Cardiac Adaptation to ExerciseCardiac Adaptation to Exercisechronicchronic

MorphologicalMorphological

•MyocardialMyocardial

•VascularVascular

FunctionalFunctional

•NeuralNeural

Myocardial hypertrophyMyocardial hypertrophy

CoronariesCoronaries

MorphologicalMorphological

CRMSCRMS

Chronic Cardiac Chronic Cardiac Adaptation to ExerciseAdaptation to Exercise

Myocardial hypertrophyMyocardial hypertrophy•EccentricEccentric•ConcentricConcentric

Coronaries

MorphologicalMorphological

CRMSCRMS

Chronic Cardiac Chronic Cardiac Adaptation to ExerciseAdaptation to Exercise

Hypertrophia-Hyperplasia

• Hyperplasia constitutes an increase in the number of cells in an organ or tissue, which may then have increased volume.

• Hypertrophy refers to an increase in the size of cells and, with such change, an increase in the size of the organ

Myocardial hypertrophyMyocardial hypertrophy

pressure overloadpressure overload

Due to physical stimuliDue to physical stimuli

volume overloadvolume overload

Due to hormonal chemical stimuliDue to hormonal chemical stimuli

CRMSCRMS

Factors promoting Cardiac hypertrophy Factors promoting Cardiac hypertrophy Mechanical Force

CRMSCRMS

Development of Myocardial Development of Myocardial HypertrophyHypertrophy

Volume OverloadVolume Overload

Increased parietal Increased parietal diastolic stressdiastolic stress

Addition of sarcomer Addition of sarcomer in seriesin series

Increase chamber sizeIncrease chamber size

Eccentric HypertrophyEccentric Hypertrophy

Pressure OverloadPressure Overload

Increased parietal Increased parietal systolic stresssystolic stress

Addition of sarcomerAddition of sarcomer in parallelin parallel

Increase wall thicknessIncrease wall thickness

Concentric HypertrophyConcentric Hypertrophy

Collagen

CRMSCRMS

Effects of pressure/volume overload Effects of pressure/volume overload on cardiac structure and functionon cardiac structure and function

Exercise (Isometric-Isotonic)Exercise (Isometric-Isotonic)

Athletic HeartAthletic Heart

MyociteMyociteHypertrophyHypertrophy

AdeguateAdeguateCapillary densityCapillary density

Overload Volume/pressureOverload Volume/pressure

Cardiac remodellingCardiac remodellingIncrease contrattilityIncrease contrattility

CRMSCRMS

Effects of Training on Left VentricleEffects of Training on Left Ventricle

Adaptation of the Heart to Adaptation of the Heart to Exercise TrainingExercise Training

Adaptation of the Heart to Exercise Adaptation of the Heart to Exercise

ConcentricConcentric EccentricEccentric

NormalNormal

Calculation of Left Ventricle MassCalculation of Left Ventricle Mass

LVM(gr) =0,80x1,05x (IVS+PWT+LVID)3-LVID 3

CRMSCRMS

Anatomical Section Through Anatomical Section Through the Short Axis of Left Ventriclethe Short Axis of Left Ventricle

Short Axis View of Left Ventricle Short Axis View of Left Ventricle in Normal Subjectin Normal Subject

Short Axis View of Left VentricleShort Axis View of Left Ventriclein Athletein Athlete

Pathological HypertrophyPathological Hypertrophy

1.1. AgeAge2.2. GenderGender3.3. Type of stimulusType of stimulus4.4. Genetic heritageGenetic heritage

Hypertrophy Modulating Hypertrophy Modulating FactorsFactors

CRMSCRMS

• AgeAge

Hypertrophy Modulating Hypertrophy Modulating FactorsFactors

Left Ventricular Mass in young athletes ( soccer players): a cross

echocardiographic study

Giorgio Galanti M.D, Paolo Manetti M.D., Maria Concetta Vono M.D., Loira Toncelli

M.D., Paola Zilli M.D., Carlo Rostagno M.D., Vieri Boddi M.Sc.*, Natale Villari

M.D**,Roberto Salti M.D.

CRMSCRMS

• Purpose Purpose - Regular exercising induces changes in left ventricular - Regular exercising induces changes in left ventricular mass (LVM). While its effects in adults are well known, few data are mass (LVM). While its effects in adults are well known, few data are so far available on those in adolescents. so far available on those in adolescents.

• Methods -Methods - group of 127 young male soccer players (aged group of 127 young male soccer players (aged 13.6±2.1 yr., mean ± standard deviation) was studied. They had been 13.6±2.1 yr., mean ± standard deviation) was studied. They had been regularly playing soccer since they were six years old. Players were regularly playing soccer since they were six years old. Players were age-matched with 70 male sedentary adolescents. LVM was age-matched with 70 male sedentary adolescents. LVM was detected with echocardiography and body composition with detected with echocardiography and body composition with bioelectrical impedance analysis. Pubertal stadiation was evaluated bioelectrical impedance analysis. Pubertal stadiation was evaluated with the Tanner method and skeletal maturation with hand x-ray. with the Tanner method and skeletal maturation with hand x-ray.

Results Results - Skeletal age, Tanner maturation and weight were - Skeletal age, Tanner maturation and weight were comparable in the two groups, while height (p=0.002), fat-free mass comparable in the two groups, while height (p=0.002), fat-free mass

(FFM, p<0.0005) and cellular body mass (p=0.002) were higher in (FFM, p<0.0005) and cellular body mass (p=0.002) were higher in athletes. Players showed increased LVM as compared with controls athletes. Players showed increased LVM as compared with controls (159±49 vs. 137±42 g, p=0.002; confirmed by measures of LVM/body (159±49 vs. 137±42 g, p=0.002; confirmed by measures of LVM/body

surface area: 97±19 g/msurface area: 97±19 g/m22 vs. 87±17 g/m vs. 87±17 g/m22, p<0.0005, respectively). , p<0.0005, respectively). Starting from similar values, LVM progressively increased more in Starting from similar values, LVM progressively increased more in players than in controls after 12 yr. (Tanner 2), reaching statistical players than in controls after 12 yr. (Tanner 2), reaching statistical

significance at 15.4 yr. (Tanner 5). In both athletes and controls LVM significance at 15.4 yr. (Tanner 5). In both athletes and controls LVM was directly correlated with all the anthropometric and was directly correlated with all the anthropometric and

cardiovascular parameters examined (p<0.0005). At multivariate cardiovascular parameters examined (p<0.0005). At multivariate analysis LVM was significantly correlated with skeletal age (b=8.54), analysis LVM was significantly correlated with skeletal age (b=8.54), height (b=1.77) in athletes, and with skeletal age (b=4.83) and FFM height (b=1.77) in athletes, and with skeletal age (b=4.83) and FFM

(b=1.83) in controls. (b=1.83) in controls.

Conclusions

• Our data suggest that exercise induces a Our data suggest that exercise induces a physiological left ventricular physiological left ventricular hypertrophy in sportive population. hypertrophy in sportive population.

• This hypertrophy becomes evident after This hypertrophy becomes evident after sexual maturation was achieved.sexual maturation was achieved.

Type of stimulusType of stimulus

CRMSCRMS

Hypertrophy Modulating Hypertrophy Modulating FactorsFactors

Hypertrophy Modulating Hypertrophy Modulating FactorsFactors

Circulation Reasearch 2001

Genetic HeritageGenetic Heritage

Hypertrophy Modulating Hypertrophy Modulating FactorsFactors

•42 elite soccer male players (from 17 to 31 years old)

•45 age matched healthy male controls

All were studied with echocardiography and DNA analysis

Studied SubjetsStudied SubjetsAllelic Frequency AnalysisAllelic Frequency Analysis

G.Galanti et al. MSSE Nov:2000

Correlation between Left Ventricular Mass (LVM) and I/D Polimorphysm

Athletes withincreased LVM Genotype

DD + ID 14 5

II 0 3

p<0,05

Athletes withoutincreased LVM

G.Galanti et al. MSSE Nov:2000

CONCLUSIONSCONCLUSIONS

• Increase of left ventricular mass is correlated Increase of left ventricular mass is correlated with I/D polimorphism: The DD athletes had with I/D polimorphism: The DD athletes had shown an increase while the II athletes had a shown an increase while the II athletes had a reduction. reduction.

• Increase of left ventricular mass is not Increase of left ventricular mass is not correlated with A/C polimorphism:correlated with A/C polimorphism:

G.Galanti et al. MSSE Nov:2000G.Galanti et al. MSSE Nov:2000 CRMSCRMS

CRMSCRMS

La scelta dello sport è La scelta dello sport è geneticamente determinata?geneticamente determinata?

Association of angiotensin-converting enzyme gene I/DAssociation of angiotensin-converting enzyme gene I/Dpolymorphism with change in left ventricular mass inpolymorphism with change in left ventricular mass inresponse to physical trainingresponse to physical training

Montgomery H, Clarkson P et alCirculation 1997, 96: 741-747)

Soggetti StudiatiSoggetti Studiati

I soggetti studiati comprendevano I soggetti studiati comprendevano

136136 atleti allenati (età media 24±3.5 atleti allenati (età media 24±3.5

anni) tra i quali 121 erano anni) tra i quali 121 erano calciatoricalciatori

(85 maschi, 36 femmine) e 15 (85 maschi, 36 femmine) e 15

ciclisticiclisti (maschi), confrontati con (maschi), confrontati con

155155 controlli, sedentari, controlli, sedentari,

comparabili per sesso ed età.comparabili per sesso ed età.

CRMSCRMS

RisultatiRisultatifrequenza allelicafrequenza allelica

La distribuzione del genotipo La distribuzione del genotipo

è risultata in accordo con è risultata in accordo con

l'equilibrio di Hardy-Weinberg l'equilibrio di Hardy-Weinberg

e la frequenza allelica è e la frequenza allelica è

risultata comparabile nei due risultata comparabile nei due

gruppi. gruppi.

Non sono state evidenziate Non sono state evidenziate

differenze significative differenze significative

comparando la distribuzione comparando la distribuzione

dei genotipi nei vari tipi di dei genotipi nei vari tipi di

sport.sport.

CRMSCRMS

Athlete’s HeartAthlete’s HeartDistinguishing normal from abnormalDistinguishing normal from abnormal

• Adeguate HypertrophyAdeguate Hypertrophy

• Normal Systolic FunctionNormal Systolic Function

• Normal Diastolic Function Normal Diastolic Function

• ReversibilityReversibility

CRMSCRMS

• Adeguate HypertrophyAdeguate Hypertrophy

• Normal Systolic FunctionNormal Systolic Function

• Normal Diastolic Function Normal Diastolic Function

• ReversibilityReversibility

Athlete’s HeartAthlete’s HeartDistinguishing normal from abnormalDistinguishing normal from abnormal

CRMSCRMS

Types of Myocardial Types of Myocardial HypertrophyHypertrophy

Normal

Adeguate NonAdeguateAdeguate

Variability of wall thickness in Variability of wall thickness in elite athleteselite athletes

0

50

100

150

200

250

300

8 9 10 11 12 13 14

N° AthlN° Athl

Wall Thickness Wall Thickness mmmm

Pelliccia.NEJM.1991

• Adeguate HypertrophyAdeguate Hypertrophy

• Normal Systolic FunctionNormal Systolic Function

• Normal Diastolic Function Normal Diastolic Function

• ReversibilityReversibility

Athlete’s HeartAthlete’s HeartDistinguishing normal from abnormalDistinguishing normal from abnormal

CRMSCRMS

Exercise EchocardiographyExercise Echocardiography

1.1. Increse Ejection fractionIncrese Ejection fraction2.2. Decreased Left Systolic Decreased Left Systolic

Ventricular Volume Ventricular Volume 3.3. No significant modifications of No significant modifications of

Wall Stress Wall Stress

Modifications during Exercise Modifications during Exercise EchocardiographyEchocardiography

CRMSCRMS

• Adeguate HypertrophyAdeguate Hypertrophy

• Normal Systolic FunctionNormal Systolic Function

• Normal Diastolic FunctionNormal Diastolic Function

• ReversibilityReversibility

Athlete’s HeartAthlete’s HeartDistinguishing normal from abnormalDistinguishing normal from abnormal

CRMSCRMS

DIASTOLIC FUNCTION IN DIASTOLIC FUNCTION IN ATHLETESATHLETES

ATHLETES CONTROLS

LVM gr/m2 208±28* 112±21

IVR msec 69±12* 76±11

DT msec 171±72 203±31

Ep cm/sec 84±12* 85±19

Ap cm/sec 41±8* 56±15

Galanti et al, Angiology 1992 4:315-20

• Adeguate HypertrophyAdeguate Hypertrophy

• Normal Systolic FunctionNormal Systolic Function

• Normal Diastolic Function Normal Diastolic Function

• ReversibilityReversibility

Athlete’s HeartAthlete’s HeartDistinguishing normal from abnormalDistinguishing normal from abnormal

CRMSCRMS

Regression of Athlete’s Regression of Athlete’s HypertrophyHypertrophy

0

50

100

150

200

250

LVM(gr) LVID(mm)

ContrAth BeAth Af

G.Galanti et al. Cardiologia 1989

Cardiac Adaptation to ExerciseCardiac Adaptation to Exercisechronicchronic

Myocardial hypertrophy•Eccentric•Concentric

CoronariesCoronaries

MorphologicalMorphological

CRMSCRMS

Coronary Arteries

Left Coronary in AthleteLeft Coronary in Athlete

Rigth Coronary in AthleteRigth Coronary in Athlete

Cardiac Adaptation to ExerciseCardiac Adaptation to Exercisechronicchronic

FunctionalFunctional Heart RateHeart Rate

H.R. b/min

Recovery

Cycloergometer

Cardiovascular Response to Cardiovascular Response to Acute Exercise in trained subjectsAcute Exercise in trained subjects