High Cardiac Output Athletes The Role of Ventricular ... · of CV adaptation to exercise. s...
Transcript of High Cardiac Output Athletes The Role of Ventricular ... · of CV adaptation to exercise. s...
Aaron L. Baggish MD, F.A.C.C., F.A.C.S.M. Institut des Sciences Du Sport l’Université de Lausanne, (ISSUL) Associate Professor of Medicine, Harvard Medical School Director, Cardiovascular Performance Program Massachusetts General Hospital Boston, MA
High Cardiac Output Athletes The Role of Ventricular Remodeling
Conflicts:NoneAthleticAffiliations:FundingSources:
– NationalInstitutesofHealth– AmericanHeartAssociation– AmericanSocietyofEchocardiography– DepartmentofDefense– NationalFootballLeaguePlayer’sAssociation
Cardiac Plasticity: Remodeling
Classic concept of LV remodeling……
Aortic Regurgitation
Aortic Stenosis
Volume Challenge Pressure ChallengeChamber Dilation
Wall Thickening
Endurance Activities
Sustained ↑ CO • 4 to 5 times rest• ↑ ↑ ↑ HR & ↑ SV• Vasodilation
Strength Activities
Repetitive↑ SBP • Systolic BP > 300 mmHg• Skeletal Mus. Contraction• Vasoconstriction
Pressure Challenge
Cardiac Remodeling: Physiology
Volume Challenge
Cardiac Remodeling: Physiology
Observation: Basketball Players are Tall
Historical Data: Limitations
Observation: Basketball Players are Tall
Explanation ?
Tall people self-select for basketball
Basketball makes people grow tall
Historical Data: Limitations
Historical Data: Causality?
Does exercise cause heart enlargement or do people born with “big hearts” simply self select for sport?
Acute Training Intensification Extended Training
ExperienceBaseline
June August October September November July
Pre-StudyPeriod
(48days)
StudyPeriod(90days)
Baseline Conditioning
Study ExerciseExposure
#1 - ECG, Blood, Echo, IHGT, Tono.
CPET, MRI, PET
The Harvard Athlete Initiative (HAI)
A platform for longitudinal, repeated measures studies of CV adaptation to exercise.
Multiyear Cycles
Alumni Follow
-up
#2 - ECG, Blood, Echo, IHGT, Tono.
CPET, MRI, PET
December
Jeremy Lin - NBA
Ryan Fitzpatrick - NFL
Esther Lofgren - USA
Andrew Campbell - USA
THE HARVARD ATHLETEINITIATIVE 2005-2018
Strength Athletes Endurance Athletes
HAI: Sport Specificity of EICR
June August October September November July
Pre-StudyPeriod
(48days)
StudyPeriod(90days)
Do these hearts change and if so do they do so differently?
Correlation:∆LVMassvs.∆LVEDV
Correlation:∆LVMassvs.∆IVS+PWT
Endurance
Endurance
Strength
Strength
* *
∆IVS
+PWT(m
m/m
2 )
∆LVE
DV(m
l/m
2 )
∆=14±4g/m2∆=16±5g/m2
J Appl Physiol 2008;104:1121
HAI: Sport Specific of EICR
Dilation
Thickness
pre post pre post100
110
120
130
140
150g/m2
Endurance Strength
∆LeftVentricularMass
(g/m
2 )
* *ROWING ADAPTATION #1:
“LV DILATION”Four chamber dilation
Large EDV potentiates Large SV“Start Big / Pump Big”
Cardiac Remodeling: Physiology
Levine, Baggish, et al. JACC 2015
Volume Load
Pr
essu
re L
oad
Endurance Sport Physiology
High CO
Incr
easi
ng P
ress
ure
Load
The Role of the Heart in Sport Performance
Trained Athlete
VO2 = CO x Δ(AO2-VO2)
VO2 = SV x HR
Beck et al. J Appl Physiol. 2006
LV Challenges: 1.) Filling 2.) Ejecting 3.) Energetics
Endurance Sport Physiology
High CO
Incr
easi
ng P
ress
ure
Load
156
142
Heart Rate ~ Work “Tightly Coupled”....All Endurance Sports
Endurance Sport Physiology
High CO
Incr
easi
ng P
ress
ure
Load
14
12
CO (HR x SV)~ Work “Tightly Coupled”....All Endurance Sports
Endurance Sport Physiology
High CO
Incr
easi
ng P
ress
ure
Load
140é
110ê
Arterial Blood Pressure Is Endurance Sport Specific
High CO
Incr
easi
ng P
ress
ure
Load
Endurance Sport Physiology
MAP=110
DBP =70
SBP =190
MAP=140
SBP =300
DBP =60
* * * *
Rowing requires high CO in the face of pressure
10 Sec. BPTracings
Endurance Remodeling Variants
Wasfy et al. JASE 2015
ROWING ADAPTATION #2:“LV WALL THICKENING”
Eccentric LV HypertrophyBalance Chamber Dilation & Wall Thickening
“Pump Big at Minimal Cost”
Endurance: LV Filling
Having a Big Heart at Rest Big Heart During Exercise≠
Heart Rate 60SEP = 300 ms / DFP = 700 ms
Heart Rate 160SEP = 200 ms / DFP = 175 ms
FUNDAMENTAL CHALLENGE FOR THE ENDURANDCE HEART...
Filling NOT PumpingNo Matter How Big You Are,
If you can’t fill, you can’t pump
LVHypertrophy&DiastolicFunction
J Appl Physiol 2008;104:1121
∆LateralE’(cm/s)
∆LVMass(g/m2)
r2=0.90
r2=0.79
Compliant Heart
Stiff Heart
pre post pre post100
110
120
130
140
150g/m2
Endurance Strength
∆LeftVentricularMass
(g/m
2 )
Endurance: LV Filling
Endurance: LV Filling
ROWING ADAPTATION #3:“ENHANCED LV RELAXATION”Fiber Speed (Intrinsic Myocyte)
Elastic Recoil“Strokers Become Suckers”
Endurance: Myocardial Energetics
Big Hearts = Inefficient Hearts....?
Wasfy et a. JACC Imaging 2018
C-11 Acetate PET
ROWING ADAPTATION #4:“PRESERVED ENERGETICS”More work, same energy
Substrate SwitchingHoly Grail of the Athlete’s Heart??
Endurance: Remodeling Time Line?
Nothing Happens Overnight.... Discrete Steps?
ROWING ADAPTATION #5:“STEPWISE PROCESS”
Dilation before Thickening& Lengthening
Vascular Volume Expansion Key
Endurance: Remodeling vs. Skill Level
ROWING ADAPTATION #6:COMPETITION LEVEL MATTERSGenetics (Baseline & Plasticity)
Chronic Training Stimulus DoseWhat You See Depends on Who You Study
Key CV Controversies
SO FAR SO GOOD.....
BUT, Can you get too much of a good thing??
Athlete’s Heart: The Beginnings…
We have seen that a great increase in size and strength is demanded of the heart and it may easily happen that it is called upon for more work than it is able to do and that instead of establishing a compensatory hypertrophy it becomes diluted and weakened. A "broken-winded " athlete is probably one with a dilated, flabby heart. -Eugene Darling 1899
Harvard Athlete Initiative
Cardiomyopathy
BL
ML
AL
BS
MS
AS
0.6±0.8*
3.5±1.8†
4.4±3.2†
1.0±0.8*
2.5±1.7†
3.9±2.4†
(-2to2) (2to4) (4to6) (>6)(<-2)
BS BL
MS ML
AS AL
LV Systolic Strain Changes with Rowing Training (n=20)
ASA
L
PI
S
8.3± 9.4*
7.3± 8.4*
8.8± 10.2*
8.4± 10.1*
9.1± 10.7*
9.8± 9.3*(-2to2) (2to4) (4to6) (>6)(<-2)
A
L
P
AS
S
I
ASA
L
PI
S
-3.3± 2.7* 3.4± 2.2†
3.3± 2.4†
3.2± 2.5†3.0± 3.6*
-3.6± 1.7†
(-2to2) (2to4) (4to6) (>6)(<-2)
A
L
P
AS
S
I
Longitudinal ~ ñ20-25% Radial ~ ñ50-60% Circumferential ~ ê20-25%
Normal to Supranormal Strain….Focal Septal Dysfunction Fatigue??
Cardiomyopathy
TheVentricularInterdependenceofPhysiologicRemodeling
Am J Physiol Heart Circ Physiol 2008;295:1109
Cardiomyopathy
Whyte et al. JAP 2011
LaGerche et al. EHJ 2011
Cardiomyopathy
• 40 trained (>10 h of intense training / week) athletes
• Competitive, top 25% finish recent endurance event
• No cardiac symptoms or traditional risk factors
• No inducible ischemia on stress echo
• MRI/echo/biochem. At 3 time points (pre-finish-6 to 11 d)
Cardiomyopathy
Cardiomyopathy
Preliminary data suggests that a small minority of chronic endurance athletes may develop a
fibrotic cardiomyopathy…a phenotype of uncertain clinical relevance that deserves our attention and further outcomes-based study
Exercise Cardiomyopathy ?
Chronic Extreme Volume & Intensity
Training / RecoveryMismatch
Host Susceptibility(Genetics)
Secondary Process(Drugs, Infection, Disease)
+
+
+
“The PerfectStorm”
A Theoretical Pathogenic
Cascade
Summary
Key Cardiac Adaptations in Rowers:
1.) Bi-ventricular growth (Ecc.-LVH)
2.) Enhanced filling capacity (High HR)
3.) Preserved energetics
4.) Phasic remodeling process
5.) Competition level-specific phenotype
6.) Fatigable... Injury prone with overuse??
Acknowledgements
MGH
G. William Dec, MD Jason Elinoff, MD Laurie Farrell, RN Adolph Hutter, MD Jonathan Kim, MD Greg Lewis, MD
Jane Marshall, RDCS Carlene McClanahan, RDCS
Deb Mcdonald Ellie Morris, RDCS
Jennifer Neary, RDCS Michael Picard, MD
Anthony Rosenzweig, MD Thomas Wang, MD Meagan Wasfy, MD Rory Weiner, MD
Arthur Weyman, MD Malissa Wood, MD
Harvard University
Brant BerkstresserArthur Boland, MD
Charles ButtsWilliam ManningTimothy MurphyElizabeth O’Leary
Harry ParkerBob Scalise
Francis Wang, MDResearch Support
American Heart AssociationAmerican Society of Echocardiography
American College of Sports MedicineCIMIT
Thank You !