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Exercise and the heart. The good, the bad and the ugly

ESC Congress Report

  • Adaptive changes to exercise are frequently difficult to separate from cardiac disease.
  • There is a U-shaped risk of developing atrial fibrillation at very low and a very high levels of exercise.

View the Slides from this session in ESC Congress 365

The session on exercise and the heart attracted many participants interested in learning about the good, the bad, and the ugly sides of exercise.

Moderate exercise has cardiovascular benefits, as Sanjay Sharma of St George’s University (London, UK) stated in his presentation on the good sides of exercise. People who exercise moderately on a regular basis live longer than sedentary individuals.
Intensive exercise is associated with a plethora of electrical (bradycardia, repolarisation anomalies, voltage criteria for chamber enlargement), structural (increased chamber wall thickness and cavity size) and functional (enhanced diastolic filling, augmentation of stroke volume, reduced systemic vascular resistance) modifications which appear benign in the medium term, but may occasionally overlap with cardiomyopathies. There are also ethnic differences. For instance, the upper limits of left ventricular wall thickness in white males are 14 mm but 16 mm in black males.
Besides changes in size, assessment of left ventricular function at rest and during exercise may help to differentiate between adaptive changes to exercise and cardiomyopathies.

Lluis Mont, (Barcelona, Spain) continued with the topic of the bad side of exercise. Their own work (L Mont et al., European Heart Journal, 2002) was triggered by the observation that the proportion of patients engaged in regular endurance training was higher among their lone atrial fibrillation (AF) patients than the general population.
Several studies have shown that the risk of AF starts to increase in individuals engaging in five hours or more of vigorous exercise a week, and that there is a kind of “dose response”, showing that the cumulated hours (years x hours of intense activity) predicts the risk of developing atrial fibrillation (Kaarhalainen et al., BMJ 1998, Abdulla J, Nielsen JR. Europace 2009; Aizer et al., Am J Cardiol 2009).
The potential changes underlying the development of AF were studied in a Murine Model of forced exercise (Guasch et al., JACC 2013). Rats that engaged in a strenuous exercise regimen for a period of 16 weeks showed a higher rate of inducible AF than sedentary animals, which seemed to be related to atrial fibrosis and increased vagal tone.
He suggested that management of AF in patients engaged in sports should probably include a reduction of endurance training at the very beginning of the process, since some degree of reversibility has been demonstrated in the animal models. AF ablation seems to be a good option, and may obtain similar results as in controls.

The next speaker talked about the worst news sportsmen or women can receive -- that they need an implantable cardioverter-defibrillator, either for primary prevention of life-threatening ventricular tachyarrhythmias or for secondary prevention in cases with documented sustained ventricular tachyarrhythmias and underlying cardiac disease. Francois Carré, (Rennes, France) said the news requires psychological counseling and patient education. After ICD implantation, most types of intense sports and competition are not recommended. Instead, ICD patients should participate in leisure-time low-to-moderate intensity physical activities, according to the classification of Mitchell et al. (JACC 2005).

Werner Franke of the Helmholtz Group for Cell Biology at the German Cancer Research Center (DKFZ) in Heidelberg addressed the crucial role of cell-to-cell connections (composite junctions) in disorders like arrhythmogenic right ventricular cardiomyopathy where serious ventricular tachyarrhythmias mostly occur during or soon after strenuous exercise.
He also discussed the ugly side of sports, i.e. doping, by addressing the risk of anabolic steroids and their effects on the myocardial structure in athletes, which sometimes may be difficult to separate from the changes typically seen in cardiomyopathies.
This session presented interesting, current data not only for those who specifically work in the field of sports cardiology, but for all who take care of cardiac patients. The very recent data on the increased risk of atrial fibrillation in relation to either very low or high levels of exercise suggests to me that sufficient exercise but with moderation may be the right way to go for most of us and for our patients.




Exercise and the heart. The good, the bad and the ugly

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.