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Cardiovascular Adaptations in Triathlon

  • Sanjay SharmaEmail author
  • Maximiliano Moreira Accame
Chapter

Abstract

Regular physical activity has a positive impact on general health and well-being. The volume and the intensity of training undertaken by competitive athletes, particularly those engaging in endurance sports, including the triathlon, is between 10- to 20-fold higher than the current recommendations for the general population. Such athletes develop a constellation structural and functional adaptations within the heart (“athlete’s heart”) that permit the generation of a large and sustained increase in cardiac output for prolonged periods and also impact on the surface 12-lead ECG.

Sinus bradycardia, first-degree atrioventricular (AV) block, voltage criteria for ventricular hypertrophy and incomplete right bundle branch block are common electrical manifestations in endurance athletes. Up to 50% of endurance athletes have a ventricular cavity dimensions that exceed the upper limit of normal, and a proportion of large males may reveal a left ventricular end diastolic diameter >60 mm. Occasionally structural adaptations may overlap with those observed in individuals with cardiomyopathy.

Sudden death is a very rare event in triathlons but usually affects males and most commonly occurs in the swim section. Deaths may be due to an inherited or genetic cardiac abnormality in young (<35-year-old) athletes and atherosclerotic coronary artery disease in older athletes.

The impact of life-long participation in endurance exercise on an otherwise normal heart is unclear, but there is emerging evidence that male endurance athletes who have been competing for several years have a higher prevalence of atrial fibrillation. A small proportion of studies have also shown a higher prevalence of myocardial scar.

Keywords

Athletes Athlete’s heart Endurance sports Cardiovascular adaptation Sudden cardiac death 

References

  1. 1.
    US Department of Health and Social Services. Physical activity guidelines for Americans. www.health.gov/paguidelines.
  2. 2.
    Pelliccia A, Fagard R, Bjørnstad HH, et al. Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005;26:1422–45.CrossRefPubMedGoogle Scholar
  3. 3.
    Waite O, Smith A, Madge L, et al. Sudden cardiac death in marathons: a systematic review. Phys Sportsmed. 2016;44(1):79–84.CrossRefPubMedGoogle Scholar
  4. 4.
    Kim J, Malhotra R, Chiampas G, et al. Cardiac arrest during long-distance running races. N Engl J Med. 2012;366:130–40.CrossRefPubMedGoogle Scholar
  5. 5.
    Redelmeier DA, Greenwald JA. Competing risks of mortality with marathons: retrospective analysis. Br Med J. 2007;335(7633):1275–7.CrossRefGoogle Scholar
  6. 6.
    Harris KM, Henry JT, Rohman E, et al. Sudden death during the triathlon. JAMA. 2010;303:1255–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Vleck V, Millet G, Bessone Alves F. The impact of triathlon training and racing on athlete’s general health. Sports Med. 2014;44:1659–92.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Harris K, Creswell L, Haas T, et al. Death and cardiac arrest in US triathlon participants, 1985 to 2016. A case series. Ann Intern Med. 2017;167:529–35.CrossRefPubMedGoogle Scholar
  9. 9.
    Marijon E, Bougouin W, Celermajer DS, et al. Major regional disparities in outcomes after sudden cardiac arrest during sports. Eur Heart J. 2013;34:3632–40.CrossRefPubMedGoogle Scholar
  10. 10.
    Möhlenkamp S, Schmermund A, Kroger K, et al. Coronary atherosclerosis and cardiovascular risk in master’s male marathon runners. Rationale and design of the “marathon study”. Herz. 2006;31:575–85.CrossRefPubMedGoogle Scholar
  11. 11.
    Möhlenkamp S, Lehmann N, Breuckmann F, et al. Running: the risk of coronary events. Prevalence and prognostic relevance of coronary atherosclerosis in marathon runners. Eur Heart J. 2008;29:1903–10.CrossRefPubMedGoogle Scholar
  12. 12.
    Tunstall Pedoe DS. Sudden death risk in older athletes: increasing the denominator. Br J Sports Med. 2004;38:671–2.CrossRefPubMedGoogle Scholar
  13. 13.
    Schnohr P, O’Keefe JH, Marott JL, et al. Dose of jogging and long-term mortality. J Am Coll Cardiol. 2015;65:411–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Lee D-C, Pate RR, Lavie CJ, et al. Leisure-time running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol. 2014;64:472–81.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    O’Donovan G, Blazevich AJ, Boreham C, et al. The ABC of physical activity for health: a consensus statement from the British Association of Sport and Exercise Sciences. J Sports Sci. 2010;28:573–91.CrossRefPubMedGoogle Scholar
  16. 16.
    De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2003;24:1601–10.CrossRefPubMedGoogle Scholar
  17. 17.
    Pescatello LS, Franklin BA, Fagard R, et al. Exercise and hypertension. Med Sci Sports Exerc. 2004;36:533–53.CrossRefPubMedGoogle Scholar
  18. 18.
    Kelley GA, Kelley KS, Tran ZV. Walking, lipids, and lipoproteins: a meta-analysis of randomized controlled trials. Prev Med. 2004;38:651–61.CrossRefPubMedGoogle Scholar
  19. 19.
    Boule NG, Haddad E, Kenny GP, Wells GA, Sigal RJ. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus a meta-analysis of controlled clinical trials. JAMA. 2001;286:11–5.CrossRefGoogle Scholar
  20. 20.
    Dallam G, Jonas S, Miller T. Triathlon competition: recommendations for triathlon organisers, competitors and coaches. Sports Med. 2005;35(2):143–61.CrossRefGoogle Scholar
  21. 21.
    Levine BD, Baggish AL, Kovacs RJ, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 1: classification of sports: dynamic, static, and impact: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66:2350–5.CrossRefPubMedGoogle Scholar
  22. 22.
    Mitchell J, Haskell W, Snell P, et al. Task force 8: classification of sports. J Am Coll Cardiol. 2005;45(8):1364–7.CrossRefPubMedGoogle Scholar
  23. 23.
    Pelliccia A, Caselli S, Sharma S, et al. European Association of Preventive Cardiology (EAPC) and European Association of Cardiovascular Imaging (EACVI) joint position statement: recommendations for the indication and interpretation of cardiovascular imaging in the evaluation of the athlete’s heart. Eur Heart J. 2017;0:1–27.Google Scholar
  24. 24.
    Sharma S, Merghani A, Mont L. Exercise and the heart: the good, the bad and the ugly. Clinical update. Eur Heart J. 2015;36:1445–53.CrossRefPubMedGoogle Scholar
  25. 25.
    Papadakis M, Wilson M, Ghani S, et al. Impact of ethnicity upon cardiovascular adaptation in competitive athletes: relevance to preparticipation screening. Br J Sports Med. 2012;46(Suppl I):i22–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Schnell F, Riding N, O’Hanlon R, et al. Recognition and significance of pathological T-wave inversions in athletes. Circulation. 2015;131:165–73.  https://doi.org/10.1161/CIRCULATIONAHA.114.011038.CrossRefPubMedGoogle Scholar
  27. 27.
    Papadakis M, Carré F, Kervio G, et al. The prevalence, distribution, and clinical outcomes of electrocardiographic repolarisation patterns in male athletes of African/Afro-Caribbean origin. Eur Heart J. 2011;32(18):2304–13.CrossRefPubMedGoogle Scholar
  28. 28.
    Malhotra A, Dhutia H, Gati S. Anterior T-wave inversion in young athletes and nonathletes: prevalence and significance. J Am Coll Cardiol. 2017;69(3):1.CrossRefPubMedGoogle Scholar
  29. 29.
    Morganroth J, Maron BJ, Henry WL, Epstein SE. Comparative left ventricular dimensions in trained athletes. Ann Intern Med. 1975;82:521–4.CrossRefPubMedGoogle Scholar
  30. 30.
    Caselli S, Di Paolo FM, Pisicchio C, et al. Three-dimensional echocardiographic characterization of left ventricular remodeling in Olympic athletes. Am J Cardiol. 2011;108:141–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Spence AL, Naylor LH, Carter HH, et al. A prospective randomised longitudinal. MRI study of left ventricular adaptation to endurance and resistance exercise. Training in humans. J Physiol. 2011;589:5443–52.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Scharf M, Brem MH, Wilhelm M, et al. Atrial and ventricular functional and structural adaptations of the heart in elite triathletes. Assessed with cardiac MR imaging. Radiology. 2010;257:71–9.CrossRefPubMedGoogle Scholar
  33. 33.
    George K, Whyte G, Green D, et al. The endurance athlete’s heart: acute stress and chronic adaptation. Br J Sports Med. 2012;46(Suppl I):i29–36.CrossRefPubMedGoogle Scholar
  34. 34.
    Sharma S, Drezner JA, Baggish A, et al. International recommendations for electrocardiographic interpretation in athletes. J Am Coll Cardiol. 2017;69(8):1057–75.CrossRefPubMedGoogle Scholar
  35. 35.
    Antzelevitch C, Yan G, Ackerman M. J-wave syndromes expert consensus conference report: emerging concepts and gaps in knowledge. J Arrhythm. 2016;32:315–39.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Brosnan M, La Gerche A, Kalman J, et al. Comparison of frequency of significant electrocardiographic abnormalities in endurance versus non-endurance athletes. Am J Cardiol. 2014;113:1567–73.CrossRefPubMedGoogle Scholar
  37. 37.
    Pelliccia A, Maron BJ, Di Paolo FM, et al. Prevalence and clinical significance of left atrial remodeling in competitive athletes. J Am Coll Cardiol. 2005;46:690–6.CrossRefPubMedGoogle Scholar
  38. 38.
    D’Andrea A, La Gerche A, Golia E, et al. Right heart structural and functional remodeling in athletes. Echocardiography. 2015;32(Suppl 1):S11–22.CrossRefPubMedGoogle Scholar
  39. 39.
    Pagourelias ED, Kouidi E, Efthimiadis GK, et al. Right atrial and ventricular adaptations to training in male Caucasian athletes: an echocardiographic study. J Am Soc Echocardiogr. 2013;26:1344–52.CrossRefPubMedGoogle Scholar
  40. 40.
    Luijkx T, Cramer MJ, Prakken NHJ, et al. Sport category is an important determinant of cardiac adaptation: an MRI study. Br J Sports Med. 2012;46:1119–24.CrossRefPubMedGoogle Scholar
  41. 41.
    Stending K, Engblom H, Buhre T, et al. Relation between cardiac dimensions and peak oxygen uptake. J Cardiovasc Magn Reson. 2010;12:8.CrossRefGoogle Scholar
  42. 42.
    Sohaib SM, Payne JR, Shukla R, et al. Electrocardiographic (ECG) criteria for determining left ventricular mass in young healthy men; data from the LARGE Heart study. J Cardiovasc Magn Reson. 2009;11(1):2.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    D’Andrea A, Riegler L, Cocchia R, et al. Left atrial volume index in highly trained athletes. Am Heart J. 2010;159:1155–61.CrossRefPubMedGoogle Scholar
  44. 44.
    Makan J, Sharma S, Firoozi S, et al. Physiological upper limits of ventricular cavity size in highly trained adolescent athletes. Heart. 2005;91:495–9.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Sharma S, Maron BJ, Whyte G, et al. Physiologic limits of left ventricular hypertrophy in elite junior athletes: relevance to differential diagnosis of athlete’s heart and hypertrophic cardiomyopathy. J Am Coll Cardiol. 2002;40:1431–6.CrossRefPubMedGoogle Scholar
  46. 46.
    Sheikh N, Papadakis M, Carre F, et al. Cardiac adaptation to exercise in adolescent athletes of African ethnicity: an emergent elite athletic population. Br J Sports Med. 2013;47:585–92.CrossRefPubMedGoogle Scholar
  47. 47.
    Bohm P, Schneider G, Linneweber L, et al. Right and left ventricular function and mass in male elite master athletes: a controlled contrast-enhanced cardiovascular magnetic resonance study. Circulation. 2016;133:1927–35.CrossRefPubMedGoogle Scholar
  48. 48.
    La Gerche A. Can intense endurance exercise cause myocardial damage and fibrosis? Curr Sports Med Rep. 2013;12:63–9.CrossRefPubMedGoogle Scholar
  49. 49.
    Hinojar R, Botnar R, Kaski JC, Prasad S, Nagel E, Puntmann VO. Individualized cardiovascular risk assessment by cardiovascular magnetic resonance. Futur Cardiol. 2014;10:273–89.CrossRefGoogle Scholar
  50. 50.
    American College of Cardiology Foundation Task Force on Expert Consensus Documents, Hundley WG, Bluemke DA, Finn JP, Flamm SD, Fogel MA, et al. ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation. 2010;121(22):2462–508.CrossRefGoogle Scholar
  51. 51.
    La Gerche A, Taylor AJ, Prior DL. Athlete’s heart: the potential for multimodality imaging to address the critical remaining questions. JACC Cardiovasc Imaging. 2009;2:350–63.CrossRefPubMedGoogle Scholar
  52. 52.
    Wilson M, O’Hanlon R, Prasad S, et al. Diverse patterns of myocardial fibrosis in lifelong, veteran endurance athletes. J Appl Physiol. 2011;110:1622–6.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    La Gerche A, Burns AT, Mooney DJ, et al. Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes. Eur Heart J. 2012;33:998–1006.CrossRefPubMedGoogle Scholar
  54. 54.
    Breuckmann F, Möhlenkamp S, Nassenstein K, et al. Myocardial late gadolinium enhancement: prevalence, pattern, and prognostic relevance in marathon runners. Radiology. 2009;251:50–7.CrossRefPubMedGoogle Scholar
  55. 55.
    Tahir E, Starekova J, Muellerleile K, et al. Myocardial fibrosis in competitive triathletes detected by contrast-enhanced CMR correlates with exercise-induced hypertension and competition history. JACC Cardiovasc Imaging. 2018;11(9):1260–70.CrossRefPubMedGoogle Scholar
  56. 56.
    de Noronha SV, Sharma S, Papadakis M. Aetiology of sudden cardiac death in athletes in the United Kingdom: a pathological study. Heart. 2009;95:1409–14.CrossRefPubMedGoogle Scholar
  57. 57.
    Corrado D, Basso C, Pavei A, et al. Trends in sudden cardiovascular death in young competitive athletes after implementation of a pre-participation screening program. JAMA. 2006;296:1593–601.CrossRefPubMedGoogle Scholar
  58. 58.
    Roberts WO, Stovitz SD. Incidence of sudden cardiac death in Minnesota high school athletes 1993–2012 screened with a standardized pre-participation evaluation. J Am Coll Cardiol. 2013;62(14):1298–301.CrossRefPubMedGoogle Scholar
  59. 59.
    Corrado D, Basso C, Rizzoli G, et al. Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol. 2003;42:1959–63.CrossRefPubMedGoogle Scholar
  60. 60.
    Maron BJ, Doerer JJ, Haas TS, et al. Sudden deaths in young competitive athletes analysis of 1866 deaths in the United States, 1980–2006. Circulation. 2009;119:1085–92.CrossRefPubMedGoogle Scholar
  61. 61.
    Maron BJ, Shirani J, Poliac LC, et al. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA. 1996;276:199–204.CrossRefGoogle Scholar
  62. 62.
    Papadakis M, Sharma S, Cox S, et al. The magnitude of sudden cardiac death in the young: a death certificate-based review in England and Wales. Europace. 2009;11(10):1353–8.CrossRefPubMedGoogle Scholar
  63. 63.
    Harmon KG, Drezner JA, Wilson MG, et al. Incidence of sudden cardiac death in athletes: a state-of-the-art review. Br J Sports Med. 2014;48:1185–92.CrossRefPubMedGoogle Scholar
  64. 64.
    Harmon KG, Asif IM, Maleszewski JJ, et al. Incidence, cause, and comparative frequency of sudden cardiac death in national collegiate athletic association athletes: a decade in review. Circulation. 2015;132:10–9.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Malhotra A, Dhutia H, Finocchiaro G, et al. Outcomes of cardiac screening in adolescent soccer players. N Engl J Med. 2018;379:524–34.CrossRefPubMedGoogle Scholar
  66. 66.
    Finocchiaro G, Papadakis M, Robertus JL, et al. Etiology of sudden death in sports: insights from a United Kingdom Regional Registry. J Am Coll Cardiol. 2016;67:2108–15.CrossRefGoogle Scholar
  67. 67.
    Harmon KG, Drezner JA, Maleszewski JJ, et al. Pathogeneses of sudden cardiac death in national collegiate athletic association athletes. Circ Arrhythm Electrophysiol. 2014;7:198–204.CrossRefPubMedGoogle Scholar
  68. 68.
    Maron BJ. Hypertrophic cardiomyopathy and other causes of sudden cardiac death in young competitive athletes, with considerations for preparticipation screening and criteria for disqualification. Cardiol Clin. 2007;25(3):399–414.CrossRefPubMedGoogle Scholar
  69. 69.
    Bagnall RD, Weintraub RG, Ingles J, et al. A prospective study of sudden cardiac death among children and young adults. N Engl J Med. 2016;374:2441–52.CrossRefGoogle Scholar
  70. 70.
    Chandra N, Bastiaenen R, Papadakis M, et al. Sudden cardiac death in young athletes. J Am Coll Cardiol. 2013;61:10.  https://doi.org/10.1016/j.jacc.2012.08.1032.CrossRefGoogle Scholar
  71. 71.
    Behr E, Wood DA, Wright M, et al. Cardiological assessment of first-degree relatives in sudden arrhythmic death syndrome. Lancet. 2003;362:1457–9.CrossRefPubMedGoogle Scholar
  72. 72.
    Behr ER, Dalageorgou C, Christiansen M, et al. Sudden arrhythmic death syndrome: familial evaluation identifies inheritable heart disease in the majority of families. Eur Heart J. 2008;29:1670–80.CrossRefPubMedGoogle Scholar
  73. 73.
    Papadakis M, Papatheodorou E, Mellor G, et al. The diagnostic yield of Brugada syndrome after sudden death with normal autopsy. J Am Coll Cardiol. 2018;71(11):1204–14.CrossRefPubMedGoogle Scholar
  74. 74.
    Risgaard B, Winkel BG, Jabbari R, et al. Sports-related sudden cardiac death in a competitive and a non-competitive athlete population aged 12 to 49 years: data from an unselected nationwide study in Denmark. Heart Rhythm. 2014;11:1673–81.CrossRefPubMedGoogle Scholar
  75. 75.
    Maron BJ, Haas TS, Duncanson ER, et al. Comparison of the frequency of sudden cardiovascular deaths in young competitive athletes versus nonathletes: should we really screen only athletes? Am J Cardiol. 2016;117(8):1339–41.CrossRefPubMedGoogle Scholar
  76. 76.
    Berdowski J, de Beus MF, Blom M, et al. Exercise-related out-of-hospital cardiac arrest in the general population: incidence and prognosis. Eur Heart J. 2013;34:3616–23.CrossRefPubMedGoogle Scholar
  77. 77.
    Pelliccia A, Di Paolo FM, De Blasiis E, et al. Prevalence and clinical significance of aortic root dilation. In highly trained competitive athletes. Circulation. 2010;122:698–706.CrossRefPubMedGoogle Scholar
  78. 78.
    Sheikh N, Papadakis M, Ghani S, et al. Comparison of electrocardiographic criteria for the detection of cardiac abnormalities in elite black and white athletes. Circulation. 2014;129(16):1637–49.CrossRefPubMedGoogle Scholar
  79. 79.
    Riding N, Sheikh N, Adamuz C, et al. Comparison of three current sets of electrocardiographic interpretation criteria for use in screening athletes. Heart. 2014;0:1–7.Google Scholar
  80. 80.
    Chugh S, Weiss J. Sudden cardiac death in the older athlete. J Am Coll Cardiol. 2015;65(5):493–502.CrossRefPubMedGoogle Scholar
  81. 81.
    Borjesson M, Urhausen A, Kouidi E, et al. Cardiovascular evaluation of middle-aged/senior individuals engaged in leisure-time sport activities: position stand from the sections of exercise physiology and sports cardiology of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2011;18(3):446–58.CrossRefPubMedGoogle Scholar
  82. 82.
    Freeman J, Froelicher V, Ashley E. The aging athlete: screening prior to vigorous exertion in asymptomatic adults without known cardiovascular disease. Br J Sports Med. 2009;43:696–701.CrossRefPubMedGoogle Scholar
  83. 83.
    Merghani A, Maestrini V, Rosmini S, et al. Prevalence of subclinical coronary artery disease in masters endurance athletes with a low atherosclerotic risk profile. Circulation. 2017;136(2):126–37.CrossRefPubMedGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Cardiology Clinical and Academic GroupSt. George’s, University of LondonLondonUK
  2. 2.Emergency MedicineUniversity of Costa RicaSan JoséCosta Rica

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