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Ramcharan T, Edwards J, O'Driscoll J, Papadakis M. The Acute Impact of Endurance Exercise on Right Ventricular Structure and Function: A Systematic Review and Meta-analysis. Card Electrophysiol Clin 2024; 16:25-34. [PMID: 38280812 DOI: 10.1016/j.ccep.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
There have been many studies since the late 1980s investigating the effect of endurance exercise on the left ventricle. More recently, attention has shifted to the right heart, with suggestions that endurance exercise may have a detrimental effect on the right ventricle. This systematic review and meta-analysis summarizes and critiques 26 studies, including 649 athletes, examining the acute impact of endurance exercise on the right ventricle. We also present a subanalysis contrasting ultraendurance with endurance exercise. Finally, we identify areas for future research, such as the influence of sex, ethnicity, and age.
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Affiliation(s)
- Tristan Ramcharan
- Heart Unit, Birmingham Children's Hospital, Birmingham, United Kingdom; MSc Sports Cardiology, St George's, University of London, London, United Kingdom
| | - Jamie Edwards
- School of Psychology and Life Sciences, Canterbury Christ Church University, Kent CT1 1QU, United Kingdom
| | - Jamie O'Driscoll
- School of Psychology and Life Sciences, Canterbury Christ Church University, Kent CT1 1QU, United Kingdom.
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group, St George's, University of London, London, United Kingdom
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2
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van Lint FHM, Hassanzada F, Verstraelen TE, Wang W, Bosman LP, van der Zwaag PA, Oomen T, Calkins H, Murray B, Tichnell C, Beuren TMA, Asselbergs FW, Houweling A, van den Berg MP, Wilde AAM, James CA, van Tintelen JP. Exercise does not influence development of phenotype in PLN p.(Arg14del) cardiomyopathy. Neth Heart J 2023:10.1007/s12471-023-01800-4. [PMID: 37474840 PMCID: PMC10400740 DOI: 10.1007/s12471-023-01800-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Endurance and frequent exercise are associated with earlier onset of arrhythmogenic right ventricular cardiomyopathy (ARVC) and ventricular arrhythmias (VA) in desmosomal gene variant carriers. Individuals with the pathogenic c.40_42del; p.(Arg14del) variant in the PLN gene are frequently diagnosed with ARVC or dilated cardiomyopathy (DCM). The aim of this study was to evaluate the effect of exercise in PLN p.(Arg14del) carriers. METHODS In total, 207 adult PLN p.(Arg14del) carriers (39.1% male; mean age 53 ± 15 years) were interviewed on their regular physical activity since the age of 10 years. The association of exercise with diagnosis of ARVC, DCM, sustained VA and hospitalisation for heart failure (HF) was studied. RESULTS Individuals participated in regular physical activities with a median of 1661 metabolic equivalent of task (MET) hours per year (31.9 MET-hours per week) until clinical presentation. The 50% most and least active individuals had a similar frequency of sustained VA (18.3% vs 18.4%; p = 0.974) and hospitalisation for HF (9.6% vs 8.7%; p = 0.827). There was no relationship between exercise and survival free from (incident) sustained VA (p = 0.65), hospitalisation for HF (p = 0.81), diagnosis of ARVC (p = 0.67) or DCM (p = 0.39) during follow-up. In multivariate analyses, exercise was not associated with sustained VA or HF hospitalisation during follow-up in this relatively not-active cohort. CONCLUSION There was no association between the amount of exercise and the susceptibility to develop ARVC, DCM, VA or HF in PLN p.(Arg14del) carriers. This suggested unaffected PLN p.(Arg14del) carriers can safely perform mild-moderate exercise, in contrast to desmosomal variant carriers and ARVC patients.
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Affiliation(s)
- Freyja H M van Lint
- Department of Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Human Genetics, Amsterdam University Medical Centres, location Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Fahima Hassanzada
- Department of Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tom E Verstraelen
- Heart Centre, Department of Cardiology, Amsterdam University Medical Centre, location Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
| | - Weijia Wang
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Laurens P Bosman
- Netherlands Heart Institute, Utrecht, The Netherlands
- Department of Cardiology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paul A van der Zwaag
- University Medical Centre Groningen, Department of Genetics, University of Groningen, Groningen, The Netherlands
| | - Toon Oomen
- Department of Cardiology, St. Antonius Hospital, Sneek, The Netherlands
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Brittney Murray
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Crystal Tichnell
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Thais M A Beuren
- Department of Human Genetics, Amsterdam University Medical Centres, location Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arjan Houweling
- Department of Human Genetics, Amsterdam University Medical Centres, location Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten P van den Berg
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Arthur A M Wilde
- Heart Centre, Department of Cardiology, Amsterdam University Medical Centre, location Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
| | - Cynthia A James
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - J Peter van Tintelen
- Department of Genetics, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.
- Department of Human Genetics, Amsterdam University Medical Centres, location Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
- Netherlands Heart Institute, Utrecht, The Netherlands.
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De Bosscher R, Claeys M, Dausin C, Goetschalckx K, Claus P, Herbots L, Ghekiere O, Van De Heyning C, Paelinck BP, Janssens K, Wright L, Flannery MD, La Gerche A, Willems R, Heidbuchel H, Bogaert J, Claessen G. Three-dimensional echocardiography of the athlete's heart: a comparison with cardiac magnetic resonance imaging. Int J Cardiovasc Imaging 2023; 39:295-306. [PMID: 36151432 DOI: 10.1007/s10554-022-02726-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/03/2022] [Indexed: 01/28/2023]
Abstract
Three-dimensional echocardiography (3DE) is the most accurate cardiac ultrasound technique to assess cardiac structure. 3DE has shown close correlation with cardiac magnetic resonance imaging (CMR) in various populations. There is limited data on the accuracy of 3DE in athletes and its value in detecting alterations during follow-up. Indexed left and right ventricular end-diastolic volume (LVEDVi, RVEDVi), end-systolic volume, ejection fraction (LVEF, RVEF) and left ventricular mass (LVMi) were assessed by 3DE and CMR in two-hundred and one competitive endurance athletes (79% male) from the Pro@Heart trial. Sixty-four athletes were assessed at 2 year follow-up. Linear regression and Bland-Altman analyses compared 3DE and CMR at baseline and follow-up. Interquartile analysis evaluated the agreement as cardiac volumes and mass increase. 3DE showed strong correlation with CMR (LVEDVi r = 0.91, LVEF r = 0.85, LVMi r = 0.84, RVEDVi r = 0.84, RVEF r = 0.86 p < 0.001). At follow up, the percentage change by 3DE and CMR were similar (∆LVEDVi r = 0.96 bias - 0.3%, ∆LVEF r = 0.94, bias 0.7%, ∆LVMi r = 0.94 bias 0.8%, ∆RVESVi r = 0.93, bias 1.2%, ∆RVEF r = 0.87 bias 0.4%). 3DE underestimated volumes (LVEDVi bias - 18.5 mL/m2, RVEDVi bias - 25.5 mL/m2) and the degree of underestimation increased with larger dimensions (Q1vsQ4 LVEDVi relative bias - 14.5 versus - 17.4%, p = 0.016; Q1vsQ4 RVEDVi relative bias - 17 versus - 21.9%, p = 0.005). Measurements of cardiac volumes, mass and function by 3DE correlate well with CMR and 3DE accurately detects changes over time. 3DE underestimates volumes and the relative bias increases with larger cardiac size.
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Affiliation(s)
- Ruben De Bosscher
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium. .,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium. .,Department of Cardiovascular Medicine, University Hospitals Leuven, B-3000, Leuven, Belgium.
| | - Mathias Claeys
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Piet Claus
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Lieven Herbots
- Department of Cardiology, Hartcentrum, Jessa Ziekenhuis, Hasselt, Belgium.,REVAL/BIOMED, Hasselt University, Diepenbeek, Belgium
| | - Olivier Ghekiere
- REVAL/BIOMED, Hasselt University, Diepenbeek, Belgium.,Department of Radiology, Jessa Ziekenhuis, Hasselt, Belgium
| | - Caroline Van De Heyning
- Department of Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium.,Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
| | - Bernard P Paelinck
- Department of Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium.,Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
| | - Kristel Janssens
- Department of Cardiology, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Leah Wright
- Department of Cardiology, Baker Heart and Diabetes Institute, Melbourne, Australia
| | | | - André La Gerche
- Department of Cardiology, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Rik Willems
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Hein Heidbuchel
- Department of Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium.,Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
| | - Jan Bogaert
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Guido Claessen
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
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4
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Hu J, Zhou S, Ryu S, Adams K, Gao Z. Effects of Long-Term Endurance Exercise on Cardiac Morphology, Function, and Injury Indicators among Amateur Marathon Runners. Int J Environ Res Public Health 2023; 20:2600. [PMID: 36767963 PMCID: PMC9916084 DOI: 10.3390/ijerph20032600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/22/2023] [Accepted: 01/29/2023] [Indexed: 06/18/2023]
Abstract
The purpose of this study was to investigate the effects of long-term endurance exercise on cardiac morphology and function, as well as injury indicators, among amateur marathon runners. We recruited 33 amateur runners who participated in a marathon. Participants were divided into experimental and control groups according to their National Athletic Grade. The experimental group included participants with a National Athletic Grade of 2 or better, and the control group included participants who did not have a National Athletic Grade. Cardiac morphology, function, and injury indicators were assessed before and after the participants' involvement in the Changsha International Marathon. All cardiac morphology and function indicators returned to pre-race levels at 24 h post-race, and left ventricular end-diastolic volume and left ventricular end-systolic volume indicators showed similar trends. Both stroke volume (SV) and percent fractional shortening (%FS) indicators showed similar trends in changes in the measurements before and after the race. SV showed no change between the pre-race and post-race periods. On the other hand, %FS showed a significant increase in the immediate post-race period, followed by restoration of its level at 24 h post-race. Among myocardial injury indicators, serum levels of cardiac troponin I, creatine kinase (CK), creatine kinase-MB (CK-MB), lactate dehydrogenase (LDH), aspartate aminotransferase (AST), and N-terminal pro-b-type natriuretic peptide (NT-proBNP) measured before the race, immediately after the race, and 24 h after the race displayed similar trends in changes among CK, CK-MB, LDH, and AST, while NT-proBNP levels did not change. We concluded that high-level amateur marathon runners had greater heart volumes, as well as wall and septal thicknesses, than low-level marathon runners, with differences in heart volume being the most pronounced. Long-term high-intensity endurance exercise caused some damage to the hearts of amateur runners. High-level runners showed better myocardial repair ability, and their levels of myocardial injury markers showed greater decreases at 24 h post-race, while low-level runners had poorer myocardial repair ability.
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Affiliation(s)
- Jianzhong Hu
- School of Physical Education, Hengyang Normal University, Hengyang 421002, China
| | - Songqing Zhou
- School of Physical Education, Hengyang Normal University, Hengyang 421002, China
| | - Suryeon Ryu
- School of Kinesiology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Kaitlyn Adams
- School of Kinesiology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Zan Gao
- School of Kinesiology, University of Minnesota, Minneapolis, MN 55455, USA
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5
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Clark J, Bakhit Y, Motwani M. Exercise-induced right ventricular cardiomyopathy in an endurance cyclist: a case report. Eur Heart J Case Rep 2023; 7:ytad002. [PMID: 36694872 PMCID: PMC9856334 DOI: 10.1093/ehjcr/ytad002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/12/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
Background The wide-ranging benefits of frequent and moderate exercise are well recorded in the literature. Chronic deleterious remodelling in response to exercise is less well described. We describe an amateur endurance cyclist who, in addition to developing a heart failure syndrome and electrocardiographic evidence of arrhythmia, also developed severe functional tricuspid regurgitation. Case summary After developing palpitations during long distance cycle rides as part of his fitness regimen, a 69-year-old male presented to emergency services but was discharged. While continuing to enjoy long-distance cycling, he began to develop peripheral swelling and presented for a second time to hospital. Subsequent investigation found he had a dilated right heart, exercise-induced arrhythmia, and mid-wall myocardial fibrosis. A diagnosis of exercise-induced cardiomyopathy was made. He was managed with diuretics and immediate cessation of exercise. His symptoms improved and he remains symptom free. Discussion The volume of blood passing through the right heart increases during exercise. In vulnerable individuals undertaking frequent endurance exercise, this can promote structural remodelling and fibrotic change. It is unclear if cessation of exercise can reverse the remodelled heart. There are some early advances in predictive biomarkers and imaging techniques in categorizing those in the population who would be at risk of developing this cardiomyopathy, and those who can undergo intense exercise regimens without concern. If those at risk of developing an exercise-induced cardiomyopathy can be accurately identified, the next dilemma is how can their risk of heart failure or sudden death be acceptably minimized.
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Affiliation(s)
| | - Yasir Bakhit
- Department of Cardiology, Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
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6
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Costa Oliveira C, Vieira C, Galvão Braga C, Martins J, Durães Campos I, Bettencourt N, Rocha S, Marques J. Syncope in the athlete - Minor changes, major diagnosis! Rev Port Cardiol 2023; 42:71.e1-71.e6. [PMID: 36442584 DOI: 10.1016/j.repc.2019.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 05/09/2019] [Accepted: 08/01/2019] [Indexed: 11/26/2022] Open
Abstract
We report the case of a 17-year-old athlete who resorted to the emergency department for palpitations and dizziness while exercising. He mentioned two exercise-associated episodes of syncope in the last six months. He was tachycardic and hypotensive. The electrocardiogram showed regular wide complex tachycardia, left bundle branch block morphology with superior axis restored to sinus rhythm after electrical cardioversion. In sinus rhythm, it showed T-wave inversion in V1-V5. Transthoracic echocardiography revealed mild dilation and dysfunction of the right ventricle (RV) with global hypocontractility. Cardiac magnetic resonance (CMR) revealed a RV end diastolic volume indexed to body surface area of 180 ml/m2, global hypokinesia and RV dyssynchrony, subepicardial late enhancement in the distal septum and in the middle segment of the inferoseptal wall. The patient underwent a genetic study which showed a mutation in the gene that encodes the desmocolin-2 protein (DSC-2), which is involved in the pathogenesis of arrhythmogenic right ventricular cardiomyopathy (ARVC). According to the modified Task Force Criteria for this diagnosis, the patient presented four major criteria for ARVC. Thus, a subcutaneous cardioverter was implanted, and the patient was followed up at the cardiology department. Arrhythmogenic right ventricular cardiomyopathy diagnosis is based on structural, functional, electrophysiological and genetic criteria reflecting underlying histological changes. This case depicts the essential characteristics for disease recognition.
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Affiliation(s)
| | | | | | | | | | | | - Sérgia Rocha
- Cardiology Service, Braga Hospital, Braga, Portugal
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7
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Miljoen H, Spera F, Van Kolen K, Saenen J, Claessen G, Huybrechts W, Sarkozy A, Heidbuchel H. Electrocardiographic phenotype of exercise-induced arrhythmogenic cardiomyopathy: A retrospective observational study. Front Cardiovasc Med 2022; 9:1052174. [PMID: 36505386 PMCID: PMC9726729 DOI: 10.3389/fcvm.2022.1052174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/31/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction The right ventricle can be susceptible to pathologic alterations with exercise. This can cause changes to the ECG. Our aim was to identify the electrocardiographic phenotype of exercise induced (ExI) arrhythmogenic cardiomyopathy (ACM). Methods A retrospective analysis of ECGs at rest, peak exercise and 1 min of recovery in four groups of individuals was performed: Arrhythmogenic Cardiomyopathy with genetic confirmation (Gen-ACM; n = 16), (genetically negative) ExI-ACM (n = 15), control endurance athletes (End; n = 16) and sedentary individuals (Sed; n = 16). The occurrence of ventricular arrhythmias (VA) and, at each stage, QRS duration, Terminal Activation Delay (TAD), the ratio of the sum of the QRS durations in the right precordials (V1-V3) over that in the left precordials (V4-V6; R/L duration ratio), the presence of complete RBBB and T-wave inversion (TWI) beyond lead V2 were evaluated. Results At rest, complete RBBB was exclusively found in Gen-ACM (6%) and ExI-ACM (13%). No epsilon waves were identified. TWI beyond V2 was uniquely present in Gen-ACM (73%) and ExI-ACM (38%; p < 0.001). VA was present in Gen-ACM (88%); ExI-ACM (80%), End (25%) and Sed (19%; p < 0.001). The presence of R/L duration ratio of >1.2 and TAD ≥ 55 ms were not significantly different over the four groups (p = 0.584 and p = 0.218, respectively). At peak exercise the most striking finding was a significant decrease of the R/L duration ratio in individuals with ACM, which was the result of lateral precordial QRS prolongation. Conclusion ExI-ACM shares important ECG-features with Gen-ACM, suggesting a similar underlying pathogenesis regardless of the presence or absence of desmosomal mutations.
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Affiliation(s)
- Hielko Miljoen
- Department of Cardiology, University Hospital, Antwerp, Belgium,Cardiovascular Research, Department GENCOR, University of Antwerp, Antwerp, Belgium,*Correspondence: Hielko Miljoen
| | - Francesco Spera
- Department of Cardiology, University Hospital, Antwerp, Belgium
| | | | - Johan Saenen
- Department of Cardiology, University Hospital, Antwerp, Belgium,Cardiovascular Research, Department GENCOR, University of Antwerp, Antwerp, Belgium
| | - Guido Claessen
- Department of Cardiology, University Hospital Leuven, Leuven, Belgium,Department of Cardiovascular Sciences, Cardiology, Leuven University, Leuven, Belgium
| | - Wim Huybrechts
- Department of Cardiology, University Hospital, Antwerp, Belgium,Cardiovascular Research, Department GENCOR, University of Antwerp, Antwerp, Belgium
| | - Andrea Sarkozy
- Department of Cardiology, University Hospital, Antwerp, Belgium,Cardiovascular Research, Department GENCOR, University of Antwerp, Antwerp, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, University Hospital, Antwerp, Belgium,Cardiovascular Research, Department GENCOR, University of Antwerp, Antwerp, Belgium
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Graziano F, Juhasz V, Brunetti G, Cipriani A, Szabo L, Merkely B, Corrado D, D’Ascenzi F, Vago H, Zorzi A. May Strenuous Endurance Sports Activity Damage the Cardiovascular System of Healthy Athletes? A Narrative Review. J Cardiovasc Dev Dis 2022; 9:jcdd9100347. [PMID: 36286299 PMCID: PMC9604467 DOI: 10.3390/jcdd9100347] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 11/18/2022] Open
Abstract
The positive effects of physical activity are countless, not only on the cardiovascular system but on health in general. However, some studies suggest a U-shape relationship between exercise volume and effects on the cardiovascular system. On the basis of this perspective, moderate-dose exercise would be beneficial compared to a sedentary lifestyle, while very high-dose physical activity would paradoxically be detrimental. We reviewed the available evidence on the potential adverse effects of very intense, prolonged exercise on the cardiovascular system, both acute and chronic, in healthy athletes without pre-existing cardiovascular conditions. We found that endurance sports activities may cause reversible electrocardiographic changes, ventricular dysfunction, and troponin elevation with complete recovery within a few days. The theory that repeated bouts of acute stress on the heart may lead to chronic myocardial damage remains to be demonstrated. However, male veteran athletes with a long sports career show an increased prevalence of cardiovascular abnormalities such as electrical conduction delay, atrial fibrillation, myocardial fibrosis, and coronary calcifications compared to non-athletes. It must be underlined that the cause-effect relationship between such abnormalities and the exercise and, most importantly, the prognostic relevance of such findings remains to be established.
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Affiliation(s)
- Francesca Graziano
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 35122 Padova, Italy
| | - Vencel Juhasz
- Heart and Vascular Center of Semmelweis University, Hataror Rd. 18, 1122 Budapest, Hungary
| | - Giulia Brunetti
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 35122 Padova, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 35122 Padova, Italy
| | - Liliana Szabo
- Heart and Vascular Center of Semmelweis University, Hataror Rd. 18, 1122 Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center of Semmelweis University, Hataror Rd. 18, 1122 Budapest, Hungary
- Department of Sports Medicine, Semmelweis University, Gaal Jozsef Str. 9-11, 1122 Budapest, Hungary
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 35122 Padova, Italy
| | - Flavio D’Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, 53100 Siena, Italy
| | - Hajnalka Vago
- Heart and Vascular Center of Semmelweis University, Hataror Rd. 18, 1122 Budapest, Hungary
- Department of Sports Medicine, Semmelweis University, Gaal Jozsef Str. 9-11, 1122 Budapest, Hungary
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, 35122 Padova, Italy
- Correspondence: ; Tel.: +39-049-8212322
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9
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La Gerche A, Wasfy MM, Brosnan MJ, Claessen G, Fatkin D, Heidbuchel H, Baggish AL, Kovacic JC. The Athlete's Heart-Challenges and Controversies: JACC Focus Seminar 4/4. J Am Coll Cardiol 2022; 80:1346-1362. [PMID: 36075838 DOI: 10.1016/j.jacc.2022.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 12/11/2022]
Abstract
Regular exercise promotes structural, functional, and electrical remodeling of the heart, often referred to as the "athlete's heart," with intense endurance sports being associated with the greatest degree of cardiac remodeling. However, the extremes of exercise-induced cardiac remodeling are potentially associated with uncommon side effects. Atrial fibrillation is more common among endurance athletes and there is speculation that other arrhythmias may also be more prevalent. It is yet to be determined whether this arrhythmic susceptibility is a result of extreme exercise remodeling, genetic predisposition, or other factors. Gender may have the greatest influence on the cardiac response to exercise, but there has been far too little research directed at understanding differences in the sportsman's vs sportswoman's heart. Here in part 4 of a 4-part seminar series, the controversies and ambiguities regarding the athlete's heart, and in particular, its arrhythmic predisposition, genetic, and gender influences are reviewed in depth.
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Affiliation(s)
- Andre La Gerche
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; National Centre for Sports Cardiology, Fitzroy, Victoria, Australia; Cardiology Department, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.
| | - Meagan M Wasfy
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maria J Brosnan
- National Centre for Sports Cardiology, Fitzroy, Victoria, Australia; Cardiology Department, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Guido Claessen
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Diane Fatkin
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Kensington, New South Wales, Australia; Cardiology Department, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Hein Heidbuchel
- Antwerp University Hospital, Department of Cardiology, Antwerp, Belgium; Cardiovascular Sciences, Antwerp University, Antwerp, Belgium
| | - Aaron L Baggish
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jason C Kovacic
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Kensington, New South Wales, Australia; Cardiology Department, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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10
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Ramcharan T, Edwards J, O’driscoll J, Papadakis M. The Acute Impact of Endurance Exercise on Right Ventricular Structure and Function. Cardiol Clin 2022. [DOI: 10.1016/j.ccl.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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11
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Sung DJ, Jeon YK, Choi J, Kim B, Golpasandi S, Park SW, Oh SB, Bae YM. Protective effect of low-intensity treadmill exercise against acetylcholine-calcium chloride-induced atrial fibrillation in mice. Korean J Physiol Pharmacol 2022; 26:313-323. [PMID: 36039732 PMCID: PMC9437371 DOI: 10.4196/kjpp.2022.26.5.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 06/15/2023]
Abstract
Atrial fibrillation (AF) is the most common supraventricular arrhythmia, and it corresponds highly with exercise intensity. Here, we induced AF in mice using acetylcholine (ACh)-CaCl2 for 7 days and aimed to determine the appropriate exercise intensity (no, low, moderate, high) to protect against AF by running the mice at different intensities for 4 weeks before the AF induction by ACh-CaCl2. We examined the AF-induced atrial remodeling using electrocardiogram, patch-clamp, and immunohistochemistry. After the AF induction, heart rate, % increase of heart rate, and heart weight/body weight ratio were significantly higher in all the four AF groups than in the normal control; highest in the high-ex AF and lowest in the low-ex (lower than the no-ex AF), which indicates that low-ex treated the AF. Consistent with these changes, G protein-gated inwardly rectifying K+ currents, which were induced by ACh, increased in an exercise intensity-dependent manner and were lower in the low-ex AF than the no-ex AF. The peak level of Ca2+ current (at 0 mV) increased also in an exercise intensity-dependent manner and the inactivation time constants were shorter in all AF groups except for the low-ex AF group, in which the time constant was similar to that of the control. Finally, action potential duration was shorter in all the four AF groups than in the normal control; shortest in the high-ex AF and longest in the low-ex AF. Taken together, we conclude that low-intensity exercise protects the heart from AF, whereas high-intensity exercise might exacerbate AF.
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Affiliation(s)
- Dong-Jun Sung
- Department of Sport and Health Studies, College of Biomedical and Health Science, Konkuk University, Chungju 27478, Korea
- Sports Convergence Institute, Chungju 27478, Korea
- Center for Metabolic Diseases, Konkuk University, Chungju 27478, Korea
| | - Yong-Kyun Jeon
- Department of Physical Education at the Graduate School of Education, Dankook University, Yongin 16890, Korea
| | - Jaeil Choi
- Department of Physical Education at the Graduate School of Education, Dankook University, Yongin 16890, Korea
| | - Bokyung Kim
- Department of Physiology, KU Open Innovation Center, Research Institute of Medical Science, Konkuk University School of Medicine, Chungju 27478, Korea
| | - Shadi Golpasandi
- Department of Physiology, KU Open Innovation Center, Research Institute of Medical Science, Konkuk University School of Medicine, Chungju 27478, Korea
| | - Sang Woong Park
- Department of Emergency Medical Services, College of Health Sciences, Eulji University, Seongam 13135, Korea
| | - Seung-Bum Oh
- Department of Sport and Health Studies, College of Biomedical and Health Science, Konkuk University, Chungju 27478, Korea
| | - Young Min Bae
- Department of Physiology, KU Open Innovation Center, Research Institute of Medical Science, Konkuk University School of Medicine, Chungju 27478, Korea
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12
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Darden D, Scheinman MM, Hoffmayer KS. Exercise-induced arrhythmogenic right ventricular cardiomyopathy: Reverse remodeling with detraining. HeartRhythm Case Rep 2022; 8:599-603. [PMID: 36147714 PMCID: PMC9485656 DOI: 10.1016/j.hrcr.2022.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Douglas Darden
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
- Address reprint requests and correspondence: Dr Douglas Darden, University of California, San Diego, 4592 Medical Center Dr, ACTRI Bldg, 3rd Floor, Room 3E-313, La Jolla, CA 92037.
| | - Melvin M. Scheinman
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Kurt S. Hoffmayer
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
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13
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Valenzuela PL, Baggish A, Castillo-García A, Santos-Lozano A, Boraita A, Lucia A. Strenuous Endurance Exercise and the Heart: Physiological versus Pathological Adaptations. Compr Physiol 2022; 12:4067-4085. [PMID: 35950659 DOI: 10.1002/cphy.c210045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Although the benefits of regular physical activity on cardiovascular health are well established, the effects of strenuous endurance exercise (SEE) have been a matter of debate since ancient times. In this article, we aim to provide a balanced overview of what is known about SEE and the heart-from epidemiological evidence to recent cardiac imaging findings. Lifelong SEE is overall cardioprotective, with endurance master athletes showing in fact a youthful heart. Yet, some lines of research remain open, such as the need to elucidate the time-course and potential relevance of transient declines in heart function (or increases in biomarkers of cardiac injury) with SEE. The underlying mechanisms and clinical relevance of SEE-associated atrial fibrillation, myocardial fibrosis, or high coronary artery calcium scores also remain to be elucidated. © 2022 American Physiological Society. Compr Physiol 12:1-19, 2022.
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Affiliation(s)
- Pedro L Valenzuela
- Physical Activity and Health Research Group ('PaHerg'), Research Institute of the Hospital 12 de Octubre ('imas12'), Madrid, Spain
| | - Aaron Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adrián Castillo-García
- Fissac - Physiology, Health and Physical Activity, Madrid, Spain.,Biology Systems Department, University of Alcalá, Madrid, Spain
| | - Alejandro Santos-Lozano
- Physical Activity and Health Research Group ('PaHerg'), Research Institute of the Hospital 12 de Octubre ('imas12'), Madrid, Spain.,i+HeALTH, European University Miguel de Cervantes, Valladolid, Spain
| | - Araceli Boraita
- Department of Cardiology, Sports Medicine Center, Spanish Agency for Health Protection in Sports, Madrid, Spain
| | - Alejandro Lucia
- Physical Activity and Health Research Group ('PaHerg'), Research Institute of the Hospital 12 de Octubre ('imas12'), Madrid, Spain.,Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain
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14
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Sharma A, Bosman LP, Tichnell C, Nanavati J, Murray B, Nonyane BA, Tandri H, Calkins H, James CA. Arrhythmogenic Right Ventricular Cardiomyopathy Prevalence and Arrhythmic Outcomes in At-Risk Family Members: A Systematic Review and Meta-Analysis. Circ Genom Precis Med 2022; 15:e003530. [DOI: 10.1161/circgen.121.003530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a complex cardiomyopathy with autosomal dominant inheritance and age-related incomplete penetrance, characterized by a high risk of sudden cardiac death. Recent professional consensus guidelines recommend clinical cardiac lifelong serial screening for at-risk family members refined only by age, but family genotype might influence necessary screening. Although numerous studies report prevalence of disease and arrhythmia in family members and explore predictors of penetrance and arrhythmic risk, a systematic review consolidating this evidence is lacking.
Methods:
We searched Medline (PubMed), Embase, The Cochrane Library, and Web of Science for studies that reported prevalence of (1) diagnosis of ARVC per 2010 Task Force Criteria and/or (2) sustained ventricular arrhythmias (VA) in at least 10 family members of definite patients with ARVC.
Results:
We identified 41 studies, including 36 that reported diagnosis by Task Force Criteria and 22 VA. Meta-analysis of 1359 family members, from 13 unique cohorts showed an average prevalence estimate of 25% for diagnosis as per Task Force Criteria (95% CI, 0.15–0.35, I
2
=
96.44%). Overall prevalence of VA among gene-positive family members was 18% (95% CI, 0.13–0.23, I
2
=33.25%) in 7 independent studies (n=597). Family genotype was a significant risk factor for diagnosis of both ARVC (odds ratio, 6.91 [95% CI, 1.27–37.70];
P
=0.0005) and VA (odds ratio, 13.62 [95% CI, 0.91–204.13];
P
=0.06). Male gender was not associated with disease prevalence (odds ratio, 1.18 [95% CI, 0.72–1.95];
P
=0.42) or VA (odds ratio, 0.81 [95% CI, 0.51–1.29];
P
=0.91).
Conclusions:
The prevalence of ARVC and VA in at-risk family members differs significantly based on family genotype. Although recent recommendations provide a guideline based only on age, we propose screening every 1 to 2 years for gene-positive family members and every 3 to 5 years for first-degree relatives of gene-elusive cases, as long as they are asymptomatic and not athletes.
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Affiliation(s)
- Apurva Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
| | - Laurens P. Bosman
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, the Netherlands (L.P.B.)
| | - Crystal Tichnell
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
| | - Julie Nanavati
- Welch Medical Library, Johns Hopkins School of Medicine (J.N.)
| | - Brittney Murray
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
| | - Bareng A.S. Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (B.A.S.N.)
| | - Harikrishna Tandri
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
| | - Cynthia A. James
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.S., C.T., B.M., H.T., H.C., C.A.J.)
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15
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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16
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Krahn AD, Wilde AAM, Calkins H, La Gerche A, Cadrin-Tourigny J, Roberts JD, Han HC. Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Clin Electrophysiol 2022; 8:533-53. [PMID: 35450611 DOI: 10.1016/j.jacep.2021.12.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 01/21/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) encompasses a group of conditions characterized by right ventricular fibrofatty infiltration, with a predominant arrhythmic presentation. First described in the late 1970s and early 1980s, it is now frequently recognized to have biventricular involvement. The prevalence is ∼1:2,000 to 1:5,000, depending on geographic location, and it has a slight male predominance. The diagnosis of ARVC is determined on the basis of fulfillment of task force criteria incorporating electrophysiological parameters, cardiac imaging findings, genetic factors, and histopathologic features. Risk stratification of patients with ARVC aims to identify those who are at increased risk of sudden cardiac death or sustained ventricular tachycardia. Factors including age, sex, electrophysiological features, and cardiac imaging investigations all contribute to risk stratification. The current management of ARVC includes exercise restriction, β-blocker therapy, consideration for implantable cardioverter-defibrillator insertion, and catheter ablation. This review summarizes our current understanding of ARVC and provides clinicians with a practical approach to diagnosis and management.
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17
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Fyyaz S, Papadakis M. Arrhythmogenesis of Sports: Myth or Reality? Arrhythm Electrophysiol Rev 2022; 11:e05. [PMID: 35734145 PMCID: PMC9194918 DOI: 10.15420/aer.2021.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/17/2022] [Indexed: 11/09/2022] Open
Abstract
Regular exercise confers health benefits with cardiovascular mortality risk reduction through a variety of mechanisms. At a population level, evidence suggests that undertaking more exercise has greater benefits. In the modern era of sport, there has been an exponential rise in professional and amateur athletes participating in endurance events, with a progressively better understanding of the associated cardiac adaptations, collectively termed ‘athletes heart’. However, emerging data raise questions regarding the risk of potential harm from endurance exercise, with an increased risk of arrhythmia from adverse cardiac remodelling. Cross-sectional studies have demonstrated that athletes may exhibit a higher burden of AF, conduction tissue disease, ventricular arrhythmias, a cardiomyopathy-like phenotype and coronary artery disease. In an attempt to separate myth from reality, this review reports on the evidence supporting the notion of ‘too much exercise’, the purported mechanisms of exercise-induced cardiac arrhythmia and complex interplay with sporting discipline, demographics, genetics and acquired factors.
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Affiliation(s)
- Saad Fyyaz
- Cardiovascular Clinical Academic Group, St George's, University of London, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group, St George's, University of London, St George's University Hospitals NHS Foundation Trust, London, UK
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18
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Bosman LP, Wang W, Lie ØH, van Lint FHM, Rootwelt-Norberg C, Murray B, Tichnell C, Cadrin-Tourigny J, van Tintelen JP, Asselbergs FW, Calkins H, Te Riele ASJM, Haugaa KH, James CA. Integrating Exercise Into Personalized Ventricular Arrhythmia Risk Prediction in Arrhythmogenic Right Ventricular Cardiomyopathy. Circ Arrhythm Electrophysiol 2022; 15:e010221. [PMID: 35089054 DOI: 10.1161/circep.121.010221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Exercise is associated with sustained ventricular arrhythmias (VA) in Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) but is not included in the ARVC risk calculator (arvcrisk.com). The objective of this study is to quantify the influence of exercise at diagnosis on incident VA risk and evaluate whether the risk calculator needs adjustment for exercise. METHODS We interviewed ARVC patients without sustained VA at diagnosis about their exercise history. The relationship between exercise dose 3 years preceding diagnosis (average METh/wk) and incident VA during follow-up was analyzed with time-to-event analysis. The incremental prognostic value of exercise to the risk calculator was evaluated by Cox models. RESULTS We included 176 patients (male, 43.2%; age, 37.6±16.1 years) from 3 ARVC centers, of whom 53 (30.1%) developed sustained VA during 5.4 (2.7-9.7) years of follow-up. Exercise at diagnosis showed a dose-dependent nonlinear relationship with VA, with no significant risk increase <15 to 30 METh/wk. Athlete status, using 3 definitions from literature (>18, >24, and >36 METh/wk), was significantly associated with VA (hazard ratios, 2.53-2.91) but was also correlated with risk factors currently in the risk calculator model. Thus, adding athlete status to the model did not change the C index of 0.77 (0.71-0.84) and showed no significant improvement (Akaike information criterion change, <2). CONCLUSIONS Exercise at diagnosis was dose dependently associated with risk of sustained VA in ARVC patients but only above 15 to 30 METh/wk. Exercise does not appear to have incremental prognostic value over the risk calculator. The ARVC risk calculator can be used accurately in athletic patients without modification.
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Affiliation(s)
- Laurens P Bosman
- Department of Cardiology (L.P.B., F.W.A., A.S.J.M.t.R.), University Medical Center Utrecht, Utrecht University, the Netherlands.,Netherlands Heart Institute, Utrecht (L.P.B., J.P.v.T., F.W.A., A.S.J.M.t.R.)
| | - Weijia Wang
- Department of Medicine, Division of Cardiology, Johns Hopkins University, School of Medicine, Baltimore, MD (W.W., B.M., C.T., H.C., C.A.J.)
| | - Øyvind H Lie
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, University of Oslo, Norway (Ø.H.L., C.R.-N., K.H.H.)
| | - Freyja H M van Lint
- Department of Genetics (F.H.M.v.L., J.P.v.T.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Christine Rootwelt-Norberg
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, University of Oslo, Norway (Ø.H.L., C.R.-N., K.H.H.)
| | - Brittney Murray
- Department of Medicine, Division of Cardiology, Johns Hopkins University, School of Medicine, Baltimore, MD (W.W., B.M., C.T., H.C., C.A.J.)
| | - Crystal Tichnell
- Department of Medicine, Division of Cardiology, Johns Hopkins University, School of Medicine, Baltimore, MD (W.W., B.M., C.T., H.C., C.A.J.)
| | - Julia Cadrin-Tourigny
- Department of Medicine, Montreal Heart Institute, University of Montreal, Canada (J.C.-T.)
| | - J Peter van Tintelen
- Department of Genetics (F.H.M.v.L., J.P.v.T.), University Medical Center Utrecht, Utrecht University, the Netherlands.,Netherlands Heart Institute, Utrecht (L.P.B., J.P.v.T., F.W.A., A.S.J.M.t.R.)
| | - Folkert W Asselbergs
- Department of Cardiology (L.P.B., F.W.A., A.S.J.M.t.R.), University Medical Center Utrecht, Utrecht University, the Netherlands.,Netherlands Heart Institute, Utrecht (L.P.B., J.P.v.T., F.W.A., A.S.J.M.t.R.).,Faculty of Population Health Sciences, Institute of Cardiovascular Science (F.W.A.), University College London, United Kingdom.,Health Data Research UK and Institute of Health Informatics (F.W.A.), University College London, United Kingdom
| | - Hugh Calkins
- Department of Medicine, Division of Cardiology, Johns Hopkins University, School of Medicine, Baltimore, MD (W.W., B.M., C.T., H.C., C.A.J.)
| | - Anneline S J M Te Riele
- Department of Cardiology (L.P.B., F.W.A., A.S.J.M.t.R.), University Medical Center Utrecht, Utrecht University, the Netherlands.,Netherlands Heart Institute, Utrecht (L.P.B., J.P.v.T., F.W.A., A.S.J.M.t.R.)
| | - Kristina H Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, University of Oslo, Norway (Ø.H.L., C.R.-N., K.H.H.)
| | - Cynthia A James
- Department of Medicine, Division of Cardiology, Johns Hopkins University, School of Medicine, Baltimore, MD (W.W., B.M., C.T., H.C., C.A.J.)
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19
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Eberly L, Garg L, Vidula M, Reza N, Krishnan S. Running the Risk: Exercise and Arrhythmogenic Cardiomyopathy. Curr Treat Options Cardiovasc Med 2022; 23. [PMID: 35082480 DOI: 10.1007/s11936-021-00943-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Purpose of review The purpose of this review is to summarize what is known about the relationship between exercise and arrhythmogenic right ventricular cardiomyopathy (ARVC) with regard to disease onset, diagnosis, progression, and clinical severity. This relationship forms the basis of the management recommendations for restricting physical activity in individuals with and at risk for ARVC. Recent findings While ARVC can be challenging to diagnose, there are several diagnostic testing and imaging modalities that may help distinguish athletic heart remodeling from ARVC. There is an increased risk of adverse clinical outcomes in ARVC from endurance and competitive sports participation, including a dose-dependent relationship between exercise intensity and risk of disease penetrance and progression. Summary High-intensity exercise can lead to earlier disease onset, increased penetrance, and clinical progression among individuals with and at risk for ARVC. Both amount and intensity of exercise are correlated with adverse outcomes, including ventricular arrhythmias and worsening biventricular function. All individuals with and at risk for ARVC should undergo detailed clinical phenotyping and risk stratification to reduce the risk of such outcomes, including sudden cardiac death. Consensus guidelines recommend against participation in competitive or high-intensity and endurance exercise for individuals with and at risk for ARVC.
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Affiliation(s)
- Lauren Eberly
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA.,Penn Cardiovascular Center for Health Equity and Justice, University of Pennsylvania, Philadelphia, PA, USA
| | - Lohit Garg
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mahesh Vidula
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Sheela Krishnan
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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20
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Haugaa KH, Rootwelt-Norberg C. Cardiac desmosomal reserve: another piece of the exercise-induced arrhythmogenic cardiomyopathy puzzle? Eur Heart J 2021; 43:1265-1267. [PMID: 34972201 PMCID: PMC8934689 DOI: 10.1093/eurheartj/ehab873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kristina H Haugaa
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Christine Rootwelt-Norberg
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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21
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Heidbuchel H, Adami PE, Antz M, Braunschweig F, Delise P, Scherr D, Solberg EE, Wilhelm M, Pelliccia A. Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions: Part 1: Supraventricular arrhythmias. A position statement of the Section of Sports Cardiology and Exercise from the European Association of Preventive Cardiology (EAPC) and the European Heart Rhythm Association (EHRA), both associations of the European Society of Cardiology. Eur J Prev Cardiol 2021; 28:1539-1551. [PMID: 32597206 DOI: 10.1177/2047487320925635] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 01/02/2023]
Abstract
Symptoms attributable to arrhythmias are frequently encountered in clinical practice. Cardiologists and sport physicians are required to identify high-risk individuals harbouring such conditions and provide appropriate advice regarding participation in regular exercise programmes and competitive sport. The three aspects that need to be considered are: (a) the risk of life-threatening arrhythmias by participating in sports; (b) control of symptoms due to arrhythmias that are not life-threatening but may hamper performance and/or reduce the quality of life; and (c) the impact of sports on the natural progression of the underlying arrhythmogenic condition. In many cases, there is no unequivocal answer to each aspect and therefore an open discussion with the athlete is necessary, in order to reach a balanced decision. In 2006 the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology published recommendations for participation in leisure-time physical activity and competitive sport in individuals with arrhythmias and potentially arrhythmogenic conditions. More than a decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of these conditions. The present document presents a combined effort by the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology and the European Heart Rhythm Association to offer a comprehensive overview of the most updated recommendations for practising cardiologists and sport physicians managing athletes with supraventricular arrhythmias, and provides pragmatic advice for safe participation in recreational physical activities, as well as competitive sport at amateur and professional level. A companion text on recommendations in athletes with ventricular arrhythmias, inherited arrhythmogenic conditions, pacemakers and implantable defibrillators is published as Part 2 in Europace.
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Affiliation(s)
- Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp, Belgium
| | - Paolo E Adami
- Italian National Olympic Committee, Institute of Sport Medicine and Science, Italy
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Germany
| | | | | | - Daniel Scherr
- Department of Medicine, Medical University of Graz, Austria
| | | | | | - Antonio Pelliccia
- Italian National Olympic Committee, Institute of Sport Medicine and Science, Italy
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22
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Dorian D, Chatterjee D, Connelly KA, Goodman JM, Yan AT, Bentley RF, Banks L, Hamilton RM, Dorian P. A Novel Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) Biomarker—Anti-DSG2—Is Absent in Athletes With Right Ventricular Enlargement. CJC Open 2021; 3:1413-1418. [PMID: 34993452 PMCID: PMC8712542 DOI: 10.1016/j.cjco.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/02/2021] [Indexed: 11/26/2022] Open
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23
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Martínez-Solé J, Sabater-Molina M, Braza-Boïls A, Santos-Mateo JJ, Molina P, Martínez-Dolz L, Gimeno JR, Zorio E. Facts and Gaps in Exercise Influence on Arrhythmogenic Cardiomyopathy: New Insights From a Meta-Analysis Approach. Front Cardiovasc Med 2021; 8:702560. [PMID: 34733888 PMCID: PMC8558346 DOI: 10.3389/fcvm.2021.702560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 09/09/2021] [Indexed: 12/29/2022] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a genetic cardiac condition characterized by fibrofatty myocardial replacement, either at the right ventricle, at the left ventricle, or with biventricular involvement. Ventricular arrhythmias and heart failure represent its main clinical features. Exercise benefits on mental and physical health are worldwide recognized. However, patients with ACM appear to be an exception. A thorough review of the literature was performed in PubMed searching for original papers with the terms “ARVC AND sports/exercise” and “sudden cardiac death AND sports/exercise.” Additional papers were then identified through other sources and incorporated to the list. All of them had to be based on animal models or clinical series. Information was structured in a regular format, although some data were not available in some papers. A total of 34 papers were selected and processed regarding sports-related sudden cardiac death, pre-clinical models of ACM and sport, and clinical series of ACM patients engaged in sports activities. Eligible papers were identified to obtain pooled data in order to build representative figures showing the global incidence of the most important causes of sudden cardiac death in sports and the global estimates of life-threatening arrhythmic events in ACM patients engaged in sports. Tables and figures illustrate their major characteristics. The scarce points of controversy were discussed in the text. Fundamental concepts were summarized in three main issues: sports may accelerate ACM phenotype with either structural and/or arrhythmic features, restriction may soften the progression, and these rules also apply to phenotype-negative mutation carriers. Additionally, remaining gaps in the current knowledge were also highlighted, namely, the applicability of those fundamental concepts to non-classical ACM phenotypes since left dominant ACM or non-plakophillin-2 genotypes were absent or very poorly represented in the available studies. Hopefully, future research endeavors will provide solid evidence about the safest exercise dose for each patient from a personalized medicine perspective, taking into account a big batch of genetic, epigenetic, and epidemiological variables, for instance, in order to assist clinicians to provide a final tailored recommendation.
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Affiliation(s)
- Julia Martínez-Solé
- Cardiology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - María Sabater-Molina
- Laboratorio de Cardiogenética, Unidad de Cardiopatías Familiares, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.,Unidad CSUR (Centros, Servicios y Unidades de Referencia) en Cardiopatías Familiares, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain.,CIBERCV, Center for Biomedical Network Research on Cardiovascular Diseases, Madrid, Spain
| | - Aitana Braza-Boïls
- CIBERCV, Center for Biomedical Network Research on Cardiovascular Diseases, Madrid, Spain.,Unidad de Cardiopatías Familiares, Muerte Súbita y Mecanismos de Enfermedad (CaFaMuSMe), Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Juan J Santos-Mateo
- Cardiology Department, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Pilar Molina
- Unidad de Cardiopatías Familiares, Muerte Súbita y Mecanismos de Enfermedad (CaFaMuSMe), Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,Instituto de Medicina Legal y Ciencias Forenses de Valencia, Histology Unit, Universitat de València, Valencia, Spain
| | - Luis Martínez-Dolz
- Cardiology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,CIBERCV, Center for Biomedical Network Research on Cardiovascular Diseases, Madrid, Spain
| | - Juan R Gimeno
- Unidad CSUR (Centros, Servicios y Unidades de Referencia) en Cardiopatías Familiares, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain.,CIBERCV, Center for Biomedical Network Research on Cardiovascular Diseases, Madrid, Spain.,Cardiology Department, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Esther Zorio
- Cardiology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,CIBERCV, Center for Biomedical Network Research on Cardiovascular Diseases, Madrid, Spain.,Unidad de Cardiopatías Familiares, Muerte Súbita y Mecanismos de Enfermedad (CaFaMuSMe), Instituto de Investigación Sanitaria La Fe, Valencia, Spain
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24
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Palmisano A, Darvizeh F, Cundari G, Rovere G, Ferrandino G, Nicoletti V, Cilia F, De Vizio S, Palumbo R, Esposito A, Francone M. Advanced cardiac imaging in athlete's heart: unravelling the grey zone between physiologic adaptation and pathology. Radiol Med 2021; 126:1518-1531. [PMID: 34420142 PMCID: PMC8380417 DOI: 10.1007/s11547-021-01411-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 08/06/2021] [Indexed: 12/11/2022]
Abstract
Over the last decades, interest toward athlete’s heart has progressively increased, leading to improve the knowledge on exercise-induced heart modifications. Sport may act as a trigger for life-threatening arrhythmias in patients with structural or electrical abnormalities, hence requiring to improve the diagnostic capability to differentiate physiological from pathological remodeling. Pathological alterations are often subtle at the initial stages; therefore, the challenge is to promptly identify athletes at risk of sudden cardiac death during the pre-participation screening protocols. Advanced imaging modalities such as coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR) can non-invasively depict coronary vessels and provide a deep morpho-functional and structural characterization of the myocardium, in order to rule out pathological life threatening alterations, which may overlap with athletes’ heart remodeling. The purpose of the present narrative review is to provide an overview of most frequent diagnostic challenges, defining the boundaries between athlete's heart remodeling and pathological structural alteration with a focus on the role and importance of CCTA and CMR.
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Affiliation(s)
- Anna Palmisano
- Experimental Imaging Center, Radiology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Fatemeh Darvizeh
- Experimental Imaging Center, Radiology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giulia Cundari
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Rovere
- Department of Radiological and Hematological Sciences -Section of Radiology, Università Cattolica Sacro Cuore, Fondazione, Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Valeria Nicoletti
- Experimental Imaging Center, Radiology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Cilia
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia De Vizio
- Department of Radiological and Hematological Sciences -Section of Radiology, Università Cattolica Sacro Cuore, Fondazione, Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Roberto Palumbo
- School of Radiology, Campus BioMedico Univerisity, Rome, Italy
| | - Antonio Esposito
- Experimental Imaging Center, Radiology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy. .,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Marco Francone
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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25
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Vergara P, Pannone L, Calvo F, Falasconi G, Foppoli L, Cireddu M, D'Angelo G, Limite L, Boccellino A, Palmisano A, Capogrosso C, Stella S, Esposito A, Agricola E, Gulletta S, Della Bella P. Physical activity volume in patients with arrhythmogenic cardiomyopathy is associated with recurrence after ventricular tachycardia ablation. J Interv Card Electrophysiol 2021; 65:15-24. [PMID: 34313898 DOI: 10.1007/s10840-021-01019-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/02/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess the role of intense physical activity (PA) on recurrence after ventricular tachycardia (VT) ablation in arrhythmogenic cardiomyopathy (ACM). METHODS We retrospectively analyzed 63 patients with definite diagnosis of ACM who underwent to catheter ablation (CA) of VT. PA was quantified in METs per week by IPAQ questionnaire in 51 patients. VT-free survival time after ablation was analyzed by Kaplan-Meier's curves. RESULTS The weekly amount of PA was higher in patients with VT recurrence (2303.1 METs vs 1043.5 METs, p = 0.042). The best cutoff to predict VT recurrence after CA was 584 METs/week (AUC = 0.66, sensibility = 85.0%, specificity = 45.2%). Based on this cutoff, 34 patients were defined as high level athletes (Hi-PA) and 17 patients as low-level athletes (Lo-PA). During a median follow-up of 32.0 months (11.5-65.5), 22 patients (34.9%) experienced VT recurrence. Lo-PA patients had a longer VT-free survival, compared with Hi-PA patients (82.4% vs 50.0%, log-rank p = 0.025). At Cox multivariate analysis, independent predictors of the VT recurrence were PA ≥ 584 METs/week (Hi-PA) (HR = 2.61, CI 95% 1.03-6.58, p = 0.04) and late potential (LP) abolition (HR = 0.38, CI 95% 0.16-0.89, p = 0.03). CONCLUSIONS PA ≥ 584 METs/week and LP abolition were independent predictors of VT recurrence after ablation.
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Affiliation(s)
- Pasquale Vergara
- Arrhythmology Unit and Clinical Electrophysiology Laboratories, Ospedale San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Luigi Pannone
- Arrhythmology Unit and Clinical Electrophysiology Laboratories, Ospedale San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Calvo
- Arrhythmology Unit and Clinical Electrophysiology Laboratories, Ospedale San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Falasconi
- Arrhythmology Unit and Clinical Electrophysiology Laboratories, Ospedale San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Foppoli
- Arrhythmology Unit and Clinical Electrophysiology Laboratories, Ospedale San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Manuela Cireddu
- Arrhythmology Unit and Clinical Electrophysiology Laboratories, Ospedale San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe D'Angelo
- Arrhythmology Unit and Clinical Electrophysiology Laboratories, Ospedale San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Limite
- Arrhythmology Unit and Clinical Electrophysiology Laboratories, Ospedale San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Boccellino
- Arrhythmology Unit and Clinical Electrophysiology Laboratories, Ospedale San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Stefano Stella
- Cardiac Imaging Unit, Ospedale San Raffaele, Milan, Italy
| | - Antonio Esposito
- Radiology Unit, Ospedale San Raffaele, Milan, Italy.,Vita-Salute University, Milan, Italy
| | - Eustachio Agricola
- Cardiac Imaging Unit, Ospedale San Raffaele, Milan, Italy.,Vita-Salute University, Milan, Italy
| | - Simone Gulletta
- Arrhythmology Unit and Clinical Electrophysiology Laboratories, Ospedale San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Arrhythmology Unit and Clinical Electrophysiology Laboratories, Ospedale San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
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26
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Heidbuchel H, Arbelo E, D'Ascenzi F, Borjesson M, Boveda S, Castelletti S, Miljoen H, Mont L, Niebauer J, Papadakis M, Pelliccia A, Saenen J, Sanz de la Garza M, Schwartz PJ, Sharma S, Zeppenfeld K, Corrado D. Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators. Europace 2021; 23:147-148. [PMID: 32596731 DOI: 10.1093/europace/euaa106] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.
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Affiliation(s)
- Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp, University Antwerp, Wilrijkstraat 10, 2650 Antwerp, Belgium
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Flavio D'Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Mats Borjesson
- Centre for Health and Performance (CHP), Department of Food, Nutrition and Sport Sciences, Gothenburg University, Sweden.,Department of Neuroscience and Physiology, Gothenburg University, Gothenburg, Sweden
| | - Serge Boveda
- Cardiology Department, Clinique Pasteur, 45 Avenue de Lombez, 31076 Toulouse, France
| | - Silvia Castelletti
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Laboratory of Cardiovascular Genetics, Milan, Italy
| | - Hielko Miljoen
- Department of Cardiology, University Hospital Antwerp, University Antwerp, Wilrijkstraat 10, 2650 Antwerp, Belgium
| | - Lluis Mont
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Josef Niebauer
- Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Michael Papadakis
- Cardiology Clinical Academic Group, St. George's University of London, London, UK.,St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Antonio Pelliccia
- National Institute of Sports Medicine, Italian National Olympic Committee, Via dei Campi Sportivi 46, Rome, Italy
| | - Johan Saenen
- Department of Cardiology, University Hospital Antwerp, University Antwerp, Wilrijkstraat 10, 2650 Antwerp, Belgium
| | | | - Peter J Schwartz
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Laboratory of Cardiovascular Genetics, Milan, Italy
| | - Sanjay Sharma
- Cardiology Clinical Academic Group, St. George's University of London, London, UK.,St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Domenico Corrado
- Department of Cardiology, University of Padova, Padova, Italy.,Department of Pathology, University of Padova, Padova, Italy
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27
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Miguel-Dos-Santos R, Moreira JBN, Loennechen JP, Wisløff U, Mesquita T. Exercising immune cells: The immunomodulatory role of exercise on atrial fibrillation. Prog Cardiovasc Dis 2021; 68:52-59. [PMID: 34274371 DOI: 10.1016/j.pcad.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022]
Abstract
Exercise training is generally beneficial for cardiovascular health, improving stroke volume, cardiac output, and aerobic capacity. Despite these benefits, some evidence indicates that endurance training may increase the risk of atrial fibrillation (AF), particularly in highly trained individuals. Among multiple mechanisms, autonomic tone changes and atrial remodeling have been proposed as main contributors for exercise-induced AF. However, the contribution of local and systemic immunity is poorly understood in the development of atrial arrhythmogenic substrates. Here we aim to update the field of immunomodulation in the context of exercise and AF by compiling and reconciling the most recent evidence from preclinical and human studies and rationalize the applicability of "lone" AF terminology in athletes.
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Affiliation(s)
- Rodrigo Miguel-Dos-Santos
- Department of Physiology, Federal University of Sergipe, Sergipe, Brazil; Cardiac Exercise Research Group (CERG), Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - José Bianco Nascimento Moreira
- Cardiac Exercise Research Group (CERG), Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Jan Pål Loennechen
- Cardiac Exercise Research Group (CERG), Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Cardiology, St. Olav's University Hospital, Trondheim, Norway
| | - Ulrik Wisløff
- Cardiac Exercise Research Group (CERG), Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; School of Human Movement and Nutrition Science, University of Queensland, Queensland, Australia.
| | - Thássio Mesquita
- Smidt Heart Institute, Cedars-Sinai Medical Center, California, United States..
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28
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Bernhard B, Asatryan B, Gräni C. Cardiac magnetic resonance imaging characteristics for the differentiation of athlete's heart from inherited cardiomyopathies. Int J Cardiovasc Imaging 2021; 37:2517-2520. [PMID: 34185212 DOI: 10.1007/s10554-021-02306-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Babken Asatryan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.
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29
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Stadiotti I, Lippi M, Maione AS, Compagnucci P, Andreini D, Casella M, Pompilio G, Sommariva E. Cardiac Biomarkers and Autoantibodies in Endurance Athletes: Potential Similarities with Arrhythmogenic Cardiomyopathy Pathogenic Mechanisms. Int J Mol Sci 2021; 22:6500. [PMID: 34204386 DOI: 10.3390/ijms22126500] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 12/13/2022] Open
Abstract
The “Extreme Exercise Hypothesis” states that when individuals perform training beyond the ideal exercise dose, a decline in the beneficial effects of physical activity occurs. This is due to significant changes in myocardial structure and function, such as hemodynamic alterations, cardiac chamber enlargement and hypertrophy, myocardial inflammation, oxidative stress, fibrosis, and conduction changes. In addition, an increased amount of circulating biomarkers of exercise-induced damage has been reported. Although these changes are often reversible, long-lasting cardiac damage may develop after years of intense physical exercise. Since several features of the athlete’s heart overlap with arrhythmogenic cardiomyopathy (ACM), the syndrome of “exercise-induced ACM” has been postulated. Thus, the distinction between ACM and the athlete’s heart may be challenging. Recently, an autoimmune mechanism has been discovered in ACM patients linked to their characteristic junctional impairment. Since cardiac junctions are similarly impaired by intense physical activity due to the strong myocardial stretching, we propose in the present work the novel hypothesis of an autoimmune response in endurance athletes. This investigation may deepen the knowledge about the pathological remodeling and relative activated mechanisms induced by intense endurance exercise, potentially improving the early recognition of whom is actually at risk.
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30
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Pelliccia A, Sharma S, Gati S, Bäck M, Börjesson M, Caselli S, Collet J, Corrado D, Drezner JA, Halle M, Hansen D, Heidbuchel H, Myers J, Niebauer J, Papadakis M, Piepoli MF, Prescott E, Roos-hesselink JW, Stuart AG, Taylor RS, Thompson PD, Tiberi M, Vanhees L, Wilhelm M. Guía ESC 2020 sobre cardiología del deporte y el ejercicio en pacientes con enfermedad cardiovascular. Rev Esp Cardiol 2021; 74:545.e1-545.e73. [DOI: 10.1016/j.recesp.2020.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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31
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Gasperetti A, James CA, Cerrone M, Delmar M, Calkins H, Duru F. Arrhythmogenic right ventricular cardiomyopathy and sports activity: from molecular pathways in diseased hearts to new insights into the athletic heart mimicry. Eur Heart J 2021; 42:1231-1243. [PMID: 33200174 DOI: 10.1093/eurheartj/ehaa821] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/12/2020] [Accepted: 09/24/2020] [Indexed: 12/14/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited disease associated with a high risk of sudden cardiac death. Among other factors, physical exercise has been clearly identified as a strong determinant of phenotypic expression of the disease, arrhythmia risk, and disease progression. Because of this, current guidelines advise that individuals with ARVC should not participate in competitive or frequent high-intensity endurance exercise. Exercise-induced electrical and morphological para-physiological remodelling (the so-called 'athlete's heart') may mimic several of the classic features of ARVC. Therefore, the current International Task Force Criteria for disease diagnosis may not perform as well in athletes. Clear adjudication between the two conditions is often a real challenge, with false positives, that may lead to unnecessary treatments, and false negatives, which may leave patients unprotected, both of which are equally inacceptable. This review aims to summarize the molecular interactions caused by physical activity in inducing cardiac structural alterations, and the impact of sports on arrhythmia occurrence and other clinical consequences in patients with ARVC, and help the physicians in setting the two conditions apart.
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Affiliation(s)
- Alessio Gasperetti
- Division of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Cynthia A James
- Division of Cardiology, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Marina Cerrone
- Leon H Charney Division of Cardiology, New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Mario Delmar
- Leon H Charney Division of Cardiology, New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Firat Duru
- Division of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland.,Center for Integrative Human Physiology, University of Zurich, Rämistrasse 71, Zurich 8006, Switzerland
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Pelliccia A, Sharma S, Gati S, Bäck M, Börjesson M, Caselli S, Collet JP, Corrado D, Drezner JA, Halle M, Hansen D, Heidbuchel H, Myers J, Niebauer J, Papadakis M, Piepoli MF, Prescott E, Roos-Hesselink JW, Graham Stuart A, Taylor RS, Thompson PD, Tiberi M, Vanhees L, Wilhelm M. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J 2021; 42:17-96. [PMID: 32860412 DOI: 10.1093/eurheartj/ehaa605] [Citation(s) in RCA: 651] [Impact Index Per Article: 217.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Abstract
PURPOSE OF REVIEW The review addresses the role of exercise in triggering ventricular arrhythmias and promoting disease progression in arrhythmogenic cardiomyopathy (AC) patients and gene-mutation carriers, the differential diagnosis between AC and athlete's heart and current recommendations on exercise activity in AC. RECENT FINDINGS AC is an inherited heart muscle disease caused by genetically defective cell-to-cell adhesion structures (mainly desmosomes). The pathophysiological hallmark of the disease is progressive myocyte loss and replacement by fibro-fatty tissue, which creates the substrates for ventricular arrhythmias. Animal and human studies demonstrated that intense exercise, but not moderate physical activity, may increase disease penetrance, worsen the phenotype, and favor life-threatening ventricular arrhythmias. It has been proposed that in some individuals prolonged endurance sports activity may in itself cause AC (so-called exercise-induced AC). The studies agree that intense physical activity should be avoided in patients with AC and healthy gene-mutation carriers. However, low-to-moderate intensity exercise does not appear detrimental and these patients should not be entirely deprived from the many health benefits of physical activity.
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Affiliation(s)
- Alessandro Zorzi
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Riccardo Bariani
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Kalliopi Pilichou
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Barbara Bauce
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
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Albiński M, Saubade M, Benaim C, Menafoglio A, Meyer P, Capelli B, Perrin T, Trachsel L, Hagemeyer D, Casagrande D, Wilhelm M, Pirrello T, Albrecht S, Schmied C, Mivelaz Y, Tercier S, Baggish A, Gabus V. Impact of early sports specialisation on paediatric ECG. Scand J Med Sci Sports 2021; 31:1335-1341. [PMID: 33619756 DOI: 10.1111/sms.13942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
Athletes of pediatric age are growing in number. They are subject to a number of risks, among them sudden cardiac death (SCD). This study aimed to characterize the pediatric athlete population in Switzerland, to evaluate electrocardiographic findings based on the International Criteria for electrocardiography (ECG) Interpretation in Athletes, and to analyze the association between demographic data, sport type, and ECG changes. Retrospective, observational study of pediatric athletes (less than 18 years old) including medical history, physical examination, and a 12-lead resting ECG. The primary focus was on identification of normal, borderline, and abnormal ECG findings. The secondary observation was the relation between ECG and demographic, anthropometric, sport-related, and clinical data. The 891 athletes (mean 14.8 years, 35% girls) practiced 45 different sports on three different levels, representing all types of static and dynamic composition of the Classification of Sports by Mitchell. There were 75.4% of normal ECG findings, among them most commonly early repolarization, sinus bradycardia, and left ventricular hypertrophy; 4.3% had a borderline finding; 2.1% were abnormal and required further investigations, without SCD-related diagnosis. While the normal ECG findings were related to sex, age, and endurance sports, no such observation was found for borderline or abnormal criteria. Our results in an entirely pediatric population of athletes demonstrate that sex, age, and type of sports correlate with normal ECG findings. Abnormal ECG findings in pediatric athletes are rare. The International Criteria for ECG Interpretation in Athletes are appropriate for this age group.
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Affiliation(s)
- Maciej Albiński
- Department of Woman-Mother-Child, Division of Paediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Mathieu Saubade
- Center of Sports Medicine, Division of Physical and Rehabilitation Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,Department of Woman-Mother-Child, Interdisciplinary Division for Adolescent Health, Lausanne University Hospital, Lausanne, Switzerland
| | - Charles Benaim
- Center of Sports Medicine, Division of Physical and Rehabilitation Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrea Menafoglio
- Department of Cardiology, San Giovanni Hospital Bellinzona, Bellinzona, Switzerland
| | - Philippe Meyer
- Service of Cardiology, University Hospital Geneva, Geneva, Switzerland
| | - Bruno Capelli
- Department of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Tilman Perrin
- Department of Cardiology, Inselspital, University Hospital Bern, Bern University, Bern, Switzerland
| | - Lukas Trachsel
- Department of Cardiology, Inselspital, University Hospital Bern, Bern University, Bern, Switzerland
| | - Daniel Hagemeyer
- Department of Cardiology, Inselspital, University Hospital Bern, Bern University, Bern, Switzerland
| | - Damien Casagrande
- Department of Cardiology, Inselspital, University Hospital Bern, Bern University, Bern, Switzerland
| | - Matthias Wilhelm
- Department of Cardiology, Inselspital, University Hospital Bern, Bern University, Bern, Switzerland
| | - Tony Pirrello
- Swiss Federal Institute of Sports, Magglingen, Switzerland
| | | | - Christian Schmied
- Department of Cardiology, University Heart Center Zurich, University of Zurich, Zurich, Switzerland
| | - Yvan Mivelaz
- Department of Woman-Mother-Child, Paediatric Cardiology Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Stéphane Tercier
- Department of Woman-Mother-Child, Interdisciplinary Division for Adolescent Health, Lausanne University Hospital, Lausanne, Switzerland
| | - Aaron Baggish
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Vincent Gabus
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
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Abstract
Regular physical activity decreases the risk of cardiovascular disease, type II diabetes, obesity, certain cancers, and all-cause mortality. Nevertheless, there is mounting evidence that extreme exercise behaviors may be detrimental to human health. This review collates several decades of literature on the physiology and pathophysiology of ultra-marathon running, with emphasis on the cardiorespiratory implications. Herein, we discuss the prevalence and clinical significance of postrace decreases in lung function and diffusing capacity, respiratory muscle fatigue, pulmonary edema, biomarkers of cardiac injury, left/right ventricular dysfunction, and chronic myocardial remodeling. The aim of this article is to inform risk stratification for ultra-marathon and to edify best practice for personnel overseeing the events (i.e., race directors and medics).
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Affiliation(s)
- Nicholas B Tiller
- Institute of Respiratory Medicine and Exercise Physiology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Glenn M Stewart
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Camilla R Illidi
- Division of Sport, Health and Exercise Sciences, Department of Life Sciences, Brunel University London, UNITED KINGDOM
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, and University of Texas Southwestern Medical Center, Dallas, TX
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Lakin R, Debi R, Yang S, Polidovitch N, Goodman JM, Backx PH. Differential negative effects of acute exhaustive swim exercise on the right ventricle are associated with disproportionate hemodynamic loading. Am J Physiol Heart Circ Physiol 2021; 320:H1261-H1275. [PMID: 33416456 DOI: 10.1152/ajpheart.00603.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Acute exhaustive endurance exercise can differentially impact the right ventricle (RV) versus the left ventricle (LV). However, the hemodynamic basis for these differences and its impact on postexercise recovery remain unclear. Therefore, we assessed cardiac structure and function along with hemodynamic properties of mice subjected to single bouts (216 ± 8 min) of exhaustive swimming (ES). One-hour after ES, LVs displayed mild diastolic impairment compared with that in sedentary (SED) mice. Following dobutamine administration to assess functional reserve, diastolic and systolic function were slightly impaired. Twenty-four hours after ES, LV function was largely indistinguishable from that in SED. By contrast, 1-h post swim, RVs showed pronounced impairment of diastolic and systolic function with and without dobutamine, which persisted 24 h later. The degree of RV impairment correlated with the time-to-exhaustion. To identify hemodynamic factors mediating chamber-specific responses to ES, LV pressure was recorded during swimming. Swimming initiated immediate increases in heart rates (HRs), systolic pressure, dP/dtmax and -dP/dtmin, which remained stable for ∼45 min. LV end-diastolic pressures (LVEDP) increased to ≥45 mmHg during the first 10 min and subsequently declined. After 45 min, HR and -dP/dtmin declined, which correlated with gradual elevations in LVEDP (to ∼45 mmHg) as mice approached exhaustion. All parameters rapidly normalized postexercise. Consistent with human studies, our findings demonstrate a disproportionate negative impact of acute exhaustive exercise on RVs that persisted for at least 24 h. We speculate that the differential effects of exhaustive exercise on the ventricles arise from a ∼2-fold greater hemodynamic load in the RV than in LV originating from profound elevations in LVEDPs as mice approach exhaustion.NEW & NOTEWORTHY Acute exhaustive exercise differentially impacts the right ventricle (RV) versus left ventricle (LV), yet the underlying hemodynamic basis remains unclear. Using pressure-volume analyses and pressure-telemetry implantation in mice, we confirmed a marked disproportionate and persistent negative impact of exhaustive exercise on the RV. These differences in responses of the ventricles to exhaustive exercise are of clinical relevance, reflecting ∼2-fold greater hemodynamic RV loads versus LVs arising from massive (∼45 mmHg) increases in LV end-diastolic pressures at exhaustion.
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Affiliation(s)
- Robert Lakin
- Department of Exercise Sciences, University of Toronto, Toronto, Ontario, Canada.,Department of Biology, York University, Toronto, Ontario, Canada.,Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Ryan Debi
- Department of Biology, York University, Toronto, Ontario, Canada
| | - Sibao Yang
- Department of Biology, York University, Toronto, Ontario, Canada.,Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Nazari Polidovitch
- Department of Biology, York University, Toronto, Ontario, Canada.,Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Jack M Goodman
- Department of Exercise Sciences, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Peter H Backx
- Department of Biology, York University, Toronto, Ontario, Canada.,Division of Cardiology, University Health Network, Toronto, Ontario, Canada
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La Gerche A. Exercise-Induced Arrhythmogenic (Right Ventricular) Cardiomyopathy Is Real…if you Consider it. JACC Cardiovasc Imaging 2020; 14:159-161. [PMID: 33221208 DOI: 10.1016/j.jcmg.2020.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 11/24/2022]
Affiliation(s)
- André La Gerche
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Australia; National Centre for Sports Cardiology, St. Vincent's Hospital Melbourne, Fitzroy, Australia.
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38
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Lie ØH, Klaboe LG, Dejgaard LA, Skjølsvik ET, Grimsmo J, Bosse G, Hopp E, Edvardsen T, Haugaa KH. Cardiac Phenotypes and Markers of Adverse Outcome in Elite Athletes With Ventricular Arrhythmias. JACC Cardiovasc Imaging 2021; 14:148-58. [PMID: 33129723 DOI: 10.1016/j.jcmg.2020.07.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/24/2020] [Accepted: 07/29/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVES This study describes the cardiac phenotypes and markers of adverse outcome in athletes with ventricular arrhythmias with no other discernable etiology than high exercise doses. BACKGROUND Little is known about phenotypes and risk markers of life-threatening arrhythmic events in athletes with ventricular arrhythmia. METHODS We compared high-performance athletes who have ventricular arrhythmia with healthy controls using clinical data and cardiac imaging. None of the patients had family history of arrhythmogenic cardiomyopathy or any other discernable etiology of ventricular arrhythmia. Right (RV) and left ventricular (LV) function was assessed by echocardiographic longitudinal strain (right ventricular free wall strain longitudinal [RVFWSL] and left ventricular global longitudinal strain [LVGLS]). Mechanical dispersion was defined as the standard deviation of time to peak strain in 16 LV segments. RV ejection fraction and presence of late gadolinium enhancement was assessed by cardiac magnetic resonance. RESULTS We included 43 athletes (45 ± 14 years of age, 16% female) with ventricular arrhythmias and 30 healthy athletes (41 ± 9 years of age, 7% female). Athletes with ventricular arrhythmias had worse RV function than healthy athletes by echocardiography (RVFWSL: -22.9 ± 4.8% vs. -26.6 ± 3.3%; p < 0.001) and by cardiac magnetic resonance (RV ejection fraction 48 ± 7% vs. 52 ± 6%; p = 0.04), and had more late gadolinium enhancement (24% vs. 3%; p = 0.03). Life-threatening arrhythmic events (aborted cardiac arrest, sustained ventricular tachycardia, or appropriate implantable cardioverter-defibrillator therapy) had occurred in 23 (53%) athletes with ventricular arrhythmias. These had impaired LV function compared to those with less severe ventricular arrhythmias (LVGLS: -17.1 ± 3.0% vs. -18.8 ± 2.0%; p = 0.04). LV mechanical dispersion was an independent marker of life-threatening events (adjusted odds ratio: 2.2 [1.1 to 4.8] by 10 ms increments; p = 0.03). CONCLUSIONS Athletes with ventricular arrhythmias had impaired RV function and more myocardial fibrosis compared to healthy athletes. Athletes with life-threatening arrhythmic events had additional LV contraction abnormalities. These phenotypes mimic arrhythmogenic cardiomyopathy and may potentially be induced by high doses of exercise in susceptible individuals.
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Dempsey JA, La Gerche A, Hull JH. Is the healthy respiratory system built just right, overbuilt, or underbuilt to meet the demands imposed by exercise? J Appl Physiol (1985) 2020; 129:1235-1256. [PMID: 32790594 DOI: 10.1152/japplphysiol.00444.2020] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In the healthy, untrained young adult, a case is made for a respiratory system (airways, pulmonary vasculature, lung parenchyma, respiratory muscles, and neural ventilatory control system) that is near ideally designed to ensure a highly efficient, homeostatic response to exercise of varying intensities and durations. Our aim was then to consider circumstances in which the intra/extrathoracic airways, pulmonary vasculature, respiratory muscles, and/or blood-gas distribution are underbuilt or inadequately regulated relative to the demands imposed by the cardiovascular system. In these instances, the respiratory system presents a significant limitation to O2 transport and contributes to the occurrence of locomotor muscle fatigue, inhibition of central locomotor output, and exercise performance. Most prominent in these examples of an "underbuilt" respiratory system are highly trained endurance athletes, with additional influences of sex, aging, hypoxic environments, and the highly inbred equine. We summarize by evaluating the relative influences of these respiratory system limitations on exercise performance and their impact on pathophysiology and provide recommendations for future investigation.
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Affiliation(s)
- Jerome A Dempsey
- John Robert Sutton Professor of Population Health Sciences, John Rankin Laboratory of Pulmonary Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Andre La Gerche
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Australia.,National Center for Sports Cardiology, St. Vincent's Hospital, Melbourne, Fitzroy, Australia
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom.,Institute of Sport, Exercise and Health (ISEH), University College London, United Kingdom
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Gasperetti A, Dello Russo A, Busana M, Dessanai M, Pizzamiglio F, Saguner AM, te Riele AS, Sommariva E, Vettor G, Bosman L, Duru F, Zeppilli P, Di Biase L, Natale A, Tondo C, Casella M. Novel risk calculator performance in athletes with arrhythmogenic right ventricular cardiomyopathy. Heart Rhythm 2020; 17:1251-1259. [DOI: 10.1016/j.hrthm.2020.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 03/06/2020] [Indexed: 12/17/2022]
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Mascia G, Arbelo E, Porto I, Brugada R, Brugada J. The arrhythmogenic right ventricular cardiomyopathy in comparison to the athletic heart. J Cardiovasc Electrophysiol 2020; 31:1836-1843. [PMID: 32367567 DOI: 10.1111/jce.14526] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/25/2020] [Accepted: 04/24/2020] [Indexed: 01/02/2023]
Abstract
Intense exercise-induced right ventricular remodeling is a potential adaptation of cardiac function and structure. The features of the remodeling may overlap with those of a very early form of arrhythmogenic right ventricular cardiomyopathy (ARVC): at this early stage, it could be difficult to discriminate ARVC, from exercise-induced cardiac adaptation that may develop in normal individuals. The purpose of this paper is to discuss which exercise-induced remodeling may be a pathological or a physiological finding. A complete evaluation may be required to identify the pathological features of ARVC that would include potential risk of sudden cardiac death during sport or, to avoid the false diagnosis of ARVC. The most recent expert assessment of arrhythmogenic cardiomyopathy focuses on endurance athletes presenting with clinical features indistinguishable from ARVC.
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Affiliation(s)
- Giuseppe Mascia
- Department of Internal Medicine (DIMI) Clinic of Cardiovascular Diseases, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Italian IRCCS Cardiovascular Network, Genoa, Italy.,Cardiology and Electrophysiology Unit, Department of Internal Medicine, Azienda USL Toscana Centro, Florence, Italy
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Institut d'Investigaciò August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Italo Porto
- Department of Internal Medicine (DIMI) Clinic of Cardiovascular Diseases, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Italian IRCCS Cardiovascular Network, Genoa, Italy
| | - Ramon Brugada
- Cardiovascular Genetics Center, Institut d'Investigació Biomèdica Girona (IDIBGI), University of Girona, Girona, Spain
| | - Josep Brugada
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Institut d'Investigaciò August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Stevens TL, Wallace MJ, Refaey ME, Roberts JD, Koenig SN, Mohler PJ. Arrhythmogenic Cardiomyopathy: Molecular Insights for Improved Therapeutic Design. J Cardiovasc Dev Dis 2020; 7:E21. [PMID: 32466575 DOI: 10.3390/jcdd7020021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/17/2020] [Accepted: 05/20/2020] [Indexed: 02/07/2023] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an inherited disorder characterized by structural and electrical cardiac abnormalities, including myocardial fibro-fatty replacement. Its pathological ventricular substrate predisposes subjects to an increased risk of sudden cardiac death (SCD). ACM is a notorious cause of SCD in young athletes, and exercise has been documented to accelerate its progression. Although the genetic culprits are not exclusively limited to the intercalated disc, the majority of ACM-linked variants reside within desmosomal genes and are transmitted via Mendelian inheritance patterns; however, penetrance is highly variable. Its natural history features an initial “concealed phase” that results in patients being vulnerable to malignant arrhythmias prior to the onset of structural changes. Lack of effective therapies that target its pathophysiology renders management of patients challenging due to its progressive nature, and has highlighted a critical need to improve our understanding of its underlying mechanistic basis. In vitro and in vivo studies have begun to unravel the molecular consequences associated with disease causing variants, including altered Wnt/β-catenin signaling. Characterization of ACM mouse models has facilitated the evaluation of new therapeutic approaches. Improved molecular insight into the condition promises to usher in novel forms of therapy that will lead to improved care at the clinical bedside.
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Leischik R, Dworrak B, Strauss M, Horlitz M, Pareja-Galeano H, de la Guía-Galipienso F, Lippi G, Lavie CJ, Perez MV, Sanchis-Gomar F. Special Article - Exercise-induced right ventricular injury or arrhythmogenic cardiomyopathy (ACM): The bright side and the dark side of the moon. Prog Cardiovasc Dis 2020; 63:671-681. [PMID: 32224113 DOI: 10.1016/j.pcad.2020.03.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023]
Abstract
There is still debate on the range of normal physiologic changes of the right ventricle or ventricular (RV) function in athletes. Genetic links to arrhythmogenic cardiomyopathy (ACM) are well-established. There is no current consensus on the importance of extensive exercise and exercise-induced injury to the RV. During the intensive exercise of endurance sports, the cardiac structures adapt to athletic load over time. Some athletes develop RV cardiomyopathy possibly caused by genetic predisposition, whilst others develop arrhythmias from the RV. Endurance sports lead to increased volume and pressure load in both ventricles and increased myocardial mass. The extent of volume increase and changes in myocardial structure contribute to impairment of RV function and pose a challenge in cardiovascular sports medicine. Genetic predisposition to ACM may play an important role in the risk of sudden cardiac death of athletes. In this review, we discuss and evaluate existing results and opinions. Intensive training in competitive dynamic/power and endurance sports leads to specific RV adaptation, but physiological adaptation without genetic predisposition does not necessarily lead to severe complications in endurance sports. Discriminating between physiological adaptation and pathological form of ACM or RV impairment provoked by reinforced exercise presents a challenge to clinical sports cardiologists.
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Affiliation(s)
- Roman Leischik
- Department of Cardiology, Section Prevention and Sports Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, 58095 Witten, Germany.
| | - Birgit Dworrak
- Department of Cardiology, Section Prevention and Sports Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, 58095 Witten, Germany
| | - Marcus Strauss
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure Medicine, University Hospital Muenster, Cardiol, 48149 Muenster, Germany
| | - Mark Horlitz
- Department of Cardiology, Section Prevention and Sports Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, 58095 Witten, Germany
| | - Helios Pareja-Galeano
- Facultad de Ciencias del Deporte y Fisioterapia, Universidad Europea, 28670 Madrid, Spain
| | - Fernando de la Guía-Galipienso
- Cardiology Service of Marina Baixa Hospital, Alicante, Spain; REMA Sports Cardiology Clinic, 03700 Denia, Alicante, Spain
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, 37134 Verona, Italy
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, 70121 New Orleans, LA, USA
| | - Marco V Perez
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 94305-5110 Stanford, CA, USA
| | - Fabian Sanchis-Gomar
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 94305-5110 Stanford, CA, USA; Department of Physiology, Faculty of Medicine, University of Valencia and INCLIVA Biomedical Research Institute, 46010 Valencia, Spain.
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Abstract
Regular aerobic physical exercise of moderate intensity is undeniably associated with improved health and increased longevity, with some studies suggesting that more is better. Endurance athletes exceed the usual recommendations for exercise by 15-fold to 20-fold. The need to sustain a large cardiac output for prolonged periods is associated with a 10-20% increase in left and right ventricular size and a substantial increase in left ventricular mass. A large proportion of endurance athletes have raised levels of cardiac biomarkers (troponins and B-type natriuretic peptide) and cardiac dysfunction for 24-48 h after events, but what is the relevance of these findings? In the longer term, some endurance athletes have an increased prevalence of coronary artery disease, myocardial fibrosis and arrhythmias. The inherent association between these 'maladaptations' and sudden cardiac death in the general population raises the question of whether endurance exercise could be detrimental for some individuals. However, despite speculation that these abnormalities confer an increased risk of future adverse events, elite endurance athletes have an increased life expectancy compared with the general population.
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Affiliation(s)
- Gemma Parry-Williams
- Cardiology Clinical and Academic Group, St. George's University of London, London, UK
| | - Sanjay Sharma
- Cardiology Clinical and Academic Group, St. George's University of London, London, UK.
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45
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Prior D, La Gerche A. Exercise and Arrhythmogenic Right Ventricular Cardiomyopathy. Heart Lung Circ 2019; 29:547-555. [PMID: 31964580 DOI: 10.1016/j.hlc.2019.12.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/08/2019] [Accepted: 12/10/2019] [Indexed: 01/30/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a group of cardiomyopathies associated with ventricular arrhythmias predominantly arising from the right ventricle, sudden cardiac death and right ventricular failure, caused largely due to inherited mutations in proteins of the desmosomal complex. Whilst long recognised as a cause of sudden cardiac death (SCD) during exercise, it has recently been recognised that intense and prolonged exercise can worsen the disease resulting in earlier and more severe phenotypic expression. Changes in cardiac structure and function as a result of exercise training also pose challenges with diagnosis as enlargement of the right ventricle is commonly seen in endurance athletes. Advice regarding restriction of exercise is an important part of patient management, not only of those with established disease, but also in individuals known to carry gene mutations associated with development of ARVC.
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Affiliation(s)
- David Prior
- National Centre for Sports Cardiology, St Vincent's Hospital, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne at St Vincent's Hospital (Melbourne), Melbourne, Vic, Australia.
| | - Andre La Gerche
- National Centre for Sports Cardiology, St Vincent's Hospital, Melbourne, Vic, Australia; Baker Heart & Diabetes Institute, Melbourne, Vic, Australia
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Pelliccia A, Caselli S, Sharma S, Basso C, Bax JJ, Corrado D, D'Andrea A, D'Ascenzi F, Di Paolo FM, Edvardsen T, Gati S, Galderisi M, Heidbuchel H, Nchimi A, Nieman K, Papadakis M, Pisicchio C, Schmied C, Popescu BA, Habib G, Grobbee D, Lancellotti P. European Association of Preventive Cardiology (EAPC) and European Association of Cardiovascular Imaging (EACVI) joint position statement: recommendations for the indication and interpretation of cardiovascular imaging in the evaluation of the athlete's heart. Eur Heart J 2019; 39:1949-1969. [PMID: 29029207 DOI: 10.1093/eurheartj/ehx532] [Citation(s) in RCA: 174] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/23/2017] [Indexed: 12/14/2022] Open
Affiliation(s)
- Antonio Pelliccia
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | - Stefano Caselli
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | | | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Jeroen J Bax
- Departmentt of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Antonello D'Andrea
- Department of Cardiology, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Flavio D'Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Fernando M Di Paolo
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | - Thor Edvardsen
- Department of Cardiology, Center of Cardiologic Innovation, Oslo University Hospital, University of Oslo, Oslo, Norway
| | | | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Hein Heidbuchel
- Jessa Hospital, Hasselt University and Heart Center Hasselt, Hasselt, Belgium
| | | | - Koen Nieman
- Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Cataldo Pisicchio
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | | | - Bogdan A Popescu
- Institute of Cardiovascular Diseases, University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania
| | - Gilbert Habib
- Department of Cardiology, Hôpital La Timone, Marseille, France
| | - Diederick Grobbee
- Department of Epidemiology, University Medical Center, Utrecht, The Netherlands
| | - Patrizio Lancellotti
- Department of Cardiology, GIGA Cardiovascular Sciences, University of Liège Hospital, Valvular Disease Clinic, Belgium
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Tran M, Kwon A, Holt D, Kierle R, Fitzgerald B, Scalia I, Scalia W, Holt G, Scalia G. Echocardiographic Pulmonary to Left Atrial Ratio (ePLAR): A Comparison Study between Ironman Athletes, Age Matched Controls and A General Community Cohort. J Clin Med 2019; 8:E1756. [PMID: 31652633 DOI: 10.3390/jcm8101756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/11/2019] [Accepted: 10/18/2019] [Indexed: 01/10/2023] Open
Abstract
Background: During exercise there is a proportionally lower rise in systemic and pulmonary pressures compared to cardiac output due to reduced vascular resistance. Invasive exercise data suggest that systemic vascular resistance reduces more than pulmonary vascular resistance. The aim of this study was the non-invasive assessment of exercise hemodynamics in ironman athletes, compared with an age matched control group and a larger general community cohort. Methods: 20 ironman athletes (40 ± 11 years, 17 male) were compared with 20 age matched non-athlete controls (43 ± 7 years, 10 male) and a general community cohort of 230 non-athletes individuals (66 ± 11 years, 155 male), at rest and after maximal-symptom limited treadmill exercise stress echocardiography. Left heart parameters (mitral E-wave, e’-wave and E/e’) and right heart parameters (tricuspid regurgitation maximum velocity and right ventricular systolic pressure), were used to calculate the echocardiographic Pulmonary to Left Atrial Ratio (ePLAR) value of the three groups. Results: Athletes exercised for 12.2 ± 0.53 min, age matched controls for 10.1 ± 2.8 min and general community cohort for 8.3 ± 2.6 min. Mitral E/e’ rose slightly for athletes (0.9 ± 1.8), age matched controls (0.6 ± 3.0) and non-athletes (0.4 ± 3.2). Right ventricular systolic pressure increased significantly more in athletes than in both non-athlete cohorts (35.6 ± 17 mmHg vs. 20.4 ± 10.8 mmHg and 18 ± 9.6 mmHg). The marker of trans-pulmonary gradient, ePLAR, rose significantly more in athletes than in both non-athlete groups (0.15 ± 0.1 m/s vs. 0.07 ± 0.1 m/s). Conclusions: Pulmonary pressures increased proportionally four-fold compared with systemic pressures in ironman athletes. This increase in pulmonary vascular resistance corresponded with a two-fold increase in ePLAR. These changes were exaggerated compared with both non-ironman cohorts. Such changes have been previously suggested to lead to right ventricle dysfunction, arrhythmias and sudden cardiac death.
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Abstract
We examine 2 means by which the healthy respiratory system contributes to exercise limitation. These include the activation of respiratory and locomotor muscle afferent reflexes, which constrain blood flow and hasten fatigue in both sets of muscles, and the excessive increases in pulmonary vascular pressures at high cardiac outputs, which constrain O2 transport and precipitate maladaptive right ventricular remodeling in endurance-trained subjects.
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Affiliation(s)
- Jerome A Dempsey
- Department Population Health Sciences, University of Wisconsin-Madison, 707 WARF Building, 610 N. Walnut Street, WI 53726, USA.
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Towbin JA, McKenna WJ, Abrams DJ, Ackerman MJ, Calkins H, Darrieux FCC, Daubert JP, de Chillou C, DePasquale EC, Desai MY, Estes NAM, Hua W, Indik JH, Ingles J, James CA, John RM, Judge DP, Keegan R, Krahn AD, Link MS, Marcus FI, McLeod CJ, Mestroni L, Priori SG, Saffitz JE, Sanatani S, Shimizu W, van Tintelen JP, Wilde AAM, Zareba W. 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy. Heart Rhythm 2019; 16:e301-e372. [PMID: 31078652 DOI: 10.1016/j.hrthm.2019.05.007] [Citation(s) in RCA: 406] [Impact Index Per Article: 81.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Indexed: 02/08/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.
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Affiliation(s)
- Jeffrey A Towbin
- Le Bonheur Children's Hospital, Memphis, Tennessee; University of Tennessee Health Science Center, Memphis, Tennessee
| | - William J McKenna
- University College London, Institute of Cardiovascular Science, London, United Kingdom
| | | | | | | | | | | | | | | | | | - N A Mark Estes
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Wei Hua
- Fu Wai Hospital, Beijing, China
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Roy M John
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel P Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Roberto Keegan
- Hospital Privado Del Sur, Buenos Aires, Argentina; Hospital Español, Bahia Blanca, Argentina
| | | | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | - Frank I Marcus
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | | | - Luisa Mestroni
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Silvia G Priori
- University of Pavia, Pavia, Italy; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); ICS Maugeri, IRCCS, Pavia, Italy
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - J Peter van Tintelen
- University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Utrecht University Medical Center Utrecht, University of Utrecht, Department of Genetics, Utrecht, the Netherlands
| | - Arthur A M Wilde
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Heidbuchel H. The athlete's heart is a proarrhythmic heart, and what that means for clinical decision making. Europace 2019; 20:1401-1411. [PMID: 29244075 DOI: 10.1093/europace/eux294] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 08/25/2017] [Indexed: 12/19/2022] Open
Abstract
Recurring questions when dealing with arrhythmias in athletes are about the cause of the arrhythmia and, more importantly, about the eligibility of the athlete to continue sports activities. In essence, the relation between sports and arrhythmias can be understood along three lines: sports as arrhythmia trigger on top of an underlying problem, sports as arrhythmic substrate promotor, or sports as substrate inducer. Often, there is no sharp divider line between these entities. The athlete's heart, a heart that adapts so magically to cope with the demands of exercise, harbours many structural and functional changes that by themselves predispose to arrhythmia development, at the atrial, nodal and ventricular levels. In essence, the athlete's heart is a proarrhythmic heart. This review describes the changes in the athlete's heart that are related to arrhythmic expression and focuses on what this concept means for clinical decision making. The concept of the athlete's heart as a proarrhythmic heart creates a framework for evaluation and counselling of athletes, yet also highlights the difficulty in predicting the magnitude of associated risk. The management uncertainties are discussed for specific conditions like extreme bradycardic remodelling, atrioventricular nodal reentrant tachycardia, atrial fibrillation and flutter, and ventricular arrhythmias.
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Affiliation(s)
- Hein Heidbuchel
- Department of Cardiology, Antwerp University and University Hospital Antwerp, Wilrijkstraat 10, Edegem, Belgium
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