Cardiovascular Effects of Performance-Enhancing Drugs

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.

Applying a systems thinking lens to anti-doping: A systematic review identifying the contributory factors to doping in sport

The use of performance enhancing substances and methods (known as "doping") in sport is an intractable issue, with current anti-doping strategies predominantly focused on the personal responsibility and strict liability of individual athletes. This is despite an emerging understanding that athletes exist as part of a broader complex sports system that includes governance, policymakers, media, sponsors, clubs, team members, and athlete support staff, to name a few. As such, there is a need to examine the broader systemic factors that influence doping in sport. The aim of this systematic review was to identify and synthesise the factors contributing to doping and doping behaviours, attitudes, and beliefs and the extent to which this knowledge extends beyond the athlete to consider broader sports systems. The review followed PRISMA guidelines with risk of bias and study quality assessed by the Mixed Methods Appraisal Tool, and identified contributory factors synthesised and mapped onto a systems thinking-based framework. Overall, the included studies were determined to be of high quality. Support personnel, the coach, and the coach-athlete relationship represent key influences on the athletes' decisions to dope. From the evidence presented, doping is an emergent property of sport systems and represents a complex systemic problem that will require whole-of-system interventions. The implications for this and the focus of future research are discussed.

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.

Impact of androgenic anabolic steroid use on cardiovascular and mental health in Danish recreational athletes: protocol for a nationwide cross-sectional cohort study as a part of the Fitness Doping in Denmark (FIDO-DK) study

INTRODUCTION

The use of androgenic anabolic steroids (AASs) among recreational athletes is steadily increasing. However, knowledge regarding the potentially harmful effects of AAS primarily originates from case reports and small observational studies. This large-scale study aims to investigate the impact of AAS use on vascular plaque formation, preclinical coronary disease, cardiac function, circulating cardiovascular risk markers, quality of life (QoL) and mental health in a broad population of illicit AAS users.

METHODS AND ANALYSES

A nationwide cross-sectional cohort study including a diverse population of men and women aged ≥18 years, with current or previous illicit AAS use for at least 3 months. Conducted at Odense University Hospital, Denmark, the study comprises two parts. In part A (the pilot study), 120 recreational athletes with an AAS history will be compared with a sex-matched and age-matched control population of 60 recreational athletes with no previous AAS use. Cardiovascular outcomes include examination of non-calcified coronary plaque volume and calcium score using coronary CT angiography, myocardial structure and function via echocardiography, and assessing carotid and femoral artery plaques using ultrasonography. Retinal microvascular status is evaluated through fundus photography. Cardiovascular risk markers are measured in blood. Mental health outcomes include health-related QoL, interpersonal difficulties, body image concerns, aggression dimensions, anxiety symptoms, depressive severity and cognitive function assessed through validated questionnaires. The findings of our comprehensive study will be used to compose a less intensive investigatory cohort study of cardiovascular and mental health (part B) involving a larger group of recreational athletes with a history of illicit AAS use.

ETHICS AND DISSEMINATION

The study received approval from the Regional Committee on Health Research Ethics for Southern Denmark (S-20210078) and the Danish Data Protection Agency (21/28259). All participants will provide signed informed consent. Research outcomes will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT05178537.

Arrhythmic Mitral Valve Prolapse and Sports Activity: Pathophysiology, Risk Stratification, and Sports Eligibility Assessment

Although mitral valve prolapse (MVP) is the most prevalent valvular abnormality in Western countries and generally carries a good prognosis, a small subset of patients is exposed to a significant risk of malignant ventricular arrhythmias (VAs) and sudden cardiac death (SCD), the so-called arrhythmic MVP (AMVP) syndrome. Recent work has emphasized phenotypical risk features of severe AMVP and clarified its pathophysiology. However, the appropriate assessment and risk stratification of patients with suspected AMVP remains a clinical conundrum, with the possibility of both overestimating and underestimating the risk of malignant VAs, with the inappropriate use of advanced imaging and invasive electrophysiology study on one hand, and the catastrophic occurrence of SCD on the other. Furthermore, the sports eligibility assessment of athletes with AMVP remains ill defined, especially in the grey zone of intermediate arrhythmic risk. The definition, epidemiology, pathophysiology, risk stratification, and treatment of AMVP are covered in the present review. Considering recent guidelines and expert consensus statements, we propose a comprehensive pathway to facilitate appropriate counseling concerning the practice of competitive/leisure-time sports, envisioning shared decision making and the multidisciplinary "sports heart team" evaluation of borderline cases. Our final aim is to encourage an active lifestyle without compromising patients' safety.

Inverse Association between Exercising Blood Pressure Response and Left Ventricular Chamber Size and Mass in Women Who Habitually Resistance Train

Exercise is a major modifiable lifestyle factor that leads to temporarily increased systolic blood pressure (SBP), which is thought to influence left ventricular mass normalized to body surface area (LVM/BSA). This relationship has never been studied in women who habitually perform resistance exercise.

PURPOSE

To determine if a direct correlation exists between the SBP response to resistance exercise (change from rest; eSBP) and LVM/BSA in young healthy women who habitually resistance train.

METHODS

Leg extension resistance exercise was performed while continuously monitoring blood pressure using finger plethysmography. LVM was estimated using echocardiography. Data are shown as mean ± SD.

RESULTS

Thirty-one women participated (age 23 ± 3 years, height 164 ± 7 cm, body mass 63.7 ± 10.3 kg). Resting SBP (110 ± 8 mmHg, r = 0.355, p = 0.049) was shown to be directly correlated to LVM/BSA (72.0 ± 28.4 g/m2). Conversely, eSBP (30.8 ± 14.6 ∆mmHg, r = -0.437, p = 0.014) was inversely related to LVM/BSA. eSBP was not correlated to interventricular septum width (0.88 ± 0.12 cm, r = -0.137, p = 0.463) or posterior wall thickness (0.91 ± 0.15 cm, r = -0.084, p = 0.654). eSBP was inversely related to left ventricle internal diameter during diastole (LVIDd) (4.25 ± 0.33 cm, r = -0.411, p = 0.021).

CONCLUSION

Counter to the hypothesis, these data suggest an inverse association between eSBP during resistance exercise and LVM/BSA in healthy young women who resistance train. This relationship is due to a smaller LVIDd with greater eSBP.

The Biological Basis of Sex Differences in Athletic Performance: Consensus Statement for the American College of Sports Medicine

ABSTRACT

Biological sex is a primary determinant of athletic performance because of fundamental sex differences in anatomy and physiology dictated by sex chromosomes and sex hormones. Adult men are typically stronger, more powerful, and faster than women of similar age and training status. Thus, for athletic events and sports relying on endurance, muscle strength, speed, and power, males typically outperform females by 10%-30% depending on the requirements of the event. These sex differences in performance emerge with the onset of puberty and coincide with the increase in endogenous sex steroid hormones, in particular testosterone in males, which increases 30-fold by adulthood, but remains low in females. The primary goal of this consensus statement is to provide the latest scientific knowledge and mechanisms for the sex differences in athletic performance. This review highlights the differences in anatomy and physiology between males and females that are primary determinants of the sex differences in athletic performance and in response to exercise training, and the role of sex steroid hormones (particularly testosterone and estradiol). We also identify historical and nonphysiological factors that influence the sex differences in performance. Finally, we identify gaps in the knowledge of sex differences in athletic performance and the underlying mechanisms, providing substantial opportunities for high-impact studies. A major step toward closing the knowledge gap is to include more and equitable numbers of women to that of men in mechanistic studies that determine any of the sex differences in response to an acute bout of exercise, exercise training, and athletic performance.

A national anti-doping education programme reduces doping susceptibility in British athletes

The World Anti-Doping Agency's International Standard for Education instructs that national and international sport organisations evaluate their education programmes. We addressed this directive by examining the effectiveness of a national anti-doping programme. Athletes (N = 302, 41% female) completed measures of doping susceptibility, intention to use dietary supplements, Spirit of Sport and moral values, anti-doping knowledge and practice, and whistleblowing, prior-to and three-months after attending an anti-doping education programme. At three-month follow-up, athletes reported decreased doping susceptibility and intention to use dietary supplements coupled with increased importance of values, anti-doping knowledge, anti-doping practice and whistleblowing. Within-participant, moderated-mediation analyses revealed that programme-related changes in doping susceptibility were indirectly related to changes in intention to use dietary supplements, and, that this indirect relationship was moderated by moral values. These findings confirm the effectiveness of a national anti-doping education programme and highlight the contribution of dietary supplement use and personal values to changes in doping susceptibility.

Potential health risks of foodborne performance-enhancing drugs in competitive sports

Athletes need to consume a significant amount of energy during prolonged training and in high-intensity competition. It is necessary for them to take nutritional foods that recharge their bodies. However, in sporting events of recent years, both domestic and international, many positive drug tests are found to be caused by the ingestion of foods that contain performance-enhancing drugs (PEDs). As a result, the prevention and control of PEDs in food supply have drawn increasing attention. For better prevention and control, the first step is to understand the food contaminants -- PEDs. This study has categorized PEDs through their presence in animal-derived foods, plant-derived foods, and synthetic nutritional supplements in competitive sports. It investigates the potential risks of foodborne doping using techniques such as external addition and endogenous component analysis. This research explored the causes of PEDs in food and their negative effects on athletes and proposed measures to ensure the safety of nutritional substances in competitive sports. PEDs in animal-derived foods include β-adrenergic agonists, anabolic steroids, and glucocorticoids, which can be found in meat and ox penis, amongst other food sources. In contrast, PEDs in plant-derived foods include alkaloids, higenamine, and zeranol, which can be found in coffee, tea, Sichuan pepper, custard apple, and cereal. Performance-enhancing drugs (PEDs) that are often added to synthetic supplements include creatine, traditional Chinese herbs, 1, 3-dimethylbutylamine (DMAA), sibutramine, ephedrine, and methylhexanamine. Targeted anti-doping training should be provided to athletes. In addition, the latest domestic and international standards and regulations regarding PEDs or prohibited and restricted ingredients in foods should be tracked in real-time. The control list for performance-enhancing drugs in food should be continually updated and refined. Research on detection methods for performance-enhancing drugs in food should also be advanced. Moreover, market surveillance and law enforcement should be strengthened to ensure that sports foods meet national safety standards before they enter the market. This paper provides workable solutions to clarify the types and scope of performance-enhancing drugs in food, aiming to improve the prevention and control of PEDs in animal-derived foods, plant-derived foods, and supplements in major sporting events.

Metabolism Study of Anamorelin, a GHSR1a Receptor Agonist Potentially Misused in Sport, with Human Hepatocytes and LC-HRMS/MS

Anamorelin, developed for the treatment of cancer cachexia, is an orally active medication that improves appetite and food intake, thereby increasing body mass and physical functioning. It is classified as a growth hormone secretagogue and strictly monitored by the World Anti-Doping Agency (WADA), owing to its anabolic enhancing potential. Identifying anamorelin and/or metabolite biomarkers of consumption is critical in doping controls. However, there are currently no data available on anamorelin human metabolic fate. The aim of this study was to investigate and identify biomarkers characteristic of anamorelin intake using in silico metabolite predictions with GLORYx, in vitro incubation with 10-donor-pooled human hepatocytes, liquid chromatography-high-resolution tandem mass spectrometry (LC-HRMS/MS) analysis, and data processing with Thermo Scientific's Compound Discoverer. In silico prediction resulted in N-acetylation at the methylalanyl group as the main transformation (score, 88%). Others including hydroxylation at the indole substructure, and oxidation and N-demethylation at the trimethylhydrazino group were predicted (score, ≤36%). Hepatocyte incubations resulted in 14 phase I metabolites formed through N-demethylation at the trimethylhydrazino group, N-dealkylation at the piperidine ring, and oxidation at the indole and methylalanyl groups; and two phase II glucuronide conjugates occurring at the indole. We propose four metabolites detected as specific biomarkers for toxicological screening.

Anabolic steroid misuse is an important reversible cause of cardiomyopathy: a case report

Background

Anabolic steroid misuse is very common and has been linked to the development of a severe cardiomyopathy, arrhythmias, and sudden death.

Case summary

A 46-year-old miner presented to hospital with subacute dyspnoea and palpitations. Investigations revealed atrial fibrillation and a severe dilated cardiomyopathy with left ventricular ejection fraction of 12%. The patient had a history of longstanding exogenous testosterone administration. Haematological investigations demonstrated a marked polycythaemia, with haematocrit of 0.60 L/L (normal 0.40–0.54 L/L). Hormonal investigations revealed an elevated testosterone level of 46.4 nmol/L (normal 8.0–30.0 nmol/L) and suppressed luteinizing and follicle-stimulating hormones, consistent with excess testosterone use. The patient was referred to the endocrinology specialty team for support with ceasing excess testosterone use, while commencing guideline-directed heart failure therapy. At 6 months of follow-up, the patient’s left ventricular ejection fraction had normalized and he was asymptomatic. Biochemical indicators of testosterone excess had also normalized.

Discussion

Anabolic steroids are widely misused, particularly among young and middle-aged males. Cardiovascular complications include a potentially reversible severe cardiomyopathy, accelerated coronary disease, dyslipidaemia, arrhythmias, and sudden death. It is important to identify a history of anabolic steroid misuse when investigating cardiomyopathy and be alert for indicators such as polycythaemia. Cessation of anabolic steroid misuse may lead to complete reversal of cardiomyopathy but should be undertaken in close partnership with the patient and endocrinologists.

Cardiac involvement in athletes infected by SARS COV-2 disease

Objectives

The aim of the present study was to conduct a review of the current literature evaluating the available evidence to date in terms of epidemiology, pathophysiology and clinical presentation of COVID-19 in relation to cardiovascular involvement, with a special focus on the myocarditis model, in the population of athletes (professional and recreational) who are preparing to return to competitions, with the ultimate aim of guaranteeing maximum safety for resuming sports activities.

News

The COVID-19 pandemic has resulted in the inevitable cancellation of most sports activities, practiced at both a professional and amateur level, in order to minimize the risk of spreading the infection. Since the number of athletes who tested positive was rather high, the potential cardiac involvement in this peculiar population of subjects contracting the disease in a mild (asymptomatic, slightly symptomatic) or moderate form, has recently raised concerns following the observation of cases of recorded myocardial damage, myocarditis, arrhythmias and a first reported case of Sudden Cardiac Death (SCD) in a 27-year-old professional basketball player. Several studies even seem to confirm the possibility of permanent impairment of the cardiorespiratory system following the infection. Medical history, biomarkers, electrocardiographical and cardiac imaging features appear to be crucial in distinguishing cardiovascular alterations related to COVID-19 infection from typical adaptations to exercise related to athletes' heart.

Prospects and Projects

Clarifications and prospective data based on long-term follow-ups on larger populations of athletes are still needed to exclude the development of myocardial damage capable of negatively affecting prognosis and increasing cardiovascular risk in athletes recovered from COVID-19 in asymptomatic (simple positivity to SARS-COV-2) or in a mild form.

Conclusion

From a clinical point of view extreme caution is necessary when planning the return to sport (Return To Play-RTP) of athletes recovered from a mild or asymptomatic form of COVID-19: a careful preliminary medical-sports evaluation should be carried out in order to assess the potential development of myocardial damage that would increase their cardiovascular risk.

Performance-enhancing drugs and the Olympics

The rules of fair play in sport generally prohibit the use of performance-enhancing drugs (PEDs). The World Anti-Doping Agency (WADA) oversees global antidoping regulations and testing for elite athletes participating in Olympic sports. Efforts to enforce antidoping policies are complicated by the diverse and evolving compounds and strategies employed by athletes to gain a competitive edge. Now between the uniquely proximate 2021 Tokyo and 2022 Beijing Olympic Games, we discuss WADA's efforts to prevent PED use during the modern Olympic Games. Then, we review the major PED classes with a focus on pathophysiology, complexities of antidoping testing, and relevant toxicities. Providers from diverse practice environments are likely to care for patients using PEDs for a variety of reasons and levels of sport; these providers should be aware of common PED classes and their risks.

Cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids in relation to sports: a position statement of the sport cardiology and exercise nucleus of the European Association of Preventive Cardiology

The use of substances and medications with potential cardiovascular effects among those practicing sports and physical activity has progressively increased in recent years. This is also connected to the promotion of physical activity and exercise as core aspects of a healthy lifestyle, which has led also to an increase in sport participation across all ages. In this context, three main users' categories can be identified, (i) professional and amateur athletes using substances to enhance their performance, (ii) people with chronic conditions, which include physical activity and sport in their therapeutic plan, in association with prescribed medications, and (iii) athletes and young individuals using supplements or ergogenic aids to integrate their diet or obtaining a cognitive enhancement effect. All the substances used for these purposes have been reported to have side effects, among whom the cardiovascular consequences are the most dangerous and could lead to cardiac events. The cardiovascular effect depends on the type of substance, the amount, the duration of use, and the individual response to the substances, considering the great variability in responses. This Position Paper reviews the recent literature and represents an update to the previously published Position Paper published in 2006. The objective is to inform physicians, athletes, coaches, and those participating in sport for a health enhancement purpose, about the adverse cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids, when associated with sport and exercise.

Potential health risks surrounding ingredients of pre-workout and post-workout dietary supplements: a thorough label analysis

ABSTRACT Objective Dietary supplements use is increasing. Dietary supplements may contain high doses of substances or dangerous ingredient combinations. This article aims to investigate, by analyzing dietary supplements labels, if there are any doping substances or dangerous amounts of any other component in the reviewed dietary supplements. Methods Several brands which possessed their supplements sorted in pre-workout and post-workout were analyzed. 40 dietary supplements with all ingredients described were included. The minimum and maximum dosages of dietary supplements were statistically described as Mean±SD. Results Citrus aurantium extract, Yohimbe extract, Garcinia cambogia extract and Maca root extract were reported in some of the analyzed dietary supplements. Regarding caffeine, the pre-workout group displayed higher mean caffeine (241±86mg) than the post-workout group (183±68mg), and the minimal mean dose was 226±84mg; meanwhile, the maximal mean dose was 242±88mg. Concerning creatine, the pre-workout group displayed lower mean creatine (3106±1079mg) than the post-workout group (4137±4177mg), and the minimal mean dose was 3167±1728mg; meanwhile, the maximal mean dose was 3917±3643mg. The salt content in the post-workout group displayed a much higher mean (2155±4486mg) than the pre-workout group (464±605mg), and the minimal mean dose was 1635±3930mg; meanwhile, the maximal mean dose was 1708±3926g. Conclusions No doping substances were reported in the dietary supplements, but consumption recommendations on the label could lead to excessive consumption of some not yet fully tested ingredients.

Sudden cardiac death in sports: could we save Pheidippides?

Hereditary diseases under the age of 35 are the most common underlying heart disease, leading to sudden cardiac death (SCD) in competitive sports, while in older people, atherosclerotic coronary artery disease (CAD) is the main cause. The following preventive measures are recommended: (a) The pre-participation cardiovascular screening, (b) the genetic testing, (c) the use of implantable cardioverter-defibrillator (ICD), (d) the prohibition of doping in sports, (e) the prevention of 'exercise-induced' cardiac complications, (f) the reduction of high-risk factors for CAD, and (g) the use of cardiopulmonary resuscitation. The cost-effectiveness of the electrocardiograms in the pre-participation screening programs remains questionable. Genetic testing is recommended in borderline cases and positive family history. Athletes with ICD can, under certain conditions, participate in competitive sports. Excessive endurance exercise appears to harm the endothelium, promotes inflammatory processes and leads to fibrosis in the myocardium, and calcium deposition in the coronary vessels. Cardiac arrest may be reversed if cardiopulmonary resuscitation is performed and a defibrillator is immediately used. Thus, equipping all fields with automatic external defibrillators are recommended.

Differences in Left Ventricular Function at Rest and during Isometric Handgrip Exercise in Elite Aquatic Sport Athletes

PURPOSE

Elite swimmers (Sw) have lower diastolic function compared to elite runners, possibly as an adaptation to the aquatic training environment. Water polo players (WP) and artistic swimmers (AS) are exposed to the same hydrostatic pressures as Sw, but are subject to different training intensities, postures, and hemodynamic stressors. Our purpose was to compare resting and exercising cardiac function in elite Sw, WP, and AS, to characterize the influence of training for aquatic-sport on left ventricular (LV) adaptation.

METHODS

Ninety athletes (Sw:20 M/17F; WP:21 M/9F; AS:23F) at the 2019 FINA World Championships volunteered for resting and stress (3 min 30% maximal isometric handgrip) echocardiographic assessment of LV global function and mechanics.

RESULTS

Male Sw displayed greater resting systolic and diastolic function compared to WP; however, both groups maintained stroke volume under high-pressure handgrip stress (Sw:[INCREMENT]-4 ± 12%; WP:[INCREMENT]-1 ± 13%, P = 0.11). There were no differences between female Sw and WP resting LV function, but Sw demonstrated greater function over AS. During isometric handgrip, all female sport athletes maintained stroke volume (Sw:[INCREMENT]3 ± 16%; WP:[INCREMENT]-10 ± 11%; AS:[INCREMENT]-2 ± 14%, P = 0.46), but WP had improved apical rotation ([INCREMENT]1.7 ± 4.5°), which was reduced in AS ([INCREMENT]-3.1 ± 4.5°) and maintained in Sw ([INCREMENT]-0.5 ± 3.8°, P = 0.04). Unlike Sw and WP, AS displayed a unique maintenance of early filling velocity during handgrip exercise (Sw:[INCREMENT]-3.5 ± 14.7 cm/s; WP:[INCREMENT]-15.1 ± 10.8 cm/s; AS:[INCREMENT]1.5 ± 15.3 cm/s, P = 0.02).

CONCLUSION

Among male athletes, Sw display primarily volume-based functional adaptations distinct from the mixed volume-pressure adaptations of WP; however, both groups can maintain stroke volume with increased afterload. Female Sw and WP do not demonstrate sport-specific differences like males, perhaps owing to sex-differences in adaptation, but have greater volume-based adaptations than AS. Lastly, AS display unique functional adaptations, that may be driven by elevated pressures under low-volume conditions.

[Cardiovascular Risks Associated with the use of Performance-Enhancing Stimulants]

The number of people involved in regular exercise and sports is increasing. Not infrequently, this is associated with intake of sports biologically active food supplements (BAS) and stimulators of physical ability. Data has been reported on the frequency of use of physical ability stimulators among professional athletes and on the use of the most popular food supplements among young people. Special attention is paid to the effect of such use on the cardiovascular system of athletes. This review describes negative cardiac effects and clinical cases of death of athletes due to the use of such supplements and stimulators.

Arrhythmogenic right ventricular cardiomyopathy and sports activity: from molecular pathways in diseased hearts to new insights into the athletic heart mimicry

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.

Subacute Stent Thrombosis After Primary Percutaneous Coronary Intervention in a Middle-Aged Anabolic Steroid-Abusing Bodybuilder

A 54-year-old male bodybuilder who was abusing anabolic steroids developed an acute ST-segment elevation myocardial infarction after strenuous strength training. Despite optimal use of dual antiplatelet therapy, on day 4 after primary coronary stenting, the patient suffered another acute coronary event due to subacute thrombosis, potentially pre-disposed by anabolic steroid use. (Level of Difficulty: Intermediate.).

Doping Attitudes, Beliefs, and Practices among Young, Amateur Croatian Athletes

Recent studies revealed that amateur athletes, especially young ones, have an increasing tendency of performance-enhancing drugs (PEDs) usage. The aim of this study was to explore PEDs attitudes, beliefs, and practices among young, amateur Croatian athletes. This cross-sectional study using a specially designed questionnaire as a research tool was done during the August 2019 to January 2020 period among a convenient sample of 400 amateur athletes of median age 18 (interquartile range 15 to 21) years. The prevalence of current PEDs usage was 1.3%, while past PEDs usage prevalence was 3.3%. Current PEDs usage was more frequent among young adults (p = 0.048) and athletes playing individual sports (p = 0.001). Athletes who were engaged in sports from one to five years had more permissive attitudes toward PEDs (p < 0.001) as measured by the Performance Enhancement Attitude Scale. Female athletes had more positive beliefs about PEDs usage (p = 0.008). The study did not establish any correlation between current or past PEDs usage and attitudes toward PEDs as well as beliefs about PEDs usage. However, there was a weak positive correlation between attitudes toward PEDs and athletes' beliefs about PEDs usage (rs = 0.465, p < 0.001). PEDs usage is present among young Croatian amateur athletes. There is a need for interventions directed toward the prevention of PEDs usage in an observed subgroup of athletes.

Intense Endurance Exercise: A Potential Risk Factor in the Development of Heart Disease

Exercise is known to improve cardiac health; however, the upper limit of exercise is not as clear. High-intensity endurance exercise and its association with cardiac dysfunction are becoming more important as more people in the USA participate in endurance activity. Intensive endurance exercise is associated with heart disease. Peer-reviewed primary literature related to endurance exercise, cardiac remodelling, myocardial fibrosis, and arrhythmia was searched and selected from the PubMed Database to be reviewed. Increased cardiac remodelling, myocardial fibrosis, and arrhythmias were associated with increased endurance exercise in most instances. Clinically significant dysfunction from endurance exercise-induced cardiac remodelling and myocardial fibrosis is not certain. However, increased incidence of sinus node disease (SND) and atrial flutter in endurance athletes, even after deconditioning, seems to be most associated with endurance exercise. Cardiac remodelling, fibrosis, and arrhythmia were associated with cardiac dysfunction. All review articles in this study were limited by a low sample size since it was difficult to obtain a full record of previous endurance activity. The reversibility of cardiac changes needs to be further investigated and can be applied in the differential diagnosis of other cardiomyopathies. The interaction between performance-enhancing drugs and endurance exercise needs to be further studied to determine its action on cardiac health. Findings from these studies could contribute to exercise recommendations.

Associations between legal performance-enhancing substance use and future cardiovascular disease risk factors in young adults: A prospective cohort study

BACKGROUND

Legal performance-enhancing substances (PES), such as creatine, are commonly used by adolescents and young adults. As PES are mostly unregulated by the US Food and Drug Administration, there has been limited empirical attention devoted to examining their long-term safety and health outcomes. Preliminary studies have demonstrated associations between PES use and severe medical events, including hospitalizations and death. PES could be linked to cardiovascular disease (CVD), the most common cause of mortality in the US, by altering the myocardium, vasculature, or metabolism. The objective of this study was to examine prospective associations between the use of legal PES in young adulthood and CVD risk factors at seven-year follow-up.

MATERIALS AND METHODS

Nationally representative longitudinal cohort data from the National Longitudinal Study of Adolescent to Adult Health, Waves III (2001-2002) and IV (2008), were analyzed. Regression models determined the prospective association between the use of legal PES (e.g. creatine monohydrate) and CVD risk factors (e.g. body mass index, diabetes, hypertension, hyperlipidemia), adjusting for relevant covariates.

RESULTS

Among the diverse sample of 11,996 male and female participants, no significant differences by PES use in body mass index, diabetes, hypertension, or hyperlipidemia were noted at Wave III. In unadjusted comparisons, legal PES users (versus non-users) were more likely to be White, be male, be college educated, drink alcohol, and engage in weightlifting, exercise, individual sports, team sports, and other strength training. There were no significant prospective associations between legal PES use at Wave III and body mass index, hemoglobin A1c, systolic and diastolic blood pressure, and cholesterol (total, HDL, LDL, triglycerides) deciles at seven-year follow-up (Wave IV), adjusting for demographics, health behaviors, and Wave III CVD risk factors. Similarly, there were no significant prospective associations between legal PES use and diabetes, hypertension, or hyperlipidemia based on objective measures or self-reported medications and diagnoses, adjusting for demographics, health behaviors, and Wave III CVD risk.

CONCLUSIONS

We do not find evidence for a prospective association between legal PES use and CVD risk factors in young adults over seven years of follow-up, including BMI, diabetes, hypertension, or hyperlipidemia. It should be noted that legal PES use was operationalized dichotomously and as one broad category, which did not account for frequency, amount, or duration of use. Given the lack of regulation and clinical trials data, observational studies can provide much needed data to inform the safety and long-term health associations of legal PES use and, in turn, inform clinical guidance and policy.

Anabolic-Androgenic Steroid Abuse Impairs Fibrin Clot Lysis

Abuse of anabolic-androgenic steroids (AASs) is suspected to increase the risk of cardiovascular disease (CVD) and cardiovascular mortality in otherwise healthy individuals. AAS abuse may increase the incidence of CVD by altering the hemostatic balance toward a procoagulant state. Studies on the effect of AAS abuse on the fibrinolytic system, however, have either demonstrated a profibrinolytic effect or no effect of AAS abuse, but the overall effect of AAS on fibrinolysis has not been addressed so far. This cross-sectional study investigated the effect of AAS on fibrin clot lysis, fibrin structure, and the hemostatic proteins, potentially affecting these measures in current and former AAS abusers and healthy age-matched controls. The study population consisted of 37 current and 33 former AAS abusers, along with 30 healthy age-matched controls. Fibrin clot lysis, fibrin structure properties, fibrinogen, coagulation factor XIII (FXIII) plasminogen, plasmin inhibitor, plasminogen activator inhibitor-1 (PAI-1), and thrombin activatable fibrinolysis inhibitor (TAFI) were determined. Fibrin clot lysis was significantly reduced in participants abusing AAS compared with former abusers and controls (p < 0.001). Plasma fibrinogen, plasminogen, and plasmin inhibitor were significantly increased in current abusers (p < 0.05). No significant differences were observed with respect to measures of fibrin structure properties, PAI-1, and TAFI (p > 0.05). In conclusion, AAS abuse depresses fibrin clot lysis. This effect is not associated with alterations in fibrin structure but is rather caused by increased plasma concentrations of fibrinogen, FXIII, and plasmin inhibitor. These findings suggest that AAS abuse may be associated with increased thrombotic disease.

Exercise and Coronary Atherosclerosis: Observations, Explanations, Relevance, and Clinical Management

Physical activity and exercise training are effective strategies for reducing the risk of cardiovascular events, but multiple studies have reported an increased prevalence of coronary atherosclerosis, usually measured as coronary artery calcification, among athletes who are middle-aged and older. Our review of the medical literature demonstrates that the prevalence of coronary artery calcification and atherosclerotic plaques, which are strong predictors for future cardiovascular morbidity and mortality, was higher in athletes compared with controls, and was higher in the most active athletes compared with less active athletes. However, analysis of plaque morphology revealed fewer mixed plaques and more often only calcified plaques among athletes, suggesting a more benign composition of atherosclerotic plaques. This review describes the effects of physical activity and exercise training on coronary atherosclerosis in athletes who are middle-aged and older and aims to contribute to the understanding of the potential adverse effects of the highest doses of exercise training on the coronary arteries. For this purpose, we will review the association between exercise and coronary atherosclerosis measured using computed tomography, discuss the potential underlying mechanisms for exercise-induced coronary atherosclerosis, determine the clinical relevance of coronary atherosclerosis in middle-aged athletes and describe strategies for the clinical management of athletes with coronary atherosclerosis to guide physicians in clinical decision making and treatment of athletes with elevated coronary artery calcification scores.

Myocarditis in athletes: A clinical perspective

Myocarditis is an important cause of arrhythmias and sudden cardiac death (SCD) in both physically active individuals and athletes. Elite athletes seem to have an increased risk for viral infection and subsequent myocarditis due to increased exposure to pathogens (worldwide traveling/international competition) or impaired immune system (continuing training during infections/resuming training early thereafter, strenuous exercise training or competition, and exercising in extreme weather conditions). Initial clinical presentation is variable, but athletes characteristically express non-specific symptoms of fatigue, muscle soreness, increased heart rate at rest, as well as during exercise and reduced overall exercise capacity. Beyond resting electrocardiogram (ECG), cardiac biomarkers, echocardiography, and 24-hour Holter ECG, diagnostic work-up should include cardiac magnetic resonance imaging (CMR) assessing inflammation, oedema, and fibrosis by late gadolinium enhancement (LGE), respectively, as these measures are crucial for prognosis and sports eligibility. For patients with insufficient cardiac recovery, endomyocardial biopsy is recommended to clarify differential diagnoses and initiate specific treatment options. In uncomplicated cases with normal left ventricular function during acute phase and absent LGE, eligibility for sports can be attested to three months after clinical recovery. In those with persistent pathological findings, even after six months, the risk for SCD remains increased and resuming exercise beyond recreational activities can only be recommended individually based on course of disease, left ventricular function, arrhythmias, pattern of LGE in CMR, as well as intensity and volume of exercise performed during training and competition. For all athletes, follow-up examination should be performed yearly.

Sildenafil enhances central hemodynamic responses to exercise, but not V̇o2peak, in people with diabetes mellitus

Exercise capacity is frequently reduced in people with diabetes mellitus (DM), and the contribution of pulmonary microvascular dysfunction remains undefined. We hypothesized that pulmonary microvascular disease, measured by a novel exercise echocardiography technique termed pulmonary transit of agitated contrast (PTAC), would be greater in subjects with DM and that the use of pulmonary vasodilator agent sildenafil would improve exercise performance by reducing right ventricular afterload. Forty subjects with DM and 20 matched controls performed cardiopulmonary exercise testing and semisupine exercise echocardiography 1 h after placebo or sildenafil ingestion in a double-blind randomized crossover design. The primary efficacy end point was exercise capacity (V̇o2peak) while secondary measures included pulmonary vascular resistance, cardiac output, and change in PTAC. DM subjects were aged 44 ± 13 yr, 73% male, with 16 ± 10 yr DM history. Sildenafil caused marginal improvements in echocardiographic measures of biventricular systolic function in DM subjects. Exercise-induced increases in pulmonary artery systolic pressure and pulmonary vascular resistance were attenuated with sildenafil, while heart rate (+2.4 ±1.2 beats/min, P = 0.04) and cardiac output (+322 ± 21 ml, P = 0.03) improved. However, the degree of PTAC did not change (P = 0.93) and V̇o2peak did not increase following sildenafil as compared with placebo (V̇o2peak: 31.8 ± 9.7 vs. 32.1 ± 9.5 ml·min-1·kg-1, P = 0.42). We conclude that sildenafil administration causes modest acute improvements in central hemodynamics but does not improve exercise capacity. This may be due to the mismatch in action of sildenafil on the pulmonary arteries rather than the distal pulmonary microvasculature and potential adverse effects on peripheral oxygen extraction. NEW & NOTEWORTHY This is one of the largest and most comprehensive studies of cardiopulmonary exercise performance in people with diabetes mellitus and to our knowledge the first to assess the effect of sildenafil using detailed echocardiographic measures during incremental exercise. Sildenafil attenuated the rise in pulmonary vascular resistance while augmenting cardiac output and intriguingly heart rate, without conferring any improvement in exercise capacity. The enhanced central hemodynamic indexes may have been offset by reduced peripheral O2 extraction.