Asterios Deligiannis

Recommendations for interpretation of 12-lead electrocardiogram in the athlete.

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

EXERCISE TRAINING IN PATIENTS WITH END-STAGE RENAL DISEASE ON HEMODIALYSIS: COMPARISON OF THREE REHABILITATION PROGRAMS

Functional capacity of end-stage renal disease patients is dramatically impaired. Although exercise training programs appear to have beneficial morphological, functional and psychosocial effects in end-stage renal disease patients on hemodialysis (HD), the adherence rate is high. The purpose of this study was to compare the effects of three modes of exercise training on aerobic capacity and to identify the most favourable, efficient and preferable to patients on HD with regard to functional improvements and participation rate in the programs. Fifty-eight volunteer patients were screened for low-risk status and selected from the dialysis population. The 48 patients who completed the study protocol were randomly assigned either to one of the three training groups or to a control group. Sixteen of them (Group A - mean age 46.4+/-13.9 years) completed a 6-month supervised outpatient exercise renal rehabilitation program consisting of three weekly sessions of aerobic and strengthening training on the non-dialysis days; 10 (Group B - mean age 48.3+/-12.1 years) completed a 6-month exercise program during HD; 10 (Group C - mean age 51.4+/-12.5 years) followed an unsupervised moderate exercise program at home, and 12 patients (Group D-mean age 50.2+/-7.9 years) were used as patient controls. The level of anemia, the medications and the HD prescription remained stable during the study. Fifteen sex- and age-matched sedentary individuals (Group E - mean age 46.9+/-6.4 years) comprised a healthy control group for baseline data. All subjects at the beginning and end of the study underwent clinical examination, laboratory tests and a treadmill exercise test to fatigue endpoints with direct measurement of aerobic capacity. Group A had a higher dropout rate (24%) compared to groups B (17%) and C (17%). Peak oxygen consumption (VO2 peak) increased by 43% (p < 0.05), anaerobic threshold (VO2AT) by 37% (p < 0.05) and exercise time by 33% (p < 0.05) after training in Group A; by 24% (p < 0.05), 18% (p < 0.05) and 22% (p < 0.05), respectively, in B; and by 17% (p < 0.05), 8% (p < 0.05) and 14% (p < 0.05), respectively, in C; while both remained almost unchanged in Group D. These results demonstrate that intense exercise training on non-dialysis days is the most effective way of training, whereas exercise during HD is also effective and preferable.

Exercise Renal Rehabilitation Program: Psychosocial Effects

The aim of this study was to assess the psychosocial effects of exercise training on hemodialysis (HD) patients. Thirty-one uremic patients, aged 50.6+/-11.6 years, on maintenance HD were studied. Twenty patients were selected at random for a 6-month exercise renal rehabilitation program (ERRP) consisting of 3 weekly sessions of exercise training. The other 11 patients were assigned to sedentary control status. A formal psychosocial assessment, which included affective (Beck Depression Inventory, BDI), quality of life (Quality of Life Index, QLI) and personality (Eysenck Personality Questionnaire, EPQ) parameters, was performed with validated questionnaires at the beginning and the end of the ERRP. After training significant improvement occurred in physical capacity (VO2max increased from 16.8+/-6.2 to 23.2+/-7.6 ml/kg/min, p < 0.05). Although the level of depression did not differ betwen the 2 groups at pretesting, the ERRP group showed a decrease in their self-report of depression (decrease in BDI score value, from 21.0+/-10.4 to 13.7+/-9.5, p < 0.05) after the training program. From the relationship between the baseline levels of BDI depression and changes in VO2max in the ERRP group it was suggested that the most severely depressed patients got the greatest beneficial effects from exercise training. Moreover, trained patients demonstrated an improvement in QLI (from 6.3+/-1.5 to 9.0+/-0.9, p < 0.05). This improvement was found to be dependent on the participation in ERRP, the effects of the training and the improvement in the depression. All the above functional and psychosocial parameters remained unchanged in the controls. The results demonstrate that ERRP is an effective emotional therapeutic method for HD patients and improves their quality of life.

Cardiac effects of exercise rehabilitation in hemodialysis patients.

Exercise training has well documented beneficial effects in a variety of cardiac disorders. End stage renal disease patients present many cardiovascular complications and suffer from impaired exercise capacity. No study to date has adequately examined the cardiac responses to exercise training in renal patients on hemodialysis (HD). To determine the effects of an exercise rehabilitation program on the left ventricular function at rest and during submaximal effort, 38 end-stage renal disease patients on maintenance HD were randomised into three groups. Sixteen of them (group A--mean age 46.4+/-13.9 years), without clinical features of heart failure, participated in a 6-month supervised exercise renal rehabilitation program consisting of three weekly sessions of aerobic training, 10 (group B--mean age 51.4+/-12.5 years) followed a moderate exercise program at home, and the other 12 (group C--mean age 50.2+/-7.9 years) were not trained and remained as controls. The level of anemia and the HD prescription remained constant during the study. Fifteen sex- and age-matched sedentary individuals (group D--mean age 46.9+/-6.4 years) were the healthy controls. All subjects at the start and end of the program underwent physical examination, laboratory tests, treadmill exercise testing, M-mode and 2-D echocardiograms performed at rest and at peak of supine bicycle exercise. Left ventricular volumes (EDV, ESV) and mass (LVM) were measured and ejection fraction (EF), stroke volume index (SVI) and cardiac output index (COI) were calculated by standard formulae. The maximal oxygen consumption increased by 43% (P<0.001) and the exercise time by 33% (P<0.001) after training in group A, by 17% (P<0.001) and 14% (P<0.01), respectively, in B, and both remained unchanged in group C. Training in group A was also associated with an increase in LVIDd (from 52.1+/-6.4 to 54.0+/-6.1 mm, P<0.001) and LVM (226+/-67 to 240+/-84 g, P<0.05) at rest with no change noted in groups B and C. Following a 6-month exercise training in group A an increase was also found in the resting EF by 5% (P<0.01) and SVI by 14% (P<0.001). There was no change found in groups B and C. Supine bicycle exercise after training in group A was associated with an improvement in EF by 14% compared to the pre-training change (P<0.001), SVI by 14% (P<0.001) and COI by 73% (P<0.001). These changes from rest to submaximal exercise were less pronounced in group B following training at home. The untrained patients demonstrated no changes in LV systolic function over the 6-month period. These results demonstrate that intense exercise training improves LV systolic function at rest in HD patients; both intense and moderate physical training leads to enhanced cardiac performance during supine submaximal exercise.

Quality of life, psychological and physiological changes following exercise training in patients with chronic heart failure.

OBJECTIVE To assess the physiological and psychosocial effects of exercise training in chronic heart failure. SUBJECTS/PATIENTS Twenty-six men with heart failure (New York Heart Association functional classes II and III) aged 52.5 (SD 9.8) years, were studied. METHODS The subjects were randomized either to rehabilitation group (Group A: 16 patients), participating in a 6-month exercise training program, or to control group (Group B: 10 patients). A psychosocial assessment, which included affective (Beck Depression Inventory and Hospital Anxiety and Depression Scale), quality of life (Quality of Life Index, Minnesota Living with Heart Failure Questionnaire and the Scale of Life Satisfaction) and personality (Eysenck Personality Questionnaire) parameters, was performed at the beginning and the end of the study. RESULTS After training VO2 peak increased by 36% and exercise time by 35%, p < 0.05. A significant decrease in anxiety and depression was also observed. Moreover, trained patients demonstrated a significant improvement in quality of life. No significant correlations were found between deltaVO2 peak and all psychosocial parameter gains. However, the more depressed patients showed the largest physiological responses. CONCLUSION An exercise rehabilitation program in patients with chronic heart failure is useful for improving their work capacity and psychosocial status. Improvements in psychological status seem to be independent of the aerobic gains.

ESC study group of sports cardiology position paper on adverse cardiovascular effects of doping in athletes.

The use of doping substances and methods is extensive not only among elite athletes, but also among amateur and recreational athletes. Many types of drugs are used by athletes to enhance performance, to reduce anxiety, to increase muscle mass, to reduce weight or to mask the use of other drugs during testing. However, the abuse of doping substances and methods has been associated with the occurrence of numerous health side-effects. The adverse effects depend on the type of the consumed drug, as well as the amount and duration of intake and the sensitivity of the body, since there is a large inter-individual variability in responses to a drug. Usually the doses used in sports are much higher than those used for therapeutic purposes and the use of several drugs in combination is frequent, leading to higher risk of side-effects. Among biomedical side-effects of doping, the cardiovascular ones are the most deleterious. Myocardial infarction, hyperlipidemia, hypertension, thrombosis, arrythmogenesis, heart failure and sudden cardiac death have been noted following drug abuse. This paper reviews the literature on the adverse cardiovascular effects after abuse of prohibited substances and methods in athletes, aiming to inform physicians, trainers and athletes and to discourage individuals from using drugs during sports.

Heart rate variability modifications following exercise training in type 2 diabetic patients with definite cardiac autonomic neuropathy

Objectives: Cardiac autonomic neuropathy (CAN) as a result of diabetic autonomic neuropathy is positively related to a poor prognosis in diabetic patients. The measurement of heart rate variability (HRV) is a remarkable index of cardiac autonomic dysfunction. The aim of this study was to examine the effects of long-term exercise training on HRV in type 2 diabetic patients with definite CAN. Methods: Seventeen type 2 diabetic patients with definite CAN (group A: 56.2 years (SD 5.8)) and 15 without CAN (group B: 55.8 years (SD 5.6)) participated in the study. All patients followed an aerobic exercise training programme three times a week for 6 months; the intensity of the session was 70% to 85% of heart rate reserve. At the beginning and end of the study all subjects underwent graded maximal exercise testing with spiroergometry for the evaluation of their aerobic capacity (VO2peak). Moreover, time and frequency domain indices of HRV were obtained from 24 h ambulatory continuous ECG Holter recordings. Results: At baseline, all measurements of HRV indices were significantly reduced in group A compared with group B (p<0.05). Moreover, group A reached a significantly lower VO2peak by 14.8% compared with group B (p<0.05). Following the exercise training programme, the SD of all normal-to-normal RR intervals in the entire recording (SDNN) was increased by 18.8% (p<0.05) and 13.8% (p<0.05), the square root of the average of sum of squares of difference between adjacent filtered RR intervals (rMSSd) was increased by 35% (p<0.05) and 15.2% (p<0.05), and the percentage of differences between adjacent filtered RR intervals which was greater than 50 ms for the entire analysis (pNN50) was increased by 400% (p<0.05) and 67.9% (p<0.05) in groups A and B, respectively. Regarding the frequency domain indices, only the high frequency power (HF) was found to be significantly increased in group A. At the end of the exercise training programme, SDNN, rMSSd and low frequency power (LF) were significantly lower (24.3% (p<0.05), 20.3% (p<0.05) and 40% (p<0.05), respectively) in group A compared with group B. Also, VO2peak increased by 17.8% (p<0.05) in group A and by 11% (p<0.05) in group B. Furthermore, the exercise training programme had significant effects on blood lipid and glucose levels and glycosylated haemoglobin (HbA1c) in both groups. Conclusions: The results indicate that 6-month aerobic exercise training improves the cardiac autonomic nervous system function in type 2 diabetic patients. However, more favourable effects are found in type 2 diabetic patients with definite CAN.

Comparative study of field and laboratory tests for the evaluation of aerobic capacity in soccer players.

The purpose of this study was to evaluate the maximal oxygen uptake (VO2max) values in soccer players as assessed by field and laboratory tests. Thirty-five elite young soccer players were studied (mean age 18.1 ± 1.0 years, training duration 8.3 ± 1.5 years) in the middle of the playing season. All subjects performed 2 maximal field tests: the Yo-Yo endurance test (T1) for the estimation of VO2max according to normogram values, and the Yo-Yo intermittent endurance test (T2) using portable telemetric ergospirometry; as well as 2 maximal exercise tests on the treadmill with continuous (T3) and intermittent (T4) protocols. The estimated VO2max values of the T1 test (56.33 ml·kg-1·min-1) were 10.5%, 11.4%, and 13.3% (p ≤ 0.05) lower than those of the T2 (62.96 ml·kg-1·min-1), T3(63.59 ml·kg-1·min-1) and T4 (64.98 ml·kg-1·min-1) tests, respectively. Significant differences were also found between the intermittent exercise protocols T1 and T3 (p ≤ 0.001) and the continuous exercise protocols T2 and T4 (p ≤ 0.001). There was a high degree of cross correlation between the VO2max values of the 3 ergospirometric tests (T2 versus T3, r = 0.47, p ≤ 0.005; T2versus T4, r = 0.59, p ≤ 0.001; T3 versus T4 r = 0.79, p ≤ 0.001). It is necessary to use ergospirometry to accurately estimate aerobic capacity in soccer players. Nevertheless, the Yo-Yo field tests should be used by coaches because they are easy and helpful tools in the training program setting and for player follow-up during the playing season.

Effects of Exercise Training on Noninvasive Cardiac Measures in Patients Undergoing Long-term Hemodialysis: A Randomized Controlled Trial

BACKGROUND Noninvasive screening studies may identify hemodialysis (HD) patients at increased risk of sudden cardiac death. Interventions that improve the findings of such screening studies may reduce sudden cardiac death. STUDY DESIGN Randomized and controlled clinical trial. SETTING & PARTICIPANTS 59 HD patients were randomly assigned to an exercise training group (group A; 30 patients) or control group (group B; 29 patients). INTERVENTION Group A participated in a 10-month supervised exercise training program during the HD sessions (3 times weekly). OUTCOMES Each risk factor separately and the composite risk score. Patients were considered high risk according to the criteria (aerobic capacity: peak oxygen consumption [Vo(2)peak] < or = 14 mL/kg/min, left ventricular ejection fraction < or = 30%, SD of normal RR intervals [SDNN] < or = 70 milliseconds, positive T-wave alternans, or positive late potentials). Statistical analysis included a 2-group comparison of change scores and analysis of covariance adjusting for baseline. MEASUREMENTS At entry and end of the study, Vo(2)peak and left ventricular ejection fraction were estimated, heart rate variability was calculated (measurement of SDNN, mean RR intervals), and the ratio between low- (LF) to high-frequency (HF) components (LF/HF) and late potentials and T-wave alternans were detected. RESULTS Baseline measurements were similar between the 2 groups. At follow-up, 9 patients from group A and 20 from group B (P = 0.003) were considered high risk. The change in number of risk markers over time was significantly different between groups (-0.5 +/- 0.7 in group A versus 0.07 +/- 0.3 in group B; P < 0.001). Additionally, the change in Vo(2)peak over time was 3.5 +/- 3.2 in group A and -0.2 +/- 3.5 mL/kg/min in group B (P < 0.001), left ventricular ejection fractions were 3.4% +/- 3.9% and 0.2% +/- 7.7% (P < 0.05), SDNNs were 12.6 +/- 16.3 and -1.1 +/- 10.2 milliseconds (P < 0.001), and LF/HF ratios were 0.3 +/- 0.4 and -0.1 +/- 0.3 (P < 0.001), respectively. Change in numerical score of the signal-averaged electrocardiogram also was found to be statistically different (P < 0.05) between groups. LIMITATIONS Clinical outcomes, including survival, were not assessed. CONCLUSIONS Exercise training improves aerobic capacity and ameliorates some indicators of risk of sudden cardiac death in HD patients.

Depression, heart rate variability, and exercise training in dialysis patients:

Background Functional limitations, altered cardiac autonomic activity, and psychological distress are known disorders in chronic hemodialysis (HD) patients, relating to increased morbidity and mortality. The aim of this study was to examine the influence of an exercise training program on emotional parameters and heart rate variability (HRV) indices, as well as to determine whether emotional stress contributes to autonomic dysfunction in these patients. Methods Forty-four HD patients were randomly assigned into group A (24 patients, aged 46.3 ± 11.2 years), who participated in a 1-year intradialytic exercise training program and group B (20 patients, aged 45.8 ± 10.8 years), who were used as controls. At baseline and a year after, measures of HRV were obtained for the estimation of standard deviation of RR intervals, the mean square successive differences, percentage of RR intervals differing by more than 50 ms from the preceding RR interval (pNN50), and low to high frequency components. Emotional parameters (Beck Depression Inventory – BDI and Hospital Anxiety and Depression Scale – HADS) were also assessed by validated questionnaires. Moreover, all patients performed a spiroergometric study for the estimation of VO2peak. Results At baseline, all measurements were similar in the two groups and remained almost unchanged after a year in group B. After a year of training, VO2peak increased from 16.79 ± 5.24 to 22.33 ± 4.90 ml/kg per min (P >0.001) in group A. Trained patients also showed an increase in standard deviation of RR intervals by 58.8% (P >0.001), the mean square successive differences by 68.1% (P >0.001), pNN50 by 23.5% (P >0.001), and a low to high frequency ratio by 17.3% (P >0.001). Finally, at the end of the study, group A showed a decrease in BDI score by 34.5% (P >0.001) and HADS by 23.9% (P >0.001). Canonical correlation revealed significant inverse correlation among depression (in BDI and HADS) and HRV indices before and after exercise training. Conclusion Cardiac autonomic modulation seemed to be sensitive to the experience of persistent depression in HD patients. Significantly, exercise training reduced emotional distress and concomitantly improved HRV.