Sportsko srce

The athlete's heart is a set of morphological and functional characteristics that develop over time due to sports training. These adaptive changes result in increase in cardiac work efficiency and economy. They are manidested as cardiac muscle hypertrophy and dilation, with accompanying angiogenesis and slower heart rate, that are influenced by variable regulatory systems and genetic predisposition. The problem of sudden cardiac death in athletes, which persists despite numerous activities aimed at prevention, creates the need for a better definition of the athlete's heart, especially in terms of its differentiation from certain pathological conditions. This is of particular importance in the context of cardiac electrical activity. Right heart adaptations, hormonal regulatory mechanisms and the effects of nonphysiological adaptations during training, that may lead to pathologic alterations direction, are all relevant in the investigation of adverse cardiac events in athletes. In order to prevent sudden cardiac death in athletes, it is necessary to examine competitive athletes as well as apparently health individuals who recreationally exercise at a high volume. There are guidelines for mass screening and individual examinations, for all age groups and both genders, as well as for public service staff who require intense physical activity during their occupation. Both American and European recommendations require a detailed anamnesis and physical examination, whereas European, apart from that, require initial electrocardiography. The implementation of additional tests is necessary if the existence of any underlying pathophysiologic process is suspected. Checks should be performed before engaging in sports activities, as well as during training and competition periods.Sportsko srce predstavlja efekat morfoloških i funkcionalnih adaptacija srca koje se razvijaju tokom vremena, pod uticajem sportskog treninga. Promene na srcu kod sportista za posledicu imaju promenu efikasnosti i ekonomičnosti srčanog rada. Manifestuju se hipertrofijom i dilatacijom srca, sa pratećom angiogenezom i usporenim srčanim radom, procesima koji su pod kontrolom različitih regulatornih sistema i genetske predispozicije. Problem iznenadne srčane smrti u sportu, čija se incidenca ne smanjuje uprkos brojnim aktivnostima koje se sprovode u cilju njene prevencije, nameće potrebu boljeg definisanja sportskog srca, naročito u smislu njegovog razlikovanja od pojedinih patoloških stanja. Kod izvesnog broja sportista uočavaju se promene električne aktivnosti, te je i u tom smislu potrebno razlikovati zdravo od bolesnog srca. Poslednjih godina posebno je u fokusu definisanje adaptivnih promena desnog srca. Dodatno, postoje nova saznanja o hormonskoj regulaciji adaptivnih promena srca sportista, a istražuju se i efekti nefizioloških manipulacija u trenažnom procesu koji mogu 'skrenuti' fiziološke procese u patološkom pravcu. U cilju prevencije iznenadne srčane smrti, neophodno je redovno pregledanje kako sportista, tako i fizički aktivnog dela populacije. Aktuelne preporuke daju smernice za masovne skrininge i individualne preglede sportista, za sve starosne grupe oba pola, kao i pripadnike javnih službi koje u opisu posla imaju intenzivne fizičke napore. Dok američke preporuke zahtevaju samo detaljnu anamnezu i fizikalni pregled, evropske preporuke zahtevaju i inicijalnu elektrokardiografiju. I evropske i američke preporuke zahtevaju sprovođenje dodatnih ispitivanja kod sumnje na postojanje bilo kakvog oboljenja. Ove preglede bi trebalo obavljati pre početka trenažnog procesa, kao i tokom perioda treniranja i takmičenja

Sex and age differences and outcomes in acute coronary syndromes

Background: There is conflicting information about sex differences in presentation, treatment, and outcome after acute coronary syndromes (ACS) in the era of reperfusion therapy and percutaneous coronary intervention. The aim of this study was to examine presentation, acute therapy, and outcomes of men and women with ACS with special emphasis on their relationship with younger age ( lt = 65 years). Methods: From January 2010 to June 2015, we enrolled 5140 patients from 3 primary PCI capable hospitals. Patients were registered according to the International Survey of Acute Coronary Syndrome in Transitional Countries (ISACS-TC) registry protocol (ClinicalTrials.gov: NCT01218776). The primary outcome was the incidence of in-hospital mortality. Results: The study population was constituted by 2876 patients younger than 65 years and 2294 patients older. Women were older than men in both the young (56.2 +/- 6.6 vs. 54.1 +/- 7.4) and old (74.9 +/- 6.4 vs. 73.6 +/- 6.0) age groups. There were 3421 (66.2%) patients with ST elevation ACS (STE-ACS) and 1719 (33.8%) patients without ST elevation ACS (NSTE-ACS). In STE-ACS, the percentage of patients who failed to receive reperfusion was higher in women than in men either in the young (21.7% vs. 15.8%) than in the elderly (35.2% vs. 29.6%). There was a significant higher mortality in women in the younger age group (age-adjusted OR 1.52, 95% CI: 1.01-2.29), but there was no sex difference in the older group (age-adjusted OR 1.10, 95% CI: 0.87-1.41). Significantly sex differences in mortality were not seen in NSTE-ACS patients. Conclusions: In-hospital mortality from ACS is not different between older men and women. A higher short-term mortality can be seen only in women with STEMI and age of 65 or less

Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial.

BACKGROUND: Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months. METHODS: We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed. FINDINGS: Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91-1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed. INTERPRETATION: Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI. FUNDING: British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden

Use of Anticoagulant Therapy in Patients with Acute Myocardial Infarction and Atrial Fibrillation

The incidence of atrial fibrillation (AF) in acute coronary syndrome (ACS) ranges from 2.3–23%. This difference in the incidence of AF is explained by the different ages of the patients in different studies and the different times of application of both reperfusion and drug therapies in acute myocardial infarction (AMI). About 6–8% of patients who underwent percutaneous intervention within AMI have an indication for oral anticoagulant therapy with vitamin K antagonists or new oral anticoagulants (NOAC).The use of oral anticoagulant therapy should be consistent with individual risk of bleeding as well as ischemic risk. Both HAS-BLED and CHA2DS2VASc scores are most commonly used for risk assessment. Except in patients with mechanical valves and antiphospholipid syndrome, NOACs have an advantage over vitamin K antagonists (VKAs). One of the advantages of NOACs is the use of fixed doses, where there is no need for successive INR controls, which increases the patient’s compliance in taking these drugs. The use of triple therapy in ACS is indicated in the case of patients with AF, mechanical valves as well as venous thromboembolism. The results of the studies showed that when choosing a P2Y12 receptor blocker, less potent P2Y12 blockers such as Clopidogrel should be chosen, due to the lower risk of bleeding. It has been proven that the presence of AF within AMI is associated with a higher degree of reinfarction, more frequent stroke, high incidence of heart failure, and there is a correlation with an increased risk of sudden cardiac death. With the appearance of AF in ACS, its rapid conversion into sinus rhythm is necessary, and in the last resort, good control of heart rate in order to avoid the occurrence of adverse clinical events

High-dose streptokinase in the treatment of acute massive pulmonary embolism complicated with cardiogenic shock, respiratory arrest and ventricular fibrillation

Background. Despite advances in prophylaxis, diagnostic modalities, and therapeutic options, pulmonary embolism remains a commonly undiagnosed entity with lethal outcome. Clinically, pulmonary embolism ranges from massive thromboembolism with cardiogenic shock to asymptomatic, microebolism with anatomically small emboli without hemodynamic, respiratory or other disturbances. Case report. A patient with massive pulmonary embolism complicated with ventricular fibrillation, respiratory arrest and cardiogenic shock was treated with a total dose of 3 750 000 IU of intravenous streptokinase in the 8- hour time period. After successful cardiopulmonary resuscitation, and thrombolytic therapy, the patient regained hemodynamic stability six hours after admission; all clinical and electrocardiographic signs of the right ventricle insufficiency disappeared. Conclusion. This case report suggested that treatment with the high-dose of streptokinase could be beneficial in the patients with massive pulmonary embolism complicated with cardiogenic shock, which must be confirmed by further randomized trials

N-Terminal-pro-Brain natriuretic peptide dynamics during effort phenotypes ischemic heart failure and determines prognosis regardless of ejection fraction

Ischemic heart disease leading to heart failure (HF) portends a high overall morbidity and mortality. A higher N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP) at rest reflects HF severity and impaired cardiac output, most often secondary to reduced ejection fraction (EF). As an insufficient increase in cardiac output during exertion is common in all HF phenotypes, we examined the value of NT-pro-BNP during exercise testing as a risk stratification index for ischemic HF secondary to either reduced (HFrEF) or mid-ranged/preserved EF (HFmrEF/HFpEF). 213 patients (123 HFrEF; 90 HFmrEF/HFpEF) underwent cardiopulmonary exercise testing (CPET). NT-pro-BNP was determined at rest and peak exercise. The distribution of HFrEF and HFmrEF/HFpEF etiology in subjects with and without oxygen consumption trajectory flattening during CPET was similar (p > 0.05). Patients with HFrEF had higher plasma levels of NT-pro-BNP at rest and peak exercise than those with HFmrEF/HFpEF (984 vs. 780; 1012 vs. 845 pg/mL, p 0.05). During the tracking period (22.4 ± 20.3 months) 34 patients died, and there were 2 cardiac transplantations and 3 LVAD implantations. In a multivariate regression model only the NT-pro-BNPpeak and ΔNT-pro-BNPpeak/rest were retained in the regression for the prediction of adverse events (Chi-square:8.97, p = 0.003). ROC analysis demonstrated that NT-pro-BNPpeak ≥1506 pg/mL and ΔNT-pro-BNPpeak/rest ≥108 pg/mL were optimal for identifying patients with a risk (Sn = 76.9, 74.4 %; Sp = 84.7, 80.9 %, respectively). NT-pro-BNP changes during effort and absolute peak values reached provide novel insights emerging as new and strong predictors of adverse events in HF of any EF

Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application

Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option

Quantification of coronary artery disease using different modalities of cardiopulmonary exercise testing

Background: This study examined the accuracy of cardiopulmonary exercise testing (CPET) on a treadmill (TM) and recumbent ergometry (RE) in the predicting coronary artery disease (CAD) severity and prognosis. Methods: Forty Caucasian subjects, mean age 63.5 +/- 7.6, with significant coronary artery lesions (>= 50%) were included. Within two months of coronary angiography, TM and RE CPET were performed on two visits 2-4 days apart and subsequently followed up to 32 +/- 10 months. Results: Mean left ventricular ejection fraction was 56.7 +/- 9.6%. TM CPET exhibited a higher occurrence of ST segment depression >= 1 mm (71.05% vs 28.95%, p = 0.04). Subjects with 1-2 stenotic coronary arteries (SCA) demonstrated a better CPET response compared to those with 3-SCA. ROC analysis revealed a high predictive value for the ventilation/carbon dioxide production (VE/VCO2) slope obtained on TM (area 0.84, p = 0.003, Sn 88.9%, Sp 72%) in distinguishing between 1 and 2-SCA and 3-SCA. Among all CPET parameters, work efficiency (Delta VO2/Delta WR) during RE predicted cumulative cardiac events (p lt 0.01). Conclusions: CPET parameters hold predictive value for CAD severity and prognosis. CPET on a TM appears to be more reliable in the quantification of CAD compared to RE

Physiological behavior during stress anticipation across different chronic stress exposure adaptive models

Anticipation of stress induces physiological, behavioral and cognitive adjustments that are required for an appropriate response to the upcoming situation. Additional research examining the response of cardiopulmonary parameters and stress hormones during anticipation of stress in different chronic stress adaptive models is needed. As an addition to our previous research, a total of 57 subjects (16 elite male wrestlers, 21 water polo player and 20 sedentary subjects matched for age) were analyzed. Cardiopulmonary exercise testing (CPET) on a treadmill was used as the laboratory stress model; peak oxygen consumption (VO2) was obtained during CPET. Plasma levels of adrenocorticotropic hormone (ACTH), cortisol, alpha-melanocyte stimulating hormone (alpha-MSH) and N-terminal-pro-B type natriuretic peptide (NT-pro-BNP) were measured by radioimmunometric, radioimmunoassay and immunoassay sandwich technique, respectively, together with cardiopulmonary measurements, 10 minutes pre-CPET and at the initiation of CPET. The response of diastolic blood pressure and heart rate was different between groups during stress anticipation (p¼0.019, 0.049, respectively), while systolic blood pressure, peak VO2 and carbon-dioxide production responses were similar. ACTH and cortisol increased during the experimental condition, NT-pro-BNP decreased and alpha-MSH remained unchanged. All groups had similar hormonal responses during stress anticipation with the exception of the ACTH/cortisol ratio. In all three groups, DNT-pro-BNP during stress anticipation was the best independent predictor of peak VO2 (B¼36.01, r¼0.37, p¼0.001). In conclusion, the type of chronic stress exposure influences the hemodynamic response during anticipation of physical stress and the path of hormonal stress axis activation. Stress hormones released during stress anticipation may hold predictive value for overall cardiopulmonary performance during the stress condition. LAY SUMMARY The study revealed differences in hormonal and hemodynamic responses during anticipation of stress between athletes and sedentary participants. Stress hormones released during stress anticipation may hold predictive value for overall cardiopulmonary performance during the stress condition. Abbreviations: ACTH: adrenocorticitropic hormone; BSA: body surface area; BW: body weight; C: controls; CPET: cardiopulmonary exercise test; DBP: diastolic arterial blood pressure; FFM: fat-free mass; FM: fat mass; HR: heart rate; MSH: melanocyte-stimulating hormone; NT-pro-BNP: N terminal-pro-B type natriuretic peptide; SBP: systolic arterial blood pressure; VCO2: carbon dioxide production; VE: minute ventilation; VO2: oxygen consumption; W: wrestlers; WP: water polo player