysis. Global longitudinal and circumferential strain and systolic strain rate were measured. LV pressure-volume analysis was performed using additional groups of rats to obtain haemodynamic data.

RESULTS

Echocardiographic examinations showed the development of LV hypertrophy in the exercised group. These differences disappeared during the detraining period. Strain and strain rate values were all increased after the training period, whereas supernormal values rapidly reversed to the control level after training cessation. Load-independent haemodynamic indices, e.g., preload recruitable stroke work, confirmed the exercise-induced systolic improvement and complete regression after detraining.

CONCLUSIONS AND TRANSLATIONAL ASPECT

Our results provide the first comprehensive data to describe the development and regression dynamics of morphological and functional aspects of physiological hypertrophy in detail. Speckle-tracking echocardiography has been proven to be feasible to follow-up changes induced by exercise training and detraining and might provide an early possibility to differentiate between physiological and pathological conditions.

Predictive role of endothelin in left ventricular remodeling of chronic kidney disease

BACKGROUND

In chronic kidney disease (CKD), endothelin-1 (ET-1) always increases and there are changes in cardiac ultrasonography. In the present study, we aimed at investigating the role of serum ET-1 in predicting cardiac complications in patients with CKD.

METHODS

The level of serum ET-1 was measured by enzyme-linked immunosorbent assay (ELISA) and cardiac ultrasonography was performed in enrolled patients. Indexes of heart failure, such as left ventricular mass index, interventricular septum thickness and left ventricular end diastolic diameter, were measured in patients with CKD.

RESULTS

In the present study, we found that the level of serum ET-1 was significantly correlated with left ventricular mass index, interventricular septum thickness and left ventricular end diastolic diameter (p < .001) in non-dialysis patients with CKD.

CONCLUSIONS

The results of the present study indicated that the level of serum ET-1 is closely related to the cardiac complications of CKD and is a useful predictor of cardiac complication.

Sleep-Disordered Breathing and Cardiovascular Correlates in College Football Players

This study sought to determine the cardiovascular physiologic correlates of sleep-disordered breathing (SDB) in American-style football (ASF) participants using echocardiography, vascular applanation tonometry, and peripheral arterial tonometry. Forty collegiate ASF participants were analyzed at pre- and postseason time points with echocardiography and vascular applanation tonometry. WatchPAT (inclusive of peripheral arterial tonometry) used to assess for SDB was then performed at the postseason time point. Twenty-two of 40 (55%) ASF participants demonstrated SDB with an apnea-hypopnea index (pAHI) ≥5. ASF participants with SDB were larger (109 ± 20 vs 92 ± 14 kg, p = 0.004) and more likely linemen position players (83% vs 50%, p = 0.03). Compared with those without SDB, ASF participants with SDB demonstrated relative impairments in left ventricular diastolic and vascular function as reflected by lower lateral e' (14 ± 3 vs 17 ± 3 cm/s, p = 0.007) and septal e' (11 ± 2 vs 13 ± 2 cm/s, p = 0.009) tissue velocities and higher pulse wave velocity (5.4 ± 0.9 vs 4.8 ± 0.5 m/s, p = 0.02). In the total cohort, there were significant positive correlations between pAHI and pulse wave velocity (r = 0.42, p = 0.008) and inverse correlations between pAHI and the averaged e' tissue velocities (r = -0.42, p = 0.01). In conclusion, SDB is highly prevalent in youthful collegiate ASF participants and associated with relative impairments in cardiac and vascular function. Targeted efforts to identify youthful populations with SDB, including ASF participants, and implement SDB treatment algorithms, represent important future clinical directives.

Exercise and Competitive Sport: Physiology, Adaptations, and Uncertain Long-Term Risks

OPINION STATEMENT

The benefits of regular and moderate exercise training on cardiovascular outcomes have been well established. In addition, strenuous exercise training leads to corollary cardiac structural and functional adaptations that are sport-specific and facilitate athletic performance. In this review, the normal physiologic and hemodynamic changes that occur during exercise and the subsequent differential exercise-induced cardiac remodeling patterns that develop will be discussed. Paradoxically, recent data have raised concern about the long-term impact of higher doses of physical activity and exercise on mortality and cardiovascular health outcomes. We will discuss important aspects of these controversial data and review the supporting evidence as well as the limitations of prior research. Specifically, we will address the association between high levels of exercise and relative reductions in overall mortality, increased risk of atrial fibrillation, arrhythmogenic cardiac remodeling, and accelerated coronary artery calcifications. For the practitioner, this review aims to detail these contemporary sports cardiology controversies and highlights the critical need to incorporate shared decision making with the athlete in dealing with the uncertainties that exist. Finally, we will discuss key "athlete-specific" variables that should be considered in the design of future important research in this arena.