Associations between 24-h heart rate variability and aerobic fitness in high-level female soccer players.

OBJECTIVE: The aim of this study was to investigate the changes in 24-h heart rate variability and aerobic fitness, and their associations, in female soccer players during the preseason period. METHODS: Sixteen players were assessed (24-h HRV and Yo-Yo Intermittent Recovery Test, level 1 [YYIR1]) before and after 4 weeks of preseason. The relationship between R-R24h length and high-frequency oscillations (HF24h) was analyzed by a quadratic regression model (revealing or not saturation of vagal activity) assessed 48-h before (PRE-preseason) and 48-h after (POST-preseason) the preseason period. Additionally, the mean HF24h was calculated from the linear portion of the R-R interval versus the HF24h regression curve (HF index). The average of the corresponding R-R24h values was defined as the R-R index. RESULTS: In PRE-preseason, seven players had a saturated HF24h, while in POST-preseason, five new cases of saturated HF24h were observed. The mean R-R24h, HF24h, R-R index, and HF index lengths significantly increased after preseason (p < 0.001). Significant differences were found in YYIR1 PRE- compared with POST-preseason (930 ± 286 m [individual range: 400-1240 m] versus 1265 ± 252 m [640-1640 m], respectively; p < 0.001). Additionally, the relative changes in HF24h and HF index were largely correlated with improvements in the distance covered during the YYIR1 (r = 0.68 and r = 0.56; respectively). CONCLUSION: Enhanced vagal activity after 4-week preseason period of soccer training increased the occurrence of vagal saturation in high-level female soccer players. Additionally, the increases in HF24h and HF index were significantly correlated with aerobic fitness change.

Subclinical coronary artery disease in veteran athletes: is a new preparticipation methodology required?

OBJECTIVE: Preparticipation evaluation of veteran athletes should focus on accurate cardiovascular (CV) risk stratification and subclinical detection of coronary artery disease (CAD), which is the main cause of sudden cardiac death in this population. We aimed to investigate the effectiveness of current preparticipation methodology used to identify veteran athletes with high coronary atherosclerotic burden. METHODS: A total of 105 asymptomatic male athletes aged ≥40 years old, with low to moderate CV risk (Systematic Coronary Risk Estimation <5%) who trained ≥4 hours/week for at least 5 years, were studied. The screening protocol included clinical evaluation, ECG, transthoracic echocardiogram and exercise testing. Cardiac CT was performed to detect CAD, defined as a high atherosclerotic burden according to coronary artery calcium score and coronary CT angiography. RESULTS: The majority of the athletes (n=88) engaged in endurance sports, with a median volume of exercise of 66 (44; 103) metabolic equivalent task score/hour/week. Exercise testing was abnormal in 13 (12.4%) athletes, 6 (5.7%) with electrocardiographic criteria for myocardial ischaemia and 7 (6.7%) with exercise-induced ventricular arrhythmias. A high coronary atherosclerotic burden was present in 27 (25.7%) athletes, of whom 11 (40.7%) had CV risk factors and 6 had abnormal exercise tests, including 3 who were positive for myocardial ischaemia. CONCLUSIONS: Conventional methodology used in preparticipation evaluation of veteran athletes, based on clinical CV risk factors and exercise testing, was poor at identifying significant subclinical CAD. The inclusion of more objective markers, particularly data derived from cardiac CT, is promising for more accurate CV risk stratification of these athletes.

Effects of combined training with different intensities on vascular health in patients with type 2 diabetes: a 1-year randomized controlled trial.

BACKGROUND: Exercise, when performed on a regular basis, is a well-accepted strategy to improve vascular function in patients with type 2 diabetes. However, the exercise intensity that yields maximal adaptations on structural and functional indices in patients with type 2 diabetes remains uncertain. Our objective was to analyze the impact of a 1-year randomized controlled trial of combined high-intensity interval training (HIIT) with resistance training (RT) vs. a combined moderate continuous training (MCT) with RT on structural and functional arterial indices in patients with type 2 diabetes. METHODS: Patients with type 2 diabetes (n = 80) were randomized into an exercise intervention with three groups: control, combined HIIT with RT and combined MCT with RT. The 1-year intervention had 3 weekly exercise sessions. High-resolution ultrasonography of the common carotid artery and central and peripheral applanation tonometry were used to assess the changes in structural and functional arterial indices. Generalized estimating equations were used to model the corresponding outcomes. RESULTS: After adjusting the models for sex, baseline moderate-to-vigorous physical activity, and mean arterial pressure changes, while using the intention-to-treat analysis, a significant interaction was observed on the carotid intima-media thickness (cIMT) for both the MCT (ß = - 4.25, p < 0.01) and HIIT group (ß = - 3.61, p < 0.01). However, only the HIIT observed favorable changes from baseline to 1-year on peripheral arterial stiffness indices such as carotid radial arterial pulse wave velocity (ß = - 0.10, p = 0.044), carotid to distal posterior tibial artery pulse wave velocity (ß = - 0.14, p < 0.01), and on the distensibility coefficient (ß = - 0.00, p < 0.01). No effect was found for hemodynamic variables after the intervention. CONCLUSIONS: Following a 1-year intervention in patients with type 2 diabetes, both the MCT and HIIT group reduced their cIMT, whereas only the HIIT group improved their peripheral arterial stiffness indices and distensibility coefficient. Taken together, HIIT may be a meaningful tool to improve long-term vascular complications in type 2 diabetes. Trial registration clinicaltrials.gov ID: NCT03144505.

Effectiveness of high-intensity interval training combined with resistance training versus continuous moderate-intensity training combined with resistance training in patients with type 2 diabetes: A one-year randomized controlled trial.

AIMS: To evaluate the impact of one-year high intensity interval training (HIIT) combined with resistance training (RT) vs continuous moderate intensity training (MCT) combined with RT on glycaemic control, body composition and cardiorespiratory fitness (CRF) in patients with type 2 diabetes. MATERIALS AND METHODS: A randomized controlled trial included 96 participants with type 2 diabetes for a one-year supervised exercise intervention with three groups: Control, HIIT with RT and MCT with RT). The control group received standard counseling regarding general PA guidelines, with no structured exercise sessions. The main outcome variable was HbA1c (%). Secondary outcomes were other glycaemic variables, body composition, anthropometry measurements, CRF and enjoyment of exercise. Generalized estimating equations (GEE) were used to model outcomes. RESULTS: Among the 96 participants enrolled in the intervention, 80 were randomized, with a mean (SD) age of 58.5 years (7.7) and a mean HbA1c of 7.2% (1.6). After adjusting the model for sex and total moderate-to-vigorous physical activity (MVPA), we found that both the MCT with RT (ß, 0.003; P, 0.921) and the HIIT with RT (ß, 0.025; P, 0.385) groups had no effect on HbA1c. A favourable effect was observed in the MCT with RT group, with a reduction in whole body fat index (ß, -0.062; P, 0.022), android fat index (ß, -0.010; P, 0.010) and gynoid fat index (ß, -0.013; P, 0.014). Additionally, CRF increased during the intervention, but only in the MCT with RT group (ß, 0.185; P, 0.019). CONCLUSIONS: The results from this study suggest that there was no effect of either MCT with RT or HIIT with RT on glycaemic control in individuals with type 2 diabetes. However, the combination of MCT and RT improved body composition and CRF following a one-year intervention.

Long-term manifestations of COVID-19 in athletes: a narrative review.

BACKGROUND: Long COVID is a condition where symptoms or complications persist beyond 3 months after COVID-19 infection. Although most athletes experience mild symptoms, those involved in sports with higher cardiovascular demands can develop long COVID, which can negatively impact sports performance. This narrative review aimed to analyze the long COVID in athletes, especially cardiovascular effects; to alert medical and sporting community for the clinical aftermaths of COVID-19, focusing on physical activity; and to discuss the potential return-to-play strategies for these athletes. METHODS: An electronic search in PubMed database for articles published between January/2020 and February/2023 was performed including athletic populations with COVID-19, emphasizing long-term complications, especially the cardiovascular effects. RESULTS AND CONCLUSIONS: While severe cardiac complications are rare, athletes with long COVID often experience symptoms such as fatigue, dyspnea, palpitations, and exercise intolerance. To manage athletes with long COVID, individualized and structured return-to-play programs with the involvement of multidisciplinary teams are crucial. This underscores the importance of recognizing long COVID in athletes, raising awareness of its potential impacts, and implementing strategies to ensure a safe return to play.

Cardiovascular benefits of resistance exercise: It's time to prescribe.

Despite the well-known health benefits of regular physical activity, sedentary behavior and physical inactivity remain a real global pandemic. Exercise is associated with increased life expectancy, improved quality of life and prevention of multiple diseases. Although less implemented in practice compared to aerobic exercise, recent evidence shows that resistance exercise (RE) is also responsible for various benefits, including improvements in body composition, control of several cardiovascular (CV) risk factors, and reduction of CV outcomes. RE increases strength and muscle mass, is effective in controlling type 2 diabetes, and improves the management of obesity, lipids, and blood pressure profiles. In this setting, clinical guidelines recommend the inclusion of RE for primary and secondary CV risk prevention, particularly in combination with aerobic exercise, in which the benefits are most pronounced. Prescription of RE should follow a methodology that includes key variables such as frequency, intensity, type, time, and progression. Despite challenges, professionals in the CV field should be familiar with RE prescription in order to maximize its referral in clinical practice. This review aims to analyze the CV effects of RE and current recommendations regarding the prescription of this type of exercise.

Coronary atherosclerotic burden in veteran athletes: The relationship between cardiovascular risk and volume of exercise.

INTRODUCTION AND OBJECTIVES: The association between exercise and coronary atherosclerosis still remains unclarified. We aimed to analyze the prevalence of high coronary atherosclerotic burden in veteran athletes, considering cardiovascular (CV) risk and volume of exercise. METHODS: A total of 105 asymptomatic male veteran athletes (48±5.6 years old) were studied. A high coronary atherosclerotic burden was defined as one of the following characteristics in coronary computed tomography angiography: calcium score >100, >75th percentile, obstructive plaques, involving left main, three-vessels or two-vessels including proximal anterior descending artery, segment involvement score >5 or CT-adapted Leaman score ≥5. CV risk was stratified by SCORE2 and volume of exercise by metabolic equivalent task score. RESULTS: Most athletes (n=88) were engaged in endurance sports for 17.1±9.8 years, with a median exercise volume of 66 [IQR 44-103] metabolic equivalent of tasks/hour/week. The mean Systematic Coronary Risk Evaluation 2 was 2.8±1.5%; 76.9% of athletes had a low-moderate risk and none a very high risk. High coronary atherosclerotic burden was present in 25.7% athletes. Athletes with high cardiovascular risk and high exercise volume (above the median) showed significantly high coronary atherosclerotic burden compared to those with low-moderate risk and high volume (50.0% vs. 15.6%; p=0.017). Among athletes with low to moderate risk, a high volume of exercise tended to be protective, while in those with low volume, there was similar rate of high coronary atherosclerotic burden, regardless of CV risk. CONCLUSIONS: A combination of higher volume of exercise and high cardiovascular risk revealed the worst association with coronary atherosclerosis in veteran athletes. The relationship between these variables is controversial, but integrating exercise characteristics and risk assessment into preparticipation evaluation is essential.

Training and attitudes concerning cardiac rehabilitation in Portugal: A national survey of physician members of the Portuguese Society of Cardiology.

INTRODUCTION AND OBJECTIVES: Cardiac rehabilitation (CR) is a central component in the management of cardiovascular disease. While its potential benefits have been extensively explored and confirmed, its implementation is still suboptimal, due to various possible barriers. This study aimed to assess training and attitudes concerning CR among physicians in a Portuguese setting. METHODS: An online questionnaire structured in three parts (participant characteristics, training and attitudes concerning CR, and a brief general knowledge assessment) was developed and sent to members of the Portuguese Society of Cardiology. The study population encompassed physicians with a medical specialty or residents from the third year onward of a specialty program. RESULTS: A total of 97 individuals (57.7% male, 61.9% aged ≤50 years) presented valid answers. CR was available at the workplace of 54.6% of participants. Most of them considered that the time allocated to CR training during residency was inadequate, and thought that more time was needed for this purpose. Most had not dedicated (or intended to dedicate) time for CR training, with lack of time being the most frequently attributed reason. In terms of referral, a substantial proportion of subjects did not refer patients, with lack of CR centers and human resources being the most frequent reasons. CONCLUSIONS: This survey provides contemporary data on CR training and attitudes, highlighting areas of potential improvement, such as time allocated to training in this area. These results could provide a useful pragmatic framework for optimization of training and awareness in this pivotal field of cardiovascular medicine.

Cardiopulmonary exercise testing in clinical practice: Principles, applications, and basic interpretation.

Cardiopulmonary exercise testing (CPET) provides a noninvasive and integrated assessment of the response of the respiratory, cardiovascular, and musculoskeletal systems to exercise. This information improves the diagnosis, risk stratification, and therapeutic management of several clinical conditions. Additionally, CPET is the gold standard test for cardiorespiratory fitness quantification and exercise prescription, both in patients with cardiopulmonary disease undergoing cardiac or pulmonary rehabilitation programs and in healthy individuals, such as high-level athletes. In this setting, the relevance of practical knowledge about this exam is useful and of interest to several medical specialties other than cardiology. However, despite its multiple established advantages, CPET remains underused. This article aims to increase awareness of the value of CPET in clinical practice and to inform clinicians about its main indications, applications, and basic interpretation.

World Heart Federation Cholesterol Roadmap: The Portuguese Case.

Atherosclerotic cardiovascular disease (ASCVD) remains the major cause of premature death and disability; effective cardiovascular (CV) risk prevention is fundamental. The World Heart Federation (WHF) Cholesterol Roadmap provides a framework for national policy development and aims to achieve ASCVD prevention.At the invitation of the WHF, a group of experts from the Portuguese Society of Cardiology (SPC), addressed the cholesterol burden at the national level and discussed possible strategies to include in a Portuguese cholesterol roadmap. The literature review showed that the cholesterol burden in Portugal is high and especially uncontrolled in those with the highest CV risk. An infographic, scorecard, was built to include in the WHF collection, for a clear idea about CV risk and cholesterol burden in Portugal, which would also be useful for health policy advocacy.The expert discussion and preventive strategies proposal followed the five pillars of the WHF document: Awareness improvement; Population-based approaches for CV risk and cholesterol; Risk assessment /population screening; System-level approaches; Surveillance of cholesterol and ASCVD outcomes. These strategies were debated by all the expert participants, with the goal of creating a national cholesterol roadmap to be used for advocacy and as a guide for CV prevention.Several key recommendations were made: Include all stakeholders in a multidisciplinary national program; Create a structured activities plan to increase awareness in the population; Improve the quality of continuous CV health education; Increase the interaction between different health professionals and non-health professionals; Increment the referral of patients to cardiac rehabilitation; Screen cholesterol levels in the general population, especially high-risk groups; Promote patients' self-care, engaging with patients' associations; Use specific social networks to spread information widely; Create a national database of cholesterol levels with systematic registry of CV events; Redefine strategies based on the evaluation of results; Create and involve more patients' associations - invert the pyramid order. In conclusion: ASCVD and the cholesterol burden remain a strong global issue in Portugal, requiring the involvement of multiple stakeholders in prevention. The Portuguese cholesterol roadmap can provide some solutions to help mitigate the problem urgently. Population-based approaches to improve awareness and CV risk assessment and surveillance of cholesterol and ASCVD outcomes are key factors in this change. A call to action is clearly needed to fight hypercholesterolemia and ASCVD burden.

Impact of ESC/ACCF/AHA/WHF universal definition of myocardial infarction on mortality at 10 years.

AIMS: Redefinition of myocardial infarction (MI) based on specific cardiac troponins (cTn) was universally accepted in 2007. The new definition has been widely discussed for including a large spectrum of quantitative myocardial necrosis and their clinical implications remain under debate. Our aim was to assess the impact of the universal definition of MI on mortality at 10 years. METHODS AND RESULTS: We studied 676 consecutive patients (Pts) admitted to our intensive cardiac care unit for acute coronary syndrome (ACS) between January 1999 and December 2000. We calculated the relative risk of the total death at 10 years adjusted with the Cox proportional hazards model, between the presence and absence of MI following different definitions: (1), typical symptoms and persistent ST-segment elevation or left bundle branch block (ST-segment elevation definition); (2), typical symptoms and CK-MB activity rise and/or fall >ULN (old definition); and (3), typical symptoms and cTn I rise and/or fall >99th percentile (universal definition). The total mortality at 10 years was 23.8%. The proportion of Pts with AMI was 33.6% for ST-segment elevation definition, 55.8% for old definition, and 70.1% for universal definition. The adjusted hazard ratio of death at 10 years between the presence and absence of AMI was 0.71 (95% confidence interval (CI): 0.46-1.08; P = 0.11) for ST-segment elevation definition, 0.84 (95% CI: 0.55-1.27; P = 0.40) for old definition, and 1.58 (95% CI: 1.07-2.40; P = 0.03) for universal definition. Patients submitted to myocardial revascularization during the initial hospital stay (72%) presented a significantly lower mortality at 10 years, compared with patients not revascularized (adjusted hazard ratio: 0.63, 95% CI: 0.44-0.91; P = 0.014). CONCLUSIONS: In a population with the entire spectrum of ACSs, the universal definition of MI increased this diagnosis by one-quarter and was an independent predictor of mortality at 10 years. Furthermore, myocardial revascularization was associated with a significantly lower mortality at 10 years.

Hypertrophic cardiomyopathy in patients with a normal electrocardiogram: A view from the east side of the Atlantic Ocean.

BACKGROUND: Although the 12­lead electrocardiogram (ECG) is abnormal in most patients with hypertrophic cardiomyopathy (HCM), some present normal ECG. This study aimed to analyse the baseline characteristics, clinical presentation and outcomes of HCM patients with normal ECG and to compare them with those with abnormal ECG. METHODS AND RESULTS: Baseline characteristics, clinical presentation, data from complementary exams and clinical outcomes of 1070 consecutive patients included in the Portuguese Registry of HCM (Pro-HCM registry) were compared between two groups of patients: normal Vs. abnormal ECG. Among this population, 98 (9.2%) patients had normal ECG at presentation; they were significantly younger and had lower frequency of hypertension, symptoms at presentation, heart failure, angina, cardiac and non-cardiac diseases. ESC and AHA risk scores for Sudden Cardiac Death (SCD) were not significantly different between the two groups. Patients with normal ECG had higher prevalence of family history of SCD and lower degree of left ventricular (LV) hypertrophy, LV systolic dysfunction, LV outflow tract obstruction and myocardial fibrosis. The combined endpoint of cardiac death, SCD, cardiac arrest, appropriate ICD shocks or evolution to systolic dysfunction, during a mean follow-up of 5 years was significantly less frequent in patients with normal ECG (2.1% Vs. 6.5%; p = 0.043). CONCLUSIONS: A normal ECG is not a marker of an overall benign profile in HCM patients. Though a normal ECG at presentation is associated with a less severe phenotype and a lower probability of evolution to heart failure at 5-years, this finding did not show a protective effect in other clinical outcomes.

"O meu coração bate saudável" - Results from a pilot project for health education in Portuguese children.

INTRODUCTION AND OBJECTIVES: Childhood offers an excellent window of opportunity to start interventions to promote behavioral changes before unhealthy lifestyles become established, leading to cardiovascular diseases. The goal of this pilot educational project for children is the promotion of healthy lifestyles and cardiovascular health. METHODS: This project was implemented in 4th grade children and included teacher-led classroom activities, a lesson given by a cardiologist and a practical lesson with dietitians. The teacher received a manual containing information on the topics to be discussed in class with the pupils and the children received a book that addresses cardiovascular risk factors and prevention. The components included were diet (D), physical activity (PA) and human body and heart awareness (BH). At the beginning and at the end of the schoolyear, a questionnaire was applied to the children to assess knowledge (K), attitudes (A) and habits (H) on these topics. RESULTS: A total of 73 children from an urban public school in Lisbon, in a low to medium income area, participated in the project. Following the intervention, there was a 9.5% increase in the overall KAH score, mainly driven by the PA component (14.5%) followed by the BH component (12.3%). No improvement was observed for component D. The benefits were also more significant in children from a lower income area, suggesting that socioeconomic status is a determinant in the response obtained. CONCLUSIONS: An educational project for cardiovascular health can be implemented successfully in children aged 9 years, but longer and larger studies are necessary.

Global warming and heat wave risks for cardiovascular diseases: A position paper from the Portuguese Society of Cardiology.

Global warming is a result of the increased emission of greenhouse gases. The consequences of this climate change threaten society, biodiversity, food and resource availability. The consequences include an increased risk of cardiovascular (CV) disease and cardiovascular mortality. In this position paper, we summarize the data from the main studies that assess the risks of a temperature increase or heat waves in CV events (CV mortality, myocardial infarction, heart failure, stroke, and CV hospitalizations), as well as the data concerning air pollution as an enhancer of temperature-related CV risks. The data currently support global warming/heat waves (extreme temperatures) as cardiovascular threats. Achieving neutrality in emissions to prevent global warming is essential and it is likely to have an effect in the global health, including the cardiovascular health. Simultaneously, urgent steps are required to adapt the society and individuals to this new climatic context that is potentially harmful for cardiovascular health. Multidisciplinary teams should plan and intervene healthcare related to temperature changes and heat waves and advocate for a change in environmental health policy.

Uncommon acquired Gerbode defect following extensive bicuspid aortic valve endocarditis.

Gerbode defect is a rare type of left ventricle to right atrium shunt. It is usually congenital in origin, but acquired cases are also described, mainly following infective endocarditis, valve replacement, trauma or acute myocardial infarction. We report a case of a 50-year-old man who suffered an extensive and complex infective endocarditis involving a bicuspid aortic valve, the mitral-aortic intervalvular fibrosa and the anterior leaflet of the mitral valve. After dual valve replacement and annular reconstruction, a shunt between the left ventricle and the right atrium--Gerbode defect, and a severe leak of the mitral prosthesis were detected. Reintervention was performed with successful shunt closure with an autologous pericardial patch and paravalvular leak correction. No major complications occurred denying the immediate post-surgery period and the follow-up at the first year was uneventful.

[Percutaneous thrombus aspiration in renal artery stenosis after renal transplantation]. / Aspiração de trombos por via percutânea em estenose da artéria renal após transplante renal.

We describe the case of a patient with chronic renal failure under hemodialysis for five years who, after renal transplantation, developed acute renal failure and hypertension refractory to medical therapy. Given the clinical and imaging (renal ultrasound and computed tomography) suspicion of renal artery graft thrombosis, invasive angiography was performed, which confirmed the diagnosis. The therapeutic approach consisted of percutaneous thrombus aspiration and subsequent balloon angioplasty of the entire artery, followed by stent implantation in a second procedure. The clinical course was uneventful with improvement of renal function and normalization of blood pressure. The case highlights the importance of percutaneous intervention in the management of patients with vascular complications after transplantation, with successful application of a procedure normally used in the setting of acute myocardial infarction - percutaneous thrombus aspiration and implantation of a drug-eluting vascular stent.

[Anomalous origin of left coronary artery: a malignant interarterial variant with a benign clinical course]. / Origem anómala da coronária esquerda: variante interarterial maligna com evolução clínica benigna.

Anomalous origin of coronary arteries represents a clinical challenge not only because of the anatomical variability, but also the possible functional consequences, pathophysiological mechanisms involved and the absence of large series in the literature that would provide evidence for clinical and therapeutic orientation. The authors describe the case of a 55-year-old male patient with a long history of atypical chest pain who was considered to have a low to intermediate likelihood of coronary artery disease. Therefore, and also bearing in mind his physical limitations (congenital left leg atrophy), he was referred for cardiac CT to rule out coronary artery disease. The exam showed a left coronary artery arising from the right coronary cusp and with an interarterial course, between the aorta and pulmonary trunk. Although this is a potentially malignant anatomical variant with surgical indication, a conservative approach was chosen, considering the late diagnosis and particular risk-benefit profile.

[Renal sympathetic denervation for treatment of resistant hypertension]. / Ablação da atividade simpática renal para tratamento da hipertensão arterial resistente.

Hypertension is an important cardiovascular risk factor and although there have been many improvements in pharmacological treatment, a significant percentage of patients are still considered resistant. The authors describe two cases of radiofrequency renal sympathetic denervation that illustrate the feasibility of this new technique for the treatment of resistant hypertension. The procedure consists of the application of radiofrequency energy inside the renal arteries to ablate afferent and efferent sympathetic renal activity, which has been implicated in the pathophysiology of hypertension.