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Sports Medicine

, Volume 24, Issue 2, pp 97–119 | Cite as

Cardiovascular Evaluation of the Athlete

Issues Regarding Performance, Screening and Sudden Cardiac Death
  • Barry A. Franklin
  • Gerald F. Fletcher
  • Neil F. Gordon
  • Timothy D. Noakes
  • Philip A. Ades
  • Gary J. Balady
Review Article

Summary

Recent studies have reported ECG anomalies and a high prevalence of exercise-related arrhythmias among well trained, apparently healthy endurance athletes with superior levels of cardiorespiratory fitness. The occurrence of sudden and premature cardiac deaths in amateur and professional athletes, who appear to embody all of the virtues of health and fitness, has raised our consciousness regarding the underlying atherosclerotic or nonatherosclerotic causes, and the need for, and extent of, preparticipation screening in competitive athletes. It appears that strenuous physical activity may trigger acute cardiovascular events in some athletes. Coronary artery disease is the most frequent autopsy finding in those over the age of 35 years who die suddenly. In contrast, structural cardiovascular abnormalities, including hypertrophic cardiomyopathy and malformations of the coronary arteries, are the major cause of sudden death in younger athletes. This article reviews these issues, with specific reference to the assessment of cardiorespiratory fitness, legal and prohibited performance-altering medications, the pathophysiological basis of exertion-related untoward events, the athlete at risk, limitations of conventional screening programmes and contemporary recommendations to identify latent cardiovascular disease in athletic populations.

Keywords

Adis International Limited Sudden Cardiac Death Hypertrophic Cardiomyopathy Cardiorespiratory Fitness Anaerobic Threshold 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Goldschmidt-Clermont PJ, Shear WS, Schwartzberg J, et al. Clues to the death of an Olympic champion [letter]. Lancet 1996; 347: 1833PubMedCrossRefGoogle Scholar
  2. 2.
    Starr M. Brave heart, broken heart. Newsweek 1995; 126(34): 70–1Google Scholar
  3. 3.
    Ades PA. Preventing sudden death: cardiovascular screening of young athletes. Physician Sports Med 1992; 20: 75–89Google Scholar
  4. 4.
    Cheitlin MD. Evaluating athletes who have heart symptoms. Physician Sports Med 1993; 21: 150–62Google Scholar
  5. 5.
    Epstein SE, Maron BJ. Sudden death and the competitive athlete: perspectives on preparticipation screening studies. J Am Coll Cardiol 1986; 7: 220–30PubMedCrossRefGoogle Scholar
  6. 6.
    Lewis JF, Maron BJ, Diggs JA, et al. Preparticipation echo-cardiographic screening for cardiovascular disease in a large, predominantly black population of collegiate athletes. Am J Cardiol 1989; 64: 1029–33PubMedCrossRefGoogle Scholar
  7. 7.
    Maron BJ, Bodison SA, Wesley YE, et al. Results of screening a large group of intercollegiate competitive athletes for cardiovascular disease. J Am Coll Cardiol 1987; 10: 1214–21PubMedCrossRefGoogle Scholar
  8. 8.
    Knowlan DM. The electrocardiogram in the athlete. In: Walter BF and Harvey WP, editors. Cardiovascular evaluation of athletes. Newton: Laennec Publishing, 1993: 43–58Google Scholar
  9. 9.
    Klemola E. Electrocardiographic observations on 650 Finnish athletes. Ann Med Intern Fenn 1951; 41: 121–32Google Scholar
  10. 10.
    Beswick FW, Jordan RC. Cardiological observations at the Sixth British Empire and Commonwealth Games. Br Heart J 1961; 23: 113–29PubMedCrossRefGoogle Scholar
  11. 11.
    Hiss RG, and Lamb LE. Electrocardiographic findings in 122,043 individuals. Circulation 1962; 25: 947–61PubMedCrossRefGoogle Scholar
  12. 12.
    Viitasalo MT, Kala R, Eissalo A. Ambulatory electrocardiographic recordings in endurance athletes. Br Heart J 1982; 47: 213–20PubMedCrossRefGoogle Scholar
  13. 13.
    Fletcher GF. Holter recording in athletes: purposes and indication. In: Walter BF, Harvey WP, editors. Cardiovascular evaluation of athletes. Newton: Laennec Publishing, 1993: 87–94Google Scholar
  14. 14.
    Zeppilli P, Fenici R, Sassrra M, et al. Wenckeback second degree A–V block in top-ranking athletes: an old problem revisited. Am Heart J 1980; 100: 281–94PubMedCrossRefGoogle Scholar
  15. 15.
    Talan DA, Bauernfeind RA, Ashley WW, et al. Twenty-four-hour continuous ECG recordings in long-distance runners. Chest 1982; 82: 19–24PubMedCrossRefGoogle Scholar
  16. 16.
    Pantano JA, Oriel FJ. Prevalence and nature of cardiac arrhythmias in apparently normal well trained runners. Am Heart J 1982; 104: 762–8PubMedCrossRefGoogle Scholar
  17. 17.
    Pilcher GF, Cook AJ, Johnston BL, et al. Twenty-four-hour continuous electrocardiography during exercise and free activity in 80 apparently healthy runners. Am J Cardiol 1983; 52: 859–61PubMedCrossRefGoogle Scholar
  18. 18.
    Franklin BA, Almany SL, Hauser AM. Cardiovascular evaluation of the athlete. In: Fu FH, Stone DA, editors. Sports injuries: mechanisms, prevention, and treatment. Baltimore: William & Wilkins Company, 1994: 111–21Google Scholar
  19. 19.
    Buskirk E, Taylor HL. Maximal oxygen intake and its relation to body composition, with specific reference to chronic physical activity and obesity. J Appl Physiol 1957; 2: 72–8Google Scholar
  20. 20.
    Bruce RA, Kusumi F, Hosmer D. Maximal oxygen intake and nomographic assessment of functional aerobic impairment in cardiovascular disease. Am Heart J 1973; 85: 546–62PubMedCrossRefGoogle Scholar
  21. 21.
    Adams GE, Marlon AM, Quinn EJ. O2 uptake in cardiac patients during treadmill testing. J Cardiovasc Pulm Technique 1980; 8: 14–24Google Scholar
  22. 22.
    Sullivan M, McKirnan M. Errors in predicting functional capacity for post myocardial infarction patients using a modified Bruce protocol. Am Heart J 1984; 107: 486–92PubMedCrossRefGoogle Scholar
  23. 23.
    Franklin BA. Pitfalls in estimating aerobic capacity from exercise time or workload. Appl Cardiol 1986; 14: 25–6Google Scholar
  24. 24.
    Buchfuhrer MJ, Hansen JE, Robinson TE, et al. Optimizing the exercise protocol for cardiopulmonary assessment. J Appl Physiol 1983; 55: 1558–64PubMedGoogle Scholar
  25. 25.
    Neuberg GW, Friedman SH, Weiss MB, et al. Cardiopulmonary exercise testing: the clinical value of gas exchange data. Ann Intern Med 1988; 148: 2221–6CrossRefGoogle Scholar
  26. 26.
    Yanowitz FG. Functional exercise testing in chronic congestive heart failure. Cardiology 1993; 10: 56–74Google Scholar
  27. 27.
    Franklin BA, Kaimal KP, Moir TW, et al. Characteristics of national-class race walkers. Physician Sports Med 1981; 9: 101–8Google Scholar
  28. 28.
    Hendrickson KD, Franklin BA, Gordon S, et al. Physiological characteristics of national-class stair climbers. Med Exerc Nutr Health 1993; 2: 269–75Google Scholar
  29. 29.
    Vander LB, Franklin BA, Wrisley D, et al. Physiological profile of national-class national collegiate athletic association fencers. JAMA 1984; 252: 500–3PubMedCrossRefGoogle Scholar
  30. 30.
    Bouchard C, Lesage R, Lortie G, et al. Aerobic performance in brothers, dizygotic and monozygotic twins. Med Sci Sports Exerc 1986; 18: 639–46PubMedGoogle Scholar
  31. 31.
    Klissouras V. Adaptability of genetic variation. J Appl Physiol 1971; 31: 338–44PubMedGoogle Scholar
  32. 32.
    Bouchard C, Dionne FT, Simoneau J-A, et al. Genetics of aerobic and anaerobic performances. Exerc Sport Sci Rev 1992; 20: 27–58PubMedCrossRefGoogle Scholar
  33. 33.
    Wasserman K, Whipp BJ, Koyal SN, et al. Anaerobic threshold and respiratory gas exchange during exercise. J Appl Physiol 1973; 35: 236–43PubMedGoogle Scholar
  34. 34.
    Davis JA, Vodak P, Wilmore JH, et al. Anaerobic threshold and maximal aerobic power for three modes of exercise. J Appl Physiol 1976; 41: 544–50PubMedGoogle Scholar
  35. 35.
    Davis JA. Anaerobic threshold: review of the concept and directions for future research. Med Sci Sports Exerc 1985; 17: 6–18PubMedGoogle Scholar
  36. 36.
    Brooks GA. Anaerobic threshold: review of the concept and directions for future research. Med Sci Sports Exerc 1985; 17: 22–31PubMedGoogle Scholar
  37. 37.
    Jones N, Ehrsam R. The anaerobic threshold. Exerc Sport Sci Rev 1982; 10: 49–83PubMedCrossRefGoogle Scholar
  38. 38.
    Costill DL. Physiology of marathon running. JAMA 1972; 221: 1024–9PubMedCrossRefGoogle Scholar
  39. 39.
    Costill DL, Fox EL. Energetics of marathon running. Med Sci Sports 1969; 1: 81–6CrossRefGoogle Scholar
  40. 40.
    Costill DL, Thomason H, Roberts E. Fractional utilization of the aerobic capacity during distance running. Med Sci Sports 1973; 5: 248–52PubMedCrossRefGoogle Scholar
  41. 41.
    Costill DL, Branam G, Eddy D, et al. Determinants of marathon running success. Int Z Angew Physiol 1971; 29: 249–54PubMedGoogle Scholar
  42. 42.
    Puffer JC, Green GA. Drugs and doping in athletes. In: Mellion MB, Walsh WM, Shelton GL, editors. The Team Physician’s Handbook. Philadelphia: Hanley and Belfus Publishers, 1990: 111–27Google Scholar
  43. 43.
    Fletcher GF, Froelicher VF, Hartley LH, et al. Exercise standards: a statement for health professionals from the American Heart Association. Circulation 1990; 82: 2286–322PubMedCrossRefGoogle Scholar
  44. 44.
    American College of Sports Medicine. ACSM guidelines for exercise testing and prescription. 5th ed. In: Kenney WL, Humphrey RH, Bryant CX, et al., editors. Baltimore: Williams and Wilkins, 1995Google Scholar
  45. 45.
    Gordon NF, Duncan JJ. Effect of beta-blockers on exercise physiology: implications for exercise training. Med Sci Sports Exerc 1991; 23: 668–76PubMedGoogle Scholar
  46. 46.
    American College of Sports Medicine. Physical activity, physical fitness, and hypertension [position stand]. Med Sci Sports Exerc 1993; 25: i–xGoogle Scholar
  47. 47.
    Kaplan NM, Deveraux RB, Miller HS. Task Force 4: Systemic hypertension. Med Sci Sports Exerc 1994; 26: S268–S70PubMedCrossRefGoogle Scholar
  48. 48.
    Kohl HW, Powell KE, Gordon NF, et al. Physical activity, physical fitness, and sudden cardiac death. Epidemiol Rev 1992; 14: 37–54PubMedGoogle Scholar
  49. 49.
    Amsterdam EA. Sudden death during exercise. Cardiology 1990; 77: 411–7PubMedCrossRefGoogle Scholar
  50. 50.
    Myerburg RJ, Castellanos A. Cardiac arrest and sudden cardiac death. In: Braunwald E, editor. Heart disease: a textbook of cardiovascular medicine. Philadelphia: WB Saunders Co., 1992: 756–89Google Scholar
  51. 51.
    Franklin BA, Kahn JK. Detecting the individual prone to exercise-related sudden cardiac death. Sport Sci Rev 1995; 4: 85–105Google Scholar
  52. 52.
    Maron BJ, Epstein SE, Roberts WC. Causes of sudden death in competitive athletes. J Am Coll Cardiol 1986; 7: 204–14PubMedCrossRefGoogle Scholar
  53. 53.
    Cobb LA, Weaver WD. Exercise: a risk for sudden death in patients with coronary heart disease. J Am Coll Cardiol 1986; 7: 215–9PubMedCrossRefGoogle Scholar
  54. 54.
    Ciampricotti R, el Gamal M, Relik T, et al. Clinical characteristics and coronary angiographic findings of patients with unstable angina, acute myocardial infarction, and survivors of sudden ischemic death occurring during and after sport. Am Heart J 1990; 120: 1267–78PubMedCrossRefGoogle Scholar
  55. 55.
    Noakes TD, Opie L, Beck W, et al. Coronary heart disease in marathon runners. Ann NY Acad Sci 1977; 301: 593–619PubMedCrossRefGoogle Scholar
  56. 56.
    Bassler TJ. Athletic deaths and longevity. Lancet 1972; II: 712–3Google Scholar
  57. 57.
    Bassler TJ, Cardello FP. Fiber-feeding and atherosclerosis. JAMA 1976; 235: 1841–2PubMedCrossRefGoogle Scholar
  58. 58.
    Bassler TJ, Scaff JH. Marathon running after myocardial infarction [letter]. JAMA 1975; 233: 511PubMedCrossRefGoogle Scholar
  59. 59.
    Bassler TJ. Cardiac rehabilitation [letter]. JAMA 1973; 226: 790PubMedCrossRefGoogle Scholar
  60. 60.
    Bassler TJ. Quality of life [letter]. West J Med 1976; 124: 343PubMedGoogle Scholar
  61. 61.
    Bassler TJ. Physician deaths [letter]. JAMA 1973; 223: 1391PubMedCrossRefGoogle Scholar
  62. 62.
    Milvy P, editor. The marathon: physiological, medical, epidemiologic and psychological studies. Ann NY Acad Sci 1977; 301: 1–1090Google Scholar
  63. 63.
    Fixx JF. The complete book of running. New York: Random House, 1977Google Scholar
  64. 64.
    Sheehan GA. Running and being. The total experience. New York: Simon and Schuster, 1978Google Scholar
  65. 65.
    Kramsch DM, Aspen AJ, Abramowitz BM, et al. Reduction of coronary atherosclerosis by moderate conditioning exercise in monkeys on an atherogenic diet. N Engl J Med 1981; 305: 1483–9PubMedCrossRefGoogle Scholar
  66. 66.
    Noakes TD, Higginson L, Opie LH. Physical training increases ventricular fibrillation thresholds of isolated rat hearts during normoxia, hypoxia and regional ischemia. Circulation 1983; 67: 24–30PubMedCrossRefGoogle Scholar
  67. 67.
    Posel D, Noakes TD, Kantor P, et al. Exercise training after experimental myocardial infarction increases the ventricular fibrillation threshold before and after the onset of reinfarction in the isolated rat heart. Circulation 1989; 80: 138–45PubMedCrossRefGoogle Scholar
  68. 68.
    Billman GE, Schwartz PJ, Stone HL. The effect of daily exercise on susceptibility to sudden cardiac death. Circulation 1984; 69: 1182–9PubMedCrossRefGoogle Scholar
  69. 69.
    Paffenbarger RS, Wing AL, Hyde RT. Physical activity as an index of heart attack risk in college alumni. Am J Epidemiol 1978; 108: 161–75PubMedGoogle Scholar
  70. 70.
    Rennie D, Hollenberg NK. Cardiomyothology and marathons. N Engl J Med 1979; 301: 103–4PubMedCrossRefGoogle Scholar
  71. 71.
    Noakes TD, Opie LH, Rose AG, et al. Autopsy-proved coronary atherosclerosis in marathon runners. N Engl J Med 1979; 301: 86–9PubMedCrossRefGoogle Scholar
  72. 72.
    Noakes TD. Heart disease in marathon runners: a review. Med Sci Sports Exerc 1987; 19: 187–94PubMedGoogle Scholar
  73. 73.
    Noakes TD, Rose AG. Exercise-related deaths in three subjects with co-existent hypertrophic cardiomyopathy and coronary artery disease. S Afr Med J 1984; 66: 183–7PubMedGoogle Scholar
  74. 74.
    Siscovick DS, Weiss NS, Fletcher RH, et al. The incidence of primary cardiac arrest during vigorous exercise. N Engl J Med 1984; 311: 874–7PubMedCrossRefGoogle Scholar
  75. 75.
    Sadaniantz A, Clayton MA, Sturner WO, et al. Sudden death immediately after a record-setting athletic performance. Am J Cardiol 1989; 63: 375PubMedCrossRefGoogle Scholar
  76. 76.
    Burke AP, Farb A, Virmani R, et al. Sports-related and non-sports-related sudden cardiac death in young adults. Am Heart J 1991; 121: 568–75PubMedCrossRefGoogle Scholar
  77. 77.
    Corrado D, Thiene G, Nava A, et al. Sudden death in young competitive athletes: clinicopathologic correlations in 22 cases. Am J Med 1990; 89: 588–96PubMedCrossRefGoogle Scholar
  78. 78.
    Kennedy HL, Whitlock JA. Sports related sudden death in young persons [abstract]. J Am Coll Cardiol 1984; 3: 622AGoogle Scholar
  79. 79.
    Northcote RJ, Flannigan C, Ballantyne D. Sudden death and vigorous exercise: a study of 60 deaths associated with squash. Br Heart J 1986; 55: 198–203PubMedCrossRefGoogle Scholar
  80. 80.
    Maron BJ, Roberts WC, McAllister HA, et al. Sudden death in young athletes. Circulation 1980; 62: 218–29PubMedCrossRefGoogle Scholar
  81. 81.
    Brandenburg RO. Syncope and sudden death in hypertrophic cardiomyopathy. J Am Coll Cardiol 1990; 15: 962–4PubMedCrossRefGoogle Scholar
  82. 82.
    Mitchell JH, Maron BJ, Epstein SE. 16th Bethesda Conference. Cardiovascular abnormalities in the athlete: recommendations regarding eligibility for competition. J Am Coll Cardiol 1985; 6: 1186–232PubMedCrossRefGoogle Scholar
  83. 83.
    Maron BJ. Structural features of the athletes heart as defined by echocardiography. J Am Coll Cardiol 1986; 7: 190–203PubMedCrossRefGoogle Scholar
  84. 84.
    Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986; 111: 941–63PubMedCrossRefGoogle Scholar
  85. 85.
    Baltaxe HA, Wixson D. The incidence of congenital anomalies of the coronary arteries in the adult population. Radiology 1977; 122: 47–52PubMedGoogle Scholar
  86. 86.
    Chaitman BR, Lesperance J, Saltiel J, et al. Clinical, angiographic and hemodynamic findings in patients with anomalous origin of the coronary arteries. Circulation 1975; 53: 122–31CrossRefGoogle Scholar
  87. 87.
    Kimibiris D, Iskandrian AS, Segal BL, et al. Anomalous aortic origin of coronary arteries. Circulation 1978; 58: 606–15CrossRefGoogle Scholar
  88. 88.
    Page Jr HL, Engel JH, Campbell WB, et al. Anomalous origin of the left circumflex coronary artery. Recognition, angiographic demonstration and clinical significance. Circulation 1974; 50: 768–73PubMedCrossRefGoogle Scholar
  89. 89.
    Ray PR, Saunders A, Sowton GE. Review of variation in origin of left circumflex coronary artery. Br Heart J 1975; 37: 287–92CrossRefGoogle Scholar
  90. 90.
    Pelliccia A, Maron BJ. Preparticipation cardiovascular evaluation of the competitive athlete: perspectives from the 30-year Italian experience. Am J Cardiol 1995; 75: 827–9PubMedCrossRefGoogle Scholar
  91. 91.
    Rossi P, Massumi A, Gillette P, et al. Arrhythmogenic right ventricular dysplasia: clinical features, diagnostic techniques, and current management. Am Heart J 1982; 103: 415–20PubMedCrossRefGoogle Scholar
  92. 92.
    Berkman NL, Lamb LE. The Wolff-Parkinson-White electrocardiogram: a follow-up study of five to twenty-eight years. N Engl J Med 1968; 278: 492–4PubMedCrossRefGoogle Scholar
  93. 93.
    Gillette PC, Garson Jr A, Kugler JD. Wolff-Parkinson-White syndrome in children: electrophysiologic and pharmacologic characteristics. Circulation 1979; 60: 1487–95PubMedCrossRefGoogle Scholar
  94. 94.
    Leitch JW, Klein GL, Yee R, et al. Prognostic value of electro-physiology testing in asymptomatic patients with Wolff-Parkinson-White pattern. Circulation 1990; 82: 1718–23PubMedCrossRefGoogle Scholar
  95. 95.
    Munger TM, Packer DL, Hammill SC, et al. A population study of the natural history of Wolff-Parkinson-White syndrome in Olmstead County, Minnesota, 1953–1989. Circulation 1993; 87: 866–73PubMedCrossRefGoogle Scholar
  96. 96.
    Kato H, Ichinose E, Yoshioka F, et al. Fate of coronary aneurysms in Kawasaki disease: serial coronary angiography and long-term follow-up study. Am J Cardiol 1977; 40: 282–6CrossRefGoogle Scholar
  97. 97.
    Kegel SM, Dorsey TJ, Rowen M, et al. Cardiac death in mucocutaneous lymph node syndrome. Am J Cardiol 1977; 40: 282–6PubMedCrossRefGoogle Scholar
  98. 98.
    Miimura I, Maki T. Sudden cardiac death in childhood. Jpn Circ J 1989; 53: 1571–80CrossRefGoogle Scholar
  99. 99.
    Jeresaty RM. Mitral valve prolapse: definition and implications in athletes. J Am Coll Cardiol 1986; 7: 231–6PubMedCrossRefGoogle Scholar
  100. 100.
    Kark J, Posey DM, Schumacher HR, et al. Sickle cell trait as a risk factor for sudden death in physical training. N Engl J Med 1987; 317: 781–7PubMedCrossRefGoogle Scholar
  101. 101.
    Pearson HA. Sickle cell trait and competitive athletics: is there a risk? Pediatrics 1989; 83: 613–4PubMedGoogle Scholar
  102. 102.
    Williams RA. Sudden cardiac death in Blacks, including Black athletes. Cardiovasc Clin 1991; 21: 297–320PubMedGoogle Scholar
  103. 103.
    Maron BJ, Poliac L, Kaplan JA, et al. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med 1995; 333: 337–42PubMedCrossRefGoogle Scholar
  104. 104.
    Kloner RA, Hale S, Alker K, et al. The effects of acute and chronic cocaine use on the heart. Circulation 1992; 85: 407–19PubMedCrossRefGoogle Scholar
  105. 105.
    Maron BJ, Shirani J, Poliac LC, et al. Sudden death in young competitive athletes: clinical, demographic and pathological profiles. JAMA 1996; 276: 199–204PubMedCrossRefGoogle Scholar
  106. 106.
    Van Camp SP, Bloor CM, Mueller FO, et al. Non-traumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995; 27: 641–7PubMedGoogle Scholar
  107. 107.
    Wigle ED, Sasson Z, Henderson MA, et al. Hypertrophic cardiomyopathy: the importance of the site and extent of hypertrophy — a review. Prog Cardiovasc Dis 1985; 28: 1–83PubMedCrossRefGoogle Scholar
  108. 108.
    Maron BJ, Bonow RO, Cannon RO III, et al. Hypertrophic cardiomyopathy: interrelations of clinical manifestations, pathophysiology, and therapy (1). N Engl J Med 1987; 316: 780–9PubMedCrossRefGoogle Scholar
  109. 109.
    Maron BJ, Bonow RO, Cannon RO III, et al. Hypertrophic cardiomyopathy: interrelations of clinical manifestations, pathophysiology, and therapy (2). N Engl J Med 1987; 316: 844–52PubMedCrossRefGoogle Scholar
  110. 110.
    Louie EK, Edwards LC III. Hypertrophic cardiomyopathy. Prog Cardiovasc Dis 1994; 36: 275–308PubMedCrossRefGoogle Scholar
  111. 111.
    Klues HG, Schiffers A, Maron BJ. Phenotypic spectrum and patterns of left ventricular hypertrophy in hypertrophic cardiomyopathy: morphologic observations and significance as assessed by two-dimensional echocardiography in 600 patients. J Am Coll Cardiol 1995; 26: 1699–1708PubMedCrossRefGoogle Scholar
  112. 112.
    Franklin BA, Blair SN, Haskell WL, et al. Exercise and cardiac complications. Physician Sports Med 1994; 22(2): 56–8Google Scholar
  113. 113.
    Curfman GD. Is exercise beneficial or hazardous to your heart? N Engl J Med 1993; 329: 1730–1PubMedCrossRefGoogle Scholar
  114. 114.
    Thompson PD, Funk EJ, Carleton RA, et al. Incidence of death during jogging in Rhode Island from 1975 through 1980. JAMA 1982; 247: 2535–8PubMedCrossRefGoogle Scholar
  115. 115.
    Spirito P, Maron BJ, Bonow RO, et al. Prevalence and significance of an abnormal S-T segment response to exercise in a young athletic population. Am J Cardiol 1983; 51: 1663–6PubMedCrossRefGoogle Scholar
  116. 116.
    McHenry PL, O’Donnell J, Morris SN, et al. The abnormal exercise electrocardiogram in apparently healthy men: a predictor of angina pectoris as an initial coronary event during long-term follow-up. Circulation 1994; 70: 547–51CrossRefGoogle Scholar
  117. 117.
    Thompson PD, Stern MP, Williams P, et al. Death during jogging or running. A study of 18 cases. JAMA 1979; 242: 1265–7PubMedCrossRefGoogle Scholar
  118. 118.
    Noakes TD, Opie LH, Rose AG. Marathon running and immunity to coronary heart disease: fact versus fiction. In: Franklin BA, Rubenfire M, editors. Symposium on cardiac rehabilitation: clinics in sports medicine. Philadelphia: W.B. Saunders Co., 1984: 527–43Google Scholar
  119. 119.
    Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979; 300: 1350–8PubMedCrossRefGoogle Scholar
  120. 120.
    Epstein SE. Implications of probability analysis on the strategy used for noninvasive detection of coronary artery disease. Am J Cardiol 1980; 46: 491–9PubMedCrossRefGoogle Scholar
  121. 121.
    American Heart Association. 1996 Heart and Stroke Facts Statistical Supplement. Dallas: AHA, 1995Google Scholar
  122. 122.
    Friedman TD, Greene AC, Iskandrian AS, et al. Exercise thallium-201 myocardial scintigraphy in women: correlation with coronary arteriography. Am J Cardiol 1982; 49: 1632–7PubMedCrossRefGoogle Scholar
  123. 123.
    Sawada SG, Ryan T, Fineberg NS, et al. Exercise echocardiographic detection of coronary artery disease in women. J Am Coll Cardiol 1989; 14: 1440–7PubMedCrossRefGoogle Scholar
  124. 124.
    Eaker ED, Chesbro JH, Sacks FM, et al. Cardiovascular disease in women. Circulation 1993; 88: 1999–2009PubMedCrossRefGoogle Scholar
  125. 125.
    Spirito P, Pelliccia A, Proschan MA, et al. Morphology of the athlete’s heart assessed by echocardiography in 947 elite athletes representing 27 sports. Am J Cardiol 1994; 74: 802–6PubMedCrossRefGoogle Scholar
  126. 126.
    26th Bethesda Conference, Jan 6–7 1994. Maron BJ, Mitchell JH, co-chairpersons. Recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. J Am Coll Cardiol 1994; 24: 845–99CrossRefGoogle Scholar
  127. 127.
    Morganroth J, Maron BJ, Henry WL, et al. Comparative left ventricular dimensions in trained athletes. Ann Intern Med 1975; 82: 521–4PubMedGoogle Scholar
  128. 128.
    Kaimal KP, Franklin BA, Moir TW, et al. Cardiac profiles of national-class race walkers. Chest 1993; 104: 935–8PubMedCrossRefGoogle Scholar
  129. 129.
    Longhurst JC, Kelly AR, Gonyea WJ, et al. Echocardiographic left ventricular masses in distance runners and weight lifters. J Appl Physiol 1980; 48: 154–62PubMedGoogle Scholar
  130. 130.
    Pelliccia A, Maron BJ, Spataro A, et al. The upper limit of physiologic hypertrophy in highly trained elite athletes. N Engl J Med 1991; 324: 295–301PubMedCrossRefGoogle Scholar
  131. 131.
    Ehsani AA, Hagberg JM, Hickson RC. Rapid changes in left ventricular dimensions in response to physical conditioning and deconditioning. Am J Cardiol 1978; 42: 52–6PubMedCrossRefGoogle Scholar
  132. 132.
    Thompson PD, Sadaniantz A, Cullinane EM, et al. Left ventricular function is not impaired in weight lifters who use anabolic steroids. J Am Coll Cardiol 1992; 19: 278–82PubMedCrossRefGoogle Scholar
  133. 133.
    Maron BJ, Pelliccia A, Spirito P. Cardiac disease in young trained athletes. Insights into methods for distinguishing athlete’s heart from structural heart disease, with particular emphasis on hypertrophic cardiomyopathy. Circulation 1995; 91: 1596–601PubMedCrossRefGoogle Scholar
  134. 134.
    Douglas PS, Berman GO, O’Toole ML, et al. Prevalence of multivalvular regurgitation in athletes. Am J Cardiol 1989; 64: 209–12PubMedCrossRefGoogle Scholar
  135. 135.
    Pelliccia A, Spataro A, Maron BJ. Prospective echocardiographic screening for coronary artery anomalies in 1,360 elite competitive athletes. Am J Cardiol 1993; 72: 978–9PubMedCrossRefGoogle Scholar
  136. 136.
    Maron BJ, Thompson PD, Puffer JC, et al. Cardiovascular preparticipation screening of competitive athletes. Circulation 1996; 94: 850–6PubMedCrossRefGoogle Scholar
  137. 137.
    Thompson PD, Mitchell JH. Exercise and sudden cardiac death: protection or provocation? [editorial]. N Engl J Med 1984; 311: 914–5PubMedCrossRefGoogle Scholar
  138. 138.
    Mittleman MA, Maclure M, Toffer GH, et al. Triggering of acute myocardial infarction by heavy physical exertion. N Engl J Med 1993; 329: 1677–83PubMedCrossRefGoogle Scholar
  139. 139.
    Murry PM, Cantwell JD, Heath DL, et al. The role of limited echocardiography in screening athletes. Am J Cardiol 1995; 76: 849–50PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 1997

Authors and Affiliations

  • Barry A. Franklin
    • 1
    • 7
  • Gerald F. Fletcher
    • 2
  • Neil F. Gordon
    • 3
  • Timothy D. Noakes
    • 4
  • Philip A. Ades
    • 5
  • Gary J. Balady
    • 6
  1. 1.Cardiac Rehabilitation and Exercise LaboratoriesWilliam Beaumont HospitalDetroitUSA
  2. 2.Mayo Clinic and Mayo Medical SchoolJacksonvilleUSA
  3. 3.The Heart and Lung Group of Savannah and Center for Heart Disease PreventionChandler HospitalSavannahUSA
  4. 4.Department of PhysiologyUniversity of Cape Town Medical School and Sports Science Institute of South AfricaNewlandsSouth Africa
  5. 5.Cardiac Rehabilitation ProgramUniversity of Vermont College of MedicineBurlingtonUSA
  6. 6.Boston University School of MedicineBostonUSA
  7. 7.Department of PhysiologyWayne State University, School of MedicineDetroitUSA

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