How to Unmask Hidden Cardiovascular Diseases through Preparticipation Screening in Master Athletes?

Cardiovascular disease (CVD) is the most common cause of death globally in general population. Sport activity is an effective and recommended non-pharmacological method of CVD prevention. Presently, the group of people practicing sport regularly is constantly growing due to increasing awareness of its health benefits. However, vigorous-intensity exercises can reveal previously undetected disease. Master athletes over 35 years old are particularly exposed to sudden cardiac death (SCD) mainly in the course of coronary artery disease (CAD). Another common disease in veteran athletes is hypertension. It is known that regular endurance training can lower blood pressure at rest, so arterial hypertension in athletes is usually masked by adaptation to effort. Despite of normal or high-normal blood pressure in the office, the values during exercises and in ambulatory blood pressure monitoring (ABPM) can exceed the norm. Hidden hypertension have the same negative impact on cardiovascular system. It increases the risk of (1) atherosclerosis and therefore myocardial infarction or stroke, (2) left ventricular hypertrophy with diastolic and/or systolic heart failure, myocardial fibrosis and ventricular arrhythmias, (3) left atrial enlargement increasing the risk of atrial fibrillation and stroke and (4) aortic dilation/dissection. Through these complications hypertension can lead to SCD during sport activities, therefore it is important to recognize this disease early and start a proper treatment. To enable safe participation in sports competition detailed guidelines for screening were created, but they mainly concern CAD. We propose an additional scheme of screening in master athletes including the detection of hidden hypertension to prevent its consequences.

Cardiac Magnetic Resonance Follow-Up of Children After Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 With Initial Cardiac Involvement.

BACKGROUND: Pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is an inflammatory disease occurring in a small minority of children a few weeks after acute infection. Cardiac manifestations are common, but little is known about the potentially persistent heart changes after PIMS-TS. PURPOSE: To analyze the frequency and type of myocardial complications of PIMS-TS with initial cardiac involvement assessed with cardiac magnetic resonance imaging (MRI), including parametric imaging, performed 3 months after hospitalization. STUDY TYPE: Retrospective. POPULATION: Nineteen consecutive children (median age 10 years, interquartile range (IQR) 10-15 years, 74% male). FIELD STRENGTH/SEQUENCE: Balanced steady state free precession (bSSFP, cine imaging), modified Look-Locker (T1 mapping), T2-prepared bSSFP (T2-mapping), dark-blood T2-weighted turbo spin echo with fat suppression and phase sensitive inversion recovery (late gadolinium enhancement (LGE)) sequences at 1.5 T. ASSESSMENT: Patients were scanned after a median of 99 days (IQR 89-104 days) from the diagnosis. MR data were reviewed by three independent observers, with 13, 2, and 5 years' experience in cardiac MRI. Pre- and post-contrast T1, T2, extra-cellular volume, and T2 signal intensity (T2 SI) ratio were calculated. Diagnosis of acute myocarditis was based on modified Lake Louise criteria. Cardiac MRI parameters were compared, where possible, to previously published pediatric normal values. STATISTICAL TESTS: Interclass correlation coefficient and Bland-Altman repeatability analysis. A P-value <0.05 was considered statistically significant. RESULTS: Despite cardiac involvement including decreased left ventricular ejection fraction (LVEF) (median LVEF = 47%, IQR 43%-53%) and increased troponin I (median 101 ng/mL, IQR 50-661 ng/mL) during hospitalization, there were no persistent cardiac changes observed in cardiac MR at follow-up. All patients had normal size and function of the left ventricle and normal precontrast T1 and T2 relaxation times. There were no signs of LGE. Persistent, mild pericardial effusion (8-9 mm) was found in three (16%) patients. DATA CONCLUSION: There were no persistent changes on cardiac MRI in a group of children approximately 3 months post hospitalization due to PIMS-TS with cardiac involvement. This supports the hypothesis that cardiac involvement during PIMS-TS is a form of transient inflammatory response rather than direct and potentially persistent injury from the virus. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY: Stage 3.

Cardiac involvement in consecutive elite athletes recovered from Covid-19: A magnetic resonance study.

Magnetic resonance (MR) studies suggested cardiac involvement post-Covid-19 in a significant subset of affected individuals, including athletes. This brings serious clinical concerns regarding the potential need for in-depth cardiac screening in athletes after Covid-19 before return to play. The aim of this study was to gain further insight into the relation between Covid-19 and cardiac involvement in professional athletes. This was a retrospective cohort study, in which 26 consecutive elite athletes (national team, Olympians, top national league players; median age 24 years, interquartile range [IQR] 21-27, 81% female) were included. At 1.5 T including balanced steady-state free precession cine imaging, T1 and T2-mapping using Myomaps software (Siemens), dark-blood T2-weighted images with fat suppression, and late gadolinium enhancement (LGE) with phase-sensitive inversion recovery sequence were used. The athletes had mainly asymptomatic or mild course of the disease (77%). They were scanned after a median of 32 days (IQR 22-62 days) from the diagnosis. MR data were reviewed by three independent observers, each with >10 years cardiac MR experience. Native T1, T2, extracellular volume, and T2 signal intensity ratio were calculated. Diagnosis of acute myocarditis was based on modified Lake Louise criteria. Statistical analyses used were Pearson correlation and Bland-Altman repeatability analysis. At the time of MR the athletes had no pathologic electrocardiogram abnormalities or elevated troponin levels. MR did not reveal any case of acute myocarditis. Cardiac abnormalities were found in five (19%) athletes, including four athletes presenting borderline signs of isolated myocardial edema and one athlete showing nonischemic LGE with pleural and pericardial effusion. Another athlete had signs of persistent lung congestion without cardiac involvement. We have shown that in a small group of elite athletes with mainly asymptomatic to mild Covid-19, lack of electrocardiographic changes, and normal troponin concentration 1-2 months after the diagnosis, there were no signs of acute myocarditis, but 19% of athletes had some abnormalities as assessed by cardiac MR. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 3.

Multimodal assessment of right ventricle overload-metabolic and clinical consequences in pulmonary arterial hypertension.

BACKGROUND: In pulmonary arterial hypertension (PAH) increased afterload leads to adaptive processes of the right ventricle (RV) that help to maintain arterio-ventricular coupling of RV and preserve cardiac output, but with time the adaptive mechanisms fail. In this study, we propose a multimodal approach which allows to estimate prognostic value of RV coupling parameters in PAH patients. METHODS: Twenty-seven stable PAH patients (49.5 ± 15.5 years) and 12 controls underwent cardiovascular magnetic resonance (CMR). CMR feature tracking analysis was performed for RV global longitudinal strain assessment (RV GLS). RV-arterial coupling was evaluated by combination of RV GLS and three proposed surrogates of RV afterload-pulmonary artery systolic pressure (PASP), pulmonary vascular resistance (PVR) and pulmonary artery compliance (PAC). 18-FDG positron emission tomography (PET) analysis was used to assess RV glucose uptake presented as SUVRV/LV. Follow-up time of this study was 25 months and the clinical end-point was defined as death or clinical deterioration. RESULTS: Coupling parameters (RV GLS/PASP, RV GLS/PVR and RV GLS*PAC) significantly correlated with RV function and standardized uptake value (SUVRV/LV). Patients who experienced a clinical end-point (n = 18) had a significantly worse coupling parameters at the baseline visit. RV GLS/PASP had the highest area under curve in predicting a clinical end-point and patients with a value higher than (-)0.29%/mmHg had significantly worse prognosis. It was also a statistically significant predictor of clinical end-point in multivariate analysis (adjusted R2 = 0.68; p < 0.001). CONCLUSIONS: Coupling parameters are linked with RV hemodynamics and glucose metabolism in PAH. Combining CMR and hemodynamic measurements offers more comprehensive assessment of RV function required for prognostication of PAH patients. TRIAL REGISTRATION: NCT03688698, 09/26/2018, retrospectively registered; Protocol ID: 2017/25/N/NZ5/02689.

Normal values of native T1 and T2 relaxation times on 3T cardiac MR in a healthy pediatric population aged 9-18 years.

BACKGROUND: Native myocardial T1 and T2 relaxation times are diagnostic tools used in clinical practice for adult and pediatric populations. Use of a mapping technique requires accurate knowledge of normal ranges in healthy patients, which is lacking in pediatric populations. PURPOSE: To establish normal values for native T1 and T2 mapping in healthy pediatric subjects of different ages and sex. STUDY TYPE: Prospective. POPULATION: Thirty-eight healthy children (9-18 years; mean age 14.0 ± 2.7). FIELD STRENGTH: Cardiac MR with a 3T scanner. T1 and T2 mapping using MyoMaps software. ASSESSMENT: T1 and T2 relaxation times were calculated from a 0.7-1.0 cm2 region of interest placed at the mid-ventricular short-axis slice in the interventricular septum by two observers. Inter- and intraobserver variability was assessed. STATISTICAL TESTS: The Student's t-test or the Mann-Whitney test for unpaired samples was applied to compare one continuous variable between two category groups. One-way analysis of variance (ANOVA) or a Kruskal-Wallis test was applied to compare one continuous variable between three category groups. Correlation between two continuous variables was assessed with a Pearson or Spearman test. RESULTS: The mean native T1 relaxation time was 1223 ± 29 msec and T2 relaxation time was 43 ± 4.5 msec. There was no correlation between T1 /T2 values and age or body surface area (for T1 P = 0.94 and 0.90 and for T2 P = 0.19 and 0.64, respectively). There was weak correlation between T1 values and body mass index (BMI) (r = 0.448, P = 0.005). T2 values were significantly higher in females compared with males (44.6 ± 4.2 vs. 40.4 ± 3.8 msec, P = 0.002). We found a significant rise of T2 relaxation time in the pubertal period (age 13-15 years) comparing to prepubertal (age 9-12 years). Inter- and intraobserver agreement of T1 (r = 0.93; r = 0.99) and T2 (r = 0.96; r = 0.95) were high. DATA CONCLUSION: We report normal values of native T1 and T2 relaxation times obtained with Myomaps software for 3T cardiac MR in a healthy pediatric population. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;51:912-918.

Children With Acute Myocarditis Often Have Persistent Subclinical Changes as Revealed by Cardiac Magnetic Resonance.

BACKGROUND: Many children presenting with myocarditis may not fully recover and have long-term complications, including dilated cardiomyopathy. Magnetic resonance imaging (MRI) has a potential for early detection of persistent changes with long-term implications, but is not performed routinely in the monitoring of myocarditis. PURPOSE: To monitor adolescents who present with acute myocarditis using MRI and routine diagnostic tests over the short- to mid-term. STUDY TYPE: Prospective. POPULATION: Eighteen consecutive adolescents (median age 15.5, interquartile range 14.8-16.9 years, 78% male) with acute myocarditis. FIELD STRENGTH: A 3T scanner including cine steady-state free precession (SSFP), dark-blood T2 -weighted (T2 W) images, and late gadolinium enhancement (LGE). ASSESSMENT: The diagnosis of acute myocarditis was based on clinical symptoms and signs and MRI criteria (cine, T2 -W images, LGE). Follow-up MRI was performed after median 7 months (range 6-9 months). Other routine diagnostic tests included electrocardiogram (ECG), high-sensitivity troponin levels, transthoracic echocardiography, and Holter monitoring. STATISTICAL TESTS: Fisher's exact test, Wilcoxon test for paired samples, Mann-Whitney test for independent samples, Kruskal-Wallis test. RESULTS: At baseline, 17 patients (94%) had elevated troponin levels and/or ST-T changes on resting ECG; ECG showed depressed left ventricular ejection fraction (LVEF<50%) in four patients (22%). At follow-up there was a complete recovery in 16 patients (89%) observed with routinely performed tests, with two cases of persistent ventricular arrhythmia. Despite normal left ventricular volume and LVEF, MRI disclosed ongoing active inflammation in five patients (28%), healed myocarditis with persistent scars in eight patients (44%), and complete resolution of initially observed changes in five patients (28%). DATA CONCLUSION: In children with acute myocarditis, despite normalization of other routinely assessed parameters (including LVEF), there is a high prevalence of persistent MRI changes showing ongoing disease or remnant scars at follow-up. MRI may allow early detection and prevention of long-term complications of myocarditis in the follow-up care of children with acute myocarditis. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2020. J. Magn. Reson. Imaging 2020;52:488-496.

Normal Values for Left Ventricular Mass in Relation to Lean Body Mass in Child and Adolescent Athletes.

It has been demonstrated that regular sport activity in children leads to physiological changes in the heart including increased left ventricular (LV) myocardial thickness and mass (LVM). The aim of the study was to establish the first specific normal values of LVM for child and adolescent athletes. Parasternal long-axis, 2D-guided echocardiographic measurements were obtained from a group of 791 Caucasian child athletes (age 5-18 years, 58.7% boys). For the preparation of normative data, LVM-for-lean body mass (LBM) reference curves were constructed using the LMS method. Then, a simple correlation plot was constructed to analyse the concordant and discordant indications of left ventricular hypertrophy (LVH), defined as LVM-for-LBM above the 95th percentile, according to the newly created and previously published normative data on LVM-for-LBM in the general population of children. Reference scatter plots of LVM-for-LBM for boys and girls in the analysed group of children practicing sports were presented, showing mean values of LVM and z-scores. The application to the studied group of reference centiles established for the general population of children would lead to false positive misclassification of increased LVH in 5.8% of the girls and 17.0% of the boys. We present the first specific normative data for LV mass in relation to lean body mass in Caucasian children and adolescents engaged in regular sport activities. The application of specific normative data for LV mass results in fewer false positive findings of left ventricular hypertrophy in this group than that of reference values for general paediatric population.

Cardiac Magnetic Resonance Assessment of the Structural and Functional Cardiac Adaptations to Soccer Training in School-Aged Male Children.

Physical training is associated with changes in cardiac morphology called the "athlete's heart", which has not been sufficiently studied in children. The aim of the study was to analyze cardiac adaptation to exercise in pre-adolescent soccer players. Thirty-six soccer players (mean age 10.1 ± 1.4 years) and 24 non-athlete male controls (10.4 ± 1.7 years) underwent cardiac magnetic resonance. Measurements of myocardial mass, end-diastolic and end-systolic volume, stroke volume and ejection fraction for left and right ventricle (LV, RV) were performed. Additionally, left and right atrial (LA, RA) areas and volumes were analysed. Relative wall thickness (RWT) was calculated to describe the pattern of cardiac remodeling. Interventricular wall thickness and LV mass were significantly higher in athletes, but remained within the reference (6.9 ± 0.8 vs. 6.2 ± 0.9 mm/√m2, p = 0.003 and 57.1 ± 7.4 vs. 50.0 ± 7.1 g/m2, p = 0.0006, respectively) with no changes in LV size and function between groups. The RWT tended to be higher among athletes (p = 0.09) indicating LV concentric remodeling geometry. Soccer players had significantly larger RV size (p < 0.04) with similar function and mass. Also, the LA volume (p = 0.01), LA area (p = 0.03) and LA diameter (p = 0.009) were significantly greater in players than in controls. Cardiac adaptations in pre-adolescent soccer players are characterized by an increased LV mass without any changes in LV size and systolic function, which is typical of resistance training with tendency to concentric remodeling. This is accompanied by increase of LA and RV size. It should be taken into account during annual pre-participation evaluation.

Cardiac deformation parameters and rotational mechanics by cardiac magnetic resonance feature tracking in pre-adolescent male soccer players.

The purpose of the study was to analyse whether prolonged and regular physical training in children leads to changes in myocardial systolic deformation and rotational mechanics. For that purpose, cardiac MRI feature tracking was performed retrospectively in 35 pre-adolescent male soccer players and 20 matched controls. There were no changes in global strain, but left ventricular twist and apical rotation were greater in soccer players, which adds to the features of paediatric athlete's heart.

Cine dyscontractility index: A novel marker of mechanical dyssynchrony that predicts response to cardiac resynchronization therapy.

PURPOSE: To investigate whether magnetic resonance imaging (MRI) cine-derived dyssynchrony indices provide additional information compared to conventional tagged MRI (tMRI) acquisitions in heart failure patients undergoing cardiac resynchronization therapy (CRT). MATERIALS AND METHODS: Patients scheduled for CRT (n = 52) underwent preprocedure MRI including cine and tMRI acquisitions. Segmental strain curves were calculated for both cine and tMRI to produce a range of standard indices for direct comparison between modalities. We also proposed and evaluated a novel index of "dyscontractility," which detects the presence of focal areas with paradoxically positive circumferential strain. RESULTS: Across conventional strain indices, there was only moderate-to-poor (R = 0.3-0.6) correlation between modalities; eight cine-derived indices showed statistically significant (P < 0.05) relations to CRT outcome compared to just two tMRI-based counterparts. The novel dyscontractility index calculated on basal slice cine images (cine dyscontractility index, "CDI") was the single best predictor of clinical response to CRT (area under the curve AUC = 0.81, P < 0.001). While poorly correlated to its tMRI counterpart (R = 0.33), CDI performed significantly better in predicting response to CRT (P < 0.005), and was also numerically better than all other tMRI indices (AUC 0.53-0.76, all P for AUC comparisons <0.17). CONCLUSION: Cine-derived strain indices offer potentially new information compared to tMRI. Specifically, the novel CDI is most strongly linked to response to cardiac resynchronization therapy in a contemporary patient cohort. It utilizes readily available MRI data, is relatively straightforward to process, and compares favorably with any conventional tagging index. J. Magn. Reson. Imaging 2016;44:1483-1492.

A study in Polish patients with cardiomyopathy emphasizes pathogenicity of phospholamban (PLN) mutations at amino acid position 9 and low penetrance of heterozygous null PLN mutations.

BACKGROUND: In humans mutations in the PLN gene, encoding phospholamban - a regulator of sarcoplasmic reticulum calcium ATPase (SERCA), cause cardiomyopathy with prevalence depending on the population. Our purpose was to identify PLN mutations in Polish cardiomyopathy patients. METHODS: We studied 161 unrelated subjects referred for genetic testing for cardiomyopathies: 135 with dilated cardiomyopathy, 22 with hypertrophic cardiomyopathy and 4 with other cardiomyopathies. In 23 subjects multiple genes were sequenced by next generation sequencing and in all subjects PLN exons were analyzed by Sanger sequencing. Control group included 200 healthy subjects matched with patients for ethnicity, sex and age. Large deletions/insertions were screened by real time polymerase chain reaction. RESULTS: We detected three different heterozygous mutations in the PLN gene: a novel null c.9_10insA:(p.Val4Serfs*15) variant and two missense variants: c.25C > T:(p.Arg9Cys) and c.26G > T:(p.Arg9Leu). The (p.Val4Serfs*15) variant occurred in the patient with Wolff-Parkinson-White syndrome in whom the diagnosis of cardiomyopathy was not confirmed and his mother who had concentric left ventricular remodeling but normal left ventricular mass and function. We did not detect large deletions/insertions in PLN in cohort studied. CONCLUSIONS: In Poland, similar to most populations, PLN mutations rarely cause cardiomyopathy. The 9(th) PLN residue is apparently a mutation hot spot whereas a single dose of c.9_10insA, and likely other null PLN mutations, cause the disease only with low penetrance or are not pathogenic.

The BAG3 gene variants in Polish patients with dilated cardiomyopathy: four novel mutations and a genotype-phenotype correlation.

BACKGROUND: BAG3 gene mutations have been recently implicated as a novel cause of dilated cardiomyopathy (DCM). Our aim was to evaluate the prevalence of BAG3 mutations in Polish patients with DCM and to search for genotype-phenotype correlations. METHODS: We studied 90 unrelated probands by direct sequencing of BAG3 exons and splice sites. Large deletions/insertions were screened for by quantitative real time polymerase chain reaction (qPCR). RESULTS: We found 5 different mutations in 6 probands and a total of 21 mutations among their relatives: the known p.Glu455Lys mutation (2 families), 4 novel mutations: p.Gln353ArgfsX10 (c.1055delC), p.Gly379AlafsX45 (c.1135delG), p.Tyr451X (c.1353C>A) and a large deletion of 17,990 bp removing BAG3 exons 3-4. Analysis of mutation positive relatives of the probands from this study pooled with those previously reported showed higher DCM prevalence among those with missense vs. truncating mutations (OR = 8.33, P = 0.0058) as well as a difference in age at disease onset between the former and the latter in Kaplan-Meier survival analysis (P = 0.006). Clinical data from our study suggested that in BAG3 mutation carriers acute onset DCM with hemodynamic compromise may be triggered by infection. CONCLUSIONS: BAG3 point mutations and large deletions are relatively frequent cause of DCM. Delayed DCM onset associated with truncating vs. non-truncating mutations may be important for genetic counseling.

Myocardial Infarction in Young Athletes.

Myocardial infarction (MI) in young athletes is very rare but can have serious consequences, including sudden cardiac death (SCD), an increased proarrhythmic burden in future life, and/or heart failure. We present two cases of young athletes with MI. They did not have previous symptoms, traditional risk factors, or a family history of MI. One case involves a 37-year-old male amateur athlete who experienced two MI following intense physical exertion, likely due to the erosion of an insignificant atherosclerotic plaque caused by a sudden increase in blood pressure during exercise. The second case describes a 36-year-old male semi-professional runner who collapsed at the finish line of a half-marathon and was diagnosed with hypertrophic cardiomyopathy. The heart's oxygen demand-supply mismatch during intensive exercise led to MI. Following the case presentation, we discuss the most common causes of MI in young athletes and their mechanisms, including spontaneous coronary artery dissection, chest trauma, abnormalities of the coronary arteries, coronary artery spasm, plaque erosion, hypercoagulability, left ventricular hypertrophy, and anabolic steroids use.

Isolated myocardial edema in cardiac magnetic resonance - in search of a management strategy.

Isolated myocardial edema not accompanied by late gadolinium enhancement (LGE) may be occasionally found on cardiac magnetic resonance (CMR). This type of picture may be encountered in patients with suspected myocarditis, post some acute cardiac events, with cardiac allograft rejection or even in athletes after an extreme exercise. Currently, there is no clear management strategy for this type of incidental finding. In this narrative review we discuss the methods and pitfalls of edema detection with means of CMR, review published data on isolated myocardial edema for each of the most probable clinical scenarios and propose a structured clinical decision-making algorithm to help clinicians navigate through this type of CMR result. Finally, we highlight the most important gaps in evidence related to isolated myocardial edema without fibrosis, where further research is particularly needed.

The impact of specific pulmonary arterial hypertension therapy on cardiac fluorodeoxyglucose distribution in PET/MRI hybrid imaging-follow-up study.

BACKGROUND: PET/MRI hybrid imaging in pulmonary arterial hypertension (PAH) provides important prognostic information identifying patients who might benefit from early therapy escalation, as right ventricle (RV) metabolic alterations are linked with hemodynamics and might precede clinical deterioration. Now, we hypothesize that adequate PAH therapy escalation may result in reversal of unfavourable increased glucose uptake of RV, which is associated with improved prognosis. METHODS: Out of twenty-six initially clinically stable PAH patients who had baseline PET/MRI scans, twenty (49.9 ± 14.9 years) had second PET/MRI after 24 months. SUVRV/SUVLV ratio was used to estimate and compare cardiac glucose uptake. Occurrences of clinical endpoints (CEP), defined as death or clinical deterioration, were assessed during 48-month follow-up from baseline. RESULTS: In first 24 months of observation, sixteen patients had CEP and needed PAH therapy escalation. At follow-up visits, we observed significant improvement of RV ejection fraction (45.1 ± 9.6% to 52.4 ± 12.9%, p = 0.01), mean pulmonary artery pressure (50.5 ± 18.3 to 42.8 ± 18.6 mmHg, p = 0.03), and SUVRV/SUVLV, which tended to decrease (mean change -0.20 ± 0.74). Patients with baseline SUVRV/SUVLV value higher than 0.54 had worse prognosis in 48 months observation (log-rank test, p = 0.0007); follow up SUVRV/SUVLV > 1 predicted CEP in the following 24 months, regardless of previously escalated treatment. CONCLUSIONS: PAH therapy escalation may influence RV glucose metabolism, what seems to be related with patients' prognosis. PET/MRI assessment may predict clinical deterioration regardless of previous clinical course, however its clinical significance in PAH requires further studies. Importantly, even mild alterations of RV glucose metabolism predict clinical deterioration in long follow-up. Clinical Trial Registration ClinicalTrials.gov, NCT03688698, 05/01/2016, https://clinicaltrials.gov/ct2/show/study/NCT03688698?term=NCT03688698&draw=2&rank=1.

External validation of VO2max prediction models based on recreational and elite endurance athletes.

In recent years, numerous prognostic models have been developed to predict VO2max. Nevertheless, their accuracy in endurance athletes (EA) stays mostly unvalidated. This study aimed to compare predicted VO2max (pVO2max) with directly measured VO2max by assessing the transferability of the currently available prediction models based on their R2, calibration-in-the-large, and calibration slope. 5,260 healthy adult EA underwent a maximal exertion cardiopulmonary exercise test (CPET) (84.76% male; age 34.6±9.5 yrs.; VO2max 52.97±7.39 mL·min-1·kg-1, BMI 23.59±2.73 kg·m-2). 13 models have been selected to establish pVO2max. Participants were classified into four endurance subgroups (high-, recreational-, low- trained, and "transition") and four age subgroups (18-30, 31-45, 46-60, and ≥61 yrs.). Validation was performed according to TRIPOD guidelines. pVO2max was low-to-moderately associated with direct CPET measurements (p>0.05). Models with the highest accuracy were for males on a cycle ergometer (CE) (Kokkinos R2 = 0.64), females on CE (Kokkinos R2 = 0.65), males on a treadmill (TE) (Wasserman R2 = 0.26), females on TE (Wasserman R2 = 0.30). However, selected models underestimated pVO2max for younger and higher trained EA and overestimated for older and lower trained EA. All equations demonstrated merely moderate accuracy and should only be used as a supplemental method for physicians to estimate CRF in EA. It is necessary to derive new models on EA populations to include routinely in clinical practice and sports diagnostic.

Repaired tetralogy of Fallot: ratio of right ventricular volume to left ventricular volume as a marker of right ventricular dilatation.

PURPOSE: To compare indexed right ventricular (RV) end-diastolic volume (RVEDVi) and the ratio of RV volume to left ventricular (LV) volume (RV/LV ratio) in prediction of significant pulmonary regurgitation (PR) after tetralogy of Fallot (TOF) repair and to assess sex differences in the RV/LV ratio. MATERIALS AND METHODS: The ethics committee approved this retrospective single-center study, and patients or their parents or guardians signed written informed consent. RVEDVi, RV/LV ratio, and PR were measured with the use of magnetic resonance imaging in 155 consecutive patients with repaired TOF (mean age, 29.2 years±10.9 [standard deviation]; 98 [63.2%] male and 57 [36.8%] female patients). PR fraction of 20% or greater was considered significant. The capability of the RVEDVi and that of the RV/LV ratio for prediction of significant PR were compared by using logistic regression analysis and receiver operating characteristic curve analysis. RESULTS: RVEDVi was significantly higher in male (162.8 mL/m2±50.4) than in female (138.2 mL/m2±37.5) patients (P=.001). Conversely, the RV/LV ratio was similar in both sexes (1.82±0.56 [male] vs 1.69±0.46 [female], P=.13) both in the entire cohort and after excluding patients with significant (≥30 mm Hg) RV outflow tract gradient and/or other residual hemodynamic abnormalities (P=.63). Receiver operating characteristic analysis revealed better discrimination of significant (≥20%) from insignificant (<20%) PR with the use of the RV/LV ratio than with RVEDVi (area under the receiver operating characteristic curve, 0.937 [model 4] vs 0.849 [model 1], P=.01). In multivariate analysis, the only independent predictor of PR fraction was the RV/LV ratio. CONCLUSION: The RV/LV ratio is more accurate than the RVEDVi in differentiation of significant from insignificant PR. After TOF repair, female and male patients have similar RV/LV ratios despite significant differences in RVEDVi between the sexes.

Mild Left Ventricular Hypertrophy in Middle-Age Male Athletes as a Sign of Masked Arterial Hypertension.

Mild left ventricular hypertrophy (LVH) has been considered as one of the possible structural, physiological adaptations to regular, intensive physical activity. However, it may also appear as one of the subclinical complications of hypertension. In athletes, the differential diagnosis between these two entities may be complicated as regular physical activity may potentially mask the presence of arterial hypertension. We sought to determine the relation between LVH in middle-age athletes and the presence of hypertension. The study included 71 healthy, male long-time amateur athletes (mean age 41 ± 6 years, 83% endurance and 17% power sports) without known hypertension or any other cardiovascular diseases and with normal self-measured and office blood pressure. All subjects underwent resting electrocardiogram, transthoracic echocardiography, maximal exercise test on a treadmill and ambulatory blood pressure monitoring. LVH was diagnosed as left ventricular wall diameter >11 mm. Hypertension was defined as mean 24 h systolic blood pressure (SBP) ≥ 130 mmHg and/or diastolic blood pressure (DBP) ≥ 80 mmHg. Exaggerated blood pressure response (EBPR) to exercise was defined as SBP ≥ 210 mmHg. LVH (range > 11 to 14 mm) was found in 20 subjects (28%) and hypertension was diagnosed in 33 subjects (46%). Athletes with LVH were more likely to have hypertension than those without LVH (70% vs. 37%, p = 0.01). EBPR to exercise was found equally common in athletes with and without LVH (35% vs. 29%, p = 0.68), but more often in subjects with hypertension (51% vs. 13%, p < 0.001). Presence of LVH and hypertension was equally common in the studied endurance and power sport athletes (p = 0.66 and p = 0.79, respectively). In comparison to athletes without LVH, those with LVH had larger left atrial size (26 ± 6 vs. 21 ± 4 cm2, p < 0.001) and a tendency for lower left ventricular diastolic function (E/A 1.2 ± 0.4 vs. 1.5 ± 0.4, p = 0.05) and a larger ascending aorta diameter (34 ± 3 vs. 32 ± 3, p = 0.05), but a similar left ventricular end-diastolic diameter (51 ± 3 vs. 51 ± 4, p = 0.71). The presence of mild left ventricular hypertrophy in middle-age male amateur athletes with normal home and office blood pressure may be considered as a potential sign of masked hypertension. It should not be overlooked as an element of a physiological adaptation to exercise and may warrant further medical evaluation with ambulatory blood pressure monitoring.

Diagnostic Yield of Cardiac Magnetic Resonance in Athletes with and without Features of the Athlete's Heart and Suspected Structural Heart Disease.

Cardiac magnetic resonance (CMR) is a second-line imaging test in cardiology. Balanced enlargement of heart chambers called athlete's heart (AH) is a part of physiological adaptation to regular physical activity. The aim of this study was to evaluate the diagnostic utility of CMR in athletes with suspected structural heart disease (SHD) and to analyse the relation between the coexistence of AH and SHD. We wanted to assess whether the presence of AH phenotype could be considered as a sign of a healthy heart less prone to development of SHD. This retrospective, single centre study included 154 consecutive athletes (57 non-amateur, all sports categories, 87% male, mean age 34 ± 12 years) referred for CMR because of suspected SHD. The suspicion was based on existing guidelines including electrocardiographic and/or echocardiographic changes suggestive of abnormality but without a formal diagnosis. CMR permitted establishment of a new diagnosis in 66 patients (42%). The main diagnoses included myocardial fibrosis typical for prior myocarditis (n = 21), hypertrophic cardiomyopathy (n = 17, including 6 apical forms), other cardiomyopathies (n = 10) and prior myocardial infarction (n = 6). Athlete's heart was diagnosed in 59 athletes (38%). The presence of pathologic late gadolinium enhancement (LGE) was found in 41 patients (27%) and was not higher in athletes without AH (32% vs. 19%, p = 0.08). Junction-point LGE was more prevalent in patients with AH phenotype (22% vs. 9%, p = 0.02). Patients without AH were not more likely to be diagnosed with SHD than those with AH (49% vs. 32%, p = 0.05). Based on the results of CMR and other tests, three patients (2%) were referred for ICD implantation for the primary prevention of sudden cardiac death with one patient experiencing adequate intervention during follow-up. The inclusion of CMR into the diagnostic process leads to a new diagnosis in many athletes with suspicion of SHD and equivocal routine tests. Athletes with AH pattern are equally likely to be diagnosed with SHD in comparison to those without AH phenotype. This shows that the development of AH and SHD can occur in parallel, which makes differential diagnosis in this group of patients more challenging.

Elite athletes with COVID-19 - Predictors of the course of disease.

OBJECTIVES: The aim of the study was to identify predictors determining the course of COVID-19 and antibody response in elite athletes. DESIGN: Observational study. METHODS: Routine medical screening with physical examination, resting ECG, and laboratory tests including antibody response was performed 12-68 days after the diagnosis of COVID-19 in 111 athletes of different sports. RESULTS: Clinical symptoms were observed in 84% of subjects. The severity of COVID-19 was mild in 82% of athletes and moderate in 2% of cases. Athletes aged above 26 and male were more likely to develop symptomatic COVID-19. Asymptomatic subjects were younger and predominantly female. In 18% of subjects, symptoms were still present 20 (12-68) days (median and range) since positive diagnosis. Antibody response was observed in 88% of athletes, and its magnitude correlated with time since diagnosis of COVID-19 (RT-PCR), fatigue, fever, and conjunctivitis. There were no differences in antibody response between groups distinguished by sports discipline (p = 0.50), and sex (p = 0.59), and antibody response did not correlate with BMI (p = 0.12), age (p = 0.13), the number of symptoms (p = 0.43) or their duration (p = 0.19). CONCLUSIONS: The severity of COVID-19 in elite athletes is predominantly mild and without complications. Athletes can return to sport after two symptom-free weeks and additional heart screening is usually not required. Determination of antibodies has been shown to be a useful indicator of a previous COVID-19 disease, and some symptoms can be used as predictors of antibody response.