prolonged endurance exercise and the ... - university of macau · liverpool john moores university....
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Prolonged Endurance Exercise and
the Right Heart: Acute Stimulus and
Chronic Adaptation – is There a
Cause for Concern?
DR DAVID OXBOROUGH PHD MSC BHSC BSE
RESEARCH INSTITUTE OF SPORTS AND EXERCISE SCIENCES
LIVERPOOL JOHN MOORES UNIVERSITY
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Overview
ACUTE cardiac response to prolonged strenuous exercise
CHRONIC cardiac adaptation in the endurance athlete
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Left Ventricle
Left AtriumRight Atrium
Right Ventricle
to the BODYto the LUNGS
from the LUNGSfrom the BODY
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Respond to Body Requirements
Ability to modify STROKE VOLUME /
CARDIAC OUTPUT
PRELOAD
AFTERLOAD
CONTRACTILITY / RELAXATION
HEART RATE
WALL
STRESS
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Increased
Ventricular
Preload
Reduced Ventricular
Afterload
Enhanced Myocardial
Perfusion
Increased Stroke
Volume / Cardiac
Output
Increased Heart
Rate
Systemic and
Pulmonary
Vasodilation
Increased Myocardial
Contractility
Sympathetic
Stimulation
Increased Myocardial
Relaxation
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Chronic Adaptation
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What is the Echocardiographic
Diagnosis?DAY 1 48 Hours Later
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What is the Echocardiographic
Diagnosis?
DAY 1 48 Hours Later
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What is the Echocardiographic
Diagnosis?
Echocardiograms – 48 hours
apart
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What is the Echocardiographic
Diagnosis? Echocardiograms – 48 hours
apart
Elevation in RV afterload
?Pulmonary
Embolism
? Acute RV
Obstruction
? RV volume
overload
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La Gerche et al 2011
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Right Heart Post-Ultramarathon
Increase in right heart size and reduction in function.
Transient and persistent
Correlations with biomarkers
Appears to be impacting on the LV
Related to duration and possibly intensity
Unpublished Data
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The Left Ventricle
Reduction in Diastolic Filling
Reduction in Systolic function (at higher exercise volumes)
Strain imaging
Torsion
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La Gerche et al 2011
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RV involvement is
significant
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ACUTE STIMULUS TO
CHRONIC
ADAPTATION
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Isotonic Exercise
CHRONIC
Eccentric Hypertrophy
Dilatation and increased wall thickness
Increased Preload
Improved Relaxation / Untwist
Right VentricleLeft Ventricle Left Atrium Right Atrium and IVC
Lower EF at Rest
Maintained Stroke Volume
Improves with Exercise
Cardiac Reserve
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PARAMETER GROUP IA GROUP IC GROUP IIIA GROUP IIIC
RVOTPlax index (mm/(m2)0.5) 21 ± 3† 22 ± 3 21 ± 3 24 ± 2*
RVOT1 index (mm/(m2)0.5) 21 ± 3† 22 ± 4 22 ± 3† 25 ± 3*‡
RVOT2 index (mm/(m2)0.5) 17 ± 2† 19 ± 3 18 ± 2† 20 ± 3*‡
RVD1 index (mm/(m2)0.5) 30 ± 4† 30 ± 4† 28 ± 4† 33 ± 3*^‡
RVD2 index (mm/(m2)0.5) 22 ± 3 22 ± 3 21 ± 3 23 ± 3
RVD3 index (mm/(m2)0.5) 63 ± 6† 62 ± 6† 60 ± 7† 69 ± 6*^‡
RVDarea index (mm/m2) 14 ± 3 16 ± 3‡ 13 ± 3^† 15 ± 2‡
RV Wall thickness (mm/m2) 3.6 ± 1.2 2.7 ± 1.4 2.6 ± 1.1 3.5 ± 1.0
RVFAC (%) 46 ± 7 44 ± 6† 44 ± 8 49 ± 6^
Longitudinal Strain (%) -28 ± 4 -28 ± 4 -29 ± 3 -28 ± 3
Unpublished data
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Parameter ET RT CT
RVFAC (%) 50 ± 10 [40:62] 50 ± 10 [42:60] 50 ± 10 [40:58]
TAPSE 24 ± 3 [21:29] 24 ± 3 [22:26] 25 ± 2 [23:26]
RVOT VTI 18 ± 3 [15:24] 20 ± 2 [19:21] 15 ± 3 [10:20]
RVSV (ml) 104 ± 53 [78:164] 92 ± 33 [62:144] 99 ± 33 [42:149]
RVSV (ml/[m2]1.5) 34 ± 15 [26:63] 29 ± 10 [21:49] 32 ± 11 [22:51]
RVS’ cm/s 15 ± 1 [13:17] 15 ± 2 [13:18] 14 ± 2 [11:17]
RVS’ ([cm/s]/cm) 1.7 ± 0.3 [1.1:2.3] 1.8 ± 0.3 [1.4:2.2] 1.7 ± 0.3 [1.3:2.3]
RVE’ cm/s 15 ± 2 [13:19] 16 ± 3 [14:19] 14 ± 3 [9:17]
RVE’ ([cm/s]/cm) 1.7 ± 0.3 [1.2:2.4] 1.7 ± 0.4 [0.5:2.8] 1.7 ± 0.4 [1.0:2.5]
RVA’ cm/s 12 ± 2 [10:17] 12 ± 1 [9:14] 12 ± 2 [9:14]
RVA’ ([cm/s]/cm) 1.5 ± 0.4 [0.9:2.4] 1.3 ± 0.4 [0.7:2.4] 1.4 ± 0.3 [0.7:2.0]
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Cardiac Adaptation in the
Endurance Athlete
Chamber enlargement
Predominantly right ventricle and atria
To a lesser degree the left ventricle
Enables higher stroke volumes
during exercise
More efficient cardiac function
NORMAL FUNCTION
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Cardiac Adaptation – The
Electrocardiogram
ESC guidelines – Corrado et al 2009
Using this criteria 4% of athletes had ‘abnormal ECG’ but had a
normal heart following further investigations
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ECG data from Western States 2013
ABNORMAL ATHLETE CRITERIA (Seattle) Numbers of Veteran
Athletes (%)
(WS100 n = 48)
Number of Young
Athletes (%)
(Brosnan et al 2013 n
= 1078)
T Wave Inversion >1mm (2 or more adjacent (V2-V6 / II
and AVF, I and AVL))
1 (2) 25 (2.3)
ST Depression 0 (0) 2 (0.2)
Pathologic Q Waves 0 (0) 2 (0.2)
Intraventricular Conduction Delay or complete LBBB 1 (2) 1 (0.1)
Left Axis Deviation 3 (6) 6 (0.6)
Left Atrial Enlargement 1 (2) 5 (0.5)
Right Ventricular Hypertrophy 1 (2) 5 (0.5)
Right Atrial Enlargment 0 (0) 6 (0.6)
Ventricular Pre-Excitation 0 (0) 1 (0.1)
Long QT Interval 0 (0) 0 (0)
Short QT Interval 0 (0) 0 (0)
Brugada type 1 ECG Pattern 0 (0) 0 (0)
Premature Ventricular Extra-systoles (more than 2 per
strip)
1 (2) 1 (0.1)
Ventricular Arrhythmias 0 (0) 0 (0)
TOTAL 8 (17) 48 (4.5)
Unpublished Data
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0
10
20
30
40
50
60
70
80
90
100
J Point
Elevation V1
Partial RBBB T Wave
Inversion V1
T Wave
Inversion
Anterior
Leads
Right Axis
Deviation
Long QT RVH Isolated
Criteria for
LVH
Early
Repolarisati
on
PRE 27 27 47 13 6 0 13 20 33
POST 60 40 80 13 6 6 6 47 53
%
PRE POST
Data in Review
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Summary
Big hearts functioning well
Completing an ultramarathon leads to some acute changes in
structure and function – particularly the right ventricle
Cardiac biomarker release appears to be a physiological
phenomenon
This acute event is likely to act as a stimulus for PHYSIOLOGICAL
cardiac adaptation
DOES REPEATED EXPOSURE AND INSUFFICIENT RECOVERY TIME LEAD TO
PATHOLOGICAL CARDIAC ADAPTATION?
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DATA IS SPARSE
HETEROGENEOUS PRESENTATION
?GENETIC PREDISPOSTION
DEFINITELY FURTHER WORK IS REQUIRED
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Summary
Right heart structure adapts to prolonged strenuous exercise in order to
improve efficiency and ability to generate and cope with higher stroke
volumes. Function is normal.
The acute stimulus of prolonged strenuous exercise appears to cause initial acute remodelling that acts a substrate for chronic physiological
adaptation.
There is some evidence of detrimental impact on the myocardium
demonstrated by fibrosis and increased p– this is in a very small number and
may well be no different to control subjects.
Thank you for listening