Progress in Cardiovascular Diseases RSS feed: Current Issue. Each issue of Progress in Cardiovascular Diseases comprehensively covers a single topic in the understanding and treatment of disorders of the heart and circulation. Some issues include special articles, definitive reviews that capture the state of the art in the management of particular clinical problems in cardiology. 2012 Topics Hypertrophic Cardiomyopathy Guest Editor: Mark Sherrid Innovation in Biomarkers Guest Editor: Wilson Tang Pulmonary Hypertension Guest Editor: Evelyn Horn Ethics in Cardiology Guest Editor: Neal Dickert Syncope Guest Editors: David Cannom and David Benditt http://www.onlinepcd.com/?rss=yesElsevier Inc.en © 2012 Published by Elsevier Inc. All rights reserved. Progress in Cardiovascular Diseases0033-0620545March 2012 © 2012 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.onlinepcd.com/article/PIIS003306201200014X/abstract?rss=yesMasthead10.1016/S0033-0620(12)00014-XProgress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7IFCIFChttp://www.onlinepcd.com/article/PIIS0033062012000114/abstract?rss=yesParticipation in recreational and competitive athletic activities such as marathon running has reached an all-time high in the United States and other developed nations. This trend is attributable in part to the recognition that routine physical exercise reduces the risk of cardiovascular disease through its beneficial effects on risk factors including obesity, diabetes, blood pressure, and serum lipids. Exercise is not, however, completely protective against the development of cardiovascular disease. The physiologic demands of exercise may precipitate symptoms or even sudden death in individuals with occult cardiac conditions. Exercise- or sports-related deaths are widely reported in the media and generate intense concern among medical providers and across the general community. In addition, many athletic individuals continue to participate in vigorous physical exercise well into their middle and old age. This confluence of increased athletic competition, concern about the cardiac risks of exercise, and the continuation of vigorous athletic activity in later life means that health care providers are increasingly faced with sports-related cardiac questions and athletic patients in clinical practice.IntroductionAaron L. Baggish, Paul D. Thompson10.1016/j.pcad.2012.02.002Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7Cardiovascular Care of the Athletic Patient379379http://www.onlinepcd.com/article/PIIS0033062012000072/abstract?rss=yesAbstract: Early investigations in the late 1890s and early 1900s documented cardiac enlargement in athletes with above-normal exercise capacity and no evidence of cardiovascular disease. Such findings have been reported for more than a century and continue to intrigue scientists and clinicians. It is well recognized that repetitive participation in vigorous physical exercise results in significant changes in myocardial structure and function. This process, termed exercise-induced cardiac remodeling (EICR), is characterized by structural cardiac changes including left ventricular hypertrophy with sport-specific geometry (eccentric vs concentric). Associated alterations in both systolic and diastolic functions are emerging as recognized components of EICR. The increasing popularity of recreational exercise and competitive athletics has led to a growing number of individuals exhibiting these findings in routine clinical practice. This review will provide an overview of EICR in athletes.Exercise-Induced Cardiac RemodelingRory B. Weiner, Aaron L. Baggish10.1016/j.pcad.2012.01.006Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7Cardiovascular Care of the Athletic Patient380386http://www.onlinepcd.com/article/PIIS0033062012000047/abstract?rss=yesAbstract: Physiologic LV remodeling in young trained athletes as a consequence of chronic training can occasionally mimic certain pathologic conditions associated with sudden death, such as HCM. A small but important subset ofelite male athletes may show a borderline increased LV wall thickness of 13 to 15 mm, which defines a gray zone of overlap between the extreme expressions of athlete's heart and a mild HCM phenotype. Such diagnostic ambiguity can be resolved by using the paradigm of noninvasive parameters including testing with echocardiography (and, more recently, with CMR): left atrial and LV chamber dimensions and shape, brief periods of deconditioning to alter LV mass, measurement of oxygen consumption and diastolic filling, and recognition of familial occurrence of HCM or a pathogenic HCM-causing sarcomere mutation. Such distinctions between physiologic/benign athlete's heart and HCM, the most common cause of sudden death in the young in the United States, can be crucial. The recognition of HCM leads to disqualification from intense competitive sports to reduce sudden death risk and, when appropriate, permits initiation of therapeutic interventions.Assessment of Left Ventricular Hypertrophy in a Trained Athlete: Differential Diagnosis of Physiologic Athlete's Heart From Pathologic HypertrophyAntonio Pelliccia, Martin S. Maron, Barry J. Maron10.1016/j.pcad.2012.01.003Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7Cardiovascular Care of the Athletic Patient387396http://www.onlinepcd.com/article/PIIS0033062012000060/abstract?rss=yesAbstract: Rigorous training remodels the heart of elite endurance athletes to produce the phenotype of the “athlete's heart.” This remodeling, which advantages cardiac performance, creates challenges in the diagnosis of cardiac disorders within this population. This is particularly so for right ventricular pathologies because of the limited number of studies documenting the impact of training on right ventricular remodeling. Although arrhythmogenic right ventricular cardiomyopathy is the focus of this review, several other pathologies that may mimic arrhythmogenic right ventricular cardiomyopathy, including right ventricular outflow tract tachycardia, Wolff-Parkinson-White syndrome, Brugada syndrome, pulmonary embolism, cardiac sarcoidosis, myocarditis, and right ventricular infarction, are also included. In particular, the electrocardiographic findings for each condition are highlighted because this is the most informative and easily accessible diagnostic clinical tool.Evaluation of Suspected Right Ventricular Pathology in the AthleteJonathan D.S. Sniderman, Daniel M. Sado, Allan D. Sniderman, William J. McKenna10.1016/j.pcad.2012.01.005Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7Cardiovascular Care of the Athletic Patient397406http://www.onlinepcd.com/article/PIIS0033062012000084/abstract?rss=yesAbstract: Prolonged endurance exercise in humans has been associated with an acute impairment in diastolic and systolic cardiac function and the release of cardiac troponin. In this chapter, we review recent evidence from studies using novel echocardiographic parameters and highly sensitive cardiac troponin assays. We demonstrate that the mechanics of left and right ventricular functions are acutely impaired after completion of prolonged exercise and that this reduction in function is likely multifactorial in etiology. However, we highlight that exercise-induced cardiac troponin release is not a marker of exercise-induced pathology but likely a physiologic response to exercise. Finally, we discuss the potential link between prolonged exercise and the increased incidence of cardiac pathology in veteran athletes.Exercise-Induced Cardiac Injury: Evidence From Novel Imaging Techniques and Highly Sensitive Cardiac Troponin AssaysRob Shave, David Oxborough10.1016/j.pcad.2012.01.007Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7Cardiovascular Care of the Athletic Patient407415http://www.onlinepcd.com/article/PIIS0033062012000102/abstract?rss=yesAbstract: Many patients and physicians correctly associate physical activity with reduced cardiovascular morbidity and mortality. Vigorous physical exertion is paradoxically associated with a transient increase in the risk of cardiovascular events and sudden cardiac death. This review extrapolates data from the general population to the management of athletes with symptoms suspicious for coronary artery disease or with prior cardiac events. A history to elicit an athlete's concerns and symptoms combined with a physical examination should guide the decision for preparticipation exercise testing for athletes without prior cardiac events. Athletes with established coronary artery disease should receive aggressive secondary prevention regimens, with special attention to adverse effects that may be unique to this group. There may be benefit in taking time away from competitive athletics to allow for stabilization of coronary artery disease with cholesterol-lowering therapy and, therefore, reduction of future risk. Exercise testing is important for defining risk before the return to participation for athletes who have sustained a cardiac event. Many athletes will ultimately be able to return to full participation provided they have received aggressive therapy and understand the residual risk associated with vigorous physical exertion in the setting of coronary artery disease.Assessment and Management of Atherosclerosis in the Athletic PatientMatthew W. Parker, Paul D. Thompson10.1016/j.pcad.2012.02.001Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7Cardiovascular Care of the Athletic Patient416422http://www.onlinepcd.com/article/PIIS0033062012000035/abstract?rss=yesAbstract: Athletes may present with palpitations, syncope, or arrest resulting in the diagnosis of arrhythmia, or screening may result in diagnosis of conditions with predisposition to arrhythmia. This chapter focuses on 3 common arrhythmic conditions in athletes—atrial fibrillation, premature ventricular contractions (PVCs), and the athlete with an implanted device.(1) Atrial fibrillation: most studies show that atrial fibrillation is more common in competitive athletes, particularly those participating in long-term endurance sports. Postulated mechanisms include morphologic changes such as atrial dilatation, autonomic changes such as increased vagal tone, or inflammatory changes due to sports participation. Treatment options include long-term antiarrhythmic agents, “pill in the pocket” medications, or radiofrequency ablation, a highly successful procedure in athletes.(2) Premature ventricular contractions: data conflict on whether the incidence of PVCs is increased in highly trained individuals. Very frequent PVCs in athletes, however, can be a manifestation of underlying heart disease, and athletes presenting with PVCs should undergo evaluation. In the absence of underlying heart disease, PVCs do not carry a poor prognosis, and US guidelines do not recommend restriction from sports.(3) Implanted devices: the safety of sports for the athlete with an implanted device is unknown, and current guidelines recommend against participation in vigorous competitive sports, based on postulated risks including failure to defibrillate and risk of injury. Many athletes with defibrillators and pacemakers do participate in sports. Ongoing research will better delineate the risks of sports for the athlete with an implanted device.Evaluation and Management of Arrhythmia in the Athletic PatientRachel Lampert10.1016/j.pcad.2012.01.002Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7Cardiovascular Care of the Athletic Patient423431http://www.onlinepcd.com/article/PIIS0033062012000059/abstract?rss=yesAbstract: Remodeling of the aortic root may be expected to occur in athletes as a consequence of hemodynamic overload associated with exercise training; however, there are few data reporting its presence or extent. This review reports the current knowledge regarding the prevalence, upper limits, and clinical significance of aortic remodeling induced by athletic training.Several determinants impact aortic dimension in healthy, nonathletic individuals, including height, body size, age, sex, and blood pressure. Of these factors, anthropometric variables have the greatest impact. In athletes, the effect of exercise training appears to have only a modest additional influence on aortic dimension, although previous studies have produced some conflicting results. Specifically, data derived from the largest available athletic cohort suggest that the most hemodynamically intense endurance disciplines (eg, cycling and swimming) are associated with a significant but mild increase in aortic dimensions. Power disciplines, instead, (eg, weight lifting, throwing events) have only trivial, if any, impact. In contrast, selected data from a different athlete population suggest a more significant dimensional aortic remodeling in strength-trained individuals.In our experience, the 99th percentile value of aortic root diameter corresponds to 40 mm in males and 34 mm in females, which can reasonably be considered the upper limits of physiologic aortic root remodeling.However, a small proportion of apparently healthy male athletes (approximately 1%) show aortic enlargement above the upper limits, in the absence of systemic disease (ie, Marfan syndrome). Athletes presenting with aortic enlargement may demonstrate a further dimensional increase in midlife leading to clinically relevant aortic dilatation. Occasionally, dilation may be severe enough to warrant consideration for surgical treatment. Therefore, serial clinical and echocardiographic evaluations are recommended in athletes when aortic root exceeds the sex-specific thresholds.Aortic Root Dilatation in Athletic PopulationAntonio Pelliccia, Fernando M. Di Paolo, Filippo M. Quattrini10.1016/j.pcad.2012.01.004Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7Cardiovascular Care of the Athletic Patient432437http://www.onlinepcd.com/article/PIIS0033062012000126/abstract?rss=yesAbstract: Syncope is a common but concerning event in athletic patients. As such, efforts must be made to distinguish presyncope from syncope with a critical distinction of syncope during exercise and postexercise syncope. Syncope most often occurs just after exercise and is usually benign; however, syncope during exercise may be a sign of pathologic structural or electrical cardiac issues. Solving this diagnostic puzzle mandates a detailed history and examination frequently augmented with diagnostic testing and imaging studies. Recommendations for treatment and potential restriction from activity also present challenging decisions to the health care provider.Syncope in the Athletic PatientJeffrey L. Hastings, Benjamin D. Levine10.1016/j.pcad.2012.02.003Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7Cardiovascular Care of the Athletic Patient438444http://www.onlinepcd.com/article/PIIS0033062012000023/abstract?rss=yesAbstract: Sudden cardiac death (SCD) is the leading cause of death in young athletes during exercise, and there is international agreement among major medical and sporting bodies that young athletes should undergo preparticipation cardiovascular screening. However, there is currently no universally accepted screening protocol, and substantial debate exists about what constitutes the ideal approach to preparticipation screening. The primary objective of preparticipation screening is the detection of intrinsic structural or electrical cardiovascular disorders that predispose an athlete to SCD. Considerable evidence exists suggesting that screening athletes with only a history and physical examination leaves most athletes with a serious underlying cardiovascular disease undetected and, thus, cannot adequately achieve the primary objective of screening. Preparticipating cardiovascular screening inclusive of an electrocardiogram (ECG) greatly enhances the ability to identify athletes at risk and is the only model shown to be cost-effective and may reduce the rate of SCD. The major obstacle to ECG screening in the United States is the lack of a physician workforce skilled in interpretation of an athlete's ECG. However, recent studies have demonstrated a capacity to distinguish physiologic ECG alterations in athletes from findings suggestive of underlying pathology that is both feasible and has a low false-positive rate. Efforts are underway to increase physician education in ECG interpretation. After 2 decades debating the proper screening strategy to identify athletes at risk, the weight of scientific evidence suggests that a screening program inclusive of ECG is the only strategy that merits promotion.Sudden Cardiac Death and Preparticipation Screening: The Debate Continues—In Support of Electrocardiogram-Inclusive Preparticipation ScreeningIrfan M. Asif, Jonathan A. Drezner10.1016/j.pcad.2012.01.001Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7Cardiovascular Care of the Athletic Patient445450http://www.onlinepcd.com/article/PIIS0033062012000096/abstract?rss=yesAbstract: One of the fundamental principles of evidence-based medicine is that clinical practice should be based on evidence derived from sufficiently robust data to ensure that the benefits, risks, and costs of an intervention are known. Although intuitively appealing, athletic screening programs with routine electrocardiograms (ECGs) followed by restriction of at-risk individuals have not been demonstrated to be effective in decreasing the inherent risk of athletic sudden death. The incremental use of a screening ECG to a history and physical examination remains debatable because of insufficient evidence to conclusively resolve the issue. Long-term outcomes with a large group of athletes undergoing screening and restriction are limited to a small number of observational trials. One supports and many do not support ECG screening with athletic restriction of at-risk athletes. Although programs and policies to decrease sudden death are laudable, they need further evaluation before being implemented on a large-scale basis. Currently, athletes are best protected by a strategy of secondary prevention with improvements in resuscitation and emergency action plans.Preparticipation Athletic Screening Including an Electrocardiogram: An Unproven Strategy for Prevention of Sudden Cardiac Death in the AthleteN.A. Mark Estes, Mark S. Link10.1016/j.pcad.2012.01.008Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7Cardiovascular Care of the Athletic Patient451454http://www.onlinepcd.com/article/PIIS0033062012000151/abstract?rss=yesTable of Contents10.1016/S0033-0620(12)00015-1Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7FrontmatterA5A5http://www.onlinepcd.com/article/PIIS0033062012000163/abstract?rss=yesRecent Topics10.1016/S0033-0620(12)00016-3Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7FrontmatterA6A6http://www.onlinepcd.com/article/PIIS0033062012000175/abstract?rss=yesEditorial Board10.1016/S0033-0620(12)00017-5Progress in Cardiovascular Diseases 54, 5 (2012)2012-03-01Progress in Cardiovascular Diseases2012-03-01545S0033-0620(11)X0008-7FrontmatterA7A7