An echocardiographic study of acute, progressive cardiac changes following a 246 km running race.

We describe the case of an ultra-marathon runner who finished first the "Spartathlon", a 246 km running race. The finishing time was the second fastest time ever in "Spartathlon". After finishing the race, the athlete suffered non-cardiac syncope and was administered intravenously 3 L of fluids for 5 hours. He underwent two echocardiographic assessments, one immediately after the finish of the race and the second 5 h later. Post-exercise fluid administration led to an increase in dimensions of all cardiac cavities, accompanied by a decrease in left ventricular (LV) end-diastolic interventricular septum thickness and posterior wall thickness of 0.1 cm. Dimensions and the respiratory profile of inferior vena cava improved after the race, reflecting alleviation of exercise-related hypovolaemia. Additionaly, LV global longitudinal strain improved, but right ventricular (RV) systolic function continued to deteriorate, mainly due to impairment of basal and medial RV free wall longitudinal strain. Study of this case offers a unique model for understanding the successive changes of cardiac structure and function following an ultra-marathon running race.

Impact of a 246 Km ultra-marathon running race on heart: Insights from advanced deformation analysis.

Although previous studies suggest that prolonged intense exercise such as marathon running transitorily alters cardiac function, there is little information regarding ultramarathon races. Aim of this study was to investigate the acute impact of ultra-endurance exercise (UEE) on heart, applying advanced strain imaging. Echocardiographic assessment was performed the day before and at the finish line of "Spartathlon": A 246 Km ultra-marathon running race. 2D speckle-tracking echocardiography was performed in all four chambers, evaluating longitudinal strain (LS) for both ventricles and atria. Peak strain values and temporal parameters adjusted for heart rate were extracted from the derived curves. Out of 60 participants initially screened, 27 athletes (19 male, age 45 ± 7 years) finished the race in 33:34:27(28:50:38-35:07:07) hours. Absolute values of right (RV) and left ventricular (LV) LS (RVLS -22.9 ± 3.6 pre- to -21.2 ± 3.0% post-, p=0.04 and LVLS -20.9 ± 2.3 pre- to -18.8 ± 2.0 post-, p=0.009) slightly decreased post-race, whereas atrial strain did not change. RV and LV LS decrease was caused mainly by strain impairment of basal regions with apical preservation. Inter-chamber relationships assessed through RV/LV, LV/LA, RV/RA and RA/LA peak values' ratios remained unchanged from pre to post-race. Finally, UEE caused an extension of the systolic phase of cardiac cycle with concomitant diastole reduction (p<0.001 for all strain curves). Conclusively, ventricular LS strain as well as effective diastolic period slightly decreased, whereas atrial strain and inter-chamber relationships remained unchanged after running a 246-km-ultra-marathon race. These changes may be attributed to concomitant pre- and afterload alterations following UEE.

Exploring the determinants of the cardiac changes after ultra-long duration exercise: The echocardiographic Spartathlon study.

AIM: The investigation of the pathophysiological determinants of cardiac changes following ultra-long duration exercise. METHODS: Twenty-seven runners who finished a 246 km running race were examined both before and after the finish of the race. Examinations included echocardiography and measurement of body weight and blood biochemical parameters. RESULTS: Exercise increased left ventricular end-diastolic interventricular septum thickness (LVIVSd) (p < 0.001) and posterior wall thickness (LVPWTd) (p = 0.001) and right ventricular end-diastolic area (p = 0.005), while reduced tricuspid annular plane systolic excursion (TAPSE) (p = 0.004). A minor decrease in the peak absolute values of both left ventricular (from -20.9 ± 2.3% to -18.8 ± 2.0%, p = 0.009) and right ventricular (from -22.9 ± 3.6% to -21.2 ± 3.0%, p = 0.040) global longitudinal strains occurred. There was decrease in body weight (p < 0.001) and increase in both circulating high-sensitivity troponin I (p = 0.028) and amino-terminal pro-B type natriuretic peptide (NT-proBNP) (p = 0.018). The change in the sum of LVIVSd and LVPWTd correlated negatively with percentage change of body weight (r = -0.416, p = 0.049). The only independent determinant of post-exercise NT-proBNP was pulmonary artery systolic pressure (r = 0.797, p = 0.002). Post-exercise NT-proBNP correlated positively with percentage changes of basal (RVbas) (r = 0.582, p = 0.037) and mid-cavity (RVmid) (r = 0.618, p = 0.043) right ventricular diameters and negatively with percentage change of TAPSE (r = -0.720, p = 0.008). Similar correlations with RVbas, RVmid and TAPSE were found for pulmonary artery systolic pressure. Post-exercise high-sensitivity troponin I correlated negatively with percentage change of body weight (r = -0.601, p = 0.039), but was not associated with any cardiac parameter. CONCLUSION: The main cardiac effects of ultra-long duration exercise were the decrease in left ventricular end-diastolic dimensions and increase in left ventricular wall thickness, as well as minimal dilatation and alteration in systolic function of right ventricle, possibly due to the altered exercise-related right ventricular afterload.

Pathophysiological mechanisms of noncardiac syncope in athletes.

OBJECTIVE: The investigation of the differences in orthostatic responses of individuals with a history of noncardiac syncope(NCS) between athletes and nonathletes. METHODS: A passive tilt test for 30min was performed in 133 athletes (54 with NCS, 79 without NCS) and 48 nonathletes (15 with NCS, 33 without NCS). We performed measurement of haemodynamic, heart rate variability and baroreflex sensitivity parameters. All comparisons were adjusted for age, gender and body mass index(BMI). RESULTS: Athletes with NCS had increased heart rate(HR) (90±11 vs 81±10bpm, p=0.001) and decreased total peripheral resistance index(TPRI) (2227±408 vs 2918±733dynesm2/cm5, p=0.039) and baroreflex effectiveness index(BEI) [70.16(37.42-89.71) vs 72.19(48.49-91.35)%, p=0.016] compared with athletes without NCS. After applying backward stepwise logistic regression analysis to predict history of NCS in athletes, the final model included age, gender, BMI, HR and TPRI. Nonathletes with NCS had increased HR (95±24 vs 83±11bpm, p=0.024) and TPRI (3744±1606 vs 2937±880dynesm2/cm5, p=0.030) and decreased stroke index(SI) (25.4±7.6 vs 33.0±7.5mL/m2, p=0.003) compared with nonathletes without NCS. After applying backward stepwise logistic regression analysis to predict history of NCS in nonathletes, the final model included SI and HR. Among individuals with NCS, athletes had increased SI and BEI and decreased HR and TPRI compared with nonathletes. Among individuals without NCS, a positive result of tilt test was less frequent in athletes compared with nonathletes (p=0.031). CONCLUSIONS: The possible main underlying mechanism for NCS during upright standing in athletes is the decreased TPRI, while the inadequate preservation of SI in nonathletes.

A novel strategy for evaluating tilt test in athletes with syncope.

BACKGROUND: The tilt test is used for the diagnosis of reflex syncope (RS) and is characterized by low sensitivity, especially in athletes. The objective of the study was the implementation of a novel diagnostic strategy for the tilt test without pharmacologic provocation in athletes based on haemodynamic criteria. METHODS: A passive tilt test for 30 min was performed in 132 athletes (53 with a history of RS, 79 without RS). Measurement of haemodynamic, heart rate variability (HRV) and baroreflex sensitivity parameters was performed. RESULTS: Tilt testing yielded 34% sensitivity and 94% specificity. Among negative tilt test responders, the ones with RS had increased heart rate (HR) (89 ± 11 vs 81 ± 10 bpm, p < 0.001), stroke index (SI) (40.2 ± 7.1 vs 35.5 ± 9.7 ml/m(2), p = 0.013), cardiac index (CI) (3.5 ± 0.6 vs 2.8 ± 0.8 l/(min·m(2)), p < 0.001) and decreased total peripheral resistance index (TPRI) (2230 ± 362 vs 2965 ± 725 dyne·s m(2)/cm(5), p < 0.001), low frequency component of HRV (76.2% (49.0-88.4) vs 79.7% (10.2-91.1), p = 0.045) during head-up tilt, compared with those without RS. Receiver-operating characteristic (ROC) curve analysis showed that among athletes with a negative tilt test the area under the curve (AUC) values were 0.727 (0.626-0.828) for HR (p < 0.001), 0.707 (0.611-0.804) for SI (p = 0.001), 0.847 (0.774-0.920) for CI (p < 0.001), 0.830 (0.754-0.905) for TPRI (p < 0.001). Further stratification of negative tilt test responders, characterizing their results as positive when TPRI <2800 dyne·s m(2)/cm(5) and CI >3 l/(min·m(2)), resulted in 85% sensitivity and 76% specificity. CONCLUSION: Our results provide supportive evidence that a novel stratification based on haemodynamic criteria can improve the sensitivity of the tilt test for the diagnosis of RS in athletes.

Eighteen years' experience applying old and current strategies in the pre-participation cardiovascular screening of athletes.

INTRODUCTION: Cardiovascular pre-participation screening (PPS) is recommended for the identification of athletes at risk for sudden cardiac death. However, there is currently no universally accepted screening protocol. METHODS: Two distinct PPS strategies were studied in a large cohort of Greek athletes (5 to 39 years old): PPS I, with routine 12-lead ECG and echo, in addition to personal and family history, and physical examination; and PPS II, without routine echo. PPS I (12,353 athletes) was performed from 1992 to 2002, and PPS II (9852 athletes) from 2003 to 2010. RESULTS: "Abnormal" findings were observed in 49.3% of the athletes (49.6% in PPS I and 48.9% in PPS II, p=0.299). Most of them were age- or exercise-related. Further evaluation was recommended for 8.3% of the athletes. Finally, 39 athletes (22 from PPS I) were excluded from competitive sports. Hypertrophic cardiomyopathy was found in 7 athletes. Other abnormalities were: dilated cardiomyopathy; complete heart block; coronary artery disease; Wolf-Parkinson-White syndrome; and severe hypertension. The ECG played a critical role in the exclusion of 13 athletes, compared to only one for echo. Both PPS methods revealed an almost equal incidence of findings. CONCLUSIONS: We suggest that the routine use of ECG alone is sufficient for the successful screening of athletes.

Functional and psychosocial effects of either a traditional dancing or a formal exercising training program in patients with chronic heart failure: a comparative randomized controlled study.

OBJECTIVE: To compare the effects of traditional dancing with formal exercise training in terms of functional and cardiovascular benefits and motivation in patients with chronic heart failure. DESIGN: Randomized controlled trial. SETTING: Sports Medicine Laboratory. SUBJECTS: Fifty-one Greek male patients aged 67.1±5.5 years with chronic heart failure of New York Heart Association (NYHA) class II-III, participated in an eight-month study. INTERVENTIONS: They were randomly assigned to either training with Greek traditional dances (group A, n=18), formal exercise training (group B, n=16) or a sedentary control group (group C, n=17). MAIN MEASURES: At entry and the end of the study all patients underwent cardiopulmonary exercise testing, functional ability assessment and quality of life evaluations. The Intrinsic Motivation Inventory was also used to assess participants' subjective experience. RESULTS: After training group A showed increased peak oxygen consumption by 33.8% (19.5 vs. 26.1 ml/kg/min, p<0.05) and B by 32.3% (19.5 vs. 25.8 ml/kg/min, p<0.05), maximal treadmill tolerance by 48.5% (p<0.05) and by 46.4% (p<0.05), and a decreased Slope of expired minute ventilation for carbon dioxide output (VE/VCO2) slope by 18% (p<0.05) and 19.5% (p<0.05), respectively. Trained patients revealed significant improvement in the quality of life indices. Intrinsic Motivation Inventory was increased only in group A by 26.2% (3.08 vs. 3.87, p<0.05). CONCLUSIONS: Exercise training in chronic heart failure patients with Greek traditional dances led to functional and cardiovascular benefits similar to formal exercise training and to a higher level of motivation.