The noninvasive cardiac evaluation of long-distance runners

Impact of ethnicity on cardiac adaptation to exercise

The increasing globalization of sport has resulted in athletes from a wide range of ethnicities emerging onto the world stage. Fuelled by the untimely death of a number of young professional athletes, data generated from the parallel increase in preparticipation cardiovascular evaluation has indicated that ethnicity has a substantial influence on cardiac adaptation to exercise. From this perspective, the group most intensively studied comprises athletes of African or Afro-Caribbean ethnicity (black athletes), an ever-increasing number of whom are competing at the highest levels of sport and who often exhibit profound electrical and structural cardiac changes in response to exercise. Data on other ethnic cohorts are emerging, but remain incomplete. This Review describes our current knowledge on the impact of ethnicity on cardiac adaptation to exercise, starting with white athletes in whom the physiological electrical and structural changes--collectively termed the 'athlete's heart'--were first described. Discussion of the differences in the cardiac changes between ethnicities, with a focus on black athletes, and of the challenges that these variations can produce for the evaluating physician is also provided. The impact of ethnically mediated changes on preparticipation cardiovascular evaluation is highlighted, particularly with respect to false positive results, and potential genetic mechanisms underlying racial differences in cardiac adaptation to exercise are described.

Recommendations for interpretation of 12-lead electrocardiogram in the athlete

Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed.

The athlete's heart. A meta-analysis of cardiac structure and function

BACKGROUND

It has been postulated that depending on the type of exercise performed, 2 different morphological forms of athlete's heart may be distinguished: a strength-trained heart and an endurance-trained heart. Individual studies have not tested this hypothesis satisfactorily.

METHODS AND RESULTS

The hypothesis of divergent cardiac adaptations in endurance-trained and strength-trained athletes was tested by applying meta-analytical techniques with the assumption of a random study effects model incorporating all published echocardiographic data on structure and function of male athletes engaged in purely dynamic (running) or static (weight lifting, power lifting, bodybuilding, throwing, wrestling) sports and combined dynamic and static sports (cycling and rowing). The analysis encompassed 59 studies and 1451 athletes. The overall mean relative left ventricular wall thickness of control subjects (0.36 mm) was significantly smaller than that of endurance-trained athletes (0.39 mm, P=0.001), combined endurance- and strength-trained athletes (0.40 mm, P=0.001), or strength-trained athletes (0.44 mm, P<0.001). There was a significant difference between the 3 groups of athletes and control subjects with respect to left ventricular internal diameter (P<0. 001), posterior wall thickness (P<0.001), and interventricular septum thickness (P<0.001). In addition, endurance-trained athletes and strength-trained athletes differed significantly with respect to mean relative wall thickness (0.39 versus 0.44, P=0.006) and interventricular septum thickness (10.5 versus 11.8 mm, P=0.005) and showed a trend toward a difference with respect to posterior wall thickness (10.3 versus 11.0 mm, P=0.078) and left ventricular internal diameter (53.7 versus 52.1 mm, P=0.055). With respect to cardiac function, there were no significant differences between athletes and control subjects in left ventricular ejection fraction, fractional shortening, and E/A ratio.

CONCLUSIONS

Results of this meta-analysis regarding athlete's heart confirm the hypothesis of divergent cardiac adaptations in dynamic and static sports. Overall, athlete's heart demonstrated normal systolic and diastolic cardiac functions.

The preparticipation sports examination for high school and college athletes

The PSE can be used as a tool to allow athletes to participate safely in sports. The goal of the PSE is not to disqualify athletes but to ensure that their participation in sports does not unnecessarily increase their risk of injury. The PSE is most effectively conducted by the station method with multiple examiners, one of whom should have specialty training in musculoskeletal disorders. The examination should be conducted 6 weeks prior to the beginning of the season and at the beginning of each new level of competition, unless directed differently by local laws. The correct use of the PSE should screen for signs and symptoms of pathological states that may lead to a nontraumatic death while participating in sports. An effective musculoskeletal examination should detect any postinjury deficits that may lead to subsequent reinjury later in the season. It is our hope that a PSE, based on the literature, can be used to prevent some of the nontraumatic deaths and musculoskeletal injury associated with sports participation.

The athlete's heart

We have provided an overview of the athlete's heart, focusing on the young athlete. Primary caretakers of athletes should know the major causes of exercise-related cardiac complications and sudden cardiac death and look for these conditions during preparticipation evaluations. We strongly suggest that coaches and other athletic personnel be required to learn basic life support measures such as cardiopulmonary resuscitation (CPR) and to update their skills on an annual basis. Such efforts will help prevent additional exercise-related cardiac deaths.

Evaluation of a training program for persons with SCI paraplegia using the Parastep 1 ambulation system: part 5. Lower extremity blood flow and hyperemic responses to occlusion are augmented by ambulation training

OBJECTIVE

To test whether 12 weeks of exercise conditioning using functional neuromuscular stimulation (FNS) ambulation alters the resting lower extremity blood flow and hyperemic responses to vascular occlusion in subjects with paraplegia, and to determine whether an association exists between limb flow and lower extremity fat-free mass.

DESIGN

Pretest, posttest.

SETTING

Academic medical center.

PARTICIPANTS

Subjects with chronic neurologically complete paraplegia.

INTERVENTION

Thirty-two sessions of microprocessor-controlled ambulation using electrically stimulated contractions of lower extremity muscles and a rolling walker.

OUTCOME MEASURES

Subjects underwent quantitative Doppler ultrasound examination of the common femoral artery (CFA) before and after training. End-diastolic arterial images and arterial flow-velocity profiles obtained at rest and after 5 minutes of suprasystolic thigh occlusion were computer-digitized for analysis of heart rate (HR), CFA peak systolic velocity (PSV), CFA cross-sectional area (CSA), flow velocity integral (FVI), pulse volume (PV), and CFA (arterial) inflow volume (AIV).

RESULTS

Significant effects of training on CSA (p < .0001), FVI (p < .05), computed PV (p < .001), and computed AIV (p < .01) were observed. Resting HR was lower following training (p < .05). The change for resting PSV approached but did not reach significance (p = .083). Analysis of postocclusion PV and AIV showed significant effects for conditioning status (p values < .01), postcompression time (p values < .0001), and their interaction (p values < .01). At 1 minute after occlusion, the posttraining AIV response was 78.2% greater in absolute magnitude and 17.4% more robust when expressed as a percentage change from its resting value than before training. Significant correlations were found between thigh fat free mass and both AIV and PV (p values < .05).

CONCLUSION

Exercise training using FNS ambulation increases the resting lower extremity AIV in individuals with paraplegia and augments the hyperemic response to vascular occlusion. Improved posttraining blood flow is attributable both to vascular structural changes and upregulation of vascular flow control mechanisms. Limb mass is associated with the volume of arterial blood flow.

Impact of different sports and training on cardiac structure and function

There is overwhelming evidence, particularly from echocardiography, that the heart of competitive athletes may differ from that of nonathletes, matched for age, gender, and body size. A larger left ventricular mass has been shown in athletes performing predominantly dynamic aerobic and anaerobic sports, in athletes engaged in static training, and in players of ball sports. Enlargement of the left ventricular internal diameter was most pronounced and reached about 10% in athletes performing predominantly dynamic sports; mainly strength training athletes had a lesser increase of the internal dimension, which was limited to 2.5%. Also the left ventricular wall appeared to be thickened in all types of athletes compared with controls. In sports with high dynamic and low static demands, wall thickness was proportionate or slightly disproportionate to the size of the internal diameter so that relative wall thickness was not different from controls or slightly increased (predominantly eccentric hypertrophy). In strength athletes, the disproportionate increase of wall thickness averaged about 12% (predominantly concentric hypertrophy). In sports with high dynamic and high static demands and requiring prolonged training, such as cycling, the increases of absolute and relative wall thickness reached 29% and 19% and were more pronounced than in runners (mixed hypertrophy). A plausible interpretation of these results is that the development of so-called eccentric or concentric left ventricular hypertrophy according to the type of sports cannot be regarded as an absolute or dichotomous concept because training regimens and sports activities are not exclusively dynamic or static and because the load on the heart is not purely of the volume or the pressure type. Most studies agree that left ventricular systolic and diastolic function is normal in the athlete at rest, whereas diastolic function seems to be enhanced in the exercising endurance athlete. The consistency of the results of studies on athletes in the competitive and the resting season, of training of sedentary subjects, and of spinal cord-injured patients suggests that variations in physical activity can alter left ventricular structure; genetic factors do not seem to be involved in the size of the left ventricular internal diameter but have to be taken into account to interpret wall thickness.

The athlete's heart: is big beautiful?

Development of the concept of "athlete's heart" is traced through early clinical and radiographic studies to modern echocardiography and magnetic resonance imaging. It is noted that the lower limits of criteria for the diagnosis of a "pathological" enlargement of the heart have frequently been revised in an upward direction, as the prevalence of large hearts has been recognised in both endurance and power sports competitors who are in good health. Belief that hypertrophic cardiomyopathy is the commonest cause of sports related death in young adults is traced to weak diagnostic criteria and frequent republication of a very small group of cases. Although the existence of a congenital myocardial dystrophy is now well established, this condition is extremely rare, and has no particular predilection for athletes. Genetically based screening tests may become available in the future, but the exclusion of young adults from sports participation on echocardiographic criteria appears costly and ineffective. For most people, the development of a large heart is not a pathological sign--rather, it is a desirable outcome that will enhance performance on the sports field, and will allow longer independence in old age.

Reversal of adaptive left ventricular atrophy following electrically-stimulated exercise training in human tetraplegics

Left ventricular (LV) myocardial atrophy and diminished cardiac function have been shown to accompany chronic human tetraplegia. These changes are attributable both to physical immobilisation and abnormal autonomic circulatory regulation imposed by a spinal cord injury (SCI). To test whether exercise training increases LV mass following chronic SCI, 8 neurologically complete quadriplegic males at 2 SCI rehabilitation and research centres underwent one month of electrically-stimulated quadriceps strengthening followed by 6 months of electrically-stimulated cycling exercise. Resting M-mode and 2-D echocardiograms were measured before and after exercise training to quantify the interventricular septal and posterior wall thicknesses at end-diastole (IVSTED and PWTED, respectively), and the LV internal dimension at end-diastole (LVIDED). LV mass was computed from these measurements using standard cube function geometry. Results showed a 6.5% increase in LVIDED following exercise training (p less than 0.02), with increases in IVSTED and PWTED of 17.8 (p less than 0.002) and 20.3% (p less than 0.01), respectively. Computed LV mass increased by 35% following exercise training (p = 0.002). These data indicate that myocardial atrophy is reversed in tetraplegics following electrically-stimulated exercise training, and that the changes in cardiac architecture are likely to be the result of both pressure and volume challenge to the heart imposed by exercise.

The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes

BACKGROUND

In some highly trained athletes, the thickness of the left ventricular wall may increase as a consequence of exercise training and resemble that found in cardiac diseases associated with left ventricular hypertrophy, such as hypertrophic cardiomyopathy. In these athletes, the differential diagnosis between physiologic and pathologic hypertrophy may be difficult.

METHODS

To address this issue, we measured left ventricular dimensions with echocardiography in 947 elite, highly trained athletes who participated in a wide variety of sports.

RESULTS

The thickest left ventricular wall among the athletes measured 16 mm. Wall thicknesses within a range compatible with the diagnosis of hypertrophic cardiomyopathy (greater than or equal to 13 mm) were identified in only 16 of the 947 athletes (1.7 percent); 15 were rowers or canoeists, and 1 was a cyclist. Therefore, the wall was greater than or equal to 13 mm thick in 7 percent of 219 rowers, canoeists, and cyclists but in none of 728 participants in 22 other sports. All athletes with walls greater than or equal to 13 mm thick also had enlarged left ventricular end-diastolic cavities (dimensions, 55 to 63 mm).

CONCLUSIONS

On the basis of these data, a left-ventricular-wall thickness of greater than or equal to 13 mm is very uncommon in highly trained athletes, virtually confined to athletes training in rowing sports, and associated with an enlarged left ventricular cavity. In addition, the upper limit to which the thickness of the left ventricular wall may be increased by athletic training appears to be 16 mm. Therefore, athletes with a wall thickness of more than 16 mm and a nondilated left ventricular cavity are likely to have primary forms of pathologic hypertrophy, such as hypertrophic cardiomyopathy.

Preseason cardiovascular examination: a review

The responsibility of the physician performing a preseason sports physical examination includes identifying cardiac disease and giving appropriate guidance about participation in competitive sports. This article reviews the leading causes of sudden cardiac death in young athletes, discusses other common cardiac conditions, assesses recommendations for competitive sports, and discusses the preseason examination as a mechanism for detecting a cardiac problem that should exclude an athlete from competition.

ECG variants and cardiac arrhythmias in athletes: clinical relevance and prognostic importance

These findings permit the following conclusions on cardiac changes induced by high-performance sports and high levels of training. Sinus bradycardia and AV block can frequently be observed in athletes, but they do not require attention as long as they are asymptomatic or do not produce pauses exceeding 4 seconds. Persistent rather than transient second-degree AV block or Mobitz second- or third-degree AV block is an extremely unusual finding even in athletes and should be considered a sign of organic lesions until proved otherwise. Supraventricular and AV node ectopic beats are not more frequent in athletes than in the general population except for atrial fibrillation. WPW syndrome is of particular importance, since rapid conduction to the ventricle via the accessory AV pathway is possible, especially if there is a tendency toward atrial fibrillation. Likewise caution is required in athletes with hypertrophic cardiomyopathy. Here hemodynamic deterioration must be anticipated with the occurrence of supraventricular tachycardia. Simple ventricular arrhythmias occur among athletes with the same frequency as in the general population, but they usually disappear with exercise. The occurrence of complex ventricular forms of arrhythmia should always prompt cardiologic examination in search of underlying cardiac disease, particularly hypertrophic or dilated cardiomyopathy. The presence of ventricular arrhythmias without evidence of underlying heart disease does not indicate a special or increased risk of sudden cardiac death. A higher incidence of right and/or left ventricular hypertrophy, exercise-reversible ST elevation, and exercise-reversible changes in T waves (T negativity, sharp and/or excessive T waves) can be considered physiologic changes in the ECGs of athletes. These changes correlate closely with the type of sports activity and degree of training and are reversible when the activity is stopped. Horizontal ST segment depression are by contrast very rare in athletes and should always be clarified by cardiologic examination. Exercise-induced sudden cardiac death in athletes is unusual without preexisting heart disease. The cause of sudden cardiac death among athletes less than 40 years of age can be predominantely ascribed to congenital heart diseases (such as hypertrophic cardiomyopathy or coronary anomalies). In athletes more than 40 years of age and with increasing age, coronary heart disease is the most frequent autopsy finding. A corresponding risk stratification should take these partial dangers into account.

Noninvasive evaluation of world class athletes engaged in different modes of training

This study evaluated by noninvasive methods the cardiac structure and functional characteristics of world class athletes participating in different types of training programs. Fourteen subjects, including 4 strength-trained (discus and shot put), 4 endurance-trained (long distance runners), 4 decathlon-trained (strength and endurance), 2 wheelchair athletes and 31 college-age control subjects were evaluated using electrocardiography, M-mode echocardiography and maximal oxygen consumption. M-mode echocardiography measurements of left ventricular structure and function were compared before and after normalization for lean body weight. As expected, endurance athletes had greater maximal O2 consumption than the other groups (p less than 0.05). Before normalization for lean body weight, there were no significant differences in end-diastolic dimensions. After normalization, the endurance, wheelchair and control subjects had end-diastolic dimensions larger than those of strength athletes. Strength athletes appeared to have a much larger posterior wall and septal thickness than all groups except the decathlon athletes. However, when normalized, there was no difference among any of the groups. Previous investigators have attempted to determine "normalcy" of cardiac hypertrophy by looking at the ratio of left ventricular wall thickness to left ventricular radius. In the present study, the thickness to radius ratio in strength athletes was 33% greater than that in endurance athletes. It appears that the left ventricular wall thickness in the strength athletes occurred without a concomitant increase in left ventricular radius and that the left ventricular hypertrophy of world class athletes is related to the total increase in lean body weight. However, ventricular dimensions may be related more to the type of overload experienced.

Electrocardiographic diagnosis of exercise-induced left ventricular hypertrophy

To assess the prevalence of physiologic left ventricular hypertrophy and the usefulness of ECG criteria for its diagnosis, we compared ECGs and M-mode echocardiograms from 44 ultraendurance athletes and 20 similarly aged sedentary control subjects. Left ventricular mass was elevated in 25 of 44 (57%) athletes including 17 of 29 (59%) men greater than 134 gm/m2 and 8 of 15 (53%) women greater than 110 gm/m2. The sensitivity and specificity of the three ECG criteria used to diagnose left ventricular hypertrophy were: Sokolow-Lyon voltage (S-V1 + R-V5 greater than or equal to 3.5 mV), 65% and 61%; Romhilt-Estes score (greater than or equal to 4), 16% and 84%; and Cornell voltage (R-aVL + S-V3 greater than 2.8 mV in men and greater than 2.0 mV in women), 8% and 95%, respectively. Left ventricular mass, mass index, posterior wall thickness, chamber diameter, and relative wall thickness were not related to any measurement of QRS voltage. Nonvoltage ECG criteria for left ventricular hypertrophy were rare in athletes. Thus hypertrophy is a common but not universal adaptation to exercise. It is only moderately well detected by standard voltage criteria for left ventricular hypertrophy and is not reflected in nonvoltage criteria.

Multiple electrocardiographic anomalies during anaesthesia in an athlete

A 22-year-old athlete was scheduled for a minor surgical procedure under general anaesthesia. During anaesthesia, his electrocardiogram demonstrated multiple episodes of dysrhythmias including complete bundle branch block, atrioventricular (AV) block, isorhythmic atrioventricular dissociation with junctional rhythm. Administration of atropine 1.0 mg IV terminated the last episode of dysrhythmias. Postoperatively, a resting 12-lead electrocardiogram showed first degree AV block, ST-segment elevation and prominent U waves. A 24 hour Holter recording demonstrated first degree atrioventricular block, episodes of marked sinus arrhythmias and one episode of sinus tachycardia at a rate of 152 beats X min-1. Treadmill stress testing revealed peak achieved heart rate of 200 beats X min-1 without ischaemia. These findings collectively indicated athletic heart syndrome. Implications of athletic heart syndrome for the anaesthetist are reviewed and discussed.

Structural features of the athlete heart as defined by echocardiography

The morphologic concepts of the "athlete heart" have been enhanced and clarified over the last 10 years by virtue of M-mode echocardiographic studies performed on more than 1,000 competitive athletes. Long-term athletic training produces relatively mild but predictable alterations in cardiac structure that result in an increase in calculated left ventricular mass. This increase in mass observed in highly trained athletes is due to a mild increase in either transverse end-diastolic dimension of the left ventricle or left ventricular wall thickness, or both. Cardiac dimensions in athletes compared with matched control subjects show increases of about 10% for left ventricular end-diastolic dimension, about 15 to 20% for wall thickness and about 45% for calculated left ventricular mass. Furthermore, there is evidence that the modest degree of "physiologic" left ventricular hypertrophy (both the cavity dilation and wall thickening) observed in athletes is dynamic in nature, that is, it may develop rapidly within weeks or months after the initiation of vigorous conditioning and may be reversed in a similar time period after the cessation of training. Several echocardiographic studies also suggest that the precise alterations in cardiac structure associated with training may differ depending on the type of athletic activity undertaken (that is, whether training is primarily dynamic [isotonic] or static [isometric]). Although the ventricular septal to free wall thickness ratio (on M-mode echocardiogram) is almost always within normal limits (less than 1.3), occasionally an athlete will show mild asymmetric thickening of the anterior basal septum (usually 13 to 15 mm). This circumstance may mimic certain pathologic conditions characterized by primary left ventricular hypertrophy such as nonobstructive hypertrophic cardiomyopathy. The long-term significance of increased left ventricular mass in trained athletes has not been conclusively defined. However, there is no evidence at this time suggesting that this form of hypertrophy is itself deleterious to the athlete or predisposes to (or prevents) the natural occurrence of cardiovascular disease later in life.

Sudden death and the competitive athlete: perspectives on preparticipation screening studies

Sudden death in healthy athletes is uncommon but, when it occurs, the primary mechanism is cardiovascular. The major cause of sudden death in the young athlete is hypertrophic cardiomyopathy or related conditions characterized by left ventricular hypertrophy, aortic rupture due to cystic medial necrosis and congenital coronary artery abnormalities. In the middle-aged or older athlete, coronary artery disease is the most significant cause of sudden death. Noninvasive screening procedures are currently available that can detect most subjects at risk of sudden death. However, although some potentially lethal diseases can be excluded by a relatively simple screening program, other diseases require expensive procedures, such as echocardiography and exercise electrocardiographic stress testing. This means that the sensitivity of detecting diseases leading to sudden death increases in proportion to the financial resources that can be applied to the screening program. Thus, when a screening program designed to identify all cardiac diseases that have the potential to cause sudden death is planned by a community, school or nonprofessional athletic team, the costs will almost undoubtedly be considered prohibitive. The practicality of applying a community- or school-initiated screening program can be questioned because of the very low incidence of sudden unexpected death in young healthy individuals. It is therefore likely that comprehensive screening programs will be confined to individuals or organizations with adequate financial resources. Less expensive, limited screening can be undertaken by individuals or groups to identify some subjects at risk of sudden death during athletic competition.

Athletic dysrhythmias. A case report and review of the phenomenon of the 'athlete's heart'

A 36-year-old athlete was anaesthetised for a minor surgical procedure. His heart rate fell to 30 beats/minute during the operation, the electrocardiogram showed A-V junctional rhythm. Sinus rhythm of 58 beats/minute was restored by atropine 1.2 mg. His resting 12-lead electrocardiogram showed sinus bradycardia and features consistent with a diagnosis of 'athlete's heart'. A review is presented of the physiological and electrocardiographical features of this phenomenon. The current popularity of running as a leisure pursuit makes it important that anaesthetists recognise the peculiarities of the trained athletic heart.

Symmetric cardiac enlargement in highly trained endurance athletes: a two-dimensional echocardiographic study

Twelve highly trained male endurance athletes and 12 normally active matched control subjects were studied by two-dimensional and M-mode echocardiography to evaluate changes in the right and left heart chambers associated with intense aerobic training. Maximal oxygen uptake, a measure of cardiovascular fitness, ranged from 62.1 to 82.6 ml/kg/min in the athletes and from 33.0 to 49.3 ml/kg/min in the control subjects (p less than 0.001). The athletes had significantly greater left ventricular wall thickness (p less than 0.01), left ventricular chamber area (p less than 0.005), left atrial area (p less than 0.01), right ventricular chamber area (p less than 0.002), right ventricular wall thickness (p less than 0.05), and right atrial area (p less than 0.01). Proportionality of cardiac chamber enlargement in the athletes was shown by similar ratios of both right-to-left ventricular areas and right-to-left atrial areas in the two groups. Left ventricular contractility was not significantly different between groups. Cardiac enlargement in endurance athletes enables a greater stroke volume for the performance of sustained, intense exercise; hypertrophy of the chamber walls normalizes wall stress. These changes occur symmetrically in both right and left cardiac chambers in the endurance athlete, reflecting bilateral hemodynamic loading. The symmetry of the endurance athlete's cardiac enlargement differs from most pathologic conditions which have heterogeneous effects on specific cardiac chambers.

Rapid ventricular filling in left ventricular hypertrophy: I. Physiologic hypertrophy

The effects of endurance training on the diastolic properties of the left ventricle were examined by comparing left ventricular filling rates in 11 male distance runners and 12 age-matched nonathletic control subjects selected to have nearly similar heart rates at rest. Maximal oxygen consumption was 69 +/- 11 ml/kg-min for the athletes and 48 +/- 8 ml/kg X min for the control subjects (p less than 0.001). Left ventricular end-diastolic dimension, posterior wall thickness and mass were determined by echocardiography, and average left ventricular filling rate was determined with a nonimaging scintillation probe. Electrocardiographic voltage was significantly greater in the athlete group than in the control group (sums of the voltages of the S wave in lead V1 and the R wave in lead V5 were 40 +/- 10 and 26 +/- 7 mV, respectively) (p less than 0.001), whereas ejection fraction was similar in the two groups. Despite a modest degree of left ventricular hypertrophy in the athlete group compared with the control group (left ventricular mass index 127 +/- 30 and 82 +/- 13 g/m2, respectively) (p less than 0.001), the average left ventricular filling rate was similar in the two groups (2.53 +/- 0.34 versus 2.38 +/- 0.29 end-diastolic counts/s, p = NS). There was no trend for the athletes with a higher left ventricular mass to exhibit a slower filling rate. These findings demonstrate that unlike pathologic hypertrophy associated with chronic hemodynamic over-loading, physiologic left ventricular hypertrophy is not accompanied by slowed left ventricular diastolic filling.

Applied physiology of marathon running

Performance in marathon running is influenced by a variety of factors, most of which are of a physiological nature. Accordingly, the marathon runner must rely to a large extent on a high aerobic capacity. But great variations in maximal oxygen uptake (VO2 max) have been observed among runners with a similar performance capacity, indicating complementary factors are of importance for performance. The oxygen cost of running or the running economy (expressed, e.g. as VO2 15 at 15 km/h) as well as the fractional utilisation of VO2 max at marathon race pace (%VO2 Ma X VO2 max-1) [where Ma = mean marathon velocity] are additional factors which are known to affect the performance capacity. Together VO2 max, VO2 15 and %VO2 Ma X VO2 max-1 can almost entirely explain the variation in marathon performance. To a similar degree, these variables have also been found to explain the variations in the 'anaerobic threshold'. This factor, which is closely related to the metabolic response to increasing exercise intensities, is the single variable that has the highest predictive power for marathon performance. But a major limiting factor to marathon performance is probably the choice of fuels for the exercising muscles, which factor is related to the %VO2 Ma X VO2 max-1. Present indications are that marathon runners, compared with normal individuals, have a higher turnover rate in fat metabolism at given high exercise intensities expressed both in absolute (m/sec) and relative (%VO2 max) terms. The selection of fat for oxidation by the muscles is important since the stores of the most efficient fuel, the carbohydrates, are limited. The large amount of endurance training done by marathon runners is probably responsible for similar metabolic adaptations, which contribute to a delayed onset of fatigue and raise the VO2 Ma X VO2max-1. There is probably an upper limit in training kilometrage above which there are no improvements in the fractional utilisation of VO2 max at the marathon race pace. The influence of training on VO2 max and, to some extent, on the running economy appears, however, to be limited by genetic factors.

Noninvasive study of left ventricular performance in obese patients: influence of duration of obesity

We studied the performance of the left ventricle in 35 obese patients by means of noninvasive methods, including echocardiography, carotid arterial pulse tracing, and phonocardiography. Patients were divided into two groups according to the duration of obesity: group 1 included patients who had been obese for less than 15 years, and group 2 comprised patients who had been obese for more than 15 years. There were no differences in the degree of obesity and cellularity of adipose tissue between two groups. Left ventricular dimension and wall thickness, stroke volume, and cardiac output were significantly greater in both groups of obese patients than in nonobese control subjects. Group 2 had a significantly increased end-diastolic dimension index (DdI, calculated as end-diastolic dimension/cube root of body surface area), stroke index (SI), and radius/wall thickness ratio (R/Th) of the left ventricle compared with group 1. Multiple regression analysis showed that DdI, SI, and R/Th correlated significantly with the duration of obesity. We conclude that alterations of cardiac performance in obese patients with left ventricular enlargement and wall thickening is attributed not only to the excess of body weight but also to the duration of obesity.

Cardiac structure and function in cyclists and runners. Comparative echocardiographic study

Twelve cyclists and 12 long distance runners matched for age, height, and weight with two control groups of 12 non-athletes were studied echocardiographically to evaluate cardiac structure and function. Runners weighed 8 kg less than cyclists, but age and height were similar. Peak oxygen uptake per kg body weight was higher in athletes than in the control subjects but was similar in the cyclists and in the runners. The athletes' hearts had a larger end diastolic left ventricular internal diameter, mean wall thickness, and cross sectional area of the left ventricular wall than those of the respective control subjects. Nevertheless, whereas the left ventricular internal diameter was not different between the cyclists and runners, mean wall thickness and cross sectional area of the left ventricular wall were greater in the cyclists even after adjustment for weight. The ratio of wall thickness to left ventricular internal radius was significantly larger in cyclists than in their control group, but the ratio was similar in runners and their control group. The echocardiographic indices of left ventricular function were similar in the athletes and the control groups. Systolic left ventricular meridional wall stress was lower in the cyclists than in the runners. The data suggest that runners develop an increase in left ventricular wall thickness which is proportionate to the internal diameter but that in cyclists the increase is disproportionate because of the isometric work of the upper part of the body during cycling.

Scintigraphic determination of ventricular function and coronary perfusion in long-distance runners

Left ventricular function and coronary perfusion were evaluated with rest-exercise gated blood pool and stress-redistribution thallium scans in a group of long-distance runners and compared to a group of catheterization-proved normal subjects. Exercise duration, work load, and oxygen consumption were significantly greater for long-distance runners. Rest end-diastolic volume (EDV), end-systolic volume (ESV), and stroke volumes (SV) were significantly larger in long-distance runners than in control subjects, while ejection fraction (EF), cardiac index (CI), and ejection rate were similar in both groups. Exercise EDV increased and ESV decreased, producing an increase in SV and EF in long-distance runners. Exercise EDV did not change and ESV decreased less, producing lesser increase in SV and EF in the control group. Qualitative evaluation of thallium scans showed apparent perfusion defects with normal redistribution in six myocardial segments in five long-distance runners. Quantitative evaluation demonstrated initial defects, which persisted on delay scans, but were associated with normal relative redistribution in three ventricular walls in three long-distance runners. In conclusion, left ventricular reserve function was greater in long-distance runners than in control subjects. Endurance exercise can be associated with apparent myocardial perfusion defects, which may be due to uneven ventricular hypertrophy resulting from the pressure and volume loads imposed by exercise.

Electrocardiographic changes after physical training in patients with myocardial infarction

Electrocardiographic voltage measurements were performed in 24 men with an inferior myocardial infarction before and after 14 +/- 0.5 weeks of physical training. Oxygen uptake at peak exercise increased 42% and heart rate at rest was significantly decreased after training. Increases were found in the magnitude of the R waves in leads II, aVF and V4 to V6; of the S wave in leads V1 and V3; of the T waves in V5 and V6; and of the Sokolow index of QRS voltage. Also, the magnitude of the mean electrical vector in the frontal plane was significantly higher after training. These data were compared with those derived from two electrocardiographic tracings, separated by an average of 19 +/- 1.5 weeks, of 20 other patients with an inferior myocardial infarction who were comparable in age, weight, risk factor and delay between infarction and first examination, but who were not trained. When the electrocardiographic changes between the two observations were compared for the two groups, the trained patients show significant increases in the magnitude of the R wave in the left precordial leads, and leads II and aVF and the Sokolow voltage criterion; in the magnitude of the T wave in leads V5 and V6; and in the magnitude of the mean electrical vector in the frontal plane. It is concluded that physical training in patients with myocardial infarction can alter cardiac structure, as evaluated by voltage measurements on the electrocardiogram.

The differential diagnosis of acute pericarditis from the normal variant: new electrocardiographic criteria

We examined the quantitative electrocardiographic differentiation of acute pericarditis from normal variant ST-T changes. The ECGs of 19 patients with acute pericarditis were compared with those of 20 subjects with typical normal variant changes. Patients were excluded if their ECGs demonstrated conditions that markedly altered repolarization. The positive predictive values (PPV) and negative predictive values (NPV) of previously reported criteria were not high (PPV = 0.54-0.83, NPV = 0.56-0.58). In contrast, in the present study, a T-wave amplitude in lead V6 of less than or equal to 0.3 mV diagnosed acute pericarditis (p less than 0.005, PPV = 0.85, NPV = 0.85), but there was overlap of patients between the groups. The ratio of the amplitude of the onset of the ST segment to the amplitude of the T wave in that lead (ST/T ratio in V6) proved to be the most reliable discriminator. An ST/T ratio greater than or equal to 0.25 diagnosed all patients with acute pericarditis (p less than or equal to 0.005, PPV = 1.0, NPV = 1.0). The ST/T ratio greater than 0.25 in V4, V5 (both p less than 0.005, PPV = 0.87, NPV = 1.0) and I (p less than or equal to 0.005, PPV = 0.80, NPV = 0.81) were also significant discriminators. Thus, if V6 is unavailable, an ST/T ratio greater than or equal to 0.24 in V5, V4 or I is highly suggestive of acute pericarditis. An ST/T ratio greater than or equal to 0.25 in V6 discriminated the ECGs of all patients with acute pericarditis from normal variants in this study.

Ambulatory electrocardiographic recording in endurance athletes

Data from ambulatory electrocardiographic recording in 35 highly trained endurance athletes and in 35 non-athletic controls of similar ages are given. The minimal, mean hourly, and maximal heart rates were significantly lower in the athletes. Thirteen athletes (37 . 1%) but only two controls (5 . 7%) had sinus pauses exceeding 2 . 0 seconds. First degree atrioventricular block was observed in 13 athletes (37 . 1%) and five controls (14 . 3%), second degree Wenckebach type block in eight athletes (22 . 9%) and two controls (5 . 7%), and second degree block with Mobitz II-like pattern in three athletes (8 . 6%) and no control. All athletes with Mobitz II-type pattern also had first degree and Wenckebach-type second degree atrioventricular block. The behavior of sinus rate on development of atrioventricular block varied, not only interindividually but also intraindividually, from absence of change to an increase or decrease in most subjects in both study groups. A decrease in sinus rate on appearance of atrioventricular block was found constantly in only two athletes and one control. Atrioventricular dissociation with junctional rhythm occurred in seven athletes (20%) and with ventricular rhythm in one athlete. Neither of these phenomena was seen in the group of controls. The athletes had slightly fewer ventricular extrasystoles than controls, and no athlete had ventricular tachycardia, whereas two controls had ventricular tachycardia.

Noninvasive evaluation of exercise training in college-age men

The purpose of this study was to assess noninvasively the effects of intense aerobic training on cardiac structure and function in a group of healthy, college-age men (25 experimental and 11 control, mean age 22 years). Echocardiographic, electrocardiographic (ECG), and fitness measurements were obtained before and after a 3-month endurance training program and compared with similar measurements obtained in nonexercising subjects. The supervised training program consisted of 50-minute jogging sessions 5 days a week at 85% of maximal heart rate. Compared with the control group, echocardiography after training showed an increase in left ventricular (LV) end-diastolic dimension (p less than 0.05). LV posterobasal wall thickness, septal wall thickness and ejection fraction did not change significantly. ECG measurements revealed a decrease in resting heart rate (p less than 0.05) and an increase in R-wave voltage in leads V5 and V6 (p less than 0.01). The measured maximal oxygen consumption increased by 16% (p less than 0.001). These data indicate that intense aerobic training in college-age men results in a significant increase in resting LV end-diastolic dimension and volume. The increase in maximal stroke volume associated with exercise training may be partially explained by these changes in cardiac dimensions.

Effects of exercise training on left ventricular mass in patients with ischemic heart disease

To determine whether exercise training results in increased left ventricular mass in patients with ischemic heart disease, we obtained echocardiograms in 14 coronary patients before and after an average of seven months (range 3 to 14 months) of supervised arm and leg exercise. Each echocardiogram was interpreted jointly by two blinded observers, using three different measurement conventions and a semiautomated method of analysis to minimize errors of interpretation. Exercise training led to subjective improvement in all 14 patients, and to an objective increase in functional capacity in 13 of 14 patients, as evidenced by an increase in maximal oxygen consumption estimated from symptom-limited treadmill exercise testing (8.8 +/- 2.7 (SD) and 10.7 +/- 2.5 METS before and after training, respectively, p less than 0.01). However, this functional improvement was not accompanied by any significant change in left ventricular end-diastolic diameter, or posterior wall or interventricular septal thickness. Likewise, left ventricular cross-sectional area (CSA), an index of left ventricular mass which corrects for altered ventricular volume and theoretically reflects directional changes in mass despite nonuniform wall thickness, did not change significantly after training by any measurement convention (CSA = 18.0 +/- 6.5 and 17.6 +/- 6.5 cm2 before and after training, respectively, by American Society of Echocardiography measurements). These data strongly suggest that improved functional capacity after exercise training in patients with ischemic heart disease is not due to exercise-induced left ventricular hypertrophy.

Echocardiography and the Athlete's Heart

In brief: Echocardiographic studies permit direct, accurate measurements of the ventricular wall thickness and cavity diameter. The authors review several of these studies, which show that elite athletes' left ventricles are larger than those of sedentary persons. Left ventricular wall thickness is greater in athletes excelling in sports involving static exercise, whereas those in endurance sports have larger ventricular cavities. These differences in cardiac dimensions may be the result of genetic makeup, prolonged and strenuous training, or a combination of both. Studies of short-term training showed only minor or no changes in left ventricular morphology, although significant improvements in performance and aerobic capacity were reported.

Non-invasive evaluation of cardiac function in professional cyclists

Cardiac dimensions and left ventricular function were investigated at rest with non-invasive methods in 14 professional road race cyclists and in 11 age-matched sedentary control subjects. The electrocardiographic findings were in agreement with previous studies in endurance athletes and the vectocardiographic data showed anterior displacement of the electrical forces. Echocardiographic dimensions at end-diastole showed higher values in the cyclists for left ventricular internal diameter, left ventricular posterior wall thickness, and interventricular septal thickness. Derived values for left ventricular volume and left ventricular mass were also much larger in the cyclists and there was excellent agreement between total heart volume measured with radiology and total measured by echocardiography. There was a significant correlation between maximal oxygen consumption and end-diastolic left ventricular diameter.

Electrocardiographic and echocardiographic characteristics of long distance runners. Comparison of left ventricular function with age- and sex-matched controls

Nineteen long distance runners and 19 age- and sex-matched sedentary controls were evaluated by echocardiography and electrocardiography (ECG) at rest and after 12 minutes of treadmill exercise. Seven of ten male athletes exhibited ECG abnormalities of prominent precordial voltage, early repolarization, and one had right ventricle hypertrophy; only three of nine females had ECG abnormalities. The resting and postexercise heart rates and blood pressures were lower in athletes than controls (P less than 0.001). The athletes increased their left ventricular end-diastolic volume and stroke volume and had a moderate increase in heart rate. Controls markedly increased only their heart rate to the same level of exercise. One female athlete and one female control had 1 mm of ST segment depression with exercise. The right ventricular wall thickness was equal to or greater than 6 mm in athletes versus equal to or less than 5 mm in controls. The left ventricular wall was thicker in athletes than controls, the resultant left ventricular mass was 60% more in athletes due to left ventricular hypertrophy (P less than 0.001). We concluded left ventricular hypertrophy is present in athletes as a result of endurance running.

Left ventricular responses to a program of lower-limb strength training

Nine healthy male subjects ages 18-27 exercised five days per week. Three days per week they performed five repetitions of squats, leg extensions and leg flexions with maximal resistance for a total of 11 sets. On the other two days each week subjects performed five leg presses and 20 calf raises with maximal resistance. Resting echocardiograms and physiologic evaluations were made prior to starting the strength training and again after ten weeks of training. Resting heart rate +/- SEM before and after training was 65 +/- 2 and 58 +/- 1.7 beats/min (P < .001). Maximal O2 uptake did not change significantly. Left ventricular wall thickness +/- SEM before and after training increased from 0.76 +/- .02 to 0.85 +/- 0.04 cm (P < .05). Left ventricular mass +/- SEM increased from 81.9 +/- 5 to 92.3 +/- 3.7 g (P < .05). The percentage of left ventricular fractional shortening +/- SEM increased from 32 percent +/- 1.2 to 36 percent +/- .9 (P < .001). Lower limb strength training in normal subjects did not increase maximal O2 uptake, but did induce increases in left ventricular wall thickness similar to that seen in champion strength-trained athletes. In addition, improvement in left ventricular performance without significant changes in left ventricular volumes was also observed.

Sudden death in young athletes

The causes of sudden and unexpected death in 29 highly conditioned, competitive athletes, ages 13-30 years, are summarized. Sudden death occurred during or just after severe exertion on the athletic field in 22 of the 29 athletes. Structural cardiovascular abnormalities were identified at necropsy in 28 of the 29 athletes (97%), and in 22 (76%) were almost certainly the cause of death. The most common cause of death in this series was hypertrophic cardiomyopathy, which was present in 14 athletes. Other cardiovascular abnormalities that occurred in more than one athlete were anomalous origin of the left coronary artery from the right (anterior) sinus of Valsalva, idiopathic concentric left ventricular hypertrophy, coronary heart disease and ruptured aorta. Cardiac disease was suspected during life in only seven of the 29 patients, and in only two of the seven was the correct diagnosis made clinically. Hence, in this series of young athletes, sudden death was usually due to structural cardiovascular disease, and hypertrophic cardiomyopathy was a frequent cause of sudden death; atherosclerotic coronary heart disease was relatively uncommon.

Echocardiographic evaluation of long-term effects of exercise on left ventricular hypertrophy and function in professional bicyclists

Echocardiographic examinations were performed in 60 professional bicyclists and control subjects to determine the effects of exercise on left ventricular hypertrophy and function. The athletes were separated by age into three groups: group 1 (n = 14), 20-29 years; group 2 (n = 17), 30-39 years; and group 3 (n = 29), 40-49 years. Echocardiograms showed enlargment of the left ventricular end-diastolic dimensions in all three groups compared with age-matched control groups (p less than 0.001). Thickness of the interventricular septum and the left ventricular posterior wall was more prominent in group 3 of the athletes than groups 1 and 2 of the athletes and control group (p less than 0.001). Resting left ventricular function evaluated with fractional shortening, ejection fraction and mean velocity of circumferential fiber shortening was significantly depressed in group 3 compared with the other groups. Moreover, 14% of group 3 subjects showed enlargement of left atrial dimension and T-wave inversion in the left precordial leads of the ECG. We conclude that left ventricular hypertrophy is an important ventricular adaptation in relatively young athletes. However, middle-aged athletes may be more susceptible to electrocardiographic abnormalities and prominent hypertrophy, and some may have slightly depressed left ventricular function.