John Somauroo

An echocardiographic assessment of cardiac morphology and common ECG findings in teenage professional soccer players: reference ranges for use in screening

OBJECTIVE To assess physiological cardiac adaptation in adolescent professional soccer players. SUBJECTS AND DESIGN Over a 32 month period 172 teenage soccer players were screened by echocardiography and ECG at a tertiary referral cardiothoracic centre. They were from six professional soccer teams in the north west of England, competing in the English Football League. One was excluded because of an atrial septal defect. The median age of the 171 players assessed was 16.7 years (5th to 95th centile range: 14–19) and median body surface area 1.68 m2 (1.39–2.06 m2). MAIN OUTCOME MEASURES Standard echocardiographic measurements were compared with predicted mean, lower, and upper limits in a cohort of normal controls after matching for age and surface area. Univariate regression analysis was used to assess the correlation between echocardiographic variables and the age and surface area of the soccer player cohort. ECG findings were also assessed. RESULTS All mean echocardiographic variables were greater than predicted for age and surface area matched controls (p < 0.001). All variables except left ventricular septal and posterior wall thickness showed a modest linear correlation with surface area (r = 0.2 to 0.4, p < 0.001); however, left ventricular mass was the only variable that was significantly correlated with age (r = 0.2, p < 0.01). Only six players (3.5%) had structural anomalies, none of which required further evaluation. All had normal left ventricular systolic function. Sinus bradycardia was found in 65 (39%). The Solokow–Lyon voltage criteria for left ventricular hypertrophy were present in 85 (50%) and the Romhilt–Estes points score (five or more) in 29 (17%). Repolarisation changes were present in 19 (11%), mainly in the inferior leads. CONCLUSIONS Chamber dimensions, left ventricular wall thickness and mass, and aortic root size were all greater than predicted for controls after matching for age and surface area. Sinus bradycardia and the ECG criteria for left ventricular hypertrophy were common but there was poor correlation with echocardiographic left ventricular hypertrophy. The type of hypertrophy found reflected the combined endurance and strength based training undertaken.

Anabolic steroids and cardiovascular risk.

Recent reports from needle exchange programmes and other public health initiatives have suggested growing use of anabolic steroids (AS) in the UK and other countries. Data indicate that AS use is not confined to bodybuilders or high-level sportsmen. Use has spread to professionals working in emergency services, casual fitness enthusiasts and subelite sportsmen and women. Although the precise health consequences of AS use is largely undefined, AS use represents a growing public health concern. Data regarding the consequences of AS use on cardiovascular health are limited to case studies and a modest number of small cohort studies. Numerous case studies have linked AS use with a variety of cardiovascular disease (CVD) events or endpoints, including myocardial infarction, stroke and death. Large-scale epidemiological studies to support these links are absent. Consequently, the impact of AS use upon known CVD risk factors has been studied in relatively small, case-series studies. Data relating AS use to elevated blood pressure, altered lipid profiles and ECG abnormalities have been reported, but are often limited in scope, and other studies have often produced equivocal outcomes. The use of AS has been linked to the appearance of concentric left ventricular hypertrophy as well as endothelial dysfunction but the data again remains controversial. The mechanisms responsible for the negative effect of AS on cardiovascular health are poorly understood, especially in humans. Possibilities include direct effects on myocytes and endothelial cells, reduced intracellular Ca2+ levels, increased release of apoptogenic factors, as well as increased collagen crosslinks between myocytes. New data relating AS use to cardiovascular health risks are emerging, as novel technologies are developed (especially in non-invasive imaging) that can assess physiological structure and function. Continued efforts to fully document the cardiovascular health consequences of AS use is important to provide a clear, accurate, public health message to the many groups now using AS for performance and image enhancement.

Predominance of normal left ventricular geometry in the male ‘athlete's heart’

Aims This study evaluated (a) global LV adaption to endurance versus resistance training in male athletes, (b) LV assessment using by modern imaging technologies and (c) the impact of scaling for body size on LV structural data. Methods A prospective cross-sectional design assessed the LV in 18 elite endurance-trained (ET), 19 elite resistance-trained (RT) and 17 sedentary control (CT) participants. Standard 2D, tissue Doppler and speckle tracking echocardiography assessed LV structure and function. Indexing of LV structures to body surface area (BSA) was undertaken using ratio and allometric scaling. Results Absolute and scaled LV end-diastolic volume (ET: 43.7±6.8; RT: 34.2±7.4; CT 32.5±8.9 mL/m1.5; p<0.05) and LV mass (ET: 29.8±6.6; RT: 25.4±8.7; CT 25.9±6.4 g/m2.7; p < 0.05) were significantly higher in ET compared with RT and CT. LV wall thickness were not different between ET and RT. 65% of ET and 95% of RT had normal geometry. Stroke volume was higher in ET compared with both RT and CT (p<0.05). Whilst regional tissue velocity data were not different between groups, longitudinal and basal circumferential strain (ε) was reduced in RT compared with ET. Conclusions In this comprehensive evaluation of the male athletes heart (AH), normal LV geometry was predominant in both athlete groups. In the ET, 30% demonstrated an eccentric hypertrophy with no concentric hypertrophy in RT. Cardiac ε data in RT require further evaluation, and any interpretation of LV size should appropriately index for differences in body size.

The endurance athletes heart: acute stress and chronic adaptation

The impact of endurance exercise training on the heart has received significant research and clinical attention for well over a century. Despite this, many issues remain controversial and clinical interpretation can be complex of biomarkers of cardiomyocyte insult. This review assesses the current state of knowledge related to two areas of research where problems with clinical decision making may arise: (1) the impact of chronic endurance exercise training on cardiac structure, function and electrical activity to the point where the athletic heart phenotype may be similar to the expression of some cardiac pathologies (a diagnostic dilemma referred to as the ‘grey-zone’) and (2) the impact of acute bouts of prolonged exercise on cardiac function and the presentation of biomarkers and cardiomyocyte insult in the circulatory system. The combination of acute endurance exercise stress on the heart and prolonged periods of training are considered together in the final section.

Performance enhancing drug abuse and cardiovascular risk in athletes: implications for the clinician

The use of performance-enhancing and social drugs by athletes raises a number of ethical and health concerns. The World Anti-Doping Agency was constituted to address both of these issues as well as publishing a list of, and testing for, banned substances in athletes. Despite continuing methodological developments to detect drug use and associated punishments for positive dope tests, there are still many athletes who choose to use performance and image enhancing drugs. Of primary concern to this review are the health consequences of drug use by athletes. For such a large topic we must put in place delimitations. Specifically, we will address current knowledge, controversies and emerging evidence in relation to cardiovascular (CV) health of athletes taking drugs. Further, we delimit our discussion to the CV consequences of anabolic steroids and stimulant (including amphetamines and cocaine) use. These drugs are reported in the majority of adverse findings in athlete drug screenings and thus are more likely to be relevant to the healthcare professionals responsible for the well-being of athletes. In detailing CV health issues related to anabolic steroid and stimulant abuse by athletes we critique current research evidence, present exemplar case studies and suggest important avenues for on-going research. Specifically we prompt the need for awareness of clinical staff when assessing the potential CV consequences of drug use in athletes.

Extrinsic compression of the left atrium: an unusual complication of a type B aortic dissection

We describe a case where rupture of a type B with extensive mediastinal hematoma. Surgical repair dissection caused compression of the left atrium with was attempted but she developed multi-organ failure impairment of left ventricular filling that presented as and died on the second postoperative day. acute pulmonary edema. The diagnosis was aided by Post mortem revealed a large blood clot (1250 g in echocardiography. weight) within the left hemithorax. This was continuA 46-year-old woman was admitted for evaluation ous with hemorrhage within the mediastinum arising of a type B dissection. She had a history of aufrom the dissection. The graft and its suture lines toimmune disease previously treated with immunowere intact. The residual native aorta at the upper suppression. She was not known to have systemic part of the graft confirmed dissection but without hypertension and there was no family history of retrograde extension into the ascending aorta nor any cardiovascular disease. On CT scanning, the dissecfurther rupture. The left ventricle had concentric tion started just below the left subclavian artery and hypertrophy. Histology showed cystic medial degeneextended to the origin of the left renal artery. ration as the underlying cause of the dissection, with On admission she was dyspneic but apyrexial. She systemic hypertension as a contributory factor. was normotensive in both arms, her heart sounds Rupture of an aortic dissection to involve a cardiac were normal and all peripheral pulses were palpable. chamber is rare. Rupture into the left atrium has been Neurological examination was normal. She was iniobserved as an incidental finding at necropsy and in tially managed medically. She later developed severe separate case reports of patients who presented with dyspnea but without pain. Clinically she had acute heart failure [1–3]. Only one report has suggested pulmonary oedema confirmed by chest X-ray. Her extrinsic compression of the left atrium as a fatal ECG was normal. Transthoracic echocardiography complication of a type B aortic dissection [4]. revealed a large hematoma arising from rupture of the We believe that the patient’s deterioration and dissection extrinsically compressing the left atrium onset of pulmonary oedema probably represented the and impairing ventricular filling (Fig. 1). Systolic time at which the rupture occurred. The echocardiogfunction was normal, as were the aortic root and ram clearly shows how the left atrium was being valve. obliterated by extrinsic compression from hematoma. At operation, she had a leaking type B dissection This lead to decreased left ventricular filling and increased pulmonary venous pressure causing pulmonary oedema and low cardiac output. *Corresponding author. Tel.: 144-151-228-1616; fax: 144-151-293Necropsy confirmed that the dissection was due to 2269. E-mail address: jason.pyatt@ccl-tr.nwest.nhs.uk (J.R. Pyatt). cystic medial degeneration and the left ventricular

A meta-analysis for the echocardiographic assessment of right ventricular structure and function in ARVC: a Study by the Research and Audit Committee of the British Society of Echocardiography

Introduction Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited pathology that can increase the risk of sudden death. Current task force criteria for echocardiographic diagnosis do not include new, regional assessment tools which may be relevant in a phenotypically diverse disease. We adopted a systematic review and meta-analysis approach to highlight echocardiographic indices that differentiated ARVC patients and healthy controls. Methods Data was extracted and analysed from prospective trials that employed a case–control design meeting strict inclusion and exclusion as well as a priori quality criteria. Structural indices included proximal RV outflow tract (RVOT1) and RV diastolic area (RVDarea). Functional indices included RV fractional area change (RVFAC), tricuspid annular systolic excursion (TAPSE), peak systolic and early diastolic myocardial velocities (S′ and E′, respectively) and myocardial strain. Results Patients with ARVC had larger RVOT1 (mean ± s.d.; 34 vs 28 mm, P < 0.001) and RVDarea (23 vs 18 cm2, P < 0.001) compared with healthy controls. ARVC patients also had lower RVFAC (38 vs 46%, P < 0.001), TAPSE (17 vs 23 mm, P < 0.001), S′ (9 vs 12 cm/s, P < 0.001), E′ (9 vs 13 cm/s, P < 0.001) and myocardial strain (−17 vs −30%, P < 0.001). Conclusion The data from this meta-analysis support current task force criteria for the diagnosis of ARVC. In addition, other RV measures that reflect the complex geometry and function in ARVC clearly differentiated between ARVC and healthy controls and may provide additional diagnostic and management value. We recommend that future working groups consider this data when proposing new/revised criteria for the echocardiographic diagnosis of ARVC.

Automated external defibrillators in public places: position statement from the Faculty of Sport and Exercise Medicine UK

Position statements published by the Faculty of Sport and Exercise Medicine UK are quick reference or information documents and include up to 10 short points of clinical relevance for the Sport and Exercise Medicine community as well as for general practitioners and health professionals. The Faculty of Sport and Exercise Medicine (FSEM) UK has published a statement to create greater awareness that the survival rate from Sudden Cardiac Arrest could improve with prompt access to an automated external defibrillator (AED).

Acute response and chronic stimulus for cardiac structural and functional adaptation in a professional boxer

The individual response to acute and chronic changes in cardiac structure and function to intense exercise training is not fully understood and therefore evidence in this setting may help to improve the timing and interpretation of pre-participation cardiac screening. The following case report highlights an acute increase in right ventricular (RV) size and a reduction in left ventricular (LV) basal radial function with concomitant increase at the mid-level in response to a weeks increase in training volume in a professional boxer. These adaptations settle by the second week; however, chronic physiological adaptation occurs over a 12-week period. Electrocardiographic findings demonstrate an acute lateral T-wave inversion at 1 week, which revert to baseline for the duration of training. It appears that a change in training intensity and volume generates an acute response within the RV that acts as a stimulus for chronic adaptation in this professional boxer.

Myopericarditis in giant cell arteritis: case report of diagnostic dilemma and review of literature

Giant cell arteritis (GCA), also known as granulomatous arteritis is a systemic vasculitis mainly affecting extra cranial branches of carotid arteries. It can rarely affect other vascular beds causing thoracic aorta aneurysm, dissection and rarely cause myocardial infarction through coronary arteritis. It can cause considerable diagnostic dilemma due to varied clinical presentations. The authors report an illustrative case of a 70-year-old woman with GCA who developed symptoms suggestive of acute myocardial infarction with chest pain, localised ST-T changes and echocardiographic left ventricular dysfunction. However, cardiac troponin T biomarkers and coronary angiography were normal. Her symptoms subsided with steroid treatment. Cardiac symptoms at first presentation of GCA are unusual.