Myocardial Fibrosis in Athletes van de Schoor, Freek R; Aengevaeren, Vincent L; Hopman, Maria T E ...
Mayo Clinic proceedings,
11/2016, Letnik:
91, Številka:
11
Journal Article
Recenzirano
Odprti dostop
Myocardial fibrosis (MF) is a common phenomenon in the late stages of diverse cardiac diseases and is a predictive factor for sudden cardiac death. Myocardial fibrosis detected by magnetic resonance ...imaging has also been reported in athletes. Regular exercise improves cardiovascular health, but there may be a limit of benefit in the exercise dose-response relationship. Intense exercise training could induce pathologic cardiac remodeling, ultimately leading to MF, but the clinical implications of MF in athletes are unknown. For this comprehensive review, we performed a systematic search of the PubMed and MEDLINE databases up to June 2016. Key Medical Subject Headings terms and keywords pertaining to MF and exercise (training) were included. Articles were included if they represented primary MF data in athletes. We identified 65 athletes with MF from 19 case studies/series and 14 athletic population studies. Myocardial fibrosis in athletes was predominantly identified in the intraventricular septum and where the right ventricle joins the septum. Although the underlying mechanisms are unknown, we summarize the evidence for genetic predisposition, silent myocarditis, pulmonary artery pressure overload, and prolonged exercise-induced repetitive micro-injury as contributors to the development of MF in athletes. We also discuss the clinical implications and potential treatment strategies of MF in athletes.
Outcomes of Cardiac Screening in Adolescent Soccer Players Malhotra, Aneil; Dhutia, Harshil; Finocchiaro, Gherardo ...
New England journal of medicine/The New England journal of medicine,
2018-Aug-09, Letnik:
379, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Reports on the incidence and causes of sudden cardiac death among young athletes have relied largely on estimated rates of participation and varied methods of reporting. We sought to investigate the ...incidence and causes of sudden cardiac death among adolescent soccer players in the United Kingdom.
From 1996 through 2016, we screened 11,168 adolescent athletes with a mean (±SD) age of 16.4±1.2 years (95% of whom were male) in the English Football Association (FA) cardiac screening program, which consisted of a health questionnaire, physical examination, electrocardiography, and echocardiography. The FA registry was interrogated to identify sudden cardiac deaths, which were confirmed with autopsy reports.
During screening, 42 athletes (0.38%) were found to have cardiac disorders that are associated with sudden cardiac death. A further 225 athletes (2%) with congenital or valvular abnormalities were identified. After screening, there were 23 deaths from any cause, of which 8 (35%) were sudden deaths attributed to cardiac disease. Cardiomyopathy accounted for 7 of 8 sudden cardiac deaths (88%). Six athletes (75%) with sudden cardiac death had had normal cardiac screening results. The mean time between screening and sudden cardiac death was 6.8 years. On the basis of a total of 118,351 person-years, the incidence of sudden cardiac death among previously screened adolescent soccer players was 1 per 14,794 person-years (6.8 per 100,000 athletes).
Diseases that are associated with sudden cardiac death were identified in 0.38% of adolescent soccer players in a cohort that underwent cardiovascular screening. The incidence of sudden cardiac death was 1 per 14,794 person-years, or 6.8 per 100,000 athletes; most of these deaths were due to cardiomyopathies that had not been detected on screening. (Funded by the English Football Association and others.).
The athlete's heart (AH) remains a popular topic of study. Controversy related to training-specific cardiac adaptation in male athletes, and continuing developments in imaging technology and scaling ...prompted this systematic review and meta-analysis.
To provide new insight in relation to: 1) cardiac adaptation to divergent training patterns in male athletes, 2) a developing research database using cardiac magnetic resonance (CMR) in athletes; 3) functional data derived from tissue-Doppler analysis as well as right ventricular (RV) and left atrial (LA) measurements in athletes; and 4) an awareness of the impact of body size on cardiac dimensions.
Systematic review and meta-analysis of prospective trials. Data extraction performed by two researchers.
Pub Med, Medline, Scopus and ISI Web of knowledge scholarly data base.
Prospective studies were included if they were echocardiographic or CMR trials of elite young male athletes, with clear indication of type of sports and passed a quality criteria checklist.
All left ventricular (LV) structural parameters were higher in athletes than in controls. Only LV end-diastolic diameter and volume were higher in endurance athletes than in resistance athletes: 54.8 mm (95% CI 54.1 to 55.6) vs 52.4 mm (95% CI 51.2 to 53.6); p<0.001 and 171 ml (95% CI 157 to 185) vs 131 ml (95% CI 120 to 142); p<0.001, respectively. RV end-diastolic volume, mass and LA diameter were higher in endurance athletes than controls. LV end-diastolic volume was larger when CMR was used rather than echocardiography: 178 ml (95% CI Q7 162 to 194) vs 135 ml (95% CI 128 to 142); p<0.001. Meta-analysis regression models demonstrated positive and significant associations between body surface area (BSA) and LV mass, RV mass and LA diameter.
Morphological features of the male AH were noted in both athlete groups. A training-specific pattern of concentric hypertrophy was not discerned in resistance athletes. Both imaging mode and BSA can have a significant impact on the interpretation of AH data.
Aims
Cardiac adaptations in elite, male adolescent youth soccer players have been demonstrated in relation to training status. The time course of these adaptations and the delineation of the ...influence of volatile growth phases from the training effect on these adaptations remain unclear. Consequently, the aims of the study were to evaluate the impact of 3 years of elite‐level soccer training on changes in left ventricular (LV) structure and function in a group of highly trained elite youth male soccer players (SP) as they transitioned through the pre‐to‐adolescent phase of their growth.
Methods
Twenty‐two male youth SP from the highest Level of English Premier League Academy U‐12 teams were evaluated once a year for three soccer seasons as the players progressed from the U‐12 to U‐14 teams. Fifteen recreationally active control participants (CON) were also evaluated over the same 3‐year period. Two‐dimensional transthoracic echocardiography was used to quantify LV structure and function.
Results
After adjusting for the influence of growth and maturation, training‐induced increases in Years 2 and 3 were noted for: LV end diastolic volume (LVEDV; p = 0.02) and LV end systolic volume (LVESV; p = 0.02) in the SP compared to CON. Training‐induced decrements were noted for LV ejection fraction (LVEF; p = 0.006) and TDI‐S′ (p < 0.001).
Conclusions
An increase in training volume (Years 2 and 3) were aligned with LV volumetric adaptations and decrements in systolic function in the SP that were independent from the influence of rapid somatic growth. Decrements in systolic function were suggestive of a functional reserve for exercise.
This guideline presents reference limits for use in echocardiographic practice, updating previous guidance from the British Society of Echocardiography. The rationale for change is discussed, in ...addition to how the reference intervals were defined and the current limitations to their use. The importance of interpretation of echocardiographic parameters within the clinical context is explored, as is grading of abnormality. Each of the following echo parameters are discussed and updated in turn: left ventricular linear dimensions and LV mass; left ventricular volumes; left ventricular ejection fraction; left atrial size; right heart parameters; aortic dimensions; and tissue Doppler imaging. There are several important conceptual changes to the assessment of the heart’s structure and function within this guideline. New terminology for left ventricular function and left atrial size are introduced. The British Society of Echocardiography has advocated a new approach to the assessment of the aortic root, the right heart, and clarified the optimal methodology for assessment of LA size. The British Society of Echocardiography has emphasized a preference to use, where feasible, indexed measures over absolute values for any chamber size.
The structure and function of the right side of the heart is influenced by a wide range of physiological and pathological conditions. Quantification of right heart parameters is important in a ...variety of clinical scenarios including diagnosis, prognostication, and monitoring response to therapy. Although echocardiography remains the first-line imaging investigation for right heart assessment, published guidance is relatively sparse in comparison to that for the left ventricle. This guideline document from the British Society of Echocardiography describes the principles and practical aspects of right heart assessment by echocardiography, including quantification of chamber dimensions and function, as well as assessment of valvular function. While cut-off values for normality are included, a disease-oriented approach is advocated due to the considerable heterogeneity of structural and functional changes seen across the spectrum of diseases affecting the right heart. The complex anatomy of the right ventricle requires special considerations and echocardiographic techniques, which are set out in this document. The clinical relevance of right ventricular diastolic function is introduced, with practical guidance for its assessment. Finally, the relatively novel techniques of three-dimensional right ventricular echocardiography and right ventricular speckle tracking imaging are described. Despite these techniques holding considerable promise, issues relating to reproducibility and inter-vendor variation have limited their clinical utility to date.
Background
The cardiac consequences of undertaking endurance exercise are the topic of recent debate. The purpose of this review is to provide an update on a growing body of literature, focusing on ...left ventricular (LV) function following prolonged endurance exercise over 2 h in duration which have employed novel techniques, including myocardial speckle tracking, to provide a more comprehensive global and regional assessment of LV mechanics.
Methods
Prospective studies were filtered independently following a pre-set criteria, resulting in the inclusion of 27 studies in the analyses. A random-effects meta-analysis was used to determine the weighted mean difference and 95% confidence intervals (CI) of LV functional and mechanical data from pre-to-post-exercise. Narrative commentary was also provided where volume of available evidence precluded meta-analysis.
Results
A significant overall reduction in LV longitudinal strain (
Ɛ
)
n
= 22 (− 18 ± 1 to − 17 ± 1%; effect size (
d
) − 9: − 1 to − 0.5%), strain rate
n
= 10 (SR;
d
− 0.9: − 0.1.3 to − 0.5 l/s) and twist
n
= 5 (11.9 ± 2.2 to 8.7 ± 2.2°,
d
− 1: − 1.6 to − 0.3°) was observed following strenuous endurance exercise (range 120–1740 min) (
P
< 0.01). A smaller number of studies (
n
= 4) also reported a non-significant reduction in global circumferential and radial
Ɛ
(
P
> 0.05).
Conclusion
The meta-analysis and narrative commentary demonstrated that a reduction in LV function and mechanics is evident following prolonged endurance exercise. The mechanism(s) responsible for these changes are complex and likely multi-factorial in nature and may be linked to right and left ventricular interaction.
Strain imaging provides an accessible, feasible and non-invasive technique to assess cardiac mechanics. Speckle tracking echocardiography (STE) is the primary modality with the utility for detection ...of subclinical ventricular dysfunction. Investigation and adoption of this technique has increased significantly in both the research and clinical environment. It is therefore important to provide information to guide the sonographer on the production of valid and reproducible data. The focus of this review is to (1) describe cardiac physiology and mechanics relevant to strain imaging, (2) discuss the concepts of strain imaging and STE and (3) provide a practical guide for the investigation and interpretation of cardiac mechanics using STE.
Pulmonary hypertension is defined as a mean arterial pressure of ≥25 mmHg as confirmed on right heart catheterisation. Traditionally, the pulmonary arterial systolic pressure has been estimated on ...echo by utilising the simplified Bernoulli equation from the peak tricuspid regurgitant velocity and adding this to an estimate of right atrial pressure. Previous studies have demonstrated a correlation between this estimate of pulmonary arterial systolic pressure and that obtained from invasive measurement across a cohort of patients. However, for an individual patient significant overestimation and underestimation can occur and the levels of agreement between the two is poor. Recent guidance has suggested that echocardiographic assessment of pulmonary hypertension should be limited to determining the probability of pulmonary hypertension being present rather than estimating the pulmonary artery pressure. In those patients in whom the presence of pulmonary hypertension requires confirmation, this should be done with right heart catheterisation when indicated. This guideline protocol from the British Society of Echocardiography aims to outline a practical approach to assessing the probability of pulmonary hypertension using echocardiography and should be used in conjunction with the previously published minimum dataset for a standard transthoracic echocardiogram.
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