Openaccess.sgul.ac.uk



Effect of Gender and Sporting Discipline on Left Ventricular Adaptation to Exercise

Authors: Gherardo Finocchiaroa MD, Harshil Dhutiaa BSc MRCP, Andrew D’Silvaa MRCP, Aneil Malhotraa MsC, MRCP, Alexandros Steriotisa MD, PhD, Lynne Millara MRCP, Keerthi Prakasha MRCP, Rajay Naraina MRCP, Michael Papadakisa MBBS, MRCP, Rajan Sharmaa BSc, MBBS, MD, Sanjay Sharmaa BSc, MBChB, FRCP, MD

Institutions:

a Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom

Author of correspondence:

Sanjay Sharma, MD, Professor of Clinical Cardiology,

St. George’s University of London, Cardiovascular Sciences, Cranmer Terrace, London, SW17 0RE, UK.

E-mail: sasharma@sgul.ac.uk

Running title: Gender differences in athlete’s heart

Word count: 3922

Abstract

Purpose: Studies assessing female and male athletes indicate that they exhibit qualitatively similar changes compared with sedentary counterparts, but female athletes reveal smaller increases in left ventricular (LV) wall thickness and cavity size compared to male athletes. However, data on gender specific changes in LV geometry in athletes is scarce. We sought to investigate the effect of different types of exercise on LV geometry in a large group of female and male athletes.

Methods: 1083 healthy, elite, white athletes (41% females, mean age 21.8 ± 5.7 years) underwent electrocardiogram (ECG) and echocardiogram as part of their cardiovascular evaluation. Sporting disciplines were divided into static, dynamic or mixed. According to European and American Society of Cardiology guidelines, LLleft ventricular geometry was classified into 4 groups according to relative wall thickness (RWT) and left ventricular mass (LVM) in accordance with the guidelines presented by the European and American Society of Echocardiography : normal (normal LVM/normal RWT), concentric hypertrophy (increased LVM/increased RWT), eccentric hypertrophy (increased LVM/normal RWT), concentric remodelling (normal LVM/increased RWT).

Results: Athletes were engaged in 40 different sporting disciplines (62% mixed, 28% dynamic, 10% static) with similar participation rates with respect to the type of exercise between females and males. Females exhibited lower LV mass (83 ± 17 vs 101 ± 21 g/m2, p 12 mm in males, (b) dilated LV with EF < 50% and (c) abnormal diastolic function, e.g. average septal/lateral E’ < 10 cm/s or E/E’ ratio > 15.

Statistical analysis

Statistical analysis was performed using the PASW software (PASW 18.0 Inc, Chicago, IL). Results are expressed as mean ± SD for continuous variables or as number of cases and percentage for categorical variables. Comparison between groups was performed using student’s t-tests for continuous variables with adjustment for unequal variance if needed and chi-square tests or Fisher Exact Tests for categorical variables. Intra- and inter-observation variability, was assessed by selecting 80 random studies which were blindly reanalyzed by a separate investigator. Intra- and inter-reader variability was quantified using mean differences as well as Pearson’s correlation and intraclass correlation coefficients.

RESULTS

Athlete demographics

The mean age of the athletes was 22 ± 6 years and 996 (92%) athletes were aged > 16 years old. The average hours of exercise were 21 ± 8 per week and was similar between males and females. Males had a greater BSA than females (2.0 ± 0.2 vs 1.7 ± 0.2, p 0.42 was observed in 8% of females and 12% of males (p=0.04). None of the female athletes showed a RWT >0.48 compared to 1.3% of males (p=0.04) (Figure 2).

Average LV mass indexed for BSA was higher in males and almost a quarter of males and females had an increased indexed LV mass. None of the females showed a maximal wall thickness > 12 mm compared to 2.5% of males (p54 mm was present in only 7% of females vs 47% of males, p31 mm/m2) compared to 10% of males (p0.48 or a LV mass >145 g/m2. Although none of the female athletes with concentric LVH/remodelling in this study showed other features of pathological LVH, these cut-off values may be an important starting point for the differential diagnosis with hypertrophic cardiomyopathy in a female athlete with cardiac symptoms or abnormal ECG.

Limitations

The present study has some limitations. We indexed cardiac dimensions for BSA, but this may be not the most accurate method of scaling LV size in athletes. Other studies have considered height, lean body mass and allometric scaling(27,28). However the majority of guidelines from both American and European guidelines suggest reference values normalized per BSA. Our study was conducted on a cohort of highly trained elite athletes (21 ± 8 hours per week of exercise) and these results may not be applicable to recreational athletes. Finally, due to our inability to access a substantial number of black female athletes during the study period, we focused solely on white athletes and the results should not be extrapolated to black athletes.

CONCLUSIONS

Gender has an important effect on cardiac adaptation to exercise. Although the majority of elite athletes manifest normal LV geometry, males show a higher prevalence of concentric hypertrophy/remodelling than females. Conversely a significant proportion of females generally adapt by developing eccentric hypertrophy, particularly those engaged in dynamic sports.

REFERENCES:

1. George KP., Warburton DER., Oxborough D., et al. Upper limits of physiological cardiac adaptation in ultramarathon runners. J Am Coll Cardiol 2011;57(6):754–5. Doi: 10.1016/j.jacc.2010.05.070.

2. Arbab-Zadeh A., Perhonen M., Howden E., et al. Cardiac remodeling in response to 1 year of intensive endurance training. Circulation 2014;130(24):2152–61. Doi: 10.1161/CIRCULATIONAHA.114.010775.

3. Pelliccia A., Maron BJ., De Luca R., Di Paolo FM., Spataro A., Culasso F. Remodeling of left ventricular hypertrophy in elite athletes after long-term deconditioning. Circulation 2002;105(8):944–9.

4. Drezner J a., Ashley E., Baggish AL., et al. Abnormal electrocardiographic findings in athletes: recognising changes suggestive of primary electrical disease. Br J Sports Med 2013;47(3):137–52. Doi: 10.1136/bjsports-2012-092069.

5. Corrado D., Schmied C., Basso C., et al. Risk of sports: do we need a pre-participation screening for competitive and leisure athletes? Eur Heart J 2011;32(8):934–44. Doi: 10.1093/eurheartj/ehq482.

6. Chandra N., Bastiaenen R., Papadakis M., Sharma S. Sudden cardiac death in young athletes: practical challenges and diagnostic dilemmas. J Am Coll Cardiol 2013;61(10):1027–40. Doi: 10.1016/j.jacc.2012.08.1032.

7. Pelliccia A., Maron BJ., Culasso F., Spataro A., Caselli G. Athlete’s heart in women. Echocardiographic characterization of highly trained elite female athletes. JAMA 1996;276(3):211–5.

8. Utomi V., Oxborough D., Ashley E., et al. Predominance of normal left ventricular geometry in the male “athlete”s heart’. Heart 2014;100(16):1264–71. Doi: 10.1136/heartjnl-2014-305904.

9. Yalçin F., Shiota T., Odabashian J., et al. Comparison by real-time three-dimensional echocardiography of left ventricular geometry in hypertrophic cardiomyopathy versus secondary left ventricular hypertrophy. Am J Cardiol 2000;85(8):1035–8.

10. Bos JM., Theis JL., Tajik AJ., Gersh BJ., Ommen SR., Ackerman MJ. Relationship between sex, shape, and substrate in hypertrophic cardiomyopathy. Am Heart J 2008;155(6):1128–34. Doi: 10.1016/j.ahj.2008.01.005.

11. Mitchell JH., Haskell W., Snell P., Van Camp SP. Task Force 8: classification of sports. J Am Coll Cardiol 2005;45(8):1364–7. Doi: 10.1016/j.jacc.2005.02.015.

12. Clementy J., Bergere P., Bricaud H. Electrocardiography and vectocardiography in the evaluation of left ventricular hypertrophy due to pressure overload. Eur Heart J 1982;3 Suppl A:37–47.

13. 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. Doi: 10.1161/CIRCULATIONAHA.113.006179.

14. Lang RM., Bierig M., Devereux RB., et al. Recommendations for chamber quantification. Eur J Echocardiogr 2006;7(2):79–108. Doi: 10.1016/j.euje.2005.12.014.

15. Nagueh SF., Appleton CP., Gillebert TC., et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr 2009;10(2):165–93. Doi: 10.1093/ejechocard/jep007.

16. Lang RM., Badano LP., Mor-Avi V., et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015;16(3):233–70. Doi: 10.1093/ehjci/jev014.

17. Morganroth J., Maron BJ., Henry WL., Epstein SE. Comparative left ventricular dimensions in trained athletes. Ann Intern Med 1975;82(4):521–4.

18. 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(Pt 22):5443–52. Doi: 10.1113/jphysiol.2011.217125.

19. Arbab-Zadeh A., Perhonen M., Howden E., et al. Cardiac remodeling in response to 1 year of intensive endurance training. Circulation 2014;130(24):2152–61. Doi: 10.1161/CIRCULATIONAHA.114.010775.

20. Bhella PS., Hastings JL., Fujimoto N., et al. Impact of lifelong exercise “dose” on left ventricular compliance and distensibility. J Am Coll Cardiol 2014;64(12):1257–66. Doi: 10.1016/j.jacc.2014.03.062.

21. Pelliccia A., Kinoshita N., Pisicchio C., et al. Long-term clinical consequences of intense, uninterrupted endurance training in olympic athletes. J Am Coll Cardiol 2010;55(15):1619–25. Doi: 10.1016/j.jacc.2009.10.068.

22. Svartberg J., von Mühlen D., Schirmer H., Barrett-Connor E., Sundfjord J., Jorde R. Association of endogenous testosterone with blood pressure and left ventricular mass in men. The Tromsø Study. Eur J Endocrinol 2004;150(1):65–71.

23. Marsh JD., Lehmann MH., Ritchie RH., Gwathmey JK., Green GE., Schiebinger RJ. Androgen receptors mediate hypertrophy in cardiac myocytes. Circulation 1998;98(3):256–61.

24. Cavasin MA., Sankey SS., Yu A-L., Menon S., Yang X-P. Estrogen and testosterone have opposing effects on chronic cardiac remodeling and function in mice with myocardial infarction. Am J Physiol Heart Circ Physiol 2003;284(5):H1560–9. Doi: 10.1152/ajpheart.01087.2002.

25. Zwadlo C., Schmidtmann E., Szaroszyk M., et al. Antiandrogenic therapy with finasteride attenuates cardiac hypertrophy and left ventricular dysfunction. Circulation 2015;131(12):1071–81. Doi: 10.1161/CIRCULATIONAHA.114.012066.

26. Zemva A., Rogel P. Gender differences in athlete’s heart: Association with 24-h blood pressure. A study of pairs in sport dancing. Int J Cardiol 2001;77(1):49–54. Doi: 10.1016/S0167-5273(00)00417-4.

27. Bella JN., Devereux RB., Roman MJ., et al. Relations of left ventricular mass to fat-free and adipose body mass: the strong heart study. The Strong Heart Study Investigators. Circulation 1998;98(23):2538–44.

28. George K., Sharma S., Batterham A., Whyte G., McKenna W. Allometric analysis of the association between cardiac dimensions and body size variables in 464 junior athletes. Clin Sci (Lond) 2001;100(1):47–54.

Figure legends

Figure 1. LV geometry according to RWT and LV mass (adapted from Lang RM, Badano LP, Mor-Avi V et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015;16:233–70. doi:10.1093/ehjci/jev014).

Figure 2. LV mass/RWT relationship and thresholds in males and females.

Figure 3. LV geometry in males and females according to type of sport (A). Concentric hypertrophy/remodelling and eccentric hypertrophy in athletes involved in dynamic sport (p ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download