Autonomic Adaptations in Andean Trained Participants to a 4220-m Altitude Marathon

Chronic Mountain Sickness: A Comprehensive Review of Current Management and Proposals for Novel Therapies

Chronic mountain sickness (CMS) is an acquired condition affecting 5%-10% of high-altitude residents. Lifelong exposure to chronic hypoxia triggers excessive erythrocytosis, resulting in an expanded hematocrit. Patients present with symptoms such as dyspnea, fatigue, and palpitations. Complications such as pulmonary hypertension and heart failure are often fatal. Relocation to sea level remains the only definitive management of CMS but poses an unacceptable personal burden. Long-term oxygen therapy provides symptomatic relief, but dependency issues remain a concern. Phlebotomy reduces hematocrit and offers short-term symptom relief. However, side effects and cultural conflicts continue to pose challenges. Acetazolamide, enalapril, and medroxyprogesterone have lowered hematocrit and alleviated symptoms in human trials. Further research into systemic side effects, application in women, and long-term use is required. Methylxanthines, adrenergic blockers, almitrine, and dopamine antagonists showed promise in murine and/or short-term human trials, highlighting the need for further long-term human trials. Inhibition of hypoxia-inducible factor and Janus Kinase-signal transducer and activator of transcription pathways is currently used to suppress hematocrit in polycythemia vera, demonstrating potential application in CMS. Topiramate may stimulate ventilation via acid-base modulation, thus providing therapeutic value. Similarly, the effect of aspirin and caffeine on ventilation may provide a low-cost, accessible intervention.

Acute effects of long-distance races on heart rate variability and arterial stiffness: A systematic review and meta-analysis

This study systematically reviewed and quantified the effects of running a long-distance race (LDR) on heart rate variability (HRV) and arterial stiffness (AS). All types of races of a distance equal to or greater than a marathon (≥42.2 km) were included. A total of 2,220 articles were identified, 52 were included in the qualitative analysis, and 48 were meta-analysed. The standardised mean difference pre- and post-race of various time-domain and frequency-domain indices of HRV, mean arterial blood pressure (MAP), systolic blood pressure (SBP), diastolic blood pressure (DBP) and carotid-femoral pulse wave velocity (cfPWV) was calculated. Regarding HRV, there was a significant decrease in most of the variables considered as markers of parasympathetic activity, indicating a shift of autonomic balance towards a reduced vagal tone. Regarding vascular variables, there was a significant drop in blood pressure and reduced AS. In conclusion, running an LDR seems to have a considerable acute effect on the autonomic nervous system, haemodynamics, and vascular properties. The observed effects could be categorised within the expected acute responses to long-lasting, strenuous exercise.

Sub-maximal aerobic exercise training reduces haematocrit and ameliorates symptoms in Andean highlanders with chronic mountain sickness

New Findings

What is the central question of this study?

What is the effect of sub‐maximal aerobic exercise training on signs and symptoms of chronic mountain sickness (CMS) in Andean highlanders?

What is the main finding and its importance?

Aerobic exercise training (ET) effectively reduces haematocrit, ameliorates symptoms and improves aerobic capacity in CMS patients, suggesting that a regular aerobic ET programme might be used as a low‐cost non‐invasive/non‐pharmacological management strategy of this syndrome.

Abstract

Excessive erythrocytosis is the hallmark sign of chronic mountain sickness (CMS), a debilitating syndrome associated with neurological symptoms and increased cardiovascular risk. We have shown that unlike sedentary residents at the same altitude, trained individuals maintain haematocrit within sea‐level range, and thus we hypothesise that aerobic exercise training (ET) might reduce excessive haematocrit and ameliorate CMS signs and symptoms. Eight highlander men (38 ± 12 years) with CMS (haematocrit: 70.6 ± 1.9%, CMS score: 8.8 ± 1.4) from Cerro de Pasco, Peru (4340 m) participated in the study. Baseline assessment included haematocrit, CMS score, pulse oximetry, maximal cardiopulmonary exercise testing and in‐office plus 24 h ambulatory blood pressure (BP) monitoring. Blood samples were collected to assess cardiometabolic, erythropoietic, and haemolysis markers. ET consisted of pedalling exercise in a cycloergometer at 60% of V˙O2peak for 1 h/day, 4 days/week for 8 weeks, and participants were assessed at weeks 4 and 8. Haematocrit and CMS score decreased significantly by week 8 (to 65.6 ± 6.6%, and 3.5 ± 0.8, respectively, P < 0.05), while V˙O2peak and maximum workload increased with ET (33.8 ± 2.4 vs. 37.2 ± 2.0 ml/min/kg, P < 0.05; and 172.5 ± 9.4 vs. 210.0 ± 27.8 W, P < 0.01; respectively). Except for an increase in high‐density lipoprotein cholesterol, other blood markers and BP showed no differences. Our results suggest that reduction of haematocrit and CMS symptoms results mainly from haemodilution due to plasma volume expansion rather than to haemolysis. In conclusion, we show that ET can effectively reduce haematocrit, ameliorate symptoms and improve aerobic capacity in CMS patients, suggesting that regular aerobic exercise might be used as a low‐cost non‐invasive and non‐pharmacological management strategy.

Influence of a 100-mile ultramarathon on heart rate and heart rate variability

Aims

This study aimed to investigate the impact of an ultramarathon (UM) with a distance of 100 miles on heart rate (HR) and heart rate variability (HRV).

Methods

28 runners (25 men and 3 women) underwent 24-hour Holter ECG monitoring 1 week before the UM, immediately after the UM and after a week of recovery. The influence of age, body mass index (BMI), HR and HRV on the run time and recovery was investigated.

Results

A rise in the baseline HR (18.98%) immediately after the run accompanied by a significant drop in the SD of all normal RR intervals (7.12%) 1 week after. Except for the runners' age, BMI, HR and HRV showed no influence on the competition time. Full return of HRV to the athletes' baseline did not occur within 1 week. There were no significant differences between finishers and non-finishers in the analysed parameters.

Conclusion

The present results show that a 100-mile run leads to an increase in sympathetic activity and thus to an increase in HR and a decrease in HRV. Also, HRV might be a suitable parameter to evaluate the state of recovery after a 100-mile run but does not help to quantify the status of recovery, as the damage to the tendomuscular system primarily characterises this after completing a UM.

Effect of exercise training in rats exposed to chronic hypoxia: Application for Monge's disease

Physical exercise may improve hematological conditions in high altitude dwellers suffering from Chronic Mountain Sickness (CMS), in reducing hemoglobin concentration. Therefore, the present study aimed to characterize the effects of 1-month exercise training session in a model of rats exposed to chronic hypoxia. Four groups of male rats were studied: normoxic sedentary (NS, n = 8), normoxic training (NT, n = 8), hypoxic sedentary (HS, n = 8), and hypoxic training group (HT, n = 8). Hypoxic groups were exposed to hypobaric hypoxia for one month (PB =433 Torr). Training intensity was progressively increased from a running speed of 10.4 to 17.8 m/min. Chronic hypoxia led to an increase in hematocrit (HCT) associated with a decrease in plasma volume despite an increase in water intake. Training led to a reduction in HCT (p < 0.01), with a non-significant increase in plasma volume and weight gain. Hypoxia and training had inhibitory effects on haptoglobin (NS group: 379 ± 92; HT: 239 ± 34 µg/ml, p < 0.01). Chronic hypoxia and exercise training increased SpO2 measured after acute hypoxic exposure. Training blunted the decrease in V ˙ O2 peak, time of exhaustion, and maximum speed associated with chronic exposure to hypoxia. Chronic hypoxia led to a right ventricular hypertrophy, which was not corrected by 1-month exercise training. Altogether, by decreasing hematocrit, reducing body weight, and limiting performance decrease, training in hypoxia may have a beneficial effect on excessive erythropoiesis in chronic hypoxia. Therefore, regular exercise training might be beneficial to avoid worsening of CMS symptoms in high altitude dwellers and to improve their quality of life.

[Adaption to chronic hypoxaemia by populations living at high altitude]

Permanent life at high altitude induces important physiological stresses linked to the exposure to chronic hypoxia. Various strategies have been adopted by diverse populations living in the Andes, Tibet or East Africa. The main mechanism is an increase in red blood cell production, more marked in Andeans than in Tibetans or Ethiopians. Other changes are observed in the cardiovascular or respiratory systems, as well as in the utero-placental circulation. Sometimes, a de-adaptation process to hypoxia develops, when erythrocytosis becomes excessive and leads to haematological, vascular and cerebral complications (Monge's disease or chronic mountain sickness). Pulmonary hypertension may also appear. Therapeutic options are available but not sufficiently used. Genetic studies have recently been undertaken to try to better understand the evolution of the human genome in populations living in various high altitude regions of the world, as well as the genetic risk factors for chronic diseases. A new model has appeared, intermittent chronic hypoxia, due to the development of economic activities (mainly mining) in desert regions of the Altiplano.

Chronic Mountain Sickness: Clinical Aspects, Etiology, Management, and Treatment

Villafuerte, Francisco C., and Noemí Corante. Chronic mountain sickness: clinical aspects, etiology, management, and treatment. High Alt Med Biol. 17:61–69, 2016.—Millions of people worldwide live at a high altitude, and a significant number are at risk of developing Chronic Mountain Sickness (CMS), a progressive incapacitating syndrome caused by lifelong exposure to hypoxia. CMS is characterized by severe symptomatic excessive erythrocytosis (EE; Hb ≥19 g/dL for women and Hb ≥21 g/dL for men) and accentuated hypoxemia, which are frequently associated with pulmonary hypertension. In advanced cases, the condition may evolve to cor pulmonale and congestive heart failure. Current knowledge indicates a genetic predisposition to develop CMS. However, there are important risk factors and comorbidities that may trigger and aggravate the condition. Thus, appropriate medical information on CMS is necessary to provide adequate diagnosis and healthcare to high-altitude inhabitants. After reviewing basic clinical aspects of CMS, including its definition, diagnosis, and common clinical findings, we discuss aspects of its etiology, and address its epidemiology, risk factors, and treatment.

A cross-sectional study of differences in 6-min walk distance in healthy adults residing at high altitude versus sea level

Background

We sought to determine if adult residents living at high altitude have developed sufficient adaptation to a hypoxic environment to match the functional capacity of a similar population at sea level. To test this hypothesis, we compared the 6-min walk test distance (6MWD) in 334 residents living at sea level vs. at high altitude.

Methods

We enrolled 168 healthy adults aged ≥35 years residing at sea level in Lima and 166 individuals residing at 3,825 m above sea level in Puno, Peru. Participants completed a 6-min walk test, answered a sociodemographics and clinical questionnaire, underwent spirometry, and a blood test.

Results

Average age was 54.0 vs. 53.8 years, 48% vs. 43% were male, average height was 155 vs. 158 cm, average blood oxygen saturation was 98% vs. 90%, and average resting heart rate was 67 vs. 72 beats/min in Lima vs. Puno. In multivariable regression, participants in Puno walked 47.6 m less (95% CI -81.7 to -13.6 m; p < 0.01) than those in Lima. Other variables besides age and height that were associated with 6MWD include change in heart rate (4.0 m per beats/min increase above resting heart rate; p < 0.001) and percent body fat (-1.4 m per % increase; p = 0.02).

Conclusions

The 6-min walk test predicted a lowered functional capacity among Andean high altitude vs. sea level natives at their altitude of residence, which could be explained by an incomplete adaptation or a protective mechanism favoring neuro- and cardioprotection over psychomotor activity.

[Heart rate variability analysis in sports]

Differences in the duration of the cycles reflects the balance of the sympathetic and parasympathetic influence on the heart. Variance in the heart rate correlates to the breathing cycle, to baroreflex sensitivity, to day and night alternations and to changes in the vegetative tone evoked by physical exercises. Analysis of the time and/or frequency power domain of the heart rate variance is expected to have diagnostic value in physiological and pathological situations as adaptation to training, overtraining, heart disease etc. Both time- and frequency domains reflect the same physiological phenomenon but from different point of view. Vagus tonus is reflected in the high frequency part of the range of variance, while an increased sympathetic tone enriches the low frequency part of the variations of the duration of the consecutive heart cycles. This technically simple and relatively inexpensive method has inspired a couple of clinical and sports medical studies. Certain tendencies seem to be clear, but for individual diagnosis or for prognosis the data must be treated very carefully.

Cerebrovascular responses to altitude

The regulation of cerebral blood flow (CBF) is a complex process that is altered significantly with altitude exposure. Acute exposure produces a marked increase in CBF, in proportion to the severity of the hypoxia and mitigated by hyperventilation-induced hypocapnia when CO(2) is uncontrolled. A number of mediators contribute to the hypoxia-induced cerebral vasodilation, including adenosine, potassium channels, substance P, prostaglandins, and NO. Upon acclimatization to altitude, CBF returns towards normal sea-level values in subsequent days and weeks, mediated by a progressive increase in PO2, first through hyperventilation followed by erythropoiesis. With long-term altitude exposure, a number of mechanisms play a role in regulating CBF, including acid-base balance, hematological modifications, and angiogenesis. Finally, several cerebrovascular disorders are associated with altitude exposure. Existing gaps in our knowledge of CBF and altitude, and areas of future investigation include effects of longer exposures, intermittent hypoxia, and gender differences in the CBF responses to altitude.