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From altus to parvus: cardiac fatigue in athletes: reply

From altus to parvus: cardiac fatigue in athletes: reply 1172 Letters to the Editor study in risk stratification. Eur Heart J 2003; energy turnover in the normal heart in doi:10.1093/eurheartj/ehm056 24:1473–1480. increased demand (relative ischaemia) is 3. Biffi A, Pelliccia A, Verdile L, Fernando F, expected to change faster to baseline level Online publish-ahead-of-print 10 April 2007 Spataro A, Caselli S, Santini M, Maron BJ. Long- than that in the diseased heart. In addition, term clinical significance of frequent and it is believed that athletes’ heart has a well From altus to parvus: cardiac fatigue complex ventricular tachyarrhythmias in adaptive mechanism to ischaemic conditions in athletes: reply trained athletes. J Am Coll Cardiol 2002;40: due to preconditioning effects of chronic 446–452. exercise. 4. Lee IM, Paffenbarger RS Jr. Physical activity and We would like to thank Professor Erdem stroke incidence: the Harvard Alumni Health In addition, two questions related to the Kasikcioglu for his interest in our article. In Study. Stroke 1998;29:2049–2054. study also especially interest me. First of response to the initial question of why 5. Sarna S, Sahi T, Koskenvuo M, Kaprio J. these, whether recurrent prolonged exer- exhaustive physical activity suppresses dias- Increased life expectancy of world class male cises in competitive athletes may lead to tolic function, we believe that exhaustive athletes. Med Sci Sports Exerc 1993;25: permanent dysfunction of ventricles or physical activity does not attenuate only 237–244. not. Another crucial question may therefore diastolic, but also systolic function as evi- 6. Williams PT. Relationship of distance run per be, does persistent diastolic dysfunction denced by a reduction in the week to coronary heart disease risk factors in affect athletic performance and contractile tissue-Doppler-derived strain values in both 8283 male runners. The National Runners’ functions of the heart. Exhaustive exercise Health Study. Arch Intern Med 1997;157: the septal and lateral walls of our volun- 191–198. may affect myocardial functions stunning- teers. The mechanism for this reduction is like effect. Related to these arguments is not completely understood, but may the speculation that the persistent diastolic involve an increase in plasma nonepinephr- Tomas G. Neilan dysfunction does not apparently affect sys- ine, ventricular wall stress, free-radical pro- Cardiac Ultrasound Laboratory tolic function and exercise performance. duction or changes in energy dynamics, and Division of Cardiology Indeed, it might be argued that many evi- calcium homeostasis. Department of Medicine dences are needed to support a theory In response to the possibility of permanent Massachusetts General Hospital and Harvard where transient and persistent cardiac impairment of ventricular function, while Medical School MA, deterioration after prolonged exercise may there has been some suggestion of a form USA define pseudo-stunning effect. of non-fibrotic arrythmogenic right ventricu- lar dysplasia in a highly selected subset of Malissa J. Wood endurance athletes, there is little other Cardiac Ultrasound Laboratory data to suggest that there are long-term Division of Cardiology sequelae to recurrent RV injury during Department of Medicine References endurance sports. In fact, many of the par- Massachusetts General Hospital and Harvard ticipants in our study were veteran marathon 1. Neilan TG, Yoerger DM, Douglas PS, Marshall JE, Medical School runners and in this subset none exhibited any Halpern EF, Lawlor D, Picard MH, Wood MJ. 55 Fruit Street, VBK 508, Boston evidence of left or right ventricular function Persistent and reversible cardiac dysfunction MA 02114-2696 at baseline. Furthermore, while there has among amateur marathon runners. Eur Heart J USA been some suggestion of an increased 2006;27:1079–1084. Tel: þ1 617 7241991 Fax: þ1 617 7268383 2. Douglas PS, O’Toole ML, Hiller WD, Hackney K, stroke risk in highly active men in the E-mail address: mjwood@partners.org Reichek N. Cardiac fatigue after prolonged Harvard Alumni Study, there is a wealth of exercise. Circulation 1987;76:1206–1213. data to suggest that there is no increased 3. Douglas PS, O’Toole ML, Hiller WD, Reichek N. cardiovascular risk associated with partici- Different effects of prolonged exercise on the 5,6 doi:10.1093/eurheartj/ehm057 pation in such event. While we observed right and left ventricles. J Am Coll Cardiol a persistent change in diastolic indices, we 1990;15:64–69. Online publish-ahead-of-print 19 April 2007 recognize that such alterations in baseline 4. Kasikcioglu E, Arslan A, Topcu B, Sayli O, could also likely represent a period of Akhan H, Oflaz H, Akin A, Kayserilioglu A, de-training rather than persistence of dys- Meric M. Cardiac fatigue and oxygen kinetics function or stunning. However, until this after prolonged exercise. Int J Cardiol 2006; Stroke prophylaxis in patients with 108:286–288. question is answered with a study, whereby atrial fibrillation: what can we do 5. Gonzalez-Alonso J, Calbet JAL. Reductions in two equivalently trained and matched about it? systemic and skeletal muscle blood flow and cohorts, one completing a marathon and oxygen delivery limit maximal aerobic capacity one not, are compared, then repeated 1 Friberg et al. have shown clearly, like in humans. Circulation 2003;107:824–830. episode of extreme strenuous activity others, that many patients with atrial 6. Kasikcioglu E. Diastolic performance after pro- within a four-week period may be cautioned. fibrillation (AF) do not receive stroke pro- longed exercise. Med Sci Sports Exerc 2005; 37:164. phylaxis. In their summary, they note that 7. Kasikcioglu E. Cardiac response to prolonged it is ‘urgent to increase awareness of the strenuous exercise: a physiologic model for need for adequate stroke prophylaxis in References stunning myocardium. Am J Cardiol 2005;95: AF patients’. I would like to highlight to 1. Hessel E, Haberland A, Muller M, Lerche D, the readers that there has been research Schimke I. Oxygen radical generation of neutro- conducted in Tasmania, Australia on an phils: a reason for oxidative stress during mara- intervention which aimed to increase thon running? Clin Chim Acta 2000;298: warfarin use in those at risk of stroke. 145–156. Erdem Kasikcioglu Jackson et al. mailed guidelines, which 2. Heidbuchel H, Hoogsteen J, Fagard R, Department of Sports Medicine were developed in consultation with local Vanhees L, Ector H, Willems R, Van Lierde J. Istanbul University specialists, to 272 general practitioners High prevalence of right ventricular involve- Istanbul 34840, Turkey and then approximately 60% of these ment in endurance athletes with ventricular E-mail address: ekasikcioglu@yahoo.com arrhythmias. Role of an electrophysiologic were visited to discuss the guidelines. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

From altus to parvus: cardiac fatigue in athletes: reply

Neilan, Tomas G.; Wood, Malissa J.
European Heart Journal , Volume 28 (9) – May 10, 2007
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References (10)

Publisher
Oxford University Press
Copyright
© Published by Oxford University Press.
ISSN
0195-668X
eISSN
1522-9645
DOI
10.1093/eurheartj/ehm056
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Abstract

1172 Letters to the Editor study in risk stratification. Eur Heart J 2003; energy turnover in the normal heart in doi:10.1093/eurheartj/ehm056 24:1473–1480. increased demand (relative ischaemia) is 3. Biffi A, Pelliccia A, Verdile L, Fernando F, expected to change faster to baseline level Online publish-ahead-of-print 10 April 2007 Spataro A, Caselli S, Santini M, Maron BJ. Long- than that in the diseased heart. In addition, term clinical significance of frequent and it is believed that athletes’ heart has a well From altus to parvus: cardiac fatigue complex ventricular tachyarrhythmias in adaptive mechanism to ischaemic conditions in athletes: reply trained athletes. J Am Coll Cardiol 2002;40: due to preconditioning effects of chronic 446–452. exercise. 4. Lee IM, Paffenbarger RS Jr. Physical activity and We would like to thank Professor Erdem stroke incidence: the Harvard Alumni Health In addition, two questions related to the Kasikcioglu for his interest in our article. In Study. Stroke 1998;29:2049–2054. study also especially interest me. First of response to the initial question of why 5. Sarna S, Sahi T, Koskenvuo M, Kaprio J. these, whether recurrent prolonged exer- exhaustive physical activity suppresses dias- Increased life expectancy of world class male cises in competitive athletes may lead to tolic function, we believe that exhaustive athletes. Med Sci Sports Exerc 1993;25: permanent dysfunction of ventricles or physical activity does not attenuate only 237–244. not. Another crucial question may therefore diastolic, but also systolic function as evi- 6. Williams PT. Relationship of distance run per be, does persistent diastolic dysfunction denced by a reduction in the week to coronary heart disease risk factors in affect athletic performance and contractile tissue-Doppler-derived strain values in both 8283 male runners. The National Runners’ functions of the heart. Exhaustive exercise Health Study. Arch Intern Med 1997;157: the septal and lateral walls of our volun- 191–198. may affect myocardial functions stunning- teers. The mechanism for this reduction is like effect. Related to these arguments is not completely understood, but may the speculation that the persistent diastolic involve an increase in plasma nonepinephr- Tomas G. Neilan dysfunction does not apparently affect sys- ine, ventricular wall stress, free-radical pro- Cardiac Ultrasound Laboratory tolic function and exercise performance. duction or changes in energy dynamics, and Division of Cardiology Indeed, it might be argued that many evi- calcium homeostasis. Department of Medicine dences are needed to support a theory In response to the possibility of permanent Massachusetts General Hospital and Harvard where transient and persistent cardiac impairment of ventricular function, while Medical School MA, deterioration after prolonged exercise may there has been some suggestion of a form USA define pseudo-stunning effect. of non-fibrotic arrythmogenic right ventricu- lar dysplasia in a highly selected subset of Malissa J. Wood endurance athletes, there is little other Cardiac Ultrasound Laboratory data to suggest that there are long-term Division of Cardiology sequelae to recurrent RV injury during Department of Medicine References endurance sports. In fact, many of the par- Massachusetts General Hospital and Harvard ticipants in our study were veteran marathon 1. Neilan TG, Yoerger DM, Douglas PS, Marshall JE, Medical School runners and in this subset none exhibited any Halpern EF, Lawlor D, Picard MH, Wood MJ. 55 Fruit Street, VBK 508, Boston evidence of left or right ventricular function Persistent and reversible cardiac dysfunction MA 02114-2696 at baseline. Furthermore, while there has among amateur marathon runners. Eur Heart J USA been some suggestion of an increased 2006;27:1079–1084. Tel: þ1 617 7241991 Fax: þ1 617 7268383 2. Douglas PS, O’Toole ML, Hiller WD, Hackney K, stroke risk in highly active men in the E-mail address: mjwood@partners.org Reichek N. Cardiac fatigue after prolonged Harvard Alumni Study, there is a wealth of exercise. Circulation 1987;76:1206–1213. data to suggest that there is no increased 3. Douglas PS, O’Toole ML, Hiller WD, Reichek N. cardiovascular risk associated with partici- Different effects of prolonged exercise on the 5,6 doi:10.1093/eurheartj/ehm057 pation in such event. While we observed right and left ventricles. J Am Coll Cardiol a persistent change in diastolic indices, we 1990;15:64–69. Online publish-ahead-of-print 19 April 2007 recognize that such alterations in baseline 4. Kasikcioglu E, Arslan A, Topcu B, Sayli O, could also likely represent a period of Akhan H, Oflaz H, Akin A, Kayserilioglu A, de-training rather than persistence of dys- Meric M. Cardiac fatigue and oxygen kinetics function or stunning. However, until this after prolonged exercise. Int J Cardiol 2006; Stroke prophylaxis in patients with 108:286–288. question is answered with a study, whereby atrial fibrillation: what can we do 5. Gonzalez-Alonso J, Calbet JAL. Reductions in two equivalently trained and matched about it? systemic and skeletal muscle blood flow and cohorts, one completing a marathon and oxygen delivery limit maximal aerobic capacity one not, are compared, then repeated 1 Friberg et al. have shown clearly, like in humans. Circulation 2003;107:824–830. episode of extreme strenuous activity others, that many patients with atrial 6. Kasikcioglu E. Diastolic performance after pro- within a four-week period may be cautioned. fibrillation (AF) do not receive stroke pro- longed exercise. Med Sci Sports Exerc 2005; 37:164. phylaxis. In their summary, they note that 7. Kasikcioglu E. Cardiac response to prolonged it is ‘urgent to increase awareness of the strenuous exercise: a physiologic model for need for adequate stroke prophylaxis in References stunning myocardium. Am J Cardiol 2005;95: AF patients’. I would like to highlight to 1. Hessel E, Haberland A, Muller M, Lerche D, the readers that there has been research Schimke I. Oxygen radical generation of neutro- conducted in Tasmania, Australia on an phils: a reason for oxidative stress during mara- intervention which aimed to increase thon running? Clin Chim Acta 2000;298: warfarin use in those at risk of stroke. 145–156. Erdem Kasikcioglu Jackson et al. mailed guidelines, which 2. Heidbuchel H, Hoogsteen J, Fagard R, Department of Sports Medicine were developed in consultation with local Vanhees L, Ector H, Willems R, Van Lierde J. Istanbul University specialists, to 272 general practitioners High prevalence of right ventricular involve- Istanbul 34840, Turkey and then approximately 60% of these ment in endurance athletes with ventricular E-mail address: ekasikcioglu@yahoo.com arrhythmias. Role of an electrophysiologic were visited to discuss the guidelines.

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European Heart Journal – Oxford University Press

Published: May 10, 2007

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