Filippo M. Quattrini

Outcomes in athletes with marked ECG repolarization abnormalities.

BACKGROUND Young, trained athletes may have abnormal 12-lead electrocardiograms (ECGs) without evidence of structural cardiac disease. Whether such ECG patterns represent the initial expression of underlying cardiac disease with potential long-term adverse consequences remains unresolved. We assessed long-term clinical outcomes in athletes with ECGs characterized by marked repolarization abnormalities. METHODS From a database of 12,550 trained athletes, we identified 81 with diffusely distributed and deeply inverted T waves (> or = 2 mm in at least three leads) who had no apparent cardiac disease and who had undergone serial clinical, ECG, and echocardiographic studies for a mean (+/-SD) of 9+/-7 years (range, 1 to 27). Comparisons were made with 229 matched control athletes with normal ECGs from the same database. RESULTS Of the 81 athletes with abnormal ECGs, 5 (6%) ultimately proved to have cardiomyopathies, including one who died suddenly at the age of 24 years from clinically undetected arrhythmogenic right ventricular cardiomyopathy. Of the 80 surviving athletes, clinical and phenotypic features of hypertrophic cardiomyopathy developed in 3 after 12+/-5 years (at the ages of 27, 32, and 50 years), including 1 who had an aborted cardiac arrest. The fifth athlete demonstrated dilated cardiomyopathy after 9 years of follow-up. In contrast, none of the 229 athletes with normal ECGs had a cardiac event or received a diagnosis of cardiomyopathy 9+/-3 years after initial evaluation (P=0.001). CONCLUSIONS Markedly abnormal ECGs in young and apparently healthy athletes may represent the initial expression of underlying cardiomyopathies that may not be evident until many years later and that may ultimately be associated with adverse outcomes. Athletes with such ECG patterns merit continued clinical surveillance.

Long-Term Clinical Consequences of Intense, Uninterrupted Endurance Training in Olympic Athletes

OBJECTIVES The aim of this study was to assess incidence of cardiac events and/or left ventricular (LV) dysfunction in athletes exposed to strenuous and uninterrupted training for extended periods of time. BACKGROUND Whether highly intensive and uninterrupted athletic conditioning over a long period of time might be responsible for cardiac events and/or LV dysfunction is unresolved. METHODS We assessed clinical profile and cardiac dimensions and function in 114 Olympic athletes (78% male; mean age 22 +/- 4 years), free of cardiovascular disease, participating in endurance disciplines, who experienced particularly intensive and uninterrupted training for 2 to 5 consecutive Olympic Games (total, 344 Olympic events), over a 4- to 17-year-period (mean 8.6 +/- 3 years). RESULTS Over the extended period of training and competition, no cardiac events or new diagnoses of cardiomyopathies occurred in the 114 Olympic athletes. Global LV systolic function was unchanged (ejection fraction: 62 +/- 5% to 63 +/- 5%; p = NS), and wall motion abnormalities were absent. In addition, LV volumes (142 +/- 26 ml to 144 +/- 25 ml; p = 0.52) and LV mass index (109 +/- 21 g/m(2) to 110 +/- 22 g/m(2); p = 0.74) were unchanged, and LV filling patterns remained within normal limits, although left atrial dimension showed a mild increase (37.8 +/- 3.7 mm to 38.9 +/- 3.2 mm; p < 0.001). CONCLUSIONS In young Olympic athletes, extreme and uninterrupted endurance training over long periods of time (up to 17 years) was not associated with deterioration in LV function, significant changes in LV morphology, or occurrence of cardiovascular symptoms or events.

The Athlete's Heart in Adolescent Africans: An Electrocardiographic and Echocardiographic Study

OBJECTIVES The goal of this study was to define electrocardiographic (ECG) and echocardiographic characteristics of adolescent African athletes. BACKGROUND Recent observations in African athletes reported large prevalence of left ventricular (LV) hypertrophy and ECG abnormalities. No data, so far, exist for adolescent Africans, which comprise a growing proportion of competitive/professional athletes. METHODS The study included 154 soccer players participating at the 8th African Under-17 Championship of 2009, representing Algeria, Burkina Faso, Cameroon, Gambia, Guinea, Malawi, Nigeria, and Zimbabwe. For comparison, 62 Italian players with similar ages, sport achievements, and training schedules were included. RESULTS African athletes showed higher R5/S1-wave voltages than Caucasian athletes (48.6 ± 12.1 mm vs. 34.1 ± 8.9 mm; p < 0.01), larger prevalence of ECG LV hypertrophy (89% vs. 42%; p < 0.001), ST-segment elevation (91% vs. 56%; p < 0.001), and deeply inverted, or diffusely flat/biphasic, T waves (14% vs. 3% [p < 0.05] and 25% vs. 8% [p < 0.008], respectively). LV wall thicknesses were increased in Africans by 5% compared with Caucasians, and exceeded normal limits (≥13 mm) in 4 Africans but in no Caucasians. No athlete showed evidence of cardiomyopathies (i.e., hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy). On individual analysis, Algerians showed lower R/S-wave voltages compared with other African athletes. Increased wall thickness (≥13 mm) was observed only in sub-Saharian athletes (from Burkina Faso, Cameroon, and Niger). CONCLUSIONS African athletes displayed large proportion of ECG abnormalities, including a striking increase in R/S-wave voltage, ST-segment elevation, and deeply inverted or diffusely flat T waves by adolescence. LV remodeling in African athletes was characterized by a disproportionate wall thickening than in Caucasians but similar cavity size. Finally, distinctive peculiarities existed in African athletes according to the country (and ethnic) origin.

Prevalence and Clinical Significance of Aortic Root Dilation in Highly Trained Competitive Athletes

Background— Few data are available that address the impact of athletic training on aortic root size. We investigated the distribution, determinants, and clinical significance of aortic root dimension in a large population of highly trained athletes. Methods and Results— Transverse aortic dimensions were assessed in 2317 athletes (56% male), free of cardiovascular disease, aged 24.8±6.1 (range, 9 to 59) years, engaged in 28 sports disciplines (28% participated in Olympic Games). In males, aortic root was 32.2±2.7 mm (range, 23 to 44; 99th percentile=40 mm); in females, aortic root was 27.5±2.6 mm (range, 20 to 36; 99th percentile=34 mm). Aortic root was enlarged ≥40 mm in 17 male (1.3%) and ≥34 mm in 10 female (0.9%) subjects. Over an 8-year follow-up period, aortic dimension increased in these male athletes (40.9±1.3 to 42.9±3.6 mm; P<0.01) and dilated substantially (to 50, 50, and 48 mm) in 3, after 15 to 17 years of follow-up, in the absence of systemic disease. Aortic root did not increase significantly (34.9±0.9 to 35.4±2.1 mm; P=0.11) in female athletes. Multiple regression and covariance analysis showed that aortic dimension was largely explained by weight, height, left ventricular mass, and age (R2=0.63; P<0.001), with type of sports training having a significant but lower impact (P<0.003). Conclusions— An aortic root dimension >40 mm in highly conditioned male athletes (and >34 mm in female athletes) is uncommon, is unlikely to represent the physiological consequence of exercise training, and is most likely an expression of a pathological condition, mandating close clinical surveillance.

Three-Dimensional Echocardiographic Characterization of Left Ventricular Remodeling in Olympic Athletes

The aim of the present study was to assess, using 3-dimensioanl echocardiography, the morphologic characteristics, determinants, and physiologic limits of left ventricular (LV) remodeling in 511 Olympic athletes (categorized in skill, power, mixed, and endurance sport disciplines) and 159 sedentary controls matched for age and gender. All subjects underwent 3-dimensional echocardiography for the assessment of LV volumes, ejection fraction, mass, remodeling index (LV mass/LV end-diastolic volume), and systolic dyssynchrony index (obtained by the dispersion of the time to minimum systolic volume in 16 segments). Athletes had higher LV end-diastolic volumes (157 ± 35 vs 111 ± 26 ml, p <0.001) and mass (156 ± 38 vs 111 ± 25 g, p <0.001) compared to controls. Body surface area and age had significant associations with LV end-diastolic volume (R(2) = 0.49, p <0.001) and mass (R(2) = 0.51, p <0.001). Covariance analysis showed that also gender and type of sport were significant determinants of LV remodeling; in particular, the highest impact on LV end-diastolic volume and mass was associated with male gender and endurance disciplines (p <0.001). Regardless of the type of sport, athletes had similar LV remodeling indexes to controls (1.00 ± 0.06 vs 1.01 ± 0.07 g/mL, p = 0.410). No differences were found between athletes and controls for the ejection fraction (62 ± 5% and 62 ± 5%, p = 0.746) and systolic dyssynchrony index (1.06 ± 0.40% and 1.37 ± 0.41%, p = 0.058). In conclusion, 3-dimensional echocardiographic morphologic and functional assessment of the left ventricle in Olympic athletes demonstrated a balanced adaptation of LV volume and mass, with preserved systolic function, regardless of specific disciplines participated.

Aortic root dilatation in athletic population.

Remodeling of the aortic root may be expected to occur in athletes as a consequence of hemodynamic overload associated with exercise training; however, there are few data reporting its presence or extent. This review reports the current knowledge regarding the prevalence, upper limits, and clinical significance of aortic remodeling induced by athletic training. Several determinants impact aortic dimension in healthy, nonathletic individuals, including height, body size, age, sex, and blood pressure. Of these factors, anthropometric variables have the greatest impact. In athletes, the effect of exercise training appears to have only a modest additional influence on aortic dimension, although previous studies have produced some conflicting results. Specifically, data derived from the largest available athletic cohort suggest that the most hemodynamically intense endurance disciplines (eg, cycling and swimming) are associated with a significant but mild increase in aortic dimensions. Power disciplines, instead, (eg, weight lifting, throwing events) have only trivial, if any, impact. In contrast, selected data from a different athlete population suggest a more significant dimensional aortic remodeling in strength-trained individuals. In our experience, the 99th percentile value of aortic root diameter corresponds to 40 mm in males and 34 mm in females, which can reasonably be considered the upper limits of physiologic aortic root remodeling. However, a small proportion of apparently healthy male athletes (approximately 1%) show aortic enlargement above the upper limits, in the absence of systemic disease (ie, Marfan syndrome). Athletes presenting with aortic enlargement may demonstrate a further dimensional increase in midlife leading to clinically relevant aortic dilatation. Occasionally, dilation may be severe enough to warrant consideration for surgical treatment. Therefore, serial clinical and echocardiographic evaluations are recommended in athletes when aortic root exceeds the sex-specific thresholds.

Benign clinical significance of J-wave pattern (early repolarization) in highly trained athletes

BACKGROUND J wave/QRS slurring (early repolarization) on 12-lead ECG has been associated with increased risk for ventricular fibrillation in the absence of cardiovascular (CV) disease. OBJECTIVE The purpose of this study was to assess the prevalence and clinical significance of J wave/QRS slurring in a large population of competitive athletes. METHODS Seven hundred four athletes (436 males [62%], age 25 ± 5 years) free of CV disease who had engaged in 30 different sports were examined. Serial clinical, ECG, and echocardiographic evaluations were available over 1 to 18 years of follow-up (mean 6 ± 4 years). RESULTS J wave was found in 102 athletes (14%) and was associated with QRS slurring in 32 (4%). It was found most commonly in anterior, lateral, and inferior leads (n = 73 [72%]), occasionally in lateral leads (n = 26 [25%]), and rarely in inferior leads (n = 3 [3%]). Most of 102 athletes (n = 86 [84%]) also showed ST-segment elevation. J wave/QRS slurring was associated with other training-related ECG changes (ie, increased R/S-wave voltages in 76%) and left ventricular (LV) morphologic remodeling (LV mass 199 ± 48 g vs 188 ± 56 g, P <.05). During follow-up, no athlete with J wave experienced cardiac event or ventricular tachyarrhythmias, or developed structural CV disease. CONCLUSION In athletes, early repolarization pattern usually is associated with other ECG changes, such as increased QRS voltages and ST-segment elevation, as well as LV remodeling, suggesting that it likely represents another benign expression of the physiologic athletes heart. J wave (early repolarization) is common in highly trained athletes and does not convey risk for adverse cardiac events, including sudden death or tachyarrhythmias.

Physiological adaptation in noncompetitive rock climbers: good for aerobic fitness?

The present investigation aimed to establish whether noncompetitive rock climbing fulfills sports medicine recommendations for maintaining a good level of aerobic fitness. The physiological profile of 13 rock climbers, 8 men (age, 43 ± 8 years) and 5 women (age, 31 ± 8 years) was assessed by means of laboratory tests. Maximal aerobic power (&OV0312;o2peak) and ventilatory threshold (VT) were assessed using a cycloergometer incremental test. During outdoor rock face climbing, &OV0312;o2 and heart rate (HR) were measured with a portable metabolimeter and the relative steady-state values (&OV0312;o2 and HR during rock climbing) were computed. Blood lactate was measured during recovery. All data are presented as mean ± SD. &OV0312;o2peak was 39.1 ± 4.3 mL·kg−1·min−1 in men and 39.7 ± 5 mL·kg−1·min−1 in women, while VT was 29.4 ± 3.0 mL·kg−1·min−1 in men and 28.8 ± 4.6 mL·kg−1·min−1 in women. The &OV0312;o2 during rock climbing was 28.3 ± 1.5 mL·kg−1·min−1 in men and 27.5 ± 3.7 mL·kg−1·min−1 in women. The HR during rock climbing was 144 ± 16 b·min−1 in men and 164 ± 13 b·min−1 in women. The aerobic profile was classified from excellent to superior in accordance with the standards of the American College of Sports Medicine (ACSM). The exercise intensity (&OV0312;o2 during rock climbing expressed as a percentage of &;o2peak) was 70 ± 6% in men and 72 ± 8% in women. Moreover, the energy expenditure was 1000-1500 kcal per week. In conclusion, noncompetitive rock climbing has proved to be a typical aerobic activity. The intensity of exercise is comparable to that recommended by the American College of Sports Medicine to maintain good cardiorespiratory fitness.

Prevalence and clinical meaning of isolated increase of QRS voltages in hypertrophic cardiomyopathy versus athlete's heart: relevance to athletic screening.

Intensiveathleticconditioningisassociatedwithphysiologiccardiacremodeling (known as “athletes heart”), consisting of augmented leftventricular (LV) mass due to increase of both cavity dimension andwall thickness, which are re flected on the electrocardiogram (ECG)mostfrequentlyasanincreaseofQRSvoltages[1,2].Becauseofthepar-tialoverlapofECGsignsofLVhypertrophy,athletesheartisofteninthedifferentialdiagnosiswithhypertrophiccardiomyopathy(HCM),whichis the leading cause of sports-related cardiac arrest in young athletes.Patients with HCM have a variety of ECG abnormalities, includingatrial enlargement, QRS left axis deviation, increase of QRS amplitudes,ST-segment and/or T-wave abnormalities, and pathologic Q waves [3].AccordingtotherecommendationsoftheEuropeanSocietyofCardiology,the ECG changes due to cardiac adaptat ion to physical exertion, predom-inantly the physiologic increase of QRS voltages, should not cause alarmand the athlete should be allowed to participate in competitive sportswithout additional evaluation [1]. Although this ECG interpretationapproach offers the potential to lower the traditional high number offalse-positives, whether and to what extent the increased speci ficityalter the ECG sensitivity for HCM remains to be established.The present study compared the ECG abnormalities associated withthe LV remodeling of HCM (nondilated, hypertrophic LV) and that ofathletes heart (augmented LV mass due to increase of both cavity di-mensionandwallthickness),withparticularreferencetotheprevalence,clinicalsignificance,andrelevancetoscreeningoftheECGpatternofiso-lated increase of QRS voltages. The main study objective was to evaluatethe risk to miss a diagnosis of HCM by interpreting as normal the ECGpattern of isolated increase of QRS amplitude in highly trained athletes.The HCM population included 247 consecutive patients (181 males;age 39 ± 14 years, range 15–65 years). The diagnosis of HCM wasbased on the presence of a hypertrophied and nondilated left ventriclein the absence of other diseases that could produce the magnitude ofhypertrophy evident. Echocardiographic criteria for diagnosis were amaximal LV wall thickness (LVWT) ≥ 15 mm in adult index patientsand ≥13 mm in adult relatives [4,5]. The athletes population includeda series of 133 Caucasian healthy, highly trained athletes (116 males;age 27 ± 6 years, range 15 –65 years) who fulfilled the echocardio-graphic criteria for augmented LV mass de fined according to Devereuxet al. as ≥134 g/m

Are Olympic athletes free from cardiovascular diseases? Systematic investigation in 2352 participants from Athens 2004 to Sochi 2014

Context Olympic athletes represent model of success in our society, by enduring strenuous conditioning programmes and achieving astonishing performances. They also raise scientific and clinical interest, with regard to medical care and prevalence of cardiovascular (CV) abnormalities. Objective Our aim was to assess the prevalence and type of CV abnormalities in this selected athletes cohort. Design, setting and participants 2352 Olympic athletes, mean age 25±6, 64% men, competing in 31 summer or 15 winter sports, were examined with history, physical examination, 12-lead and exercise ECG and echocardiography. Additional testing (cardiac MRI, CT scan) or electrophysiological assessments were selectively performed when indicated. Main outcome measures Prevalence and type of CV findings, abnormalities and diseases found in Olympic athletes over 10 years. Results A subset of 92 athletes (3.9%) showed abnormal CV findings. Structural abnormalities included inherited cardiomyopathies (n=4), coronary artery disease (n=1), perimyocarditis (n=4), myocardial bridges (n=2), valvular and congenital diseases (n=45) and systemic hypertension (n=10). Primary electrical diseases included atrial fibrillation (n=2), supraventricular reciprocating tachycardia (n=14), complex ventricular tachyarrhythmias (non-sustained ventricular tachycardia, n=7; bidirectional ventricular tachycardia, n=1) or major conduction disorders (Wolff-Parkinson-White (WPW), n=1; Long QT syndrome (LQTS), n=2). Conclusions Our study revealed an unexpected prevalence of CV abnormalities among Olympic athletes, including a small, but not negligible proportion of pathological conditions at risk. This observation suggests that Olympic athletes, despite the absence of symptoms or astonishing performances, are not immune from CV disorders and might be exposed to unforeseen high-risk during sport activity.