Aortic Root Diameter in Highly-Trained Competitive Athletes: Reference Values According to Sport and Prevalence of Aortic Enlargement.

BACKGROUND: Studies exploring the extent of aortic root dilation across the different types of sport are limited. We aimed to define the physiological limits of aortic remodelling in a large population of healthy elite athletes in comparison with nonathletic controls. METHODS: A total of 1995 consecutive athletes evaluated at the Institute of Sports Medicine (Rome, Italy) and 515 healthy controls underwent a comprehensive cardiovascular screening. The aortic diameter was measured at the level of the sinuses of Valsalva. The 99th percentile from the mean of the aortic diameter in the control population was used to define an abnormally enlarged aortic root dimension. RESULTS: Athletes showed a larger aortic root diameter (30.6 [± 3.3] vs 28.1 [± 3.1] mm, P value < 0.001) than controls. The difference was evident in male and female athletes, regardless of sport- predominant component and level of intensity. The 99th percentile value for aortic root diameter in control male and female subjects was 37 mm and 32 mm, respectively. Based on these values, 50 (4.2%) male and 21 (2.6%) female athletes would have been diagnosed with an enlarged aortic root. However, aortic root diameter of clinical relevance-ie, ≥ 40 mm-was observed in only 17 male athletes (0.85%) and did not exceed > 44 mm. CONCLUSIONS: Athletes show a mild, although significant, increased aortic dimension in comparison with healthy controls. The degree of aortic enlargement varies in relation to type of sports and sex. Eventually, only a small minority of athletes exhibited a markedly enlarged aortic diameter (ie, ≥ 40 mm) in a range of clinical relevance.

Physiologic and Clinical Features of the Paralympic Athlete's Heart.

Importance: Paralympic medicine is a newly adopted term to describe the varied health care issues associated with athletes in the Paralympics. Scarce scientific data, however, are currently available describing the cardiac remodeling in Paralympic athletes. Objective: To investigate the physiological and clinical characteristics of the Paralympic athlete's heart and derive the normative values. Design, Setting, and Participants: This is a single-center study on a relatively large cohort of Paralympic athletes, conducted at the Italian Institute of Sport Medicine and Science. Paralympic athletes free of cardiac or systemic pathologic conditions other than their cause of disability were selected for participation in the Paralympic Games from January 2000 to June 2014. Athletes were arbitrarily classified for disability in 2 groups: those with spinal cord injuries (SCI) and those with non-SCI (NSCI). Data analysis occurred from March 2019 to June 2020. Main Outcomes and Measures: The primary outcome was the difference in cardiac remodeling in Paralympic athletes according to disability type and sports discipline type. Athletes underwent cardiac evaluation, including 12-lead and exercise electrocardiograms, echocardiography, and cardiopulmonary exercise testing. Results: Among 252 consecutive Paralympic athletes (median [interquartile range (IQR)] age, 34 [29-41] years; 188 men [74.6%]), 110 had SCI and 142 had NSCI. Those with SCI showed a higher prevalence of abnormal electrocardiogram findings than those with NSCI (13 of 110 [11.8%] vs 6 of 142 [4.2%]; P = .003), smaller left ventricular end-diastolic dimension (median [IQR], 48 [46-52] vs 51 [48-54] mm; P = .001) and left ventricular mass index (median [IQR], 80.6 [69-94] vs 91.3 [80-108] g/m2; P = .001), and lower peak oxygen uptake (VO2) (median [IQR], 27.1 [2-34] vs 38.5 [30-47] mL/min/kg; P = .001) in comparison with those with NSCI. Regarding sport discipline, endurance athletes had a larger left ventricular cavity (median [IQR], 52 [47-54] vs 49 [47-53] mm; P = .006) and higher peak VO2 (median [IQR], 46 [39-55] vs 30 [25-35] mL/min/kg; P = .001) than athletes in nonendurance sports. Conclusions and Relevance: Cardiac remodeling in Paralympic athletes differed by disability and sport discipline. Having NSCI lesions and engaging in endurance sports were associated with the largest left ventricular cavity and left ventricular mass and highest VO2 peak. Having SCI lesions and engaging in nonendurance disciplines, on the contrary, were associated with the smallest left ventricular cavity and mass and lowest VO2 peak.

Clinical outcomes in adult athletes with hypertrophic cardiomyopathy: a 7-year follow-up study.

OBJECTIVE: Current guidelines recommend precautionary disqualification from competitive sports in patients with hypertrophic cardiomyopathy (HCM). We assessed the incidence of cardiovascular events in a cohort of patients with HCM engaged in long-term exercise programmes and competitive sport. METHODS: We reviewed data on 88 consecutive athletes diagnosed with HCM, from 1997 to 2017; 92% male, 98% Caucasian, median age 31 (IQR: 19-44) years. All participated in regular exercise programmes and competitive sport at study entry.We performed follow-up evaluation after 7±5 (1-21) years. 61 (69%) of the athletes had substantially reduced or stopped exercise and sport (ie, HCM-detrained), and 27 had continued with regular training and sport competitions (HCM-trained). At baseline evaluation, both groups were similar for age, gender balance, symptoms, ECG abnormalities, extent of left ventricular hypertrophy, arrhythmias and risk profile for sudden cardiac death/arrest. RESULTS: During the follow-up period, two participants suffered sudden cardiac arrest or death (0.3% per year) both outside of sport participation. In addition, 19 (22%) reported symptoms (syncope in 3, palpitations in 10, chest pain in 4 and dyspnoea in 2). The Kaplan-Meier analyses of freedom from combined sudden cardiac arrest/death and symptoms (log-rank test p=0.264) showed no differences between HCM-trained and detrained patients. CONCLUSION: In this adult cohort of low-risk HCM athletes, voluntary decision to pursue in participation in competitive sport events was not associated with increased risk for major cardiac events or clinical worsening compared with decision to reduce or withdraw from exercise programmes and sport. Similar results may not be seen in younger or racially diverse athlete populations, or in patients with more severe HCM phenotypes.

Exercise stress test in apparently healthy individuals - where to place the finish line? The Ferrari corporate wellness programme experience.

AIMS: The aim of our study was to assess the clinical significance of the exercise stress testing endpoints, namely 85% of maximal theoretical heart rate (MTHR), metabolic equivalent of task, and rating of perceived exertion (RPE), and their relation to electrocardiographic (ECG) changes in a healthy adult population. METHODS: A cross-sectional study was conducted on 408 males and 52 females (mean age 39.4 ± 8.6 years) who performed the maximal cycle ergometer exercise stress test until volitional exhaustion, reporting the RPE score at 85% of MTHR and at peak exercise. Metabolic equivalents of task were indirectly calculated from the maximum workload and compared with the predicted values. Sitting torso-lead ECG and blood pressure were recorded at rest, during exercise and during recovery. RESULTS: Of 460 participants, 73% exceeded 85% of MTHR. The RPE score represented the overall most significant endpoint of exercise stress testing, with the median value of 17 at peak exercise. ECG events were detected in 23/124 (18.5%) who reached ≤ 85% of MTHR and in 61/336 (18.2%) who achieved >85% of MTHR ( p = 0.92). In the latter group, 54% of ECG changes occurred at < 85% of MTHR and 46% at > 85% of MTHR ( p = 0.51). If the exercise stress testing had been interrupted at ≤ 85% of MTHR, almost half of the ECG events would have remained undetected and 35% of the cardiovascular abnormalities observed at the diagnostic follow-up would have remained undiagnosed. CONCLUSION: Terminating exercise stress testing before volitional exhaustion and an RPE score of 17 limits the test accuracy and reduces the possibility to detect cardiovascular abnormalities in apparently healthy adult populations.

Pre-participation health evaluation in adolescent athletes competing at Youth Olympic Games: proposal for a tailored protocol.

OBJECTIVE: To promote sports participation in young people, the International Olympic Committee (IOC) introduced the Youth Olympic Games (YOG) in 2007. In 2009, the IOC Consensus Statement was published, which highlighted the value of periodic health evaluation in elite athletes. The objective of this study was to assess the efficacy of a comprehensive protocol for illness and injury detection, tailored for adolescent athletes participating in Summer or Winter YOG. METHODS: Between 2010 and 2014, a total of 247 unique adolescent elite Italian athletes (53% females), mean age 16±1,0 years, competing in 22 summer or 15 winter sport disciplines, were evaluated through a tailored pre-participation health evaluation protocol, at the Sports Medicine and Science Institute of the Italian Olympic Committee. RESULTS: In 30 of the 247 athletes (12%), the pre-participation evaluation led to the final diagnosis of pathological conditions warranting treatment and/or surveillance, including cardiovascular in 11 (4.5%), pulmonary in 11 (4.5%), endocrine in five (2.0%), infectious, neurological and psychiatric disorders in one each (0.4%). Based on National and International Guidelines and Recommendations, none of the athletes was considered at high risk for acute events and all were judged eligible to compete at the YOG. Athletes with abnormal conditions were required to undergo a periodic follow-up. CONCLUSIONS: The Youth Pre-Participation Health Evaluation proved to be effective in identifying a wide range of disorders, allowing prompt treatment, appropriate surveillance and avoidance of potential long-term consequences, in a significant proportion (12%) of adolescent Italian Olympic athletes.

Ferrari Corporate Wellness Program: Results of a Pilot Analysis and the "Drag" Impact in the Workplace.

INTRODUCTION: Preventive strategies based on advice and interventions on lifestyle habits represent the most powerful resource available to reduce the burden of cardiovascular (CV) diseases. Workplace represents an unmissable context for lifestyle changes at population level. AIM: To evaluate the mid-term efficacy of a corporate wellness program in a cohort of healthy and physically active employees of the Ferrari car manufacturer. METHODS: A corporate wellness program, named "Ferrari Formula Benessere", was proposed to adult individuals working in a Ferrari car company at Maranello, Modena (Italy). Employees who voluntarily agreed to the program received healthy nutritional advice and were trained three times a week (60 min per session), and periodically re-evaluated during a 4-year follow-up period. RESULTS: Among the 719 Ferrari employees that joined the program, 168 (23%) subjects (88.5% males, age 30.8 ± 5.9 years) were considered the most active participants, based on a self-administered standardized questionnaire, and included in the study. A relevant improvement of several CV risk factors (body mass index, total and LDL cholesterol, triglycerides, blood pressure) and cardio-respiratory fitness parameters (estimated VO2max, Wattpeak, METs) was observed compared to baseline values. Furthermore, it was recorded a clear "drag effect" towards non-participating and sedentary peers, resulting in a 90% adherence increase over the years. CONCLUSIONS: The "Ferrari Formula Benessere" corporate wellness project proved to be effective in improving CV risk profile and cardio-respiratory fitness in a population of already physically active employees.

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 athlete's 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.

RV Remodeling in Olympic Athletes.

OBJECTIVES: The aim of this study was to assess the impact of sex and different sports on right ventricular (RV) remodeling and compare the derived upper limits with widely used revised Task Force (TF) reference values. BACKGROUND: Uncertainties exist regarding the extent and physiological determinants of RV remodeling in highly trained athletes. The issue is important, considering that in athletes RV size occasionally exceeds the cutoff limits proposed to diagnose arrhythmogenic RV cardiomyopathy. METHODS: A total of 1,009 Olympic athletes (mean age 24 ± 6 years; n = 647 [64%] males) participating in skill, power, mixed, and endurance sport were evaluated by 2-dimensional echocardiography and Doppler/tissue Doppler imaging. The right ventricular outflow tract (RVOT) in parasternal long-axis (PLAX) and short-axis views, fractional area change, s' velocity, and morphological features were assessed. RESULTS: Indexed RVOT PLAX was greater in females than in males (15.3 ± 2.2 mm/m2 vs. 14.4 ± 1.9 mm/m2; p < 0.001). Both RVOT PLAX and parasternal short-axis view were significantly different among skill, power, mixed, and endurance sports: 14.3 ± 2.1 mm/m2 versus 14.7 ± 1.9 mm/m2 versus 14.0 ± 1.8 mm/m2 versus 15.7 ± 2.2 mm/m2, respectively (p < 0.001); and 15.2 ± 2.7 mm/m2 versus 15.3 ± 2.4 mm/m2 versus 14.8 ± 2.1 mm/m2 versus 16.2 ± 2.5 mm/m2, respectively (p < 0.001). The 95th percentile for indexed RVOT PLAX and parasternal short-axis view was 18 mm/m2 and 20 mm/m2, respectively. Fractional area change and s' velocity did not differ among the groups (p = 0.34 for both). RV enlargement compatible with major and minor TF diagnostic criteria for arrhythmogenic RV cardiomyopathy was observed in 41 (4%) and 319 (32%) athletes. A rounded apex was described in 823 (81%) athletes, prominent trabeculations in 378 (37%) athletes, and a prominent/hyperreflective moderator band in 5 (0.5%) athletes. CONCLUSIONS: RV remodeling occurs in Olympic athletes, with male sex and endurance practice playing the major impact. A significant subset (up to 32%) of athletes exceeds the normal TF limits; therefore, we recommend referring to the 95th percentiles here reported as referral values; alternatively, only major diagnostic TF criteria for arrhythmogenic RV cardiomyopathy may be appropriate.

Prominent left ventricular trabeculations in competitive athletes: A proposal for risk stratification and management.

BACKGROUND: Recently, an unexpectedly large prevalence of Left Ventricular Non Compaction (LVNC) has been reported in athletes, raising the question of the appropriateness of current diagnostic criteria. We sought to describe prevalence and clinical characteristics of athletes with suspected LVNC in a large cohort of Olympic athletes. METHODS: Over 29months, 2501 consecutive athletes underwent a cardiac evaluation including physical examination, ECG, exercise test and echocardiography. Additional investigations (Cardiac Magnetic Resonance and/or genetic testing) were selectively performed in athletes with abnormal ECGs, ventricular arrhythmias, borderline LV dysfunction or positive family history. RESULTS: Of the 2501 athletes, 36 (1.4%) showed prominent trabeculations suggestive for LVNC. Of these, 3 (0.1%) were considered to be affected by LVNC, based on presence of LV dysfunction (ejection fraction<50%) and/or positive family history and genetic testing; these athletes were cautiously restricted from competitions and entered a clinical follow-up program. The remaining 33 athletes, in the absence of LV impairment or familial cardiac diseases, were considered normal (n=24) or unlikely affected (n=9), regardless of the extent of the trabeculations. CONCLUSIONS: In a large athlete population, a marked LV trabecular pattern was seen in 1.4%. Only a small subset of these athletes (0.1%) showed familial, clinical and morphologic changes supporting the diagnosis of LVNC. In the vast majority of the athletes, the increased trabeculations were not associated with LV dysfunction and/or positive family history, likely representing a morphologic LV variant, deprived of clinical significance.

Differential diagnosis between early repolarization of athlete's heart and coved-type Brugada electrocardiogram.

Early repolarization (ER) is typically observed in highly trained athletes as a physiologic consequence of increased vagal tone. The variant of anterior (V1 to V3) ER characterized by "domed" ST-segment elevation and negative T wave raises problems of differential diagnosis with the "coved-type" electrocardiographic pattern seen in Brugada syndrome (BS). This study was designed to identify electrocardiographic criteria for distinguishing athlete's ER from BS. The study compared the electrocardiographic tracings of 61 healthy athletes (80% men, median age 23 ± 8 years), showing "domed" ST-segment elevation and negative T wave in leads V1 to V3, with those of 92 consecutive age- and sex-matched BS patients with a "coved-type" electrocardiographic pattern. The electrocardiographic analysis focused on the ST-segment elevation at J point (STJ) and at 80 milliseconds after J point (ST80). Athletes had a lower maximum amplitude of STJ (1.46 ± 0.7 vs 3.25 ± 0.6 mm, p <0.001) and lower STJ/ST80 (0.8 ± 0.3 vs 1.6 ± 0.3, p <0.001). All patients (100%) with BS showed a downsloping ST-segment configuration (STJ/ST80 >1) versus only 2 (3%) athletes (p <0.001). An upsloping ST-segment configuration (STJ/ST80 <1) showed a sensitivity of 97%, a specificity of 100%, and a diagnostic accuracy of 98.7% for the diagnosis of ER. At multivariate analysis, STJ/ST80 ratio remained the only independent predictor for ER (odds ratio 87, 95% confidence interval 19 to 357, p <0.001). In conclusion, the STJ/ST80 ratio is a highly accurate electrocardiographic parameter for differential diagnosis between anterior ER of the athlete and BS. Our results may help in reducing the number of athletes who undergo expensive diagnostic workup or are unnecessarily disqualified from competition for changes that fall within the normal range of athlete's heart.

Patterns of left ventricular longitudinal strain and strain rate in Olympic athletes.

BACKGROUND: Two-dimensional speckle-tracking echocardiography is an emerging modality for the assessment of systolic and diastolic myocardial deformation in a broad variety of clinical scenarios. However, normal values and physiologic limits of left ventricular strain and strain rate in trained athletes are largely undefined. METHODS: Two hundred consecutive Olympic athletes (grouped into skill, power, mixed, and endurance disciplines) and 50 untrained controls were evaluated by two-dimensional speckle-tracking echocardiography. Left ventricular global systolic longitudinal strain (GLS), systolic strain rate, early diastolic strain rate (SRE) and late diastolic strain rate (SRA) were calculated. RESULTS: GLS was normal, although mildly lower, in athletes compared with controls (-18.1 ± 2.2% vs -19.4 ± 2.3%, P < .001), without differences related to type of sport. Systolic strain rate was also lower in athletes (-1.00 ± 0.15 vs -1.11 ± 0.15 sec(-1), P < .001), with the lowest value in endurance disciplines (-0.96 ± 0.13 sec(-1), P < .001). No difference existed for SRE (1.45 ± 0.32 vs 1.51 ± 0.35 sec(-1), P = .277), while SRA was lower in athletes (0.67 ± 0.25 vs 0.81 ± 0.20 sec(-1), P < .001). Both SRE (1.37 ± 0.30 sec(-1), P < .001) and SRA (0.62 ± 0.23 sec(-1), P < .001) showed the lowest values in endurance disciplines. The fifth and 95th percentiles calculated as reference values in athletes were as follows: for GLS, -15% and -22%; for systolic strain rate, -0.8 and -1.2 sec(-1); for SRE, 1.00 and 2.00 sec(-1); and for SRA, 0.30 and 1.20 sec(-1). CONCLUSION: The present study shows that highly trained athletes have normal GLS and strain rate parameters of the left ventricle, despite mild differences compared with untrained controls. These data may be implemented as reference values for the clinical assessment of the athletes and to support the diagnosis of physiologic cardiac adaptations in borderline cases.

Patterns of left ventricular diastolic function in Olympic athletes.

BACKGROUND: Whether morphologic left ventricular (LV) changes in elite athletes are associated with altered diastolic properties is undefined. The aim of this study was to investigate LV diastolic properties in a large population of Olympic athletes compared to untrained controls. METHODS: A total of 1,145 Olympic athletes (61% men), and 154 controls, free of cardiovascular disease, underwent two-dimensional echocardiography, Doppler echocardiography, and Doppler tissue imaging. RESULTS: Athletes had similar E velocities (87 ± 15 vs 89 ± 16 cm/sec, P = .134) but significantly decreased A velocities (47 ± 10 vs 56 ± 12 cm/sec, P < .001) compared with controls, with increased E/A ratios (1.93 ± 0.50 vs 1.63 ± 0.35, P < .001) and values ranging up to 4.8. Isovolumic relaxation (83 ± 13 vs 71 ± 16 msec, P < .001) and deceleration times (203 ± 40 vs 181 ± 36 msec, P < .001) were longer in athletes compared with controls. Doppler tissue imaging e' (13.8 ± 2.2 vs 16.2 ± 3.7 cm/sec, P < .001) and a' (7.2 ± 1.8 vs 8.5 ± 2.1 cm/sec, P < .001) were lower in athletes than in controls, but their ratio was not different between groups; E/e' ratios (6.37 ± 1.2 vs 5.72 ± 1.33, P < .001) were mildly higher in athletes. Subgroup analysis for type of sport showed that endurance athletes had the lowest A and a' velocities and the largest E/A ratios. Gender analysis revealed that men had significantly lower E and A velocities, as well as e', e'/a' ratios, and E/e' ratios (P < .01), compared with women. CONCLUSION: This study provides normal values for Doppler echocardiographic and Doppler tissue imaging parameters describing diastolic function in elite athletes, which may be implemented as reference values in the clinical assessment of athlete's heart and prove useful in understanding the physiologic limits of cardiac adaptations in athletes.

Screening athletes for cardiovascular disease in Africa: a challenging experience.

AIMS: Preparticipation cardiovascular (CV) screening has been advocated as an efficient strategy to reduce sudden cardiac death in Caucasian athletes. At present, uncertainty remains if such strategy is feasible and efficient in native African athletes. To this scope, we performed a CV screening in an African setting. METHODS: 210 male Gabonian football players were examined with history, physical examination, ECG and echocardiography. RESULTS: On history, 19 players (9%) referred atypical chest discomfort/oppression. Familial sudden death was referred by 36 (17%). No anomalies were detected at physical examination. ECG showed large proportions of 'training-related' abnormalities, that is, ST-segment elevation in precordial leads in 150 (71.4%), and isolated increase in R/S-wave voltage in 116 (55.2%). A substantial subset (12.4%) showed 'training-unrelated' abnormalities, that is, inverted T-waves in 10 (4.8%), left atrial enlargement in 8 (4%), deep Q-waves in 3 (1.4%). On echocardiography, one athlete meet criteria for hypertrophic cardiomyopathy (HCM); none showed evidence for arrhythmogenic right ventricular cardiomyopathy (ARVC) or dilated cardiomyopathy (DCM). Other abnormalities included mitral valve prolapse in three, atrial septal defect in two and pulmonary hypertension in one. CONCLUSIONS: About 12% of native African athletes showed ECG abnormalities unrelated to training and requiring additional testing and periodical follow-up. Structural abnormalities were found, however, in a minority (5%), including HCM in one, but no ARVC or DCM. In conclusion, this study demonstrates that preparticipation CV screening is efficient to identify (or raise suspicion) for CV abnormalities in native African athletes, but challenging for conclusive identification of cardiac diseases in the difficult scenario of a developing African country.

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.

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.

Left ventricular systolic performance is improved in elite athletes.

AIMS: We sought to investigate the systolic time interval (STI) and efficiency of left ventricular (LV) contraction comparatively in elite athletes and healthy sedentary controls by means of three-dimensional echocardiography (3DE). METHODS AND RESULTS: Four hundred and twenty-nine elite athletes, involved in skill (n = 41), power (n = 63), mixed (n = 167), and endurance (n = 158) disciplines and 98 sedentary controls, matched for age, underwent 3DE. By off-line analysis, we measured the absolute and relative (normalized by the R-R interval) timing of LV systolic emptying (STI and STI%) and the systolic flow velocity (SFV = stroke volume/STI). Both STI and STI% were shorter in athletes, regardless of the sport discipline, compared with controls (respectively, 324 ± 36 vs. 345 ± 33 ms, P < 0.001; 30 ± 4 vs. 40 ± 4%; P< 0.001). Regression analysis showed that heart rate was the most important determinant of STI (R(2) = 0.38; P < 0.001), while age, body surface area, blood pressure, LV volumes, and mass had no significant association. After removing the effects of heart rate and gender, athletes showed a significant reduction (by 50.4 ms; 95% confidence interval, from 57.7 to 43.1) in STI compared with untrained subjects. Finally, higher SFV were identified in skill (256 ± 60 mL/s; P < 0.001), strength (297 ± 78 mL/s; P < 0.001), mixed (308 ± 67 mL/s; P < 0.001), and endurance (334 ± 74 mL/s; P < 0.001) athletes compared with controls (204 ± 50 mL/s). CONCLUSION: Elite athletes show a significant shortening of the systolic time duration in comparison with sedentary controls, in association with a significant increase in LV emptying velocity. This pattern characterizes the physiological LV adaptation of the athletes and may potentially be useful in differential diagnosis of the 'athlete heart'.