Ten-year mortality among older male recreational endurance athletes in the Birkebeiner Aging Study in comparison with older men from the Tromsø Study.

BACKGROUND: Physical activity (PA) is associated with reduced mortality. However, whether there is an added benefit of long-term endurance training is unclear. Thus, we aimed to examine 10-year mortality in older male endurance athletes compared with an older male general population. METHOD: Male athletes (n = 503) participating in an annual long-distance ski race (median years of participation: 14, range: 1-53) from the Norwegian Birkebeiner Aging study (BiAS), and non-athletic men (n = 1867) attending the sixth Tromsø Study (Tromsø6) aged ≥65 years were included. Associations with endurance sport practice and joint exposures of endurance sport practice and self-reported leisure-time PA with all-cause mortality were examined. We analyzed the data with Cox proportional hazard models and regression standardization. RESULTS: After 10 years (median: 10.4, range: 0.5-11.1) the mortality rate was lower in athletes (hazard ratio (HR) 0.34, 95% confidence interval (CI): 0.24-0.49) compared with non-athletes, corresponding to a 15% (95% CI: 12-19%) absolute risk reduction associated with endurance sport practice. In joint analyses categorized according to PA and endurance sport practice, we observed an inverse dose-response relationship with mortality (p < 0.001). Compared to inactive non-athletes, PA was associated with lower mortality in both active non-athletes and athletes. However, the observed benefit among participants reporting moderate-to-vigorous PA was larger in athletes (HR: 0.21, 95% CI: 0.14-0.32) than non-athletes (HR: 0.43, 95% CI: 0.31-0.59) (p < 0.01). CONCLUSION: Endurance sport practice was associated with reduced 10-year mortality, beyond the effect of PA in older men. This study suggests that long-term endurance sport practice maintained into older adulthood promotes longevity.

Rationale and design of the Birkebeiner Ageing Study - a prospective cohort study of older endurance athletes.

BACKGROUND: While regular physical activity is associated with reduced mortality and morbidity in general populations, health outcomes and functional capacity related to upholding strenuous endurance exercise beyond the age of 65 years are only sparsely studied. The aim of this study is to assess associations of prolonged strenuous endurance sport practice with ageing, functional decline, morbidity and longevity among older recreational endurance athletes, during long-term follow-up. METHODS: Prospective cohort study of older recreational endurance athletes in Norway. All skiers aged 65 years and older who participated in a long-distance endurance competition, the annual 54-km Birkebeiner cross-country ski race in 2009 or 2010, were invited. The participants answered an extensive baseline questionnaire about lifestyle habits, including leisure-time physical activity and endurance sport participation, diseases, medication use and physical and mental health, with follow-up questionnaires planned every fifth year until 2029. New participants may be invited with the aim to increase the study size. Endpoints such as all-cause and disease-specific mortality, incidence and cumulative prevalence of diseases, use of medication, physical and mental health and functional decline will be assessed subsequently. Out of 658 invited skiers (51 women), 551(84%) completed the baseline questionnaire and were included in the study. The mean age was 68.8 years (median 68, range 65- 90). At baseline, the participants had completed the Birkebeiner race for an average of 16.6 years and reported an average of 33.4 years of regular endurance exercise, with one out of five reporting at least 50 years of exercise. In all, 479 (90%) reported that they were still practicing leisure-time physical activity of moderate or vigorous intensity at least twice weekly. The prevalence of cardiovascular risk factors and diseases was low. DISCUSSION: This prospective study of a cohort of recreational athletes exposed to prolonged and strenuous endurance exercise, could complement population-based studies by providing data on associations between life-long endurance sport participation, aging, functional decline and health outcomes during long-term follow-up.

Left atrial dyssynchrony in veteran endurance athletes with and without paroxysmal atrial fibrillation.

BACKGROUND: Prolonged endurance exercise increase the risk of atrial fibrillation (AF) in men. Functional parameters may help separate physiological from pathological atrial remodeling in athletes. LA mechanical dispersion (LA MD) is associated with AF in the general population, but the associations between prolonged exercise, LA MD and AF are not known. PURPOSE: To describe LA MD in veteran athletes with and without paroxysmal AF (pAF) and to investigate LA MD's ability to identify veteran athletes with pAF. METHODS: Two hundred and ninety-three men, skiers with (n = 57) and without (n = 87) pAF, and controls with (n = 61) and without pAF (n = 88) underwent an echocardiographic exam in sinus rhythm. LA reservoir strain (LASr) was measured, and LA MD defined as the standard deviation of time-to-peak strain (SD-TPS). RESULTS: Skiers (mean age 70.7 ± 6.7 years) reported an average of 40-50 years of endurance exercise. LA volumes were associated with pAF and athletic status (p < .001). SD-TPS was associated with pAF (p < .001) but not athletic status (p = .173). We found no significant trend between years of exercise and SD-TPS in individuals without AF (p = .893). SD-TPS did not add incremental value in identifying athletes with pAF in addition to clinical markers, QRS width, LA volume, and LASr (p = .056). CONCLUSION: LA MD was associated with pAF regardless of athletic status but not related to years of endurance exercise, suggesting LA MD could be a promising marker of pathological atrial remodeling in athletes. However, we found no incremental value of LA MD identifying athletes with pAF when LASr was included in the model.

Effects of training adaption in endurance athletes with atrial fibrillation: protocol for a multicentre randomised controlled trial.

Endurance athletes have a high prevalence of atrial fibrillation (AF), probably caused by exercise-induced cardiac remodelling. Athletes diagnosed with AF are often advised to reduce the intensity and amount of training but the efficacy of this intervention has not been investigated in endurance athletes with AF. Effects of detraining in endurance athletes with atrial fibrillation is a two-arm international multicentre randomised (1:1) controlled trial on the effects of a period of training adaption on AF burden in endurance athletes with paroxysmal AF. One-hundred-and-twenty endurance athletes diagnosed with paroxysmal AF are randomised to a 16-week period of intervention (training adaption) or a control group. We define training adaption as training with a heart rate (HR) not exceeding 75% of the individual maximum HR (HRmax), and total duration of weekly training not exceeding 80% of the self-reported average before the study. The control group is instructed to uphold training intensity including sessions with HR ≥85% of HRmax. AF burden is monitored with insertable cardiac monitors, and training intensity with HR chest-straps and connected sports watches. The primary endpoint, AF burden, will be calculated as the cumulative duration of all AF episodes lasting ≥30sec divided by total duration of monitoring. Secondary endpoints include number of AF episodes, adherence to training adaption, exercise capacity, AF symptoms and health-related quality of life, echocardiographic signs of cardiac remodelling and risk of cardiac arrhythmias related to upholding training intensity. Trial registration number: NCT04991337. Study protocol version: 4.7 (Date 9 March 2023).

Right Heart Structure and Function in Lifelong Recreational Endurance Athletes with and without Paroxysmal Atrial Fibrillation.

BACKGROUND: Healthy young athletes adapt to the increased demands of endurance exercise with symmetric cardiac remodeling. Male veteran endurance athletes have an increased risk for atrial fibrillation (AF), and some athletes seem susceptible to changes mimicking arrhythmogenic cardiomyopathy. Intense exercise puts a disproportionate hemodynamic load on the right-sided heart chambers. Despite this, data describing right heart structure and function in older veteran athletes are scarce. The aim of this study was to investigate structural and functional characteristics of the right heart in veteran athletes with and without AF to contribute to the understanding of exercise-induced cardiac remodeling in this group. METHODS: Three hundred two male participants, of whom 151 were veteran skiers (62 with paroxysmal AF) and 151 were control subjects from the general population (62 with paroxysmal AF), underwent echocardiographic examinations in sinus rhythm to evaluate right atrial (RA) and right ventricular (RV) structure and function. While 87 of the participants had never exercised regularly, 50, 43, and 122 men had practiced regular endurance exercise for 1 to 20, 20 to 40, and >40 years, respectively. RESULTS: RA volume and RV size increased with cumulative years of exercise (P < .001), with a disproportionate increase in RV size compared with left ventricular (LV) size, regardless of AF status (P < .001). RA and RV function assessed by strain remained similar despite lifelong exposure to endurance exercise. AF was associated with reduced RA strain irrespective of exposure to exercise (P < .001). CONCLUSIONS: RA and RV sizes and RV/LV ratio showed a dose-response relationship with cumulative years of endurance exercise, whereas RA and RV function did not, indicating that increasing RV/LV ratio may represent a physiologic adaptation to prolonged endurance exercise. AF was associated with reduced RA function, regardless of exposure to exercise, suggesting that RA functional parameters are more closely linked to AF than RA size in veteran athletes.

Risk of atrial fibrillation and stroke among older men exposed to prolonged endurance sport practice: a 10-year follow-up. The Birkebeiner Ageing Study and the Tromsø Study.

AIMS: Endurance sport practice is associated with a high prevalence of atrial fibrillation (AF), which increases the risk of stroke in the general population. However, stroke risk in endurance athletes with AF is sparsely investigated. Most studies have been limited by design and are largely restricted to younger and middle-aged populations. Thus, we aimed to investigate AF and stroke risk in older athletes exposed to prolonged endurance training. METHOD: During a 10-year period, 505 male athletes aged ≥65 years frequently participating in a long-distance ski race were compared with 1867 men of the same age from the general population. The main exposure was endurance sport practice with self-reported AF and stroke as outcomes. Stroke risk was further examined by joint modelling of AF and endurance practice. Statistical analysis was conducted with a modified Poisson model. RESULTS: Athletes (median age: 68, range: 65-90) participated in a long-distance ski race over a median of 14 years (range: 1-53). Prevalence (28.5% vs 17.8%) and adjusted risk of AF (risk ratio (RR): 1.88, 95% CI: 1.49 to 2.37) were higher in athletes compared with non-athletes, whereas the prevalence (5.4% vs 9.7%) and risk of stroke were lower (RR: 0.60, 95% CI: 0.37 to 0.95). Compared with athletes without AF, risk of stroke was twofold in athletes (RR: 2.38, 95% CI: 1.08 to 5.24) and nearly fourfold in non-athletes (RR: 3.87, 95% CI: 1.98 to 7.57) with AF. CONCLUSION: Although older male endurance athletes experienced an increased risk of AF, the long-term risk of stroke was substantially reduced compared with non-athletes.

Left atrial function in male veteran endurance athletes with paroxysmal atrial fibrillation.

AIMS: To assess left atrial (LA) function in sinus rhythm in veteran athletes with a history of paroxysmal atrial fibrillation (AF) exposed to prolonged endurance exercise compared with veteran athletes without AF and controls with and without paroxysmal AF from a non-athletic population. METHODS AND RESULTS: Three hundred and two male participants from four groups, veteran recreational skiers with paroxysmal AF (n = 62), veteran skiers without AF (n = 89), and controls from a non-athletic population with (n = 62) and without paroxysmal AF (n = 89) underwent an echocardiographic examination in sinus rhythm to evaluate LA anatomy and function. The skiers (mean age 70.8±6.7 years) reported an average exposure to regular endurance exercise for 40-50 years. LA maximum and minimum volumes were larger in skiers (P < 0.001). LA volumes differed within the athletic and non-athletic groups with larger volumes in the AF groups ( P < 0.001). We observed a considerable overlap in LA volumes among non-athletes with AF and athletes without AF. LA reservoir strain (33.6% ± 4.8% vs. 28.3% ± 6.7% P < 0.001) and contractile strain (18.3% ± 4.0% vs. 15.0% ± 5.2% P < 0.001) were lower in both AF groups regardless of athletic status. LA reservoir strain was superior to volumetric measurements at identifying participants with AF (area under the curve 0.740 ±0.041). CONCLUSION: Male veteran athletes had significantly larger LA volumes than non-athletes. In contrast, LA strain values were similar in athletes and non-athletes with paroxysmal AF, and significantly lower than in subjects without AF.