Nº de abstracts = 45

Alterado em 23 Fevereiro 2012

Electrocardiographic amplitudes: a new risk factor for sudden death in hypertrophic cardiomyopathy.

Ostman-Smith I, Wisten A, Nylander E, Bratt EL, Granelli AW, Oulhaj A, Ljungström E.: European Heart Journal , 2010, 31(4):439-49. Division of Paediatrics, Department of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Queen Silvia Childrens Hospital, SE-416 85 Gothenburg, Sweden.

AIMS: Assessment of ECG-features as predictors of sudden death in adults with hypertrophic cardiomyopathy (HCM). METHODS AND RESULTS: ECG-amplitude sums were measured in 44 normals, 34 athletes, a hospital-cohort of 87 HCM-patients, and 29 HCM-patients with sudden death or cardiac arrest (HCM-CA). HCM-patients with sudden death or cardiac arrest had substantially higher ECG-amplitudes than the HCM-cohort for limb-lead and 12-lead QRS-amplitude sums, and amplitude-duration products (P = 0.00003-P = 0.000002). Separation of HCM-CA from the HCM-cohort is obtained by limb-lead QRS-amplitude sum >or=7.7 mV (odds ratio 18.8, sensitivity 87%, negative predictive value (NPV) 94%, P or=2.2 mV s (odds ratio 31.0, sensitivity 92%, NPV 97%, P or=0.70 mV s (odds ratio 31.5, sensitivity 93%, NPV 96%, P < 0.0001). Sensitivity in HCM-patients or=6 gives a sensitivity of 85% but a higher positive predictive value than above measures. Optimal separation between HCM-CA or=6 (odds ratio 345, sensitivity 85%, specificity 100%, P < 0.0001). CONCLUSION: Twelve-lead ECG is a powerful instrument for risk-stratification in HCM.

Diagnosis and management of elite young athletes undergoing arrhythmia intervention.

Kelly J, Kenny D, Martin RP, Stuart AG.: Archives of disease in childhood, 2011 96(1):21-4. Consultant Cardiologist, Bristol Congenital Heart Centre, Bristol Royal Infirmary, Bristol BS2 8HW, Avon, UK.

Background Sudden cardiac death is the most common cause of mortality in young athletes. In some of these, the final pathway is arrhythmia. The authors aimed to identify the incidence, diagnosis and management of athletes undergoing investigation and intervention for cardiac arrhythmias. Methods Retrospective analysis of all patients between 10 and 17 years presenting to a supra-regional paediatric cardiac unit for investigation and intervention for a cardiac arrhythmia. Elite athletes (county and national level) were identified from the departmental clinical and arrhythmia databases (October 1997-2007). Patients with significant congenital heart disease were excluded. Results From 657 patients undergoing 680 interventions, 324 were excluded. From the remaining 333 we identified 11 elite athletes - football (n=3), martial arts (n=2), rugby (n=2), triple jump, netball, canoeing, and motor sport (n=1). Presenting symptoms included palpitations (n=8) and syncope (n=1). Two were asymptomatic and investigated following routine screening. Diagnoses included atrioventricular (AV) re-entry tachycardia (n=3), AV node re-entry tachycardia (n=4), complete heart block (n=1), sinus node dysfunction (n=1), vasovagal syncope (n=1) and pre-excited atrial fibrillation (n=1). Arrhythmia interventions included implantable loop recorder (n=2), diagnostic electrophysiology study (n=9), including radiofrequency ablation (n=5), cryoablation (n=2) and pacemaker implantation (n=2). Following intervention, 10 children returned to competitive sport. There were no deaths. No child required long-term medication post-intervention. Conclusion Of the young competitive athletes identified from the authors' study, there was a high incidence of significant arrhythmias. Intervention is usually successful and most athletes return to elite sport without the need for long-term medication.

Cardiac rehabilitation after acute myocardial infarction].

Ghannem M.: Annales de cardiologie et d'angéiologie, 201012 59(6):367-79. Centre de réadaptation cardiaque Léopold-Bellan-d'Ollencourt, centre hospitalier de Gonesse, Tracy Le Mont, France.

At the time of evidence-based medicine, while the proofs of the benefits of cardiac rehabilitation to the coronary multiply, a large number of patients are still managed without any form of rehabilitation. In particular, younger patients with myocardial infarction treated by early reperfusion and older subjects. The objective of in-hospital or ambulatory cardiac rehabilitation is a global coverage of the patient and his/her risk factors, that the short duration of hospitalization in the acute phase does not allow. Several randomized studies, metaanalyses, and registers show a decrease from 20 to 30% of the mortality after cardiac rehabilitation. The benefits of physical training on risk factors modification are demonstrated by numerous works: improvement of lipid parameters and arterial pressure, prevention of diabetes, increased smoking cessation, loss of weight, better overall well-being; besides the management of risk factors, physical training improves exercise capacity, a recognised prognostic factor. The efficiency of cardiac rehabilitation may be comparable with that of the key treatments of coronary artery disease, such as beta-blockers or coronary angioplasty. All these proofs give to the cardiac rehabilitation in post-myocardial infarction a high-level recommendation, grade IA.

Heart rate variability and baroreceptor sensitivity following exercise-induced hyperthermia in endurance trained men. Armstrong RG, Ahmad S, Seely AJ, Kenny GP

112(2):501-11, 2012 We evaluated the effect of exercise-induced hyperthermia (EIH) on autonomic nervous system (ANS) function in the early (<80 min) and late (24 and 48 h) stages of recovery. Eight males underwent three repeated 6 min 70° head-up tilts (HUT1, HUT2 and HUT3), each separated by 10-min supine rest in a non-exercise/non-heat stress control state (NHS). On a separate day, three 6 min 70° HUT were performed following EIH (esophageal temperature =40°C) and repeated after 24 and 48 h of recovery. Heart rate, stroke volume (SV), mean arterial pressure and cardiac output ([Formula: see text]) were evaluated during the last min prior to a change in posture. Responses to 70° HUT were compared to the same challenge performed without prior exercise and under a NHS condition. Relative to NHS, [Formula: see text] was maintained during the repeated HUT's following EIH, despite significant reductions in SV and sustained elevations in esophageal temperature (p < 0.05). The preserved [Formula: see text] appears to be due to increased HR (HUT1: NRS = 76 ± 3 beats min(-1), EIH = 126 ± 6 beats min(-1)) stemming from modulation of the ANS toward sympathetic dominance. Parasympathetic withdrawal was evidenced by a reduction in root mean squared successive difference (i.e., HUT1: NHS = 66 ± 12 ms, EIH = 9 ± 1 ms) of heart rate variability and paralleled by a reduction in baroreceptor sensitivity for all HUT's following EIH (p < 0.05). Despite significant modulation in ANS activity, Q is maintained and participants do not become orthostatic intolerant/syncopal during the short-term recovery period following EIH. Normal ANS and cardiovascular function is restored following 24 h of recovery.

Effect of sprint interval exercise on postexercise metabolism and blood pressure in adolescents. Burns SF, Oo HH, Tran A TT

22(1):47-54, 2012 The current study examined the effect of sprint interval exercise on postexercise oxygen consumption, respiratory-exchange ratio (RER), substrate oxidation, and blood pressure in adolescents. Participants were 10 normal-weight healthy youth (7 female), age 15-18 years. After overnight fasts, each participant undertook 2 trials in a random balanced order: (a) two 30-s bouts of sprint interval exercise on a cycle ergometer and (b) rested in the laboratory for an equivalent period. Time-matched measurements of oxygen consumption, RER, and blood pressure were made 90 min into recovery, and substrate oxidation were calculated over the time period. Total postexercise oxygen uptake was significantly higher in the exercise than control trial over the 90 min (mean [SD]: control 20.0 [6.0] L, exercise 24.8 [9.8] L; p = .030). After exercise, RER was elevated above control but then fell rapidly and was lower than control 30-60 min postexercise, and fat oxidation was significantly higher in the exercise than control trial 45-60 min postexercise. However, total fat oxidation did not differ between trials (control 4.5 [2.5] g, exercise 5.4 [2.7] g; p = .247). Post hoc tests revealed that systolic blood pressure was significantly lower than in control at 90 min postexercise (control 104 [10] mm Hg, exercise 99 [10] mm Hg; p < .05). These data indicate that acute sprint interval exercise leads to short-term increases in oxygen uptake and reduced blood pressure in youth. The authors suggest that health outcomes in response to sprint interval training be examined in children.

Mandatory ECG Screening of Athletes: Is this Question Now Resolved? Shephard RJ

Sports medicine (Auckland, N.Z.) 41(12):989-1002, 2011 Dez European and North American cardiologists have long debated the need for mandatory ECG screening of athletes in order to prevent sudden cardiac death. European investigators have recently adduced new evidence, which they believe supports the need for such screening. They note a decrease of sudden cardiac deaths among Italian athletes following the introduction of mandatory screening in that country, clearer definitions of resting ECG abnormalities in athletes, new and more encouraging calculations of cost/benefit ratios and direct comparisons of clinical examination alone against clinical examination plus ECG screening. Nevertheless, it seems that critical criteria for the success of any screening procedure (a substantial prevalence of the problem, coupled with an adequate test sensitivity and specificity) have yet to be satisfied. Very few athletes are liable to sudden cardiac death, only a few of those who are vulnerable will be identified by ECG screening, and even if all potential cases could be detected, restriction of their physical activity would be unlikely to have a major influence on their prognosis. At the same time, a requirement of mandatory testing would discourage engagement in physical activity, and would impose substantial direct costs on the community. Moreover, the large number of false positive test results could have important and undesirable consequences for both indirect medical costs and the overall health of competitors. ECG screening might become more effective if it could be focused on a smaller sub-group of vulnerable athletes, or if the problem of false positive tests could be addressed through an increase of test specificity. However, on the basis of current information, it would seem better to direct efforts in preventive medicine to more common causes of premature death in the young adult.

Cardiac adaptation to acute and chronic participation in endurance sports. George K, Spence A, Naylor LH, Whyte GP, Green DJ

Heart (British Cardiac Society), 2012, Dez, 97(24):1999-2004Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom Street, Liverpool L3 3AF, UK; Este endereço de e-mail está protegido de spam bots, pelo que necessita do Javascript activado para o visualizar .

The pervasive public health message is that moderate amounts of endurance exercise help maintain optimal health and reduce cardiovascular risk. While not enough people meet national physical activity guidelines, there are some at the opposite end of the activity spectrum who far exceed the recommended 'dose' of exercise. The cardiovascular health consequences of single and/or multiple (lifelong) 'doses' of high-volume endurance exercise are currently being debated. Recent commentaries, case reports and case series data have posed the question whether you can 'overdose on exercise', and that is the focus of this brief review.

The effects of performing isometric training at two exercise intensities in healthy young males.

Wiles JD, Coleman DA, Swaine IL.: European Journal of Applied Physiology, 2010, 108(3):419-28. Department of Sport Science, Canterbury Christ Church University, Canterbury, UK..

No previous studies have examined the effects of isometric training intensity upon resting blood pressure (BP). The aims of this study were (a) to compare the effects of leg isometric training, performed at two intensities, upon resting systolic-SBP, diastolic-DBP and mean arterial-MAP BP; and (b) to examine selected cardiovascular variables, in an attempt to explain any changes in resting BP following training. Thirty-three participants were randomly allocated to either control, high- (HI) or low-intensity (LI) training for 8 weeks. Participants performed 4 x 2 min exercise bouts 3x weekly. Resting BP was measured at baseline, 4-weeks and post-training. SBP, DBP and MAP fell significantly in both groups after training. Changes were -5.2 +/- 4.0, -2.6 +/- 2.9 and -2.5 +/- 2.2 mmHg [HI]; -3.7 +/- 3.7, -2.5 +/- 4.8 and -2.6 +/- 2.5 mmHg

• for SBP, DBP and MAP, respectively. There were no significant changes in BP at 4 weeks. No significant changes were observed in any of the other cardiovascular variables examined. These findings suggest that isometric training causes reductions in SBP, DBP and MAP at a range of exercise intensities, when it is performed over 8 weeks. Furthermore, it is possible to reduce resting BP using a much lower isometric exercise intensity than has previously been shown.

   

  Analysis of 12-lead electrocardiogram in top competitive professional athletes in the light of recent guidelines.

  Swiatowiec A, Król W, Kuch M, Braksator W, Krysztofiak H, Dluzniewski M, Mamcarz A. Kardiologia polska, 2009, 67(10):1095-102. Department of Cardiology, Hypertension and Internal Disease, Medical University, Warsaw, Poland.

  Background: One of the most important aims of modern sports cardiology is prevention of sudden cardiac death among athletes. Adequate pre-participation screening is a crucial part of prevention, however, current ACC, AHA or ESC guidelines are not uniform in this context. There is recently ongoing discussion on implementation of 12-lead ECG to the screening protocol. Aim: To assess the prevalence of alterations of resting 12-lead ECG in a population of top-level professional athletes - members of the Polish Olympic Team - using recently accepted criteria. Methods: During the period of intensive training before the Summer Olympic Games in Beijing (2008), a 12-lead, resting ECG was performed in 73 members (20 women and 53 men) of the Polish Olympic Team. Commonly accepted criteria were used to assess the ECG, and alterations were divided into two groups according to recent publications: group I - 'benign', common - thought to be consistent with the athlete's heart syndrome (i.e.: sinus bradycardia, 1st degree atrioventricular block, early repolarisation, right bundle branch hemiblock, isolated signs of left ventricular hypertrophy); and group II - 'suspected', uncommon - which may occur due to organic heart disease (i.e. complete bundle branch block, ventricular arrhythmia, inverse T wave or pathological QRS axis deviation). Results: Completely normal ECG was present in 11% of those examined, common (group I) findings were observed in 65% and 'suspected' (group II) in 23%. The most commonly occurring 'benign' findings were bradycardia incomplete, right bundle branch block and isolated left ventricular hypertrophy, found in 75, 71 and 41%, respectively. From 'suspected' (group II) the most frequent was left posterior fascicular hemiblock, present in 10% of those examined; other findings were complete right bundle branch block, left atrial hypertrophy, inverse T waves and left anterior fascicular hemiblock in single cases. Conclusions: 1. Most of the observed alterations in resting ECG of professional athletes belong to the 'common' group and result from adaptation to exercise. 2. Frequent occurrence of left posterior fascicular hemiblock, which is thought to be 'potentially malignant', requires further investigation.

  
  

  Athletes at risk for sudden cardiac death.

  Subasic K.: The Journal of School Nursing, 2010, 26(1):18-25. University of Scranton, Scranton, Pennsylvania, USA.

  High school athletes represent the largest group of individuals affected by sudden cardiac death, with an estimated incidence of once or twice per week. Structural cardiovascular abnormalities are the most frequent cause of sudden cardiac death. Athletes participating in basketball, football, track, soccer, baseball, and swimming were found to have the highest incidence of sudden cardiac death. Screening of athletes prior to participation in competitive sports usually falls short of recommended guidelines. Poorly defined legislation and the absence of a national standard for sports physicals have contributed to inadequate health screenings of athletes. This article will describe the incidence and causes of sudden cardiovascular death in young athletes as well as guidelines intended to prevent this unfortunate problem.

  
  

  The effects of endurance and recreational exercise on subclinical evidence of atherosclerosis in young adults.
  

  Popovic M, Puchner S, Endler G, Foraschik C, Minar E, Bucek RA.: The American Journal of the Medical Sciences, 2010, 339(4):332-6. Division of Cardiovascular and Interventional Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria.

  Background: This study set out to identify the effects of recreational and endurance exercise on subclinical evidence of atherosclerosis in young adults. Methods: Cardiovascular disease risk factors and intima-media thickness determination by B-mode ultrasonography of 150 subjects were correlated to endurance exercise, recreational exercise, and sedentary lifestyle. The subjects comprised 20- to 40-year-old men and women without cardiovascular disease. This cross-sectional, case-control study analyzed data on the laboratory parameters and information collected from a risk factor questionnaire. Results: The athletes, both endurance and recreational groups, have significantly superior values with respect to physiognomy, lipid profile, and inflammatory markers in relation to the nonexercising study population (all P 0.05). Conclusion: Exercise, in recreational and endurance form, between the ages of 20 and 40 years exerts a preventive influence on cardiovascular risk factors but seems to fail to affect early, atherosclerotic vascular wall changes.

   

  
  

  Adaptative or maladaptative hypertrophy, different spatial distribution of myocardial contraction.

  Cappelli F, Toncelli L, Cappelli B, De Luca A, Stefani L, Maffulli N, Galanti G.: Clinical Physiology and Functional Imaging, 2010, 30(1):6-12. Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.

  Summary background: Left ventricular hypertrophy (LVH) may be an adaptative remodelling process induced by physical training, or result from pathological stimuli. We hypothesized that different LVH aetiology could lead to dissimilar spatial distribution left ventricular (LV) contraction, and compared different components of LV contraction using 2-dimensional (2-D) speckle tracking derived strain in subjects with adaptative hypertrophy (endurance athletes), maladaptative hypertrophy (hypertensive patients) and healthy controls. Method: We enrolled 22 patients with essential hypertension, 50 endurance athletes and 24 healthy controls. All subjects underwent traditional echocardiography and 2-D strain evaluation of LV longitudinal, circumferential and radial function. LV basal and apical rotation and their net difference, defined as LV torsion, were evaluated. Results: LV wall thicknesses, LV mass and left atrium diameter were comparable between hypertensive group and athletes. LV longitudinal strain was reduced only in hypertensive patients (P < 0.05). LV apex circumferential strain was higher in hypertensive patients than in other groups (P < 0.001), LV basal circumferential strain, although slightly increased, did not reach significant difference. Hypertensive patients showed significantly increased rotation and torsion (P < 0.001), while no differences were observed between athletes and control. Conclusion: In patients with pathological LVH, LV longitudinal strain was reduced, while circumferential deformation and torsion were increased. No differences were observed in LV contractile function between subjects with adaptative LVH and controls. In pathological LVH, increasing torsion could be considered a compensatory mechanism to counterbalance contraction and relaxation abnormalities to maintain a normal LV output.

  Benefits and limitations of cardiovascular pre-competition screening in international football. Thünenkötter T, Schmied C, Dvorak J, Kindermann W.: Clinical Research in Cardiology, 2010, 99(1):29-35. Institute of Sports and Preventive Medicine, University of Saarland, Saarbrücken, Germany. Background: Competitive sport can serve as a trigger for sudden cardiac death (SCD). The majority of athletes who die suddenly have previously unsuspected structural heart disease. Medical evaluation before competition offers the potential to identify cardiovascular abnormalities in asymptomatic athletes. Consensus on the ideal screening programme has not been reached. So, a cardiovascular pre-competition screening of elite football players was developed and implemented prior to the 2006 FIFA World Cup Germany to detect SCD risk factors. Method: Medical history, physical examination, 12-lead resting- and exercise electrocardiogram (ECG) and echocardiography results of the players were recorded on a standardised form by the team physicians and submitted after the final match for retrospective evaluation by two blinded independent cardiologic reviewers. Results: Response rate was 82% (605 of 736 players). Completeness and quality of the recordings and examination methods differed amongst teams. In 25 players (4.8%), the examining physicians evaluated the resting ECG as pathological. Suspicious echocardiographic findings demanding further investigations to rule out serious cardiovascular disease existed in 1% of the players. Conclusion: Cardiovascular pre-competition screening proved feasible in international elite football teams, but turned out to be vital to ensure high quality of data, particularly with regard to stress testing and echocardiography. The screening concept was revised mainly to improve completeness and quality of data acquisition. Resting ECG and echocardiography were retained, but it is questionable if exercise testing should be included in this context.

  
  

  Intervention study shows outpatient cardiac rehabilitation to be economically at least as attractive as inpatient rehabilitation.

  Schweikert B, Hahmann H, Steinacker JM, Imhof A, Muche R, Koenig W, Liu Y, Leidl R.: Clinical Research in Cardiology, 2009, 98(12):787-95. Institute of Health Economics and Health Care Management, Helmholtz Zentrum München - German Research Center for Environmental Health, P.O.Box 1129, 85758, Neuherberg, Germany.

  Background: Since the late 1990 s, cost pressure has led to a growing interest in outpatient rehabilitation in Germany where predominantly inpatient rehabilitation has been provided. Taking into account the feasibility of a randomized design, the aim of this study was to compare outpatient and inpatient cardiac rehabilitation from a societal perspective. Method: A comprehensive cohort design was applied. Costs during rehabilitation were measured using individual documentation of the rehabilitation centers. Economic end points were quality of life (EQ-5D), and total direct and indirect costs. A propensity score approach, integrated into a simultaneous regression framework for cost and effects, was used to control for selection bias. Bootstrap analysis was applied for assessing uncertainty in cost-effectiveness. Results: A total of 163 patients were included in the study (112 inpatients, 51 outpatients). As randomization was chosen by only 2.5% of participants, the study had to be analyzed as an observational study. Direct costs during inpatient rehabilitation were significantly higher by 600 euro (+/-318; p < 0.001) compared to outpatient rehabilitation (2,016 euro +/- 354 euro vs. 1,416 euro +/- 315), while there was no significant difference in health-related quality of life. Over the 12-month follow-up period, adjusted costs difference in total cost was estimated at -2,895 euro (p = 0.102) and adjusted difference in effects at 0.018 quality-adjusted life years (QALYs) (n.s.) in favor of outpatient treatment. Conclusion: The ratio of mean cost over mean effect difference (incremental cost-effectiveness ratio) indicates dominance of outpatient rehabilitation, but at a considerable statistical uncertainty. However, outpatient rehabilitation cannot be rejected from an economic perspective.

   

  
  

  Modificado em 26 de Maio de 2010, 4ª feira

   

  Impaired left and right ventricular function following prolonged exercise in young athletes: influence of exercise intensity and responses to dobutamine stress.

  Banks L, Sasson Z, Busato M, Goodman JM.: Journal of Applied Physiology (Bethesda, Md. : 1985)

  2010 108(1):112-9. Faculty of Physical Education and Health, Univ. of Toronto, Toronto, Ontario, Canada.

  We examined the effect of intensity during prolonged exercise (PE) on left (LV) and right ventricular (RV) function. Subjects included 18 individuals (mean +/- SE: age = 28.1 +/- 1.1 yr, maximal aerobic power = 55.1 +/- 1.6 ml . kg(-1) . min(-1)), who performed 150 min of exercise at 60 and 80% maximal aerobic power on two separate occasions. Transthoracic echocardiography assessed systolic and diastolic performance, and blood sampling assessed hydration status and noradrenaline levels before (pre), during (15 and 150 min), and 60 min following (post) PE. beta-Adrenergic sensitivity pre- and post-PE was assessed by dobutamine stress. High-intensity PE (15 vs. 150 min) induced reductions in LV ejection fraction (69.3 +/- 1.3 vs. 63.5 +/- 1.3%, P = 0.000), LV strain (-23.5 +/- 0.6 vs. -22.3 +/- 0.6%, P = 0.034), and RV strain (-26.3 +/- 0.6 vs. -23.0 +/- 0.6%, P < 0.01). Both exercise intensities induced diastolic reductions (pre vs. post) in the ratio of septal early wave of annular tissue velocities to late/atrial wave of annular tissue velocities (2.15 +/- 0.15 vs. 1.62 +/- 0.09; 2.21 +/- 0.15 vs. 1.48 +/- 0.10), ratio of lateral early wave of annular tissue velocities to late/atrial wave of annular tissue velocities (3.84 +/- 0.42 vs. 2.49 +/- 0.20; 3.56 +/- 0.32 vs. 2.08 +/- 0.18), ratio of early to late LV strain rate (2.42, +/- 0.16 vs. 1.97 +/- 0.13; 2.30 +/- 0.15 vs. 1.81 +/- 0.11), and ratio of early to late RV strain rate (2.03 +/- 0.17 vs. 1.51 +/- 0.09; 2.16 +/- 0.16 vs. 1.44 +/- 0.11) (P < 0.001). Evidence of beta-adrenergic sensitivity was supported by a decreased strain, strain rate, ejection fraction, and systolic pressure-volume ratio response to dobutamine (P < 0.05) with elevated noradrenaline (P < 0.01). PE-induced reductions in LV and RV systolic function were related to exercise intensity and beta-adrenergic desensitization. The clinical significance of exercise-induced cardiac fatigue warrants further research.

   

  
  

  Modificado em 23 de Maio de 2010, Domingo

   

  Women's and men's exercise adherence after a cardiac event.

  Dolansky MA, Stepanczuk B, Charvat JM, Moore SM.: Research in Gerontological Nursing, 2010, 3(1):30-8. Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA.

  The purpose of this secondary analysis was to determine whether age affects women's and men's exercise adherence after a cardiac event. In a convenience sample of 248 adults ages 38 to 86 who had a cardiac event, exercise adherence (three exercise sessions per week) was compared between men and women in three age groups (younger than 60, 61 to 70, and older than 70). Exercise patterns were recorded by heart rate monitors worn during exercise. No differences were found in adherence between the age groups for women; older men were nonadherent sooner than younger men when controlling for fitness level, pain, comorbidity, self-efficacy, depressed mood, and social support. Exercise adherence after a cardiac event was higher for younger men compared with older men. For all age groups, less than 37% of the total sample adhered to a three-times-per-week exercise regimen after 1 year, suggesting that interventions to maintain exercise adherence are needed.

   

  Acute cardiac events and deployment of emergency medical teams and automated external defibrillators in large football stadiums in the Netherlands.

  van de Sandt F, Umans V.: European Journal of Cardiovascular Prevention and Rehabilitation, 2009, 16(5):571-5. Department of Cardiology, Medical Center Alkmaar, Wilhelminalaan 12, Alkmaar, The Netherlands.

  Background: The incidence of acute cardiac events - including out-of-hospital cardiac arrest - may be increased in visitors of large sports stadiums when compared with the general population. This study sought to investigate the incidence of acute cardiac events inside large Dutch football stadiums, as well as the emergency response systems deployed in these stadiums and the success rate for in-stadium resuscitation. Design and methods: Retrospective cohort study using a questionnaire sent to the 20 Dutch stadiums that hosted professional matches during the 2006-2007 and 2007-2008 football seasons. Results: Stadium capacity ranged from 3600 to 51 600 spectators. Nearly 13 million spectators attended 686 'Eredivisie' (Honorary Division) and European football matches. All stadiums distribute multiple emergency medical teams among the spectators. Eighty-five percent of the stadiums have an ambulance standby during matches, 95% of the stadiums were equipped with automated external defibrillators (AEDs) during the study period. On an average, one AED was available for every 7576 spectators (range 1800-29 600). Ninety-three cardiac events were reported (7.3 per 1 million spectators). An AED was used 22 times (1.7 per 1 million spectators). Resuscitation was successful in 18 cases (82%, 95% confidence interval: 61-93). Conclusion: The incidence of out-of-hospital cardiac arrest inside large football stadiums in the Netherlands, albeit increased when compared with the general population, is low. The success rate for in-stadium resuscitation by medical teams equipped with AEDs is high. Dutch stadiums appear vigilant in regard to acute cardiac events. This report highlights the importance of adequate emergency medical response systems (including AEDs) in large sports venues.

   

   

   

  The Lausanne recommendations: a Dutch experience

  B Bessem, F P Groot, W Nieuwland: Br J Sports Med 2009;43:708-715.

  Objective: This study presents the results of 28 months of preparticipation cardiovascular screening using the Lausanne recommendations, which include a personal and family history, physical examination and electrocardiogram (ECG). Design: From January 2006 to April 2008 the data of the Lausanne screenings carried out at the University Centre of Sports Medicine in Groningen were collected. Participants: 825 cardiovascular screenings were performed of which 397 were excluded. Exclusion criteria were age under 12 or over 35 years, multiple screenings (only the first was included) and known cardiovascular disease. Main outcome measures: Negative screening result, (false) positive screening result, medical consumption and number needed to screen. Results: A total of 371 (87%) athletes had a negative screening result. Fifty-five athletes (13%) underwent additional (stage 2) testing and seven (1.6%) further (stage 3) testing. Only 27 athletes (6.3%) were referred for additional testing based only on abnormalities of their ECG. Forty-seven athletes (11%) had a false-positive screening result. Ten athletes (2%) had a positive screening result and three (0.7%) were ultimately restricted from sports participation. Stage 2 medical consumption was 62%, 20% and 18% for one, two and three or more additional tests, respectively. Stage 3 medical consumption was 1.6%. The number of athletes needed to screen to find a single athlete with a potentially lethal cardiovascular disease was 143. Conclusion: This study found that when the Lausanne recommendations are implemented in The Netherlands, screening results resemble those found in previous studies. The number of athletes needed to screen to detect one athlete with a potentially lethal cardiovascular disease is also within an acceptable range.
  

  
  

  Sudden cardiac death in athletes: the Lausanne Recommendations

  Bille, Karin; Figueiras, David; Schamasch, Patrick; Kappenberger, Lukas; Brenner, Joel I.; Meijboom, Folkert J.; Meijboom, Erik J.: European Journal of Cardiovascular Prevention & Rehabilitation: December 2006 - Volume 13 - Issue 6 - pp 859-875.

  Objectives: This study reports on sudden cardiac death (SCD) in sport in the literature and aims at achieving a generally acceptable preparticipation screening protocol (PPSP) endorsed by the consensus meeting of the International Olympic Committee (IOC).Background: The sudden death of athletes under 35 years engaged in competitive sports is a well-known occurrence; the incidence is higher in athletes (∼2/100 000 per year) than in non-athletes (2.5 : 1), and the cause is cardiovascular in over 90%.Methods: A systematic review of the literature identified causes of SCD, sex, age, underlying cardiac disease and the type of sport and PPSP in use. Methods necessary to detect pre-existing cardiac abnormalities are discussed to formulate a PPSP for the Medical Commission of the IOC.Results: SCD occurred in 1101 (1966-2004) reported cases in athletes under 35 years, 50% had congenital anatomical heart disease and cardiomyopathies and 10% had early-onset atherosclerotic heart disease. Forty percent occurred in athletes under 18 years, 33% under 16 years; the female/male ratio was 1/9. SCD was reported in almost all sports; most frequently involved were soccer (30%), basketball (25%) and running (15%). The PPSP were of varying quality and content. The IOC consensus meeting accepted the proposed Lausanne Recommendations based on this research and expert opinions (http://multimedia.olympic.org/pdf/en_report_886.pdf).

  Conclusion: SCD occurs more frequently in young athletes, even those under the age of 18 years, than expected and is predominantly caused by pre-existing congenital cardiac abnormalities. Premature atherosclerotic disease forms another important cause in these young adults. A generally acceptable PPSP has been achieved by the IOC's acceptance of the Lausanne Recommendations.

  
  

  Preparticipation cardiovascular screening in young athletes (Editorial)

  N M Panhuyzen-Goedkoop: Br J Sports Med 2009;43:629-630.

  The sudden and unexpected death of an apparently healthy young athlete is relatively uncommon (0.5–2.1/100 000 athletes per year), but the catastrophic nature of these events mandates the medical community to adopt more widespread and extensive preparticipation cardiovascular screening (PPS). PPS in young athletes (<35 years old) is a systemic method to identify athletes at risk for life-threatening cardiovascular events.3 Excluding these athletes from competitive sports participation leads to a reduction in the incidence of exercise related sudden cardiac death (SCD).3 According to the Italian law all young competitive athletes (about 10% of the population) have been screened in a nationwide screening program in Italy for over 25 years. In the Veneto region in northern Italy, this resulted in a decrease of SCD among young athletes of 89% (from 3.6/100 000 per year in 1979 to 0.4/100 000 athletes per year in 2004).3 This reduction was predominantly attributed to identification of cardiomyopathy and electrical disease, and by excluding these athletes from competitive sports participation. The number of false positive test results was reported at 7%. The “Italian experience” is at the moment the only prospective population based study regarding PPS. This Italian protocol was adopted by the European Society of Cardiology (ESC) as the “common European protocol”, and by the International Olympic Committee (IOC), the international soccer association Fédération Internationale de Football Association (FIFA) and the international federation for cyclists Union Cycliste Internationale (UCI) as …
  

  
  

  The ageing athlete: screening prior to vigorous exertion in asymptomatic adults without known cardiovascular disease (revisão)

  J Freeman, V Froelicher, E Ashley: Br J Sports Med 2009;43:696-701.

  The exercise electrocardiogram (ECG) is widely considered the best available test for screening asymptomatic adults without known cardiovascular (CV) disease prior to initiating a vigorous exercise programme due to its prognostic value, widespread availability and low cost. Observational studies have demonstrated an increased relative risk of CV events with positive screening exercise ECG tests in men with diabetes, advanced age, or multiple cardiac risk factors. Recent observational studies have not demonstrated similar prognostic value for exercise ECG testing in asymptomatic healthy women. Despite the predictive ability of exercise ECG testing in several groups, there have been no studies demonstrating a significant impact of screening on morbidity and mortality in completely asymptomatic patients, leading to significant discordance in consensus guidelines on screening. One prospective observational study is ongoing in Italy that may for the first time demonstrate the ability to decrease incident CV events using preparticipation screening exercise ECG testing in adult athletes with targeted exclusion from athletics. Until more conclusive data is available the authors currently recommend screening exercise ECG testing in asymptomatic men with diabetes and asymptomatic men over age 45 with two or more CV risk factors prior to initiating a vigorous exercise programme. Consideration should also be given to screening asymptomatic patients younger than 45 with particularly strong risk factor exposure or elderly patients with fewer than two risk factors.
  

  
  

  Incidence and aetiology of sudden cardiac death in young athletes: an international perspective (revisão)

  M Borjesson, A Pelliccia: Br J Sports Med 2009;43:644-648 doi:10.1136/bjsm.2008.054718

  The incidence of sudden cardiac death (SCD) among young athletes is estimated to be 1–3 per 100 000 person years, and may be underestimated. The risk of SCD in athletes is higher than in non-athletes because of several factors associated with sports activity that increase the risk in people with an underlying cardiovascular abnormality. A clear gender difference in the incidence of SCD exists in young athletes, with the risk in male athletes being up to 9 times higher than in female athletes. The most common causes of SCD in young athletes is underlying inherited/congenital cardiac disease, such as cardiomyopathies, congenital coronary anomalies and ion channelopathies. Blunt chest trauma also may cause ventricular fibrillation in a structurally normal heart, known as commotio cordis. Although geographical differences in the causes of SCD in young athletes have been reported, these disparities are more likely to be related to the type and implementation of pre-participation screening leading to the identification of athletes at risk, rather than reflecting a truly different ethiology. More studies are needed to clarify the role of ethnicity in the prevalence of diseases known to cause SCD in young athletes.

  
  

  Risk factors for exercise-related acute cardiac events. A case–control study

  W M van Teeffelen, M F de Beus, A Mosterd, M L Bots, W L Mosterd, J Pool, P A Doevendans, D E Grobbee: Br J Sports Med 2009;43:722-725.

  Background: In spite of the benefits of physical activity, exercise may provoke acute cardiac events in susceptible individuals. Understanding risk factors of exercise-related acute cardiac events may identify opportunities for prevention. Methods: A case–control study was conducted to examine determinants of acute cardiac events in athletes. The cases were athletes who suffered an acute cardiac event during or shortly after vigorous exercise. Athletes who visited a hospital because of a minor sports injury were selected as controls. Information on cardiovascular disease, family history of cardiovascular disease, cardiovascular symptoms and other potential risk factors was collected through questionnaires. Results: 57 cases (mean age 41.8 years, range 11–73) and 57 controls (mean age 40.9 years, range 13–68) were included in the study. Athletes with a history of cardiovascular disease were at a markedly increased risk for cardiac events during exercise (OR = 32; 95% CI 7.4 to 143). Smoking (OR 5.9; 95% CI 1.9 to 18), fatigue (OR = 12; 95% CI 1.2 to 118) and flu-like symptoms (OR 13; 95% CI 1.4 to 131) in the month preceding the event were related to acute cardiac events in athletes. Conclusions: Prior cardiovascular disease, smoking, and a recent episode of fatigue or flu-like symptoms are associated with an increased risk of exercise-related acute cardiac events. Athletes and physicians should pay careful attention when these factors exist or occur.
  

  
  

  Cardiac findings in the precompetition medical assessment of football players participating in the 2009 African Under-17 Championships in Algeria

  C Schmied, Y Zerguini, A Junge, P Tscholl, A Pelliccia, B M Mayosi, J Dvorak: Br J Sports Med 2009;43:716-721.

  Objectives: To screen all players registered for the 8th CAF African Under-17 Championship for risk factors of sudden cardiac death. Design: Standardised cardiac evaluation prior to the start of the competition. Study population: 155 male football players from all eight qualified teams; mean age 16.4 (SD 0.68) years (range 14 to 17). Methods: The cardiac evaluation consisted of a medical history, clinical examination, 12-lead resting electrocardiogram (ECG) and echocardiography, and was performed by three experienced cardiologists using established guidelines. Results: Nine (5.8%) players reported cardiac symptoms, and the clinical examination was abnormal in only two players with elevated blood pressure. A total of 40 players (25.8%) showed abnormal ECG patterns. None of the players with a positive ECG showed correlating echocardiographic findings. The echocardiogram of one player appeared highly suspicious for early-stage hypertrophic cardiomyopathy, and in another player the myocardium was suspicious for non-compaction cardiomyopathy, but both had normal ECGs. Thirteen (8.4%) players showed echocardiographic findings that needed further follow-up. The percentage of players with pathological ECG patterns and some abnormal echocardiographic measurements varied substantially between different ethnic groups. Conclusion: Cardiological screening for risk factors of sudden cardiac death of football players prior to an international competition proved feasible, and conduction by independent experts allowed high-quality standards and a consistent protocol for the examinations. Differences observed between ethnic groups indicate that guidelines for the analysis of ECGs and echocardiography might be adjusted to the target population.
  

  
  

  Preparing for sudden cardiac arrest—the essential role of automated external defibrillators in athletic medicine: a critical review

  J A Drezner: Br J Sports Med 2009;43:702-707.

  Sudden cardiac arrest (SCA) is the leading cause of death in exercising young athletes. Three factors—prompt recognition of SCA, the presence of a trained rescuer to initiate cardiopulmonary resuscitation (CPR) and access to early defibrillation through on-site automated external defibrillators (AEDs)—are critical to improving survival. Schools, clubs and organisations sponsoring athletic events should have an established emergency response plan for SCA. Essential elements of an emergency response plan include an effective communication system to alert first responders and retrieve the AED, training of anticipated responders in CPR and AED use, access to an AED for early defibrillation, integration of on-site AED programmes with the local emergency medical services system, and practice and review of the response plan. Timely access to AEDs at training and sporting competitions permits effective management of SCA and the prevention of sudden cardiac death in athletes. SCA should be suspected in any collapsed and unresponsive athlete and an AED applied as soon as possible for rhythm analysis and defibrillation if indicated. This article reviews emergency response planning for SCA and highlights recent data that provide a compelling case for the essential role of AEDs in the athletic setting.

  
  

  Distinguishing hypertrophic cardiomyopathy from athlete’s heart physiological remodelling: clinical significance, diagnostic strategies and implications for preparticipation screening (Revisão)

  B J Maron: Br J Sports Med 2009;43:649-656.

  Sudden cardiac death in young competitive athletes is an important public health problem, although a relatively low-event-rate phenomenon. The single most common cardiovascular cause of these unexpected catastrophes is hypertrophic cardiomyopathy (HCM), accounting for about one-third of cases. Since the phenotypic expression of HCM is variable, and not uncommonly includes patients with mild and localised left ventricular hypertrophy, the differential diagnosis with physiological remodelling of athlete’s heart not uncommonly arises. This review discusses those non-invasive strategies that are useful in distinguishing the benign consequences of systematic athletic training from pathological left ventricular hypertrophy with the potential for sudden cardiac death. Preparticipation screening in healthy general athlete populations may raise the suspicion of HCM, and ultimately lead to definitive diagnosis. However, recently controversy has arisen regarding the most effective and practical strategy for the screening of athletes. European investigators have promoted routine 12-lead ECGs as part of a national mandatory programme distinct from the customary practice in the US which is limited to history and physical examinations. Consensus criteria and recommendations for eligibility and disqualification of athletes with HCM (and other cardiovascular abnormalities) have proved useful to the practising community.

  
  

  QTc: how long is too long? (revisão)

  J N Johnson, M J Ackerman: Br J Sports Med 2009;43:657-662.

  Congenital long QT syndrome (LQTS) affects an estimated 1 in 2500 people and typically presents with syncope, seizures or sudden death. Whereas someone exhibiting marked prolongation of the QT interval with QTc exceeding 500 ms who was just externally defibrillated from torsades de pointes while swimming poses negligible diagnostic challenge as to the unequivocal probability of LQTS, the certainty is considerably less for the otherwise asymptomatic person who happens to host a QTc value coined “borderline” (QTc ≥440 ms). Although a normal QT interval imparts a much lower risk of life-threatening events, it does not preclude a patient from nevertheless harbouring a potentially lethal LQTS-causing genetic mutation. Indeed, genetic testing exerts significant diagnostic, prognostic and therapeutic implications. However, the 12-lead ECG remains the universal initial diagnostic test in the evaluation of LQTS and is subject to miscalculation, misinterpretation and mishandling. This review discusses the components of accurate QTc measurement and diagnosis, re-examines what is known about factors affecting QT interval measurement, and clarifies current recommendations regarding diagnosis of so-called “borderline” QT interval prolongation. The current guideline recommendations for the athlete with LQTS are also summarised.

  
  

  12-lead ECG in the athlete: physiological versus pathological abnormalities (revisão)

  D Corrado, A Biffi, C Basso, A Pelliccia, G Thiene: Br J Sports Med 2009;43:669-676.

  Participation in sports activity and regular physical training is associated with physiological structural and electrical changes in the heart (athlete’s heart) that enable sustained increases in cardiac output for prolonged periods. Cardiovascular remodelling in the conditioned athlete is often associated with ECG changes. In rare cases, abnormalities of an athlete’s ECG may reflect an underlying heart disease which puts the athlete at risk of arrhythmic cardiac arrest during sport. It is mandatory that ECG abnormalities resulting from intensive physical training and those of a potential cardiac pathology are properly defined. This article provides a modern approach to interpreting 12-lead ECGs of athletes based on recently published new findings. The main objective is to distinguish between physiological adaptive ECG changes and pathological ECG abnormalities. The most important aims are to prevent physiological changes in the athlete being erroneously attributed to heart disease, or signs of life-threatening cardiovascular conditions being dismissed as a normal variant of athlete’s heart. As pathological ECG abnormalities not only cause alarm but also require action with additional testing to exclude (or confirm) the suspicion of a lethal cardiovascular disorder, appropriate interpretation of an athlete’s ECG will prevent unnecessary distress and also result in considerable cost saving in the context of a population-based preparticipation screening programme.

  
  

  Modificado Domingo, 04 de Abril de 2010 - 18h53

  
  

  Influence of age on syncope following prolonged exercise: differential responses but similar orthostatic intolerance.

  Murrell C, Cotter JD, George K, Shave R, Wilson L, Thomas K, Williams MJ, Lowe T, Ainslie PN

   

   

  The Journal of physiology, 587(Pt 24):5959-69, 2009. Department of Human Kinetics, University of British Columbia-Okanagan, Kelowna, Canada.

  Orthostatic tolerance is reduced with increasing age and following prolonged exercise. The aim of this study was to determine the effect of age on cardiovascular and cerebrovascular responses to orthostatic stress following prolonged exercise. Measurements were obtained before, and within 45 min after, 4 h of continuous running at 70-80% of maximal heart rate in nine young (Y; 27 +/- 4 years; V(O(2)max)) 59 +/- 10 ml kg(1) min(1)) and twelve older (O; 65 +/- 5 years; V(O(2)max)) 46 +/- 8 ml kg(1) min(1)) athletes. Middle cerebral artery blood flow velocity (MCAv; transcranial Doppler ultrasound), blood pressure (BP; Finometer) and stroke volume (SV) were measured continuously whilst supine and during 60 deg head-up tilt for 15 min or to pre-syncope. Orthostatic tolerance was reduced post-exercise (tilt completed (min:s, mean +/- s.d.): Pre, 14:39 +/- 0:55; Post, 5:59 +/- 4:53; P 0.05). Despite a 25% higher supine MCAv in the young, MCAv at syncope was the same in both groups (Y: 34 +/- 10 cm s(1); O: 32 +/- 13; P > 0.05). Although the hypotensive response to syncope did not differ with age, the components of BP did; SV was lowered more in the young (Y: -57 +/- 16%; O: -34 +/- 13%; P < 0.05); and total peripheral resistance was lowered in the older athletes but was unchanged in the young (Y: +8 +/- 10%; O: -21 +/- 12%; (at 10 s pre-syncope) P < 0.05). Despite a lower MCAv in the older athletes, time to syncope was similar between groups; however, the integrative mechanisms responsible for syncope did differ with age. The similar MCAv at pre-syncope indicates there is an age-independent critical cerebral blood flow threshold at which syncope occurs.

   

   

  
  

  Effects of treadmill running and resistance exercises on lowering blood pressure during the daily work of hypertensive subjects.

  Mota MR, Pardono E, Lima LC, Arsa G, Bottaro M, Campbell CS, Simões HG.:

  Journal of Strength and Conditioning research / National Strength & Conditioning Association, 23(8):2331-8, 2009. Laboratory of Physical Activity Assessment and Training, Catholic University of Brasilia, Brasilia, Brazil.

   

  The purposes of this study were to compare the hypotensive effects of treadmill running (TR) and resistance exercise (RE) performed by hypertensive subjects and to verify if the hypotensive effects of these exercises are maintained during a regular white-collar workday. Fifteen white-collar workers (42.9 +/- 1.6 years), treated with antihypertensive medication, accomplished three different sessions: 20 minutes of TR (approximately 70-80% of heart rate reserve), 20 minutes of circuit training RE (20 repetitions at 40% of 1 repetition maximum), and a control session without exercise (CON). The systolic blood pressure (BP), diastolic BP, heart rate, and blood lactate were measured at resting (Rest) and after sessions at 15th (R15), 30th (R30), 45th (R45), and 60th (R60) min, as well as after lunch (AL), four (R4h) and seven (R7h) hours of recovery at the participants' workplace. In relation to rest, a higher decrease of systolic BP after TR (-11.1 +/- 7.6 mm Hg) and RE (-12.6 +/- 7.3 mm Hg) was observed respectively at the R30 and R45. For diastolic BP, the highest decreases after TR (-4.0 +/- 6.4 mm Hg) and RE (-9.0 +/- 7.0 mm Hg) were observed respectively at the R45 and R30. The systolic BP and mean BP after TR and RE differed significantly from CON session (p < 0.05), and lower post-exercise values could be observed over the workday. In conclusion, both 20 minutes of TR and RE resulted in postexercise hypotension, and were able to reduce BP throughout 7 hours after exercise, even throughout the subject's regular occupational activities. Also, the RE promoted higher cardiac protection and can be a useful model of physical exercise prescription for hypertension individuals.

   

   

  Endurance exercise training in older patients with heart failure: results from a randomized, controlled, single-blind trial.

  Brubaker PH, Moore JB, Stewart KP, Wesley DJ, Kitzman DW.:

  Journal of the American Geriatrics Society. 57(11):1982-9, 2009. Department of Health and Exercise Science, Wake Forest University, Wake Forest University, Winston-Salem, NC 27109, USA.

  Objectives: To test the hypothesis that exercise training (ET) improves exercise capacity and other clinical outcomes in older persons with heart failure with reduced ejection fraction (HfrEF). DESIGN: Randomized, controlled, single-blind trial. Setting: Outpatient cardiac rehabilitation program. Participants: Fifty-nine patients aged 60 and older with HFrEF recruited from hospital records and referring physicians were randomly assigned to a 16-week supervised ET program (n=30) or an attention-control, nonexercise, usual care control group (n=29). Intervection: Sixteen-week supervised ET program of endurance exercise (walking and stationary cycling) three times per week for 30 to 40 minutes at moderate intensity regulated according to heart rate and perceived exertion. Measurements: Individuals blinded to group assignment assessed four domains pivotal to HFrEF pathophysiology: exercise performance, left ventricular (LV) function, neuroendocrine activation, and health-related quality of life (QOL). Results: At follow-up, the ET group had significantly greater exercise time and workload than the control group, but there were no significant differences between the groups for the primary outcomes: peak exercise oxygen consumption (VO(2) peak), ventilatory anaerobic threshold (VAT), 6-minute walk distance, QOL, LV volumes, EF, or diastolic filling. Other than serum aldosterone, there were no significant differences after ET in other neuroendocrine measurements. Despite a lack of a group "training" effect, a subset (26%) of individuals increased VO(2) peak by 10% or more and improved other clinical variables as well. Conclusion: In older patients with HFrEF, ET failed to produce consistent benefits in any of the four pivotal domains of HF that were examined, although the heterogeneous response of older patients with HFrEF to ET requires further investigation to better determine which patients with HFrEF will respond favorably to ET.

  
  

   

   

  Resistance exercise training improves heart function and physical fitness in stable patients with heart failure.

  Palevo G, Keteyian SJ, Kang M, Caputo JL. Journal of cardiopulmonary rehabilitation and prevention, 29(5):294-8, 2009. RehabCare Group, St Louis, Missouri 63105, USA.

  Purpose: This study determined the effect of a structured isotonic strength training (ST) program on left ventricular (LV) function (ejection fraction, stroke volume, and end-diastolic and end-systolic volumes) and physical fitness (6-minute walk test, upper body strength, lower body strength, and body composition) in patients with New York Heart Association class II and III heart failure. Methods: Sixteen patients were randomized into 2 groups, ST and usual care. The ST group (10 patients) performed 24 ST exercise sessions (3 per week, 8 weeks), while the usual care (6 patients) group followed routine medical care. The structured isotonic ST program involved 12 different exercises on circuit weight machines. LV function (3D echocardiography) and physical fitness were assessed at baseline and 8 weeks. Results: Modest improvements (P < .05) in resting ejection fraction (0.32-0.37) and stroke volume (46 to 53 mL/beat), as well as in muscular strength and 6-minute walk distance, were found after training. Conclusions: A short-term structured isotonic ST program appears to improve selected measures of resting LV function and fitness in patients with mild congestive heart failure. Additional studies utilizing larger numbers of subjects, including women, are needed.

  
  

  Improvement in left ventricular diastolic stiffness induced by physical training in patients with dilated cardiomyopathy.

  Malfatto G, Branzi G, Osculati G, Valli P, Cuoccio P, Ciambellotti F, Parati G, Facchini M. Journal of Cardiac Failure, 15(4):327-33, 2009.

  Divisione di Cardiologia, Ospedale San Luca, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milano, Italy.

  Background: Diastolic dysfunction in long-term heart failure is accompanied by abnormal neurohormonal control and ventricular stiffness. The diastolic phase is determined by a balance between pressure gradients and intrinsic ventricular wall properties: according to a mathematical model, the latter (ie, left ventricular [LV] elastance, K(LV)) may be calculated by the formula: K(LV) = (70/[DT-20])(2) mm Hg/mL, where DT is the transmitral Doppler deceleration time. Methods and results: In 54 patients with chronic systolic heart failure (39 men, 15 women; age 65 +/- 10 years; New York Heart Association [NYHA], 2.3 +/- 0.9; ejection fraction [EF], 32% +/- 5%), we analyzed the relationship between K(LV) and an index of neurohormonal derangement (levels of brain natriuretic peptide [BNP]), and investigated whether 3 months of physical training could modulate diastolic operating stiffness. Patients were randomized to physical training (n = 27) or to a control group (n = 27). Before and after training, patients underwent Doppler echocardiogram and cardiopulmonary stress test. At baseline, ventricular stiffness was related to BNP levels (P < .01). Training improved NYHA class, exercise performance, and estimated pulmonary pressure. BNP was reduced. Ventricular volumes, mean blood pressure, and EF remained unchanged. A 27% reduction of elastance was observed (K(LV), 0.111 +/- 0.044 from 0.195 +/- 0.089 mm Hg/mL; P < .01), whose magnitude was related to changes in BNP (P < .05) and to K(LV) at baseline (P < .01). No changes in K(LV) were observed in controls after 3 months (0.192 +/- 0.115 from 0.195 +/- 0.121 mm Hg/mL). Conclusions: In heart failure, left ventricular diastolic stiffness is related to neurohormonal derangement and is modified by physical training. This improvement in LV compliance could result from a combination of hemodynamic improvement and regression of the fibrotic process.

   

   

  Exercise protects the cardiovascular system: effects beyond traditional risk factors.

  Joyner MJ, Green DJ. The Journal of physiology, 587(Pt 23):5551-8, 2009.

  Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.

  In humans, exercise training and moderate to high levels of physical activity are protective against cardiovascular disease. In fact they are 40% more protective than predicted based on the changes in traditional risk factors (blood lipids, hypertension, diabetes etc.) that they cause. In this review, we highlight the positive effects of exercise on endothelial function and the autonomic nervous system. We also ask if these effects alone, or in combination, might explain the protective effects of exercise against cardiovascular disease that appear to be independent of traditional risk factor modification. Our goal is to use selected data from our own work and that of others to stimulate debate on the nature and cause of the 'risk factor gap' associated with exercise and physical activity.

  
  

  Acute cardiac and neurologic decompensation in a high school athlete.

  Vatthyam RK, Bates JR, Waller BF. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography, 2

  St Vincent Hospitals and Health Services, Indianapolis, Indiana, USA.

  A 19-year-old African American man presented to a local emergency room with atrial flutter, dysarthria, and left-sided hemiparesis. He was previously healthy and a successful high school athlete. The patient decompensated and went into cardiac arrest. Two-dimensional echocardiography revealed biventricular dilation, severe systolic dysfunction, and a spongy myocardial appearance. Postmortem examination was diagnostic of biventricular noncompaction. Such a fulminant presentation of isolated ventricular noncompaction in a previously healthy and physically fit individual has not yet been described.

   

   

  Analysis of 6-minute walk test safety in pre-heart transplantation patients.

  Cipriano G, Yuri D, Bernardelli GF, Mair V, Buffolo E, Branco JN.Arquivos Brasileiros de Cardiologia, 92(4):312-9, 2009

  Universidade de São Paulo, Universidade Federal de São Paulo, São Paulo, SP, Brazil.

  Background: The 6-minute walk test (6WT) has been used as a means of assessment of the functional capacity, clinical staging and cardiovascular prognosis. Its safety and metabolic impact have not been frequently described in the literature, especially in patients with severe heart failure with clinical indication for cardiovascular transplantation. OBJECTIVE: To evaluate the occurrence of arrhythmias and cardiovascular changes during 6WT. To correlate 6WT performance with clinical staging and cardiovascular prognosis. Methods: Twelve patients, 10 of whom males, aged 52 +/- 8 years were evaluated at baseline. 6WT was performed with telemetry electrocardiography, vital signs and lactate monitoring. The patients were followed-up for 12 months. Results: The patients walked 399.4+/-122.5 (D, m), reaching a perceived exertion (PE) of 14.3+/-1.5 and a 34% baseline heart rate variation. Two patients presented more severe pre-6WT arrhythmia which did not worsen with the exercise, four patients presented a significant increase of blood lactate levels (>5 mmol/dl), and three interrupted the test. The distance walked correlated with the ejection fraction (%) and functional class (NYHA). After 12-month follow-up, three patients died and seven were rehospitalized for cardiac decompensation. The D/PE ratio and 2-minute heart rate recovery (HRR2, bpm) were lower in the death group. Conclusion: The clinical and electrocardiographic behaviors suggest that the method is safe, but it may be considered too strenuous for some patients with severe heart failure. Variables related to 6WT performance may be associated with the one-year follow-up mortality.

   

  Traumatic mitral valve injury after blunt chest trauma: a case report and review of the literature.
  

  Pasquier M, Sierro C, Yersin B, Delay D, Carron PN.: The Journal of Trauma, 68(1):243-6, 2010. Emergency Services, University Hospital Center, Lausanne, Switzerland.
  

  Mitral valve injury after blunt chest trauma is a rare occurrence. We recently admitted a patient with severe traumatic mitral regurgitation who was successfully treated with surgery. Review of the literature aimed at taking an inventory of cases of traumatic nonpenetrating mitral insufficiency that were operated on, since the earliest report in 1964. Eighty-two cases were found and analyzed allowing for a better understanding of the epidemiology, etiology, natural history, pathology, and treatment of this rare condition. The most common lesions reach the papillary muscles (PM), followed by the chordae and then the mitral valve leaflets. Among the 82 cases reported that have been treated with surgery, 57% required a valve replacement. More than half of the patients had a PM injury with a complete or partial rupture. When the rupture is complete, and especially when it involves the anterior PM, the clinical picture is most always acute with clinically important hemodynamic repercussions, often necessitating emergency surgery, most of the time with mitral valve replacement. One must always suspect traumatic mitral injury after blunt chest trauma. The most common mitral lesions affect the PM. The clinical course can be indolent or devastating, and most often requires urgent or delayed surgical treatment, either with mitral valve repair or replacement.

   

  Sudden death of a young woman shortly after fleeing from violence.

  Takahashi S, Funayama M.: Legal medicine (Tokyo, Japan), 11 Suppl 1:S526-7, 2009.

  Division of Forensic Medicine, Department of Public Health and Forensic Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan.

  A woman in her late-teens ran downstairs and out into the street to escape from violence by her boyfriend. She ran approximately 150 m and was suddenly collapsed immediately after stopping to call for help. She underwent cardiopulmonary resuscitation, which was unsuccessful. Autopsy revealed some minor injuries on the face, trunk and extremities. Meanwhile, the left coronary artery was originated from the right sinus of Valsalva, and the orifice had a slit-like appearance. Additionally, the main trunk of the left coronary artery coursed between the aortic sinus and the pulmonary trunk. Microscopically, the heart (240 g) showed small foci of contraction band necrosis and wavy changes. This type of coronary artery anomaly makes up only 0.0375% among all varieties of the anomaly according to a report of the US. However, it has a greater risk of sudden cardiac death during physical exercise. Taking the eyewitness testimony into account, we determined that the 150 m run at full speed, rather than the assault itself, had caused acute coronary insufficiency, leading the death of the decedent.

  
  

  Objectively measured daily physical activity related to cardiac size in young children.

  Dencker M, Thorsson O, Karlsson MK, Lindén C, Wollmer P, Andersen LB. Scandinavian Journal of Medicine & Science in Sports. 19(5):664-8, 2009.

  Clinical Physiology and Nuclear Medicine Unit, Department of Clinical Sciences, Lund University, Malmö University Hospital, Malmö, Sweden.

  Training studies in children have suggested that endurance training can give enlargement of cardiac dimensions. This relationship has not been studied on a population-based level in young children with objective methods. A cross-sectional study was made of 248 children (140 boys and 108 girls), aged 8-11 years, from a population-based cohort. Left ventricular end-diastolic diameter (LVDD) and left atrial end-systolic diameter (LA) were measured with echocardiography and indexed for body surface area (BSA). Physical activity was assessed by accelerometry, and the duration of vigorous physical activity per day (VPA) was calculated. Acceptable accelerometer and echocardiography measurements were obtained in 228 children (boys=127, girls=101). Univariate correlations between VPA and LVDD were indexed for BSA in boys (r=0.27, P<0.05) and in girls (r=0.10, NS). Multiple regression analysis showed that independent factors for LVDD, indexed for BSA for boys, were age and VPA. LA indexed for BSA was not related to physical activity variables in either gender. No clear relationship exists between cardiac size and daily physical activity in children aged 8-11 years. This suggests that significant cardiac remodelling due to volume exposure secondary to a high amount of physical activity begins later in life.

   

  Cardiac rehabilitation in Austria: long term health-related quality of life outcomes. Hofer, S., Kulich, W., et al: Medical University Innsbruck, Department of Medical Psychology, Innsbruck, Austria.Health and quality of life outcomes, 7:99, 2009. BACKGROUND: The goal of cardiac rehabilitation programs is not only to prolong life but also to improve physical functioning, symptoms, well-being, and health-related quality of life (HRQL). The aim of this study was to document the long-term effect of a 1-month inpatient cardiac rehabilitation intervention on HRQL in Austria. METHODS: Patients (N = 487, 64.7% male, age 60.9 +/- 12.5 SD years) after myocardial infarction, with or without percutaneous interventions, coronary artery bypass grafting or valve surgery underwent inpatient cardiac rehabilitation and were included in this long-term observational study (two years follow-up). HRQL was measured with both the MacNew Heart Disease Quality of Life Instrument [MacNew] and EuroQoL-5D [EQ-5D]. RESULTS: All MacNew scale scores improved significantly (p < 0.001) and exceeded the minimal important difference (0.5 MacNew points) by the end of rehabilitation. Although all MacNew scale scores deteriorated significantly over the two year follow-up period (p < .001), all MacNew scale scores still remained significantly higher than the pre-rehabilitation values. The mean improvement after two years in the MacNew social scale exceeded the minimal important difference while MacNew scale scores greater than the minimal important difference were reported by 40-49% of the patients.Two years after rehabilitation the mean improvement in the EQ-5D Visual Analogue Scale score was not significant with no significant change in the proportion of patients reporting problems at this time. CONCLUSION: These findings provide a first indication that two years following inpatient cardiac rehabilitation in Austria, the long-term improvements in HRQL are statistically significant and clinically relevant for almost 50% of the patients. Future controlled randomized trials comparing different cardiac rehabilitation programs are needed.

  A longitudinal study of quality of life in patients with chronic heart failure following an exercise training program. Miche, E., Roelleke, E., et al: MediClin Reha-Zentrum Gernsbach, 76593 Gernsbach, Germany.European journal of cardiovascular nursing : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology, 8(4):281-7, 2009.

  BACKGROUND: Chronic heart failure (CHF) will become one of the greatest medical challenges during the next decades. This is especially true with regard to elderly patients. Besides medical diagnostics and drug therapy, efficient treatment of CHF must also include exercise training. AIMS: The purpose of our study was 1) to record health-related quality of life (QOL) in elderly patients with CHF and 2) to assess the efficacy of a training program, as well as to evaluate any changes detected during a six month follow-up. METHODS: In our non-randomized study, 116 patients, divided according to age into Group 1 (>70 years) and Group 2 (<70 years), took part in a 4-week training program. RESULTS: There were differences in the clinical parameters and the QOL between the older and the younger patients both after 4 weeks and at the follow-up. After six months, however, the older patients again recorded having an inferior QOL to that of the younger patients. CONCLUSION: Elderly patients can also benefit from physical exercise training, with improvement in clinical parameters and QOL. In order to maintain the subjectively improved QOL in the long term, however, continued special heart failure education and support is required.

  Resistance training reduces the blood pressure response of older men during submaximum aerobic exercise. Lovel, D. I., Cuneo, R., Gass, G. C.: School of Health and Sport Sciences, Faculty of Science, Health and Education, University of the Sunshine Coast, Queensland, Australia.Blood pressure monitoring, 14(4):137-44, 2009.
  

  OBJECTIVE: The objective of this study was to determine whether 16 weeks of resistance training (RT) can reduce the blood pressure response and improve the cardiovascular function of men aged 70-80 years during submaximum aerobic exercise. METHODS: Twenty-four men aged between 70 and 80 years were randomly assigned to an RT group (n = 12) and control group (n = 12). Training consisted of three sets of six to 10 repetitions at 70-90% of one repetition maximum, three times per week, on an incline squat machine for 16 weeks. Blood pressure and cardiovascular function were assessed during submaximum cycle exercise at 40 W, and 50 and 70% of maximum oxygen consumption (VO2max) before training and after 16 weeks of training. Leg strength and VO2max were assessed every 4 weeks of the 16-week study. RESULTS: At 40 W, heart rate, systolic blood pressure, and rate pressure product were lower and stroke volume was significantly higher after 16 weeks of training. At 50% VO2max, heart rate and rate pressure product were lower after 16 weeks of training and at 70% VO2max, cycle ergometry power, VO2, and arterio-venous oxygen difference were higher after 16 weeks of training. Leg strength significantly increased after 16 weeks of training. CONCLUSION: Sixteen weeks of RT significantly reduces the blood pressure response and improves the cardiovascular function of older men during submaximum aerobic exercise. Therefore, RT not only increases muscular strength and hypertrophy but also provides significant cardiovascular benefits for older individuals.

  The Marfan syndrome: implications for athletes and their echocardiographic assessment.

  Stout, M.: Exercise Science and B.Sc Sports Science, Sheffield Hallam University, Centre for Sport and Exercise Science, Collegiate Crescent, Sheffield, UK. Echocardiography (MNount Kisco, N.Y.), 26(9):1075-1081, 2009. Sudden death of competitive athletes is rare. These deaths challenge the perception that trained athletes represent the healthiest segment of modern society. The increasing frequency of such reported deaths worldwide and the visibility of the issue is underlined by the high-profile nature of each case. The majority of these deaths have been due to a variety of undiagnosed cardiovascular diseases. Marfan syndrome is a heritable disorder of the connective tissue that can hold life threatening consequences, especially for the athletic population. This paper will aim to review cardiovascular pathophysiology and assessment in relation to Marfan syndrome with particular reference to echocardiography and the athletic population.

  Exercise performance in patients with pulmonary hypertension linked to cardiac magnetic resonance measures.

  
  
  Stevens, G. R., Lala, A., et al.Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, New York, USA. The Journal of heart and lung transplantation (the official publication of the International Society for Heart Transplantation): 28(9), 2009.

  BACKGROUND: The 6-minute walk distance (6MWD) is a useful measure of functional class and has been shown to predict mortality in patients with pulmonary hypertension (PH). Determinants of functional class in PH are incompletely understood. We hypothesized that cardiovascular structure and function, as determined by cardiac magnetic resonance (CMR) imaging, and cardiac hemodynamics, as determined by right heart catheterization (RHC), would predict 6MWD in adult patients with PH. METHODS: Forty-three patients (32 women) with PH underwent RHC, CMR and 6MWD testing within a 3-month period. The 6MWD was correlated with RHC and CMR variables using Spearman rho (r) coefficients. These relationships were further evaluated using linear regression analysis. RESULTS: Median 6MWD was 233.2 (interquartile range 161.6 to 338.4) meters. The 6MWD was correlated with pulmonary artery (PA) elasticity (r = 0.42, p = 0.006), PA average blood flow velocity (r = 0.38, p = 0.014), right ventricular stroke volume index (RVSVI; r = 0.41, p = 0.008), left ventricular SVI (LVSVI; r = 0.36, p = 0.018) and RV stroke work index (RVSWI; r = 0.37, p = 0.017). These associations remained significant after adjustment for age, gender, body mass index and the presence of lung disease. Exercise performance did not correlate with commonly measured indices such as ventricular volume, ejection fraction or pulmonary pressure. CONCLUSIONS: Stroke volume index, PA elasticity and PA average blood flow velocity are novel CMR parameters associated with functional class in PH. CMR can provide insights into determinants of exercise performance and may be a useful tool to non-invasively monitor cardiovascular status in patients with PH.

  Effects of low-intensity exercise conditioning on blood pressure, heart rate, and autonomic modulation of heart rate in men and women with hypertension.Hua, L.P., Brown, C. A., et al.: School of Nursing, Queen's University, Kingston, Ontario, Canada. Biological research for nursing, 11(2), 2009.

  
  

  Untreated hypertension increases cardiovascular risk 2-fold to 3-fold, leading to serious cardiovascular problems that include left ventricular hypertrophy, stroke, ischemic heart disease, myocardial infarction, vascular disease, renal disease, and death. Exercise conditioning is recommended as one of the initial treatments for hypertension. The purpose of this pretest-posttest study was to quantify the effects of a 12-week home-based low-intensity exercise conditioning (walking) program in hypertensive men and women on systolic and diastolic blood pressure, heart rate, and autonomic modulation of heart rate. A total of 20 mildly hypertensive men and women who were assigned to a structured exercise (walking) program were compared with a control group of 20 nonexercising mildly hypertensive participants. Electrocardiographic heart rate and R-R interval data and beat-by-beat arterial blood pressure data were collected continuously for 10 min with participants in the supine and standing postures and during low-intensity steady-state exercise. The results show that systolic and diastolic blood pressure and R-R interval decreased and spontaneous baroreflex sensitivity increased in the exercise group. The decline in blood pressure was significant statistically and clinically. The increase in spontaneous baroreflex sensitivity indicates that the ability of the cardiovascular system to respond rapidly to changing stimuli improved after the 12-week walking protocol. The low-intensity exercise conditioning program achieved a training effect in this population.

   

  Effect of extreme exercise on myocardial function as assessed by tissue Doppler imaging.Aslani, A., Babaee Bigi, M. A., et al.. Sport Physiology Research Center, Baghiyatallah University of Medical Sciences, Tehran, Iran.Echocardiography (Mount Kisco, N.Y.), 26(9), 2009

  BACKGROUND: Response of the human heart to exercise has been studied extensively, but little information is available on the effects of exhaustive exercise on cardiac performance. OBJECTIVES: The aim of this study was to evaluate the effect of severe prolong exercise on both left and right ventricular performance. To maximize the sensitivity of our study we used tissue Doppler imaging. METHODS: Participants in army ranger training program were invited to participate in this prospective study. All patients underwent transthoracic echocardiography using tissue Doppler imaging before and after Ranger training program. RESULTS: A total of 45 consecutive male rangers who completed 8 weeks of training were included in this study. Peak systolic myocardial velocity (S) decreased significantly after training (12.46 +/- 0.54 vs. 9.93 +/- 0.45 cm/s; P < 0.001). In the right ventricle, tissue Doppler measures of systolic and early diastolic function decreased significantly after training compared to pretraining values. CONCLUSION: In conclusion, very strenuous prolonged exercise may result in depressed left ventricular contractile function. This raises the possibility of cardiac fatigue.