SARS-CoV-2 infection and return to play in junior competitive athletes: is systematic cardiac screening needed?

BACKGROUND: SARS-CoV-2 infection might be associated with cardiac complications in low-risk populations, such as in competitive athletes. However, data obtained in adults cannot be directly transferred to preadolescents and adolescents who are less susceptible to adverse clinical outcomes and are often asymptomatic. OBJECTIVES: We conducted this prospective multicentre study to describe the incidence of cardiovascular complications following SARS-CoV-2 infection in a large cohort of junior athletes and to examine the effectiveness of a screening protocol for a safe return to play. METHODS: Junior competitive athletes suffering from asymptomatic or mildly symptomatic SARS-CoV-2 infection underwent cardiac screening, including physical examination, 12-lead resting ECG, echocardiogram and exercise ECG testing. Further investigations were performed in cases of abnormal findings. RESULTS: A total of 571 competitive junior athletes (14.3±2.5 years) were evaluated. About half of the population (50.3%) was mildly symptomatic during SARS-CoV-2 infection, and the average duration of symptoms was 4±1 days. Pericardial involvement was found in 3.2% of junior athletes: small pericardial effusion (2.6%), moderate pericardial effusion (0.2%) and pericarditis (0.4%). No relevant arrhythmias or myocardial inflammation was found in subjects with pericardial involvement. Athletes with pericarditis or moderate pericardial effusion were temporarily disqualified, and a gradual return to play was achieved after complete clinical resolution. CONCLUSIONS: The prevalence of cardiac involvement was low in junior athletes after asymptomatic or mild SARS-CoV-2 infection. A screening strategy primarily driven by cardiac symptoms should detect cardiac involvement from SARS-CoV-2 infection in most junior athletes. Systematic echocardiographic screening is not recommended in junior athletes.

Cardiovascular risk profile in Olympic athletes: an unexpected and underestimated risk scenario.

BACKGROUND: Prevalence of cardiovascular (CV) risk factors has been poorly explored in subjects regularly engaged in high-intensity exercise programmes. Our aim was, therefore, to assess the prevalence and distribution of CV risk factors in a large population of competitive athletes, to derive the characteristics of athlete's lifestyle associated with the best CV profile. METHODS: 1058 Olympic athletes (656 males, 402 females), consecutively evaluated in the period 2014-2016, represent the study population. Prevalence and distribution of CV risk factors was assessed, in relation to age, body size and sport. FINDINGS: Dyslipidemia was the most common risk (32%), followed by increased waist circumference (25%), positive family history (18%), smoking habit (8%), hypertension (3.8%) and hyperglycaemia (0.3%). Large subset of athletes (418, 40%) had none or 1 (414, 39%) risk factor, while only a few (39, 3.7%) had 3/4 CV risk factors. The group without risks largely comprised endurance athletes (34%). Ageing was associated with higher total and low-density lipoprotein cholesterol, triglycerides (p<0.001) and glycaemia (p=0.002) and lower high-density lipoprotein cholesterol. On multivariate logistic regression analysis, age, BMI and body fat were identified as independent predictors of increased CV risk. INTERPRETATION: Dyslipidemia and increased waist circumference are common in elite athletes (32% and 25%, respectively). A large proportion (40%) of athletes, mostly endurance, are totally free from risk factors. Only a minority (3%) presents a high CV risk, largely expression of lifestyle and related to modifiable CV risk factors.

Left ventricular strain modifications after maximal exercise in athletes: a speckle tracking study.

PURPOSE: The increase in systolic indexes from rest (R) to exercise is achieved by combination of enhanced heart rate (HR) and stroke volume (SV). Aim of this study was to evaluate left ventricular (LV) longitudinal, circumferential, and torsional components immediately after a maximal intensity exercise (ME) by speckle tracking echocardiography (STE). METHODS: Twenty-seven male water polo players performed an ME that consisted of 6 repeats of 100 m freestyle swim sets. An echocardiographic examination was performed before and after ME. STE was performed to obtain the analysis of LV myocardial deformation. RESULTS: There were no differences between R and ME regarding LV longitudinal strains (PVLS). Apical circumferential LV strain (AVCS) and LV longitudinal strain rate (SR) increased at ME with respect to R (R: -23.1 ± 4.9%; ME: -28.4 ± 7.6%, P < 0.05; R: -1.1 ± 0.1/sec, ME: -1.5 ± 0.2/sec, P < 0.01). LV twisting (LVT) and untwisting (UTW) increased at ME (R: 7.9 ± 2.4°, ME: 14.2 ± 3.2°, P < 0.001; R: -107.2 ± 47.4; ME: -158.5 ± 61.5 °/sec; P < 0.01). At ME, apical rotation (Arot) had higher values than R values (5.4 ± 3.0°; 10.0 ± 6.0°; P < 0.01) and time-to-peak (TTP) of apical segments are earlier than all TTP. SV was related to LVT (r = 0.56, P = 0.01), AVCS (r = -0.59, P = 0.005) and Arot (r = 0.46, P = 0.04). At multivariate analysis, AVCS was the independent predictor of SV (ß = -0.58; P < 0.05). CONCLUSIONS: Apical fibers and LVT give the main contribution to systolic components at ME. The storage of energy during LVT, released during early diastole, seems to be a fundamental mechanism to support diastolic filling during maximal exercise.

Left ventricular twisting modifications in patients with left ventricular concentric hypertrophy at increasing after-load conditions.

AIMS: Left ventricular hypertrophy (LVH) develops as a result of several clinical conditions, such as intensive training, hypertension, aortic valve stenosis. Aim of this study was to analyze the left ventricular twist (LVT) modifications in LVH patients with increasing after-load conditions. METHODS: A total of 131 patients were enrolled: 17 healthy sedentary people (Hg), without concentric LVH; 45 water polo players (ATg); 22 patients with hypertensive cardiopathy (HPg); 47 patients with different degrees of aortic stenosis (ASg); all patients had concentric LVH, ejection fraction (EF) >54%, and were age-matched. The left ventricular end-systolic wall stress (LV-ESWS) was used as index of after-load. RESULTS: Left ventricular twist value showed a progressive increase from ATg to ASg, according to increasing after-load. Longitudinal left ventricular function by tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) was reduced in HPg and ASg. There was a negative correlation between LVT and longitudinal systolic function at TDI and STE (r = -0.4; P < 0.001; -0.23; P < 0.05). E/A ratio was lower in HPg and ASg than ATg and Hg. LVT was linearly related to LV-ESWS (r = 0.36; P < 0.01), E/A ratio (r = -0.59; P < 0.001), E/E' ratio (r = 0.43; P < 0.001), age (r = 0.5; P < 0.001), relative wall thickness (RWT) (r = 0.38; P < 0.01), heart rate (HR) (r = 0.3; P < 0.05), maximum (G. max), and mean transvalvular gradient (G. mean) in ASg (r = 0.37; P < 0.01, r = 0.4; P < 0.01). RWT, E/A ratio, and HR were independent predictor of LVT (ß = 0.23; P = 0.007; -0.44; P = 0.001; 0.17; P = 0.049). Only in ASg, G. mean was independent predictor of LVT (ß = 0.44; P = 0.01). CONCLUSION: Left ventricular twist showed a linear trend at increasing after-load values to compensate the reduction in systolic longitudinal function in pathological LVH patients.

[Premature ventricular beats in young athletes: interpretation and diagnostic pathway]. / L'extrasistolia ventricolare nel giovane atleta: inquadramento e percorso diagnostico.

Adolescents and adults with cardiovascular disease who are engaged in sports activity have an increased risk of sudden cardiac death (SCD) related to the sports practice that acts as a trigger for life-threatening ventricular arrhythmias. Premature ventricular beats (PVBs) detected in athletes at the time of pre-participation screening may be a sign of heart disease at risk of SCD but are also found in athletes without cardiovascular abnormalities. Thus, the interpretation of PVBs could represent a clinical dilemma. However, while some characteristics of PVBs can be considered common and benign, others occur uncommonly in the athletic population and raise the suspicion of underlying cardiovascular disease. This review discusses the prevalence and the clinical significance of PVBs in the athlete, with a focus on exercise-induced PVBs, on the analysis of PVB's morphology at 12-lead ECG, and on the morphological substrates identified by imaging techniques. The implications on eligibility for competitive sports participation are also discussed, according to the relevance of PVBs detection for disqualifying athletes from competitions.

Left atrial strain after maximal exercise in competitive waterpolo players.

Left atrial (LA) function is a determinant of left ventricular (LV) filling. It carries out three main functions: reservoir, conduit, contractile. Aim of this study was to evaluate the role of LA and its deformation properties on LV filling at rest (R) and immediately after a maximal exercise (ME) through the speckle tracking echocardiography. Population enrolled was composed by 23 water polo athletes who performed a ME of six repeats of 100 m freestyle swim sets. At ME peak atrial longitudinal strain was reduced but all strain rate (SR) parameters increased, respectively positive peak SR at reservoir phase, SR negative peak at rapid ventricular filling (SRep) and SR negative peak at late ventricular filling (SRlp), that corresponds to atrial contraction phase. We showed a parallel increase in E and A pulsed Doppler wave and SRep and SRlp; particularly at ME, A wave and SRlp increased more respectively than E wave and SRep. SRlp was related to ejection fraction (EF) (r = -0.47; p < 0.01). At multivariate analysis SRlp was an independent predictor of EF (ß: -0.47; p = 0.016). The increased sympathetic tone results into increased late diastolic LV filling with augmented atrial contractility and a decrease in diastolic filling time. During exercise LV filling was probably optimized by an enhanced and rapid LA conduit phase and by a vigorous atrial contraction during late LV filling.

Right ventricular remodelling induced by exercise training in competitive athletes.

AIMS: Conflicting evidence exists concerning right ventricular (RV) morphological and functional remodelling in trained athletes, with a very few longitudinal data prospectively investigating the RV changes. The aim of this study was to assess the morphological and functional RV changes occurring during the competitive season in young athletes engaged in the most popular team sports. METHODS AND RESULTS: Twenty-nine top-level athletes (age: 20.9 ± 6.7 years), practicing basketball and volleyball, were evaluated at pre-season, mid-season, and end-season time-points, using tissue Doppler imaging and 2D speckle-tracking echocardiography. RV basal and mid-cavity end-diastolic diameters (EDDs; overall P = 0.011 and P < 0.0001, respectively), and RV diastolic area (overall P < 0.0001) increased during the season. Conversely, RV outflow tract did not vary (overall P = 0.96). During the season, no significant differences were observed in RV diastolic functional indexes and in RV fractional area change (overall P = 0.35). Global RV longitudinal strain did not significantly change (overall P = 0.52), although apical longitudinal strain significantly increased (overall P = 0.017). In association, left ventricular (LV) volume and mass increased during the season (overall P = 0.007). On multivariate analysis, LV mass was the only independent predictor of RVEDD at pre-season (ß = 0.69, P < 0.0001) and at end-season (ß = 0.82, P < 0.0001). CONCLUSIONS: Right ventricular chamber size increases during the competitive season in top-level athletes, with no significant changes in the outflow tract. RV morphological adaptation in top-level athletes practicing team sports is not associated with a reduction in RV function or in myocardial deformation and occurs in close association with changes on the left ventricle, suggesting a physiological remodelling of the right ventricle.

Age related diastolic function in amateur athletes.

Diastolic function get worse with increasing age. Aim of this study was to investigate the impact of aerobic training on diastolic function with increasing age with speckle tracking echocardiography. We enrolled 125 amateur swimmers (AG), divided in three groups at increasing age: young athletes, adult athletes (AG2), old athletes (AG3). We enrolled 95 sedentary controls (SG) age-matched with athletes and divided into three groups: young sedentary group, adult sedentary group (SG2) and old sedentary group (SG3). AG had better diastolic function than SG. AG showed lower left ventricular twist than controls. E/A ratio got worse at increasing of age in all population (r = -0.34; p < 0.001); particularly in SG2 and SG3 there was a worsening of diastolic function respect to diastolic function of AG2 and AG3; in fact E/A ratio decreased with aging. Furthermore in SG E/A ratio showed a linear correlation with age (r = -0.54; p < 0.001); in AG this correlation was lost. Therefore the training and age were independent predictor of E/A (respectively ß = -0.27; p = 0.004; ß = -0.24, p = 0.008). Regular and aerobic training may minimize aging changes of diastolic function. This training-effect may play a key role to preserve diastolic filling in older athletes.

Effects of training on LV strain in competitive athletes.

OBJECTIVE: LV longitudinal strain, a recognised marker of LV function, has been recently applied to the evaluation of the athlete's heart. At present, little is known about the influence of training on LV global longitudinal strain (GLS) in athletes. The aim of this study was to prospectively investigate the impact of training on LV longitudinal strain and twist mechanics in a cohort of competitive athletes. METHODS: Ninety-one competitive athletes, practising team sports and competing at national or international level, were analysed. Echocardiographic evaluation was performed at the beginning of the season (low training) and after 18±2 weeks of a supervised, intensive training programme (peak training). RESULTS: A significant increase in LV mass (p<0.0001), LV end-diastolic and end-systolic volume (p=0.0001 and <0.0001, respectively) was found at peak training. LV basal and apical torsion (p=0.59 and 0.43, respectively) and LV twisting (p=0.78) did not change, and only a mild increase in LV GLS was evident after training (p=0.044). Resting heart rate was identified as the only independent predictor of LV GLS after training (ß=0.30, p=0.005). CONCLUSIONS: A 18-week, intensive training programme induced only a slight increase in LV GLS despite marked changes in cardiac morphology, suggesting a physiological adaptation of the LV to exercise conditioning.

Increased left atrial size is associated with reduced atrial stiffness and preserved reservoir function in athlete's heart.

Left atrial (LA) fibrosis with increased stiffness has been assumed to be the substrates for occurrence of atrial arrhythmias in athletes. However, this hypothesis has not yet been confirmed in humans. Aim of this study was, therefore, to assess LA remodeling and stiffness in competitive athletes. 150 competitive athletes and 90 age and sex-matched sedentary subjects were analyzed by speckle-tracking echocardiography to measure peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS). LA stiffness was determined using E/e' ratio in conjunction with PALS. Left ventricular (LV) stiffness was also calculated. LA volume index was greater in athletes as compared with controls (24.6 ± 7.3 vs. 18.4 ± 7.8 mL/m(2), p < .0001). LA PALS, LA PACS, and E/e' ratio were lower in athletes in comparison with controls (p < .05, p ≤ .001, and p < .0001, respectively). Despite greater LA size, competitive athletes had lower LA stiffness as compared with controls (0.13 ± 0.04 vs. 0.16 ± 0.06, p ≤ .001). In addition, LV stiffness was lower in athletes (0.84 ± 0.27 vs. 1.07 ± 0.46, p ≤ .001). The only independent predictor of LA stiffness was LV stiffness (ß = 0.46, p < .0001), while the only independent predictor of LA volume index was LV end-systolic volume index (ß = 0.25, p = .002). Competitive athletes showed greater LA size associated with lower stiffness as compared with controls. Thus, LA remodeling in the context of the athlete's heart is not associated with increased LA stiffness. These findings support the benign nature of LA remodeling in athletes, occurring as a physiological adaptation to exercise conditioning.

Endurance and Strength Athlete's Heart: Analysis of Myocardial Deformation by Speckle Tracking Echocardiography.

BACKGROUND: Intensive training induces two morphological myocardial typologies of athlete's heart. Endurance training (ET) induces eccentric remodeling, bradycardia and better diastolic filling. Strength training (ST) determines concentric chamber remodelling maintaining a normal heart rate (HR). Aim of the study was to compare ET and ST athletes' heart using speckle tracking echocardiography (STE). METHODS: 33 professional ET, 36 ST athletes, and 17 healthy controls (CT) were enrolled. All subjects underwent standard transthoracic echocardiography at rest and STE. RESULTS: In ET group, HR was lower than ST group and CT group (p < 0.001; p < 0.01). ET group had higher E/A ratio than ST group and CT group (p < 0.01; p < 0.001). The left ventricular apical circumferential strain in ET group was lower than ST group and CT group (-21.6 ± 4.1% vs. -26.8 ± 7.7%, p < 0.05; vs. -27.8 ± 5.6%, p < 0.01). ET group had lower left ventricular twist (LVT) and untwisting (UTW) than ST group (6.2 ± 0.1° vs. 12.0 ± 0.1°, p < 0.01; -67.3 ± 22.9°/s vs. -122.5 ± 52.8°/s, p < 0.01) and CT group (10.0 ± 0.1°, p < 0.01; -103.3 ± 29.3°/s, p < 0.01). The univariate analysis showed significant correlation between E/A ratio and HR (r = -0.54; p < 0.001), LVT (r = -0.45; p < 0.01), UTW (r = 0.24; p < 0.05). At the multivariate analysis only HR was confirmed as independent predictor of diastolic function in all groups (Beta -0.52; p < 0.001). CONCLUSION: In ET there was a better global systolic and diastolic functional reserve at rest observed with strain analysis and it maybe depended on autonomic modulation.

Precompetitive assessment of heart rate variability in elite female athletes during play offs.

BACKGROUND: Heart rate variability (HRV) has been rarely applied in elite athletes prior to competition. The aim of this study was to examine the changes in HRV in elite female volleyball players before a stressful match during play offs and to evaluate the impact on sport-specific performance. METHODS: A short-term resting HRV analysis was applied right after the night sleep in ten female athletes 1 and 2 days prior to the match and the day of the competition. RESULTS: Approaching the decisive match, RR interval, resting heart rate (HR), pNN50, rMSDD and SD1 did not significantly vary. SD2 significantly increased in comparison with first-day measurement (P<0·05). HF% levels significantly decreased the prematch day and the match day (P<0·05); however, no significant changes in LF/HF% ratio were observed. A gradual increase in VLF% and in LnVLF was observed, with a significant difference between first-day and match-day measurements (P<0·01 and P<0·05, respectively). The number of positive receptions was inversely correlated with LF/HFms(2) ratio, with LF/HF% ratio (R = -0·98, P<0·05 for both) and with resting HR (R = -0·92, P<0·05). CONCLUSIONS: Elite female athletes practising team sports exhibit a slight change in HRV prior to a decisive competition, without a pronounced variation of the autonomic nervous system activity. A day-to-day HRV measurement could be a useful tool to evaluate the impact of a competition on the autonomic nervous system in athletes, also considering the relationship between sympathetic activity and athletic performance.

Morphological and functional adaptation of left and right atria induced by training in highly trained female athletes.

BACKGROUND: Exercise is able to induce atrial remodeling in top-level athletes. However, evidence is mainly limited to men and based on cross-sectional studies. The aim of this prospective, longitudinal study was to investigate whether exercise is able to influence left and right atrial morphology and function also in female athletes. :ETHODS AND RESULTS- Two-dimensional echocardiography was performed before season and after 16 weeks of intensive training in 24 top-level female athletes. Left and right atrial myocardial deformation was assessed by two-dimensional speckle-tracking echocardiography. Left atrial volume index (24.0±3.6 versus 26.7±6.9 mL/m(2); P<0.001) and right atrial volume index (15.66±3.09 versus 20.47±4.82 mL/m(2); P<0.001) significantly increased after training in female athletes. Left atrial global peak atrial longitudinal strain and peak atrial contraction strain significantly decreased after training in female athletes (43.9±9.5% versus 39.8±6.5%; P<0.05 and 15.5±4.0% versus 13.9±4.0%; P<0.05, respectively). Right atrial peak atrial longitudinal strain and peak atrial contraction strain showed a similar, although non-significant decrease (42.8±10.6% versus 39.3±8.3%; 15.6±5.6% versus 13.1±6.1%, respectively). Neither biventricular E/e' ratio nor biatrial stiffness changed after training, suggesting that biatrial remodeling occurs in a model of volume rather than pressure overload. CONCLUSIONS: Exercise is able to induce biatrial morphological and functional changes in female athletes. Biatrial enlargement, with normal filling pressures and low atrial stiffness, is a typical feature of the heart of female athletes. These findings should be interpreted as physiological adaptations to exercise and should be considered in the differential diagnosis with cardiomyopathies.

Characterization of right atrial function and dimension in top-level athletes: a speckle tracking study.

Although many echocardiographic studies are available about the adaptation of left ventricle to intensive training, right heart function has been poorly investigated and no data are available about the right atrial (RA) function in top-level athletes. The aim of the study was to investigate RA function and dimension by standard echocardiography and 2D speckle tracking echocardiography (STE). One hundred top-levels athletes were recruited from professional sports team and were compared with 78 normal subjects. Athletes during an off-training period or during prolonged forced rest resulting from injuries were excluded. Top-level athletes had higher BSA as compared with controls and, as expected, a lower resting heart rate (p ≤ 0.001). RA area, volume, and volume index were significantly greater in athletes than in controls (p ≤ 0.001). This increase was associated with greater right ventricular and inferior vena cava diameters (p ≤ 0.001). Peak atrial longitudinal strain and peak atrial contraction strain values were significantly lower in athletes in comparison with controls (40.92 ± 9.86% vs. 48.00 ± 12.68%, p ≤ 0.001; 13.05 ± 4.84% vs. 15.99 ± 5.74%, p ≤ 0.001, respectively). Interestingly, while athletes presented a higher E/A ratio (p ≤ 0.001) and a lower peak A velocity (p ≤ 0.001), the E/e' ratio did not differ between the two groups. In top-level athletes the RA presents a physiological adaptation to intensive exercise conditioning which determines not only a morphological but also a functional remodeling. We reported for the first time reference values of RA strain in elite athletes, demonstrating that 2D STE is a useful tool to investigate RA longitudinal myocardial deformation dynamics in athlete's heart.