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athlete's heart

Physiology: 1) regular endurance exercise a) increases left ventricular mass & biventricular chamber size; LV diastolic cavity diameter > 55 mm b) reduces resting heart rate c) does NOT increase left ventricular wall thickness beyond 11-12 mm d) may be physiologic S3 or S4 gallop e) systolic murmur due to turbulence in right ventricular outflow tract may be heard at left sternal border 2) static exercise a) increases left ventricular mass b) does not reduce resting heart rate c) may be associated with hypertension Pathology: - left ventricular hypertrophy -> left atrial enlargement resulting in increased risk of atrial fibrillation (RR=3) [3,4] - coronary artery calcification with higher levels of lifelong physical exercise in men [5] - suggested to be a benign condition [5] Special laboratoary 1) electrocardiogram: common ECG findings a) increased R-wave or S-wave amplitude (> 35 m) b) concave upward anterior ST segment elevation c) terminal T-wave inversion d) anterior biphasic T-waves e) classic LVH strain pattern f) loss of R waves, or significant Q-waves suggest hypertrophic cardiomyopathy or myocardial damage g) Q waves > 4 mm 2) echocardiogram a) may be normal or show a mild increase in left & right ventricular chamber size b) normal diastolic filling c) mitral valve prolapse & bicuspid aortic valve are the most common abnormalities 3) exercise testing - VO2max > 120% of predicted Differential diagnosis: - hypertrophic cardiomyopathy a) distinction of cardiac hypertrophy associated with intense exercise from hypertrophic cardiomyopathy b) factors favoring hypertrophic cardiomyopathy: 1] right ventricular involvement 2] wall thickness > 13 mm 3] outflow obstruction 4] asymmetric involvement 5] LV diastolic cavity diameter < 45 mm 6] marked left atrial enlargement 7] abnormal left ventricular filling 8] positive family history

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athletics sudden death in competitive sports

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2015, 2018.
  2. Journal Watch 20(16):127, 2000 Pelliccia A et al Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 102:278, 2000 PMID: 10899089
  3. Mont L et al Endurance sport practice as a risk factor for atrial fibrillation and atrial flutter Europace 2009 11(1):11-17 PMID: 18988654
  4. Mohanty S, Mohanty P, Tamaki M et al Differential Association of Exercise Intensity With Risk of Atrial Fibrillation in Men and Women: Evidence from a Meta- Analysis. J Cardiovasc Electrophysiol. 2016 Sep;27(9):1021-9. PMID: 27245609
  5. Davenport L Coronary Plaques Common but 'Benign' in Lifelong Athletes. Medscape. May 12, 2017. http://www.medscape.com/viewarticle/879923 - Aengevaeren VL, Mosterd A, Braber TL et al The Relationship Between Lifelong Exercise Volume and Coronary Atherosclerosis in Athletes. Circulation. 2017 Apr 27. PMID: 28450347