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Flanagan H, Cooper R, George KP, Augustine DX, Malhotra A, Paton MF, Robinson S, Oxborough D. The athlete's heart: insights from echocardiography. Echo Res Pract 2023; 10:15. [PMID: 37848973 PMCID: PMC10583359 DOI: 10.1186/s44156-023-00027-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/07/2023] [Indexed: 10/19/2023] Open
Abstract
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.
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Affiliation(s)
- Harry Flanagan
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom Street, Liverpool, L3 3AF, UK
| | - Robert Cooper
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom Street, Liverpool, L3 3AF, UK
| | - Keith P George
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom Street, Liverpool, L3 3AF, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department for Health, University of Bath, Bath, UK
| | - Aneil Malhotra
- Institute of Sport, Manchester Metropolitan University and University of Manchester, Manchester, UK
| | - Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - David Oxborough
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom Street, Liverpool, L3 3AF, UK.
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2
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Rafailakis L, Deli CK, Fatouros IG, Tsiokanos A, Draganidis D, Poulios A, Soulas D, Jamurtas AZ. Functional and Morphological Adaptations in the Heart of Children Aged 12-14 Years following Two Different Endurance Training Protocols. Sports (Basel) 2023; 11:157. [PMID: 37624137 PMCID: PMC10459334 DOI: 10.3390/sports11080157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/13/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
This study investigated the cardiac functional and the morphological adaptations because of two endurance training protocols. Untrained children (N = 30, age: 12-14 years) were divided into three groups (N = 10/group). The first group did not perform any session (CONTROL), the second performed ventilatory threshold endurance training (VTT) for 12 weeks (2 sessions/week) at an intensity corresponding to the ventilatory threshold (VT) and the third (IT) performed two sessions per week at 120% of maximal oxygen uptake (VO2max). Two other sessions (30 min running at 55-65% of VO2max) per week were performed in VVT and IT. Echocardiograms (Left Ventricular end Diastolic Diameter, LVEDd; Left Ventricular end Diastolic Volume, LVEDV; Stroke Volume, SV; Ejection Fraction, EF; Posterior Wall Thickness of the Left Ventricle, PWTLV) and cardiopulmonary ergospirometry (VO2max, VT, velocity at VO2max (vVO2max), time in vVO2max until exhaustion (Tlim) was conducted before and after protocols. Significant increases were observed in both training groups in LVEDd (VTT = 5%; IT = 3.64%), in LVEDV (VTT = 23.7%; ITT = 13.6%), in SV (VTT = 25%; IT = 16.9%) but not in PWTLV and EF, after protocols. No differences were noted in the CONTROL group. VO2max and VT increased significantly in both training groups by approximately 9% after training. Our results indicate that intensity endurance training does not induce meaningful functional and morphological perturbations in the hearts of children.
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Affiliation(s)
| | | | | | | | | | | | | | - Athanasios Z. Jamurtas
- Department of Physical Education and Sport Science, University of Thessaly, 42100 Trikala, Greece; (L.R.); (C.K.D.); (I.G.F.); (A.T.); (D.D.); (D.S.)
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3
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McClean G, Wilson MG, Riding NR, Pieles G, Watt V, Adamuz C, Shaw A, Harkness A, Johnson A, George KP, Oxborough D. A New Tool to Aid the Differential Diagnosis of Physiological Remodelling from Cardiac Pathology When Assessing Left Ventricle, Left Atrial and Aortic Structure and Function in Male Arab and Black Paediatric Athletes. J Cardiovasc Dev Dis 2023; 10:jcdd10020037. [PMID: 36826533 PMCID: PMC9963999 DOI: 10.3390/jcdd10020037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/13/2023] [Accepted: 01/15/2023] [Indexed: 01/24/2023] Open
Abstract
Aim: To determine if published Z-scores for left ventricular (LV), left atrial (LA) and aortic structure as well as indices of LV function (Doppler and TDI) in paediatric athletes and non-athletes are appropriate for application in male Arab and black paediatric athletes. If inappropriate, we aim to provide new nomograms and Z-scores for clinical application. Methods: 417 (297 Arab, 120 black) male paediatric (11-18 years) athletes, were evaluated by 2D echocardiography as per British Society of Echocardiography recommendations, and biological age (by radiological X-ray) assessment. Z-scores were tested by residual and correlation analysis together with visual inspection. New Z-scores involved allometric (a*BSA(b+c*chronological age)) and second-order polynomial (y=a*chronological age2+b*chronological age+c) equations for measures of cardiac size and indices of LV function, respectively. Results: Residual linear regression, correlation analysis and visual inspection revealed published z-scores in white peri-pubertal footballers and paediatric non-athletes to be inappropriate for application in male Arab and black paediatric athletes. Residual linear regression revealed new Z-scores for measures of LV, LA and aortic root size to be independent of BSA, ethnicity, chronological and biological age. Residual linear regression revealed new Z-scores for measures of function to be independent of chronological age. Conclusion: Our new z-scores may aid differential diagnosis of suspected pathology versus physiology remodelling, in cardiac screening of the Arab and black paediatric athlete. Nomograms are provided to assist the tracking of the paediatric athlete necessitating annual follow-up and Excel z-score calculation to facilitate use in day-to-day practice.
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Affiliation(s)
- Gavin McClean
- Echocardiography Laboratory, St Bartholomew’s Hospital, Barts Health NHS, London EC1A 7BE, UK
- Echocardiography Laboratory, University College London Hospital, London NW1 2BU, UK
- Athlete Health and Performance Research Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha 23833, Qatar
- Research Institute for Sport and Exercise Science, Liverpool John Moores University, Liverpool L3 3AF, UK
| | - Mathew G. Wilson
- Athlete Health and Performance Research Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha 23833, Qatar
- Research Institute for Sport and Exercise Science, Liverpool John Moores University, Liverpool L3 3AF, UK
- Institute of Sport Exercise and Health (ISEH), University College London, London 1T 7HA, UK
| | - Nathan R. Riding
- Athlete Health and Performance Research Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha 23833, Qatar
- Institute of Sport Exercise and Health (ISEH), University College London, London 1T 7HA, UK
- Bristol Medical School, University of Bristol, Bristol BS8 1UD, UK
| | - Guido Pieles
- Institute of Sport Exercise and Health (ISEH), University College London, London 1T 7HA, UK
- Bristol Medical School, University of Bristol, Bristol BS8 1UD, UK
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Congenital Heart Unit, Bristol Royal Hospital for Children and Bristol Heart Institute, Bristol BS2 8ED, UK
- Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha 23833, Qatar
| | - Victoria Watt
- Wythenshawe Hospital, Manchester University NHS Foundation Trust (MFT), Manchester M23 9LT, UK
| | - Carmen Adamuz
- Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha 23833, Qatar
| | - Anthony Shaw
- Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha 23833, Qatar
| | - Allan Harkness
- Colchester Hospital National Health Service Trust, Colchester CO4 5JL, UK
| | - Amanda Johnson
- Health Sciences Department, Manchester Metropolitan University, Manchester M15 6BH, UK
| | - Keith P. George
- Research Institute for Sport and Exercise Science, Liverpool John Moores University, Liverpool L3 3AF, UK
| | - David Oxborough
- Research Institute for Sport and Exercise Science, Liverpool John Moores University, Liverpool L3 3AF, UK
- Correspondence:
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4
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Certainties and Uncertainties of Cardiac Magnetic Resonance Imaging in Athletes. J Cardiovasc Dev Dis 2022; 9:jcdd9100361. [PMID: 36286312 PMCID: PMC9604894 DOI: 10.3390/jcdd9100361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/16/2022] Open
Abstract
Prolonged and intensive exercise induces remodeling of all four cardiac chambers, a physiological process which is coined as the “athlete’s heart”. This cardiac adaptation, however, shows overlapping features with non-ischemic cardiomyopathies, such as dilated, arrhythmogenic and hypertrophic cardiomyopathy, also associated with athlete’s sudden cardiac death. Cardiac magnetic resonance (CMR) is a well-suited, highly reproducible imaging modality that can help differentiate athlete’s heart from cardiomyopathy. CMR allows accurate characterization of the morphology and function of cardiac chambers, providing full coverage of the ventricles. Moreover, it permits an in-depth understanding of the myocardial changes through specific techniques such as mapping or late gadolinium enhancement. In this narrative review, we will focus on the certainties and uncertainties of the role of CMR in sports cardiology. The main aspects of physiological adaptation due to regular and intensive sports activity and the application of CMR in highly trained athletes will be summarized.
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Weberruß H, Baumgartner L, Mühlbauer F, Shehu N, Oberhoffer-Fritz R. Training intensity influences left ventricular dimensions in young competitive athletes. Front Cardiovasc Med 2022; 9:961979. [PMID: 36277759 PMCID: PMC9582149 DOI: 10.3389/fcvm.2022.961979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 08/22/2022] [Indexed: 01/11/2023] Open
Abstract
Background In young athletes, exercise causes changes in the heart that include growth in wall thickness and mass of the left ventricle and expansion of the heart’s chambers. The heart’s function is either preserved or enhanced, but this may change to the opposite over time. Objective This study aimed to assess structural and functional cardiac adaptations in relation to exercise training time, intensity, and performance in young competitive athletes. Methods A total of 404 children and adolescents (14.23 ± 2.0 years, 97 females) were enrolled in the Munich Cardiovascular Adaptations in Young Athletes Study (MuCAYA-Study). Eighty-five participants were examined two times a year. Two-dimensional echocardiography was performed to assess left ventricular structure and function. Training time and intensity was measured with the MoMo physical activity questionnaire, maximum aerobic capacity by cardiopulmonary exercise testing, and strength with the handgrip strength test. Results Maximum aerobic capacity significantly influenced interventricular septal thickness in diastole. Training intensity significantly influenced left ventricular internal diameter in diastole and systole, and left ventricular mass indexed to body surface area. Within one year, interventricular wall thickness, relative wall thickness and left ventricular mass, indexed to body surface area and height, increased significantly. Training intensity and aerobic capacity contributed to cardiac adaptations in young competitive athletes, as represented by altered structural parameters but preserved cardiac function. Within a year, however, structural changes and a decline in diastolic performance were observed within the longitudinal sub-sample. Conclusion Our results confirm the hypothesis that cardiac adaptations to exercise occur at a young age. Cardiac adaptation in our cohort was influenced by exercise intensity and maximum aerobic capacity.
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Affiliation(s)
- Heidi Weberruß
- Department of Preventive Pediatrics, TUM Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany,*Correspondence: Heidi Weberruß,
| | - Lisa Baumgartner
- Department of Preventive Pediatrics, TUM Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Frauke Mühlbauer
- Department of Preventive Pediatrics, TUM Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Nerejda Shehu
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Renate Oberhoffer-Fritz
- Department of Preventive Pediatrics, TUM Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany,Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
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6
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De Bosscher R, Dausin C, Janssens K, Bogaert J, Elliott A, Ghekiere O, Van De Heyning CM, Sanders P, Kalman J, Fatkin D, Herbots L, Willems R, Heidbuchel H, La Gerche A, Claessen G. Rationale and design of the PROspective ATHletic Heart (Pro@Heart) study: long-term assessment of the determinants of cardiac remodelling and its clinical consequences in endurance athletes. BMJ Open Sport Exerc Med 2022; 8:e001309. [PMID: 35368514 PMCID: PMC8935177 DOI: 10.1136/bmjsem-2022-001309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2022] [Indexed: 12/25/2022] Open
Abstract
Background Exercise-induced cardiac remodelling (EICR) results from the structural, functional and electrical adaptations to exercise. Despite similar sports participation, EICR varies and some athletes develop phenotypic features that overlap with cardiomyopathies. Training load and genotype may explain some of the variation; however, exercise ‘dose’ has lacked rigorous quantification. Few have investigated the association between EICR and genotype. Objectives (1) To identify the impact of training load and genotype on the variance of EICR in elite endurance athletes and (2) determine how EICR and its determinants are associated with physical performance, health benefits and cardiac pathology. Methods The Pro@Heart study is a multicentre prospective cohort trial. Three hundred elite endurance athletes aged 14–23 years will have comprehensive cardiovascular phenotyping using echocardiography, cardiac MRI, 12-lead ECG, exercise-ECG and 24-hour-Holter monitoring. Genotype will be determined using a custom cardiomyopathy gene panel and high-density single-nucleotide polymorphism arrays. Follow-up will include online tracking of training load. Cardiac phenotyping will be repeated at 2, 5, 10 and 20 years. Results The primary endpoint of the Pro@Heart study is the association of EICR with both training load and genotype. The latter will include rare variants in cardiomyopathy-associated genes and polygenic risk scores for cardiovascular traits. Secondary endpoints are the incidence of atrial and ventricular arrhythmias, physical performance and health benefits and their association with training load and genotype. Conclusion The Pro@Heart study is the first long-term cohort study to assess the impact of training load and genotype on EICR. Trial registration number NCT05164328; ACTRN12618000716268.
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Affiliation(s)
- Ruben De Bosscher
- Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Cardiology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | | | - Kristel Janssens
- Cardiology, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Jan Bogaert
- Radiology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Adrian Elliott
- Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Centre for Heart Rhythm Disorders, The University of Adelaide, Adelaide, South Australia, Australia
| | - Olivier Ghekiere
- Cardiology, Jessa Hospital Campus Virga Jesse, Hasselt, Belgium.,Cardivacsular Sciences, University Hasselt Biomedical Research Institute Rehabilitation Research Center, Diepenbeek, Belgium
| | - Caroline M Van De Heyning
- Cardiology, University of Antwerp, Antwerpen, Belgium.,Cardiovascular Sciences, University Hospital Antwerp, Edegem, Belgium
| | - Prashanthan Sanders
- Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Centre for Heart Rhythm Disorders, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jonathan Kalman
- Cardiology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Diane Fatkin
- Inherited Heart Diseases, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Lieven Herbots
- Cardiology, Jessa Hospital Campus Virga Jesse, Hasselt, Belgium.,Cardivacsular Sciences, University Hasselt Biomedical Research Institute Rehabilitation Research Center, Diepenbeek, Belgium
| | - Rik Willems
- Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Cardiology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Hein Heidbuchel
- Cardiology, University Hospital Antwerp, Edegem, Belgium.,Cardiovascular Sciences, University of Antwerp, Antwerpen, Belgium
| | - André La Gerche
- Department of Cardiology, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Guido Claessen
- Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Cardiology, KU Leuven University Hospitals Leuven, Leuven, Belgium
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7
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Rodriguez-López AM, Javier G, Carmen P, Esteban P, Luisa GC, Tomas F, Josefa HM, Luis F. Athlete Heart in Children and Young Athletes. Echocardiographic Findings in 331 Cases. Pediatr Cardiol 2022; 43:407-412. [PMID: 34586455 DOI: 10.1007/s00246-021-02736-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/10/2021] [Indexed: 11/25/2022]
Abstract
The changes of the athlete's heart are not well defined and characterized in children. We aimed to describe the morphological changes of the heart related to sport in young athletes. We evaluated a group of 331 young athletes under 18 years (mean 11.9 ± 3.2) who practice tennis: 58 (16.52%), football: 118 (33.62%), basketball: 16 (4.56%), athletics: 40 (11.4%), and swimming: 99 (28.21%). Type of sport, years of practice, and duration of the training were collected. All children underwent echocardiography with the following M-mode parameters: left atrium diameter (LAD), interventricular septum (IVS), and left ventricle posterior Wall (LVPW), diastolic diameter of the left ventricle (LVDD), and right ventricle outflow tract (RVOT). The major finding of our study was that 20% of the children had a Z score > 2 for the IVS and that increased to 30% for the children playing tennis or swimming. Also, other changes like LA and RVOT dilatation were observed in about 10 and 14% of the cases, respectively. Taken together, these figures indicate that cardiac remodeling is frequent in children. Further studies are needed to establish consensus-based criteria of athlete's heart in young children.
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Affiliation(s)
- Ana M Rodriguez-López
- Department of Cardiology, Hospiten Sur, Tenerife, Spain.
- Department of Cardiology, Hospiten Bellevue, Tenerife, Spain.
| | - González Javier
- Service of Sport Medicine Ayuntamiento del Puerto de la Cruz, Hospital Universitario de Canarias, Tenerife, Spain
| | - Padrón Carmen
- Department of Paediatric, Hospiten Sur, Tenerife, Spain
| | | | | | - Febles Tomas
- Department of Cardiology, Hospiten Sur, Tenerife, Spain
| | | | - Febles Luis
- Department of Cardiology, Hospiten Bellevue, Tenerife, Spain
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Scheer V, Costa RJS, Doutreleau S, Knechtle B, Nikolaidis PT, Roberts WO, Stoll O, S Tenforde A, Krabak B. Recommendations on Youth Participation in Ultra-Endurance Running Events: A Consensus Statement. Sports Med 2021; 51:1123-1135. [PMID: 33704697 DOI: 10.1007/s40279-021-01441-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2021] [Indexed: 12/28/2022]
Abstract
Participation in ultra-endurance running (UER) events continues to grow across ages, including youth athletes. The 50- and 100-km are the most popular distances among youth athletes. Most youth athletes are between 16-18 years; however, some runners younger than 12 years have successfully completed UER events. Parents, athletes, coaches, race directors, and medical professionals often seek advice regarding the safety of youth athletes participating in these events, especially with regard to potential short and long-term health consequences. UER may impact key organ systems during growth and development. We propose a decision-making process, based on current knowledge and the experience of the consensus group that addresses age regulations, medical and psychological well-being, training status and race-specific factors (such as distance, elevation change, remoteness, ambient temperatures, level of medical assistance, and type of provisions provided by the race organizers) to use until evidence of long-term consequences of UER in youth athletes is available. These recommendations are aimed at safe participation in UER events for youth athletes with a proper and individualized assessment.
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Affiliation(s)
- Volker Scheer
- Ultra Sports Science Foundation, 109 Boulevard de l'Europe, 69310, Pierre-Benite, France. .,Health Science Department, Universidad a Distancia de Madrid (UDIMA), Madrid, Spain.
| | - Ricardo J S Costa
- Department of Nutrition Dietetics and Food, Monash University, Melbourne, Australia
| | | | - Beat Knechtle
- Medbase St. Gallen am Vadianplatz, St. Gallen, Switzerland.,Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | | | - William O Roberts
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Oliver Stoll
- Institute of Sport Science, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Adam S Tenforde
- Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Brian Krabak
- University of Washington and Seattle Children's Sports Medicine, Seattle, WA, USA
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9
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Augustine DX, Keteepe-Arachi T, Malhotra A. Coronavirus Disease 2019: Cardiac Complications and Considerations for Returning to Sports Participation. Eur Cardiol 2021; 16:e03. [PMID: 33708264 PMCID: PMC7941378 DOI: 10.15420/ecr.2020.36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/03/2020] [Indexed: 12/14/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2. While the majority of symptoms and morbidity relate to the lung, cardiac complications have been well reported and confer increased mortality. Many countries in Europe have passed the peak of the pandemic and adaptations are being made as we progress towards a 'new normal'. As part of this, governments have been planning strategies for the return of elite sports. This article summarises the potential implications of COVID-19 for athletes returning to sport, including common cardiac complications of the disease; consensus recommendations for the return to sport after having COVID-19; and international recommendations for the management of cardiac pathology that may occur as a result of COVID-19. The authors also examine the potential overlap of pathology with physiological change seen in athletes' hearts.
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Affiliation(s)
- Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation TrustBath, UK
- Department for Health, University of BathBath, UK
| | | | - Aneil Malhotra
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of ManchesterManchester, UK
- Manchester University NHS Foundation Trust, Manchester Academic Health Science CentreManchester, UK
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10
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Characterisation of LV myocardial exercise function by 2-D strain deformation imaging in elite adolescent footballers. Eur J Appl Physiol 2020; 121:239-250. [PMID: 33030575 PMCID: PMC7815563 DOI: 10.1007/s00421-020-04510-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/19/2020] [Indexed: 12/15/2022]
Abstract
Purpose Few data exist on the descriptions of LV myocardial mechanics and reserve during dynamic exercise of adolescent athletes. The aim of this study was to describe the LV myocardial and cardiopulmonary changes during exercise using 2-D strain deformation imaging. Methods Elite adolescent male football players (n = 42) completed simultaneous cardiopulmonary exercise testing (CPET) and exercise echocardiography measurement of LV myocardial deformation by 2-D strain imaging. LV longitudinal and circumferential 2-D strain and strain rates were analyzed at each stage during incremental exercise to a work rate of 150 W. Additionally, exercise LV myocardial deformation and its relation to metabolic exercise parameters were evaluated at each exercise stage and in recovery using repeated measures ANOVA, linear regression and paired t tests. Results LV peak systolic baseline 2-D strain (longitudinal: − 15.4 ± 2.5%, circumferential: − 22.5 ± 3.1%) increased with each exercise stage, but longitudinal strain plateaued at 50 W (mean strain reserve − 7.8 ± 3.0) and did not significantly increase compared to subsequent exercise stages (P > 0.05), whilst circumferential strain (mean strain reserve − 11.6 ± 3.3) significantly increased (P < 0.05) throughout exercise up to 150 W as the dominant mechanism of exercise LV contractility increase. Regression analyses showed LV myocardial strain increased linearly relative to HR, VO2 and O2 pulse (P < 0.05) for circumferential deformation, but showed attenuation for longitudinal deformation. Conclusion This study describes LV myocardial deformation dynamics by 2-D strain and provides reference values for LV myocardial strain and strain rate during exercise in adolescent footballers. It found important differences between LV longitudinal and circumferential myocardial mechanics during exercise and introduces a methodology that can be used to quantify LV function and cardiac reserve during exercise in adolescent athletes.
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11
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Ozo U, Sharma S. The Impact of Ethnicity on Cardiac Adaptation. Eur Cardiol 2020; 15:e61. [PMID: 32944090 DOI: 10.15420/ecr.2020.01] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/22/2020] [Indexed: 01/15/2023] Open
Abstract
Regular intensive exercise is associated with a plethora of electrical, structural and functional adaptations within the heart to promote a prolonged and sustained increase in cardiac output. Bradycardia, increased cardiac dimensions, enhanced ventricular filling, augmentation of stroke volume and high peak oxygen consumption are recognised features of the athlete's heart. The type and magnitude of these adaptations to physical exercise are governed by age, sex, ethnicity, sporting discipline and intensity of sport. Some athletes, particularly those of African or Afro-Caribbean (black) origin reveal changes that overlap with diseases implicated in sudden cardiac death. In such instances, erroneous interpretation has potentially serious consequences ranging from unfair disqualification to false reassurance. This article focuses on ethnic variation in the physiological cardiac adaption to exercise.
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12
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Pieles GE, Stuart AG. The adolescent athlete's heart; A miniature adult or grown-up child? Clin Cardiol 2020; 43:852-862. [PMID: 32643161 PMCID: PMC7403711 DOI: 10.1002/clc.23417] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 06/16/2020] [Accepted: 06/26/2020] [Indexed: 12/18/2022] Open
Abstract
The systematic development of early age talent in sports academies has led to the professionalization of pediatric sport and the sports physician need to be aware of pediatric cardiological problems. Research into the medical cardiac care and assessment of the pediatric athlete are accumulating, but specific pediatric international guidelines are not available yet and reference data for ECG and echocardiography are incomplete, in particular for the age group <12 years of age. This article is an introduction to the physiological and diagnostics specifics of the pediatric athlete. The focus lies in the differences in presentation and diagnosis between pediatric and adult athletes for the most common pathologies. Reference data for electrical and structural adaptations to intensive exercise are sparse particularly in athletes aged below 12 years old. Training related changes include decrease of resting heart rate, increase of cardiac output, ventricular cavity size, and wall thickness. Cardiac hypertrophy is less pronounced in pediatric athletes, as HR mediated cardiac output increase to endurance exercise is the dominant mechanism in peripubertal children. As in adults, the most pronounced cardiovascular adaptations appear in classical endurance sports like rowing, triathlon, and swimming, but the specifics of pediatric ECG and echocardiographic changes need to be considered.
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Affiliation(s)
- Guido E Pieles
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Congenital Heart Unit, Bristol Heart Institute, Bristol, UK.,Institute of Sport, Exercise and Health, University College London, London, UK
| | - A Graham Stuart
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Congenital Heart Unit, Bristol Heart Institute, Bristol, UK
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13
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Baggish AL, Battle RW, Beaver TA, Border WL, Douglas PS, Kramer CM, Martinez MW, Mercandetti JH, Phelan D, Singh TK, Weiner RB, Williamson E. Recommendations on the Use of Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes: A Report from the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2020; 33:523-549. [PMID: 32362332 DOI: 10.1016/j.echo.2020.02.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Robert W Battle
- University of Virginia Health System, Charlottesville, Virginia
| | | | - William L Border
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Dermot Phelan
- Sanger Heart and Vascular Institute in Atrium Health, Charlotte, North Carolina
| | | | - Rory B Weiner
- Massachusetts General Hospital, Boston, Massachusetts
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14
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Baumgartner L, Schulz T, Oberhoffer R, Weberruß H. Influence of Vigorous Physical Activity on Structure and Function of the Cardiovascular System in Young Athletes-The MuCAYA-Study. Front Cardiovasc Med 2019; 6:148. [PMID: 31649936 PMCID: PMC6794339 DOI: 10.3389/fcvm.2019.00148] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/24/2019] [Indexed: 12/21/2022] Open
Abstract
Objective: Moderate physical activity (PA) is associated with a reduced risk to develop cardiovascular disease. However, junior athletes exercise between 10 and 20 h a week with intensities exceeding moderate levels by far. In this regard, the cardiovascular system has to increase its work five to six times compared to moderate intensities. This may result in potentially pathological adaptations of the cardiovascular system. The underlying process of vascular adaptations to exercise is yet not fully understood and hardly investigated in junior athletes. An increased blood pressure and pulse wave velocity, ventricular hypertrophy, arrhythmia, and even sudden cardiac death (SCD) has been reported in adult athletes. Studies, examining the cardiovascular system in children, its association to intensity and type of exercise, are rare. Therefore, we present the study protocol of a prospective cross-sectional study that investigates the influence of PA on the cardiovascular system in young athletes. Methods and Design: Children and adolescents, 7–18 years, presenting for their annual pre-participation screening at the Institute of Preventive Pediatrics, Faculty of Sports and Health Sciences, Technical University of Munich (TUM), are examined in this prospective cross-sectional study. Vascular parameters measured by ultrasound are carotid intima-media thickness (cIMT), vascular stiffness (AC, Ep, β, PWV β), and the vascular diameter (D) to calculate the IMT:Diameter-Ratio (IDR). Cardiac function is evaluated by a 12-lead ECG, and echocardiographic parameters (end-diastolic left ventricular diameter, left ventricular diastolic posterior wall thickness, diastolic septal thickness, left ventricular mass and relative wall thickness, ejection fraction, and shortening fraction). A cardiopulmonary exercise test is performed on a bicycle ergometer, muscular strength is assessed with the handgrip test, and physical activity with the MoMo questionnaire. Discussion: It is essential to follow young athletes over the course of their career in order to detect pathophysiological changes in the myocardium as soon as possible. If these changes are preceded or followed by changes in vascular structure and function is not known yet. Therefore, we present the study protocol of the Munich Cardiovascular adaptations in young athletes study (MuCAYA-Study) which investigates the association between vascular and cardiac adaptation to intensive exercise in junior athletes.
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Affiliation(s)
- Lisa Baumgartner
- Institute of Preventive Pediatrics, TUM Department of Sport and Health Science, Technical University of Munich, Munich, Germany
| | - Thorsten Schulz
- Institute of Preventive Pediatrics, TUM Department of Sport and Health Science, Technical University of Munich, Munich, Germany
| | - Renate Oberhoffer
- Institute of Preventive Pediatrics, TUM Department of Sport and Health Science, Technical University of Munich, Munich, Germany
| | - Heidi Weberruß
- Institute of Preventive Pediatrics, TUM Department of Sport and Health Science, Technical University of Munich, Munich, Germany
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15
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Malhotra A, Dhutia H, Yeo TJ, Finocchiaro G, Gati S, Bulleros P, Fanton Z, Papatheodorou E, Miles C, Keteepe-Arachi T, Basu J, Parry-Williams G, Prakash K, Gray B, D'Silva A, Ensam B, Behr E, Tome M, Papadakis M, Sharma S. Accuracy of the 2017 international recommendations for clinicians who interpret adolescent athletes’ ECGs: a cohort study of 11 168 British white and black soccer players. Br J Sports Med 2019; 54:739-745. [DOI: 10.1136/bjsports-2017-098528] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2019] [Indexed: 01/01/2023]
Abstract
AimTo investigate the accuracy of the recently published international recommendations for ECG interpretation in young athletes in a large cohort of white and black adolescent soccer players.Methods11 168 soccer players (mean age 16.4±1.2 years) were evaluated with a health questionnaire, ECG and echocardiogram; 10 581 (95%) of the players were male and 10 163 (91%) were white. ECGs were retrospectively analysed according to (1) the 2010 European Society of Cardiology (ESC) recommendations, (2) Seattle criteria, (3) refined criteria and (4) the international recommendations for ECG interpretation in young athletes.ResultsThe ESC recommendations resulted in a higher number of abnormal ECGs compared with the Seattle, refined and international criteria (13.2%, 4.3%, 2.9% and 1.8%, respectively). All four criteria were associated with a higher prevalence of abnormal ECGs in black athletes compared with white athletes (ESC: 16.2% vs 12.9%; Seattle: 5.9% vs 4.2%; refined: 3.8% vs 2.8%; international 3.6% vs 1.6%; p<0.001 each). Compared with ESC recommendations, the Seattle, refined and international criteria identified a lower number of abnormal ECGs—by 67%, 78% and 86%, respectively. All four criteria identified 36 (86%) of 42 athletes with serious cardiac pathology. Compared with ESC recommendations, the Seattle criteria improved specificity from 87% to 96% in white athletes and 84% to 94% in black athletes. The international recommendations demonstrated the highest specificity for white (99%) and black (97%) athletes and a sensitivity of 86%.ConclusionsThe 2017 international recommendations for ECG interpretation in young athletes can be applied to adolescent athletes to detect serious cardiac disease. These recommendations perform more effectively than previous ECG criteria in both white and black adolescent soccer players.
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16
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Cantinotti M, Koestenberger M, Santoro G, Assanta N, Franchi E, Paterni M, Iervasi G, D'Andrea A, D'Ascenzi F, Giordano R, Galderisi M. Normal basic 2D echocardiographic values to screen and follow up the athlete's heart from juniors to adults: What is known and what is missing. A critical review. Eur J Prev Cardiol 2019; 27:1294-1306. [PMID: 31266355 DOI: 10.1177/2047487319862060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the last few years, multiple echocardiographic nomograms have been published. However, normal values calculated in the general population are not applicable to athletes, whose hearts may be enlarged and hypercontractile. Accordingly, athletes require specific nomograms. Our aim is to provide a critical review of echocardiographic nomograms on two-dimensional (2D) measures for athletes. We performed a systematic search in the National Library of Medicine for Medical Subject Headings and free text terms including echocardiography, athletes, normal values and nomograms. The search was refined by adding the keywords heart, sport, elite, master, children and young. Twenty-eight studies were selected for the final analysis. Our research revealed that currently available ranges of normality for athletes reported by different authors are quite consistent, with limited exceptions (e.g. atria, aorta). Numerical and methodological limitations, however, emerged. Numerical limitations included a limited sample size (e.g. < 450 subjects) of the population assessed and the paucity of data in women, non-Caucasian athletes, and junior and master athletes. Some data on M-mode measurements are available, while those for some specific structures (e.g. left atrial (LA) area and volumes, right ventricular diameters and aorta) are limited or rare (e.g. LA area). There was heterogeneity in data normalization (by gender, sport type and ethnicity) and their expression was limited to mean values (Z-scores have rarely been employed), while variability analysis was often lacking or incomplete. We conclude that comprehensive nomograms using an appropriate sample size, evaluating a complete dataset of 2D (and three-dimensional) measures and built using a rigorous statistical approach are warranted.
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Affiliation(s)
- Massimiliano Cantinotti
- Fondazione G. Monasterio CNR-Regione Toscana, Massa and Pisa, Italy.,Institute of Clinical Physiology, Pisa, Italy
| | - Martin Koestenberger
- Division of Paediatric Cardiology, Department of Paediatrics, Medical University Graz, Austria.,European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Giuseppe Santoro
- Fondazione G. Monasterio CNR-Regione Toscana, Massa and Pisa, Italy
| | - Nadia Assanta
- Fondazione G. Monasterio CNR-Regione Toscana, Massa and Pisa, Italy
| | - Eliana Franchi
- Fondazione G. Monasterio CNR-Regione Toscana, Massa and Pisa, Italy
| | | | | | - Antonello D'Andrea
- Division of Cardiology, Umberto I' Hospital Nocera Inferiore (Salerno), Luigi Vanvitelli University, Caserta, Italy
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Italy
| | - Raffaele Giordano
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy
| | - Maurizio Galderisi
- Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy
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17
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Méndez C, Soler R, Rodríguez E, Barriales R, Ochoa JP, Monserrat L. Differential diagnosis of thickened myocardium: an illustrative MRI review. Insights Imaging 2018; 9:695-707. [PMID: 30302634 PMCID: PMC6206373 DOI: 10.1007/s13244-018-0655-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/18/2018] [Accepted: 08/07/2018] [Indexed: 02/07/2023] Open
Abstract
Objectives The purpose of this article is to describe the key cardiac magnetic resonance imaging (MRI) features to differentiate hypertrophic cardiomyopathy (HCM) phenotypes from other causes of myocardial thickening that may mimic them. Conclusions Many causes of myocardial thickening may mimic different HCM phenotypes. The unique ability of cardiac MRI to facilitate tissue characterisation may help to establish the aetiology of myocardial thickening, which is essential to differentiate it from HCM phenotypes and for appropriate management. Teaching points • Many causes of myocardial thickening may mimic different HCM phenotypes. • Differential diagnosis between myocardial thickening aetiology and HCM phenotypes may be challenging. • Cardiac MRI is essential to differentiate the aetiology of myocardial thickening from HCM phenotypes.
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Affiliation(s)
- Cristina Méndez
- Radiology Department, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), Servizo Galego de Saúde (SERGAS), Universidade da Coruña, Xubias de Arriba 86, 15006, A Coruña, Spain
| | - Rafaela Soler
- Radiology Department, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), Servizo Galego de Saúde (SERGAS), Universidade da Coruña, Xubias de Arriba 86, 15006, A Coruña, Spain
| | - Esther Rodríguez
- Radiology Department, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), Servizo Galego de Saúde (SERGAS), Universidade da Coruña, Xubias de Arriba 86, 15006, A Coruña, Spain.
| | - Roberto Barriales
- Cardiology Department, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), Servizo Galego de Saúde (SERGAS), Universidade da Coruña, Xubias de Arriba, 84, 15006, A Coruña, Spain
| | - Juan Pablo Ochoa
- Cardiology Department, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), Servizo Galego de Saúde (SERGAS), Universidade da Coruña, Xubias de Arriba, 84, 15006, A Coruña, Spain
| | - Lorenzo Monserrat
- Cardiology Department, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), Servizo Galego de Saúde (SERGAS), Universidade da Coruña, Xubias de Arriba, 84, 15006, A Coruña, Spain
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18
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Popple E, George K, Somauroo J, Sharma S, Utomi V, Lord R, Cooper R, Malhotra A, Forster J, Oxborough D. Right ventricular structure and function in senior and academy elite footballers. Scand J Med Sci Sports 2018; 28:2617-2624. [DOI: 10.1111/sms.13272] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 07/31/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Emily Popple
- Research Institute for Sport and Exercise Sciences; Liverpool John Moores University; Liverpool UK
| | - Keith George
- Research Institute for Sport and Exercise Sciences; Liverpool John Moores University; Liverpool UK
| | - John Somauroo
- Research Institute for Sport and Exercise Sciences; Liverpool John Moores University; Liverpool UK
- Countess of Chester Hospital; NHS Trust; Chester UK
| | | | - Victor Utomi
- Research Institute for Sport and Exercise Sciences; Liverpool John Moores University; Liverpool UK
| | | | - Robert Cooper
- Institute of Cardiovascular Medicine and Science; Liverpool Heart and Chest Hospital; Liverpool UK
| | | | - Jan Forster
- Leeds Teaching Hospitals NHS Trust; Leeds UK
| | - David Oxborough
- Research Institute for Sport and Exercise Sciences; Liverpool John Moores University; Liverpool UK
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19
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Malhotra A, Dhutia H, Finocchiaro G, Gati S, Beasley I, Clift P, Cowie C, Kenny A, Mayet J, Oxborough D, Patel K, Pieles G, Rakhit D, Ramsdale D, Shapiro L, Somauroo J, Stuart G, Varnava A, Walsh J, Yousef Z, Tome M, Papadakis M, Sharma S. Outcomes of Cardiac Screening in Adolescent Soccer Players. N Engl J Med 2018; 379:524-534. [PMID: 30089062 DOI: 10.1056/nejmoa1714719] [Citation(s) in RCA: 165] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Reports on the incidence and causes of sudden cardiac death among young athletes have relied largely on estimated rates of participation and varied methods of reporting. We sought to investigate the incidence and causes of sudden cardiac death among adolescent soccer players in the United Kingdom. METHODS From 1996 through 2016, we screened 11,168 adolescent athletes with a mean (±SD) age of 16.4±1.2 years (95% of whom were male) in the English Football Association (FA) cardiac screening program, which consisted of a health questionnaire, physical examination, electrocardiography, and echocardiography. The FA registry was interrogated to identify sudden cardiac deaths, which were confirmed with autopsy reports. RESULTS During screening, 42 athletes (0.38%) were found to have cardiac disorders that are associated with sudden cardiac death. A further 225 athletes (2%) with congenital or valvular abnormalities were identified. After screening, there were 23 deaths from any cause, of which 8 (35%) were sudden deaths attributed to cardiac disease. Cardiomyopathy accounted for 7 of 8 sudden cardiac deaths (88%). Six athletes (75%) with sudden cardiac death had had normal cardiac screening results. The mean time between screening and sudden cardiac death was 6.8 years. On the basis of a total of 118,351 person-years, the incidence of sudden cardiac death among previously screened adolescent soccer players was 1 per 14,794 person-years (6.8 per 100,000 athletes). CONCLUSIONS Diseases that are associated with sudden cardiac death were identified in 0.38% of adolescent soccer players in a cohort that underwent cardiovascular screening. The incidence of sudden cardiac death was 1 per 14,794 person-years, or 6.8 per 100,000 athletes; most of these deaths were due to cardiomyopathies that had not been detected on screening. (Funded by the English Football Association and others.).
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Affiliation(s)
- Aneil Malhotra
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Harshil Dhutia
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Gherardo Finocchiaro
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Sabiha Gati
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Ian Beasley
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Paul Clift
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Charlotte Cowie
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Antoinette Kenny
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Jamil Mayet
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - David Oxborough
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Kiran Patel
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Guido Pieles
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Dhrubo Rakhit
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - David Ramsdale
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Leonard Shapiro
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - John Somauroo
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Graham Stuart
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Amanda Varnava
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - John Walsh
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Zaheer Yousef
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Maite Tome
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Michael Papadakis
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
| | - Sanjay Sharma
- From the Cardiology Clinical Academic Group, St. George's, University of London (A.M., H.D., G.F., S.G., M.T., M.P., S.S.), the Department of Sports Medicine, Bartholomew's and London Hospital (I.B.), and the Department of Cardiology, Imperial College NHS Trust (J.M., A.V.), London, the Football Association, Burton Upon Trent (A.M., C.C.), the Department of Cardiology, Queen Elizabeth Hospital, Birmingham (P.C.), the Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne (A.K.), the Faculty of Science, Liverpool John Moores University (D.O., J.S.), and the Department of Cardiology, Liverpool Heart and Chest Hospital (D. Ramsdale), Liverpool, the Department of Cardiology, Good Hope Hospital, Sutton Coldfield (K.P.), Bristol Heart Institute, Bristol (G.P., G.S.), University Hospital Southampton, Southampton (D. Rakhit), the Department of Cardiology, Papworth Hospital, Papworth (L.S.), Nottingham City Hospital, Nottingham (J.W.), and the University Hospital of Wales, Cardiff (Z.Y.) - all in the United Kingdom
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20
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Gabrielli L, Herrera S, Contreras-Briceño F, Vega J, Ocaranza MP, Yáñez F, Fernández R, Saavedra R, Sitges M, García L, Chiong M, Lavandero S, Castro PF. Increased active phase atrial contraction is related to marathon runner performance. Eur J Appl Physiol 2018; 118:1931-1939. [DOI: 10.1007/s00421-018-3927-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/26/2018] [Indexed: 01/19/2023]
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21
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Oxborough D, Augustine D, Gati S, George K, Harkness A, Mathew T, Papadakis M, Ring L, Robinson S, Sandoval J, Sarwar R, Sharma S, Sharma V, Sheikh N, Somauroo J, Stout M, Willis J, Zaidi A. A guideline update for the practice of echocardiography in the cardiac screening of sports participants: a joint policy statement from the British Society of Echocardiography and Cardiac Risk in the Young. Echo Res Pract 2018; 5:G1-G10. [PMID: 29551755 PMCID: PMC5861331 DOI: 10.1530/erp-17-0075] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 02/02/2018] [Indexed: 12/19/2022] Open
Abstract
Sudden cardiac death (SCD) in an athlete is a rare but tragic event. In view of this, pre-participation cardiac screening is mandatory across many sporting disciplines to identify those athletes at risk. Echocardiography is a primary investigation utilized in the pre-participation setting and in 2013 the British Society of Echocardiography and Cardiac Risk in the Young produced a joint policy document providing guidance on the role of echocardiography in this setting. Recent developments in our understanding of the athlete’s heart and the application of echocardiography have prompted this 2018 update.
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Affiliation(s)
- David Oxborough
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | | | - Sabiha Gati
- Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, UK
| | - Keith George
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Allan Harkness
- Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Thomas Mathew
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Liam Ring
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmonds, UK
| | | | | | - Rizwan Sarwar
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Vishal Sharma
- Royal Liverpool and Broadgreen University Hospitals, Liverpool, UK
| | | | - John Somauroo
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Martin Stout
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - James Willis
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
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22
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Brown B, Somauroo J, Green DJ, Wilson M, Drezner J, George K, Oxborough D. The Complex Phenotype of the Athlete's Heart: Implications for Preparticipation Screening. Exerc Sport Sci Rev 2017; 45:96-104. [PMID: 28306678 DOI: 10.1249/jes.0000000000000102] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Preparticipation screening is vital to exclude inherited cardiac conditions that have the potential to cause sudden cardiac death in seemingly healthy athletes. Recent research has questioned traditional theories of load-induced, dichotomous cardiac adaptation. We therefore considered whether a one-size-fits-all approach to screening can account for interindividual differences brought about by sporting discipline, training volume, ethnicity, body size, sex, and age.
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Affiliation(s)
- Benjamin Brown
- 1Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom; 2School of Sports Science, Exercise and Health, The University of Western Australia, Western Australia, Australia; 4Department of Sports Medicine, ASPETAR, Qatar; and 5Department of Family Medicine, University of Washington, Seattle, WA
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23
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McClean G, Riding NR, Ardern CL, Farooq A, Pieles GE, Watt V, Adamuz C, George KP, Oxborough D, Wilson MG. Electrical and structural adaptations of the paediatric athlete’s heart: a systematic review with meta-analysis. Br J Sports Med 2017; 52:230. [DOI: 10.1136/bjsports-2016-097052] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2017] [Indexed: 01/27/2023]
Abstract
AimTo describe the electrocardiographic (ECG) and echocardiographic manifestations of the paediatric athlete’s heart, and examine the impact of age, race and sex on cardiac remodelling responses to competitive sport.DesignSystematic review with meta-analysis.Data sourcesSix electronic databases were searched to May 2016: MEDLINE, PubMed, EMBASE, Web of Science, CINAHL and SPORTDiscus.Inclusion criteria(1) Male and/or female competitive athletes, (2) participants aged 6–18 years, (3) original research article published in English language.ResultsData from 14 278 athletes and 1668 non-athletes were included for qualitative (43 articles) and quantitative synthesis (40 articles). Paediatric athletes demonstrated a greater prevalence of training-related and training-unrelated ECG changes than non-athletes. Athletes ≥14 years were 15.8 times more likely to have inferolateral T-wave inversion than athletes <14 years. Paediatric black athletes had significantly more training-related and training-unrelated ECG changes than Caucasian athletes. Age was a positive predictor of left ventricular (LV) internal diameter during diastole, interventricular septum thickness during diastole, relative wall thickness and LV mass. When age was accounted for, these parameters remained significantly larger in athletes than non-athletes. Paediatric black athletes presented larger posterior wall thickness during diastole (PWTd) than Caucasian athletes. Paediatric male athletes also presented larger PWTd than females.ConclusionsThe paediatric athlete’s heart undergoes significant remodelling both before and during ‘maturational years’. Paediatric athletes have a greater prevalence of training related and training-unrelated ECG changes than non-athletes, with age, race and sex mediating factors on cardiac electrical and LV structural remodelling.
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24
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D'Andrea A, Formisano T, Riegler L, Scarafile R, America R, Martone F, di Maio M, Russo MG, Bossone E, Galderisi M, Calabrò R. Acute and Chronic Response to Exercise in Athletes: The "Supernormal Heart". ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 999:21-41. [PMID: 29022255 DOI: 10.1007/978-981-10-4307-9_2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
During last decades, most studies have examined the exercise-induced remodeling defined as "athlete's heart". During exercise, there is an increased cardiac output that causes morphological, functional, and electrical modification of the cardiac chambers. The cardiac remodeling depends also on the type of training, age, sex, ethnicity, genetic factors, and body size. The two main categories of exercise, endurance and strength, determine different effects on the cardiac remodeling. Even if most sport comprise both strength and endurance exercise, determining different scenarios of cardiac adaptation to the exercise. The aim of this paper is to assemble the current knowledge about physiologic and pathophysiologic response of both the left and the right heart in highly trained athletes.
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Affiliation(s)
- Antonello D'Andrea
- Luigi Vanvitelli, University of Naples Monaldi Hospital, AORN Ospedali dei Colli, Corso Vittorio Emanuele 121, 80121, Naples, Italy.
| | - Tiziana Formisano
- Luigi Vanvitelli, University of Naples Monaldi Hospital, AORN Ospedali dei Colli, Corso Vittorio Emanuele 121, 80121, Naples, Italy
| | - Lucia Riegler
- Luigi Vanvitelli, University of Naples Monaldi Hospital, AORN Ospedali dei Colli, Corso Vittorio Emanuele 121, 80121, Naples, Italy
| | - Raffaella Scarafile
- Luigi Vanvitelli, University of Naples Monaldi Hospital, AORN Ospedali dei Colli, Corso Vittorio Emanuele 121, 80121, Naples, Italy
| | - Raffaella America
- Luigi Vanvitelli, University of Naples Monaldi Hospital, AORN Ospedali dei Colli, Corso Vittorio Emanuele 121, 80121, Naples, Italy
| | - Francesca Martone
- Luigi Vanvitelli, University of Naples Monaldi Hospital, AORN Ospedali dei Colli, Corso Vittorio Emanuele 121, 80121, Naples, Italy
| | - Marco di Maio
- Luigi Vanvitelli, University of Naples Monaldi Hospital, AORN Ospedali dei Colli, Corso Vittorio Emanuele 121, 80121, Naples, Italy
| | - Maria Giovanna Russo
- Luigi Vanvitelli, University of Naples Monaldi Hospital, AORN Ospedali dei Colli, Corso Vittorio Emanuele 121, 80121, Naples, Italy
| | - Eduardo Bossone
- Department of Cardiology and Cardiac Surgery, University Hospital San Giovanni di Dio, Salern, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Raffaele Calabrò
- Luigi Vanvitelli, University of Naples Monaldi Hospital, AORN Ospedali dei Colli, Corso Vittorio Emanuele 121, 80121, Naples, Italy
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25
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Galderisi M, Cardim N, D'Andrea A, Bruder O, Cosyns B, Davin L, Donal E, Edvardsen T, Freitas A, Habib G, Kitsiou A, Plein S, Petersen SE, Popescu BA, Schroeder S, Burgstahler C, Lancellotti P. The multi-modality cardiac imaging approach to the Athlete's heart: an expert consensus of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2016; 16:353. [PMID: 25681828 DOI: 10.1093/ehjci/jeu323] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The term 'athlete's heart' refers to a clinical picture characterized by a slow heart rate and enlargement of the heart. A multi-modality imaging approach to the athlete's heart aims to differentiate physiological changes due to intensive training in the athlete's heart from serious cardiac diseases with similar morphological features. Imaging assessment of the athlete's heart should begin with a thorough echocardiographic examination.Left ventricular (LV) wall thickness by echocardiography can contribute to the distinction between athlete's LV hypertrophy and hypertrophic cardiomyopathy (HCM). LV end-diastolic diameter becomes larger (>55 mm) than the normal limits only in end-stage HCM patients when the LV ejection fraction is <50%. Patients with HCM also show early impairment of LV diastolic function, whereas athletes have normal diastolic function.When echocardiography cannot provide a clear differential diagnosis, cardiac magnetic resonance (CMR) imaging should be performed.With CMR, accurate morphological and functional assessment can be made. Tissue characterization by late gadolinium enhancement may show a distinctive, non-ischaemic pattern in HCM and a variety of other myocardial conditions such as idiopathic dilated cardiomyopathy or myocarditis. The work-up of athletes with suspected coronary artery disease should start with an exercise ECG. In athletes with inconclusive exercise ECG results, exercise stress echocardiography should be considered. Nuclear cardiology techniques, coronary cardiac tomography (CCT) and/or CMR may be performed in selected cases. Owing to radiation exposure and the young age of most athletes, the use of CCT and nuclear cardiology techniques should be restricted to athletes with unclear stress echocardiography or CMR.
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MESH Headings
- Adult
- Arrhythmogenic Right Ventricular Dysplasia/diagnosis
- Cardiac Imaging Techniques/methods
- Cardiac-Gated Single-Photon Emission Computer-Assisted Tomography
- Cardiomegaly/diagnosis
- Cardiomegaly, Exercise-Induced
- Cardiomyopathy, Dilated/diagnosis
- Cardiomyopathy, Hypertrophic/diagnosis
- Consensus
- Contrast Media
- Death, Sudden, Cardiac/prevention & control
- Echocardiography, Stress/methods
- Electrocardiography
- European Union
- Gadolinium
- Humans
- Hypertrophy, Left Ventricular/diagnosis
- Magnetic Resonance Imaging, Cine
- Predictive Value of Tests
- Sensitivity and Specificity
- Societies, Medical
- Technetium Tc 99m Sestamibi
- Tomography, Emission-Computed, Single-Photon
- Tomography, X-Ray Computed/methods
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26
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Impact of specific training and competition on myocardial structure and function in different age ranges of male handball players. PLoS One 2015; 10:e0143609. [PMID: 26630561 PMCID: PMC4668105 DOI: 10.1371/journal.pone.0143609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 11/06/2015] [Indexed: 11/23/2022] Open
Abstract
Handball activity involves cardiac changes and demands a mixture of both eccentric and concentric remodeling within the heart. This study seeks to explore heart performance and cardiac remodeling likely to define cardiac parameters which influence specific performance in male handball players across different age ranges. Forty three players, with a regular training and competitive background in handball separated into three groups aged on average 11.78±0.41 for youth players aka “schools”, “elite juniors” 15.99±0.81 and “elite adults” 24.46±2.63 years, underwent echocardiography and ECG examinations. Incremental ergocycle and specific field (SFT) tests have also been conducted. With age and regular training and competition, myocardial remodeling in different age ranges exhibit significant differences in dilatation’s parameters between “schools” and “juniors” players, such as the end-diastolic diameter (LVEDD) and the end-systolic diameter of the left ventricle (LVESD), the root of aorta (Ao) and left atrial (LA), while significant increase is observed between “juniors” and “adults” players in the interventricular septum (IVS), the posterior wall thicknesses (PWT) and LV mass index. ECG changes are also noted but NS differences were observed in studied parameters. For incremental maximal test, players demonstrate a significant increase in duration and total work between “schools” and “juniors” and, in total work only, between “juniors” and “seniors”. The SFT shows improvement in performance which ranged between 26.17±1.83 sec to 31.23±2.34 sec respectively from “seniors” to “schools”. The cross-sectional approach used to compare groups with prior hypothesis that there would be differences in exercise performance and cardiac parameters depending on duration of prior handball practice, leads to point out the early cardiac remodeling within the heart as adaptive change. Prevalence of cardiac chamber dilation with less hypertrophy remodeling was found from “schools” to “juniors” while a prevalence of cardiac hypertrophy with less pronounced chamber dilation remodeling was noted later.
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27
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Changes of Cardiac Function During Ultradistance Trail Running. Am J Cardiol 2015; 116:1284-9. [PMID: 26294134 DOI: 10.1016/j.amjcard.2015.07.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/09/2015] [Accepted: 07/09/2015] [Indexed: 11/23/2022]
Abstract
Previous studies have noted reversible cardiac dysfunction during marathon races, but few data are available concerning ultradistance trail running. The aim of this study was to assess echocardiographic parameters during ultradistance trail running. We performed an observational study in 66 participants to the 80-km Ecotrail of Paris Ile de France. All subjects had echocardiographic examinations before the race and on arrival, and 28 of them underwent serial echocardiographic examinations during the race (21 and 53 km). A single experienced physician performed all echocardiographic examinations, and the same protocol was always used (conventional 2-dimensional and Doppler left ventricular parameters and longitudinal strain). All echocardiographic parameters of left ventricular (LV) systolic function were significantly decreased on arrival (p ≤0.002). A significant reduction of LV systolic function was observed in 48% of study subjects on arrival. No significant modification was observed at 21 or at 53 km, and only global longitudinal strain was significantly decreased (p = 0.0008). At arrival, mitral E/A ratio and average mitral tissue Doppler imaging e' wave were significantly decreased (p = 0.0001 and p = 0.0004, respectively), but these changes were observed from 21 km. In conclusion, ultradistance trail running can lead to abnormalities of LV systolic and diastolic functions in amateur runners. Diastolic dysfunction arises earlier than systolic dysfunction. Left ventricular systolic dysfunction occurred in 48% of the study subjects and was detected early by assessment of longitudinal strain.
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28
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Bartkevičienė A. Echocardiographic Characteristic Of Left Ventricular Geometry Of 12-17 Years Athletes. ACTA ACUST UNITED AC 2015. [DOI: 10.5200/sm-hs.2015.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Aim. To compare the type of left ventricular geometry associated with training among 12-17 years athletes currently competing in cycling, rowing and basketball playing and to determine the factors influencing left ventricular geometry. Methods. A total 167 male athletes 12-17 year-old, involved in basketball (n = 62), academic rowing (n =51) and cycling (n = 54) and 168 sedentary non-athletes, matched for age and sex were involved in this study. All participants underwent twodimensional, M-mode and Doppler echocardiography. To estimate left ventricular geometry relative wall thickness and left ventricular mass index were calculated. Left ventricular geometry was assessed as normal, eccentric ventricular hypertrophy, concentric left ventricular hypertrophy, concentric left ventricular remodeling. Results. Left ventricular hypertrophy was present in 48 % of all athletes, predominantly (34 %) eccentric hypertrophy. 16% of athletes had concentric hypertrophy. Only 7% of athletes manifested concentric remodeling. The prevalence of eccentric hypertrophy was more common in cyclists (54%), concentric hypertrophy was more frequent in rowers (38%), and normal left ventricular geometry was more common in basketball players (53%). Multivariate regression analysis showed that age was the important determinant of eccentric and concentric left ventricular hypertrophy. Eccentric left ventricular hypertrophy also was independently associated to training volume (hour per week) and cycling sporting discipline. Conclusion. Almost half of athletes (48%) had left ventricular hypertrophy, predominantly eccentric hypertrophy, and the age was the important determinant of left ventricular hypertrophy (eccentric and concentric). Training volume and cycling sporting discipline were significantly associated with eccentric left ventricular hypertrophy.
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Abstract
The rigorous cardiovascular (CV) demands of sport, combined with training-related cardiac adaptations, render the athlete a truly unique CV patient and sports cardiology a truly unique discipline. Cardiologists are advised to adopt a systematic approach to the CV evaluation of athletes, taking into consideration the individual sports culture, sports-specific CV demands, CV adaptations and their appearance on cardiac testing, any existing or potential interaction of the heart with the internal and external sports environment, short- and long-term CV risks, and potential effect of performance-enhancing agents and antidoping regulations. This article outlines the systematic approach, provides a detailed example, and outlines contemporary sports cardiology core competencies.
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Affiliation(s)
- Christine E Lawless
- Sports Cardiology Consultants LLC, 360 West Illinois Street, #7D, Chicago, IL 60654, USA; Department of Nutrition and Health Sciences, University of Nebraska, Lincoln, 110 Ruth Leverton Hall, Lincoln, NE 68583-0806, USA.
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Sharma S, Merghani A, Mont L. Exercise and the heart: the good, the bad, and the ugly. Eur Heart J 2015; 36:1445-53. [DOI: 10.1093/eurheartj/ehv090] [Citation(s) in RCA: 188] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 03/04/2015] [Indexed: 12/17/2022] Open
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Jolley M, Hickey K, Annese D, Gauvreau K, Geva T, Valente AM, Powell AJ. Resting heart rate influences right ventricular volume in repaired tetralogy of Fallot. Pediatr Cardiol 2015; 36:813-20. [PMID: 25527228 DOI: 10.1007/s00246-014-1088-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 12/11/2014] [Indexed: 11/30/2022]
Abstract
The aim of this study is to examine the impact of heart rate (HR) on right ventricular end-diastolic volume indexed to body surface area (RVEDVi) in patients with repaired tetralogy of Fallot (TOF). In this cross-sectional study, an institutional database search identified all patients with repaired TOF who underwent cardiac magnetic resonance (CMR) and had a Holter study within 3 months. The association of HR on Holter, HR at the time of CMR, and other clinical and CMR parameters on RVEDVi was explored with univariate and then multivariable models. In the study group (n = 161, median age 23 years), a lower mean Holter HR was associated with a larger RVEDVi (p = 0.004). In a model that also included pulmonary regurgitation fraction, tricuspid regurgitation grade, RV ejection fraction, age at CMR, and gender, mean Holter HR remained associated with RVEDVi (p < 0.0001); for a decrease of 1 bpm, mean RVEDVi increased by 1.09 ml/m(2). When limiting to those with a Holter within 5 days of CMR (n = 70), the impact of mean Holter HR on RVEDVi was stronger (-1.9 ml/m(2)/bpm). HR at time of CMR had a significant but less pronounced relationship to RVEDVi (-0.58 ml/m(2)/bpm, p = 0.002). In conclusion, in repaired TOF patients, a lower HR was significantly associated with a larger RVEDVi. This relationship was stronger with a shorter time interval between the Holter and CMR, and stronger for the mean HR on Holter than for the HR at CMR. Accounting for HR in the interpretation of RVEDVi may impact decisions regarding pulmonary valve replacement and the interpretation of serial CMR data.
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Affiliation(s)
- Matthew Jolley
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA,
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Castanheira J, Valente-dos-Santos J, Duarte J, Vaz V, Figueiredo AJ, Leite N, Cyrino ES, Coelho-e-Silva MJ. Morfologia do ventrículo esquerdo em adolescentes: comparação entre atletas e não atletas. REV BRAS MED ESPORTE 2014. [DOI: 10.1590/1517-86922014200601888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introdução: A morfologia do ventrículo esquerdo altera-se com o crescimento e desenvolvimento, durante a infância e adolescência. Contudo, são escassos os estudos comparativos entre não atletas e jovens atletas de elite.Objetivo: Analisar possíveis diferenças na morfologia do ventrículo esquerdo entre jovens atletas de elite e não atletas, do sexo masculino.Métodos: Trinta atletas de elite (15,4±0,6 anos; 68,0±11,3 kg; 175,2±7,5 cm) e 28 adolescentes saudáveis sem experiência com a prática esportiva (15,2±1,3 anos; 62,9± 3,8 kg; 168,8±7,7 cm) foram submetidos a medidas antropométricas (estatura, massa corporal e espessura de dobras cutâneas) e avaliações ecocardiográficas.Resultados: Diferenças estatisticamente significantes foram encontradas nos diâmetros telediastólico e telesistólico do ventrículo esquerdo, na espessura do septo interventricular em diástole, na espessura da parede posterior do ventrículo esquerdo, no diâmetro do átrio esquerdo e na relação entre o diâmetro do átrio esquerdo e o diâmetro da raiz da aorta, com os jovens atletas de elite apresentando valores superiores aos não atletas (P<0,01), mesmo após ajuste pela estatura. Correlações positivas e de moderada magnitude entre a massa do ventrículo esquerdo e a estatura foram encontradas em atletas (r=0,57) e não atletas (r=0,40).Conclusão: Os resultados do presente estudo sugerem que os valores superiores nas medidas da cavidade e de espessura da parede ventricular esquerda, encontrados no coração de jovens atletas de elite não podem ser explicados pela maior estatura, destacando a importância da exploração de modelos alométricos simples e multiplicativos que integrem medidas de maturação biológica em futuras investigações.
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Affiliation(s)
| | - João Valente-dos-Santos
- Universidade de Coimbra, Portugal; Universidade Lusófona de Humanidades e Tecnologias, Portugal
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Abstract
Physical activity is a potent therapy for both the prevention and treatment of cardiovascular disease. Exercise appears to most benefit people who are the least active. There is some evidence to suggest that a curvilinear relationship exists between exercise and survival, whereby beyond an optimal level of fitness, the principle of diminishing returns applies. Indeed, some go further in suggesting that there is evidence that extreme athletic training may be harmful in some individuals. The incidence of sudden cardiac death in athletes is greater than in matched, nonathletic counterparts, and this finding is driven by the provocation of an underlying cardiac abnormality by strenuous exertion. The task of detecting pathological myocardial substrate in athletes is made difficult by physiological adaptations to exercise that can mimic the appearance of cardiomyopathies and ion channelopathies in some individuals. This article details the clinical evaluation of the athlete with reference limits for cardiac physiological remodeling and discusses the diagnostic dilemmas that arise.
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Affiliation(s)
- Andrew D'Silva
- Department of Cardiovascular Sciences, St. George's University of London, London, UK
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Abstract
The increasing globalization of sport has resulted in athletes from a wide range of ethnicities emerging onto the world stage. Fuelled by the untimely death of a number of young professional athletes, data generated from the parallel increase in preparticipation cardiovascular evaluation has indicated that ethnicity has a substantial influence on cardiac adaptation to exercise. From this perspective, the group most intensively studied comprises athletes of African or Afro-Caribbean ethnicity (black athletes), an ever-increasing number of whom are competing at the highest levels of sport and who often exhibit profound electrical and structural cardiac changes in response to exercise. Data on other ethnic cohorts are emerging, but remain incomplete. This Review describes our current knowledge on the impact of ethnicity on cardiac adaptation to exercise, starting with white athletes in whom the physiological electrical and structural changes--collectively termed the 'athlete's heart'--were first described. Discussion of the differences in the cardiac changes between ethnicities, with a focus on black athletes, and of the challenges that these variations can produce for the evaluating physician is also provided. The impact of ethnically mediated changes on preparticipation cardiovascular evaluation is highlighted, particularly with respect to false positive results, and potential genetic mechanisms underlying racial differences in cardiac adaptation to exercise are described.
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Affiliation(s)
- Nabeel Sheikh
- Division of Clinical Sciences, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Sanjay Sharma
- Division of Clinical Sciences, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
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Zaidi A, Sharma S. Exercise and heart disease: from athletes and arrhythmias to hypertrophic cardiomyopathy and congenital heart disease. Future Cardiol 2013; 9:119-36. [PMID: 23259479 DOI: 10.2217/fca.12.81] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The beneficial effects of regular physical activity on cardiovascular health are well established, with convincing evidence of improvements in blood pressure, lipid profile and overall mortality. Conversely, individuals with pre-existing congenital, inherited or acquired heart conditions may experience functional cardiac deterioration or sudden death during even moderate exertion. Exclusion from high-level sporting activity may be mandated in some cases, and pre-participation screening of competitive athletes plays an important role in the identification of such individuals. The issue of screening is complicated by the fact that physiological cardiovascular adaptation in healthy athletes, including modest left ventricular hypertrophy and biventricular cavity dilatation, may create a diagnostic overlap with pathological conditions such as hypertrophic cardiomyopathy. Furthermore, much interest has focused recently on the possibility of irreversible cardiac remodeling in a proportion of veteran endurance athletes, with the potential for arrhythmogenesis and adverse cardiac events.
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Affiliation(s)
- Abbas Zaidi
- Department of Cardiovascular Sciences, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK
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Griffet V, Finet G, Di Filippo S, Lantelme P, Caignault JR, Guérard S. [Athlete's heart in the young: electrocardiographic and echocardiographic patterns in 107 French athletes]. Ann Cardiol Angeiol (Paris) 2013; 62:116-21. [PMID: 23538055 DOI: 10.1016/j.ancard.2013.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 02/15/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE Since 2009 in France, every people practicing sport in competition must have a cardiovascular exam with electrocardiogram, to prevent sudden cardiac death. Sometimes, an echocardiography will be necessary. Little is known about athlete's heart in the young, particularly in the French people. PATIENTS AND METHODS One hundred and seven French elite adolescent athletes had an electrocardiogram with echocardiography to establish reference values in this population. RESULTS QTcorrected (QTc) interval calculated by the Hodges formula, is always in the normal values. Interventricular septal thickness is always ≤ 11 mm and left ventricular end diastolic diameter ≤ 55 mm in about 90 % of the athletes. Females have QTc interval longer than males and interventricular septal thickness finer. Diastolic function (18.9 ± 2.6 cm/s for e', E/e' ratio at 5.3 ± 0.8) is "supernormal" and correlate with age and cardiac frequency. Right ventricular systolic function is always good. CONCLUSION Adolescent athlete's heart is normal. If QTc interval is not normal, be afraid of a QT long syndrome. Furthermore, when interventricular septal thickness is > 11 mm or left ventricular end diastolic diameter > 55 mm, myocardiopathy will have to be ruled out.
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Affiliation(s)
- V Griffet
- Service de cardiologie, hôpital d'instruction des armées Desgenettes, 108, boulevard Pinel, 69275 Lyon cedex 03, France.
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Pavlik G, Major Z, Csajági E, Jeserich M, Kneffel Z. The athlete’s heart Part II Influencing factors on the athlete’s heart: Types of sports and age (Review). ACTA ACUST UNITED AC 2013; 100:1-27. [DOI: 10.1556/aphysiol.100.2013.1.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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A Review and Critique of the Statistical Methods Used to Generate Reference Values in Pediatric Echocardiography. J Am Soc Echocardiogr 2013; 26:29-37. [DOI: 10.1016/j.echo.2012.09.021] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Indexed: 11/18/2022]
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Koch S, Cassel M, Linné K, Mayer F, Scharhag J. ECG and echocardiographic findings in 10-15-year-old elite athletes. Eur J Prev Cardiol 2012; 21:774-81. [PMID: 23008134 DOI: 10.1177/2047487312462147] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Data on electrocardiographic and echocardiographic pre-participation screening findings in paediatric athletes are limited. METHODS AND RESULTS 10--15 year-old athletes (n = 343) were screened using electro- and echocardiography. The electrocardiogram (ECG) was normal in 220 (64%), mildly abnormal in 108 (31%), and distinctly abnormal in 15 (4%) athletes. Echocardiographic upper reference limits (URL, 97.5 percentile) for the left ventricular (LV) wall thickness in 10-11-year-old boys and girls were 9-10 mm and 8-9 mm, respectively; in 12-13-year-old boys and girls 9-10 mm; and in 14-15-year-old boys and girls 10-11 mm and 9-10 mm, respectively. Three athletes were excluded from competitive sports: one for symptomatic Wolff-Parkinson-White syndrome with a normal echocardiogram; one for negative T-waves in V1-V4 and a dilated right ventricle by echocardiography suggestive of (arrhythmogenic) right ventricular disease; and one for normal ECG and biscupid aortic valve including an aneurysm of the ascending aorta detected by echocardiography. Related to echocardiographic findings, the sensitivity and specificity of the ECG to identify cardiovascular abnormalities was 38% and 64%, respectively. The ECG's positive-predictive and negative-predictive values were 13% and 88%, respectively. The numbers needed to screen and calculated costs were 172 for ECG (€7049), 172 for echocardiography (€11,530), and 114 combining ECG and echocardiography (€9323). CONCLUSIONS Compared to adults, paediatric athletes presented with fewer distinctly abnormal ECGs, and there was no gender difference in paediatric athletes' ECG-pattern distribution. A combination of ECG and echocardiography for pre-participation screening of paediatric athletes is superior to ECG alone but 30% more costly.
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Affiliation(s)
- Sarah Koch
- University of Potsdam, Potsdam, Germany University of British Columbia, Vancouver, Canada
| | | | | | | | - Jürgen Scharhag
- University of Potsdam, Potsdam, Germany University of Heidelberg, Heidelberg, Germany
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Cardiovascular effects of the valsalva maneuver during static arm exercise in elite power lifting athletes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 755:335-42. [PMID: 22826084 DOI: 10.1007/978-94-007-4546-9_42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The objective of the study was to investigate whether a blood pressure increase during static exercises might affect the left ventricular function and whether a possible pressure overload might decrease cardio-respiratory adaptation to aerobic exercise in power lifting athletes. Nine resistance-trained athletes and ten age-matched untrained men participated in high intensity isometric exercise performed during the Valsalva maneuver and in an incremental arm cranking test. All subjects underwent echocardiographic evaluation. The combine effect of exercise and increased intrathoracic pressure due to the Valsalva maneuver was a significant increase in systolic blood pressure in the athletes compared with controls. Echocardiography demonstrated significant differences in left ventricular mass and left ventricular mass index; both being higher in the athletes than in controls. The intraventricular septum diameter and left ventricular posterior wall thickness were significantly greater and the myocardial performance index was lower in the athletes compared with controls, indicating a better left ventricular function in the athletes. A cumulative effect of mechanical compression of peripheral blood vessels by contracting muscles and intrathoracic pressure increase during the Valsalva maneuver did not compromise myocardial contractility and cardiorespiratory adaptation to incremental arm exercise in power lifting athletes.
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41
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Jang Y, Kim SM. Influences of the G2350A polymorphism in the ACE gene on cardiac structure and function of ball game players. J Negat Results Biomed 2012; 11:6. [PMID: 22239999 PMCID: PMC3278340 DOI: 10.1186/1477-5751-11-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 01/12/2012] [Indexed: 11/13/2022] Open
Abstract
Background Except for the I/D polymorphism in the angiotensin I-converting enzyme (ACE) gene, there were few reports about the relationship between other genetic polymorphisms in this gene and the changes in cardiac structure and function of athletes. Thus, we investigated whether the G2350A polymorphism in the ACE gene is associated with the changes in cardiac structure and function of ball game players. Total 85 healthy ball game players were recruited in this study, and they were composed of 35 controls and 50 ball game players, respectively. Cardiac structure and function were measured by 2-D echocardiography, and the G2350A polymorphism in the ACE gene analyzed by the SNaPshot method. Results There were significant differences in left ventricular mass index (LVmassI) value among each sporting discipline studied. Especially in the athletes of basketball disciplines, indicated the highest LVmassI value than those of other sporting disciplines studied (p < 0.05). However, there were no significant association between any echocardiographic data and the G2350A polymorphism in the ACE gene in the both controls and ball game players. Conclusions Our data suggests that the G2350A polymorphism in the ACE gene may not significantly contribute to the changes in cardiac structure and function of ball game players, although sporting disciplines of ball game players may influence the changes in LVmassI value of these athletes. Further studies using a larger sample size and other genetic markers in the ACE gene will be needed.
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Affiliation(s)
- Yongwoo Jang
- College of Pharmacy, Seoul National University, Seoul 151-742, Korea
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42
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Affiliation(s)
- Abbas Zaidi
- Department of Cardiovascular Sciences, St. George's, University of London, London SW17 0RE
| | - Sanjay Sharma
- Department of Cardiovascular Sciences, St. George's, University of London, London SW17 0RE
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Mantziari A, Vassilikos VP, Giannakoulas G, Karamitsos TD, Dakos G, Girasis C, Papadopoulou KN, Ditsios K, Karvounis H, Styliadis IH, Parcharidis G. Left ventricular function in elite rowers in relation to training-induced structural myocardial adaptation. Scand J Med Sci Sports 2009; 20:428-33. [DOI: 10.1111/j.1600-0838.2009.00957.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Papadakis M, Basavarajaiah S, Rawlins J, Edwards C, Makan J, Firoozi S, Carby L, Sharma S. Prevalence and significance of T-wave inversions in predominantly Caucasian adolescent athletes. Eur Heart J 2009; 30:1728-35. [DOI: 10.1093/eurheartj/ehp164] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Abstract
The symptoms and signs of heart failure can occur in the setting of an increased cardiac output and has been termed 'high output heart failure'. An elevated cardiac output with clinical heart failure is associated with several diseases including chronic anaemia, systemic arterio-venous fistulae, sepsis, hypercapnia and hyperthyroidism. The underlying primary physiological problem is of reduced systemic vascular resistance either due to arterio-venous shunting or peripheral vasodilatation. Both scenarios can lead to a fall in systemic arterial blood pressure and neurohormonal activation leading to overt clinical heart failure. In contrast to low output heart failure, clinical trial data in this area are lacking. The use of conventional therapies for heart failure, such as angiotensin converting enzyme inhibitors, angiotensin receptor blockers and certain beta-blockers with vasodilatory properties, is likely to further reduce systemic vascular resistance resulting in deterioration. The condition, although uncommon, is often associated with a potentially correctable aetiology. In the absence of a remediable cause, therapeutic options are very limited but include dietary restriction of salt and water combined with judicious use of diuretics. Vasodilators and beta-adrenoceptor positive inotropes are not recommended.
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Affiliation(s)
- P A Mehta
- Clinical Cardiology, National Heart and Lung Institute, Imperial College, Dovehouse Street, London SW3 6LY, UK.
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Rawlins J, Bhan A, Sharma S. Left ventricular hypertrophy in athletes. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:350-6. [PMID: 19246500 DOI: 10.1093/ejechocard/jep017] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Participation in regular intensive exercise is associated with a modest increase in left ventricular wall thickness (LVWT) and cavity size. The magnitude of these physiological changes is predominantly determined by a variety of demographic factors which include age, gender, size, ethnicity, and sporting discipline. A small minority of male athletes participating in sporting disciplines involving intensive isotonic and isometric exercise may exhibit substantial increases in cardiac size that overlap with the phenotypic manifestation of the cardiomyopathies. The most challenging clinical dilemma incorporates the differentiation between physiological left ventricular hypertrophy (LVH) (athlete's heart) and hypertrophic cardiomyopathy (HCM), which is recognized as the commonest cause of non-traumatic exercise related sudden cardiac death in young (<35 years old) athletes. This review aims to highlight the distribution and physiological upper limits of LVWT in athletes, determinants of LVH in athletes, and echocardiographic methods of differentiating athlete's heart from HCM.
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Affiliation(s)
- John Rawlins
- King's College Hospital, Denmark Hill, London, UK
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47
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Mijailović ZM, Stajić Z, Tavciovski D, Matunović R. [Sudden cardiac death in athletes]. MEDICINSKI PREGLED 2009; 62:37-41. [PMID: 19514599 DOI: 10.2298/mpns0902037m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The entity of sudden cardiac death in young athletes has been known since the year 490 B.C. when young Greek soldier Phidipides had run the distance from Marathon to Athens and suddenly fell down dead. In the last twenty years, sudden death of famous athletes have attracted huge attention of medical and social community; afterwards both American and European Cardiology Societies started to publish periodically guidelines for preparticipation screening. These guidelines have focused on both identifying athletes with potential cardiovascular risk for sudden death and eligibility conditions for athletes participating in competitive sports. Structural and functional abnormalities causing sudden cardiac death in young athletes have been identified by autopsy-based studies. Unrecognized congenital cardiovascular abnormalities associated with excessive physical effort create background for electrophysiological instability and occurrence of malignant ventricular tachyarrhythmia and consequent death. The most frequent causes of sudden cardiac death in young athletes include hypertrophic cardiomyopathy, anomalies of the coronary arteries and idiopathic left ventricular hypertrophy. Current ACC/AHA & ESC guidelines should be widely used in order to reduce potential sudden cardiac death in young athletes.
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Poh KK, Ton-Nu TT, Neilan TG, Tournoux FB, Picard MH, Wood MJ. Myocardial adaptation and efficiency in response to intensive physical training in elite speedskaters. Int J Cardiol 2008; 126:346-51. [PMID: 17602763 DOI: 10.1016/j.ijcard.2007.04.051] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Accepted: 04/01/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Physiological cardiac adaptations to exercise training resulting in the 'athlete's heart' are well known. Most of these studies, however, were included either those who exercise to exhaustion, non-elite athletes or those who participate primarily in sports requiring extensive weight training. Studies utilizing conventional and tissue Doppler echocardiographic studies in highly competitive elite athletes whose training includes both aerobic and weight training are limited. AIMS AND METHODS 1) To identify baseline cardiovascular structural and physiologic adaptations present in elite athletes who participate in both endurance aerobic and weight training programs and to compare them to similarly aged sedentary controls. The population includes 24 speedskaters participating in the 2006 Olympic Games and 15 sedentary young subjects. 2) To evaluate possible structural and physiologic cardiac changes following short duration, vigorous exercise. We repeated the baseline echocardiographic protocol in the athletes following a 3000 m sprint conducted at race pace. RESULTS Compared to non-athletes, the atrial and left ventricular (LV) volumes at rest were larger in elite athletes. There was enhanced LV diastolic function as manifested by higher early annular (septal and lateral) tissue Doppler velocities (E'): 12.7+/-2.3 vs 11.3+/-1.1 cm/s and 17.4+/-4.7 vs 14.4+/-1.2 cm/s, P=0.025 and 0.020 respectively. Evidence of right ventricular (RV) remodeling included larger basal RV dimensions (38+/-5 vs 32+/-4 mm, P=0.001), attenuated RV systolic function at rest (RV area change 35+/-13% in athletes vs 47+/-11% in controls, P=0.006) and lower RV systolic strain rate (SSR) 1.9+/-0.5 vs 2.9+/-1.1/s, P<0.001). However, there was better right ventricular (RV) diastolic function at rest, E': 13.5+/-3.6 vs 11.1+/-1.5 cm/s (P=0.016). Following exercise, the athletes exhibited augmentation of RV systolic function with increased RV fractional area change (increasing to 43+/-10%, P=0.007) and SSR (2.5+/-1.2/s post-exercise, P=0.038). CONCLUSION Participation by world-class speedskaters in a vigorous training regimen results in cardiovascular anatomic and physiologic adaptations. These changes, including cardiac chamber dilatation, enhanced ventricular diastolic function and attenuated resting RV systolic function, are likely adaptive and allow for more efficient energy use at rest and a robust response to demands of exercise.
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Affiliation(s)
- Kian-Keong Poh
- Cardiac Ultrasound Laboratory, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115-2696, USA
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Basavarajaiah S, Wilson M, Naghavi R, Whyte G, Turner M, Sharma S. Physiological upper limits of left ventricular dimensions in highly trained junior tennis players. Br J Sports Med 2008; 41:784-8. [PMID: 17957014 DOI: 10.1136/bjsm.2006.033993] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The differentiation between physiological cardiac enlargement and cardiomyopathy is crucial, considering that most young non-traumatic deaths in sport are due to cardiomyopathy. Currently, there are few data relating to cardiac dimensions in junior elite tennis players. The aim of this study was to define the upper limits of left ventricular dimensions in a large cohort of national adolescent tennis players. METHODS Between 1996 and 2003, 259 adolescent tennis players (152 males), mean (SD) age 14.8 (1.4) years (range 13-19) and 86 healthy age, gender and body surface matched sedentary controls underwent 12-lead ECG and 2D-transthoracic echocardiography. RESULTS Inter-ventricular septal end diastolic dimension (IVSd), left ventricular end diastolic dimension (LVEDd) and left ventricular end diastolic posterior wall dimension (LVPWd) in tennis players were significantly higher than in controls (8.9 mm vs 8.3 mm p<0.001, 48.9 mm vs 47.9 mm p<0.05 and 9 mm vs 8.3 mm p<0.001 respectively), however in absolute terms, the difference did not exceed 7%. None of the tennis players had a wall thickness exceeding 12 mm or a left ventricular cavity size exceeding 60 mm. CONCLUSIONS Tennis players exhibit modest increases in cardiac dimensions, which do not resemble those seen in individuals with cardiomyopathy affecting the left ventricle.
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Abstract
Long-term athletic training is associated with changes in cardiac morphology, commonly described as "athlete's heart." Although numerous studies have investigated the effects of training on cardiac dimensions, most are limited to male Caucasian athletes, and few data are available regarding the effect of long-term exercise training on the woman's heart. This article reviews the athlete's heart in relation to gender and race.
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