Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks Into Perspective-An Update: A Scientific Statement From the American Heart Association

Biomarkers of aging: from molecules and surrogates to physiology and function

Many countries face an unprecedented challenge in aging demographics. This has led to an exponential growth in research on aging, which, coupled to a massive financial influx of funding in the private and public sectors, has resulted in seminal insights into the underpinnings of this biological process. However, critical validation in humans has been hampered by the limited translatability of results obtained in model organisms, additionally confined by the need for extremely time-consuming clinical studies in the ostensible absence of robust biomarkers that would allow monitoring in shorter time frames. In the future, molecular parameters might hold great promise in this regard. In contrast, biomarkers centered on function, resilience, and frailty are available at the present time, with proven predictive value for morbidity and mortality. In this review, the current knowledge of molecular and physiological aspects of human aging, potential antiaging strategies, and the basis, evidence, and potential application of physiological biomarkers in human aging are discussed.

Adherence Trends to Physical Activity Guidelines in Adults With Cardiovascular Diseases and the Impact of Wearables on Adherence: Findings From a National Representative Sample

BACKGROUND

Physical activity (PA) is crucial for primary and secondary prevention of cardiovascular diseases (CVDs); however, adherence to PA guidelines remains challenging.

OBJECTIVES

We examined adherence trends to PA guidelines among adults with CVD and the effects of engagement with wearables on adherence.

METHODS

We used data from 3 cycles of the Health Information National Trends Survey collected in 2019, 2020, and 2022. Adults 18 years or older with a self-reported history of CVD were included in the study. Adherence to PA guidelines was measured as self-reported engagement in at least 150 min/wk of moderate-intensity aerobic PA and a minimum of 2 d/wk of muscle-strengthening activity. Engagement with wearables was assessed as the use of wearables within the past 12 months and the frequency of use in the past month. Weighted multivariate logistic regression was used to examine the effect of engagement on adherence to the PA guidelines.

RESULTS

The sample comprised 1540 respondents. The estimated proportions of adults with CVD who adhered to aerobic PA guidelines were 22.9% (95% confidence interval [CI], 16.8-27.8), 29.6% (95% CI, 21.8-35.4), and 27.2% (95% CI, 21.8-30.0) in 2019, 2020, and 2022, respectively. In addition, 24.0% (95% CI, 18.4-29.7), 25.6% (95% CI, 18.9-32.3), and 26.8% (95% CI, 21.1-32.4) adhered to muscle-strengthening activity guidelines in 2019, 2020, and 2022, respectively. There were no significant changes in adherence trends for either aerobic (odds ratio [OR], 1.12; P = .228) or muscle-strengthening (OR, 1.07; P = .508) activities in the included years. The use of wearables was positively associated with adherence to aerobic PA (OR, 2.72; P = .023) and muscle-strengthening activity (OR, 2.85; P = .020) in the cumulative years.

CONCLUSIONS

Adherence to PA guidelines among adults with CVD remains consistently low. However, the use of wearables may be beneficial for promoting adherence.

Biological variation of cardiac biomarkers in athletes during an entire sport season

OBJECTIVES

Cardiac biomarkers are useful for the diagnostic and prognostic assessment of myocardial injury (MI) and heart failure. By measuring specific proteins released into the bloodstream during heart stress or damage, these biomarkers help clinicians detect the presence and extent of heart injury and tailor appropriate treatment plans. This study aims to provide robust biological variation (BV) data for cardiac biomarkers in athletes, specifically focusing on those applied to detect or exclude MI, such as myoglobin, creatine kinase-myocardial band (CK-MB) and cardiac troponins (cTn), and those related to heart failure and cardiac dysfunction, brain natriuretic peptide (BNP) and N-terminal brain natriuretic pro-peptide (NT-proBNP).

METHODS

Thirty athletes participated, providing monthly fasting blood samples over 11 months. Samples were analyzed using chemiluminescent immunoassays and statistical analyses were conducted using the classical ANOVA method, a linear mixed model and a Bayesian approach.

RESULTS

The study observed significant gender differences in biomarker concentrations, with higher BNP and NT-proBNP in females and higher myoglobin and CK-MB in males. Physical activity within 24 h before sampling notably affected CK-MB, myoglobin, and hs-cTnI variability. The BV estimates demonstrated high individuality for most biomarkers, suggesting their potential for personalized monitoring. The study also revealed substantial heterogeneity for NT-proBNP and BNP within the population.

CONCLUSIONS

These findings underscore the importance of considering gender-specific reference intervals and the impact of recent physical activity when interpreting cardiac biomarkers in athletes. The study delivers new BV estimates for CK-MB and myoglobin while emphasizing the need for tailored clinical assessments in athlete populations.

High-Volume Physical Activity and Clinical Coronary Artery Disease Outcomes: Findings From the Cooper Center Longitudinal Study

BACKGROUND

High-volume physical activity (PA) is associated with a higher prevalence of subclinical coronary artery disease (CAD). However, the clinical significance of subclinical CAD among high-volume exercisers remains incompletely understood, and the dose-response relationship between high-volume PA and clinical CAD events remains uncertain.

METHODS

Individual participant data from the Cooper Center Longitudinal Study (1987-2018) were linked to Medicare claims files. PA volume was determined by self-report and categorized as <500, 500 to 1499, 1500 to 2999, and ≥3000 metabolic equivalent of task (MET)-minutes per week. Subclinical CAD (coronary artery calcium [CAC]) was measured by cardiac computed tomography. All other risk factors were measured in the standard fashion. Composite CAD events (acute myocardial infarction and revascularization) and all-cause mortality were determined from Medicare claims files. A multivariable-adjusted proportional hazards illness-death model with random shared frailty was used to estimate the association between PA volume, CAC, and both clinical CAD and death. Heterogeneity in the association between CAC and clinical CAD across levels of PA was determined with multiplicative interaction terms.

RESULTS

We included 26 724 participants (54 years of age; 28% women). Mean exercise volume was 1130 MET-minutes per week, with 1997 (7.5%) reporting ≥3000 MET-minutes per week. After a mean follow-up of 20.5 years, we observed 811 acute myocardial infarction events, 1636 composite CAD events, and 2857 deaths without CAD. Compared with individuals exercising <500 MET-minutes per week, the lowest risk for acute myocardial infarction occurred among individuals with intermediate PA volumes (500-1499 MET-minutes per week: hazard ratio [HR], 0.77 [95% CI, 0.65-0.91]; 1500-2499 MET-minutes per week: HR, 0.78 [95% CI, 0.63-0.95]). There was no association between high-volume PA (>3000 MET-minutesw per week) and risk for acute myocardial infarction (HR, 0.95 [95% CI, 0.72-1.25]). In contrast, the lowest risk for death was observed among the high-volume PA group (HR, 0.71 [95% CI, 0.60-0.83]). CAC (on log scale) was associated with a higher risk for composite CAD across all PA categories, including among the high-volume PA subgroup (HR, 1.29 [95% CI, 1.16-1.44]; P<0.001; Pinteraction= 0.969).

CONCLUSIONS

Compared with low-volume PA, high-volume PA was associated with a lower risk for all-cause mortality but a similar risk for clinical CAD. CAC was associated with an increased risk for clinical CAD regardless of the volume of PA.

Sex Differences in Response to a 12-Week Resistance Training Exercise Intervention After Cardiac Surgery: A Proof-of-Concept Intervention Trial

PURPOSE

Cardiopulmonary rehabilitation, which often follows major acute cardiac events, is traditionally focused on aerobic exercise and has been associated with decreased morbidity and mortality. Its benefit among cardiac surgery patients is less clear, as is the role of resistance-based exercise programs and their sex-specific effects. This study seeks to evaluate the safety and feasibility of a 12-week resistance training program in patients post cardiac surgery through a sex-specific lens.

METHODS

We conducted a nonrandomized feasibility trial with a 12-week strength training exercise intervention. The primary outcome was safety and feasibility. Secondary outcomes included changes in strength, endurance, and functional capacity; and sex differences among these. Adult participants post open-heart surgery who had completed traditional cardiac rehabilitation were consented. Both patients who completed (cases) or did not complete (controls) a tailored 12-week resistance training program underwent comprehensive assessment of physiologic and physical fitness measures pre- and postintervention.

FINDINGS

Nine participants enrolled in the trial, including 6 in the intervention arm (median age 61 years; 67% male) and 3 in the control arm (median age 66 years; 67% male). No serious adverse events were noted, indicating safety of the intervention. Participants completed a mean of 34.8/36 (96.7%) of sessions, indicating the feasibility of the program. Although not powered for statistical significance, patients experienced positive trends of improvement in measures of hand grip strength, endurance, and functional capacity with the intervention. When stratified, females experienced greater gains than males in these measures.

IMPLICATIONS

This proof-of-concept study found that resistance-based exercise after cardiac surgery is well tolerated and feasible. Although all patients experienced improvements in exercise parameters, females reported greater relative improvement than males.

Southeast Asian, African, and Middle East Expert Consensus on Structured Physical Activity-Dance, Exercise, and Sports

Physical inactivity (PIA) is a pressing public health issue globally, contributing significantly to the rise of non-communicable diseases (NCD), such as cardiovascular disease and type 2 diabetes. The World Health Organization emphasises the importance of regular physical activity (PA) for preventing and managing NCDs. Initiatives to promote active living have gained momentum, ranging from community programs to workplace wellness campaigns, all focused on reducing sedentary lifestyles in modern society. Structured Physical Activity-Dance, Exercise, and Sports (SPADES) has emerged as an innovative approach to addressing PIA and promoting holistic health. After thoroughly reviewing existing literature from PubMed and Google Scholar databases, a panel of experts developed consensus statements through in-depth discussions, and the strength of concurrence on these statements was voted on using a Likert scale. The panel reached a consensus on the best strategies for PA, dance, exercise, sports, and key factors to consider during PA. This consensus targets individuals with metabolic diseases, particularly in regions like South Asia, East Africa, the Gulf, and Latin America, where these conditions are highly prevalent. The SPADES guidelines emphasise overcoming the barriers people with metabolic disorders face in achieving adequate PA, providing tailored recommendations to improve health outcomes for this population.

The SCeiP Model for Remote Rehabilitation in Homebound Patients With Coronary Heart Disease

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Association of weekend warriors and other physical activity patterns with hypertension in NHANES 2007-2018

To accommodate the fast-paced nature of modern life, the "Weekend Warriors (WW)" has emerged as a novel physical activity (PA) indicator. This study aims to investigate the relationship between WW and other PA patterns with hypertension, thereby addressing a significant research gap. Data from 30,697 participants in the National Health and Nutrition Examination Survey conducted between 2007 and 2018 were analyzed. We employed multiple regression analyses to examine the relationships among WW, other PA patterns, PA duration, PA intensity, and hypertension, with data stratified by various characteristics. Results showed that compared to the inactive group, the insufficiently PA pattern (OR = 0.9, 95% CI 0.8, 1.0), the WW group (OR = 0.9, 95% CI 0.7, 1.1), and the regularly active group (OR = 0.8, 95% CI 0.8, 0.9) were all negatively associated with hypertension, with the WW group showing a trend towards a reduced prevalence of hypertension (P for trend < 0.01). This association was particularly evident among middle-aged and older adults aged 41-80 years. Additionally, total moderate-to-vigorous physical activity (MVPA) time, as well as moderate and vigorous PA intensity, showed "L"-shaped and "U"-shaped relationships with hypertension, with inflection points at 2640 MET minutes, 45%, and 62%, respectively. Our study provides insights for selecting suitable PA patterns but indicates the need for further research.

Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology

COLLABORATORS

Larry A. Allen, MD, MHS, FAHA, FACC; Mats Börjesson, MD, PhD, FACC; Alan C. Braverman, MD, FACC; Julie A. Brothers, MD; Silvia Castelletti, MD, MSc, FESC; Eugene H. Chung, MD, MPH, FHRS, FAHA, FACC; Timothy W. Churchill, MD, FACC; Guido Claessen, MD, PhD; Flavio D'Ascenzi, MD, PhD; Douglas Darden, MD; Peter N. Dean, MD, FACC; Neal W. Dickert, MD, PhD, FACC; Jonathan A. Drezner, MD; Katherine E. Economy, MD, MPH; Thijs M.H. Eijsvogels, PhD; Michael S. Emery, MD, MS, FACC; Susan P. Etheridge, MD, FHRS, FAHA, FACC; Sabiha Gati, BSc (Hons), MBBS, PhD, MRCP, FESC; Belinda Gray, BSc (Med), MBBS, PhD; Martin Halle, MD; Kimberly G. Harmon, MD; Jeffrey J. Hsu, MD, PhD, FAHA, FACC; Richard J. Kovacs, MD, FAHA, MACC; Sheela Krishnan, MD, FACC; Mark S. Link, MD, FHRS, FAHA, FACC; Martin Maron, MD; Silvana Molossi, MD, PhD, FACC; Antonio Pelliccia, MD; Jack C. Salerno, MD, FACC, FHRS; Ankit B. Shah, MD, MPH, FACC; Sanjay Sharma, BSc (Hons), MBChB, MRCP (UK), MD; Tamanna K. Singh, MD, FACC; Katie M. Stewart, NP, MS; Paul D. Thompson, MD, FAHA, FACC; Meagan M. Wasfy, MD, MPH, FACC; Matthias Wilhelm, MD.

This American Heart Association/American College of Cardiology scientific statement on clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities or diseases is organized into 11 distinct sections focused on sports-specific topics or disease processes that are relevant when considering the potential risks of adverse cardiovascular events, including sudden cardiac arrest, during competitive sports participation. Task forces comprising international experts in sports cardiology and the respective topics covered were assigned to each section and prepared specific clinical considerations tables for practitioners to reference. Comprehensive literature review and an emphasis on shared decision-making were integral in the writing of all clinical considerations presented.

Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology

This American Heart Association/American College of Cardiology scientific statement on clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities or diseases is organized into 11 distinct sections focused on sports-specific topics or disease processes that are relevant when considering the potential risks of adverse cardiovascular events, including sudden cardiac arrest, during competitive sports participation. Task forces comprising international experts in sports cardiology and the respective topics covered were assigned to each section and prepared specific clinical considerations tables for practitioners to reference. Comprehensive literature review and an emphasis on shared decision-making were integral in the writing of all clinical considerations presented.

Are Subjective Reports of Exercise Intensity Accurate in Recreational Athletes?

BACKGROUND

Quantifying exercise intensity accurately is crucial for understanding links between cumulative exercise and cardiovascular outcomes. Exercise burden, the integral of intensity and duration is often estimated from subjective self-reports which have uncertain accuracy.

METHODS

We studied 40 endurance athletes (EAs) 41 to 69 years of age with > 10 years of training history during a scripted outdoor 42-km cycling training session. Heart rate and power output (watts) were continuously measured. Reports of perceived exertion (RPE) using a word (RPEWord) and numerical Borg scale (RPEBorg) were obtained during and 30 minutes postride and were related to cardiac (heart rate) and metabolic (metabolic equivalent [MET] per minute) exercise endpoints.

RESULTS

RPEs were highly variable, underestimating objective metrics of exercise intensity. Poor agreement was observed between either scale reported 30 minutes after exercise relative to heart rate: exercise RPEBorg vs mean exercise heart rate and % heart ratepeak (both rs = 0.29; P = 0.07), with no agreement between either scale vs other objective endpoints. Agreement between RPEBorg and RPEWord was good during exercise (rs = 0.86; 95% confidence interval (CI), 0.75- 0.92; P = 0.001), but diminished postride (rs = 0.54; 95% CI, 0.28-0.73; P = 0.001). Different cardiac and metabolic profiles during exercise and a contrast between metabolic and cardiac burden was greater in less fit individuals as they accrued greater cardiac (14,039 ± 2649 vs 11,784 ± 1132 heart rate per minute; P < 0.01) but lower metabolic (808 ± 59 vs 858 ± 61 MET per minute; P < 0.05) burden vs fitter EA.

CONCLUSIONS

Caution is advised in interpreting MET per minute and heart rate burden estimated from self-reports. Objective measurements of exercise intensity are required for detailed assessment of the risks and benefits of long-term exercise.

Liraglutide combined with HIIT preserves contractile apparatus and blunts the progression of heart failure in diabetic cardiomyopathy rats

Liraglutide has been shown to alleviate heart failure in patients with type 2 diabetes. High-intensity interval training (HIIT) has also been proven to improve cardiac function in diabetes. The present study explored the effects and underlying mechanisms of liraglutide and HIIT combination therapy in alleviating diabetic cardiomyopathy (DCM). A high-fat diet and low-dose streptozotocin (STZ) were utilized to induce the DCM model. Eight weeks of liraglutide injection and HIIT were used to treat DCM. Subsequently, cardiac function, serum metabolic biomarkers, serum glucagon-like peptide-1 (GLP-1), histology examination, cardiac alpha-myosin heavy chain (α-MHC), and β-MHC messenger RNA (mRNA) expression, forkhead box protein O1 (FOXO1) and muscle-specific RING finger protein 1 (MURF1) mRNA expression and colocalization, and expression of GLP-1 and GLP-1 receptor (GLP-1R) proteins were detected after the intervention. Results showed that DCM rats developed hyperglycemia with eccentric hypertrophy, fibrosis, and reduced systolic and diastolic function. All interventions significantly reversed the development of heart failure by alleviating the disruption of contractile apparatus, reversed the adult α-MHC transformed to fetal β-MHC, and reduced FOXO1 and MURF1 mRNA expression. Combination therapy had a better effect in alleviating cardiac fibrosis, reducing cardiovascular risk biomarkers, controlling eccentric hypertrophy, and improving systolic function. Combination therapy significantly reduced FOXO1 and MURF1 colocalization and improved the GLP-1R sensitivity in diabetic hearts. Overall, these findings demonstrate that combination therapy can reverse cardiac failure in diabetic rats by controlling the degradation of contractile apparatus by downregulating the cardiac atrophy gene expression and interrupting their colocalization, as well as upregulating GLP-1 signaling.

Assessment of cardiovascular risk and physical activity: the role of cardiac-specific biomarkers in the general population and athletes

The first part of this Inter-Society Document describes the mechanisms involved in the development of cardiovascular diseases, particularly arterial hypertension, in adults and the elderly. It will also examine how consistent physical exercise during adolescence and adulthood can help maintain blood pressure levels and prevent progression to symptomatic heart failure. The discussion will include experimental and clinical evidence on the use of specific exercise programs for preventing and controlling cardiovascular diseases in adults and the elderly. In the second part, the clinical relevance of cardiac-specific biomarkers in assessing cardiovascular risk in the general adult population will be examined, with a focus on individuals engaged in sports activities. This section will review recent studies that suggest a significant role of biomarkers in assessing cardiovascular risk, particularly the presence of cardiac damage, in athletes who participate in high-intensity sports. Finally, the document will discuss the potential of using cardiac-specific biomarkers to monitor the effectiveness of personalized physical activity programs (Adapted Physical Activity, APA). These programs are prescribed for specific situations, such as chronic diseases or physical disabilities, including cardiovascular diseases. The purposes of this Inter-Society Document are the following: 1) to discuss the close pathophysiological relationship between physical activity levels (ranging from sedentary behavior to competitive sports), age categories (from adolescence to elderly age), and the development of cardiovascular diseases; 2) to review in detail the experimental and clinical evidences supporting the role of cardiac biomarkers in identifying athletes and individuals of general population at higher cardiovascular risk; 3) to stimulate scientific societies and organizations to develop specific multicenter studies that may take into account the role of cardiac biomarkers in subjects who follow specific exercise programs in order to monitor their cardiovascular risk.

Temporal trends in aerobic physical activity guideline adherence among nationally representative samples of U.S adults between 2011 and 2019: Cross-sectional findings from a sample of over 2 million adults

BACKGROUND

Physical inactivity is a significant public health concern associated with numerous adverse health outcomes and substantial economic costs. This study describes the prevalence, trends and correlates for adherence to moderate to vigorous physical activity (MVPA) guidelines among a large sample of U.S. adults.

METHODS

Data from the 2011, 2013, 2015, 2017, and 2019 Behavioral Risk Factor Surveillance System surveys were analyzed. Self-reported MVPA was assessed by the same item across each survey. Population-weighted prevalence was calculated for meeting MVPA guidelines (150+ mins/wk). Adjusted prevalence ratios for reporting sufficient MVPA across sociodemographic, behavioral and health variables were calculated by multivariate Poisson regression.

RESULTS

Data was available for 2,052,288 respondents (≥ 18 years). Across the surveys, the prevalence of sufficient MVPA fluctuated but remained between 49.5% and 51.1%. Among those aged 18 to 24, the prevalence of sufficient MVPA declined between surveys, from 56.5% in 2011 to 49.7% in 2019. Notable correlates of adhering to guidelines included male sex, higher education, former and never smokers, normal body mass index and increased fruit and vegetable consumption.

CONCLUSION

From 2011 to 2019, approximately half of US adults reported sufficient MVPA, with a steady decline observed among young adults. While many identified correlates of adhering to PA guidelines were observed, this study has provided further evidence for correlates that had previously provided inconsistent or inconclusive results. These findings emphasize the complexity of addressing physical inactivity and the importance of multifaceted public health strategies tailored to diverse populations.

Effects of exercise intensity and diet on cardiac tissue structure and FGF21/β-Klotho signaling in type 2 diabetic mice: a comparative study of HFD and HFD + STZ induced type 2 diabetes models in mice

BACKGROUND

Structural heart disease is one of the leading causes of death in people with type 2 diabetes (T2D), which is not known to have an effect on exercise training. The aim of this study was to compare the effects of high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) on heart tissue structure, the serum level of FGF21 and the heart tissue level of β-Klotho, an FGF21 coreceptor, in HFD and HFD + STZ-induced diabetic mice.

METHODS

Thirty-six male C57BL/6J mice were divided into high-fat diet (HFD) and normal chow diet (ND) groups. After 20 weeks of diet, the HFD mice were divided into HFD and HFD + STZ groups, and the latter group was injected with STZ. Then, the mice in the ND, HFD and HFD + STZ groups were divided into three subgroups of control (C), HIIT and MICT, and mice were placed in one of nine groups ND-C, ND-HIIT, ND-MICT, HFD-C, HFD-HIIT, HFD-MICT, HFD + STZ-C, HFD + STZ-HIIT, and HFD + STZ-MICT. The mice in the exercise training (ET) groups were run on a treadmill for eight weeks. Finally, the tissue and serum samples were collected and analyzed by two-way ANOVA.

RESULTS

Statistical analyses showed that the main effect of diabetes inducing model (DIM) was significant for all variables (p < 0.05), except vascular density (p = 0.055); the main effect of ET type on fasting blood glucose and FGF21 was significant (p < 0.001); and the interaction was significant for fasting blood glucose, heart weight and FGF21 (p < 0.001). Post hoc and subgroup analysis showed a superior effect of MICT over HIIT in decreasing fasting blood glucose and serum level of FGF21 (p < 0.001). Additionally, the results of the myocardial tissue qualitative analyses differed between the diabetic mouse models and the ET groups.

CONCLUSIONS

In a mouse model, type 2 diabetes can negatively affect heart tissue structure and FGF21 signaling in cardiac tissue, and both HIIT and MICT can prevent this effect. However, MICT likely more effective that HIIT in reducing circulating FGF21.

Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR)

Aging, a universal and inevitable process, is characterized by a progressive accumulation of physiological alterations and functional decline over time, leading to increased vulnerability to diseases and ultimately mortality as age advances. Lifestyle factors, notably physical activity (PA) and exercise, significantly modulate aging phenotypes. Physical activity and exercise can prevent or ameliorate lifestyle-related diseases, extend health span, enhance physical function, and reduce the burden of non-communicable chronic diseases including cardiometabolic disease, cancer, musculoskeletal and neurological conditions, and chronic respiratory diseases as well as premature mortality. Physical activity influences the cellular and molecular drivers of biological aging, slowing aging rates-a foundational aspect of geroscience. Thus, PA serves both as preventive medicine and therapeutic agent in pathological states. Sub-optimal PA levels correlate with increased disease prevalence in aging populations. Structured exercise prescriptions should therefore be customized and monitored like any other medical treatment, considering the dose-response relationships and specific adaptations necessary for intended outcomes. Current guidelines recommend a multifaceted exercise regimen that includes aerobic, resistance, balance, and flexibility training through structured and incidental (integrated lifestyle) activities. Tailored exercise programs have proven effective in helping older adults maintain their functional capacities, extending their health span, and enhancing their quality of life. Particularly important are anabolic exercises, such as Progressive resistance training (PRT), which are indispensable for maintaining or improving functional capacity in older adults, particularly those with frailty, sarcopenia or osteoporosis, or those hospitalized or in residential aged care. Multicomponent exercise interventions that include cognitive tasks significantly enhance the hallmarks of frailty (low body mass, strength, mobility, PA level, and energy) and cognitive function, thus preventing falls and optimizing functional capacity during aging. Importantly, PA/exercise displays dose-response characteristics and varies between individuals, necessitating personalized modalities tailored to specific medical conditions. Precision in exercise prescriptions remains a significant area of further research, given the global impact of aging and broad effects of PA. Economic analyses underscore the cost benefits of exercise programs, justifying broader integration into health care for older adults. However, despite these benefits, exercise is far from fully integrated into medical practice for older people. Many healthcare professionals, including geriatricians, need more training to incorporate exercise directly into patient care, whether in settings including hospitals, outpatient clinics, or residential care. Education about the use of exercise as isolated or adjunctive treatment for geriatric syndromes and chronic diseases would do much to ease the problems of polypharmacy and widespread prescription of potentially inappropriate medications. This intersection of prescriptive practices and PA/exercise offers a promising approach to enhance the well-being of older adults. An integrated strategy that combines exercise prescriptions with pharmacotherapy would optimize the vitality and functional independence of older people whilst minimizing adverse drug reactions. This consensus provides the rationale for the integration of PA into health promotion, disease prevention, and management strategies for older adults. Guidelines are included for specific modalities and dosages of exercise with proven efficacy in randomized controlled trials. Descriptions of the beneficial physiological changes, attenuation of aging phenotypes, and role of exercise in chronic disease and disability management in older adults are provided. The use of exercise in cardiometabolic disease, cancer, musculoskeletal conditions, frailty, sarcopenia, and neuropsychological health is emphasized. Recommendations to bridge existing knowledge and implementation gaps and fully integrate PA into the mainstream of geriatric care are provided. Particular attention is paid to the need for personalized medicine as it applies to exercise and geroscience, given the inter-individual variability in adaptation to exercise demonstrated in older adult cohorts. Overall, this consensus provides a foundation for applying and extending the current knowledge base of exercise as medicine for an aging population to optimize health span and quality of life.

The Optimal Time of High-Intensity Pre-rehabilitation for Surgical Lung Cancer Patients: A Retrospective Cohort Study with 4452 Patients

BACKGROUND

The aim of this study was to investigate the influence of the time of pre-rehabilitation (PR) combined with respiratory training and aerobic exercise on surgical patients with lung cancer.

PATIENTS AND METHODS

A retrospective study from a 5-year database of a single center, including patients with lung cancer who underwent surgery between 1 January 2016 and 31 December 2020, was conducted. The patients were divided into the PR group, in which they received the PR regimen, and the non-PR group, in which they received routine care.

RESULTS

A total of 4452 patients were retrospectively included, 684 of whom received PR regimen. A lower postoperative pulmonary complication (PPC) rate was observed in PR group than in non-PR group before or after propensity score matching (PSM) (before: 12.6% vs 18.5%, P < 0.001; after: 12.6% vs 18.7%, P < 0.001). For the PR group, a restricted cubic spline model revealed a significant nonlinear dose‒response association between PR time and the occurrence of PPCs (P for nonlinearity = 0.002). The PR time associated with the lowest occurrence of PPCs was 7 days, and the odds ratio (OR) of PPCs decreased steeply, with an OR of 0.8 [95% confidence interval (CI) 0.66-0.97] per day until 7 days, and then remained stable with a slight increase afterward with an OR of 1.11 (95% CI 0.99-1.25) per day.

CONCLUSION

The study validated the effectiveness of a pre-rehabilitation regimen for decreasing the occurrence of PPCs. A U-shaped nonlinear relationship was found between pre-rehabilitation time and the PPC rate, indicating that both excessive and insufficient pre-rehabilitation time may increase the incidence of PPCs. Registry Number: ChiCTR1800020097.

Current Strategies for Atrial Fibrillation Prevention and Management: Taming the Commonest Cardiac Arrhythmia

Atrial fibrillation (AF) is the commonest cardiac arrhythmia, constituting a major cause of morbidity and mortality, with an age-dependent incidence and prevalence ranging from 1-2% in the general population to ~10% in persons aged >60 years. The global prevalence of AF is rapidly increasing, mostly due to the aging population. If not properly and timely managed, this arrhythmia adversely affects left ventricular function, increases the risk of stroke five-fold, impairs quality of life, and shortens longevity. There is a genetic, hence non-modifiable, predisposition to the arrhythmia, while several life-style and cardiometabolic inciting factors, such as hypertension, heart failure, coronary disease, metabolic syndrome, alcohol use, and thyroid disorders, can be addressed, attesting to the importance of a holistic approach to its management. Thromboembolism is a serious consequence of AF, which could lead to a disabling stroke or have a lethal outcome. The risk of a thromboembolic complication can be estimated as based on a scoring system that takes into consideration the patient's age, previous thromboembolic events, and clinical comorbidities. In addition, rapid AF could affect cardiac performance, leading to an elusive type of arrhythmia- induced cardiomyopathy and heart failure with grave consequences if undetected and untreated. Furthermore, AF may cause silent brain infarcts and/or its hemodynamic perturbations can account for a type of dementia that needs to be taken into account, emphasizing the need for AF screening and prevention strategies. All these issues are herein detailed, the causes of the arrhythmia are tabulated, and an algorithm illustrates our current approach to its management.

Olympic distance duathlon and cardiac performance in highly-trained triathletes

The effects of triathlon exercise on cardiac function are well documented. While Olympic triathlon (swim-bike-run) remains the standard format, increasing concerns about water quality in natural waterways present ongoing challenges for open-water swimming events, highlighting the potential need to consider alternative formats such as duathlon (run-bike-run) in some circumstances. An additional run may increase the overall metabolic and cardiovascular demand compared with the swim in triathlon, leading to reduced future performance. Conversely, the majority of EICF research reports reversal of post-exercise perturbations within 24-7 days of recovery but duathlon has not yet been studied in this context. Therefore, this study aimed to investigate the cardiac, autonomic, haemodynamic and biomarker responses during and following two Olympic distance (OD) duathlon separated by 7 days of recovery. Highly-trained (V O2max >60 mL·kg-1·min-1) male participants (n = 10) completed two lab-based OD duathlons, either continuous (BD) or with functional measurements after each leg (UD), separated by 7 days of rest. Conventional echocardiography recorded standard and tissue Doppler measures of left ventricular (LV) structure and function. Speckle tracking echocardiography was used to measure global longitudinal strain (GLS). Time and frequency domain analysis of HRV, as well as plasma high sensitivity cardiac troponin T (hs-cTnT) were measured pre and post exercise. In the broken duathlon trial (BD) cardiac measurements and blood samples were also taken between each leg. In the unbroken duathlon (UD) participants performed each leg sequentially. Duathlon exercise resulted in similar cardiac functional and biomarker alterations as previously reported in triathlon and standalone running and cycling exercise. Cardiac troponins were still elevated following 24 h-1 of recovery. However, functional changes were resolved within 24 h-1 of passive recovery and did not impair subsequent duathlon performance, or pre-exercise measurements 7 days after the first trial. Whether or not elite or recreational athletes experience the same magnitude and reversibility of these changes remains to be elucidated further.

Acute cardiovascular responses to the 100-mi Western States Endurance Run

Ultramarathon participation is growing in popularity and exposes runners to unique stressors including extreme temperatures, high altitude, and exceedingly long exercise duration. However, the acute effects of ultramarathon participation on the cardiovascular system are not well understood. To determine the acute effects of trail ultramarathon participation on central artery stiffness and hemodynamics, 41 participants (9 F, 32 M) participating in the 2023 Western States Endurance Run underwent measures of carotid-femoral pulse wave velocity (cf-PWV) and pulse wave analysis pre- and <1 h post-race. Subendocardial viability ratio (SEVR) was calculated from central blood pressure (BP) waveforms. Serum was analyzed for creatine kinase (CK) activity as a measure of muscle damage. Normally distributed data are presented as means ± standard deviation (SD), and nonnormally distributed data are presented as median (interquartile range). Runners were middle-aged and generally lean [age = 44 ± 9 yr, body mass index (BMI) = 22.7 ± 1.8 kg·m-2]. There was no difference in cf-PWV from pre- to post-race (pre = 6.4 ± 1.0, post = 6.2 ± 0.85 m/s, P = 0.104), a finding that persisted after adjusting for mean arterial pressure (P = 0.563). Systolic and diastolic BPs were lower post-race (pre = 129/77 ± 9/7, post = 122/74 ± 10/8 mmHg, P < 0.001). Augmentation index (AIx; pre = 17.3 ± 12.2, post = 6.0 ± 13.7%, P < 0.001), AIx normalized to a heart rate of 75 beats/min (P = 0.043), reflection magnitude (pre = 55.5(49.0-60.8), post = 45.5(41.8-48.8)%, P < 0.001), and SEVR (pre = 173.0(158.0-190.0), post = 127.5(116.5-145.8)%, P < 0.001) were reduced post-race. CK increased markedly from pre- to post-race (pre = 111(85-162), post = 11,973(5,049-17,954) U/L, P < 0.001). Completing a 161-km trail ultramarathon does not affect central arterial stiffness and acutely reduces BP despite eliciting profound muscle damage. However, the reduced post-race SEVR suggests a short-term mismatch between myocardial work and coronary artery perfusion.NEW AND NOTEWORTHY Ultramarathon participation is growing dramatically. However, the acute cardiovascular effects of completing a 161-km trail ultramarathon remain unknown. We examined the acute effects of completing the 2023 Western States Endurance Run on arterial stiffness and central hemodynamics in a relatively large sample of males and females. We observed dramatic postexercise hypotension, reductions in reflected wave amplitude and reduced subendocardial viability ratio post-race. These findings suggest that ultramarathon participation has few negative effects on cardiovascular health.

Maternal physical activity in healthy pregnancy: Effect on fetal oxygen supply

AIM

We review evidence for effects of physical activity before and during gestation on the course of pregnancy and ask if there are circumstances where physical activity can stress the fetus due to competition for oxygen and energy substrates.

RESULTS

We first summarize physiological responses to exercise in nonpregnant people and known physiological adaptations to pregnancy. Comparing the two, we conclude that physical activity prior to and continuing during gestation is beneficial to pregnancy outcome. The effect of starting an exercise regimen during pregnancy is less easy to assess as few studies have been undertaken. Results from animal models suggest that the effects of maternal exercise on the fetus are transient; the fetus can readily compensate for a short-term reduction in oxygen supply.

CONCLUSION

In general, we conclude that physical activity before and during pregnancy is beneficial, and exercise started during pregnancy is unlikely to affect fetal development. We caution, however, that there are circumstances where this may not apply. They include the intensive exercise regimens of elite athletes and pregnancies at high altitudes where hypoxia occurs even in the resting state.

From the armchair to contemporary cardiac rehabilitation: the remarkable ongoing journey of exercise training in ischemic heart disease

Exercise is an important physiological activity with several health benefits. In the setting of ischemic heart disease (IHD), the view toward exercise has greatly evolved throughout the years, concurrently to several major advances in the management of this complex entity. Currently, exercise training has broad applications across the IHD continuum as a powerful tool in its overall management, being a core component of comprehensive cardiac rehabilitation programs. Beyond this, exercise has also been incorporated as an integral part of contemporary methodologies aiming to provide diagnostic and prognostic data, such as cardiopulmonary exercise stress testing or stress echocardiography. In this article, we provide a pragmatic overview concerning the role of exercise in IHD, with a focus on its incorporation in cardiac rehabilitation frameworks, while also discussing some of the challenges and unmet needs concerning these interventions.

Sudden cardiac arrest during marathons among young, middle-aged, and senior runners

AIM

There is limited evidence showing a relationship with age in the incidence of sudden cardiac arrest during exercise, which can be lethal at times.

METHODS

To examine the incidence by age group in sudden cardiac arrest, we prospectively observed cases of sudden cardiac arrest in full marathons certified by the Japan Association of Athletics Federations held between April 2011 and March 2019. Sudden cardiac arrest was defined as collapse during or 1 h after the race requiring chest compressions or the use of an automatic electrical defibrillation.

RESULTS

4.1 million persons ran in 516 marathons. Of the participants, 78.6 % were men. By age group, 37.4 %, 34.7 %, 19.6 %, and 8.3 % belonged to the < 40 s, 40 s, 50 s, and ≥ 60 s groups, respectively. During the study period, 69 sudden cardiac arrests (1.7 per 100,000 participants, 95 % confidence interval [CI]: 1.3-2.1) were observed, of which 66 were men. The incidence per 100,000 runners of sudden cardiac arrest was 0.9 (95 % CI: 0.4, 1.4), 0.9 (95 % CI: 0.4, 1.4), 2.6 (95 % CI: 1.5, 3.8), and 5.5 (95 % CI: 2.9, 8.2) for those in their under 40 s, 40 s, 50 s, and over 60 s, respectively, with higher rates for older age groups. Compared to men, the cases of SCA among women were less common (only three cases), and the incidence did not differ by age group.

CONCLUSIONS

Men, unlike women, had a higher incidence of sudden cardiac arrest during marathons according to age. Identification of this high-risk population could be important information in encouraging marathoners pre-participation self-screening.

The role and underlying mechanisms of irisin in exercise-mediated cardiovascular protection

Irisin, a product of the post-translational processing of fibronectin type III domain-containing protein 5 (FNDC5), is a novel myokine which is upregulated during exercise. This hormone not only promotes the transformation of white adipose tissue into a brown-fat-like phenotype but also enhances energy expenditure and mitigates fat accumulation. Its role is crucial in the management of certain metabolic disorders such as diabetes and heart disease. Of note, the type of exercise performed significantly affects blood irisin levels, indicating the critical role of physical activity in regulating this hormone. This article aims to summarize the current scientific understanding of the role of irisin and the mechanisms through which it mediates cardiovascular protection through exercise. Moreover, this article aims to establish irisin as a potential target for preventing and treating cardiovascular diseases.

Right ventricular remodeling induced by prolonged excessive endurance exercise is mediated by upregulating Wnt/β-catenin signaling in rats

BACKGROUND

The aim of this study was to develop an animal model to investigate whether prolonged intensive endurance exercise induces RV remodeling, taking into account the involvement of Wnt/β-catenin signaling.

METHODS

Four-week-old male Wistar rats (100 to 125 g) were assigned to four groups (n = 8/group): 1) sixteen weeks of intensive (36 m/min) exercise (INT), 2) twelve weeks of the intensive exercise followed by four weeks of moderate intensity (18 m/min) exercise (INT + MOD), 3) twelve weeks of the intensive exercise followed by four weeks of detraining (INT + DT), and 4) sedentary rats (SED). The exercise protocols were performed five days a week for one h/day. Echocardiography, real-time PCR, western blotting, and histological staining were performed at the end of week sixteen.

RESULTS

INT rats developed concentric hypertrophy without diastolic dysfunction compared to SED (p = 0.006) and INT + DT (p = 0.035). Wnt1, β-catenin and CyclinD1 proteins in the training groups were significantly higher than SED rats (p < 0.001). Interestingly, INT rats had higher protein levels than INT + DT and INT + MOD (p < 0.001), with higher gene expression compared to SED rats (p < 0.05). There was also a significant increase in collagen deposition in INT rats compared to SED (p = 0.046) and INT + DT (p = 0.034). Furthermore, INT + MOD and INT + DT rats did not show any adverse structural, functional, or histological changes.

CONCLUSIONS

Long-term intensive endurance training seems to be associated with increased collagen deposition and wall thickness in the RV through Wnt/β-catenin signaling (which is concentration dependent), without changes in diastolic function.

CLINICAL PERSPECTIVE

Over the past decades, there has been an ongoing debate about whether the structural and functional adaptations of the cardiovascular system in trained endurance athletes are benign physiological responses to training or potentially pathological changes related to disease. While the adaptations of the left heart are well-documented, the remodeling of the right heart remains a subject of discussion. To gain insights into the ability of sustained high-intensity exercise to cause adverse right ventricular (RV) remodeling, we conducted an experimental study in which male rats were trained to run vigorously for 1 h daily over a 16-week period and compared them to a parallel group of sedentary control rats. Our findings revealed that intense long-term exercise induced morphological changes along with fibrosis affecting the RV. These fibrotic changes were a result of the 16-week vigorous exercise training regimen. If these results are confirmed in humans, they suggest that prolonged high-intensity endurance exercise training may lead to adverse cardiac remodeling. Our findings have important potential implications for the assessment of cardiac remodeling in individuals engaged in high-level exercise training.

Excessive Blood Pressure Rise and Cardiovascular Remodeling in Marathon Runners

Exercise-induced hypertension (EIH) is thought to be associated with increased cardiovascular (CV) risks. However, no previous studies have investigated the effects of EIH on CV systems in marathon runners without CV risk factors using both 24-hr ambulatory blood pressure (BP) monitoring and exercise stress echocardiography (ESE). This study firstly described differences in CV adaptations according to EIH assessed by both exams. Marathon runners between 35 and 64 years of age without CV risk factors were eligible. All the participants underwent both 24-hr ambulatory BP monitoring and ESE. EIH was defined as a maximal exercise systolic BP≥210 mmHg. The EIH group (n=19) had shorter training history and higher exercise intensity compared to the non-EIH group (n=23). The average systolic BP was higher in the EIH group than in the non-EIH group. Left cardiac chamber size and left ventricular mass (LVM) were also higher in the EIH group compared to the non-EIH group. Maximal BP during ESE was positively correlated with both parameters. Exaggerated BP response during exercise needs to be monitored for pre-emptive measurements before it results in progressive cardiovascular maladaptation.

Cardiomyocyte Adaptation to Exercise: K+ Channels, Contractility and Ischemic Injury

Cardiovascular disease is a leading cause of morbidity and mortality, and exercise-training (TRN) is known to reduce risk factors and protect the heart from ischemia and reperfusion injury. Though the cardioprotective effects of exercise are well-documented, underlying mechanisms are not well understood. This review highlights recent findings and focuses on cardiac factors with emphasis on K+ channel control of the action potential duration (APD), β-adrenergic and adenosine regulation of cardiomyocyte function, and mitochondrial Ca2+ regulation. TRN-induced prolongation and shortening of the APD at low and high activation rates, respectively, is discussed in the context of a reduced response of the sarcolemma delayed rectifier potassium channel (IK) and increased content and activation of the sarcolemma KATP channel. A proposed mechanism underlying the latter is presented, including the phosphatidylinositol-3kinase/protein kinase B pathway. TRN induced increases in cardiomyocyte contractility and the response to adrenergic agonists are discussed. The TRN-induced protection from reperfusion injury is highlighted by the increased content and activation of the sarcolemma KATP channel and the increased phosphorylated glycogen synthase kinase-3β, which aid in preventing mitochondrial Ca2+ overload and mitochondria-triggered apoptosis. Finally, a brief section is presented on the increased incidences of atrial fibrillation associated with age and in life-long exercisers.

Racial Disparities in Sports Cardiology: A Review

Importance

Racial disparities in cardiovascular health, including sudden cardiac death (SCD), exist among both the general and athlete populations. Among competitive athletes, disparities in health outcomes potentially influenced by social determinants of health (SDOH) and structural racism remain inadequately understood. This narrative review centers on race in sports cardiology, addressing racial disparities in SCD risk, false-positive cardiac screening rates among athletes, and the prevalence of left ventricular hypertrophy, and encourages a reexamination of race-based practices in sports cardiology, such as the interpretation of screening 12-lead electrocardiogram findings.

Observations

Drawing from an array of sources, including epidemiological data and broader medical literature, this narrative review discusses racial disparities in sports cardiology and calls for a paradigm shift in approach that encompasses 3 key principles: race-conscious awareness, clinical inclusivity, and research-driven refinement of clinical practice. These proposed principles call for a shift away from race-based assumptions towards individualized, health-focused care in sports cardiology. This shift would include fostering awareness of sociopolitical constructs, diversifying the medical team workforce, and conducting diverse, evidence-based research to better understand disparities and address inequities in sports cardiology care.

Conclusions and Relevance

In sports cardiology, inadequate consideration of the impact of structural racism and SDOH on racial disparities in health outcomes among athletes has resulted in potential biases in current normative standards and in the clinical approach to the cardiovascular care of athletes. An evidence-based approach to successfully address disparities requires pivoting from outdated race-based practices to a race-conscious framework to better understand and improve health care outcomes for diverse athletic populations.

2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play

Youth and adult participation in sports continues to increase, and athletes may be diagnosed with potentially arrhythmogenic cardiac conditions. This international multidisciplinary document is intended to guide electrophysiologists, sports cardiologists, and associated health care team members in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction. Expert, disease-specific risk assessment in the context of athlete symptoms and diagnoses is emphasized throughout the document. After appropriate risk assessment, management of arrhythmias geared toward return to play when possible is addressed. Other topics include shared decision-making and emergency action planning. The goal of this document is to provide evidence-based recommendations impacting all areas in the care of athletes with arrhythmic conditions. Areas in need of further study are also discussed.

Lifelong physiology of a former marathon world-record holder: the pros and cons of extreme cardiac remodeling

In a 77-year-old former world-record-holding male marathoner (2:08:33.6), this study sought to investigate the impact of lifelong intensive endurance exercise on cardiac structure, function, and the trajectory of functional capacity (determined by maximal oxygen consumption, V̇o2max) throughout the adult lifespan. As a competitive runner, our athlete (DC) reported performing up to 150-300 miles/wk of moderate-to-vigorous exercise and sustained 10-15 h/wk of endurance exercise after retirement from competition. DC underwent maximal cardiopulmonary exercise testing in 1970 (aged 27 yr), 1991 (aged 49 yr), and 2020 (aged 77 yr) to determine V̇o2max. At his evaluation in 2020, DC also underwent comprehensive cardiac assessments including resting echocardiography, and resting and exercise cardiac magnetic resonance to quantify cardiac structure and function at rest and during peak supine exercise. DC's V̇o2max showed minimal change from 27 yr (69.7 mL/kg/min) to 49 yr (68.1 mL/kg/min), although it eventually declined by 36% by the age of 77 yr (43.6 mL/kg/min). DC's V̇o2max at 77 yr, was equivalent to the 50th percentile for healthy 20- to 29-yr-old males and 2.4 times the requirement for maintaining functional independence. This was partly due to marked ventricular dilatation (left-ventricular end-diastolic volume: 273 mL), which facilitates a large peak supine exercise stroke volume (200 mL) and cardiac output (22.2 L/min). However, at the age of 78 yr, DC developed palpitations and fatigue and was found to be in atrial fibrillation requiring ablation procedures to revert his heart to sinus rhythm. Overall, this life study of a world champion marathon runner exemplifies the substantial benefits and potential side effects of many decades of intense endurance exercise.NEW & NOTEWORTHY This life study of a 77-yr-old former world champion marathon runner exemplifies the impact of lifelong high-volume endurance exercise on functional capacity (V̇o2max equivalent to a 20- to 29-yr-old), partly due to extreme ventricular remodeling that facilitates a large cardiac output during exercise despite reduced maximal heart rate. Although it is possible that this extreme remodeling may contribute to developing atrial fibrillation, the net benefits of extreme exercise throughout this athlete's lifespan favor increased health span and expected longevity.

Cardiorespiratory fitness, atrial fibrillation and stroke: a review of the evidence in 2024

INTRODUCTION

The body of evidence linking cardiorespiratory fitness (CRF) levels with the risk of atrial fibrillation (AF) and stroke - two interconnected cardiovascular conditions - is not entirely consistent. Furthermore, specific CRF thresholds beyond which the risk of AF or stroke might not decrease are not well defined.

AREAS COVERED

This review summarizes research evidence on the role of CRF in the development of AF and stroke including dose-response relationships in general population participants, explores the biological mechanisms through which CRF may exert its effects, assesses the potential implications for clinical care and population health, identifies gaps in the current evidence, and suggest directions for future research. MEDLINE and Embase were searched from inception until July 2024 to identify observational longitudinal and interventional studies as well as systematic reviews and meta-analyses related to these study designs.

EXPERT OPINION

In the general population, increasing levels of CRF, achieved through consistent physical activity, can significantly reduce the likelihood of developing AF and stroke. The findings also advocate for a tailored approach to exercise prescriptions, acknowledging the plateau in benefits for AF risk beyond certain CRF levels, while advocating for higher intensity or prolonged activity to further reduce stroke risk.

The Spectrum of Coronary Artery Disease in Elite Endurance Athletes-A Long-Standing Debate: State-of-the-Art Review

Physical activity is recommended for the prevention of primary and secondary cardiovascular (CV) disease as it is linked to a number of health benefits, especially CV. However, recent research suggests that high-volume, long-term endurance exercise may hasten rather than slow the coronary atherosclerosis progression. This contentious theory has generated a great discussion and is still a major source of doubt when it comes to the clinical treatment of coronary artery disease (CAD) in athletes. CAD is the primary cause of sudden cardiac death in athletes over 35 years. Thus, recent studies evaluated the prevalence of CAD in athletes and its clinical and prognostic implications. Indeed, many studies have shown a relationship between endurance sports and higher volumes of coronary calcified plaque as determined by computed tomography. However, the precise pathogenetic substrate for the existence of an increased coronary calcification burden among endurance athletes remains unclear. Moreover, the idea that coronary plaques in elite athletes present a benign morphology has been cast into doubt by some recent studies showing potential association with adverse cardiovascular events. This review aims to analyze the association between physical activity and CAD, explaining possible underlying mechanisms of atherosclerotic progression and non-ischemic coronary lesions, focusing primarily on clinical and prognostic implications, multimodal evaluation, and management of CAD in endurance athletes.

Assessing athletes beyond routine screening: Incorporating essential factors to optimize cardiovascular health and performance

The American Heart Association (AHA) has devised Life's Essential 8, a set of eight evidence-based health behaviors that play a crucial role in optimizing cardiovascular health and overall well-being. In addition to Life's Essential 8, enhanced screening for Cardiovascular-Kidney-Metabolic (CKM) Syndrome risk factors into routine athlete screening also provides a more comprehensive approach for ensuring athlete safety and long-term health. Incorporating Life's Essential 8 and CKM Syndrome metrics into athlete health evaluations will improve the sports performance of athletes and help optimize their long-term health.

Intensity-specific physical activity measured by accelerometer and the risk of mortality among individuals with cardiometabolic diseases: A prospective study from the UK Biobank

BACKGROUND

While the health benefits of physical activity for general population are well-recognized, the prospective associations of physical activity volume and intensity with mortality among cardiometabolic disease individuals remain unclear.

OBJECTIVE

The objective of this study was to investigate the associations of accelerometer-measured intensity-specific physical activity with mortality risk among population with cardiometabolic disease.

DESIGN

Prospective cohort study.

SETTING

Participants were recruited from the United Kingdom (UK) across 22 assessment centers from 2006 to 2010.

PARTICIPANTS

A total of 9524 participants from the UK Biobank (median: 67.00 years, interquartile range: 61.00-70.00 years) were included in final study.

METHODS

Accelerometer-measured total volume, moderate-to-vigorous and light intensity physical activity collecting from 2013 to 2015 were quantified using a machine learning model. Multivariable restricted cubic splines and Cox proportional hazard models with hazard ratios (HRs) and 95 % confidence intervals (CIs) were employed to examine the associations of interests.

RESULTS

During the follow-up period (median: 6.87 years; interquartile range: 6.32-7.39 years), there were 659 (6.92 %) death events with 218 (2.29 %) cardiovascular disease-related deaths and 441 (4.63 %) non-cardiovascular disease-related deaths separately. In the fully adjusted models, compared with participants in the lowest quartiles of total volume, moderate-to-vigorous and light physical activities, the adjusted HRs (95 % CIs) of all-cause mortality for those in the highest quartiles were 0.40 (0.31, 0.52), 0.48 (0.37, 0.61), and 0.56 (0.44, 0.71) while those for cardiovascular diseases-related mortality were 0.35 (0.22, 0.55), 0.52 (0.35, 0.78) and 0.59 (0.39, 0.88), and for non-cardiovascular diseases-related mortality, they were 0.42 (0.30, 0.59), 0.40 (0.29, 0.54) and 0.54 (0.40, 0.73), separately. The optimal moderate-to-vigorous-intensity physical activity level for cardiovascular diseases-related mortality reduction was found to be in the third quartile (17.75-35.33 min/day). Furthermore, the observed inverse associations were mainly non-linear.

CONCLUSIONS

Promoting physical activity, regardless of intensity, is essential for individuals with cardiometabolic disease to reduce mortality risk. For both all-cause and cardiovascular disease-related and non-cardiovascular disease-related mortality, the observed decrease in risk seems to level off at a moderate level. The current findings deriving from precise device-based physical activity data provide inference for secondary prevention of cardiometabolic disease.

Endurance Sporting Events

Endurance sports encompass a broad range of events from marathons and triathlons to ultramarathons, long-distance cycling, skiing, and swimming. As these events have experienced a surge in popularity, we have a greater need to understand the associated medical risks. This article reviews the history of endurance races, reviews the most critical and common causes of cardiovascular, heat, electrolyte, and musculoskeletal injuries/illnesses, and discusses considerations for medical directors/personnel associated with such events.

Cardiac function and autonomic cardiac function during a multi-stage cycling event: a brief report

Introduction

Prolonged and repeated exercise performed during an ultra-endurance event can induce general and cardiac fatigue known as exercise-induced cardiac fatigue. Our objective was to find a possible correlation between the cardiac function and the autonomic cardiac function.

Methods

During a multistage ultra-endurance event, a female well-trained cyclist underwent daily rest echocardiography and heart rate variability measurements to assess the cardiac function and the cardiac autonomic function.

Results

The athlete completed 3,345 km at 65% of her maximum heart rate and 39% of her maximum aerobic power. A progressive improvement of the systolic function for both the left ventricle and the right ventricle was observed during the event.

Discussion

Alterations were observed on the cardiac autonomic function with an imbalance between sympathetic and parasympathetic, but there was no sign of a significant correlation between the cardiac function and the autonomic cardiac function and no signs of cardiac fatigue either. Further analysis should be performed on a larger sample to confirm the obtained results.

Exploring the Molecular Adaptations, Benefits, and Future Direction of Exercise Training: Updated Insights into Cardiovascular Health

This review emphasizes the globally accepted physical activity guidelines and explores the various molecular adaptations that occur with continuous exercise. It is essential to highlight the critical roles of cardiorespiratory fitness, muscular strength, and muscle mass in reducing mortality and enhancing quality of life. It has been shown in various studies that there are certainly substantial reductions in cardiovascular and all-cause mortality among individuals with high cardiorespiratory fitness levels. Resistance training is also examined, which, likewise, reveals significant mortality benefits, even with minimal weekly engagement. When delving into the molecular mechanisms, it is apparent that exercise training favorably influences certain cardiovascular conditions, mostly owing to its effect on enhanced lipid metabolism, improvement in glucose regulation, ability to modulate inflammation and oxidative processes, and induction of other cardioprotective effects like improved sympathetic tone and left ventricular remodeling. Cardiovascular diseases and malignancy also share the same risk factors, which explains why exercise can also mitigate the risk of developing many types of cancers. But despite these advancements in research, cardiovascular diseases continue to be prevalent, which may suggest the need to devise other means of promoting physical activity involvement. These approaches may include a greater emphasis on the societal benefits of increased exercise adherence, facilitated by community involvement and technological advancements in fitness tracking devices. We conclude that the future directions for exercise research should emphasize the need for personalized or tailored exercise programs to make it more engaging, accessible, and inclusive for a diverse set of people.

The interplay of exercise and polyphenols in cancer treatment: A focus on oxidative stress and antioxidant mechanisms

Exercise has been demonstrated to induce an elevated production of free radicals, leading to the onset of oxidative stress. Numerous studies highlight the positive impacts of aerobic exercise, primarily attributed to the increase in overall antioxidant capacity. The evidence suggests that engaging in aerobic exercise contributes to a reduction in the likelihood of advanced cancer and mortality. Oxidative stress occurs when there is an imbalance between the generation of free radicals and the collective antioxidant defense system, encompassing both enzymatic and nonenzymatic antioxidants. Typically, oxidative stress triggers the formation of reactive oxygen or nitrogen species, instigating or advancing various issues in cancers and other diseases. The pro-oxidant-antioxidant balance serves as a direct measure of this imbalance in oxidative stress. Polyphenols contain a variety of bioactive compounds, including flavonoids, flavanols, and phenolic acids, conferring antioxidant properties. Previous research highlights the potential of polyphenols as antioxidants, with documented effects on reducing cancer risk by influencing processes such as proliferation, angiogenesis, and metastasis. This is primarily attributed to their recognized antioxidant capabilities. Considering the extensive array of signaling pathways associated with exercise and polyphenols, this overview will specifically focus on oxidative stress, the antioxidant efficacy of polyphenols and exercise, and their intricate interplay in cancer treatment.

Physical Activity and Progression of Coronary Artery Calcification in Men and Women

Importance

Prior cross-sectional studies have suggested that very high levels of physical activity (PA) are associated with a higher prevalence of coronary artery calcium (CAC). However, less is known regarding the association between high-volume PA and progression of CAC over time.

Objective

To explore the association between PA (measured at baseline and during follow-up) and the progression of CAC over time.

Design, Setting, and Participants

This cohort study included data from 8771 apparently healthy men and women 40 years and older who had multiple preventive medicine visits at the Cooper Clinic (Dallas, Texas), with a mean (SD) follow-up time of 7.8 (4.7) years between the first and last clinic visit. Participants with reported PA and CAC measurements at each visit during 1998 to 2019 were included in the study. Data were analyzed from March 2023 to February 2024.

Exposures

PA reported at baseline and follow-up, examined continuously per 500 metabolic equivalent of task minutes per week (MET-min/wk) and categorically: less than 1500, 1500 to 2999, 3000 or more MET-min/wk.

Main Outcomes and Measures

Negative binomial regression was used to estimate the rate of mean CAC progression between visits, with potential modification by PA volume, calculated as the mean of PA at baseline and follow-up. In addition, proportional hazards regression was used to estimate hazard ratios for baseline PA as a predictor of CAC progression to 100 or more Agatston units (AU).

Results

Among 8771 participants, the mean (SD) age at baseline was 50.2 (7.3) years for men and 51.1 (7.3) years for women. The rate of mean CAC progression per year from baseline was 28.5% in men and 32.1% in women, independent of mean PA during the same time period. That is, the difference in the rate of CAC progression per year was 0.0% per 500 MET-min/wk for men and women (men: 95% CI, -0.1% to 0.1%; women: 95% CI, -0.4% to 0.5%). Moreover, baseline PA was not associated with CAC progression to a clinically meaningful threshold of 100 AU or more over the follow-up period. The hazard ratio for a baseline PA value of 3000 or more MET-min/wk vs less than 1500 MET-min/wk to cross this threshold was 0.84 (95% CI, 0.66 to 1.08) in men and 1.16 (95% CI, 0.57 to 2.35) in women.

Conclusions and Relevance

This study found that PA volume was not associated with progression of CAC in a large cohort of healthy men and women who were initially free of overt cardiovascular disease.

Knowledge, attitudes, practice, and public health education demand regarding PARI prevention: a cross-sectional study among Chinese undergraduates

OBJECTIVES

The purpose of this study was to assess the level of knowledge, attitudes, and practices (KAP) of university students in China regarding the need for PARI and public health education.

METHODS

A cross-sectional online and offline survey was conducted in China website through Wenjuanxing and in different cities such as Changsha Hunan Province, Shanghai, Chongqing and in different public scenarios, such as hospitals, universities, and commercial venues between September 1 and September 7, 2023, using a 28-question questionnaire designed and reviewed by multidisciplinary experts.

RESULTS

A total of 4,096 respondents were recruited for this study, with 3,957 valid questionnaires. The mean knowledge score was 1.84 ± 0.52, the mean attitude score was 2.12 ± 0.51, and the mean practice score was 3.18 ± 0.55. Regression analyses found that: region, grade, school, and weekly anaerobic exercise time were influences on the knowledge score; region, grade, school, and weekly anaerobic exercise time were influences on the attitude score; region, grade, school attended, weekly anaerobic exercise time and weekly anaerobic exercise time as influences on the practice score. Subgroup analyses revealed that undergraduates from southern regions and 985 schools had higher knowledge attitude scores and lower practice scores. As the grade level increased, the knowledge and attitude scores showed a V-shaped trend and the behavior scores showed an inverted V-shaped trend. Correlation analysis found a positive correlation between knowledge and attitude scores, and a negative correlation between both and behavior, respectively. The public health education needs survey found that undergraduate students generally preferred guided instruction methods and content centered on the RICE principles, they preferred learning through books and pamphlets, and they were happy to see relevant content promoted in the campus environment.

CONCLUSION

This study shows that Chinese undergraduate students have less knowledge, neutral attitudes, and good behaviors regarding PARI prevention. Special attention should be paid to meeting the needs of undergraduate students for public health education to equip them with relevant knowledge so that they can better behave in PARI prevention.

Outrunning the grim reaper: longevity of the first 200 sub-4 min mile male runners

OBJECTIVES

To determine the impact of running a sub-4 min mile on longevity. It was hypothesised that there would be an increase in longevity for runners who successfully completed a sub-4 min mile compared with the general population.

METHODS

As part of this retrospective cohort study, the Sub-4 Alphabetic Register was used to extract the first 200 athletes to run a sub-4 min mile. Each runner's date of birth, date of their first successful mile attempt, current age (if alive) or age at death was compared with the United Nations Life Tables to determine the difference in each runner's current age or age at death with their country of origin-specific life expectancy.

RESULTS

Of the first 200 sub-4 min mile runners (100% male), 60 were dead (30%) and 140 were still alive. Sub-4 min mile runners lived an average of 4.7 years beyond their predicted life expectancy (95% CI 4.7 to 4.8). When accounting for the decade of completion (1950s, 1960s or 1970s), the longevity benefits were 9.2 years (n=22; 95% CI 8.3 to 10.1), 5.5 years (n=88; 95% CI 5.3 to 5.7) and 2.9 years (n=90; 95% CI 2.7 to 3.1), respectively.

CONCLUSION

Sub-4 min mile runners have increased longevity compared with the general population, thereby challenging the notion that extreme endurance exercise may be detrimental to longevity.

Consensus statement of Chinese experts on exercise prescription (2023)

Exercise prescriptions play a vital role in the prevention and treatment of chronic diseases. A consensus regarding exercise prescription is important for physical health. The "Consensus statement of Chinese experts on exercise prescription" (hereinafter referred to as "Expert Consensus") divides exercise prescription into two categories: fitness exercise prescription and medical exercise prescription. Traditional Chinese fitness exercises, exercise risk, exercise prescription, and basic precautions for exercise prescription are explained.

The nature of inappropriate referrals to wellness services in primary care setting in Qatar: Outcome of multifaced interventions on rate and quality of referrals

Objectives

The objectives of this study were to explore the rate and types of inappropriate referrals to the wellness services and to assess the impact of multi-level interventions on the rate of inappropriate referrals at Rawdat Al-Khail health center in Qatar.

Methods

This study employed a retrospective analysis of all referrals data to Rawdat Al-Khail wellness services extracted from the Electronic Health Records (EHRs) between July 2022 and August 2023. The monthly rates and types of inappropriate referrals were calculated. In this study, pre-post analyses were performed to evaluate the impact of two sets of interventions on reducing inappropriate referral rates. The first set involved the development and distribution of e-referral pathways training manual in September 2022. The second set, implemented in April 2023, included close monitoring the rate and types of referrals, and the initiation of feedback communication between wellness services supervisors and referring physicians for advice and corrective actions.

Results

A total of 966 referrals were received during the study period, with 1:5 male-to-female ratio. Of all referrals, 34.9 % were classified as inappropriate, exhibiting considerable variations among different referring health centers. The most common reason for inappropriate referrals was due to the lack of "exercise wellness gym assessment form" (23.8 %). While interventions aimed at enhancing the referral process, they did not result in a significant overall reduction in inappropriate referral rates. However, there was a noteworthy reduction in the inappropriate referrals caused by the lack of "exercise wellness gym assessment form" observed from March to August 2023 (41 %-18 %).

Conclusion

This study sheds light on the complexities of wellness services referrals, revealing a high rate of inappropriate referrals that require closer scrutiny. Despite interventions not significantly reducing the rate of these referrals, it emphasizes the need for ongoing improvement strategies. Structured, periodic interventions at higher levels are recommended to enhance referral appropriateness.

Cost-effectiveness of incentives for physical activity in coronary heart disease in Germany: pre-trial health economic model of a complex intervention following the new MRC framework

Objectives

The German Incentives for Physical Activity in Cardiac Patients trial is a three-arm, randomised controlled trial for secondary prevention of coronary heart disease (CHD). Guidance for developing complex interventions recommends pre-trial health economic modelling. The aim of this study is to model the long-term cost-effectiveness of the incentive-based physical activity interventions in a population with CHD.

Methods

A decision-analytical Markov model was developed from a health services provider perspective, following a cohort aged 65 years with a previous myocardial infarction for 25 years. Monetary and social incentives were compared relative to no incentive. Intervention effects associated with physical activity were used to determine the costs, quality-adjusted life-years (QALYs) gained, incremental cost-effectiveness and cost-utility ratios. The probability of cost-effectiveness was calculated through sensitivity analyses.

Results

The incremental QALYs gained from the monetary and social incentives, relative to control, were respectively estimated at 0.01 (95% CI 0.00 to 0.01) and 0.04 (95% CI 0.02 to 0.05). Implementation of the monetary and social incentive interventions increased the costs by €874 (95% CI €744 to €1047) and €909 (95% CI €537 to €1625). Incremental cost-utility ratios were €25 912 (95% CI €15 056 to €50 210) and €118 958 (95% CI €82 930 to €196 121) per QALY gained for the social and monetary incentive intervention, respectively. With a willingness-to-pay threshold set at €43 000/QALY, equivalent to the per-capita gross domestic product in Germany, the probability that the social and monetary incentive intervention would be seen as cost-effective was 95% and 0%, respectively.

Conclusions

Exercise-based secondary prevention using inventive schemes may offer a cost-effective strategy to reduce the burden of CHD.

Comparison of intramyocellular lipid metabolism in patients with diabetes and male athletes

Despite opposing insulin sensitivity and cardiometabolic risk, both athletes and patients with type 2 diabetes have increased skeletal myocyte fat storage: the so-called "athlete's paradox". In a parallel non-randomised, non-blinded trial (NCT03065140), we characterised and compared the skeletal myocyte lipid signature of 29 male endurance athletes and 30 patients with diabetes after undergoing deconditioning or endurance training respectively. The primary outcomes were to assess intramyocellular lipid storage of the vastus lateralis in both cohorts and the secondary outcomes were to examine saturated and unsaturated intramyocellular lipid pool turnover. We show that athletes have higher intramyocellular fat saturation with very high palmitate kinetics, which is attenuated by deconditioning. In contrast, type 2 diabetes patients have higher unsaturated intramyocellular fat and blunted palmitate and linoleate kinetics but after endurance training, all were realigned with those of deconditioned athletes. Improved basal insulin sensitivity was further associated with better serum cholesterol/triglycerides, glycaemic control, physical performance, enhanced post insulin receptor pathway signalling and metabolic sensing. We conclude that insulin-resistant, maladapted intramyocellular lipid storage and turnover in patients with type 2 diabetes show reversibility after endurance training through increased contributions of the saturated intramyocellular fatty acid pools. Clinical Trial Registration: NCT03065140: Muscle Fat Compartments and Turnover as Determinant of Insulin Sensitivity (MISTY).