Blood pressure response during exercise testing in individuals with and without hypertension: The value of the recovery phase.

BACKGROUND: Hypertension and exercise testing are essential for cardiovascular risk assessment. However, an exact description of blood pressure (BP) in patients with a hypertensive response during exercise (HRE), especially in the recovery phase is lacking. Herein, we aimed to analyse BP and heart rate during exercise testing and recovery in patients with an HRE. METHODS: 800 patients aged 17-90 with an HRE during a standardized bicycle ergometry test were recruited. The BP behaviour during exercise testing was correlated with clinical data. Furthermore, data were analysed according to the presence of pre-existent hypertension. RESULTS: Of the 800 patients included in this study 497 (62%) were previously diagnosed with hypertension. Analysis of covariance showed a significantly faster systolic (ß [95% CI] 8.0 [4.9-11.1]) and diastolic (2.4 [0.4-4.4]) BP recovery 3 min after maximal exercise in patients without hypertension in univariable models. These results remained robust in fully adjusted models taking into account age, sex, body mass index, cardiovascular disease, and antihypertensive treatment for systolic (5.3 [1.2-9.4]) and diastolic BP (4.5 [1.9-7.0]). Furthermore, patients with hypertension displayed higher systolic BP during maximal exercise in univariable (3.8 [0.1-7.5]) and fully adjusted (5.5 [1.1-10.0]) models. There was no difference in maximum diastolic BP between groups. CONCLUSION: In this large cohort study, patients without hypertension showed a faster systolic and diastolic BP recovery and lower maximal systolic BP compared to patients with hypertension. Overall, this study provides new insights into cardiovascular health during recovery phase.

Alive and kicking: suicide rates and major soccer events in Austria, Germany and Switzerland.

BACKGROUND: Major sporting events are postulated to reduce suicide rates by increased social connectedness, by identifying with winning teams, or, conversely, to increase suicide rates by the 'broken promise effect'. METHODS: In our observational epidemiological study, we investigated changes in suicide rates between 1970 and 2017 in Austria, Germany and Switzerland during the European and World Soccer Championships in general, and on days that the home team played, won or lost. RESULTS: Combining all three studied nations no statistically significant change in the incidence of daily suicides during soccer championships compared to a control period was noted (38.29 ± 9.02 vs. 37.33 ± 10.58; incidence risk ratio = 1.03; 95% confidence interval: 1.01-1.05, P = 0.05). Essentially, no differences in the expected directions were found, and none remained statistically significant after correcting for multiple comparisons in subgroups for country, age and gender in all three studied countries. Compared to a control period, neither a significant difference in the respective national suicide rate was found after Germany's four championship victories nor after Austria's emotional only win over Germany. CONCLUSION: Our results do not support the assumption of increased social connectedness and, thus, lowered suicide risk during major sporting events or changes in suicide risk depending on the outcome of important games as predicted by the broken promise effect or changes in self-efficacy by identification with winning teams.

Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis: position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC).

Myocardial diseases are associated with an increased risk of potentially fatal cardiac arrhythmias and sudden cardiac death/cardiac arrest during exercise, including hypertrophic cardiomyopathy, dilated cardiomyopathy, left ventricular non-compaction, arrhythmogenic cardiomyopathy, and myo-pericarditis. Practicing cardiologists and sport physicians are required to identify high-risk individuals harbouring these cardiac diseases in a timely fashion in the setting of preparticipation screening or medical consultation and provide appropriate advice regarding the participation in competitive sport activities and/or regular exercise programmes. Many asymptomatic (or mildly symptomatic) patients with cardiomyopathies aspire to participate in leisure-time and amateur sport activities to take advantage of the multiple benefits of a physically active lifestyle. In 2005, The European Society of Cardiology (ESC) published recommendations for participation in competitive sport in athletes with cardiomyopathies and myo-pericarditis. One decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of cardiomyopathies and myo-pericarditis. The present document, therefore, aims to offer a comprehensive overview of the most updated recommendations for practicing cardiologists and sport physicians managing athletes with cardiomyopathies and myo-pericarditis and provides pragmatic advice for safe participation in competitive sport at professional and amateur level, as well as in a variety of recreational physical activities.

The Cardiovascular Response to Interval Exercise Is Modified by the Contraction Type and Training in Proportion to Metabolic Stress of Recruited Muscle Groups.

BACKGROUND: Conventional forms of endurance training based on shortening contractions improve aerobic capacity but elicit a detriment of muscle strength. We hypothesized that eccentric interval training, loading muscle during the lengthening phase of contraction, overcome this interference and potentially adverse cardiovascular reactions, enhancing both muscle metabolism and strength, in association with the stress experienced during exercise. METHODS: Twelve healthy participants completed an eight-week program of work-matched progressive interval-type pedaling exercise on a soft robot under predominately concentric or eccentric load. RESULTS: Eccentric interval training specifically enhanced the peak power of positive anaerobic contractions (+28%), mitigated the strain on muscle's aerobic metabolism, and lowered hemodynamic stress during interval exercise, concomitant with a lowered contribution of positive work to the target output. Concentric training alone lowered blood glucose concentration during interval exercise and mitigated heart rate and blood lactate concentration during ramp exercise. Training-induced adjustments for lactate and positive peak power were independently correlated (p < 0.05, |r| > 0.7) with indices of metabolic and mechanical muscle stress during exercise. DISCUSSION: Task-specific improvements in strength and muscle's metabolic capacity were induced with eccentric interval exercise lowering cardiovascular risk factors, except for blood glucose concentration, possibly through altered neuromuscular coordination.

International recommendations for electrocardiographic interpretation in athletes.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

International criteria for electrocardiographic interpretation in athletes: Consensus statement.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

Prevalence and management of familial hypercholesterolaemia in patients with acute coronary syndromes.

AIMS: We aimed to assess the prevalence and management of clinical familial hypercholesterolaemia (FH) among patients with acute coronary syndrome (ACS). METHODS AND RESULTS: We studied 4778 patients with ACS from a multi-centre cohort study in Switzerland. Based on personal and familial history of premature cardiovascular disease and LDL-cholesterol levels, two validated algorithms for diagnosis of clinical FH were used: the Dutch Lipid Clinic Network algorithm to assess possible (score 3-5 points) or probable/definite FH (>5 points), and the Simon Broome Register algorithm to assess possible FH. At the time of hospitalization for ACS, 1.6% had probable/definite FH [95% confidence interval (CI) 1.3-2.0%, n = 78] and 17.8% possible FH (95% CI 16.8-18.9%, n = 852), respectively, according to the Dutch Lipid Clinic algorithm. The Simon Broome algorithm identified 5.4% (95% CI 4.8-6.1%, n = 259) patients with possible FH. Among 1451 young patients with premature ACS, the Dutch Lipid Clinic algorithm identified 70 (4.8%, 95% CI 3.8-6.1%) patients with probable/definite FH, and 684 (47.1%, 95% CI 44.6-49.7%) patients had possible FH. Excluding patients with secondary causes of dyslipidaemia such as alcohol consumption, acute renal failure, or hyperglycaemia did not change prevalence. One year after ACS, among 69 survivors with probable/definite FH and available follow-up information, 64.7% were using high-dose statins, 69.0% had decreased LDL-cholesterol from at least 50, and 4.6% had LDL-cholesterol ≤1.8 mmol/L. CONCLUSION: A phenotypic diagnosis of possible FH is common in patients hospitalized with ACS, particularly among those with premature ACS. Optimizing long-term lipid treatment of patients with FH after ACS is required.

Improvement of cardiac screening in amateur athletes.

Although not performing on a professional level, amateur athletes, nevertheless, are participating in competitive sports and thus underlie a relevant risk for exercise-related SCD which implicates the need for an adequate pre-competition cardiac screening. As many amateur athletes belong to the category of "older" individuals, particularly CAD among male athletes with risk factors has to be targeted by the screening. However, the detection of clinically silent underlying coronary heart disease is challenging and cannot be accurately achieved by a standard screening provided to young athletes (history, clinical status, ECG). An extended work-up, at least, mandates the detection of cholesterol levels to estimate the individual cardiovascular risk. The fact that only less than 10% of Swiss amateur athletes have undergone cardiac screening led to various promising approaches to improve the awareness of the issue. Exemplarily, we successfully invented an "on-site" prevention campaign that positively influenced the attitude of the athletes towards cardiac screening.

Robot-Assisted Training Early After Cardiac Surgery.

BACKGROUND: To assess feasibility and safety of a robot-assisted gait therapy with the Lokomat® system in patients early after open heart surgery. METHODS: Within days after open heart surgery 10 patients were subjected to postoperative Lokomat® training (Intervention group, IG) whereas 20 patients served as controls undergoing standard postoperative physiotherapy (Control group, CG). All patients underwent six-minute walk test and evaluation of the muscular strength of the lower limbs by measuring quadriceps peak force. The primary safety end-point was freedom from any device-related wound healing disturbance. Patients underwent clinical follow-up after one month. RESULTS: Both training methods resulted in an improvement of walking distance (IG [median, interquartile range, p-value]: +119 m, 70-201 m, p = 0.005; CG: 105 m, 57-152.5m, p < 0.001) and quadriceps peak force (IG left: +5 N, 3.8 7 N, p = 0.005; IG right: +3.5 N, 1.5-8.8 N, p = 0.011; CG left: +5.5 N, 4-9 N, p < 0.001; CG right: +6 N, 4.3-9.8 N, p < 0.001) in all participants. Results with robot-assisted training were comparable to early postoperative standard in hospital training (median changes in walking distance in percent, p = 0.81; median changes in quadriceps peak force in percent, left: p = 0.97, right p = 0.61). No deep sternal wound infection or any adverse event occurred in the robot-assisted training group. CONCLUSIONS: Robot-assisted gait therapy with the Lokomat® system is feasible and safe in patients early after median sternotomy. Results with robot-assisted training were comparable to standard in hospital training. An adapted and combined aerobic and resistance training intervention with augmented feedback may result in benefits in walking distance and lower limb muscle strength (ClinicalTrials.gov number, NCT 02146196).

Dental Health Benefits of Swimming in Chlorinated Water.

Poor oral health is an important concern for athletes, as it can affect both general health and athletic performance. The aim of this study is to investigate the effects of activity in chlorinated water on oral health in elite swimmers compared to non-swimming athletes. This cross-sectional study included 101 swimmers and 100 other athletes aged 13-26 years with a minimum training intensity of five hours per week (for at least the preceding two years). Oral health was assessed using the approximal plaque index (API) and the decayed/missing/filled teeth (DMFT) index. A DIAGNOcam was used to detect caries. Results show that swimmers were younger (15 years vs. 18 years), were more likely to be female (54% vs. 17%), and had a lower body mass index (20.1 kg/m2 vs. 21.9 kg/m2) and a lower juice consumption (9% vs. 24%). Non-swimmers had significantly more decayed, missing, or filled teeth due to caries and plaque. In conclusion, by comparing elite swimmers and athletes competing in different sports, we have shown that competitive swimmers have a lower incidence of dental caries and plaque. Further research is needed to test our findings and to understand this relationship in greater detail.

Effect of a Hypertensive Response During Exercise on Growth Rates of Aortic Diameters.

BACKGROUND: Aortic diameters are related to age, sex, and body size. There is a scarcity of data on the long-term sequelae of a hypertensive response to exercise (HRE) on aortic diameters. In this retrospective cohort study, we aimed to evaluate the relationship between the growth rates of the aorta in individuals with a HRE. METHODS: Our analysis included follow-up data of 649 patients recruited between January 2009 and December 2014 with a HRE. Participants with known connective tissue disease or a history of acute aortic syndrome were excluded. Sinus of Valsalva (SoV) and ascending aorta (AscAo) diameters were measured by transthoracic echocardiography using leading edge to leading edge convention at end-diastole. RESULTS: At baseline, median age, maximum systolic blood pressure (BP), body mass index (BMI), diameter of the SoV, and AscAo were 62 years, 208 mm Hg, 26.9 kg/m2, 35 mm, and 35 mm respectively. 32% of patients were female and 67% had hypertension. After a median follow-up of 7.1 years, mean yearly growth rates (±SD) of the SoV and AscAo were 0.09 (0.41) mm and 0.13 (0.56) mm, respectively. No significant associations were observed between growth rates of aortic diameters and maximum systolic and diastolic BP or when considering only individuals with a baseline diameter >40 mm. CONCLUSIONS: In this large cohort study, maximum systolic and diastolic BP during exercise showed no association with growth rates of aortic diameters. Furthermore, the mean growth rates of aortic diameters in this population were in line with growth rates in a normal population.

The FIFA medical emergency bag and FIFA 11 steps to prevent sudden cardiac death: setting a global standard and promoting consistent football field emergency care.

Life-threatening medical emergencies are an infrequent but regular occurrence on the football field. Proper prevention strategies, emergency medical planning and timely access to emergency equipment are required to prevent catastrophic outcomes. In a continuing commitment to player safety during football, this paper presents the FIFA Medical Emergency Bag and FIFA 11 Steps to prevent sudden cardiac death. These recommendations are intended to create a global standard for emergency preparedness and the medical response to serious or catastrophic on-field injuries in football.

Normal electrocardiographic findings: recognising physiological adaptations in athletes.

Electrocardiographic changes in athletes are common and usually reflect benign structural and electrical remodelling of the heart as a physiological adaptation to regular and sustained physical training (athlete's heart). The ability to identify an abnormality on the 12-lead ECG, suggestive of underlying cardiac disease associated with sudden cardiac death (SCD), is based on a sound working knowledge of the normal ECG characteristics within the athletic population. This document will assist physicians in identifying normal ECG patterns commonly found in athletes. The ECG findings presented as normal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Electrocardiographic interpretation in athletes: the 'Seattle criteria'.

Sudden cardiac death (SCD) is the leading cause of death in athletes during sport. Whether obtained for screening or diagnostic purposes, an ECG increases the ability to detect underlying cardiovascular conditions that may increase the risk for SCD. In most countries, there is a shortage of physician expertise in the interpretation of an athlete's ECG. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from abnormal findings suggestive of pathology. On 13-14 February 2012, an international group of experts in sports cardiology and sports medicine convened in Seattle, Washington, to define contemporary standards for ECG interpretation in athletes. The objective of the meeting was to develop a comprehensive training resource to help physicians distinguish normal ECG alterations in athletes from abnormal ECG findings that require additional evaluation for conditions associated with SCD.

Abnormal electrocardiographic findings in athletes: recognising changes suggestive of cardiomyopathy.

Cardiomyopathies are a heterogeneous group of heart muscle diseases and collectively are the leading cause of sudden cardiac death (SCD) in young athletes. The 12-lead ECG is utilised as both a screening and diagnostic tool for detecting conditions associated with SCD. Fundamental to the appropriate evaluation of athletes undergoing ECG is an understanding of the ECG findings that may indicate the presence of an underlying pathological cardiac disorder. This article describes ECG findings present in cardiomyopathies afflicting young athletes and outlines appropriate steps for further evaluation of these ECG abnormalities. The ECG findings defined as abnormal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Abnormal electrocardiographic findings in athletes: recognising changes suggestive of primary electrical disease.

Cardiac channelopathies are potentially lethal inherited arrhythmia syndromes and an important cause of sudden cardiac death (SCD) in young athletes. Other cardiac rhythm and conduction disturbances also may indicate the presence of an underlying cardiac disorder. The 12-lead ECG is utilised as both a screening and a diagnostic tool for detecting conditions associated with SCD. Fundamental to the appropriate evaluation of athletes undergoing ECG is an understanding of the ECG findings that may indicate the presence of a pathological cardiac disease. This article describes ECG findings present in primary electrical diseases afflicting young athletes and outlines appropriate steps for further evaluation of these ECG abnormalities. The ECG findings defined as abnormal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Hypertensive response to exercise, hypertension and heart failure with preserved ejection fraction (HFpEF)-a continuum of disease?

INTRODUCTION: Heart failure with preserved ejection fraction (HFpEF) has been shown to be a long-term consequence of uncontrolled arterial hypertension (aHT). Other than that, hypertensive response to exercise (HRE) precedes aHT. We aim to evaluate the available evidence for a continuum of HRE, aHT and HFpEF. METHODS: A literature search on PubMed was conducted to assembly the most recent data on the topic. After collecting the data, a qualitative analysis was instrumented. RESULTS: 10 studies including 16,165 subjects were analyzed with respect to the association between HRE and the future risk of developing aHT. With the exception of one study, all reported on a positive association between HRE and the future development of aHT despite methodological issues related to different definitions for HRE. Furthermore, HRE was associated with an increased risk of coronary artery disease. Moreover, we analysed 6 studies including overall 1366 subjects investigating the association between HRE and HFpEF. In these studies, increased left atrial volume index (LAVI), elevated E/e' (as surrogate parameters of increased LV end-diastolic filling pressure and of diastolic dysfunction) and higher LV mass index have been proposed as independent predictor of HRE in patients with no known HFpEF diagnosis. DISCUSSION AND CONCLUSION: The literature search revealed suggestive data on a connection of HRE, aHT and HFpEF. HRE seems to be an independent risk factor for aHT and aHT in turn is one of the main risk factors for HFpEF. However, further research is needed to improve our knowledge of a possible continuum of disease.

Hypertensive Response to Exercise in Athletes: Unremarkable Finding or Relevant Marker for Future Cardiovascular Complications?

Background: In the general population, hypertensive response to exercise (HRE) predicts new-onset resting hypertension or other cardiovascular diseases. Methods: PubMed was searched for English articles published between January 1st 2000 and April 30th 2020. Additional studies were identified via reference lists of included studies. 92 papers were selected for full text analysis, finally 30 studies were included. Results: The results from 5 follow-up studies suggested an association between HRE and the risk of developing hypertension, while 10 studies reported a link with adverse cardiovascular events in the general population. Another study showed an association between HRE and future hypertension in athletes after a follow-up of 7 years. HRE in athletes was associated with left ventricular hypertrophy in three studies. Two other studies showed a link between HRE and focal myocardial fibrosis in triathletes and myocardial injury, respectively. One study found lower Apoliprotein-1 serum levels in athletes with HRE leading to a higher risk for cardiovascular disease. Only in one study no association with cardiovascular dysfunction in athletes with HRE was found. Conclusions: Based on current evidence, HRE is not a normal finding in athletes. If detected, it should be interpreted as a risk factor for future cardiovascular complications. Future research should address the adequate follow-up and management of athletes with HRE.

Definitions for Hypertensive Response to Exercise.

Broad evidence indicates that hypertensive response to exercise (HRE) is associated with future hypertension (aHT) at rest and cardiovascular morbidity and mortality. Nevertheless, a consensus on the definition of HRE is lacking and the comparability of the available data is difficult due to a wide variation of definitions used. This review aims to harmonize currently available definitions of HRE in normotensive and athletic populations and to propose a generally valid cut-off applicable in everyday clinical practice. A literature search on PubMed and Embase was conducted to assemble and analyze the most recent data. Various definitions of HRE were identified and linked with future cardiovascular diseases. Forty-one studies defined HRE at a peak systolic blood pressure (SBP) above or equal to 200 mmHg in men and 25 studies for 190 mmHg in women. Peak diastolic blood pressure (DBP) between 90 and 110 mmHg was reported in 14 studies, relative DBP increase in four. Eight studies defined HRE as SBP between 160 and 200 mmHg at 100 watts. 17 studies performed submaximal exercise testing, while two more looked at BP during recovery. A plethora of other definitions was identified. In athletes, total workload and average blood pressure during exercise were considerably higher. Based on the presented data, the most commonly used definition of HRE at peak exercise is 210/105 mmHg for men, 190/105 mmHg for women, and 220/210 mmHg for athletes. Furthermore, a uniform exercise testing protocol, a position statement by leading experts to unify the definition of HRE, and prospective studies are warranted to confirm these cut-offs and the associated morbidity and mortality.