May Strenuous Endurance Sports Activity Damage the Cardiovascular System of Healthy Athletes? A Narrative Review

The positive effects of physical activity are countless, not only on the cardiovascular system but on health in general. However, some studies suggest a U-shape relationship between exercise volume and effects on the cardiovascular system. On the basis of this perspective, moderate-dose exercise would be beneficial compared to a sedentary lifestyle, while very high-dose physical activity would paradoxically be detrimental. We reviewed the available evidence on the potential adverse effects of very intense, prolonged exercise on the cardiovascular system, both acute and chronic, in healthy athletes without pre-existing cardiovascular conditions. We found that endurance sports activities may cause reversible electrocardiographic changes, ventricular dysfunction, and troponin elevation with complete recovery within a few days. The theory that repeated bouts of acute stress on the heart may lead to chronic myocardial damage remains to be demonstrated. However, male veteran athletes with a long sports career show an increased prevalence of cardiovascular abnormalities such as electrical conduction delay, atrial fibrillation, myocardial fibrosis, and coronary calcifications compared to non-athletes. It must be underlined that the cause–effect relationship between such abnormalities and the exercise and, most importantly, the prognostic relevance of such findings remains to be established

Certainties and Uncertainties of Cardiac Magnetic Resonance Imaging in Athletes

Prolonged and intensive exercise induces remodeling of all four cardiac chambers, a physiological process which is coined as the “athlete’s heart”. This cardiac adaptation, however, shows overlapping features with non-ischemic cardiomyopathies, such as dilated, arrhythmogenic and hypertrophic cardiomyopathy, also associated with athlete’s sudden cardiac death. Cardiac magnetic resonance (CMR) is a well-suited, highly reproducible imaging modality that can help differentiate athlete’s heart from cardiomyopathy. CMR allows accurate characterization of the morphology and function of cardiac chambers, providing full coverage of the ventricles. Moreover, it permits an in-depth understanding of the myocardial changes through specific techniques such as mapping or late gadolinium enhancement. In this narrative review, we will focus on the certainties and uncertainties of the role of CMR in sports cardiology. The main aspects of physiological adaptation due to regular and intensive sports activity and the application of CMR in highly trained athletes will be summarized

Data_Sheet_2_Immunological response and temporal associations in myocarditis after COVID-19 vaccination using cardiac magnetic resonance imaging: An amplified T-cell response at the heart of it?.PDF

IntroductionAlthough myocarditis after anti-SARS-CoV-2 vaccination is increasingly recognized, we have little data regarding the course of the disease and, consequently, the imaging findings, including the tissue-specific features. The purpose of this study is to describe the clinical, immunological, and cardiac magnetic resonance (CMR) features of myocarditis after COVID-19 immunization in the acute phase and during follow-up. We aimed to compare the trajectory of the disease to myocarditis cases unrelated to COVID-19.MethodsWe assembled a CMR-based registry of potentially COVID-19 vaccination-related myocarditis cases. All patients who experienced new-onset chest pain and troponin elevation after COVID-19 vaccination and imaging confirming the clinical suspicion of acute myocarditis were enrolled in our study. Participants underwent routine laboratory testing and testing of their humoral and cellular immune response to COVID-19 vaccination. Clinical and CMR follow-up was performed after 3–6 months. We included two separate, sex- and age-matched control groups: (1) individuals with myocarditis unrelated to COVID-19 infection or vaccination confirmed by CMR and (2) volunteers with similar immunological exposure to SARS-CoV-2 compared to our group of interest (no difference in the number of doses, types and the time since anti-SARS-CoV-2 vaccination and no difference in anti-nucleocapsid levels).ResultsWe report 16 CMR-confirmed cases of myocarditis presenting (mean ± SD) 4 ± 2 days after administration of the anti-SARS-CoV-2 vaccine (male patients, 22 ± 7 years), frequently with predisposing factors such as immune-mediated disease and previous myocarditis. We found that 75% received mRNA vaccines, and 25% received vector vaccines. During follow-up, CMR metrics depicting myocardial injury, including oedema and necrosis, decreased or completely disappeared. There was no difference regarding the CMR metrics between myocarditis after immunization and myocarditis unrelated to COVID-19. We found an increased T-cell response among myocarditis patients compared to matched controls (p ConclusionIn our cohort, myocarditis occurred after both mRNA and vector anti-SARS-CoV-2 vaccination, frequently in individuals with predisposing factors. Upon follow-up, the myocardial injury had healed. Notably, an amplified cellular immune response was found in acute myocarditis cases occurring 4 days after COVID-19 vaccination.</p

Calibration plot of the apparent and optimism-corrected models.

Calibration curves were created using a smoother on the scatter plot of expected versus observed risks. Differences between predicted and observed event rates were smaller in the expanded models in both apparent and optimism-corrected models, as shown by the decreased mean absolute error. The rug plots across the top of the figures show distribution of predicted risk. Also, the le Cessie-van Houwelingen-Copas-Hosmer test for global goodness of fit demonstrated better model fit in all apparent expanded logistic regression models (Table 3).</p

Analysis of variance of the expanded models.

(PDF)</p

Patient flow chart.

For details: see text. PCI: percutaneous coronary intervention; STEMI: ST-segment elevation myocardial infarction.</p

ROC curves for lactate as predictor.

Lactate level alone may have good predictive ability for predicting both in-hospital and 30-day mortality. ROC: Receiver Operating Characteristics; AUC: area under curve.</p

Table_1_Immunological response and temporal associations in myocarditis after COVID-19 vaccination using cardiac magnetic resonance imaging: An amplified T-cell response at the heart of it?.DOCX

IntroductionAlthough myocarditis after anti-SARS-CoV-2 vaccination is increasingly recognized, we have little data regarding the course of the disease and, consequently, the imaging findings, including the tissue-specific features. The purpose of this study is to describe the clinical, immunological, and cardiac magnetic resonance (CMR) features of myocarditis after COVID-19 immunization in the acute phase and during follow-up. We aimed to compare the trajectory of the disease to myocarditis cases unrelated to COVID-19.MethodsWe assembled a CMR-based registry of potentially COVID-19 vaccination-related myocarditis cases. All patients who experienced new-onset chest pain and troponin elevation after COVID-19 vaccination and imaging confirming the clinical suspicion of acute myocarditis were enrolled in our study. Participants underwent routine laboratory testing and testing of their humoral and cellular immune response to COVID-19 vaccination. Clinical and CMR follow-up was performed after 3–6 months. We included two separate, sex- and age-matched control groups: (1) individuals with myocarditis unrelated to COVID-19 infection or vaccination confirmed by CMR and (2) volunteers with similar immunological exposure to SARS-CoV-2 compared to our group of interest (no difference in the number of doses, types and the time since anti-SARS-CoV-2 vaccination and no difference in anti-nucleocapsid levels).ResultsWe report 16 CMR-confirmed cases of myocarditis presenting (mean ± SD) 4 ± 2 days after administration of the anti-SARS-CoV-2 vaccine (male patients, 22 ± 7 years), frequently with predisposing factors such as immune-mediated disease and previous myocarditis. We found that 75% received mRNA vaccines, and 25% received vector vaccines. During follow-up, CMR metrics depicting myocardial injury, including oedema and necrosis, decreased or completely disappeared. There was no difference regarding the CMR metrics between myocarditis after immunization and myocarditis unrelated to COVID-19. We found an increased T-cell response among myocarditis patients compared to matched controls (p ConclusionIn our cohort, myocarditis occurred after both mRNA and vector anti-SARS-CoV-2 vaccination, frequently in individuals with predisposing factors. Upon follow-up, the myocardial injury had healed. Notably, an amplified cellular immune response was found in acute myocarditis cases occurring 4 days after COVID-19 vaccination.</p

Data_Sheet_1_Immunological response and temporal associations in myocarditis after COVID-19 vaccination using cardiac magnetic resonance imaging: An amplified T-cell response at the heart of it?.PDF

IntroductionAlthough myocarditis after anti-SARS-CoV-2 vaccination is increasingly recognized, we have little data regarding the course of the disease and, consequently, the imaging findings, including the tissue-specific features. The purpose of this study is to describe the clinical, immunological, and cardiac magnetic resonance (CMR) features of myocarditis after COVID-19 immunization in the acute phase and during follow-up. We aimed to compare the trajectory of the disease to myocarditis cases unrelated to COVID-19.MethodsWe assembled a CMR-based registry of potentially COVID-19 vaccination-related myocarditis cases. All patients who experienced new-onset chest pain and troponin elevation after COVID-19 vaccination and imaging confirming the clinical suspicion of acute myocarditis were enrolled in our study. Participants underwent routine laboratory testing and testing of their humoral and cellular immune response to COVID-19 vaccination. Clinical and CMR follow-up was performed after 3–6 months. We included two separate, sex- and age-matched control groups: (1) individuals with myocarditis unrelated to COVID-19 infection or vaccination confirmed by CMR and (2) volunteers with similar immunological exposure to SARS-CoV-2 compared to our group of interest (no difference in the number of doses, types and the time since anti-SARS-CoV-2 vaccination and no difference in anti-nucleocapsid levels).ResultsWe report 16 CMR-confirmed cases of myocarditis presenting (mean ± SD) 4 ± 2 days after administration of the anti-SARS-CoV-2 vaccine (male patients, 22 ± 7 years), frequently with predisposing factors such as immune-mediated disease and previous myocarditis. We found that 75% received mRNA vaccines, and 25% received vector vaccines. During follow-up, CMR metrics depicting myocardial injury, including oedema and necrosis, decreased or completely disappeared. There was no difference regarding the CMR metrics between myocarditis after immunization and myocarditis unrelated to COVID-19. We found an increased T-cell response among myocarditis patients compared to matched controls (p ConclusionIn our cohort, myocarditis occurred after both mRNA and vector anti-SARS-CoV-2 vaccination, frequently in individuals with predisposing factors. Upon follow-up, the myocardial injury had healed. Notably, an amplified cellular immune response was found in acute myocarditis cases occurring 4 days after COVID-19 vaccination.</p

Internal validation.

Internal validation.</p