Are There Deleterious Cardiac Effects of Acute and Chronic Endurance Exercise?

Multiple epidemiological studies document that habitual physical activity reduces the risk of atherosclerotic cardiovascular disease (ASCVD), and most demonstrate progressively lower rates of ASCVD with progressively more physical activity. Few studies have included individuals performing high-intensity, lifelong endurance exercise, however, and recent reports suggest that prodigious amounts of exercise may increase markers for, and even the incidence of, cardiovascular disease. This review examines the evidence that extremes of endurance exercise may increase cardiovascular disease risk by reviewing the causes and incidence of exercise-related cardiac events, and the acute effects of exercise on cardiovascular function, the effect of exercise on cardiac biomarkers, including "myocardial" creatine kinase, cardiac troponins, and cardiac natriuretic peptides. This review also examines the effect of exercise on coronary atherosclerosis and calcification, the frequency of atrial fibrillation in aging athletes, and the possibility that exercise may be deleterious in individuals genetically predisposed to such cardiac abnormalities as long QT syndrome, right ventricular cardiomyopathy, and hypertrophic cardiomyopathy. This review is to our knowledge unique because it addresses all known potentially adverse cardiovascular effects of endurance exercise. The best evidence remains that physical activity and exercise training benefit the population, but it is possible that prolonged exercise and exercise training can adversely affect cardiac function in some individuals. This hypothesis warrants further examination.

Heart Rate and Neurological Outcomes in Patients Undergoing Targeted Temperature Management.

INTRODUCTION: There is a paucity of data evaluating the impact of heart rate (HR) during Targeted Temperature Management (TTM) and neurologic outcomes. Current resuscitation guidelines do not specify a HR goal during TTM. We sought to determine the relationship between HR and neurologic outcomes in a single-center registry dataset. METHODS: We retrospectively studied 432 consecutive patients who completed TTM (33°C) after cardiac arrest from 2008 to 2017. We evaluated the relationship between neurologic outcomes and HR during TTM. Pittsburgh Cerebral Performance Categories (CPC) at discharge were used to determine neurological recovery. Statistical analysis included chi square, Student's t-test and Mann-Whitney U. A logistic regression model was created to evaluate the strength of contribution of selected variables on the outcome of interest. RESULTS: Approximately 94,000 HR data points from 432 patients were retrospectively analyzed; the mean HR was 82.17 bpm over the duration of TTM. Favorable neurological outcomes were seen in 160 (37%) patients. The mean HR in the patients with a favorable outcome was lower than the mean HR of those with an unfavorable outcome (79.98 bpm vs 85.67 bpm p < 0.001). Patients with an average HR of 60-91 bpm were 2.4 times more likely to have a favorable neurological outcome compared to than HR's < 60 or > 91 (odds ratio [OR] = 2.36, 95% confidence interval [CI] 1.61-3.46, p < 0.001). Specifically, mean HR's in the 73-82 bpm range had the greatest rate of favorable outcomes (OR 3.56, 95% CI 1.95-6.50), p < 0.001. Administration of epinephrine, a history of diabetes mellitus and hypertension all were associated with worse neurological outcomes independent of HR. CONCLUSION: During TTM, mean HRs between 60-91 showed a positive association with favorable outcomes. It is unclear whether a specific HR should be targeted during TTM or if heart rates between 60-91 bpm might be a sign of less neurological damage.

Exercise Participation for Patients with Valvular Heart Disease: a Review of the Current Guidelines.

PURPOSE OF REVIEW: Valvular heart disease affects many individuals who aspire to partake in competitive or recreational sports. This manuscript reviews the most recent European and American guidelines related to exercise and sport participation in individuals with valvular heart disease (VHD) and identifies areas not addressed by these guidelines. RECENT FINDINGS: Exercise recommendations for individuals with VHD have been presented since at least 1984. There is limited data on the impact of intensive physical activity on the progression and outcomes of VHD. Therefore, current recommendations are based on consensus opinion. Most recent consensus guidelines address exercise participation in young and active older individuals. Exercise guidelines for patients with VHD have become progressively less restrictive to allow exercise participation for many VHD patients. These more progressive recommendations should be included in clinical decision-making when evaluating physical activity levels for athletes and active adults with VHD.

Compression Socks Worn During Flight and Hemostatic Balance in Boston Marathon Runners on Oral Contraceptives.

OBJECTIVE: To investigate the effect of oral contraceptive (OC) use and compression socks on hemostatic activation in women flying cross-country to and from a marathon. DESIGN: Prospective study. SETTING: 2015 Boston Marathon. PARTICIPANTS: Women were divided into non-OC using (CONTROL; n = 12), OC-using (OC; n = 15), and OC-using plus compression sock (OC + SOCK; n = 14) groups. INTERVENTION: Women in OC + SOCK wore compression socks during flights to and from the marathon. MAIN OUTCOME MEASURES: Venous blood samples were collected within 24 hours of arriving in Boston (EXPO), immediately after the marathon (RUN), and within 24 hours after a return flight home (Post-Flight) for analysis of thrombin-antithrombin complex (TAT), d-dimer, and tissue plasminogen activator (t-PA). RESULTS: TAT did not increase with exercise (P = 0.48) and was not affected by group (P = 0.08) or the interaction between these 2 factors (P = 0.80). Group, time, and their interaction were significant for d-dimer (all P < 0.05) such that d-dimer increased with acute exercise to a greater extent (Δ d-dimer from expo to postrace = 909.5 ± 1021.9 ng/mL) in the OC + SOCK group relative to OC (Δ d-dimer = 240.0 ± 178.5 ng/mL; P = 0.02) and CONTROL (Δ d-dimer = 230.3 ± 120.3 ng/mL; P = 0.02). There was a significant effect of time, group, and the interaction on t-PA (all P < 0.01) such that t-PA increased with acute exercise to a greater extent (Δ t-PA from expo to postrace = 19.6 ± 10.0 ng/mL) in the CONTROL group relative to OC (Δ t-PA = 4.0 ± 1.8 ng/mL; P < 0.01) and OC + SOCK (Δ t-PA = 3.3 ± 1.2 ng/mL; P < 0.01). CONCLUSIONS: Female runners using OCs did not exhibit disproportionately increased coagulation. The use of compression socks in women on OCs, surprisingly, resulted in a greater increase in d-dimer after exercise.

Multicenter evaluation of stress-first myocardial perfusion image triage by nuclear technologists and automated quantification.

BACKGROUND: A stress-first myocardial perfusion imaging (MPI) protocol saves time, is cost effective, and decreases radiation exposure. A limitation of this protocol is the requirement for physician review of the stress images to determine the need for rest images. This hurdle could be eliminated if an experienced technologist and/or automated computer quantification could make this determination. METHODS: Images from consecutive patients who were undergoing a stress-first MPI with attenuation correction at two tertiary care medical centers were prospectively reviewed independently by a technologist and cardiologist blinded to clinical and stress test data. Their decision on the need for rest imaging along with automated computer quantification of perfusion results was compared with the clinical reference standard of an assessment of perfusion images by a board-certified nuclear cardiologist that included clinical and stress test data. RESULTS: A total of 250 patients (mean age 61 years and 55% female) who underwent a stress-first MPI were studied. According to the clinical reference standard, 42 (16.8%) and 208 (83.2%) stress-first images were interpreted as "needing" and "not needing" rest images, respectively. The technologists correctly classified 229 (91.6%) stress-first images as either "needing" (n = 28) or "not needing" (n = 201) rest images. Their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 66.7%, 96.6%, 80.0%, and 93.5%, respectively. An automated stress TPD score ≥1.2 was associated with optimal sensitivity and specificity and correctly classified 179 (71.6%) stress-first images as either "needing" (n = 31) or "not needing" (n = 148) rest images. Its sensitivity, specificity, PPV, and NPV were 73.8%, 71.2%, 34.1%, and 93.1%, respectively. In a model whereby the computer or technologist could correct for the other's incorrect classification, 242 (96.8%) stress-first images were correctly classified. The composite sensitivity, specificity, PPV, and NPV were 83.3%, 99.5%, 97.2%, and 96.7%, respectively. CONCLUSION: Technologists and automated quantification software had a high degree of agreement with the clinical reference standard for determining the need for rest images in a stress-first imaging protocol. Utilizing an experienced technologist and automated systems to screen stress-first images could expand the use of stress-first MPI to sites where the cardiologist is not immediately available for interpretation.

Body Mass Index and Risk for Mental Stress Induced Ischemia in Coronary Artery Disease.

Acute emotionally reactive mental stress (MS) can provoke prognostically relevant deficits in cardiac function and myocardial perfusion, and chronic inflammation increases risk for this ischemic phenomenon. We have described parasympathetic withdrawal and generation of inflammatory factors in MS. Adiposity is also associated with elevated markers of chronic inflammation. High body mass index (BMI) is frequently used as a surrogate for assessment of excess adiposity, and associated with traditional CAD risk factors, and CAD mortality. BMI is also associated with autonomic dysregulation, adipose tissue derived proinflammatory cytokines, which are also attendant to emotion provoked myocardial ischemia. Thus, we sought to determine if body mass index (BMI) contributes to risk of developing myocardial ischemia provoked by mental stress. We performed a prospective interventional study in a cohort of 161 patients with stable CAD. They completed an assessment of myocardial blood flow with single photon emission computed tomography (SPECT) simultaneously during 2 conditions: laboratory mental stress and at rest. Multivariate logistic regression determined the independent contribution of BMI to the occurrence of mental-stress induced ischemia. Mean age was 65.6 ±9.0 years; 87.0% had a history of hypertension, and 28.6% had diabetes. Mean BMI was 30.4 ± 4.7. Prevalence of mental stress ischemia was 39.8%. BMI was an independent predictor of mental stress ischemia, OR=1.10, 95% CI [1.01-1.18] for one-point increase in BMI and OR=1.53, 95% CI [1.06-2.21] for a 4.7 point increase in BMI (one standard deviation beyond the cohort BMI mean), p=0.025 for all. These data suggest that BMI may serve as an independent risk marker for mental stress ischemia. The factors attendant with greater BMI, which include autonomic dysregulation and inflammation, may represent pathways by which high BMI contribute to this risk and serve as a conceptual construct to replicate these findings in larger CAD populations.

Reliability and Time Course of Postexercise Hypotension during Exercise Training among Adults with Hypertension.

Postexercise hypotension (PEH), or the immediate decrease in blood pressure (BP) lasting for 24 h following an exercise bout, is well-established; however, the influence of exercise training on PEH dynamics is unknown. This study investigated the reliability and time course of change of PEH during exercise training among adults with hypertension. PEH responders (n = 10) underwent 12 weeks of aerobic exercise training, 40 min/session at moderate-to-vigorous intensity for 3 d/weeks. Self-measured BP was used to calculate PEH before and for 10 min after each session. The intraclass correlation coefficient (ICC) and Akaike Information Criterion (AIC) determined PEH reliability and goodness-of-fit for each week, respectively. Participants were obese (30.6 ± 4.3 kg∙m-2), middle-aged (57.2 ± 10.5 years), and mostly men (60%) with stage I hypertension (136.5 ± 12.1/83.4 ± 6.7 mmHg). Exercise training adherence was 90.6 ± 11.8% with 32.6 ± 4.2 sessions completed. PEH occurred in 89.7 ± 8.3% of these sessions with BP reductions of 9.3 ± 13.1/3.2 ± 6.8 mmHg. PEH reliability was moderate (ICC ~0.6). AIC analysis revealed a stabilization of maximal systolic and diastolic BP reductions at 3 weeks and 10 weeks, respectively. PEH persisted throughout exercise training at clinically meaningful levels, suggesting that the antihypertensive effects of exercise training may be largely due to PEH. Further studies in larger samples and under ambulatory conditions are needed to confirm these novel findings.

A Cooling Conundrum: Is Therapeutic Hypothermia Safe in the Immunosuppressed?

Targeted temperature management (TTM) may increase the risk of infection, and immunosuppression is considered a relative contraindication despite the lack of robust evidence for this risk. We present a case of a 44-year-old immunosuppressed woman who suffered an out-of-hospital cardiac arrest, underwent TTM, and recovered neurological function without serious complications. The aim of this case is to navigate the challenging decision-making process regarding postcardiac arrest care in a patient on immunosuppressants.

Prevalence of lipoprotein(a) measurement in patients with or at risk of cardiovascular disease.

INTRODUCTION: Lipoprotein(a) [Lp(a)] is a genetically determined independent risk factor for atherosclerotic cardiovascular disease (ASCVD) and calcific aortic valve disease. Despite recommendations from professional societies in the cardiovascular field, the awareness of elevated Lp(a) as a risk factor and screening for Lp(a) are suspected to be low. METHODS: We conducted a retrospective, observational case control study of patient charts from January 1, 2017 to June 19, 2022. The primary aims were 1) to describe the proportion of patients at the healthcare network's primary care and cardiology clinics that met Lp(a) screening criteria and were tested; and 2) to describe the proportion of patients throughout the entire healthcare network that had Lp(a) measured. RESULTS: Of the 2,412,020 patient charts in the health network, only 5,942 (0.25 %) had Lp(a) measured. Of the 84,581 patients in primary care or cardiology clinics who met screening criteria, only 1,311 (1.55 %) had Lp(a) measured. Patients with Lp(a) measured were more likely to be younger, non-Hispanic/Latinx, had a lipid panel measured, a cardiac computed tomography (CT) imaging study, and higher low-density lipoprotein-cholesterol. Patients with ASCVD, heart failure, ischemic heart disease, aortic stenosis, peripheral vascular disease, or a stroke did not feature highly among patients who received Lp(a) testing. Having an abnormal or risk-enhancing Lp(a) level was associated with being female and/or being Black/African American. CONCLUSIONS: Despite increased awareness of Lp(a) and its contribution to cardiovascular disease there exists a paucity of testing. Increased Lp(a) testing can identify patients who have an increased cardiovascular risk underestimated by other metrics.

The Relationship between Postexercise Hypotension and Heart Rate Variability before and after Exercise Training.

Because data are scarce, we examined the relationship between postexercise hypotension (PEH) and heart rate variability (HRV) before and after aerobic exercise training among adults with hypertension. Participants completed a 12 w aerobic training program. Before and after training, they performed a peak graded exercise stress test (GEST) and nonexercise control (CONTROL) and were left attached to an ambulatory BP monitor. Prior to CONTROL, HRV was measured supine for 5 min using a 12-lead electrocardiogram (ECG). The participants (n = 18) were middle-aged (52.1 ± 11.7 y) and 50% men with hypertension (131.7 ± 9.8/85.9 ± 8.5 mmHg) and obesity (30.0 ± 3.7 kg·m-2). Before training, ambulatory systolic BP (ASBP) and diastolic ABP (ADBP) decreased by 3.2 ± 2.1 mmHg and 2.5 ± 1.5 mmHg, respectively, from baseline after the GEST versus CONTROL (p < 0.05). After training, ASBP tended to decrease by 3.5 ± 2.2 mmHg (p = 0.055) and ADBP decreased by 1.7 ± 2.5 mmHg (p = 0.001) from baseline after the GEST versus CONTROL. Before training, HRV high frequency (HFms2) (ß = -0.441), age (ß = 0.568), and resting SBP (ß = 0.504) accounted for 66.8% of the ASBP response (p = 0.001), whereas the low frequency (LF)/HF ratio (ß = 0.516) and resting DBP (ß = 0.277) accounted for 35.7% of the ADBP response (p = 0.037). After training, the standard deviation of NN intervals (SDNN) (ß = -0.556), age (ß = 0.506), and resting SBP (ß = 0.259) accounted for 60.7% of the ASBP response (p = 0.004), whereas SDNN (ß = -0.236) and resting DBP (ß = 0.785) accounted for 58.5% of the ADBP response (p = 0.001). Our preliminary findings show that adults with hypertension and parasympathetic suppression (i.e., lower SDNN and HFms2 and higher LF/HF) may elicit PEH to the greatest degree independent of training status versus adults with parasympathetic predominance, suggesting that resting HRV may be an important determinant of PEH.

The effects of an acute weight stigma exposure on cardiovascular reactivity among women with obesity and hypertension: A randomized trial.

OBJECTIVE: Weight stigma induces cardiovascular health consequences for people with obesity. How stigma affects cardiovascular reactivity in individuals with both obesity and hypertension is not known. METHODS: In a randomized experiment, we assessed the influence of two video exposures, depicting either weight stigmatizing (STIGMA) or non-stigmatizing (NEUTRAL) scenes, on cardiovascular reactivity [resting blood pressure (BP), heart rate (HR), ambulatory BP (ABP), and ambulatory HR (AHR)], among women with obesity and high BP (HBP; n=24) or normal BP (NBP; n=25). Systolic ABP reactivity was the primary outcome. Laboratory BP and HR were measured before/during/following the videos, and ABP and AHR were measured over 19 hours (10 awake hours, 9 sleep hours) upon leaving the laboratory. A repeated measures ANCOVA tested differences in BP and HR changes from baseline in the laboratory and over ambulatory conditions between the two groups after each video, controlling for body mass index, baseline BP and HR. RESULTS: Laboratory SBP/DBP increased 5.5+7.3/2.4+8.8mmHg more in women with HBP than NBP following the STIGMA versus NEUTRAL video (Ps<0.05). For the primary outcome, ABP increased more in HBP than NBP over sleep (SBP/DBP=4.2+20.6/4.7+14.2mmHg; Ps<0.05) following the STIGMA versus NEUTRAL video, as did HR during sleep (7.5+15.7bpm more in HBP than NBP; P<0.05). CONCLUSIONS: Weight stigma increases cardiovascular reactivity among women with obesity and HBP in the laboratory and under ambulatory conditions. CLINICAL TRIAL REGISTRATION: Registered at ClinicalTrials.gov (Identifier: NCT04161638).

Impact of Sex on Cardiovascular Adaptations to Exercise: JACC Review Topic of the Week.

Routine exercise leads to cardiovascular adaptations that differ based on sex. Use of cardiac testing to screen athletes has driven research to define how these sex-based adaptations manifest on the electrocardiogram and cardiac imaging. Importantly, sex-based differences in cardiovascular structure and outcomes in athletes often parallel findings in the general population, underscoring the importance of understanding their mechanisms. Substantial gaps exist in the understanding of why cardiovascular adaptations and outcomes related to exercise differ by sex because of underrepresentation of female participants in research. As female sports participation rates have increased dramatically over several decades, it also remains unknown if differences observed in older athletes reflect biological mechanisms vs less lifetime access to sports in females. In this review, we will assess the effect of sex on cardiovascular adaptations and outcomes related to exercise, identify the impact of sex hormones on exercise performance, and highlight key areas for future research.

The spectrum of aortic pathology in alport syndrome: a case report and review of the literature.

Alport syndrome is an inherited disorder of type IV collagen most commonly leading to glomerulonephritis and kidney failure. Various extrarenal manifestations have been reported, including a spectrum of aortic and aortic valve diseases. We report a case of a 34-year-old man with Alport syndrome presenting with chest pain. Work-up showed a dilated aortic root, bicuspid aortic valve, aortic insufficiency, and small ascending aortic dissection necessitating surgical repair. We provide a review of the literature describing aortic pathology in Alport syndrome and suggest that clinicians caring for patients with Alport syndrome have a high index of suspicion for such entities in patients presenting with symptoms of chest pain.

Age-related macular degeneration and incident cardiovascular disease: the Multi-Ethnic Study of Atherosclerosis.

OBJECTIVE: To determine whether age-related macular degeneration (AMD) is a risk indicator for coronary heart disease (CHD) and cardiovascular disease (CVD) events independent of other known risk factors in a multi-ethnic cohort. DESIGN: Population-based prospective cohort study. PARTICIPANTS: A diverse population sample of 6233 men and women aged 45 to 84 years without known CVD from the Multi-Ethnic Study of Atherosclerosis (MESA). METHODS: Participants in the MESA had retinal photographs taken between 2002 and 2003. Photographs were evaluated for AMD. Incident CHD and CVD events were ascertained during clinical follow-up visits for up to 8 years after the retinal images were taken. MAIN OUTCOME MEASURES: Incident CHD and CVD events. RESULTS: Of the 6814 persons at risk of CHD, there were 893 participants with early AMD (13.1%) and 27 patients (0.5%) at baseline. Over a mean follow-up period of 5.4 years, there was no statistically significant difference in incident CHD or CVD between the AMD and non-AMD groups (5.0% vs. 3.9%, P = 0.13 for CHD and 6.6% vs. 5.5%, P = 0.19 for CVD). In Cox regression models adjusting for CVD risk factors, there was no significant relationship between presence of any AMD and any CHD/CVD events (hazard ratio 0.99; 95% confidence interval, 0.74-1.33; P = 0.97). No significant association was found between subgroups of early AMD or late AMD and incident CHD/CVD events. CONCLUSIONS: In persons without a history of CVD, AMD was not associated with an increased risk of CHD or CVD.

The Association of Serum Magnesium Levels and QT Interval with Neurological Outcomes After Targeted Temperature Management.

Targeted temperature management (TTM) is associated with corrected QT (QTc) prolongation and decrease in serum magnesium (Mg) levels that may lead to recurrent ventricular arrhythmia and poor neurological outcomes. We aimed to evaluate the association between QTc interval and Mg levels during TTM with neurological outcomes. We reviewed the electrocardiograms of 366 patients who underwent TTM during the induction, maintenance, and rewarming phase after cardiac arrest. We reviewed the association of change in QTc interval, and Mg levels with neurological outcomes. In total, 71.3% of the patients had a significant increase in QTc interval defined as >60 ms or any QTc >500 ms during TTM. Poor neurological outcome was associated with persistent prolongation of QTc after rewarming (507 vs. 483 ms, p = 0.046) and higher Mg levels at presentation (2.08 ± 0.41 mg/dL, p = 0.014). Supplemental Mg did not have any significant change in their QTc. Patients with prolonged QTc during TTM should be promptly evaluated for QTc-prolonging factors given its association with worse neurological outcomes. The inverse correlation between Mg levels and poor neurological outcomes deserves further investigation.

Prevention and Management of Hypertriglyceridemia-Induced Acute Pancreatitis During Pregnancy: A Systematic Review.

Severe gestational hypertriglyceridemia can lead to acute pancreatitis, with maternal mortality rate of approximately 20%. The recent National Lipid Association part 2 expert panel recommendations provide guidance on monitoring pregnant women at high risk for hyperlipidemia. We suggest that high-risk women have triglyceride levels checked once every trimester. Fasting triglycerides >250 mg/dL should prompt monthly triglyceride levels, screening for gestational diabetes, and implementing a strict low-carbohydrate, low-fat diet, exercise. Fasting triglycerides >500 mg/dL, despite a strict dietary and lifestyle modifications, should prompt treatment with omega-3-fatty acids and continue a fat-restricted diet (<20 g total fat/d or <15% total calories) under the guidance of a registered dietician. The use of fibrates should be considered as a second-line therapy due to their unclear risk versus benefit and potential teratogenic effects. Plasmapheresis should be considered early in asymptomatic pregnant women with fasting triglyceride levels >1000 mg/dL or in pregnant women with clinical signs and symptoms of pancreatitis and triglyceride levels >500 mg/dL despite maximal lifestyle changes and pharmacologic therapy.

Cardiometabolic Biomarkers and Habitual Caffeine Consumption Associate with the Adverse Ambulatory Blood Pressure Response to Strenuous Physical Exertion among Firefighters.

Caffeine has beneficial effects on firefighter job performance reducing fatigue and improving psychomotor vigilance. However, excessive caffeine intake may raise blood pressure (BP) following a bout of acute exercise among adults with elevated BP. The influence of caffeine intake on the ambulatory BP (ABP) response to vigorous physical exertion among firefighters has not been studied. In this sub-study we conducted secondary statistical analyses from a larger clinical trial (NCT04514354) that included examining the influence of habitual caffeine intake, and cardiometabolic biomarkers shown to influence BP, on the ABP response following a bout of sudden vigorous exertion over 19 h among firefighters. Previously, we found high amounts of calcium and sodium intake raised BP following a bout of acute exercise among adults with elevated BP. Thus, other secondary aims were to examine the influence of habitual calcium and sodium intake, and cardiometabolic biomarkers have shown to influence BP, on the ABP response following sudden vigorous exertion over 19 h among firefighters. Firefighters (n = 15) completed a Food-Frequency Questionnaire assessing habitual dietary intake over the past year. They randomly completed a maximal graded exercise stress test (GEST) and non-exercise CONTROL on separate non-workdays leaving the laboratory wearing an ABP monitor for 19 h. Prior to and immediately after the GEST, fasting venous blood was collected to measure lipid-lipoproteins, c-reactive protein, and blood glucose. Height and weight were taken to calculate body mass index. Repeated measures ANCOVA tested if the ABP response differed after GEST vs. CONTROL. Linear mixed models examined the relationships among caffeine, calcium, sodium, cardiometabolic biomarkers, and the ABP response following GEST vs. CONTROL. Firefighters were middle-aged (40.2 ± 9.5 year), overweight (29.0 ± 3.9 kg/m2) men with elevated BP (124.1 ± 10.3/79.6 ± 11.5 mmHg) who consumed 542.0 ± 348.9 mg of caffeine/day, about ~50% more than the dietary reference intake. Unexpectedly, systolic ABP was higher by 18.0 ± 6.7 mmHg and diastolic ABP by 9.1 ± 5.4 mmHg (ps < 0.01) over 19 h following GEST vs. CONTROL. We found 24% of the variance in the adverse ABP response to maximal physical exertion was explained by caffeine intake, and when combined with c-reactive protein, non-high-density lipoprotein-cholesterol, body mass index, blood glucose, and resting heart rate, up to 74% of the variability in the ABP response was explained. Additionally, we found calcium (ps < 0.001) and sodium (p < 0.0001) intake each explained up to 24% of the ABP response. Further investigation is needed in a larger, more diverse sample of firefighters to better establish how caffeine contributes to the adverse BP response to strenuous physical exertion.

Elevated risk of venous thromboembolism in patients undergoing therapeutic hypothermia after cardiac arrest.

INTRODUCTION: Targeted Temperature Management (TTM) reduces mortality and improves neurological outcomes after cardiac arrest. Cardiac arrest is considered a pro-thrombotic state. Endovascular cooling catheters may increase the risk of thrombosis. Targeted Temperature Management, however, increases fibrinolysis. The net outcome of these opposing effects remains largely unexplored. Moreover, the exact rate of venous thromboembolism (VTE) is uncertain in these patients. We sought to determine the incidence and potential predictors of VTE in patients undergoing TTM. METHODS: Single center retrospective analysis. Participants were age ≥18 years old, admitted with out-of-hospital or in-hospital cardiac arrest, underwent TTM between January 1, 2007 and April 30, 2019 with endovascular cooling catheter. A total of 562 patients who underwent TTM (Study group) were compared to 562 patients treated for ARDS (control group). This control group was based on presumed similarities in factors affecting VTE: intensive care setting, immobility, length of stay and likely presence of central venous catheters. RESULTS: Patients who underwent TTM had a significantly higher rate of VTE (6.6% vs 2.3%, p = 0.006) and deep vein thrombosis (DVT) (4.6% vs 1.3%, p = 0.011) when compared to control group. In multivariate analysis age, gender, race and hospital length of stay were not associated with development of VTE in the study group. CONCLUSION: Patients undergoing TTM after cardiac arrest have statistically higher incidence of VTE and DVT compared to patients with ARDS. This risk is independent of age, gender, race or length of stay.

Exercise-Induced Cardiovascular Adaptations and Approach to Exercise and Cardiovascular Disease: JACC State-of-the-Art Review.

The role of the sports cardiologist has evolved into an essential component of the medical care of athletes. In addition to the improvement in health outcomes caused by reductions in cardiovascular risk, exercise results in adaptations in cardiovascular structure and function, termed exercise-induced cardiac remodeling. As diagnostic modalities have evolved over the last century, we have learned much about the healthy athletic adaptation that occurs with exercise. Sports cardiologists care for those with known or previously unknown cardiovascular conditions, distinguish findings on testing as physiological adaptation or pathological changes, and provide evidence-based and "best judgment" assessment of the risks of sports participation. We review the effects of exercise on the heart, the approach to common clinical scenarios in sports cardiology, and the importance of a patient/athlete-centered, shared decision-making approach in the care provided to athletes.