Figure - available from: Current Treatment Options in Cardiovascular Medicine
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ECG patterns in male (a) and female (b) athletes. Note the combination of anterior T wave inversion and significant (> 0.1 mV) J point elevation and the voltage criteria for LVH in the male athlete’s ECG. Conversely, the female athlete’s ECG is characterized by the absence of J point elevation and voltage criteria for LVH.
Source publication
Purpose of the review
For many years, competitive sport has been dominated by men. Recent times have witnessed a significant increase in women participating in elite sports. As most studies investigated male athletes, with few reports on female counterparts, it is crucial to have a better understanding on physiological cardiac adaptation to exercis...
Citations
... That aside, the direct impact of lifelong exercise training on LV geometry in the veteran athlete's heart has not been fully reported. Moreso our understanding of the female heart in young and veteran athletes is less clear with few studies focusing on sexdifferences of LV structure [9,10] and although there is some evidence to suggest less adaptation in female compared to male MES athletes [7,11] the nature and absolute magnitude of change still needs to be elucidated. ...
Background
The athlete’s heart (AH) defines the phenotypical changes that occur in response to chronic exercise training. Echocardiographic assessment of the AH is used to calculate LV mass (LVM) and determine chamber geometry. This is, however, interpreted using standard linear (ratiometric) scaling to body surface area (BSA) whereas allometric scaling is now widely recommended. This study (1) determined whether ratiometric scaling of LVM to BSA (LVMi ratio ) provides a size-independent index in young and veteran athletes of mixed and endurance sports (MES), and (2) calculated size-independent beta exponents for allometrically derived (LVMi allo ) to BSA and (3) describes the physiological range of LVMi allo and the classifications of LV geometry.
Methods
1373 MES athletes consisting of young (< 35 years old) (males n = 699 and females n = 127) and veteran (> 35 years old) (males n = 327 and females n = 220) were included in the study. LVMi ratio was calculated as per standard scaling and sex-specific LVMi allo were derived from the population. Cut-offs were defined and geometry was classified according to the new exponents and relative wall thickness.
Results
LVMi ratio did not produce a size independent index. When tested across the age range the following indexes LVMi/BSA 0.7663 and LVMi/BSA 0.52 , for males and females respectively, were size independent (r = 0.012; P = 0.7 and r = 0.003; P = 0.920). Physiological cut-offs for LVMi allo were 135 g/(m ² ) 0.7663 in male athletes and 121 g/(m ² ) 0.52 in female athletes. Concentric remodelling / hypertrophy was present in 3% and 0% of young male and female athletes and 24% and 17% of veteran male and female athletes, respectively. Eccentric hypertrophy was observed in 8% and 6% of young male and female athletes and 9% and 11% of veteran male and female athletes, respectively.
Conclusion
In a large cohort of young and veteran male and female MES athletes, LVMi ratio to BSA is not size independent. Sex-specific LVMi allo to BSA with LVMi/BSA 0.77 and LVMi/BSA 0.52 for male and female athletes respectively can be applied across the age-range. Population-based cut-offs of LVMi allo provided a physiological range demonstrating a predominance for normal geometry in all athlete groups with a greater percentage of concentric remodelling/hypertrophy occurring in veteran male and female athletes.
... Также вполне логично полагать, что чем чаще и сильнее поднимается АД при занятиях спотом, тем больше вероятность гипертрофии левого желудочка и других камер сердца. Последнее, как известно, является независимым ФР сердечно-сосудистых осложнений [39][40][41]. ...
Hypertension (HTN) is widespread among middle-aged and elderly people, including those doing sports. For the first time in 2020, the European Society of Cardiology guidelines on sports cardiology and exercise in patients with cardiovascular disease included adult and elderly patients in a separate group. However, this is a heterogeneous category of patients, including everyone over 35 years of age. Therefore, admittance of athletes to training and competitions still remains at the discretion of physician.
Aim. To assess the relationship and mutual influence of hypertension, other cardiovascular risk factors and sports in middle-aged and elderly people.
Material and methods . Our narrative review is based on 50 articles published on Pubmed, Scopus, Web of Science and eLIBRARY.ru, selected using the keywords "veteran athletes", "arterial hypertension", "cardiovascular risk", "physical activity". Related papers over the past 5 years were evaluated.
Results. Currently, there is a trend toward an increase in the number of veteran athletes whose problems are not reflected in guidelines on sports and exercise.
Conclusion. In the future, large randomized studies are needed to assess the response of blood pressure (BP) to intense exercise, as well as to determine the normal BP response and clear strategy to manage this category of people, depending on the presence of hypertension.
... These geometric changes are influenced by factors such as age, sex, training duration, sport type, and genetic factors. 1,2 Although the left ventricular ejection fraction (LVEF) has been the main measure of systolic function for over 50 years, recent studies have questioned the reliability of LVEF due to the impact of structural changes. Specifically, LVEF is increased by an increase in wall thickness 3,4 or a decreased internal diameter, 5 and length 6 independently of any change in myocardial strain. ...
Background:
Global longitudinal active strain energy density (GLASED) is an innovative method for assessing myocardial function by quantifying the work performed by the left ventricular muscle. The use of GLASED holds promise for improving the diagnosis and management of cardiac diseases. This study aimed to evaluate the feasibility of measuring GLASED using echocardiography and investigate potential differences in GLASED values among athletes based on age and sex.
Methods and Results:
An observational echocardiographic study was conducted, involving male controls, male and female young athletes, and male and female veteran athletes. GLASED was calculated from the myocardial stress and strain. The mean age (years) of young athletes was 21.6 for males and 21.4 for females, while the mean age of veteran athletes was 53.5 for males and 54.2 for females. GLASED was found to be highest in young male athletes (2.40 kJ/m3) and lowest in female veterans (1.96 kJ/m3). Veteran males exhibited lower values (1.96 kJ/m3) compared to young male athletes (P<0.001). Young females demonstrated greater GLASED (2.28 kJ/m3) than veteran females (P<0.01). However, no significant difference in GLASED was observed between male and female veterans.
Conclusions:
Our findings demonstrate the feasibility of measuring GLASED using echocardiography. GLASED values were higher in young male athletes compared to female athletes, and it decreased with age. Importantly, the sex-related differences observed in GLASED values among young athletes were no longer present in veteran athletes. Estimating GLASED may serve as a valuable screening tool for cardiac diseases in athletes, particularly for those with borderline phenotypes of hypertrophic and dilated cardiomyopathies.
... The mechanistic underpinnings for these sex differences are not well understood but have been hypothesized to be primarily linked to sex hormones [85]. The following putative mechanisms have been recently suggested [86]: ...
Regular exercise confers multifaceted and well-established health benefits. Yet, transient and asymptomatic increases in markers of cardio-renal injury are commonly observed in ultra-endurance athletes during and after competition. This has raised concerns that chronic recurring insults could cause long-term cardiac and/or renal damage. Indeed, extreme endurance exercise (EEE) over decades has sometimes been linked with untoward cardiac effects, but a causal relation with acute injury markers has not yet been established. Here, we summarize the current knowledge on markers of cardiac and/or renal injury in EEE athletes, outline the possible interplay between cardiac and kidney damage, and explore the roles of various factors in the development of potential exercise-related cardiac damage, including underlying diseases, medication, sex, training, competition, regeneration, mitochondrial dysfunction, oxidative stress, and inflammation. In conclusion, despite the undisputed health benefits of regular exercise, we speculate, based on the intimate link between heart and kidney diseases, that in rare cases excessive endurance sport may induce adverse cardio-renal interactions that under specific, hitherto undefined conditions could result in persistent cardiac damage. We highlight future research priorities and provide decision support for athletes and clinical consultants who are seeking safe strategies for participation in EEE training and competition.
... Women, however, exhibit different cardiac adaptations to exercise than men (Di Paolo and Pelliccia, 2007). There are several biochemical, physiological, and psychological factors that determine sex-dependent cardiac response (Colombo and Finocchiaro, 2018). Women, on average smaller, have lower mean body mass, different autonomic tone, and hormonal profile than men. ...
Endurance athletes have an increased risk of atrial remodeling and atrial arrhythmias. However, data regarding atrial adaptation to physical exercise in non-elite athletes are limited. Even less is known about atrial performance in women. We aimed to elucidate exercise-induced changes in atrial morphology and function in female amateur marathon runners using three-dimensional (3D) echocardiography and two-dimensional (2D) speckle tracking echocardiography (STE). The study group consisted of 27 female (40 ± 7 years) amateur athletes. Right (RA) and left atrial (LA) measures were assessed three times: 2–3 weeks before the marathon (stage 1), immediately after the run (stage 2), and 2 weeks after the competition (stage 3). Directly after the marathon, a remarkable RA dilatation, as assessed by RA maximal volume (RAVmax, 31.3 ± 6.8 vs. 35.0 ± 7.0 ml/m2; p = 0.008), with concomitant increase in RA contractile function [RA active emptying fraction (RA active EF), 27.7 ± 8.6 vs. 35.0 ± 12.1%; p = 0.014; RA peak atrial contraction strain (RA PACS) 13.8 ± 1.8 vs. 15.6 ± 2.5%; p = 0.016] was noticed. There were no significant changes in LA volumes between stages, while LA active EF (34.3 ± 6.4 vs. 39.4 ± 8.6%; p = 0.020), along with LA PACS (12.8 ± 2.1 vs. 14.9 ± 2.7%; p = 0.002), increased post race. After the race, an increase in right ventricular (RV) dimensions (RV end-diastolic volume index, 48.8 ± 11.0 vs. 60.0 ± 11.1 ml/m2; p = 0.001) and a decrease in RV function (RV ejection fraction, 54.9 ± 6.3 vs. 49.1 ± 6.3%; p = 0.006) were observed. The magnitude of post-race RV dilatation was correlated with peak RA longitudinal strain deterioration (r = −0.56, p = 0.032). The measured parameters did not differ between stages 1 and 3. In female amateur athletes, apart from RV enlargement and dysfunction, marathon running promotes transient biatrial remodeling, with more pronounced changes in the RA. Post-race RA dilatation and increment of the active contraction force of both atria are observed. However, RA reservoir function diminishes in those with post-race RV dilation.
... In turn, a growing proportion of highly active individuals and athletes involved in competitive sport has led to the development of sports cardiology; an evolving entity within cardiovascular medicine aimed at addressing the unique needs of this specialized population [2]. The improved understanding of physiologic demands and anticipated exercise-induced cardiovascular adaptations of different sporting disciplines has led to the better stratification of the electrical and structural changes associated with what is colloquially referred to as the athletic heart [3][4][5]. Much of the current understanding of athletic cardiac function and adaptation, however, stems from analyses of male athletic data, creating significant challenges when translating this understanding to care of the female athlete [4]. ...
... The improved understanding of physiologic demands and anticipated exercise-induced cardiovascular adaptations of different sporting disciplines has led to the better stratification of the electrical and structural changes associated with what is colloquially referred to as the athletic heart [3][4][5]. Much of the current understanding of athletic cardiac function and adaptation, however, stems from analyses of male athletic data, creating significant challenges when translating this understanding to care of the female athlete [4]. Female cardiac remodeling data is crucial to differentiating benign exercise-associated physiologic changes from more deleterious pathologic findings, a distinction that is often difficult due to the subtle sex-specific differences in cardiovascular structural physiology. ...
... Sex-specific differences in cardiac remodeling are thought to be multifactorial, including hormonal, molecular, and genetic influences [4]. As EICR incorporates some degree of adaptive hypertrophy, many investigators have focused on elucidating underlying mechanisms of cardiomyocyte turnover. ...
The cardiovascular care of highly active individuals and competitive athletes has developed into an important focus within the field of sports medicine. An evolving understanding of exercise-induced cardiovascular remodeling in athletes has led to a more robust characterization of physiologic adaptation versus pathological dysfunction, but this distinction is often challenging due to diagnostic commonalities. Current data reflects sporting-focused analyses of mainly male athletes, which may not be easily applicable to the female athletic heart. Increasingly female-specific cardiac dimensional and physiologic data are starting to emerge from comparative studies that may be utilized to address this growing need, and further guide individualized care. Here, we review current literature evaluating female-specific cardiovascular adaptations of the athletic heart, and formulate a discussion on cardiac remodeling, cardiodiagnostic findings, etiologic mechanisms, limitations of currently available data, and direction for future research in the cardiovascular care of female athletes.
... A study of 360 female and 360 age-and sport-matched male Olympic athletes found virtually no left ventricular wall thickening in female athletes, while some male athletes did show concentric remodeling or hypertrophy (D'Ascenzi et al., 2020). These sex-specific differences in cardiac adaptation among elite athletes may help explain the 10:1 male-to-female ratio in sportsrelated sudden cardiac deaths (Colombo and Finocchiaro, 2018). ...
Cardiovascular disease in women remains under-diagnosed and under-treated. Recent studies suggest that this is caused, at least in part, by the lack of sex-specific diagnostic criteria. While it is widely recognized that the female heart is smaller than the male heart, it has long been ignored that it also has a different microstructural architecture. This has severe implications on a multitude of cardiac parameters. Here, we systematically review and compare geometric, functional, and structural parameters of female and male hearts, both in the healthy population and in athletes. Our study finds that, compared to the male heart, the female heart has a larger ejection fraction and beats at a faster rate but generates a smaller cardiac output. It has a lower blood pressure but produces universally larger contractile strains. Critically, allometric scaling, e.g., by lean body mass, reduces but does not completely eliminate the sex differences between female and male hearts. Our results suggest that the sex differences in cardiac form and function are too complex to be ignored: the female heart is not just a small version of the male heart. When using similar diagnostic criteria for female and male hearts, cardiac disease in women is frequently overlooked by routine exams, and it is diagnosed later and with more severe symptoms than in men. Clearly, there is an urgent need to better understand the female heart and design sex-specific diagnostic criteria that will allow us to diagnose cardiac disease in women equally as early, robustly, and reliably as in men.
Systematic Review Registration
https://livingmatter.stanford.edu/ .
... The incidence of SCD is consistently higher for males in both the general population [16] and among competitive athletes [20,23]. Despite an increasing participation of women in competitive sports, this gap persists [24]. The degree to which this sex difference is applicable to the paediatric and adolescent age range, remains to be definitively determined, although one UK-based study including children reported lower SCD rates among females than males [21]. ...
High-level sports competition is popular among Swiss youth. Even though preparticipation evaluation for competitive athletes is widespread, screening strategies for diseases responsible for sudden death during sport are highly variable. Hence, we sought to develop age-specific preparticipation cardiovascular evaluation (PPCE) proposals for Swiss paediatric and adolescent athletes (under 18 years of age). We recommend that all athletes practising in a squad with a training load of at least 6 hours per week should undergo PPCE based on medical history and physical examination from the age of 12 years on. Prior to 12 years, individual judgement of athletic performance is required. We suggest the inclusion of a standard 12-lead electrocardiogram (ECG) evaluation for all post-pubertal athletes (or older than 15 years) with analysis in accordance with the International Criteria for ECG Interpretation in Athletes. Echocardiography should not be a first-line screening tool but rather serve for the investigation of abnormalities detected by the above strategies. We recommend regular follow-up examinations, even for those having normal history, physical examination and ECG findings. Athletes with an abnormal history (including family history), physical examination and/or ECG should be further investigated and pathological findings discussed with a paediatric cardiologist. Importantly, the recommendations provided in this document are not intended for use among patients with congenital heart disease who require individualised care according to current guidelines.
... Highly trained female athletes might also have display structural cardiac adaptations, but those adaptations are less pronounced than in male athletes. 37 Nonetheless, due to differences in circulating hormones leading to a higher sympathetic activity and a lower parasympathetic modulation in men compared to women, 13 differences in training-related adaptations may arise, even when sexes are matched for training volume. 38 It is likely that the increased R-R 24h and R-R index can also be modulated by the higher vagal outflow throughout the day. ...
Objective
The aim of this study was to investigate the changes in 24-hour heart rate variability ¹ and aerobic fitness, and their associations, in female soccer players during the preseason period.
Methods
Sixteen players were assessed (24-hour HRV and Yo-Yo Intermittent Recovery Test, level 1 [YYIR1]) before and after 4 weeks of preseason. The relationship between R-R24h length and high-frequency oscillations (HF24h) was analysed by a quadratic regression model (revealing or not saturation of vagal activity) assessed 48-h before (PRE-preseason) and 48-h after (POST-preseason) the preseason period. Additionally, the mean HF24h was calculated from the linear portion of the R–R interval versus the HF24h regression curve (HF index). The average of the corresponding R-R24h values was defined as the R–R index.
Results
In PRE-preseason, 7 players had a saturated HF24h, while in POST-preseason, 5 new cases of saturated HF24h were observed. The mean R-R24h, HF24h, R-R index, and HF index lengths significantly increased after preseason (p<0.001). Significant differences were found in YYIR1 PRE- compared to POST-preseason [930 ± 286 m (individual range: 400–1240 m) vs. 1265 ± 252 m (640–1640 m), respectively; p<0.001]. Additionally, the relative changes in HF24h and HF index were largely correlated with improvements in the distance covered during the YYIR1 (r = 0.68 and r = 0.56; respectively).
Conclusion
Enhanced vagal activity after 4-week preseason period of soccer training increased the occurrence of vagal saturation in high-level female soccer players. Additionally, the increases in HF24h and HF index were significantly correlated with aerobic fitness change.
... CAD is the most common cause of SCD 3 and diabetes is a risk factor for SCD. 10 SrSCD has been found to occur significantly more often in males than females. 1 While both short-and long-term exercise are known to be associated with a multitude of cardiac structural and functional changes to accommodate increased demand for cardiac output, [11][12][13] biological differences between males and females may result in distinct cardiac adaptations following exercise, leading to a disproportion in SrSCD incidence between the sexes. 14 Furthermore, sex differences in catecholamine release during exercise may be consequential. ...
Sudden cardiac death (SCD) is a tragic incident accountable for up to 50% of deaths from cardiovascular disease. Sports-related SCD (SrSCD) is a phenomenon which has previously been associated with both competitive and recreational sport activities. SrSCD has been found to occur 5–33-fold less frequently in women than in men, and the sex difference persists despite a rapid increase in female participation in sports. Establishing the reasons behind this difference could pinpoint targets for improved prevention of SrSCD. Therefore, this review summarizes existing knowledge on epidemiology, characteristics, and causes of SrSCD in females, and elaborates on proposed mechanisms behind the sex differences. Although literature concerning the aetiology of SrSCD in females is limited, proposed mechanisms include sex-specific variations in hormones, blood pressure, autonomic tone, and the presentation of acute coronary syndromes. Consequently, these biological differences impact the degree of cardiac hypertrophy, dilation, right ventricular remodelling, myocardial fibrosis, and coronary atherosclerosis, and thereby the occurrence of ventricular arrhythmias in male and female athletes associated with short- and long-term exercise. Finally, cardiac examinations such as electrocardiograms and echocardiography are useful tools allowing easy differentiation between physiological and pathological cardiac adaptations following exercise in women. However, as a significant proportion of SrSCD causes in women are non-structural or unexplained after autopsy, channelopathies may play an important role, encouraging attention to prodromal symptoms and family history. These findings will aid in the identification of females at high risk of SrSCD and development of targeted prevention for female sport participants.
