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Zureigat H, Osborne MT, Abohashem S, Mezue K, Gharios C, Grewal S, Cardeiro A, Naddaf N, Civieri G, Abbasi T, Radfar A, Aldosoky W, Seligowski AV, Wasfy MM, Guseh JS, Churchill TW, Rosovsky RP, Fayad Z, Rosenzweig A, Baggish A, Pitman RK, Choi KW, Smoller J, Shin LM, Tawakol A. Effect of Stress-Related Neural Pathways on the Cardiovascular Benefit of Physical Activity. J Am Coll Cardiol 2024; 83:1543-1553. [PMID: 38631773 DOI: 10.1016/j.jacc.2024.02.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/25/2024] [Accepted: 02/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The mechanisms underlying the psychological and cardiovascular disease (CVD) benefits of physical activity (PA) are not fully understood. OBJECTIVES This study tested whether PA: 1) attenuates stress-related neural activity, which is known to potentiate CVD and for its role in anxiety/depression; 2) decreases CVD in part through this neural effect; and 3) has a greater impact on CVD risk among individuals with depression. METHODS Participants from the Mass General Brigham Biobank who completed a PA survey were studied. A subset underwent 18F-fluorodeoxyglucose positron emission tomography/computed tomographic imaging. Stress-related neural activity was measured as the ratio of resting amygdalar-to-cortical activity (AmygAC). CVD events were ascertained from electronic health records. RESULTS A total of 50,359 adults were included (median age 60 years [Q1-Q3: 45-70 years]; 40.1% male). Greater PA was associated with both lower AmygAC (standardized β: -0.245; 95% CI: -0.444 to -0.046; P = 0.016) and CVD events (HR: 0.802; 95% CI: 0.719-0.896; P < 0.001) in multivariable models. AmygAC reductions partially mediated PA's CVD benefit (OR: 0.96; 95% CI: 0.92-0.99; P < 0.05). Moreover, PA's benefit on incident CVD events was greater among those with (vs without) preexisting depression (HR: 0.860; 95% CI: 0.810-0.915; vs HR: 0.929; 95% CI: 0.910-0.949; P interaction = 0.011). Additionally, PA above guideline recommendations further reduced CVD events, but only among those with preexisting depression (P interaction = 0.023). CONCLUSIONS PA appears to reduce CVD risk in part by acting through the brain's stress-related activity; this may explain the novel observation that PA reduces CVD risk to a greater extent among individuals with depression.
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Affiliation(s)
- Hadil Zureigat
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael T Osborne
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shady Abohashem
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kenechukwu Mezue
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Charbel Gharios
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Simran Grewal
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Alex Cardeiro
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nicki Naddaf
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Giovanni Civieri
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Taimur Abbasi
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Azar Radfar
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wesam Aldosoky
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Antonia V Seligowski
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts, USA, and Harvard Medical School, Boston, Massachusetts, USA
| | - Meagan M Wasfy
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - James Sawalla Guseh
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy W Churchill
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel P Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Zahi Fayad
- Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anthony Rosenzweig
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron Baggish
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Roger K Pitman
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Karmel W Choi
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jordan Smoller
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa M Shin
- Department of Psychology, Tufts University, Medford, Massachusetts, USA
| | - Ahmed Tawakol
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA.
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Murphy SP, Deferm S, Yucel E, Urbut SM, Hung J, Dal-Bianco JP, Bertrand PB, Churchill TW. Right Ventricular-Pulmonary Arterial Coupling and All-Cause Mortality in Patients with Mitral Annular Calcification-Related Mitral Valve Dysfunction. J Am Soc Echocardiogr 2024; 37:474-476. [PMID: 38253110 DOI: 10.1016/j.echo.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 01/11/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024]
Affiliation(s)
- Seán P Murphy
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Yawkey 5B, 55 Fruit Street Boston, MA 02114.
| | - Sébastien Deferm
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Yawkey 5B, 55 Fruit Street Boston, MA 02114
| | - Evin Yucel
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Yawkey 5B, 55 Fruit Street Boston, MA 02114
| | - Sarah M Urbut
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Yawkey 5B, 55 Fruit Street Boston, MA 02114
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Yawkey 5B, 55 Fruit Street Boston, MA 02114
| | - Jacob P Dal-Bianco
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Yawkey 5B, 55 Fruit Street Boston, MA 02114
| | - Philippe B Bertrand
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Yawkey 5B, 55 Fruit Street Boston, MA 02114
| | - Timothy W Churchill
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Yawkey 5B, 55 Fruit Street Boston, MA 02114
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Churchill TW, Smith MR, Michaelson MD, Lee RJ, Guseh JS, Wasfy MM, Meneely E, Olivier K, Baggish AL, Saylor PJ. Cardiac Structural Changes and Declining Cardiorespiratory Fitness During Androgen Deprivation Therapy for Prostate Cancer. J Am Soc Echocardiogr 2024:S0894-7317(24)00113-5. [PMID: 38499230 DOI: 10.1016/j.echo.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 03/08/2024] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Matthew R Smith
- Massachusetts General Hospital Cancer Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - M Dror Michaelson
- Massachusetts General Hospital Cancer Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Richard J Lee
- Massachusetts General Hospital Cancer Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - James Sawalla Guseh
- Cardiovascular Performance Program, Massachusetts General Hospital, Division of Cardiology, Harvard Medical School, Boston, Massachusetts; Massachusetts General Hospital, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Meagan M Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Division of Cardiology, Harvard Medical School, Boston, Massachusetts; Massachusetts General Hospital, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Erika Meneely
- Massachusetts General Hospital Cancer Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Kara Olivier
- Massachusetts General Hospital Cancer Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Division of Cardiology, Harvard Medical School, Boston, Massachusetts; Institut des sciences du sport (ISSUL), University of Lausanne, Lausanne, Switzerland
| | - Philip J Saylor
- Massachusetts General Hospital Cancer Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Card Electrophysiol Clin 2024; 16:35-49. [PMID: 38280813 DOI: 10.1016/j.ccep.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
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5
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Namasivayam M, Churchill TW, Capoulade R, Pibarot P, Danik JS, Picard MH, Levine RA, Hung J. Combined Value of Dimensionless Index and Transvalvular Flow Rate in Risk Stratification of Aortic Stenosis. Am J Cardiol 2024; 213:69-71. [PMID: 38103765 PMCID: PMC10842843 DOI: 10.1016/j.amjcard.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/18/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
Aortic stenosis (AS) is difficult to phenotype. The metrics of severity are frequently discordant, making prognostication challenging. Flow state is central to accurately determining severity. We sought to evaluate the prognostic value of dimensionless index (DI) and transvalvular flow rate (Q) in AS. We evaluated 2 independent, longitudinal registries of ≥ moderate severity AS (aortic valve area ≤1.5 cm2 or mean gradient ≥20 mm Hg) with complete data follow-up. In the primary cohort (n = 1,104, 77 ± 11 years, 40% female), the DI and Q category significantly predicted mortality (p <0.001) (Figure 1), with the highest risk being low DI and low Q (DI <0.25, Q ≤210 mL/s). In the validation cohort (n = 939, 70 ± 13 years, 42% female), similar results were seen in Kaplan-Meier (p <0.001) and multivariable Cox model analyses (p <0.01). We advocate for wider combined use of DI and Q in AS assessment to augment current diagnostic and prognostic approaches.
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Affiliation(s)
- Mayooran Namasivayam
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Cardiology, St. Vincent's Hospital, and Heart Valve Disease and Artificial Intelligence Laboratory, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.
| | - Timothy W Churchill
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Romain Capoulade
- University of Nantes, Nantes University Hospital, National Center for Scientific Research, National Institute of Health and Medical Research, Thorax Institute, F-44000, Nantes, France
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Jacqueline S Danik
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert A Levine
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Churchill TW, O’Kelly AC, Montembeau SC, Kim JH, Guseh JS, Wasfy MM, Dickert NW, Baggish AL. Risk tolerance and eligibility decision-making strategies among young competitive athletes: novel insights into the emerging practice of shared decision making. Eur J Prev Cardiol 2024; 31:e1-e3. [PMID: 37494730 PMCID: PMC10811746 DOI: 10.1093/eurjpc/zwad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Timothy W. Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey 5B, 55 Fruit St., Boston, MA 02114, USA
| | - Anna C. O’Kelly
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
| | - Sarah C. Montembeau
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30307, USA
| | - Jonathan H. Kim
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute, Atlanta, GA 30307, USA
| | - James S. Guseh
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey 5B, 55 Fruit St., Boston, MA 02114, USA
| | - Meagan M. Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey 5B, 55 Fruit St., Boston, MA 02114, USA
| | - Neal W. Dickert
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30307, USA
| | - Aaron L. Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey 5B, 55 Fruit St., Boston, MA 02114, USA
- Department of Cardiology, Lausanne University Hospital and Institute for Sport Science, CH-1015 Lausanne, Switzerland
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7
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Khurshid S, Churchill TW, Diamant N, Di Achille P, Reeder C, Singh P, Friedman SF, Wasfy MM, Alba GA, Maron BA, Systrom DM, Wertheim BM, Ellinor PT, Ho JE, Baggish AL, Batra P, Lubitz SA, Guseh JS. Deep learned representations of the resting 12-lead electrocardiogram to predict at peak exercise. Eur J Prev Cardiol 2024; 31:252-262. [PMID: 37798122 PMCID: PMC10809171 DOI: 10.1093/eurjpc/zwad321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/14/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023]
Abstract
AIMS To leverage deep learning on the resting 12-lead electrocardiogram (ECG) to estimate peak oxygen consumption (V˙O2peak) without cardiopulmonary exercise testing (CPET). METHODS AND RESULTS V ˙ O 2 peak estimation models were developed in 1891 individuals undergoing CPET at Massachusetts General Hospital (age 45 ± 19 years, 38% female) and validated in a separate test set (MGH Test, n = 448) and external sample (BWH Test, n = 1076). Three penalized linear models were compared: (i) age, sex, and body mass index ('Basic'), (ii) Basic plus standard ECG measurements ('Basic + ECG Parameters'), and (iii) basic plus 320 deep learning-derived ECG variables instead of ECG measurements ('Deep ECG-V˙O2'). Associations between estimated V˙O2peak and incident disease were assessed using proportional hazards models within 84 718 primary care patients without CPET. Inference ECGs preceded CPET by 7 days (median, interquartile range 27-0 days). Among models, Deep ECG-V˙O2 was most accurate in MGH Test [r = 0.845, 95% confidence interval (CI) 0.817-0.870; mean absolute error (MAE) 5.84, 95% CI 5.39-6.29] and BWH Test (r = 0.552, 95% CI 0.509-0.592, MAE 6.49, 95% CI 6.21-6.67). Deep ECG-V˙O2 also outperformed the Wasserman, Jones, and FRIEND reference equations (P < 0.01 for comparisons of correlation). Performance was higher in BWH Test when individuals with heart failure (HF) were excluded (r = 0.628, 95% CI 0.567-0.682; MAE 5.97, 95% CI 5.57-6.37). Deep ECG-V˙O2 estimated V˙O2peak <14 mL/kg/min was associated with increased risks of incident atrial fibrillation [hazard ratio 1.36 (95% CI 1.21-1.54)], myocardial infarction [1.21 (1.02-1.45)], HF [1.67 (1.49-1.88)], and death [1.84 (1.68-2.03)]. CONCLUSION Deep learning-enabled analysis of the resting 12-lead ECG can estimate exercise capacity (V˙O2peak) at scale to enable efficient cardiovascular risk stratification.
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Affiliation(s)
- Shaan Khurshid
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Demoulas Center for Cardiac Arrhythmias, Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, 415 Main Street, Cambridge, MA 02142, USA
| | - Timothy W Churchill
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Cardiovascular Performance Program, Division of Cardiology, Mass General Sports Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
| | - Nathaniel Diamant
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Paolo Di Achille
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Christopher Reeder
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Pulkit Singh
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Samuel F Friedman
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Meagan M Wasfy
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Cardiovascular Performance Program, Division of Cardiology, Mass General Sports Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
| | - George A Alba
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- University of Maryland, Institute for Health Computing, Bethesda, MD, USA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Bradley M Wertheim
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Patrick T Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Demoulas Center for Cardiac Arrhythmias, Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, 415 Main Street, Cambridge, MA 02142, USA
| | - Jennifer E Ho
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, CardioVascular Institute, Boston, MA, USA
| | - Aaron L Baggish
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Cardiovascular Performance Program, Division of Cardiology, Mass General Sports Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
- Département Coeur-Vaisseaux, Le Centre Hospitalier Universitaire Vaudois (CHUV), Institut des Sciences du Sport, Université de Lausanne, Écublens, Vaud, Switzerland
| | - Puneet Batra
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Steven A Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Demoulas Center for Cardiac Arrhythmias, Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, 415 Main Street, Cambridge, MA 02142, USA
| | - J Sawalla Guseh
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street Suite 3201, Boston, MA 02114, USA
- Cardiovascular Performance Program, Division of Cardiology, Mass General Sports Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 109, Boston, MA 02114, USA
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8
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Petek BJ, Churchill TW, Moulson N, Kliethermes SA, Baggish AL, Drezner JA, Patel MR, Ackerman MJ, Kucera KL, Siebert DM, Salerno L, Suchsland MZ, Asif IM, Maleszewski JJ, Harmon KG. Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A 20-Year Study. Circulation 2024; 149:80-90. [PMID: 37955565 PMCID: PMC10843024 DOI: 10.1161/circulationaha.123.065908] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 08/24/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Understanding the incidence, causes, and trends of sudden cardiac death (SCD) among young competitive athletes is critical to inform preventive policies. METHODS This study included National Collegiate Athletic Association athlete deaths during a 20-year time frame (July 1, 2002, through June 30, 2022). Athlete deaths were identified through 4 separate independent databases and search strategies (National Collegiate Athletic Association resolutions list, Parent Heart Watch database and media reports, National Center for Catastrophic Sports Injury Research database, and insurance claims). Autopsy reports and medical history were reviewed by an expert panel to adjudicate causes of SCD. RESULTS A total of 143 SCD cases in National Collegiate Athletic Association athletes were identified from 1102 total deaths. The National Collegiate Athletic Association resolutions list identified 117 of 143 (82%), the Parent Heart Watch database or media reports identified 89 of 143 (62%), the National Center for Catastrophic Sports Injury Research database identified 63 of 143 (44%), and insurance claims identified 27 of 143 (19%) SCD cases. The overall incidence of SCD was 1:63 682 athlete-years (95% CI, 1:54 065-1:75 010). Incidence was higher in male athletes than in female athletes (1:43 348 [95% CI, 1:36 228-1:51 867] versus 1:164 504 [95% CI, 1:110 552-1:244 787] athlete-years, respectively) and Black athletes compared with White athletes (1:26 704 [1:20 417-1:34 925] versus 1:74 581 [1:60 247-1:92 326] athlete-years, respectively). The highest incidence of SCD was among Division I male basketball players (1:8188 [White, 1:5848; Black, 1:7696 athlete-years]). The incidence rate for SCD decreased over the study period (5-year incidence rate ratio, 0.71 [95% CI, 0.61-0.82]), whereas the rate of noncardiovascular deaths remained stable (5-year incidence rate ratio, 0.98 [95% CI, 0.94-1.04]). Autopsy-negative sudden unexplained death (19.5%) was the most common postmortem examination finding, followed by idiopathic left ventricular hypertrophy or possible cardiomyopathy (16.9%) and hypertrophic cardiomyopathy (12.7%), in cases with enough information for adjudication (118 of 143). Eight cases of death were attributable to myocarditis over the study period (1 case from January 1, 2020, through June 30, 2022), with none attributed to COVID-19 infection. SCD events were exertional in 50% of cases. Exertional SCD was more common among those with coronary artery anomalies (100%) and arrhythmogenic cardiomyopathy (83%). CONCLUSIONS The incidence of SCD in college athletes has decreased. Male sex, Black race, and basketball are associated with a higher incidence of SCD.
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Affiliation(s)
- Bradley J. Petek
- Sports Cardiology Program, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA
| | - Timothy W. Churchill
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA
| | - Nathaniel Moulson
- Division of Cardiology and Sports Cardiology BC, University of British Columbia, Vancouver, BC, Canada
| | | | - Aaron L. Baggish
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA
- Swiss Olympic Medical Center, Lausanne University Hospital (CHUV), Lusanne, Switzerland
- Institute for Sport Science, University of Lausanne (ISSUL), Lusanne, Switzerland
| | - Jonathan A. Drezner
- Department of Family Medicine and Center for Sports Cardiology, University of Washington, Seattle, WA
| | - Manesh R. Patel
- Division of Cardiology, Duke Heart Center, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Michael J. Ackerman
- Department of Molecular Pharmacology & Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, MN
- Department of Cardiovascular Medicine (Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic), Mayo Clinic, Rochester, MN
- Department of Pediatric and Adolescent Medicine (Division of Pediatric Cardiology), Mayo Clinic
| | - Kristen L. Kucera
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David M. Siebert
- Department of Family Medicine and Center for Sports Cardiology, University of Washington, Seattle, WA
| | - Lauren Salerno
- Department of Family Medicine and Center for Sports Cardiology, University of Washington, Seattle, WA
| | - Monica Zigman Suchsland
- Department of Family Medicine and Center for Sports Cardiology, University of Washington, Seattle, WA
| | - Irfan M. Asif
- Family and Community Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL
| | | | - Kimberly G. Harmon
- Department of Family Medicine and Center for Sports Cardiology, University of Washington, Seattle, WA
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9
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Namasivayam M, Bertrand PB, Bernard S, Churchill TW, Khurshid S, Marcus FI, Mestroni L, Saffitz JE, Towbin JA, Zareba W, Picard MH, Sanborn DY. Utility of Left and Right Ventricular Strain in Arrhythmogenic Right Ventricular Cardiomyopathy: A Prospective Multicenter Registry. Circ Cardiovasc Imaging 2023; 16:e015671. [PMID: 38113321 PMCID: PMC10803132 DOI: 10.1161/circimaging.123.015671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 11/13/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Imaging evaluation of arrhythmogenic right ventricular cardiomyopathy (ARVC) remains challenging. Myocardial strain assessment by echocardiography is an increasingly utilized technique for detecting subclinical left ventricular (LV) and right ventricular (RV) dysfunction. We aimed to evaluate the diagnostic and prognostic utility of LV and RV strain in ARVC. METHODS Patients with suspected ARVC (n = 109) from a multicenter registry were clinically phenotyped using the 2010 ARVC Revised Task Force Criteria and underwent baseline strain echocardiography. Diagnostic performance of LV and RV strain was evaluated using the area under the receiver operating characteristic curve analysis against the 2010 ARVC Revised Task Force Criteria, and the prognostic value was assessed using the Kaplan-Meier analysis. RESULTS Mean age was 45.3±14.7 years, and 48% of patients were female. Estimation of RV strain was feasible in 99/109 (91%), and LV strain was feasible in 85/109 (78%) patients. ARVC prevalence by 2010 ARVC Revised Task Force Criteria is 91/109 (83%) and 83/99 (84%) in those with RV strain measurements. RV global longitudinal strain and RV free wall strain had diagnostic area under the receiver operating characteristic curve of 0.76 and 0.77, respectively (both P<0.001; difference NS). Abnormal RV global longitudinal strain phenotype (RV global longitudinal strain > -17.9%) and RV free wall strain phenotype (RV free wall strain > -21.2%) were identified in 41/69 (59%) and 56/69 (81%) of subjects, respectively, who were not identified by conventional echocardiographic criteria but still met the overall 2010 ARVC Revised Task Force Criteria for ARVC. LV global longitudinal strain did not add diagnostic value but was prognostic for composite end points of death, heart transplantation, or ventricular arrhythmia (log-rank P=0.04). CONCLUSIONS In a prospective, multicenter registry of ARVC, RV strain assessment added diagnostic value to current echocardiographic criteria by identifying patients who are missed by current echocardiographic criteria yet still fulfill the diagnosis of ARVC. LV strain, by contrast, did not add incremental diagnostic value but was prognostic for identification of high-risk patients.
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Affiliation(s)
- Mayooran Namasivayam
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Cardiology, St Vincent’s Hospital, Faculty of Medicine and Health, University of New South Wales, Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Philippe B. Bertrand
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Samuel Bernard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
- Division of Cardiology, NYU Langone Health, New York University
| | - Timothy W. Churchill
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Shaan Khurshid
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - Luisa Mestroni
- Division of Cardiology and Cardiovascular Institute, University of Colorado Anschutz Medical Campus, Aurora
| | | | - Jeffrey A. Towbin
- St. Jude Children’s Research Hospital, University of Tennessee Health Science Center, Memphis
| | | | - Michael H. Picard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
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10
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Klein CF, Petek BJ, Moulson N, Baggish AL, Churchill TW, Harmon KG, Kliethermes SA, Patel MR, Drezner JA. Non-COVID-19 cardiovascular pathology from return-to-play screening in college athletes after COVID-19. Heart 2023; 109:1851-1857. [PMID: 37460194 PMCID: PMC10792102 DOI: 10.1136/heartjnl-2023-322645] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/27/2023] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVE Concerns for cardiac involvement after SARS-CoV-2 infection led to widespread cardiac testing in athletes. We examined incidental non-COVID-19 cardiovascular pathology in college athletes undergoing postinfection return-to-play screening. METHODS The Outcomes Registry for Cardiac Conditions in Athletes was a nationwide prospective multicentre observational cohort study that captured testing and outcomes data from 45 institutions (September 2020-June 2021). Athletes with an ECG and transthoracic echocardiogram (TTE) and no pre-existing conditions were included. Findings were defined as major (associated with sudden cardiac death or requiring intervention), minor (warrants surveillance), incidental (no follow-up needed) or uncertain significance (abnormal with subsequent normal testing). RESULTS Athletes with both ECG and TTE (n=2900, mean age 20±1, 32% female, 27% black) were included. 35 (1.2%) had ECG abnormalities. Of these, 2 (5.7%) had TTE abnormalities indicating cardiomyopathy (hypertrophic-1, dilated-1), and 1 with normal TTE had atrial fibrillation. Of 2865 (98.8%) athletes with a normal ECG, 54 (1.9%) had TTE abnormalities: 3 (5.6%) with aortic root dilatation ≥40 mm, 15 (27.8%) with minor abnormalities, 25 (46.3%) with incidental findings and 11 (20.4%) with findings of uncertain significance. Overall, 6 (0.2%) athletes had major conditions; however, coronary anatomy and aortic dimensions were inconsistently reported and pathology may have been missed. CONCLUSION Major non-COVID-19 cardiovascular pathology was identified in 1/500 college athletes undergoing return-to-play screening. In athletes without ECG abnormalities, TTE's added value was limited to pathological aortic root dilatation in 1/1000 athletes and minor abnormalities warranting surveillance in 1/160 athletes. Two-thirds of findings were incidental or of uncertain significance.
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Affiliation(s)
- Christian F Klein
- Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Bradley J Petek
- Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nathaniel Moulson
- Centre for Cardiovascular Innovation, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Aaron L Baggish
- Cardiovascular Performance Program, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Stephanie A Kliethermes
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | - Jonathan A Drezner
- Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
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11
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Khurshid S, Al-Alusi MA, Churchill TW, Guseh JS, Ellinor PT. Accelerometer-Derived "Weekend Warrior" Physical Activity and Incident Cardiovascular Disease. JAMA 2023; 330:247-252. [PMID: 37462704 PMCID: PMC10354673 DOI: 10.1001/jama.2023.10875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Importance Guidelines recommend 150 minutes or more of moderate to vigorous physical activity (MVPA) per week for overall health benefit, but the relative effects of concentrated vs more evenly distributed activity are unclear. Objective To examine associations between an accelerometer-derived "weekend warrior" pattern (ie, most MVPA achieved over 1-2 days) vs MVPA spread more evenly with risk of incident cardiovascular events. Design, Setting, and Participants Retrospective analysis of UK Biobank cohort study participants providing a full week of accelerometer-based physical activity data between June 8, 2013, and December 30, 2015. Exposures Three MVPA patterns were compared: active weekend warrior (active WW, ≥150 minutes with ≥50% of total MVPA achieved in 1-2 days), active regular (≥150 minutes and not meeting active WW status), and inactive (<150 minutes). The same patterns were assessed using the sample median threshold of 230.4 minutes or more of MVPA per week. Main Outcomes and Measures Associations between activity pattern and incident atrial fibrillation, myocardial infarction, heart failure, and stroke were assessed using Cox proportional hazards regression, adjusted for age, sex, racial and ethnic background, tobacco use, alcohol intake, Townsend Deprivation Index, employment status, self-reported health, and diet quality. Results A total of 89 573 individuals (mean [SD] age, 62 [7.8] years; 56% women) who underwent accelerometry were included. When stratified at the threshold of 150 minutes or more of MVPA per week, a total of 37 872 were in the active WW group (42.2%), 21 473 were in the active regular group (24.0%), and 30 228 were in the inactive group (33.7%). In multivariable-adjusted models, both activity patterns were associated with similarly lower risks of incident atrial fibrillation (active WW: hazard ratio [HR], 0.78 [95% CI, 0.74-0.83]; active regular: 0.81 [95% CI, 0.74-0.88; inactive: HR, 1.00 [95% CI, 0.94-1.07]), myocardial infarction (active WW: 0.73 [95% CI, 0.67-0.80]; active regular: 0.65 [95% CI, 0.57-0.74]; and inactive: 1.00 [95% CI, 0.91-1.10]), heart failure (active WW: 0.62 [95% CI, 0.56-0.68]; active regular: 0.64 [95% CI, 0.56-0.73]; and inactive: 1.00 [95% CI, 0.92-1.09]), and stroke (active WW: 0.79 [95% CI, 0.71-0.88]; active regular: 0.83 [95% CI, 0.72-0.97]; and inactive: 1.00 [95% CI, 0.90-1.11]). Findings were consistent at the median threshold of 230.4 minutes or more of MVPA per week, although associations with stroke were no longer significant (active WW: 0.89 [95% CI, 0.79-1.02]; active regular: 0.87 [95% CI, 0.74-1.02]; and inactive: 1.00 [95% CI, 0.90-1.11]). Conclusions and Relevance Physical activity concentrated within 1 to 2 days was associated with similarly lower risk of cardiovascular outcomes to more evenly distributed activity.
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Affiliation(s)
- Shaan Khurshid
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Mostafa A Al-Alusi
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Cardiology Division, Massachusetts General Hospital, Boston
| | - Timothy W Churchill
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Cardiovascular Performance Program, Cardiology Division, Massachusetts General Hospital, Boston
| | - J Sawalla Guseh
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Cardiovascular Performance Program, Cardiology Division, Massachusetts General Hospital, Boston
| | - Patrick T Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts
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12
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Petek BJ, Al-Alusi MA, Moulson N, Grant AJ, Besson C, Guseh JS, Wasfy MM, Gremeaux V, Churchill TW, Baggish AL. Consumer Wearable Health and Fitness Technology in Cardiovascular Medicine: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:245-264. [PMID: 37438010 PMCID: PMC10662962 DOI: 10.1016/j.jacc.2023.04.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 07/14/2023]
Abstract
The use of consumer wearable devices (CWDs) to track health and fitness has rapidly expanded over recent years because of advances in technology. The general population now has the capability to continuously track vital signs, exercise output, and advanced health metrics. Although understanding of basic health metrics may be intuitive (eg, peak heart rate), more complex metrics are derived from proprietary algorithms, differ among device manufacturers, and may not historically be common in clinical practice (eg, peak V˙O2, exercise recovery scores). With the massive expansion of data collected at an individual patient level, careful interpretation is imperative. In this review, we critically analyze common health metrics provided by CWDs, describe common pitfalls in CWD interpretation, provide recommendations for the interpretation of abnormal results, present the utility of CWDs in exercise prescription, examine health disparities and inequities in CWD use and development, and present future directions for research and development.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA; Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Mostafa A Al-Alusi
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nathaniel Moulson
- Division of Cardiology and Sports Cardiology BC, University of British Columbia, Vancouver, British Columbia, Canada
| | - Aubrey J Grant
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cyril Besson
- Swiss Olympic Medical Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland; Institute for Sport Science, University of Lausanne (ISSUL), Lausanne, Switzerland
| | - J Sawalla Guseh
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meagan M Wasfy
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vincent Gremeaux
- Swiss Olympic Medical Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland; Institute for Sport Science, University of Lausanne (ISSUL), Lausanne, Switzerland
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aaron L Baggish
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA; Swiss Olympic Medical Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland; Institute for Sport Science, University of Lausanne (ISSUL), Lausanne, Switzerland.
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13
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Moulson N, Petek BJ, Ackerman MJ, Churchill TW, Day SM, Kim JH, Kliethermes SA, Lampert R, Levine BD, Martinez MW, Patel MR, Phelan D, Harmon KG, Baggish AL, Drezner JA. Rationale and Design of the ORCCA (Outcomes Registry for Cardiac Conditions in Athletes) Study. J Am Heart Assoc 2023; 12:e029052. [PMID: 37259981 PMCID: PMC10382007 DOI: 10.1161/jaha.122.029052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/13/2023] [Indexed: 06/02/2023]
Abstract
Background Clinical practice recommendations for participation in sports and exercise among young competitive athletes with cardiovascular conditions at risk for sudden death are based largely on expert consensus with a paucity of prospective outcomes data. Recent guidelines have taken a more permissive approach, using a shared decision-making model. However, the impact and outcomes of this strategy remain unknown. Methods The ORCCA (Outcomes Registry for Cardiac Conditions in Athletes) study is a prospective, multicenter, longitudinal, observational cohort study designed to monitor clinical outcomes in athletes with potentially life-threatening cardiovascular conditions. The study will assess sports eligibility decision-making, exercise habits, psychosocial well-being, and long-term cardiovascular outcomes among young competitive athletes with cardiovascular conditions. Competitive athletes aged 18 to <35 years diagnosed with a confirmed cardiovascular condition or borderline finding with potential increased risk of major adverse cardiovascular events are eligible. Outcomes will be monitored for an initial 5-year follow-up period or until age 35, and metrics of psychosocial well-being and composite adverse cardiovascular events including arrhythmias, sudden cardiac arrest/sudden cardiac death, and evidence of disease progression will be compared among athletes who continue versus discontinue competitive sports participation. Conclusions The ORCCA study aims to assess the process and results of return to sport decision-making and to monitor major adverse cardiovascular events, exercise habits, and the psychosocial well-being among young competitive athletes diagnosed with confirmed cardiovascular conditions or borderline findings with potential increased risk of major adverse cardiovascular events. The results of this work will generate an evidence base to inform future guidelines.
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Affiliation(s)
- Nathaniel Moulson
- Division of Cardiology and Sports Cardiology BCUniversity of British ColumbiaVancouverBCUSA
| | - Bradley J. Petek
- Massachusetts General Hospital Division of CardiologyBostonMAUSA
- Cardiovascular Performance ProgramBostonMAUSA
| | - Michael J. Ackerman
- Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology & Experimental Therapeutics, Divisions of Heart Rhythm Services and Pediatric CardiologyWindland Smith Rice Genetic Heart Rhythm Clinic and Windland Smith Rice Sudden Death Genomics LaboratoryRochesterMNUSA
| | - Timothy W. Churchill
- Massachusetts General Hospital Division of CardiologyBostonMAUSA
- Cardiovascular Performance ProgramBostonMAUSA
| | - Sharlene M. Day
- Division of Cardiovascular MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Jonathan H. Kim
- Division of CardiologyEmory University School of MedicineAtlantaGAUSA
| | | | - Rachel Lampert
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of MedicineNew HavenCTUSA
| | - Benjamin D. Levine
- Division of CardiologyUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Matthew W. Martinez
- Department of Cardiovascular Medicine, Morristown Medical Center, Atlantic Health SystemMorristownNJUSA
| | - Manesh R. Patel
- Division of CardiologyDuke Heart Center, and Duke Clinical Research Institute, Duke University School of MedicineDurhamNCUSA
| | - Dermot Phelan
- Sports Cardiology CenterAtrium Health Sanger Heart & Vascular InstituteCharlotteNCUSA
| | - Kimberly G. Harmon
- Department of Family Medicine and Center for Sports CardiologyUniversity of WashingtonSeattleWAUSA
| | - Aaron L. Baggish
- Department of CardiologyLausanne University Hospital (CHUV)LausanneSwitzerland
- Institute for Sport Science, University of Lausanne (ISSUL)LausanneSwitzerland
| | - Jonathan A. Drezner
- Department of Family Medicine and Center for Sports CardiologyUniversity of WashingtonSeattleWAUSA
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14
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Churchill TW, Yucel E, Bernard S, Namasivayam M, Nagata Y, Lau ES, Deferm S, He W, Danik JS, Sanborn DY, Picard MH, Levine RA, Hung J, Bertrand PB. Sex Differences in Extensive Mitral Annular Calcification With Associated Mitral Valve Dysfunction. Am J Cardiol 2023; 193:83-90. [PMID: 36881941 PMCID: PMC10066827 DOI: 10.1016/j.amjcard.2023.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 03/07/2023]
Abstract
Mitral annular calcification (MAC)-related mitral valve (MV) dysfunction is an increasingly recognized entity, which confers a high burden of morbidity and mortality. Although more common among women, there is a paucity of data regarding how the phenotype of MAC and the associated adverse clinical implications may differ between women and men. A total of 3,524 patients with extensive MAC and significant MAC-related MV dysfunction (i.e., transmitral gradient ≥3 mm Hg) were retrospectively analyzed from a large institutional database, with the goal of defining gender differences in clinical and echocardiographic characteristics and the prognostic importance of MAC-related MV dysfunction. We stratified patients into low- (3 to 5 mm Hg), moderate- (5 to 10 mm Hg), and high- (≥10 mm Hg) gradient groups and analyzed the gender differences in phenotype and outcome. The primary outcome was all-cause mortality, assessed using adjusted Cox regression models. Women represented the majority (67%) of subjects, were older (79.3 ± 10.4 vs 75.5 ± 10.9 years, p <0.001) and had a lower burden of cardiovascular co-morbidities than men. Women had higher transmitral gradients (5.7 ± 2.7 vs 5.3 ± 2.6 mm Hg, p <0.001), more concentric hypertrophy (49% vs 33%), and more mitral regurgitation. The median survival was 3.4 years (95% confidence interval 3.0 to 3.6) among women and 3.0 years (95% confidence interval 2.6 to 4.5) among men. The adjusted survival was worse among men, and the prognostic impact of the transmitral gradient did not differ overall by gender. In conclusion, we describe important gender differences among patients with MAC-related MV dysfunction and show worse adjusted survival among men; although, the adverse prognostic impact of the transmitral gradient was similar between men and women.
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Affiliation(s)
- Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Evin Yucel
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Bernard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, New York University School of Medicine, New York University, New York, New York
| | - Mayooran Namasivayam
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Victor Chang Cardiac Research Institute, St. Vincent's Hospital, University of New South Wales, Sydney, Australia
| | - Yasufumi Nagata
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; The Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Emily S Lau
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sebastien Deferm
- Department of Cardiology, Mainz University Hospital, Mainz Germany
| | - Wei He
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline S Danik
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danita Y Sanborn
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Philippe B Bertrand
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Ziekenhuis Oost-Limburg, Genk, Belgium
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15
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Bavishi A, Kliethermes SA, Petek B, Moulson N, Mellacheruvu P, Churchill TW, Harmon K, Patel MR, Baggish AL, Drezner JA, Mutharasan RK. Clinical spectrum of COVID-19 complications in young adults: combined analysis of the American Heart Association COVID-19 Cardiovascular Disease Registry and the Outcomes Registry for Cardiac Conditions in Athletes. BMJ Open 2023; 13:e069943. [PMID: 37045581 PMCID: PMC10105915 DOI: 10.1136/bmjopen-2022-069943] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND While young adults 18-24 years old bear a significant proportion of COVID-19 diagnoses, the risk factors for hospitalisation and severe COVID-19 complications in this population are poorly understood. OBJECTIVE The objective of this study was to identify risk factors for hospitalisation and other COVID-19 complications across the health spectrum of young adults diagnosed with COVID-19 infection. STUDY DESIGN Retrospective cohort study. PARTICIPANTS Young adults (aged 18-24) with confirmed COVID-19 infection from the American Heart Association (AHA) COVID-19 Cardiovascular Disease Registry of hospitalised patients and the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) study of collegiate athletes. The AHA registry included 636 young adults from 152 hospitals. The ORCCA registry consisted of 3653 competitive college athletes from 42 colleges and universities. INTERVENTION None (exposure to COVID-19). PRIMARY AND SECONDARY OUTCOME MEASURES Main outcomes included hospitalisation, death, major adverse cardiovascular events (MACE) and other severe clinical events. RESULTS In comparison to the ORCCA registry, patients in the AHA registry were more likely to be female (59% vs 33%); had higher average body mass index (BMI) (32.4 vs 25.6); and had increased prevalence of diabetes (10% vs 0.4%), hypertension (7% vs 0.6%), chronic kidney disease (2% vs 0%) and asthma (14% vs 8%), all with p<0.01. There were eight (2%) deaths in the AHA hospitalised registry compared with zero in the ORCCA cohort. BMI was a statistically significant predictor of death in the hospitalised cohort (OR 1.05, 95% CI 1.00, 1.10). No significant predictors of MACE or other severe clinical events were identified. CONCLUSIONS The risk of cardiac events in young adults aged 18-24 diagnosed with COVID-19 infection is low. Patients who were hospitalised (AHA registry) were more likely to have pre-existing medical comorbidities and higher BMI than healthy collegiate athletes (ORCCA registry). Once hospitalised, elevated BMI is associated with increased mortality although other drivers of MACE and other severe clinical events remain unclear.
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Affiliation(s)
- Aakash Bavishi
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Stephanie A Kliethermes
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Bradley Petek
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nathaniel Moulson
- Department of Cardiology, The University of British Columbia Library Vancouver Campus, Vancouver, British Columbia, Canada
| | - Pranav Mellacheruvu
- Department of Internal Medicine, Washington State University Elson S Floyd College of Medicine, Spokane, Washington, USA
| | - Timothy W Churchill
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kimberly Harmon
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Manesh R Patel
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Aaron L Baggish
- Department of Sports Science, University of Lausanne, Lausanne, Switzerland
| | - Jonathan A Drezner
- Department of Family Medicine, Washington State University Spokane, Spokane, Washington, USA
| | - Raja Kannan Mutharasan
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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16
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Petek BJ, Moulson N, Klein CF, Drezner JA, Harmon KG, Kliethermes SA, Patel MR, Isselbacher EM, Baggish AL, Churchill TW. Echocardiographic Reporting of the Aorta in Young Competitive Athletes. J Am Soc Echocardiogr 2023; 36:335-337. [PMID: 36370965 PMCID: PMC10290883 DOI: 10.1016/j.echo.2022.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Nathaniel Moulson
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia
| | - Christian F Klein
- Department of Medicine, University of Washington, Seattle, Washington
| | - Jonathan A Drezner
- Department of Family Medicine and Center for Sports Cardiology, University of Washington, Seattle, Washington
| | - Kimberly G Harmon
- Department of Family Medicine and Center for Sports Cardiology, University of Washington, Seattle, Washington
| | - Stephanie A Kliethermes
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin
| | - Manesh R Patel
- Division of Cardiology, Duke Heart Center, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eric M Isselbacher
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Aaron L Baggish
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts.
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17
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Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Cardiol Clin 2023; 41:35-49. [PMID: 36368810 PMCID: PMC10292923 DOI: 10.1016/j.ccl.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
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18
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Petek BJ, Churchill TW, Gustus SK, Schoenike MW, Nayor M, Moulson N, Guseh JS, VanAtta C, Blodgett JB, Contursi M, Lewis GD, Baggish AL, Wasfy MM. Characterization of Ventilatory Efficiency During Cardiopulmonary Exercise Testing in Healthy Athletes. Eur J Prev Cardiol 2022; 30:e21-e24. [PMID: 36321382 DOI: 10.1093/eurjpc/zwac255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/17/2022] [Accepted: 10/31/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Bradley J Petek
- Massachusetts General Hospital Division of Cardiology
- Cardiovascular Performance Program
| | - Timothy W Churchill
- Massachusetts General Hospital Division of Cardiology
- Cardiovascular Performance Program
| | - Sarah K Gustus
- Massachusetts General Hospital Division of Cardiology
- Cardiovascular Performance Program
| | | | - Matthew Nayor
- Sections of Cardiovascular Medicine and Preventive Medicine and Epidemiology, Boston University School of Medicine
| | - Nathaniel Moulson
- Massachusetts General Hospital Division of Cardiology
- Cardiovascular Performance Program
| | - J Sawalla Guseh
- Massachusetts General Hospital Division of Cardiology
- Cardiovascular Performance Program
| | - Carolyn VanAtta
- Massachusetts General Hospital Division of Cardiology
- Cardiovascular Performance Program
| | - Jasmine B Blodgett
- Massachusetts General Hospital Division of Cardiology
- Cardiovascular Performance Program
| | | | | | - Aaron L Baggish
- Massachusetts General Hospital Division of Cardiology
- Cardiovascular Performance Program
| | - Meagan M Wasfy
- Massachusetts General Hospital Division of Cardiology
- Cardiovascular Performance Program
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19
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Churchill TW, Yucel E, Deferm S, Levine RA, Hung J, Bertrand PB. Mitral Valve Dysfunction in Patients With Annular Calcification: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 80:739-751. [PMID: 35953139 PMCID: PMC10290884 DOI: 10.1016/j.jacc.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 10/15/2022]
Abstract
Mitral annular calcification (MAC) is a common clinical finding and is associated with adverse clinical outcomes, but the clinical impact of MAC-related mitral valve (MV) dysfunction remains underappreciated. Patients with MAC frequently have stenotic, regurgitant, or mixed valvular disease, and this valvular dysfunction is increasingly recognized to be independently associated with worse prognosis. MAC-related MV dysfunction is a distinct pathophysiologic entity, and importantly much of the diagnostic and therapeutic paradigm from published rheumatic MV disease research cannot be applied in this context, leaving important gaps in our knowledge. This review summarizes the current epidemiology, pathophysiology, diagnosis, and classification of MAC-related MV dysfunction and proposes both an integrative definition and an overarching approach to this important and increasingly recognized clinical condition.
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Affiliation(s)
- Timothy W Churchill
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/TimChurchillMD
| | - Evin Yucel
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sébastien Deferm
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Robert A Levine
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Judy Hung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philippe B Bertrand
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.
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20
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Moulson N, Petek BJ, Churchill TW, Drezner JA, Harmon KG, Kliethermes SA, Mellacheruvu P, Patel MR, Baggish AL. Cardiac Troponin Testing as a Component of Return to Play Cardiac Screening in Young Competitive Athletes Following SARS-CoV-2 Infection. J Am Heart Assoc 2022; 11:e025369. [PMID: 35929475 PMCID: PMC9496314 DOI: 10.1161/jaha.122.025369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Initial protocols for return to play cardiac testing in young competitive athletes following SARS-CoV-2 infection recommended cardiac troponin (cTn) to screen for cardiac involvement. This study aimed to define the diagnostic yield of cTn in athletes undergoing cardiovascular testing following SARS-CoV-2 infection. Methods and Results This prospective, observational cohort study from ORCCA (Outcomes Registry for Cardiac Conditions in Athletes) included collegiate athletes who underwent cTn testing as a component of return to play protocols following SARS-CoV-2 infection. The cTn values were stratified as undetectable, detectable but within normal limits, and abnormal (>99% percentile). The presence of probable or definite SARS-CoV-2 myocardial involvement was compared between those with normal versus abnormal cTn levels. A total of 3184/3685 (86%) athletes in the ORCCA database met the inclusion criteria for this study (age 20±1 years, 32% female athletes, 28% Black race). The median time from SARS-CoV-2 diagnosis to cTn testing was 13 days (interquartile range, 11, 18 days). The cTn levels were undetectable in 2942 athletes (92%), detectable but within normal limits in 210 athletes (7%), and abnormal in 32 athletes (1%). Of the 32 athletes with abnormal cTn testing, 19/32 (59%) underwent cardiac magnetic resonance imaging, 30/32 (94%) underwent transthoracic echocardiography, and 1/32 (3%) did not have cardiac imaging. One athlete with abnormal troponin met the criteria for definite or probable SARS-CoV-2 myocardial involvement. In the total cohort, 21/3184 (0.7%) had SARS-CoV-2 myocardial involvement, among whom 20/21 (95%) had normal troponin testing. Conclusions Abnormal cTn during routine return to play cardiac screening among competitive athletes following SARS-CoV-2 infection appears to have limited diagnostic utility.
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Affiliation(s)
- Nathaniel Moulson
- Division of Cardiology and Sports Cardiology BC University of British Columbia Vancouver British Columbia Canada
| | - Bradley J Petek
- Division of Cardiology Massachusetts General Hospital Boston MA.,Cardiovascular Performance Program Massachusetts General Hospital Boston MA
| | - Timothy W Churchill
- Division of Cardiology Massachusetts General Hospital Boston MA.,Cardiovascular Performance Program Massachusetts General Hospital Boston MA
| | - Jonathan A Drezner
- Department of Family Medicine and Center for Sports Cardiology University of Washington Seattle WA
| | - Kimberly G Harmon
- Department of Family Medicine and Center for Sports Cardiology University of Washington Seattle WA
| | | | | | - Manesh R Patel
- Division of Cardiology Duke Heart Center, and Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Aaron L Baggish
- Division of Cardiology Massachusetts General Hospital Boston MA.,Cardiovascular Performance Program Massachusetts General Hospital Boston MA
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21
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Moulson N, Gustus SK, Scirica C, Petek BJ, Vanatta C, Churchill TW, Guseh JS, Baggish A, Wasfy MM. Diagnostic evaluation and cardiopulmonary exercise test findings in young athletes with persistent symptoms following COVID-19. Br J Sports Med 2022; 56:bjsports-2021-105157. [PMID: 35584886 PMCID: PMC9157326 DOI: 10.1136/bjsports-2021-105157] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Persistent or late-onset cardiopulmonary symptoms following COVID-19 may occur in athletes despite a benign initial course. We examined the yield of cardiac evaluation, including cardiopulmonary exercise testing (CPET), in athletes with cardiopulmonary symptoms after COVID-19, compared CPETs in these athletes and those without COVID-19 and evaluated longitudinal changes in CPET with improvement in symptoms. METHODS This prospective cohort study evaluated young (18-35 years old) athletes referred for cardiopulmonary symptoms that were present>28 days from COVID-19 diagnosis. CPET findings in post-COVID athletes were compared with a matched reference group of healthy athletes without COVID-19. Post-COVID athletes underwent repeat CPET between 3 and 6 months after initial evaluation. RESULTS Twenty-one consecutive post-COVID athletes with cardiopulmonary symptoms (21.9±3.9 years old, 43% female) were evaluated 3.0±2.1 months after diagnosis. No athlete had active inflammatory heart disease. CPET reproduced presenting symptoms in 86%. Compared with reference athletes (n=42), there was similar peak VO2 but a higher prevalence of abnormal spirometry (42%) and low breathing reserve (42%). Thirteen athletes (62%) completed longitudinal follow-up (4.8±1.9 months). The majority (69%) had reduction in cardiopulmonary symptoms, accompanied by improvement in peak VO2 and oxygen pulse, and reduction in resting and peak heart rate (all p<0.05). CONCLUSION Despite a high burden of cardiopulmonary symptoms after COVID-19, no athlete had active inflammatory heart disease. CPET was clinically useful to reproduce symptoms with either normal testing or identification of abnormal spirometry as a potential therapeutic target. Improvement in post-COVID symptoms was accompanied by improvements in CPET parameters.
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Affiliation(s)
- Nathaniel Moulson
- Cardiology Division, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah K Gustus
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christina Scirica
- Pediatric Pulmonary Medicine Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bradley J Petek
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Caroyln Vanatta
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James Sawalla Guseh
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aaron Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meagan M Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
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22
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Petek BJ, Moulson N, Drezner JA, Harmon KG, Kliethermes SA, Churchill TW, Patel MR, Baggish AL. Cardiovascular Outcomes in Collegiate Athletes Following SARS-CoV-2 Infection: 1-year Follow-up from the Outcomes Registry for Cardiac Conditions in Athletes. Circulation 2022; 145:1690-1692. [PMID: 35545946 DOI: 10.1161/circulationaha.121.058272] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bradley J Petek
- Massachusetts General Hospital, Division of Cardiology, Boston, MA; Massachusetts General Hospital, Cardiovascular Performance Program, Boston, MA
| | - Nathaniel Moulson
- Division of Cardiology and Sports Cardiology BC, University of British Columbia, Vancouver, Canada
| | - Jonathan A Drezner
- Department of Family Medicine and Center for Sports Cardiology, University of Washington, Seattle, WA
| | - Kimberly G Harmon
- Department of Family Medicine and Center for Sports Cardiology, University of Washington, Seattle, WA
| | | | - Timothy W Churchill
- Massachusetts General Hospital, Division of Cardiology, Boston, MA; Massachusetts General Hospital, Cardiovascular Performance Program, Boston, MA
| | - Manesh R Patel
- Division of Cardiology, Duke Heart Center, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Aaron L Baggish
- Massachusetts General Hospital, Division of Cardiology, Boston, MA; Massachusetts General Hospital, Cardiovascular Performance Program, Boston, MA
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23
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Gustus S, Moulson N, Churchill TW, Guseh JS, Petek BJ, VanAtta C, Baggish AL, Wasfy MM. Impact of the COVID-19 pandemic on perceived cardiorespiratory fitness in athlete patients. PM R 2022; 14:561-568. [PMID: 35238166 PMCID: PMC9088663 DOI: 10.1002/pmrj.12800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/10/2022] [Accepted: 02/15/2022] [Indexed: 11/20/2022]
Abstract
Introduction Cardiorespiratory fitness (CRF), as one of the most potent prognostic factors in medicine, is followed longitudinally to guide clinical management. Coronavirus disease 2019 (COVID‐19) pandemic‐related changes in lifestyle stand to influence CRF. Objective To assess the influence of the pandemic on perceived CRF in athlete patients and evaluate how perceived CRF change was related to demographics, pre‐pandemic measured CRF, and current physical activity (PA). Design Prospective cohort study, utilizing electronic survey. Setting Tertiary care sports cardiology clinical practice. Participants Adult athlete patients without COVID‐19 with pre‐pandemic measured CRF using cardiopulmonary exercise testing. Interventions Not applicable. Main Outcome Measures Perceived change in CRF since pandemic onset; association between perceived CRF change and demographics, PA, health status, and pre‐pandemic measured CRF assessed via analysis of variance (ANOVA). Results Among 62 participants (male: 71%, 50.1 ± 12.1 years old), 40% (25/62) reported no change and 32% (20/62) reported an increase in perceived CRF since pandemic onset. Among the 27% (17/62) who reported a decrease in perceived CRF, in most (12/17), this was characterized as only mild. Demographics and pre‐pandemic measured CRF did not differ across groups of perceived CRF change. Participants with a moderate or greater decrease in perceived CRF regarded their overall health (via Euro Quality of Life Visual Analogue Scale) as worse than other groups (ANOVA, p = .001). Although total PA was similar across groups, those who had improvement in perceived CRF reported higher levels of moderate intensity PA (ANOVA, p = .008). Conclusions The majority of participants perceived that they had maintained or improved CRF over the pandemic. Findings from this study suggest that a reduction in perceived CRF from pre‐pandemic values in athletic patients in clinical practice may not result from population‐wide pandemic changes in lifestyle. Worse health status and lower levels of moderate intensity PA were associated with perceived reduction in CRF over the pandemic in athlete patients.
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Affiliation(s)
- Sarah Gustus
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Massachusetts General Hospital Cardiovascular Performance Program, Boston, Massachusetts, USA
| | - Nathaniel Moulson
- Division of Cardiology and Sports Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Massachusetts General Hospital Cardiovascular Performance Program, Boston, Massachusetts, USA
| | - James Sawalla Guseh
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Massachusetts General Hospital Cardiovascular Performance Program, Boston, Massachusetts, USA
| | - Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Massachusetts General Hospital Cardiovascular Performance Program, Boston, Massachusetts, USA
| | - Carolyn VanAtta
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Massachusetts General Hospital Cardiovascular Performance Program, Boston, Massachusetts, USA
| | - Aaron L Baggish
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Massachusetts General Hospital Cardiovascular Performance Program, Boston, Massachusetts, USA
| | - Meagan M Wasfy
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Massachusetts General Hospital Cardiovascular Performance Program, Boston, Massachusetts, USA
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24
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Roh JD, Kitchen RR, Guseh JS, McNeill JN, Aid M, Martinot AJ, Yu A, Platt C, Rhee J, Weber B, Trager LE, Hastings MH, Ducat S, Xia P, Castro C, Singh A, Atlason B, Churchill TW, Di Carli MF, Ellinor PT, Barouch DH, Ho JE, Rosenzweig A. Plasma Proteomics of COVID-19-Associated Cardiovascular Complications: Implications for Pathophysiology and Therapeutics. JACC Basic Transl Sci 2022; 7:425-441. [PMID: 35530264 PMCID: PMC9067411 DOI: 10.1016/j.jacbts.2022.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 12/30/2022]
Abstract
To gain insights into the mechanisms driving cardiovascular complications in COVID-19, we performed a case-control plasma proteomics study in COVID-19 patients. Our results identify the senescence-associated secretory phenotype, a marker of biological aging, as the dominant process associated with disease severity and cardiac involvement. FSTL3, an indicator of senescence-promoting Activin/TGFβ signaling, and ADAMTS13, the von Willebrand Factor-cleaving protease whose loss-of-function causes microvascular thrombosis, were among the proteins most strongly associated with myocardial stress and injury. Findings were validated in a larger COVID-19 patient cohort and the hamster COVID-19 model, providing new insights into the pathophysiology of COVID-19 cardiovascular complications with therapeutic implications.
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Affiliation(s)
- Jason D. Roh
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert R. Kitchen
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - J. Sawalla Guseh
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jenna N. McNeill
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Malika Aid
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Amanda J. Martinot
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Biomedical Sciences, Section of Pathology, Tufts University Cummings School of Veterinary Medicine, North Grafton, Massachusetts, USA
| | - Andy Yu
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Colin Platt
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James Rhee
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brittany Weber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena E. Trager
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret H. Hastings
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Ducat
- Department of Biomedical Sciences, Section of Pathology, Tufts University Cummings School of Veterinary Medicine, North Grafton, Massachusetts, USA
| | - Peng Xia
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Claire Castro
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abhilasha Singh
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bjarni Atlason
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy W. Churchill
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo F. Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Patrick T. Ellinor
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Dan H. Barouch
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA
| | - Jennifer E. Ho
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony Rosenzweig
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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25
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Stucky F, Churchill TW, Churchill JL, Petek BJ, Guseh JS, Wasfy MM, Kayser B, Baggish AL. Priming Cardiac Function with Voluntary Respiratory Maneuvers and Effect on Early Exercise Oxygen Uptake. J Appl Physiol (1985) 2022; 132:1179-1189. [PMID: 35271410 DOI: 10.1152/japplphysiol.00750.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Oxygen uptake (V'O2) at exercise onset is determined in part by acceleration of pulmonary blood flow (Q'p). Impairments in the Q'p response can decrease exercise tolerance. Prior research has shown that voluntary respiratory maneuvers can augment venous return, but the corollary impacts on cardiac function, Q'p and early-exercise V'O2 remain uncertain. We examined a) the cardiovascular effects of 3 distinct respiratory maneuvers (abdominal, AB; rib cage, RC and deep breathing, DB) under resting conditions in healthy subjects (Protocol 1, n=13) and b) the impact of pre-exercise DB on pulmonary O2 transfer during initiation of moderate intensity exercise (Protocol 2, n=8). In Protocol 1, echocardiographic analysis showed increased RV and LV cardiac output (RVCO and LVCO, respectively) following AB (by +23±13 and +18±15%, respectively, P<0.05), RC (+23±16; +14±15%, P<0.05) and DB (+27±21; +23±14%, P<0.05). In Protocol 2, DB performed for 12 breaths produced a pre-exercise increase in V'O2 (+801±254 ml·min-1 over ~ 6 s), presumably from increased Q'p followed by a reduction in pulmonary O2 transfer during early phase exercise (first 20 s) compared to the control condition (149±51 vs 233±65 ml, P<0.05). We conclude that (1) respiratory maneuvers enhance RVCO and LVCO in healthy subjects under resting conditions, (2) AB, RC and DB have similar effects on RVCO and LVCO, and (3) DB can increase Q'p prior to exercise onset. These findings suggest that pre-exercise respiratory maneuvers may represent a promising strategy to prime V'O2 kinetics and thereby to potentially improve exercise tolerance in patients with impaired cardiac function.
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Affiliation(s)
- Frédéric Stucky
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA, United States.,Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, MA, United States
| | - Jessica L Churchill
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, MA, United States
| | - Bradley J Petek
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA, United States
| | - James Sawalla Guseh
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA, United States
| | - Meagan M Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA, United States.,Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, MA, United States
| | - Bengt Kayser
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA, United States.,Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, MA, United States
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26
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Petek BJ, Moulson N, Drezner JA, Harmon KG, Klein CF, Kliethermes SA, Churchill TW, Patel MR, Baggish AL. Echocardiographic Reporting of Proximal Coronary Artery Origins in Young Competitive Athletes. JACC Cardiovasc Imaging 2022; 15:544-546. [PMID: 35033493 DOI: 10.1016/j.jcmg.2021.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/29/2021] [Indexed: 12/31/2022]
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27
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Lau ES, Panah LG, Zern EK, Liu EE, Farrell R, Schoenike MW, Namasivayam M, Churchill TW, Curreri L, Malhotra R, Nayor M, Lewis GD, Ho JE. Arterial Stiffness and Vascular Load in HFpEF: Differences Among Women and Men. J Card Fail 2022; 28:202-211. [PMID: 34955334 PMCID: PMC8840989 DOI: 10.1016/j.cardfail.2021.10.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mechanisms underlying sex differences in heart failure with preserved ejection fraction (HFpEF) are poorly understood. We sought to examine sex differences in measures of arterial stiffness and the association of arterial stiffness measures with left ventricular hemodynamic responses to exercise in men and women. METHODS We studied 83 men (mean age 62 years) and 107 women (mean age 59 years) with HFpEF who underwent cardiopulmonary exercise testing with invasive hemodynamic monitoring and arterial stiffness measurement (augmentation pressure [AP], augmentation index [AIx], and aortic pulse pressure [AoPP]). Sex differences were compared using multivariable linear regression. We examined the association of arterial stiffness with abnormal left ventricular diastolic response to exercise, defined as a rise in pulmonary capillary wedge pressure relative to cardiac output (∆PCWP/∆CO) ≥ 2 mmHg/L/min by using logistic regression models. RESULTS Women with HFpEF had increased arterial stiffness compared with men. AP was nearly 10 mmHg higher, and AIx was more than 10% higher in women compared with men (P < 0.0001 for both). Arterial stiffness measures were associated with a greater pulmonary capillary wedge pressure response to exercise, particularly among women. A 1-standard deviation higher AP was associated with > 3-fold increased odds of abnormal diastolic exercise response (AP: OR 3.16, 95% CI 1.34-7.42; P = 0.008 [women] vs OR 2.07, 95% CI 0.95-5.49; P = 0.15 [men]) with similar findings for AIx and AoPP. CONCLUSIONS Arterial stiffness measures are significantly higher in women with HFpEF than in men and are associated with abnormally steep increases in pulmonary capillary wedge pressure with exercise, particularly in women. Arterial stiffness may preferentially contribute to abnormal diastolic function during exercise in women with HFpEF compared with men.
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Petek BJ, Gustus SK, Churchill TW, Guseh JS, Loomer G, VanAtta C, Baggish AL, Wasfy MM. Sex-Based Differences in Peak Exercise Blood Pressure Indexed to Oxygen Consumption Among Competitive Athletes. Clin Ther 2021; 44:11-22.e3. [PMID: 34819243 DOI: 10.1016/j.clinthera.2021.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/01/2021] [Accepted: 10/27/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE Although exercise testing guidelines define cutoffs for an exaggerated exercise systolic blood pressure (SBP) response, SBPs above these cutoffs are not uncommon in athletes given their high exercise capacity. Alternately, guidelines also specify a normal SBP response that accounts for metabolic equivalents (METs; mean [SD] of 10 [2] mm Hg per MET or 3.5 mL/kg/min oxygen consumption [V˙o2]). SBP and V˙o2 increase less during exercise in females than males. It is not clear if sex-based differences in exercise V˙o2 are related to differences in SBP or if current recommendations for normal increase in SBP per MET produce reasonable estimates using measured METs (ie, V˙o2) in athletes. We therefore examined sex-based differences in exercise SBP indexed to V˙o2 in athletes with the goal of defining normative values for exercise SBP that account for fitness and sex. METHODS Using prospectively collected data from a single sports cardiology program, normotensive athlete patients were identified who had no relevant cardiopulmonary disease and had undergone cardiopulmonary exercise testing with cycle ergometry or treadmill. The relationship between ΔSBP (peak - rest) and ΔV˙o2 (peak - rest) was examined in the total cohort and compared between sexes. FINDINGS A total of 413 athletes (mean [SD] age, 35.5 [14] years; 38% female; mean [SD] peak V˙o2, 46.0 [10.2] mL/kg/min, 127% [27%] predicted) met the inclusion criteria. The ΔSBP correlated with unadjusted ΔV˙o2 (cycle: R2 = 0.18, treadmill: R2 = 0.12; P < 0.0001). Female athletes had lower mean (SD) peak SBP (cycle: 161 [15] vs 186 [24] mm Hg; treadmill: 165 [17] vs 180 [20] mm Hg; P < 0.05) than male athletes. Despite lower peak SBP, mean (SD) ΔSBP relative to unadjusted ΔV˙o2 was higher in female than male athletes (cycle: 25.6 [7.2] vs 21.1 [7.3] mm Hg/L/min; treadmill: 21.6 [7.2] vs 17.0 [6.2] mm Hg/L/min; P < 0.05). When V˙o2 was adjusted for body size and converted to METs, female and male athletes had similar mean (SD) ΔSBP /ΔMET (cycle: 6.0 [2.1] vs 5.8 [2.0] mm Hg/mL/kg/min; treadmill: 4.7 [1.8] vs 4.8 [1.7] mm Hg/mL/kg/min). IMPLICATIONS In this cohort of athletes without known cardiopulmonary disease, observed sex-based differences in peak exercise SBP were in part related to the differences in ΔV˙o2 between male and female athletes. Despite lower peak SBP, ΔSBP/unadjusted ΔV˙o2 was paradoxically higher in female athletes. Future work should define whether this finding reflects sex-based differences in the peripheral vascular response to exercise. In this athletic cohort, ΔSBP/ΔMET was similar between sexes and much lower than the ratio that has been proposed by guidelines to define a normal SBP response. Our observed ΔSBP/ΔMET, based on measured rather than estimated METs, provides a clinically useful estimate for normal peak SBP range in athletes.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Sarah K Gustus
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - J Sawalla Guseh
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Garrett Loomer
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Carolyn VanAtta
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Aaron L Baggish
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Meagan M Wasfy
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts.
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Petek BJ, Churchill TW, Sawalla Guseh J, Loomer G, Gustus SK, Lewis GD, Weiner RB, Baggish AL, Wasfy MM. Utility of the oxygen pulse in the diagnosis of obstructive coronary artery disease in physically fit patients. Physiol Rep 2021; 9:e15105. [PMID: 34767313 PMCID: PMC8587175 DOI: 10.14814/phy2.15105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/24/2021] [Accepted: 10/14/2021] [Indexed: 11/24/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) guidelines recommend analysis of the oxygen (O2 ) pulse for a late exercise plateau in evaluation for obstructive coronary artery disease (OCAD). However, whether this O2 pulse trajectory is within the range of normal has been debated, and the diagnostic performance of the O2 pulse for OCAD in physically fit individuals, in whom V ˙ O 2 may be more likely to plateau, has not been evaluated. Using prospectively collected data from a sports cardiology program, patients were identified who were free of other cardiac disease and underwent clinically-indicated CPET within 90 days of invasive or computed tomography coronary angiography. The diagnostic performance of quantitative O2 pulse metrics (late exercise slope, proportional change in slope during late exercise) and qualitative assessment for O2 pulse plateau to predict OCAD was assessed. Among 104 patients (age:56 ± 12 years, 30% female, peak V ˙ O 2 119 ± 34% predicted), the diagnostic performance for OCAD (n = 24,23%) was poor for both quantitative and qualitative metrics reflecting an O2 pulse plateau (late exercise slope: AUC = 0.55, sensitivity = 68%, specificity = 41%; proportional change in slope: AUC = 0.55, sensitivity = 91%, specificity = 18%; visual plateau/decline: AUC = 0.51, sensitivity = 33%, specificity = 67%). When O2 pulse parameters were added to the electrocardiogram, the change in AUC was minimal (-0.01 to +0.02, p ≥ 0.05). Those patients without OCAD with a plateau or decline in O2 pulse were fitter than those with linear augmentation (peak V ˙ O 2 133 ± 31% vs. 114 ± 36% predicted, p < 0.05) and had a longer exercise ramp time (9.5 ± 3.2 vs. 8.0 ± 2.5 min, p < 0.05). Overall, a plateau in O2 pulse was not a useful predictor of OCAD in a physically fit population, indicating that the O2 pulse should be integrated with other CPET parameters and may reflect a physiologic limitation of stroke volume and/or O2 extraction during intense exercise.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - J Sawalla Guseh
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Garrett Loomer
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah K Gustus
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gregory D Lewis
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rory B Weiner
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aaron L Baggish
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meagan M Wasfy
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
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Petek BJ, Moulson N, Baggish AL, Kliethermes SA, Patel MR, Churchill TW, Harmon KG, Drezner JA. Prevalence and clinical implications of persistent or exertional cardiopulmonary symptoms following SARS-CoV-2 infection in 3597 collegiate athletes: a study from the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA). Br J Sports Med 2021; 56:913-918. [PMID: 34725052 PMCID: PMC8561826 DOI: 10.1136/bjsports-2021-104644] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 01/05/2023]
Abstract
Objective To assess the prevalence and clinical implications of persistent or exertional cardiopulmonary symptoms in young competitive athletes following SARS-CoV-2 infection. Methods This observational cohort study from the Outcomes Registry for Cardiac Conditions in Athletes included 3597 US collegiate athletes after SARS-CoV-2 infection. Clinical characteristics, advanced diagnostic testing and SARS-CoV-2-associated sequelae were compared between athletes with persistent symptoms >3 weeks, exertional symptoms on return to exercise and those without persistent or exertional symptoms. Results Among 3597 athletes (mean age 20 years (SD, 1 year), 34% female), data on persistent and exertional symptoms were reported in 3529 and 3393 athletes, respectively. Persistent symptoms >3 weeks were present in 44/3529 (1.2%) athletes with 2/3529 (0.06%) reporting symptoms >12 weeks. Exertional cardiopulmonary symptoms were present in 137/3393 (4.0%) athletes. Clinical evaluation and diagnostic testing led to the diagnosis of SARS-CoV-2-associated sequelae in 12/137 (8.8%) athletes with exertional symptoms (five cardiac involvement, two pneumonia, two inappropriate sinus tachycardia, two postural orthostatic tachycardia syndrome and one pleural effusion). No SARS-CoV-2-associated sequelae were identified in athletes with isolated persistent symptoms. Of athletes with chest pain on return to exercise who underwent cardiac MRI (CMR), 5/24 (20.8%) had probable or definite cardiac involvement. In contrast, no athlete with exertional symptoms without chest pain who underwent CMR (0/20) was diagnosed with probable or definite SARS-CoV-2 cardiac involvement. Conclusion Collegiate athletes with SARS-CoV-2 infection have a low prevalence of persistent or exertional symptoms on return to exercise. Exertional cardiopulmonary symptoms, specifically chest pain, warrant a comprehensive evaluation.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nathaniel Moulson
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stephanie A Kliethermes
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Manesh R Patel
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kimberly G Harmon
- Department of Family Medicine, Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
| | - Jonathan A Drezner
- Department of Family Medicine, Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
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Divakaran S, Singh A, DeFilippis EM, Churchill TW, Cuddy S, Ge Y, Ip IK, Zhou W, Skali H, Taqueti VR, Dorbala S, Spalding J, Xu Y, Khorasani R, Di Carli MF, Yialamas MA, Blankstein R. Appropriateness of inpatient stress testing: Implications for development of clinical decision support mechanisms and future criteria. J Nucl Cardiol 2021; 28:1988-1997. [PMID: 31741326 PMCID: PMC7231672 DOI: 10.1007/s12350-019-01955-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 10/18/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND An upcoming national mandate will require consultation of appropriate use criteria (AUC) through a clinical decision support mechanism (CDSM) for advanced imaging. We aimed to evaluate our current ability to ascertain test appropriateness. METHODS We prospectively collected data on 288 consecutive stress tests and coronary computed tomography angiography studies for medical inpatients. Study appropriateness was determined independently by two physicians using the 2013 Multimodality AUC. RESULTS The median age of the study population was 66 years [interquartile range (IQR) 56, 75], 40.8% were female, and 52.8% had a history of coronary artery disease. Review of the electronic health record (EHR) alone was sufficient to deem appropriateness for 87.2% of cases. The most common reason it was insufficient was inability to determine if the patient could exercise (59.5%). After reviewing the EHR and pilot CDSM data together, appropriateness could be determined for 95.8% of the cases. The most common reason appropriateness could not be determined was that the exam indication was not addressed by an AUC criterion (83.3%). CONCLUSION In preparing for the mandate, it will be important for future CDSM to obtain information on the patient's ability to exercise and for future AUC to include additional indications that are not currently addressed.
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Affiliation(s)
- Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Avinainder Singh
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, New York Presbyterian-Columbia University Irving Medical Center, New York, NY, USA
| | - Timothy W Churchill
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Cuddy
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yin Ge
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ivan K Ip
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Wunan Zhou
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hicham Skali
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James Spalding
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Yanqing Xu
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | - Ramin Khorasani
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maria A Yialamas
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Petek BJ, Tso JV, Churchill TW, Guseh JS, Loomer G, DiCarli M, Lewis GD, Weiner RB, Kim JH, Wasfy MM, Baggish AL. Normative cardiopulmonary exercise data for endurance athletes: the Cardiopulmonary Health and Endurance Exercise Registry (CHEER). Eur J Prev Cardiol 2021; 29:536-544. [PMID: 34487164 DOI: 10.1093/eurjpc/zwab150] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/05/2021] [Accepted: 08/24/2021] [Indexed: 11/14/2022]
Abstract
AIMS Accurate interpretation of cardiopulmonary exercise testing (CPET) relies on age, gender, and exercise modality-specific reference values. To date, clinically applicable CPET reference values derived from a source population of endurance athletes (EAs) have been lacking. The purpose of this study was to generate CPET reference values for use in the clinical assessment of EA. METHODS AND RESULTS Prospective data accrued during the clinical care of healthy EA were used to derive CPET reference values and to develop novel equations for V˙O2peak. The performance of these equations was compared to the contemporary standard of care equations and assessed in a discrete EA validation cohort. A total of 272 EA (age = 42 ± 15 years, female = 31%, V˙O2peak = 3.6 ± 0.83 L/min) met inclusion criteria and comprised the derivation cohort. V˙O2peak prediction equations derived from general population cohorts described a modest amount of V˙O2peak variability [R2 = 0.58-0.70, root mean square error (RMSE) = 0.46-0.54 L/min] but were mis-calibrated (calibration-in-the-large = 0.45-1.18 L/min) among EA leading to significant V˙O2peak underestimation. Newly derived, externally validated V˙O2peak prediction equations for EA that included age, sex, and height for both treadmill (R2 = 0.74, RMSE = 0.42 L/min) and cycle ergometer CPET (Cycle: R2 = 0.69, RMSE = 0.42 L/min) demonstrated improved accuracy. CONCLUSION Commonly used V˙O2peak prediction equations derived from general population cohorts perform poorly among competitive EA. Newly derived CPET reference values including novel V˙O2peak prediction equations may improve the clinical utility of CPET in this rapidly growing patient population.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jason V Tso
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute, 1462 Clifton Road, NE, Suite 502, Atlanta, GA 30322, USA
| | - Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - J Sawalla Guseh
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Garrett Loomer
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Milena DiCarli
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Gregory D Lewis
- Division of Cardiology, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Rory B Weiner
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan H Kim
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute, 1462 Clifton Road, NE, Suite 502, Atlanta, GA 30322, USA
| | - Meagan M Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
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Bertrand PB, Churchill TW, Yucel E, Namasivayam M, Bernard S, Nagata Y, He W, Andrews CT, Picard MH, Weyman AE, Levine RA, Hung J. Prognostic importance of the transmitral pressure gradient in mitral annular calcification with associated mitral valve dysfunction. Eur Heart J 2021; 41:4321-4328. [PMID: 33221855 DOI: 10.1093/eurheartj/ehaa819] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/21/2020] [Accepted: 09/22/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS The aim of this study was to define the natural history of patients with mitral annular calcification (MAC)-related mitral valve dysfunction and to assess the prognostic importance of mean transmitral pressure gradient (MG) and impact of concomitant mitral regurgitation (MR). METHODS AND RESULTS The institutional echocardiography database was examined from 2001 to 2019 for all patients with MAC and MG ≥3 mmHg. A total of 5754 patients were stratified by MG in low (3-5 mmHg, n = 3927), mid (5-10 mmHg, n = 1476), and high (≥10 mmHg, n = 351) gradient. The mean age was 78 ± 11 years, and 67% were female. MR was none/trace in 32%, mild in 42%, moderate in 23%, and severe in 3%. Primary outcome was all-cause mortality, and outcome models were adjusted for age, sex, and MAC-related risk factors (hypertension, diabetes, coronary artery disease, chronic kidney disease). Survival at 1, 5, and 10 years was 77%, 42%, and 18% in the low-gradient group; 73%, 38%, and 17% in the mid-gradient group; and 67%, 25%, and 11% in the high-gradient group, respectively (log-rank P < 0.001 between groups). MG was independently associated with mortality (adjusted HR 1.064 per 1 mmHg increase, 95% CI 1.049-1.080). MR severity was associated with mortality at low gradients (P < 0.001) but not at higher gradients (P = 0.166 and 0.372 in the mid- and high-gradient groups, respectively). CONCLUSION In MAC-related mitral valve dysfunction, mean transmitral gradient is associated with increased mortality after adjustment for age, sex, and MAC-related risk factors. Concomitant MR is associated with excess mortality in low-gradient ranges (3-5 mmHg) but gradually loses prognostic importance at higher gradients, indicating prognostic utility of transmitral gradient in MAC regardless of MR severity.
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Affiliation(s)
- Philippe B Bertrand
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Timothy W Churchill
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Evin Yucel
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Mayooran Namasivayam
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Samuel Bernard
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Yasufumi Nagata
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Wei He
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Carl T Andrews
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Michael H Picard
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Arthur E Weyman
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Robert A Levine
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
| | - Judy Hung
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA
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Hadzibegovic S, Lena A, Churchill TW, Ho JE, Potthoff S, Denecke C, Rösnick L, Heim KM, Kleinschmidt M, Sander LE, Witzenrath M, Suttorp N, Krannich A, Porthun J, Friede T, Butler J, Wilkenshoff U, Pieske B, Landmesser U, Anker SD, Lewis GD, Tschöpe C, Anker MS. Heart failure with preserved ejection fraction according to the HFA-PEFF score in COVID-19 patients: clinical correlates and echocardiographic findings. Eur J Heart Fail 2021; 23:1891-1902. [PMID: 33932255 PMCID: PMC8239668 DOI: 10.1002/ejhf.2210] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 01/08/2023] Open
Abstract
Aims Viral‐induced cardiac inflammation can induce heart failure with preserved ejection fraction (HFpEF)‐like syndromes. COVID‐19 can lead to myocardial damage and vascular injury. We hypothesised that COVID‐19 patients frequently develop a HFpEF‐like syndrome, and designed this study to explore this. Methods and results Cardiac function was assessed in 64 consecutive, hospitalized, and clinically stable COVID‐19 patients from April–November 2020 with left ventricular ejection fraction (LVEF) ≥50% (age 56 ± 19 years, females: 31%, severe COVID‐19 disease: 69%). To investigate likelihood of HFpEF presence, we used the HFA‐PEFF score. A low (0–1 points), intermediate (2–4 points), and high (5–6 points) HFA‐PEFF score was observed in 42%, 33%, and 25% of patients, respectively. In comparison, 64 subjects of similar age, sex, and comorbidity status without COVID‐19 showed these scores in 30%, 66%, and 4%, respectively (between groups: P = 0.0002). High HFA‐PEFF scores were more frequent in COVID‐19 patients than controls (25% vs. 4%, P = 0.001). In COVID‐19 patients, the HFA‐PEFF score significantly correlated with age, estimated glomerular filtration rate, high‐sensitivity troponin T (hsTnT), haemoglobin, QTc interval, LVEF, mitral E/A ratio, and H2FPEF score (all P < 0.05). In multivariate, ordinal regression analyses, higher age and hsTnT were significant predictors of increased HFA‐PEFF scores. Patients with myocardial injury (hsTnT ≥14 ng/L: 31%) vs. patients without myocardial injury, showed higher HFA‐PEFF scores [median 5 (interquartile range 3–6) vs. 1 (0–3), P < 0.001] and more often showed left ventricular diastolic dysfunction (75% vs. 27%, P < 0.001). Conclusion Hospitalized COVID‐19 patients frequently show high likelihood of presence of HFpEF that is associated with cardiac structural and functional alterations, and myocardial injury. Detailed cardiac assessments including echocardiographic determination of left ventricular diastolic function and biomarkers should become routine in the care of hospitalized COVID‐19 patients.
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Affiliation(s)
- Sara Hadzibegovic
- Department of Cardiology (CBF), Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Alessia Lena
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA, USA.,Echocardiography Laboratory, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer E Ho
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA.,Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sophia Potthoff
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Corinna Denecke
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lukas Rösnick
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Katrin Moira Heim
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Malte Kleinschmidt
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Leif Erik Sander
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Witzenrath
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Norbert Suttorp
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Krannich
- Clinical Study Center (CSC), Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Porthun
- Norwegian University of Science and Technology, Gjøvik, Norway
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Javed Butler
- Mississippi State University Jackson Design Center Library, Starkville, MS, USA
| | - Ursula Wilkenshoff
- Department of Cardiology (CBF), Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Burkert Pieske
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Heart Center, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology (CBF), Charité Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan D Anker
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Carsten Tschöpe
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Markus S Anker
- Department of Cardiology (CBF), Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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Churchill TW, Petek BJ, Wasfy MM, Guseh JS, Weiner RB, Singh TK, Schmied C, O'Malley H, Chiampas G, Baggish AL. Cardiac Structure and Function in Elite Female and Male Soccer Players. JAMA Cardiol 2021; 6:316-325. [PMID: 33263734 DOI: 10.1001/jamacardio.2020.6088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Population-specific normative data are essential for the evaluation of competitive athletes. At present, there are limited data defining normal electrocardiographic (ECG) and echocardiographic values among elite US soccer players. Objective To describe ECG and echocardiographic findings in healthy elite US soccer players. Design, Setting, and Participants This cross-sectional study analyzed Fédération Internationale de Football Association-mandated screening sessions performed at US Soccer National Team training locations from January 2015 to December 2019. US women's and men's national team soccer players undergoing mandated cardiovascular screening were included. Main Outcomes and Measures Normal training-related and abnormal ECG findings were reported using the International Recommendations for Electrocardiographic Interpretation in Athletes. Echocardiographic measurements of structural and functional parameters relevant to cardiovascular remodeling were assessed relative to American Society of Echocardiography guideline-defined normal ranges. Results A total of 238 athletes (122 [51%] female; mean [SD] age, 20 [4] years; age range, 15-40 years) were included. Male athletes demonstrated a higher prevalence of normal training-related ECG findings, while female athletes were more likely to have abnormal ECG patterns (14 [11%] vs 0 in male cohort), largely accounted for by abnormal T-wave inversions. Echocardiography revealed no pathologic findings meeting criteria for sport restriction, but athletes frequently exceeded normal ranges for structural cardiac parameters responsive to exercise-induced remodeling including body surface area-indexed left ventricular (LV) mass (58 of 113 female athletes [51%] and 67 of 114 male athletes [59%]), indexed LV volume (89 of 115 female athletes [77%] and 76 of 111 male athletes [68%]), and LV wall thickness (37 of 122 female athletes [30%] and 47 of 116 male athletes [41%]). Age-stratified analysis revealed age-dependent increases in LV wall thickness, mass, and volumes among female athletes and LV wall thickness and mass among male athletes. Conclusions and Relevance These data represent the first set of comprehensive normative values for elite US soccer players and one of the largest sport-specific echocardiographic remodeling studies in female athletes. Abnormal ECG findings were more common in female athletes, while both female and male athletes frequently exceeded clinical normality cut points for remodeling-associated echocardiographic parameters.
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Affiliation(s)
- Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston
| | - Bradley J Petek
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston
| | - Meagan M Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston
| | - James S Guseh
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston
| | - Rory B Weiner
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston
| | | | | | | | - George Chiampas
- United States Soccer Federation, Chicago, Illinois.,Feinberg School of Medicine, Department of Emergency Medicine, Northwestern University, Evanston, Illinois
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston.,United States Soccer Federation, Chicago, Illinois
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36
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Churchill TW, Li SX, Curreri L, Zern EK, Lau ES, Liu EE, Farrell R, Shoenike MW, Sbarbaro J, Malhotra R, Nayor M, Tschöpe C, de Boer RA, Lewis GD, Ho JE. Evaluation of 2 Existing Diagnostic Scores for Heart Failure With Preserved Ejection Fraction Against a Comprehensively Phenotyped Cohort. Circulation 2021; 143:289-291. [PMID: 33464963 PMCID: PMC8059354 DOI: 10.1161/circulationaha.120.050757] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Timothy W. Churchill
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Shawn X Li
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lisa Curreri
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily K Zern
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily S. Lau
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth E. Liu
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Robyn Farrell
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark W. Shoenike
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John Sbarbaro
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rajeev Malhotra
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew Nayor
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Carsten Tschöpe
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité, University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
- Department of Cardiology, Charité, University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Rudolf A. de Boer
- University Medical Centre Groningen, University of Groningen, Department of Cardiology, Groningen, The Netherlands
| | - Gregory D. Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer E. Ho
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
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Churchill TW, Groezinger E, Kim JH, Loomer G, Guseh JS, Wasfy MM, Isselbacher EM, Lewis GD, Weiner RB, Schmied C, Baggish AL. Association of Ascending Aortic Dilatation and Long-term Endurance Exercise Among Older Masters-Level Athletes. JAMA Cardiol 2021; 5:522-531. [PMID: 32101252 DOI: 10.1001/jamacardio.2020.0054] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Aortic dilatation is frequently encountered in clinical practice among aging endurance athletes, but the distribution of aortic sizes in this population is unknown. It is additionally uncertain whether this may represent aortic adaptation to long-term exercise, similar to the well-established process of ventricular remodeling. Objective To assess the prevalence of aortic dilatation among long-term masters-level male and female athletes with about 2 decades of exercise exposure. Design, Setting, and Participants This cross-sectional study evaluated aortic size in veteran endurance athletes. Masters-level rowers and runners aged 50 to 75 years were enrolled from competitive athletic events across the United States from February to October 2018. Analysis began January 2019. Exposures Long-term endurance exercise. Main Outcomes and Measures The primary outcome was aortic size at the sinuses of Valsalva and the ascending aorta, measured using transthoracic echocardiography in accordance with contemporary guidelines. Aortic dimensions were compared with age, sex, and body size-adjusted predictions from published nomograms, and z scores were calculated where applicable. Results Among 442 athletes (mean [SD] age, 61 [6] years; 267 men [60%]; 228 rowers [52%]; 214 runners [48%]), clinically relevant aortic dilatation, defined by a diameter at sinuses of Valsalva or ascending aorta of 40 mm or larger, was found in 21% (n = 94) of all participants (83 men [31%] and 11 women [6%]). When compared with published nomograms, the distribution of measured aortic size displayed a rightward shift with a rightward tail (all P < .001). Overall, 105 individuals (24%) had at least 1 z score of 2 or more, indicating an aortic measurement greater than 2 SDs above the population mean. In multivariate models adjusting for age, sex, body size, hypertension, and statin use, both elite competitor status (rowing participation in world championships or Olympics or marathon time under 2 hours and 45 minutes) and sport type (rowing) were independently associated with aortic size. Conclusions and Relevance Clinically relevant aortic dilatation is common among aging endurance athletes, raising the possibility of vascular remodeling in response to long-term exercise. Longitudinal follow-up is warranted to establish corollary clinical outcomes in this population.
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Affiliation(s)
- Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston
| | - Erich Groezinger
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston
| | - Jonathan H Kim
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia
| | - Garrett Loomer
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston
| | - J Sawalla Guseh
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston
| | - Meagan M Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston
| | - Eric M Isselbacher
- Echocardiography Laboratory, Massachusetts General Hospital, Boston.,Thoracic Aortic Center, Massachusetts General Hospital, Boston
| | - Gregory D Lewis
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston
| | - Rory B Weiner
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston
| | | | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston
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Namasivayam M, He W, Churchill TW, Capoulade R, Liu S, Lee H, Danik JS, Picard MH, Pibarot P, Levine RA, Hung J. Transvalvular Flow Rate Determines Prognostic Value of Aortic Valve Area in Aortic Stenosis. J Am Coll Cardiol 2020; 75:1758-1769. [PMID: 32299587 DOI: 10.1016/j.jacc.2020.02.046] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/01/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aortic valve area (AVA) ≤1.0 cm2 is a defining characteristic of severe aortic stenosis (AS). AVA can be underestimated at low transvalvular flow rate. Yet, the impact of flow rate on prognostic value of AVA ≤1.0 cm2 is unknown and is not incorporated into AS assessment. OBJECTIVES This study aimed to evaluate the effect of flow rate on prognostic value of AVA in AS. METHODS In total, 1,131 patients with moderate or severe AS and complete clinical follow-up were included as part of a longitudinal database. The effect of flow rate (ratio of stroke volume to ejection time) on prognostic value of AVA ≤1.0 cm2 for time to death was evaluated, adjusting for confounders. Sensitivity analysis was performed to identify the optimal cutoff for prognostic threshold of AVA. The findings were validated in a separate external longitudinal cohort of 939 patients. RESULTS Flow rate had a significant effect on prognostic value of AVA. AVA ≤1.0 cm2 was not prognostic for mortality (p = 0.15) if AVA was measured at flow rates below median (≤242 ml/s). In contrast, AVA ≤1.0 cm2 was highly prognostic for mortality (p = 0.003) if AVA was measured at flow rates above median (>242 ml/s). Findings were irrespective of multivariable adjustment for age, sex, and surgical/transcatheter aortic valve replacement (as time-dependent covariates); comorbidities; medications; and echocardiographic features. AVA ≤1.0 cm2 was also not an independent predictor of mortality below median flow rate in the validation cohort. The optimal flow rate cutoff for prognostic threshold was 210 ml/s. CONCLUSIONS Transvalvular flow rate determines prognostic value of AVA in AS. AVA measured at low flow rate is not a good prognostic marker and therefore not a good diagnostic marker for truly severe AS. Flow rate assessment should be incorporated into clinical diagnosis, classification, and prognosis of AS.
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Affiliation(s)
- Mayooran Namasivayam
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. https://twitter.com/MayoNamasivayam
| | - Wei He
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy W Churchill
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Romain Capoulade
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000, Nantes, France; Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Shiying Liu
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hang Lee
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline S Danik
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Robert A Levine
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Deferm S, Bertrand PB, Churchill TW, Sharma R, Vandervoort PM, Schwamm LH, Yoerger Sanborn DM. Left Atrial Mechanics Assessed Early during Hospitalization for Cryptogenic Stroke Are Associated with Occult Atrial Fibrillation: A Speckle-Tracking Strain Echocardiography Study. J Am Soc Echocardiogr 2020; 34:156-165. [PMID: 33132019 DOI: 10.1016/j.echo.2020.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Occult atrial fibrillation (AF) is an important contributor to cryptogenic stroke, yet remains difficult to unmask at presentation. This study investigated the predictive value of left atrial (LA) mechanics by strain echocardiography during stroke hospitalization for the presence of AF as detected on early 30-day monitoring and routine clinical follow-up. METHODS Left atrial mechanics were studied by strain echocardiography in a retrospective cohort of 191 patients with cryptogenic stroke and 30-day mobile cardiac outpatient telemetry poststroke to diagnose AF. After this, AF was diagnosed via routine clinical follow-up. The independent and incremental value of measures of LA size and mechanics (i.e., strain and strain rate in the reservoir, conduit, and booster pump phase) to predict AF on top of clinical characteristics was assessed. RESULTS Of 191 patients, 15% (n = 28) developed AF, of which 10 were observed during 30-day mobile cardiac outpatient telemetry and 18 were observed at a median follow-up of 25 (interquartile range, 10-43) months. Median time from embolic stroke to strain echocardiography was 1 day (interquartile range, 1-2 days). Left atrial mechanics were significantly worse in AF (P < .05 for all), despite largely similar baseline cardiovascular risk profile. Booster pump strain rate was the strongest predictor for AF, independent of age, LA volume index, E/e', and reservoir strain (odds ratio = 2.88 per SD increase; 95% confidence interval, 1.29-6.41; P = .010). Adding LA strain reservoir strain and booster pump function significantly enhanced a multivariate model to predict AF. Freedom from AF was significantly lower in subjects with a booster pump strain rate (at stroke presentation) worse than -0.67 sec-1, as derived from receiver operator curve analysis (P < .001). CONCLUSIONS Left atrial mechanics and particularly the LA booster pump function assessed early during hospitalization for cryptogenic stroke can identify patients at greater likelihood of future diagnosis of AF. These findings could in part relate to LA mechanical stunning after spontaneous cardioversion, which-when identified by early strain echocardiography-can inform further risk stratification and decision-making.
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Affiliation(s)
- Sébastien Deferm
- Department of Cardiology, Hospital Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Philippe B Bertrand
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Timothy W Churchill
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Richa Sharma
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Pieter M Vandervoort
- Department of Cardiology, Hospital Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Danita M Yoerger Sanborn
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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40
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Bernard S, Churchill TW, Namasivayam M, Bertrand PB. Agitated Saline Contrast Echocardiography in the Identification of Intra- and Extracardiac Shunts: Connecting the Dots. J Am Soc Echocardiogr 2020; 34:S0894-7317(20)30615-5. [PMID: 34756394 DOI: 10.1016/j.echo.2020.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/01/2020] [Accepted: 09/05/2020] [Indexed: 02/08/2023]
Abstract
Agitated saline contrast studies are an essential component of contemporary echocardiography. Agitated saline contrast plays a critical role in the elucidation of intracardiac versus intrapulmonary shunting and can have major therapeutic implications, particularly in light of the evolution of percutaneous treatment options for atrial septal defects or a patent foramen ovale. Despite their perceived simplicity, however, there are numerous pitfalls of these investigations that can occur during their performance and interpretation. As such, the authors review the "bubble study" in identifying intracardiac and extracardiac shunts, including the history of its development, the physics and physiology of contrast enhancement, how to optimally perform and interpret an agitated saline contrast study, and its safety in unique populations.
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Affiliation(s)
- Samuel Bernard
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Timothy W Churchill
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mayooran Namasivayam
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Philippe B Bertrand
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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41
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Namasivayam M, Churchill TW, Hung J. Reply: Refining Prognostication of Severe Aortic Stenosis: The Q Factor. J Am Coll Cardiol 2020; 76:634-635. [PMID: 32731944 DOI: 10.1016/j.jacc.2020.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/01/2020] [Indexed: 11/16/2022]
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Guseh JS, Churchill TW, Yeri A, Lo C, Brown M, Houstis NE, Aragam KG, Lieberman DE, Rosenzweig A, Baggish AL. An expanded repertoire of intensity-dependent exercise-responsive plasma proteins tied to loci of human disease risk. Sci Rep 2020; 10:10831. [PMID: 32616758 PMCID: PMC7331669 DOI: 10.1038/s41598-020-67669-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 06/10/2020] [Indexed: 12/14/2022] Open
Abstract
Routine endurance exercise confers numerous health benefits, and high intensity exercise may accelerate and magnify many of these benefits. To date, explanatory molecular mechanisms and the influence of exercise intensity remain poorly understood. Circulating factors are hypothesized to transduce some of the systemic effects of exercise. We sought to examine the role of exercise and exercise intensity on the human plasma proteome. We employed an aptamer-based method to examine 1,305 plasma proteins in 12 participants before and after exercise at two physiologically defined intensities (moderate and high) to determine the proteomic response. We demonstrate that the human plasma proteome is responsive to acute exercise in an intensity-dependent manner with enrichment analysis suggesting functional biological differences between the moderate and high intensity doses. Through integration of available genetic data, we estimate the effects of acute exercise on exercise-associated traits and find proteomic responses that may contribute to observed clinical effects on coronary artery disease and blood pressure regulation. In sum, we provide supportive evidence that moderate and high intensity exercise elicit different signaling responses, that exercise may act in part non-cell autonomously through circulating plasma proteins, and that plasma protein dynamics can simulate some the beneficial and adverse effects of acute exercise.
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Affiliation(s)
- J Sawalla Guseh
- Cardiovascular Research Center, Division of Cardiology, Corrigan Minehan Heart Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114-2696, USA
- Cardiovascular Performance Program, Division of Cardiology, Corrigan Minehan Heart Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114-2696, USA
| | - Timothy W Churchill
- Cardiovascular Performance Program, Division of Cardiology, Corrigan Minehan Heart Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114-2696, USA
| | - Ashish Yeri
- Cardiovascular Research Center, Division of Cardiology, Corrigan Minehan Heart Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114-2696, USA
| | - Claire Lo
- Cardiovascular Performance Program, Division of Cardiology, Corrigan Minehan Heart Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114-2696, USA
- Department of Human Evolutionary Biology, Harvard University, Cambridge, MA, 02138, USA
| | - Marcel Brown
- Cardiovascular Performance Program, Division of Cardiology, Corrigan Minehan Heart Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114-2696, USA
| | - Nicholas E Houstis
- Cardiovascular Research Center, Division of Cardiology, Corrigan Minehan Heart Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114-2696, USA
| | - Krishna G Aragam
- Cardiovascular Research Center, Division of Cardiology, Corrigan Minehan Heart Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114-2696, USA
| | - Daniel E Lieberman
- Department of Human Evolutionary Biology, Harvard University, Cambridge, MA, 02138, USA
| | - Anthony Rosenzweig
- Cardiovascular Research Center, Division of Cardiology, Corrigan Minehan Heart Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114-2696, USA.
| | - Aaron L Baggish
- Cardiovascular Performance Program, Division of Cardiology, Corrigan Minehan Heart Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114-2696, USA.
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Churchill TW, Bertrand PB, Bernard S, Namasivayam M, Churchill J, Crousillat D, Davis EF, Hung J, Picard MH. Echocardiographic Features of COVID-19 Illness and Association with Cardiac Biomarkers. J Am Soc Echocardiogr 2020; 33:1053-1054. [PMID: 32580898 PMCID: PMC7253994 DOI: 10.1016/j.echo.2020.05.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Timothy W Churchill
- Echocardiography Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Philippe B Bertrand
- Echocardiography Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Samuel Bernard
- Echocardiography Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Mayooran Namasivayam
- Echocardiography Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Jessica Churchill
- Echocardiography Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniela Crousillat
- Echocardiography Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Esther F Davis
- Echocardiography Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Judy Hung
- Echocardiography Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael H Picard
- Echocardiography Laboratory, Massachusetts General Hospital, Boston, Massachusetts
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Abstract
Masters athletes (MA), men and woman older than 35 years who participate in competitive athletics, is a rapidly growing population that is increasingly encountered in clinical cardiovascular practice. Although the high levels of exercise typically performed by MA confer numerous health advantages, no amount of exercise confers complete immunity from cardiovascular disease. The review was written to cover the clinical management of MA with cardiovascular disease. Focus is dedicated to four of the most common clinical scenarios including atrial fibrillation, myocardial fibrosis, coronary artery disease, and dilation of the ascending aorta.
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Affiliation(s)
- Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Harvard Medical School, Yawkey Suite 5B, 55 Fruit Street, Boston, MA, 02114, USA
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Harvard Medical School, Yawkey Suite 5B, 55 Fruit Street, Boston, MA, 02114, USA.
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Abstract
A 77-year-old patient presented with a mobile structure on the anterior mitral valve leaflet and was diagnosed with endocarditis. Subsequent imaging demonstrated this finding was consistent with a left atrial mitral valve chord. Recognition of this rare mitral valve anomaly is key to avoid overdiagnostics and/or overtreatment. (Level of Difficulty: Beginner.)
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Affiliation(s)
- Philippe B Bertrand
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy W Churchill
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan J Passeri
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Heart Valve Clinic, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Churchill TW, Wasfy MM. Exercise in Heart Failure: The Added Pressure Is Worth the Payoff. J Am Soc Echocardiogr 2020; 33:157-160. [DOI: 10.1016/j.echo.2019.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/06/2019] [Indexed: 11/26/2022]
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Guseh JS, Churchill TW, Yeri A, Lo C, Brown M, Rosenzweig A, Baggish A. Abstract 930: Aerobic Dose Intensity and the Human Exercise Plasma Proteome. Circ Res 2019. [DOI: 10.1161/res.125.suppl_1.930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aerobic exercise confers myriad benefits to human health but the mechanism by which it does so remain incompletely understood. We hypothesize that exercise works in part through circulating protein signaling. Healthy adult men (n, 12) participated in treadmill running sessions at both low (6 mph) and high intensity (maximal effort). We used pre- and post-exercise plasma and a high-throughput aptamer-based assay (SomaScan) to examine the acute impact of exercise on the plasma proteome.
Acute aerobic exercise consistently alters the resting plasma proteome in an intensity-dependent fashion. Of 1,305 proteins assayed 184 (14%) and 598 (46%) change at low and high intensity respectively (FDR p < 0.05). 159 protein species (12%) are common to both intensities. Gene ontology analysis revealed enrichment of pathways associated with leukocyte chemotaxis and chylomicron metabolism at low intensity and Wnt signaling, neuronal axonogenesis, and nitric oxide metabolism pathways at high intensity. We used human sequencing data from the GTEX Consortium (Broad, Cambridge MA) to computationally infer the sources of increasing proteins and found major contributions from the cardiovascular, gastrointestinal, and nervous systems. We identified 43 cis-SNPs that approximate the upregulated proteomic response to acute exercise and used Mendelian randomization to infer a causal relationship between the exercise proteome and decreased muscle wasting in a UK Biobank cohort.
Although guidelines present low and high intensity exercise as equivalent alternatives for health, these data suggest that distinct exercise intensities might offer common and distinct exercise benefits.
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Affiliation(s)
| | | | | | - Claire Lo
- Massachusetts General Hosp, Boston, MA
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Affiliation(s)
- Timothy W Churchill
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston
| | - Aaron L Baggish
- From the Cardiovascular Performance Program, Massachusetts General Hospital, Boston.
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Churchill TW, Krishnan S, Weisskopf M, A Yates B, Speizer FE, Kim JH, Nadler LE, Pascual-Leone A, Zafonte R, Baggish AL. Weight Gain and Health Affliction Among Former National Football League Players. Am J Med 2018; 131:1491-1498. [PMID: 30102909 PMCID: PMC6279549 DOI: 10.1016/j.amjmed.2018.07.042] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Professional American-style football players are among the largest athletes across contemporary sporting disciplines. Weight gain during football participation is common, but the health implications of this early-life weight gain remain incompletely understood. We sought to define weight trajectories of former professional American-style football athletes and to establish their relationship with 5 common health afflictions (cardiovascular disease, cardiometabolic disease, neurocognitive impairment, sleep apnea, and chronic pain). METHODS A health survey was distributed to former National Football League (NFL) players. Former players reported body weight at 4 time points (high school, college, professional, and time of survey response) as well as maximal retirement weight. Logistic regression was used to assess associations between weight gain during football participation and health affliction. RESULTS In this cohort of former NFL players (n = 3,506, age 53 ± 14 years), mean weight increase from high school to time of survey response was 40 ± 36 pounds, with the majority of weight gain occurring during periods of football participation (high-school-to-college and college-to-professional). The prevalence of health afflictions ranged from 9% (cardiovascular disease) to 28% (chronic pain). Weight gain during football participation was independently associated with risk of multiple later-life health afflictions in models adjusted for football exposure, lifestyle variables, and post-career weight gain. CONCLUSIONS Early-life weight gain among American-style football athletes is common and is associated with risk of adverse health profiles during later-life. These findings establish football-associated weight gain as a key predictor of post-career health and raise important questions about the central role of targeted weight gain in this population.
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Affiliation(s)
- Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Mass
| | | | | | - Brandon A Yates
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Mass
| | - Frank E Speizer
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Jonathan H Kim
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Ga
| | - Lee E Nadler
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Mass
| | | | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Mass
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Mass.
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Affiliation(s)
- Joshua C Ziperstein
- From the Departments of Medicine (J.C.Z., T.W.C., G.W.D.), Radiology (S.S.H.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (J.C.Z., T.W.C., G.W.D.), Radiology (S.S.H.), and Pathology (J.R.S.), Harvard Medical School - both in Boston
| | - Timothy W Churchill
- From the Departments of Medicine (J.C.Z., T.W.C., G.W.D.), Radiology (S.S.H.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (J.C.Z., T.W.C., G.W.D.), Radiology (S.S.H.), and Pathology (J.R.S.), Harvard Medical School - both in Boston
| | - Sandeep S Hedgire
- From the Departments of Medicine (J.C.Z., T.W.C., G.W.D.), Radiology (S.S.H.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (J.C.Z., T.W.C., G.W.D.), Radiology (S.S.H.), and Pathology (J.R.S.), Harvard Medical School - both in Boston
| | - G William Dec
- From the Departments of Medicine (J.C.Z., T.W.C., G.W.D.), Radiology (S.S.H.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (J.C.Z., T.W.C., G.W.D.), Radiology (S.S.H.), and Pathology (J.R.S.), Harvard Medical School - both in Boston
| | - James R Stone
- From the Departments of Medicine (J.C.Z., T.W.C., G.W.D.), Radiology (S.S.H.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (J.C.Z., T.W.C., G.W.D.), Radiology (S.S.H.), and Pathology (J.R.S.), Harvard Medical School - both in Boston
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