[Sports cardiology : Overview of relevant clinical topics]. / Sportkardiologie : Überblick über relevante klinische Themen.

Physical activity is nowadays an established therapeutic principle concerning primary and secondary prevention of cardiovascular diseases; therefore, in internal sports medicine various aspects go beyond basic cardiological knowledge and require special medical expertise (sports cardiology). Acute cardiac risk is increased during physical activity; therefore, physical activity should be individually phased under consideration of the whole clinical situation. Physical training results in a functional adaptation of the cardiovascular system. Moreover, a structural adaptation can also be observed in competitive athletes but a differentiation between athlete's heart and cardiomyopathy is sometimes challenging. Preparticipation screening verifiably reduces the incidence of sudden cardiac death in athletes. Respective recommendations for the required diagnostics have been published and statutory health insurances are increasingly more willing to bear the incurred costs. Statistically, doping is more frequent in performance-orientated leisure time sports than in competitive sports. Drugs which are relevant for doping have partially irreversible cardiac side effects.

Blood lactate concentrations are mildly affected by mobile gas exchange measurements.

We sought to investigate the effects of wearing a mobile respiratory gas analysis system during a treadmill test on blood lactate (bLa) concentrations and commonly applied bLa thresholds. A total of 16 recreational athletes (31±3 years, VO2max: 58±6 ml · min(-1) · kg(-1)) performed one multistage treadmill test with and one without gas exchange measurements (GEM and noGEM). The whole bLa curve, the lactate threshold (LT), the individual anaerobic thresholds according to Stegmann (IATSt) and Dickhuth (IATDi), and a fixed bLa concentration of 4 mmol ∙ l(-1) (OBLA) were evaluated. The bLa curve was shifted slightly leftward in GEM compared to noGEM (P<0.05), whereas the heart rate response was not different between conditions (P=0.89). There was no difference between GEM and noGEM for LT (2.61±0.34 vs. 2.64±0.39 m · s(-1), P=0.49) and IATSt (3.47±0.42 vs. 3.55±0.47 m · s(-1), P=0.12). However, IATDi (3.57±0.39 vs. 3.66±0.44 m · s(-1), P<0.01) and OBLA (3.85±0.46 vs. 3.96±0.47 m · s(-1), P<0.01) occurred at slower running velocities in GEM. The bLa response to treadmill tests is mildly affected by wearing a mobile gas analysis system. This also applies to bLa thresholds located at higher exercise intensities. While the magnitude of the effects is of little importance for recreational athletes, it might be relevant for elite athletes and scientific studies.

Echocardiography of the right ventricle in athlete's heart and hearts of normal size compared to magnetic resonance imaging: which measurements should be applied in athletes?

Right ventricular (RV) pathologic hypertrophy and cardiomyopathy have been reported to be related to ventricular arrhythmias and sudden cardiac death in athletes. However, it is unclear which echocardiographic measurements reflect RV dimensions in athlete's heart (AH) correctly. We aimed to compare two-dimensional echocardiography of the RV in AH and normal hearts to magnetic resonance imaging (MRI), and derive recommendations for RV echocardiography in athletes. Twenty-three healthy male endurance athletes with AH (A; 28+/-4 yrs) and 26 healthy untrained males (C; 26+/-4 yrs) matched for body-dimensions were examined. In recommended echocardiographic parasternal and 4-chamber views, three enddiastolic RV free wall-thicknesses (T1,T5,T9) and RV diameters were determined (M-mode enddiastolic diameter [RV-EDD]; longitudinal [RV-LAX], sagittal, outflow-tract and tricuspid valve anulus diameters). MRI determined RV enddiastolic volumes (RV-EDV) and masses (RVM) in A and C were: 162+/-29 vs. 136+/-15 ml and 76+/-10 vs. 59+/-13 g (p<0.001). Significant correlations between RV-EDV and RV-EDD (r=0.49; p=0.001) as well as RV-LAX (r=0.38; p=0.01), and RVM and T5 (r=0.52; p=0.01) were found. For RV echocardiography, significant differences between A and C were documented for RV-EDD (medians [quartiles]: A: 26 mm [24/29 mm]; C: 22 mm [21/27 mm]; p=0.04; measurable in 49/49 subjects), and in the parasternal short axis view for T5 (A: 6.0 mm [5.4/7.8 mm]; C: 5.0 mm [4.5/5.2 mm]; p=0.04; measurable in 22/49). In conclusion, two-dimensional echocardiographic RV measurements offer only a limited potential to reflect true RV dimensions. Only RV-EDD may differentiate between normal hearts and exercise related RV adaptations in AH, and is the only recommendable parameter to be measured in athletes routinely. In unclear cases additional methods should be used to examine the RV in athletes.

Volume vs. intensity in the training of competitive swimmers.

The present study aimed at comparing a high-volume, low-intensity vs. low-volume, high-intensity swim training. In a randomized cross-over design, 10 competitive swimmers performed two different 4-week training periods, each followed by an identical taper week. One training period was characterized by a high-training volume (HVT) whereas high-intensity training was prevalent during the other program (HIT). Before, after two and four weeks and after the taper week subjects performed psychometric and performance testing: profile of mood states (POMS), incremental swimming test (determination of individual anaerobic threshold, IAT), 100 m and 400 m. A small significant increase in IAT was observed after taper periods compared to pre-training (+ 0.01 m/s; p = 0.01). Maximal 100-m and 400-m times were not significantly affected by training. The POMS subscore of "vigor" decreased slightly after both training periods (p = 0.06). None of the investigated parameters showed a significant interaction between test-time and training type (p > 0.13). Nearly all (83 %) subjects swam personal best times during the 3 months after each training cycle. It is concluded that, for a period of 4 weeks, high-training volumes have no advantage compared to high-intensity training of lower volume.

Exercise-induced increases in NT-proBNP are not related to the exercise-induced immune response.

OBJECTIVE: To investigate if the exercise-induced immune response contributes to the exercise-induced increase in brain natriuretic peptide (BNP) in healthy athletes. This has previously been speculated, as elevated concentrations of BNP or N-terminal pro brain natriuretic peptide (NT-proBNP) in cardiovascular patients were found to be related to immune reactions and elevations in inflammatory cytokines such as interleukin 6 (IL-6). METHODS: Stored serum samples were analysed for NT-proBNP concentrations of 14 healthy endurance athletes (mean age: 25 (SD 5) years; VO(2peak) 67 (SD 6) ml/min/kg), who had been examined previously for exercise-induced immune reactions and their dependence on carbohydrate supplementation (6 or 12% carbohydrate vs placebo beverages) after three bouts of 4 h cycling at a given workload of 70% of the individual anaerobic threshold. Venous blood samples were taken before, immediately after, and 1 h and 1 day after exercise. Leucocyte subpopulations were determined immediately after blood sampling by flow cytometry. Serum samples for posterior analysis of C-reactive protein (CRP), IL-6, cortisol and NT-proBNP were stored at -80 degrees C. RESULTS: The exercise-induced increases in NT-proBNP (p<0.001) were not related to the exercise-induced immune response, although exercise induced marked (CHOS-dependent) increases in IL-6, CRP, cortisol, leucocytes, neutrophils, monocytes and natural killer cells. CONCLUSION: It is unlikely that the exercise-induced increases in NT-proBNP or BNP in healthy athletes are caused by the exercise-induced immune response. Therefore, exercise-induced increases in NT-proBNP or BNP in healthy athletes have to be differentiated from increases in cardiovascular patients with systemic inflammation.

Cardiac tissue Doppler in steroid users.

Anabolic steroids cause a variety of side effects, among them a slight concentric left ventricular hypertrophy. The objective of the present study was to clarify if they also induce alterations in left ventricular function. 14 male body builders with substantial intake of anabolic steroids (users) were examined by standard echocardiography and cardiac tissue Doppler imaging. They were compared to 11 steroid-free strength athletes (non-users) and 15 sedentary control subjects. Users showed an increased left ventricular muscle mass index. The ratio of peak transmitral blood flow velocities during early diastolic filling and atrial contraction did not differ between groups (users: 1.4 +/- 0.3; non-users: 1.7 +/- 0.5; controls: 1.4 +/- 0.4). In contrast an analogous tissue Doppler parameter, the ratio of myocardial velocities during early and late ventricular filling in the basal septum, was significantly lower in users (1.2 +/- 0.4) when compared to non-users (1.6 +/- 0.5) or controls (1.6 +/- 0.6). The velocity gradient during myocardial E-wave in the posterior wall showed significantly lower values in users (3.8 +/- 1.3 1/s) as compared to controls (5.8 +/- 2.5 1/s). There were no differences in systolic function. Summarizing strength athletes abusing anabolic steroids show negative alterations in diastolic function.

Peak oxygen uptake. Myth and truth about an internationally accepted reference value.

This article critically examines the execution of VO(2)-peak testing in cardiac patients and questions their appropriate interpretation. In the first part, the most common clinical implications of VO(2)peak measurements are discussed: assessment of (changes in) functional capacity, evaluation of the necessity of invasive diagnostic/therapeutic measures, reference for exercise prescriptions, determination of prognosis. In the second part, important methodological problems and constraints are addressed and illustrated by references to scientific studies. Finally, recommendations are given for meaningful VO(2)peak testing. It is evident that failure to strictly follow such recommendations might result in misleading ergometric findings and, thus, in over- or underestimation of endurance capacity and/ or training effects.

Does prolonged cycling of moderate intensity affect immune cell function?

BACKGROUND: Prolonged exercise may induce temporary immunosuppression with a presumed increased susceptibility for infection. However, there are only few data on immune cell function after prolonged cycling at moderate intensities typical for road cycling training sessions. METHODS: The present study examined the influence on immune cell function of 4 h of cycling at a constant intensity of 70% of the individual anaerobic threshold. Interleukin-6 (IL-6) and C-reactive protein (CRP), leukocyte and lymphocyte populations, activities of natural killer (NK), neutrophils, and monocytes were examined before and after exercise, and also on a control day without exercise. RESULTS: Cycling for 4 h induced a moderate acute phase response with increases in IL-6 from 1.0 (SD 0.5) before to 9.6 (5.6) pg/ml 1 h after exercise and CRP from 0.5 (SD 0.4) before to 1.8 (1.3) mg/l 1 day after exercise. Although absolute numbers of circulating NK cells, monocytes, and neutrophils increased during exercise, on a per cell basis NK cell activity, neutrophil and monocyte phagocytosis, and monocyte oxidative burst did not significantly change after exercise. However, a minor effect over time for neutrophil oxidative burst was noted, tending to decrease after exercise. CONCLUSIONS: Prolonged cycling at moderate intensities does not seem to seriously alter the function of cells of the first line of defence. Therefore, the influence of a single typical road cycling training session on the immune system is only moderate and appears to be safe from an immunological point of view.

Is lactic acidosis a cause of exercise induced hyperventilation at the respiratory compensation point?

OBJECTIVES: The respiratory compensation point (RCP) marks the onset of hyperventilation ("respiratory compensation") during incremental exercise. Its physiological meaning has not yet been definitely determined, but the most common explanation is a failure of the body's buffering mechanisms which leads to metabolic (lactic) acidosis. It was intended to test this experimentally. METHODS: During a first ramp-like exercise test on a cycle ergometer, RCP (range: 2.51-3.73 l x min(-1) oxygen uptake) was determined from gas exchange measurements in five healthy subjects (age 26-42; body mass index (BMI) 20.7-23.9 kg x m(-2); Vo(2peak) 51.3-62.1 ml x min(-1) x kg(-1)). On the basis of simultaneous determinations of blood pH and base excess, the necessary amount of bicarbonate to completely buffer the metabolic acidosis was calculated. This quantity was administered intravenously in small doses during a second, otherwise identical, exercise test. RESULTS: In each subject sufficient compensation for the acidosis, that is, a pH value constantly above 7.37, was attained during the second test. A delay but no disappearance of the hyperventilation was present in all participants when compared with the first test. RCP occurred on average at a significantly (p = 0.043) higher oxygen uptake (+0.15 l x min(-1)) compared with the first test. CONCLUSIONS: For the first time it was directly demonstrated that exercise induced lactic acidosis is causally involved in the hyperventilation which starts at RCP. However, it does not represent the only additional stimulus of ventilation during intense exercise. Muscle afferents and other sensory inputs from exercising muscles are alternative triggering mechanisms.

Can serum NT-proBNP detect changes of functional capacity in patients with chronic heart failure?

Recently, in a cross-sectional study, a correlation of moderate degree was documented between serum BNP (brain natriuretic peptide) and exercise capacity in patients with chronic heart failure (CHF). However, it remains unknown if BNP, which increases in response to high myocardial wall stress, is sufficiently sensitive for changes in exercise capacity during clinical follow-up. To elucidate this, 42 CHF patients were recruited and randomized into a training (T; 58 +/- 10 years; n = 14 NYHA II; n = 5 NYHA III) and a control group (CO; 54 +/- 9, n = 17 NYHA II; n = 6 NYHA III). T carried out 12 weeks of endurance training on a cycle ergometer (4 sessions per week, 45 min duration). Venous blood sampling and cycle ergometry with simultaneous gas exchange measurements were carried out prior to and after the experimental phase. Due to its superior stability during laboratory procedures, NTproBNP was determined instead of BNP. Both proteins are secreted in equimolar amounts and share an identical diagnostic meaning. In both groups, NT-proBNP decreased slightly (T: from 1092 +/- 980 to 805 +/- 724 pg x ml(-1); CO: from 1075 +/- 1068 to 857 +/- 1138 pg x ml(-1); T vs CO: p = 0.65). Anaerobic threshold (AT) as a measure of exercise capacity went up in T (from 0.96 +/- 0.17 to 1.10 +/- 0.22 l x min(-1)) but remained almost constant in CO (pre: 1.02 +/- 0.27; post: 1.00 +/- 0.27 l x min(-1); T vs CO: p < 0.001). The correlation between changes in NT-proBNP and changes in AT remained insignificant (r = 0.02, p = 0.89)-even if only T was considered (r = 0.09, p = 0.72). Improved exercise capacity in CHF patients due to 3 months of endurance training is not reflected in the course of NT-proBNP. These findings are inconsistent with a sufficient sensitivity of this parameter to detect changes in exercise capacity during clinical follow-up. Changes in NT-proBNP beyond its spontaneous variability are more likely to be detected following therapeutical interventions which aim more clearly at the myocardium. In determining alterations of functional capacity ergometric testing cannot be replaced by serial determinations of NT-proBNP.

[Left ventricular mass in endurance-athletes with athlete's heart and untrained subjects--comparison between different echocardiographic methods and MRI]. / Vergleich echokardiographischer Methoden zur linksventrikulären Muskelmassenbestimmung mit der MRT bei Ausdauerathleten mit Sportherz und Untrainierten.

UNLABELLED: The echocardiographic determination of left ventricular mass (LVM) and volume is of importance for the interpretation of cardiac adaptations and risk-stratification. In pathologically hypertrophied hearts, conventional one- and two-dimensional echocardiographic methods tend to overestimate LVM. For the athlete's heart, a comparison between different echocardiographic methods and magnetic resonance imaging (MRI) has not been performed so far. 23 healthy male endurance-athletes (28+/-4 yr) with athlete's heart (A) and 26 healthy untrained males (U; 26+/-4 yr) were examined by MRI and the following echocardiographic methods: ASE-Cube (ASE), Devereux (DEV), Troy (TRO), Teichholz (TEI), Reichek (REI) and Dickhuth (DIC). Indexed LVM were: MRI: 107+/-6 g/m(2) (A), 79+/-7 g/m(2) (U); ASE: 170+/-20 g/m(2) (A), 119+/-14 g/m(2) (U); DEV: 134+/-16 g/m(2) (A), 95+/-11 g/m(2) (U); TRO: 134+/-16 g/m(2) (A), 92+/-12 g/m(2) (U); TEI: 115+/-10 g/m(2) (A), 91+/-8 g/m(2) (U); REI: 114+/-14 g/m(2) (A), 89+/-11 g/m(2) (U); DIC: 110+/-14 g/m(2) (A); 80+/-9 g/m(2) (U). In A and U, LVM is significantly overestimated by ASE, DEV, TRO, TEI, and REI compared to MRI (p<0.05), but not by DIC. Although coefficients of correlation were similar, only DIC revealed acceptable limits of agreement (ASE: +20 to +172 g; DEV: -13 to +93 g; TRO: -18 to +92 g; TEI: -17 to +53 g; REI: -25 to +57 g; DIC: -37 to +45 g). Depending on the used method, LVM upper limits range between 93 (MRT) and 146 g/m(2) (ASE) in U, and 119 (MRT) and 209 g/m(2) (ASE) in A. CONCLUSION: Compared to MRI, DIC is the most accurate conventional echocardiographic method to determine LVM in U and A. For a correct interpretation of LVM, differences of the echocardiographic methods have to be considered.

[Competitive sports and dilated cardiomyopathy: the case of a 32-year-old soccer player with ventricular tachycardia]. / Leistungssport bei dilatativer Kardiomyopathie: Kasuistik eines 32-jährigen Fussballspielers mit ventrikulären Tachykardien.

HISTORY AND ADMISSION FINDINGS: A 32-year-old competitive soccer player presented with palpitations he had felt for 4 weeks during maximal activity (soccer training and match). The physical examination and an exercise electrocardiogram were carried out by his general practitioner up to 19 s at 350 W and a heart rate of 147/min without showing any abnormalities. INVESTIGATIONS: All blood parameters revealed no signs of illness. During treadmill exercise at a heart rate of 181/min, a non-sustained ventricular tachycardia was induced. Echocardiography showed a dilated left ventricle with an enddiastolic diameter of 70 mm and low fractional shortening (28 %). Cardiac catheterization demonstrated a diminished left ventricular ejection fraction (38 %) and an enlarged enddiastolic volume (199 ml) without signs of coronary artery disease. Electrophysiologic testing induced a non-sustained ventricular tachycardia. DIAGNOSIS, TREATMENT AND COURSE: The echocardiographic and angiographic results indicated a dilated cardiomyopathy. Competitive sports activities were stopped and treatment with a beta-blocker (metoprolol) and an ACE-antagonist (ramipril) was started. CONCLUSION: In young male and female athletes, the possibility of severe cardiac abnormalities have to be considered even in the presence of good physical fitness and performance. To reach a high sensitivity for diagnostic ergometry, the work-load must reach the maximal capacity of the cardio-pulmonary system. Differences in the exercise performance of athletes and untrained subjects have to be considered.

Maximal oxygen uptake during field running does not exceed that measured during treadmill exercise.

Modern ergometric equipment enables the simulation of laboratory maximal oxygen uptake (.VO(2max)) testing in the field. Therefore, it was investigated whether the improved event specificity on the track might lead to higher .VO(2max) measurements in running. Identical protocols were used on the treadmill and on the track (speed was indicated by a computer-driven flashing light system). Ambulatory measurements of gas exchange were carried out throughout both tests, which were executed in randomized order. There were no significant differences ( P=0.71) in .VO(2max) between treadmill [4.65 (0.51) ml.min(-1)] and field tests [4.63 (0.55) ml.min(-1)]. However, the test duration differed significantly ( P<0.001) by approximately 5%: treadmill 691 (39) s; field test 727 (42) s. With the exception of maximum heart rate (HR(max); significantly higher in the field with P=0.02) all criteria for the degree of effort were similar between the two tests. However, the difference in HR(max) at less than 2 beats.min(-1), was practically negligible. Submaximal measurements of oxygen uptake and minute ventilation were significantly higher on the treadmill ( P<0.001 for both parameters). In summary, field tests with incremental running protocols do not result in higher .VO(2max) measurements compared to laboratory treadmill exercise. A better running economy on the track results in higher maximal velocities and longer exercise durations being sustained. The determination of .VO(2max) is not a reasonable application for ambulatory gas exchange measurements because laboratory values are not surpassed.

Metabolic profile of 4 h cycling in the field with varying amounts of carbohydrate supply.

Several laboratory studies have demonstrated a performance-enhancing effect of carbohydrate (CHO) supplementations during endurance sessions of long duration. However, the transferability of these results to real training and competition circumstances has not been conclusively shown. Therefore, we tried to test the influence of graded CHO substitution on substrate utilization and selected physiological parameters under standardized but practically orientated field conditions. Fourteen endurance-trained male subjects [mean (SD): 25 (5) years, 72 (9) kg, .VO(2max) 67 (6) ml.min(-1).kg(-1), individual anaerobic threshold (IAT) 269 (30) W] after a stepwise increasing pre-test had to perform three 4-h endurance rides on their own bicycles with simultaneous spiroergometry: constant workload 70% IAT (monitoring by SRM-System). Before and during exercise, solutions without (0%), with 6% or 12% CHO were administered double-blindly and in randomized order (total volume: 50 ml.kg(-1)). After cessation of exercise, significant differences between 0% and both CHO concentrations were detected for blood glucose (GLU; 75 mg dl(-1) for 0% vs 101 mg dl(-1) for 6% vs 115 mg dl(-1) for 12%; P<0.001) and respiratory exchange ratio (0.84 vs 0.88 vs 0.90; P<0.01; correlation to GLU: r=0.46, P<0.05). Free fatty acids (0.19 vs 0.16 vs 0.10 mmol l(-1)) and glycerol (0.41 vs 0.22 vs 0.12 mmol l(-1)) were significantly different between the endurance trials in a dose-dependent manner (both P<0.001). Lactate concentration ( P=0.42) and heart rate ( P=0.12) had no significant influence from CHO substitution. We conclude that CHO substitution during 4-h endurance training inhibits lipolysis in a dose-dependent manner and enhances aerobic glycolysis. This proves that earlier laboratory findings can be replicated under field conditions using modern portable equipment.

Mobilization and oxidative burst of neutrophils are influenced by carbohydrate supplementation during prolonged cycling in humans.

Prolonged, strenuous exercise may lead to suppressive effects on the immune system, which might be responsible for a greater susceptibility to opportunistic infections. The aim of this study was to examine the influence of carbohydrate substitution (CHS) during prolonged, strenuous exercise on neutrophil granulocytes and their oxidative burst (intracellular oxidation of dihydrorhodamine(123) to rhodamine(123) after induction by formylized 1-methionyl-1-leucyl-1-phenylalanin) using flow cytometry. In three trials different concentrations of CHS (placebo compared to 6% and 12% CHS; 50 ml.kg(-1)) were given randomly to 14 endurance trained cyclists [mean (SD) age 25 (5) years, maximal oxygen uptake 67 (6) ml.min(-1).kg(-1)] cycling for 4 h in a steady state at 70% of their individual anaerobic threshold. Blood samples were taken before, immediately after cessation, 1 h and 19 h after exercise. A significant rise in neutrophil counts was observed immediately after cessation and 1 h after exercise with a return to normal rest values 19 h after exercise for all three conditions ( P<0.001). The relative proportions of rhodamine(123)+ neutrophils were significantly diminished in all three conditions 1 h after exercise ( P<0.01), while the mean fluorescence intensity was lowest in the placebo trial and differed significantly to the 12% CHS trial ( P=0.024) and almost significantly to the 6% CHS trial ( P=0.052). In conclusion, these data suggest a beneficial effect of CHS on the neutrophil oxidative burst and a possible attenuation of the susceptibility to infections, presumably due to the reduction of metabolic stress in prolonged, strenuous exercise.

Intravascular ultrasound detected classification of coronary lesions as a predictor of dissections after balloon angioplasty.

Dissection after balloon angioplasty of coronary arteries may give rise to an unfavourable early outcome. Compared with coronary angiography, intravascular ultrasound (IVUS) allows more detailed characterisation of dissections. We investigated the incidence and type of dissections after balloon angioplasty in calcified coronary lesions. IVUS was performed in 43 patients with 48 lesions before and after percutaneous balloon angioplasty. Significant calcification was defined as an arc of more than 90 degrees with typical acoustic shadowing. Dissections were classified as type A when the media was not involved by the dissection and as type B when media involvement had occurred. In the group with significant calcification dissection was observed in 79% of the cases vs 38% in the control group (p < 0.03). Type B dissection was present in 71% of the dissections in the calcified lesions vs. 15% in the control group (p < 0.02). The balloon diameter and the ratio of balloon area to vessel area was not different in both groups but the required pressure for the first complete balloon inflation was significantly greater in the group with calcified lesions (9.46 +/- 3.6 atm vs. 6.65 +/- 2.6 atm; p < 0.001). Thus balloon angioplasty in calcified coronary lesions is more likely to lead to dissection with frequency involve the media.