Principles of Exercise Testing and Interpretation

Several relatively uncommon, but important cardiovascular diseases are associated with increased risk for acute cardiac events during exercise (including sudden death), such as hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), arrhythmogenic right ventricular cardiomyopathy (ARVC) and myo-pericarditis. Practising cardiologists are frequently asked to advise on exercise programmes and sport participation in young individuals with these cardiovascular diseases. Indeed, many asymptomatic (or mildly symptomatic) patients with cardiomyopathies aspire to a physically active lifestyle to take advantage of the many documented benefits of exercise. While recommendations dictating the participation in competitive sport for athletes with cardiomyopathies and myo-pericarditis have recently been published as a consensus document of the European Society of Cardiology, no European guidelines have addressed the possible participation of patients with cardiomyopathies in recreational and amateur sport activities. The present document is intended to offer a comprehensive overview to practising cardiologists and sport physicians of the recommendations governing safe participation in different types of competitive sport, as well as the participation in a variety of recreational physical activities and amateur sports in individuals with cardiomyopathies and myo-pericarditis. These recommendations, based largely on the experience and insights of the expert panel appointed by the European Society of Cardiology, include the most up-to-date information concerning regular exercise and sports activity in patients with cardiomyopathies and myo-pericarditis.

/pdf/recommendations-for-participation-in-competitive-sport-and-us5wu4auw1.pdf

Recommendations for participation in competitive sport and leisure-time physical activity in individuals with cardiomyopathies, myocarditis and pericarditis.

As hypertrophic cardiomyopathy is a common cause of sudden deaths among athletes, differentiating this condition from the non-pathological “athlete’s heart” presents an important challenge

https://heart.bmj.com/content/heartjnl/91/11/1380.full.pdf

Distinguishing hypertrophic cardiomyopathy from athlete's heart: a clinical problem of increasing magnitude and significance.

Background Brazil is the world's largest producer of sugarcane. Harvest is predominantly manual, exposing workers to health risks: intense physical exertion, heat, pollutants from sugarcane burning. Design Panel study to evaluate the effects of burnt sugarcane harvesting on blood markers and on cardiovascular system. Methods Twenty-eight healthy male workers, living in the countryside of Brazil were submitted to blood markers, blood pressure, heart rate variability, cardiopulmonary exercise testing, sympathetic nerve activity evaluation and forearm blood flow measures (venous occlusion plethysmography) during burnt sugarcane harvesting and four months later while they performed other activities in sugar cane culture. Results Mean participant age was 31±6.3 years, and had worked for 9.8±8.4 years on sugarcane work. Work during the harvest period was associated with higher serum levels of Creatine Kinase – 136.5 U/L (IQR: 108.5–216.0) vs. 104.5 U/L (IQR: 77.5–170.5), (p = 0.001); plasma Malondialdehyde–7.5±1.4 µM/dl vs. 6.9±1.0 µM/dl, (p = 0.058); Glutathione Peroxidase – 55.1±11.8 Ug/Hb vs. 39.5±9.5 Ug/Hb, (p<0.001); Glutathione Transferase– 3.4±1.3 Ug/Hb vs. 3.0±1.3 Ug/Hb, (p = 0.001); and 24-hour systolic blood pressure – 120.1±10.3 mmHg vs. 117.0±10.0 mmHg, (p = 0.034). In cardiopulmonary exercise testing, rest-to-peak diastolic blood pressure increased by 11.12 mmHg and 5.13 mmHg in the harvest and non-harvest period, respectively. A 10 miliseconds reduction in rMSSD and a 10 burst/min increase in sympathetic nerve activity were associated to 2.2 and 1.8 mmHg rises in systolic arterial pressure, respectively. Conclusion Work in burnt sugarcane harvesting was associated with changes in blood markers and higher blood pressure, which may be related to autonomic imbalance.

/pdf/burnt-sugarcane-harvesting-cardiovascular-effects-on-a-group-yynzkowkde.pdf

Burnt Sugarcane Harvesting – Cardiovascular Effects on a Group of Healthy Workers, Brazil

Objective To establish which risk factors are predictive for sudden death in hypertrophic cardiomyopathy (HCM) diagnosed in childhood. Methods A Swedish national cohort of patients with HCM diagnosed 2 years (n=100), and features significantly more common in SD/CA group were further analysed with univariate and multivariate Cox hazard regression in the total cohort. Results Ranked according to relative risk (RR) the ECG risk score >5 points had an RR of 46.5 (95% CI 6.6 to 331), sensitivity of 97% (83% to 100%) and specificity of 80% (71% to 88%) (p 4.5: 9.9 (3.1 to 31.2); septal thickness ≥190% of upper limit of normal for age (septum in % of 95th centile for age (SEPPER) ≥190%): 7.9 (3.2 to 19.4); ventricular tachycardia: 9.1 (3.6 to 22.8); ventricular ectopics on exercise testing: 7.4 (2.7 to 20.2); and left ventricular outflow gradient (left ventricular outflow tract obstruction (LVOTO)) >50 mm Hg: 6.6 (4.0 to 11.0). Family history was non-significant. Multivariate Cox hazard analysis gives the following as early predictors: limb-lead QRS amplitude sum (p=0.020), SEPPER ≥190% (p Conclusions ECG phenotype as assessed by ECG risk score is important for risk of sudden death and should be considered for inclusion in risk stratification of paediatric patients with HCM.

https://openheart.bmj.com/content/openhrt/4/2/e000658.full.pdf

Predictors of risk for sudden death in childhood hypertrophic cardiomyopathy: the importance of the ECG risk score

Differentiating between young, athletic patients with hypertrophic cardiomyopathy (HCM) and elite athletes sometimes can be problematic.1–4 Left ventricular hypertrophy is seen mainly in athletes participating in endurance sports.1 A conflict exists with regard to strength athletes.2 Recent investigations suggest that strength athletes who use anabolic steroids have increased left ventricular hypertrophic response to exercise2 compared with drug-free, sport matched athletes. Therefore, in some cases athletic, young patients with HCM and strength athletes must also be differentiated.

Cardiopulmonary exercise testing (CET) metabolic parameters have been considered to contribute to differentiating patients with HCM from athletes participating in endurance sports.1 However, the metabolic profiles of patients with HCM5 and of strength athletes have not yet been compared.

The objective of the present study was to identify the relation between the CET profiles of young, male athletic patients with HCM and the profiles of elite, male strength athletes, and to question the value of CET in differentiating patients with HCM from strength athletes.

For this study, 19 strength athletes from the Greek Olympic weight lifting team, 20 endurance athletes (middle and long distance runners) from the national team, and 27 patients with HCM with recent physical activity (mainly aerobic type) were compared. All patients had diagnosed non-obstructive HCM. They were subjectively asymptomatic and …

https://heart.bmj.com/content/heartjnl/91/11/1477.full.pdf

Similarities in the profile of cardiopulmonary exercise testing between patients with hypertrophic cardiomyopathy and strength athletes

Sudden cardiac death: investigation of the classical risk factors in a community-based hypertrophic cardiomyopathy cohort.

Background: The appearance of a discrete upward deflection of the ST segment termed "the ST hump sign" (STHS) during exercise testing has been associated with resting hypertension and exaggerated blood pressure response to exercise.Objective: We investigated the prevalence and clinical significance of this sign in a population of patients with hypertrophic cardiomyopathy.Methods: Eighty-one patients with hypertrophic cardiomyopathy (HCM) who underwent cardiopulmonary exercise testing were followed in a retrospective cohort study for a mean period of 5.3 years.Results: The appearance of the STHS at the peak of exercise testing was observed in 42 patients (52%), particularly in the inferior and the lateral leads. Patients with the STHS had higher fractional shortening and maximum left ventricular wall thickness and exhibited more frequently outflow tract gradient > 30 mmHg at rest. Furthermore, the presence of STHS was a strong independent predictor of the risk of sudden cardiac death (SCD), as the latter occurred in eight of the patients with this sign (8/42, 19%) and in none of the patients without it (0/39, 0%) (P < 0.001).Conclusion: The appearance of a "hump" at the ST segment during exercise testing appears to be a risk factor for SCD in patients with HCM. However, further studies are necessary to validate this finding in larger populations and to elucidate the mechanism of the appearance of the "hump."Ann Noninvasive Electrocardiol 2009;14(2):158-164.

/pdf/st-segment-hump-during-exercise-testing-and-the-risk-of-ir5woy0tt5.pdf

ST segment "hump" during exercise testing and the risk of sudden cardiac death in patients with hypertrophic cardiomyopathy.

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Similarities in the profile of cardiopulmonary exercise testing between patients with hypertrophic cardiomyopathy and strength athletes

Sudden cardiac death: investigation of the classical risk factors in a community-based hypertrophic cardiomyopathy cohort.

ST segment "hump" during exercise testing and the risk of sudden cardiac death in patients with hypertrophic cardiomyopathy.