ࡱ>  &bjbj££ 4~+- V& 8AnXnnn%(% 4%@ @ @ @ @ @ @$6DF^-@:<%$"%N% Z%-@nn@2+2+2+b%8n:n7\2+<%@2+2+w-"-nx`'-7DA`A-,FG),FG--FG|C.T <%<%2+<%<%<%<%<%-@-@2+<%<%<%A<%<%<%<%FG<%<%<%<%<%<%<%<%<% : Effect of Gender and Sporting Discipline on Left Ventricular Adaptation to Exercise Authors: Gherardo Finocchiaroa MD, Harshil Dhutiaa BSc MRCP, Andrew DSilvaa MRCP, Aneil Malhotraa MsC, MRCP, Alexandros Steriotisa MD, PhD, Lynne Millara MRCP, Keerthi Prakasha MRCP, Rajay Naraina MRCP, Michael Papadakisa MBBS, MRCP, Rajan Sharmaa BSc, MBBS, MD, Sanjay Sharmaa BSc, MBChB, FRCP, MD Institutions: a Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom Author of correspondence: Sanjay Sharma, MD, Professor of Clinical Cardiology, St. Georges University of London, Cardiovascular Sciences, Cranmer Terrace, London, SW17 0RE, UK. E-mail: sasharma@sgul.ac.uk Running title: Gender differences in athletes heart Word count: 3922 Abstract Purpose: Studies assessing female and male athletes indicate that they exhibit qualitatively similar changes compared with sedentary counterparts, but female athletes reveal smaller increases in left ventricular (LV) wall thickness and cavity size compared to male athletes. However, data on gender specific changes in LV geometry in athletes is scarce. We sought to investigate the effect of different types of exercise on LV geometry in a large group of female and male athletes. Methods: 1083 healthy, elite, white athletes (41% females, mean age 21.8 5.7 years) underwent electrocardiogram (ECG) and echocardiogram as part of their cardiovascular evaluation. Sporting disciplines were divided into static, dynamic or mixed. According to European and American Society of Cardiology guidelines, LLleft ventricular geometry was classified into 4 groups according to relative wall thickness (RWT) and left ventricular mass (LVM) in accordance with the guidelines presented by the European and American Society of Echocardiography : normal (normal LVM/normal RWT), concentric hypertrophy (increased LVM/increased RWT), eccentric hypertrophy (increased LVM/normal RWT), concentric remodelling (normal LVM/increased RWT). Results: Athletes were engaged in 40 different sporting disciplines (62% mixed, 28% dynamic, 10% static) with similar participation rates with respect to the type of exercise between females and males. Females exhibited lower LV mass (83 17 vs 101 21 g/m2, p<0.001) and RWT (0.35 0.05 vs 0.36 0.05, p<0.001) compared to male athletes. Females also demonstrated lower absolute LV dimensions (49 4 vs 54 5 mm, p<0.001) but following correction for BSA the indexed LV dimensions were greater in females (28.6 2.7 vs 27.2 2.7 mm/m2, p<0.001). The majority of athletes showed normal LV geometry (69% of males vs 71% of females, p=0.54). There were no significant gender differences between LV geometry in athletes competing in static or mixed sport, however a greater proportion of females competing in dynamic sport exhibited eccentric hypertrophy compared to males (22% vs 14%, p<0.001). In this subgroup only 4% of females compared to 15% of males demonstrated concentric hypertrophy/remodelling (p<0.001). Conclusions: Highly trained athletes generally show Elite athletes are generally characterized by a normal LV geometry, however Ffemale athletes participating in dynamic sport often exhibit predominantly eccentric hypertrophy. Our results indicate that although concentric remodelling or hypertrophy in male athletes engaged in dynamic sport is a relatively common phenotype, it is rare in female athletes and may be a marker of cardiac pathology in a symptomatic athlete. Keywords: left ventricular geometry; athletes heart; physiological adaptation to exercise. INTRODUCTION Long-term athletic training is associated with a series of alterations in cardiac structure, function and electrical activity that are collectively termed athletes heartADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jacc.2010.05.070", "ISSN" : "1558-3597", "PMID" : "21292137", "author" : [ { "dropping-particle" : "", "family" : "George", "given" : "Keith P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Warburton", "given" : "Darren E R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Oxborough", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Scott", "given" : "Jessica M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Esch", "given" : "Ben T A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Williams", "given" : "Karen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Charlesworth", "given" : "Sarah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Foulds", "given" : "Heather", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Oxborough", "given" : "Adele", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hoffman", "given" : "Martin D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shave", "given" : "Rob", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of the American College of Cardiology", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2011", "2", "8" ] ] }, "page" : "754-5", "title" : "Upper limits of physiological cardiac adaptation in ultramarathon runners.", "type" : "article-journal", "volume" : "57" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=a0f6c05e-7e0b-4847-ab61-878ea71118bf" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1161/CIRCULATIONAHA.114.010775", "ISSN" : "1524-4539", "PMID" : "25281664", "abstract" : "BACKGROUND: It is unclear whether, and to what extent, the striking cardiac morphological manifestations of endurance athletes are a result of exercise training or a genetically determined characteristic of talented athletes. We hypothesized that prolonged and intensive endurance training in previously sedentary healthy young individuals could induce cardiac remodeling similar to that observed cross-sectionally in elite endurance athletes.\\n\\nMETHODS AND RESULTS: Twelve previously sedentary subjects (aged 29\u00b16 years; 7 men and 5 women) trained progressively and intensively for 12 months such that they could compete in a marathon. Magnetic resonance images for assessment of right and left ventricular mass and volumes were obtained at baseline and after 3, 6, 9, and 12 months of training. Maximum oxygen uptake ( max) and cardiac output at rest and during exercise (C2H2 rebreathing) were measured at the same time periods. Pulmonary artery catheterization was performed before and after 1 year of training, and pressure-volume and Starling curves were constructed during decreases (lower body negative pressure) and increases (saline infusion) in cardiac volume. Mean max rose from 40.3\u00b11.6 to 48.7\u00b12.5 mL/kg per minute after 1 year (P<0.00001), associated with an increase in both maximal cardiac output and stroke volume. Left and right ventricular mass increased progressively with training duration and intensity and reached levels similar to those observed in elite endurance athletes. In contrast, left ventricular volume did not change significantly until 6 months of training, although right ventricular volume increased progressively from the outset; Starling and pressure-volume curves approached but did not match those of elite athletes.\\n\\nCONCLUSIONS: One year of prolonged and intensive endurance training leads to cardiac morphological adaptations in previously sedentary young subjects similar to those observed in elite endurance athletes; however, it is not sufficient to achieve similar levels of cardiac compliance and performance. Contrary to conventional thinking, the left ventricle responds to exercise with initial concentric but not eccentric remodeling during the first 6 to 9 months after commencement of endurance training depending on the duration and intensity of exercise. Thereafter, the left ventricle dilates and restores the baseline mass-to-volume ratio. In contrast, the right ventricle responds to endurance training with eccentric remodeling at a\u2026", "author" : [ { "dropping-particle" : "", "family" : "Arbab-Zadeh", "given" : "Armin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Perhonen", "given" : "Merja", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Howden", "given" : "Erin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Peshock", "given" : "Ronald M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zhang", "given" : "Rong", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Adams-Huet", "given" : "Beverly", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haykowsky", "given" : "Mark J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Levine", "given" : "Benjamin D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Circulation", "id" : "ITEM-2", "issue" : "24", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "2152-61", "title" : "Cardiac remodeling in response to 1 year of intensive endurance training.", "type" : "article-journal", "volume" : "130" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=639b84de-cfa8-46a9-b860-8f2282676ae3" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "1524-4539", "PMID" : "11864923", "abstract" : "BACKGROUND The clinical significance and long-term consequences of left ventricular (LV) hypertrophy associated with intensive athletic conditioning remain unresolved. METHODS AND RESULTS We prospectively evaluated 40 elite male athletes who had shown marked LV cavity enlargement of > or = 60 mm, wall thickness of > or = 13 mm, or both in a longitudinal fashion with serial echocardiograms, initially at peak training (age 24 +/- 4 years) and subsequently after a long-term deconditioning period (1 to 13 years; mean, 5.6 +/- 3.8). After detraining, LV cavity dimension decreased by 7% (61.2 +/- 2.9 to 57.2 +/- 3.1 mm; P<0.001), maximum wall thickness by 15% (12.0 +/- 1.3 to 10.1 +/- 0.8 mm; P<0.001), and mass normalized to height by 28% (194 +/- 25 to 140 +/- 21 g/m; P<0.001). However, individual subject analysis showed persistent substantial cavity dilatation (> or = 60 mm) in 9 athletes (22%); in contrast, wall thickness returned to normal in each athlete. Multiple regression analysis demonstrated that approximately 50% of the incomplete reduction in cavity dimension was explained by increased body weight and recreational physical activity performed during the follow-up period. No athlete had developed cardiac symptoms, impaired exercise performance, or evidence of LV dysfunction. CONCLUSIONS LV remodeling was evident after long-term detraining, with significant reduction in cavity size and normalization of wall thickness. Resolution of cavity enlargement was, however, incomplete in most cases, and substantial chamber dilatation persisted in >20% of athletes. The possibility that this residual LV hypertrophy, apparently part of the athlete's heart syndrome, may have future long-term clinical implications in some individuals cannot be excluded with certainty.", "author" : [ { "dropping-particle" : "", "family" : "Pelliccia", "given" : "Antonio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Maron", "given" : "Barry J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Luca", "given" : "Rosanna", "non-dropping-particle" : "De", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Paolo", "given" : "Fernando M", "non-dropping-particle" : "Di", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spataro", "given" : "Antonio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Culasso", "given" : "Franco", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Circulation", "id" : "ITEM-3", "issue" : "8", "issued" : { "date-parts" : [ [ "2002", "2", "26" ] ] }, "page" : "944-9", "title" : "Remodeling of left ventricular hypertrophy in elite athletes after long-term deconditioning.", "type" : "article-journal", "volume" : "105" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=ffb57698-b36a-4306-9f2a-60e21a258911" ] } ], "mendeley" : { "formattedCitation" : "(1\u20133)", "plainTextFormattedCitation" : "(1\u20133)", "previouslyFormattedCitation" : "(1\u20133)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(13)HYPERLINK \l "_ENREF_4" \o "Arbab-Zadeh, 2014 #20". The ability to accurately diagnose cardiovascular diseases and specifically, to differentiate physiological cardiac adaptation due to exercise from cardiac pathology constitutes one of the most fundamental aspects of sports cardiologyADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/bjsports-2012-092069", "ISBN" : "0306-3674", "ISSN" : ", 14730480", "PMID" : "23303761", "abstract" : "Cardiac channelopathies are potentially lethal inherited arrhythmia syndromes and an important cause of sudden cardiac death (SCD) in young athletes. Other cardiac rhythm and conduction disturbances also may indicate the presence of an underlying cardiac disorder. The 12-lead ECG is utilised as both a screening and a diagnostic tool for detecting conditions associated with SCD. Fundamental to the appropriate evaluation of athletes undergoing ECG is an understanding of the ECG findings that may indicate the presence of a pathological cardiac disease. This article describes ECG findings present in primary electrical diseases afflicting young athletes and outlines appropriate steps for further evaluation of these ECG abnormalities. The ECG findings defined as abnormal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.", "author" : [ { "dropping-particle" : "", "family" : "Drezner", "given" : "Jonathan a.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ashley", "given" : "Euan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baggish", "given" : "Aaron L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Borjesson", "given" : "M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Corrado", "given" : "Domenico", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Owens", "given" : "David S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "a.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pelliccia", "given" : "Antonio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vetter", "given" : "Victoria L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ackerman", "given" : "Michael J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Anderson", "given" : "Jeffrey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Asplund", "given" : "Chad a.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cannon", "given" : "Bryan C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "DiFiori", "given" : "John P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fischbach", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Froelicher", "given" : "Victor", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harmon", "given" : "Kimberly G.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Heidbuchel", "given" : "Hein", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marek", "given" : "Joseph", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Paul", "given" : "Stephen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Prutkin", "given" : "Jordan M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Salerno", "given" : "Jack C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmied", "given" : "Christian M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sharma", "given" : "Sanjay", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stein", "given" : "Ricardo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wilson", "given" : "Mathew G.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Corrado", "given" : "Domenico", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Heidbuchel", "given" : "Hein", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Prutkin", "given" : "Jordan M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Salerno", "given" : "Jack C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Anderson", "given" : "Jeffrey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ashley", "given" : "Euan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Asplund", "given" : "Chad a.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baggish", "given" : "Aaron L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "B\u00f6rjesson", "given" : "Mats", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "DiFiori", "given" : "John P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fischbach", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Froelicher", "given" : "Victor", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harmon", "given" : "Kimberly G.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marek", "given" : "Joseph", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Owens", "given" : "David S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Paul", "given" : "Stephen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pelliccia", "given" : "Antonio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmied", "given" : "Christian M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sharma", "given" : "Sanjay", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stein", "given" : "Ricardo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vetter", "given" : "Victoria L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wilson", "given" : "Mathew G.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British Journal of Sports Medicine", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2013" ] ] }, "page" : "137-152", "title" : "Abnormal electrocardiographic findings in athletes: recognising changes suggestive of primary electrical disease", "type" : "article-journal", "volume" : "47" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=b33fc846-981f-43bc-bf5c-1fde0173a2dd" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1093/eurheartj/ehq482", "ISSN" : "1522-9645", "PMID" : "21278396", "abstract" : "Sudden cardiac arrest is most often the first clinical manifestation of an underlying cardiovascular disease and usually occurs in previously asymptomatic athletes. The risk benefit ratio of physical exercise differs between young competitive athletes and middle-age/senior individuals engaged in leisure-time sports activity. Competitive sports are associated with an increase in the risk of sudden cardiovascular death (SCD) in susceptible adolescents and young adults with underlying cardiovascular disorders. In middle-age/older individuals, physical activity can be regarded as a 'two-edged sword': vigorous exertion increases the incidence of acute coronary events in those who did not exercise regularly, whereas habitual physical activity reduces the overall risk of myocardial infarction and SCD. Although cardiovascular pre-participation evaluation offers the potential to identify athletes with life-threatening cardiovascular abnormalities before onset of symptoms and may reduce their risk of SCD, there is a significant debate among cardiologists about efficacy, impact of false-positive results and cost-effectiveness of routine screening. This review presents an appraisal of the available data and criticisms concerning screening programmes aimed to prevent SCD of either young competitive athletes or older individuals engaged in leisure-time sports activity.", "author" : [ { "dropping-particle" : "", "family" : "Corrado", "given" : "Domenico", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmied", "given" : "Christian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Basso", "given" : "Cristina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Borjesson", "given" : "Mats", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schiavon", "given" : "Maurizio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pelliccia", "given" : "Antonio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vanhees", "given" : "Luc", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Thiene", "given" : "Gaetano", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "European heart journal", "id" : "ITEM-2", "issue" : "8", "issued" : { "date-parts" : [ [ "2011", "4" ] ] }, "page" : "934-44", "title" : "Risk of sports: do we need a pre-participation screening for competitive and leisure athletes?", "type" : "article-journal", "volume" : "32" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=767e1927-fa05-419c-b617-e5c028fbc25a" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1016/j.jacc.2012.08.1032", "ISBN" : "1558-3597 (Electronic)\\r0735-1097 (Linking)", "PMID" : "23473408", "abstract" : "Sudden cardiac death (SCD) in an athlete is a rare yet highly visible tragedy that generates significant media attention and discussion among medical personnel, sports communities, and laypersons alike. The incidence of SCD is greater in athletes compared with their nonathletic counterparts due to the increased risk associated with strenuous exercise in the context of a quiescent cardiac abnormality. Numerous structural, electrical, and acquired cardiovascular abnormalities are capable of causing SCD, many of which can be identified during life and managed by lifestyle modifications, pharmacotherapy, and device therapy. Strategies for the prevention of SCD, including pre-participation cardiovascular screening, are endorsed by sports governing bodies, but mandatory pre-participation cardiovascular screening remains rare. Evaluation of athletes poses diagnostic difficulties, particularly differentiating between physiological adaptation to exercise, known as athlete's heart, and cardiomyopathic processes capable of causing SCD. This paper provides a detailed review regarding the etiology of SCD in young athletes and provides insight into the challenges and dilemmas faced when evaluating athletes for underlying pathological conditions.", "author" : [ { "dropping-particle" : "", "family" : "Chandra", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bastiaenen", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Papadakis", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sharma", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J Am Coll Cardiol", "id" : "ITEM-3", "issue" : "10", "issued" : { "date-parts" : [ [ "2013" ] ] }, "page" : "1027-1040", "title" : "Sudden cardiac death in young athletes: practical challenges and diagnostic dilemmas", "type" : "article-journal", "volume" : "61" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=d585fcba-b200-4a3d-a61d-8043a8e2b9fd" ] } ], "mendeley" : { "formattedCitation" : "(4\u20136)", "plainTextFormattedCitation" : "(4\u20136)", "previouslyFormattedCitation" : "(4\u20136)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(46). Although numerous studies have evaluated the cardiac response to regular physical training in male athletes, there is limited data on female athletes, who constitute an increasing number of elite athletes worldwide. A former large study of female Italian Olympian athletes revealed that none exhibited an absolute left ventricular (LV) wall thickness exceeding predicted upper limits for the general population and the LV cavity was considered enlarged in only 8%ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0098-7484", "PMID" : "8667565", "abstract" : "UNLABELLED OBJECTIVES; To define the expression of \"athlete's heart\" in women by determining the alterations in cardiac dimensions associated with long-term intense conditioning in elite female athletes. DESIGN; Prospective cardiovascular assessment conducted from 1986 through 1993. Subjects were evaluated using 2-dimensional, M-mode, and Doppler echo-cardiographic studies. SETTING Institute of Sports Science, Italian National Olympic Committee, Rome, Italy. PARTICIPANTS A total of 600 elite female athletes (mean age, 21 years; range, 12-49 years) who had participated in vigorous training (mean duration, 9 years; range, 2-32 years) and had competed in 27 sports, including 211 athletes at the international level and 389 at the national level. A control group consisted of 65 sedentary volunteer women (mean age, 23.7 years; range, 14-41 years) who were free of cardiovascular disease and who did not participate in regular athletic training. MAIN OUTCOME MEASURES Left ventricular end-diastolic cavity dimension and wall thickness. RESULTS Athletes demonstrated larger left ventricular end-diastolic cavity dimension (mean +/- SD) (49 +/- 4 mm) and greater maximal wall thickness (8.2 +/- 0.9 mm) than controls (46 +/- 3 mm and 7.2 +/- 0.6 mm; P < .001). These dimensions were 6% and 14% larger in athletes. Among athletes, left ventricular cavity dimension was 40 mm to 66 mm, exceeded normal limits ( > 54 mm) in 47 women (8%), and was within the range consistent with primary dilated cardiomyopathy ( > or = 60 mm) in 4 athletes (1%). Training for endurance sports, such as cycling, cross-country skiing, and rowing had the greatest effect on cavity dimension. Left ventricular wall thickness was 6 mm to 12 mm in athletes and did not exceed normal limits or extend into the borderline gray zone with hypertrophic cardiomyopathy in any subject. Compared with data from 738 previously studied male athletes, female athletes showed significantly smaller left ventricular cavity dimension (11% less; P < .001) and wall thickness (23% less; P < .001). CONCLUSIONS Highly trained women athletes frequently demonstrate cardiac dimensional changes as an adaptation to physical training, although absolute left ventricular cavity size exceeding normal limits was evident in a minority (8%) of women athletes and was rarely (1% of athletes) within the range of dilated cardiomyopathy. Athletic training was not a stimulus for substantial increases in absolute left ventricular wall thickness, w\u2026", "author" : [ { "dropping-particle" : "", "family" : "Pelliccia", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Maron", "given" : "B J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Culasso", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spataro", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Caselli", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "JAMA", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "1996", "7" ] ] }, "page" : "211-5", "title" : "Athlete's heart in women. Echocardiographic characterization of highly trained elite female athletes.", "type" : "article-journal", "volume" : "276" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=714b9846-9984-4e29-95b6-a6498afbfdff" ] } ], "mendeley" : { "formattedCitation" : "(7)", "plainTextFormattedCitation" : "(7)", "previouslyFormattedCitation" : "(7)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(7). These results indicate that the quantitative alterations in absolute cardiac dimensions in females rarely overlap with the primary cardiomyopathies, which are recognized causes of exercise related sudden cardiac death in young adults. Absolute values for cardiac dimensions are dependent of sex, size and type of sport. In this regard, tThe assessment of LV geometry using left ventricular mass index and relative wall thickness is an increasingly important component in differentiating athletes heart pathological left ventricular hypertrophy such as from hypertrophic cardiomyopathyADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/heartjnl-2014-305904", "ISSN" : "1468-201X", "PMID" : "24916049", "abstract" : "AIMS: This study evaluated (a) global LV adaption to endurance versus resistance training in male athletes, (b) LV assessment using by modern imaging technologies and (c) the impact of scaling for body size on LV structural data.\\n\\nMETHODS: A prospective cross-sectional design assessed the LV in 18 elite endurance-trained (ET), 19 elite resistance-trained (RT) and 17 sedentary control (CT) participants. Standard 2D, tissue Doppler and speckle tracking echocardiography assessed LV structure and function. Indexing of LV structures to body surface area (BSA) was undertaken using ratio and allometric scaling.\\n\\nRESULTS: Absolute and scaled LV end-diastolic volume (ET: 43.7\u00b16.8; RT: 34.2\u00b17.4; CT 32.5\u00b18.9\u2005mL/m(1.5); p<0.05) and LV mass (ET: 29.8\u00b16.6; RT: 25.4\u00b18.7; CT 25.9\u00b16.4\u2005g/m(2.7); p\u2009<\u20090.05) were significantly higher in ET compared with RT and CT. LV wall thickness were not different between ET and RT. 65% of ET and 95% of RT had normal geometry. Stroke volume was higher in ET compared with both RT and CT (p<0.05). Whilst regional tissue velocity data were not different between groups, longitudinal and basal circumferential strain (\u03b5) was reduced in RT compared with ET.\\n\\nCONCLUSIONS: In this comprehensive evaluation of the male athlete's heart (AH), normal LV geometry was predominant in both athlete groups. In the ET, 30% demonstrated an eccentric hypertrophy with no concentric hypertrophy in RT. Cardiac \u03b5 data in RT require further evaluation, and any interpretation of LV size should appropriately index for differences in body size.", "author" : [ { "dropping-particle" : "", "family" : "Utomi", "given" : "Victor", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Oxborough", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ashley", "given" : "Euan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lord", "given" : "Rachel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fletcher", "given" : "Sarah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stembridge", "given" : "Mike", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shave", "given" : "Rob", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hoffman", "given" : "Martin D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Whyte", "given" : "Greg", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Somauroo", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sharma", "given" : "Sanjay", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "George", "given" : "Keith", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Heart (British Cardiac Society)", "id" : "ITEM-1", "issue" : "16", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "1264-71", "title" : "Predominance of normal left ventricular geometry in the male 'athlete's heart'.", "type" : "article-journal", "volume" : "100" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=0a0d3db2-d204-4e3c-9b62-7636ef6d7aea" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0002-9149", "PMID" : "10760354", "author" : [ { "dropping-particle" : "", "family" : "Yal\u00e7in", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shiota", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Odabashian", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Agler", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Greenberg", "given" : "N L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Garcia", "given" : "M J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lever", "given" : "H M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Thomas", "given" : "J D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The American journal of cardiology", "id" : "ITEM-2", "issue" : "8", "issued" : { "date-parts" : [ [ "2000", "4", "15" ] ] }, "page" : "1035-8", "title" : "Comparison by real-time three-dimensional echocardiography of left ventricular geometry in hypertrophic cardiomyopathy versus secondary left ventricular hypertrophy.", "type" : "article-journal", "volume" : "85" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=f37b9f16-3b4c-4943-b444-2e647c2d839a" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1016/j.ahj.2008.01.005", "ISSN" : "1097-6744", "PMID" : "18513529", "abstract" : "BACKGROUND Hypertrophic cardiomyopathy (HCM) is a disease characterized by substantial genetic, morphologic, and prognostic heterogeneity. Recently, sex-related differences in HCM were reported, with women being older at diagnosis and exhibiting greater left ventricular outflow tract obstruction than men. We sought to evaluate the influence of sex on the HCM phenotype in a large cohort of unrelated patients with genetically and morphologically classified HCM. METHODS Comprehensive genotyping of 13 HCM-susceptibility genes encoding myofilament and Z-disc proteins of the cardiac sarcomere was performed previously on 382 unrelated patients with HCM. Blinded to the genotype, the septal morphology was graded as reverse-curvature, sigmoidal, apical, or neutral-contour HCM by echocardiography. RESULTS Overall, women (a) were significantly older at diagnosis (45.1 +/- 20 vs 35.8 +/- 17 years, P < .001), (b) had greater left ventricular outflow tract obstruction (53.5 +/- 45 vs 41.7 +/- 42 mm Hg, P = .009), (c) were more likely to have concomitant hypertension (19% vs 11%, P = .02), and (d) had a higher rate of surgical myectomy (49% vs 36%, P = .01) than men. Interestingly, these sex-based differences were apparent only among patients with sigmoidal HCM (P < .001). CONCLUSIONS In this largest cohort of comprehensively genotyped and morphologically classified patients with clinically diagnosed HCM, we observed that the striking sex-related differences in the clinical phenotype are confined largely to the subset of mutation-negative sigmoidal HCM. Whereas mutations within the sarcomere appear to dominate the disease process, in their absence, sex has a significant modifying effect, specifically noted in cases of sigmoidal HCM.", "author" : [ { "dropping-particle" : "", "family" : "Bos", "given" : "J Martijn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Theis", "given" : "Jeanne L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tajik", "given" : "A Jamil", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gersh", "given" : "Bernard J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ommen", "given" : "Steve R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ackerman", "given" : "Michael J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "American heart journal", "id" : "ITEM-3", "issue" : "6", "issued" : { "date-parts" : [ [ "2008", "6" ] ] }, "page" : "1128-34", "title" : "Relationship between sex, shape, and substrate in hypertrophic cardiomyopathy.", "type" : "article-journal", "volume" : "155" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=d947ff8b-ef3d-4c91-a0fd-dfdda14a559e" ] } ], "mendeley" : { "formattedCitation" : "(8\u201310)", "plainTextFormattedCitation" : "(8\u201310)", "previouslyFormattedCitation" : "(8\u201310)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(810). Given the use of parameters scaled for body size and the useconsideration of both LV mass and relative wall thickness (RWT), LV geometry is likely to be the most genuine representation of the whole spectrum of changes characterizing athletes heart. hHowever there are few reports on gender specific LV geometry alterations in athletes. This study compared LV geometry in a large cohort of highly trained male and female athletes. METHODS Study setting The UK does not support a state sponsored cardiac screening program in athletes. However, the charitable organisation Cardiac Risk in the Young (www.c-ry.org.uk) has an established cardiac screening program for young individuals and that also serves many professional sporting organisations in the UK. Up to 1000 athletes from numerous regional or national sporting squads are assessed annually. Most preliminary evaluations, including ECG and echocardiography, are performed at training centres by experienced cardiologists through a mobile investigations unit and supervised by the principal investigator (SS). BetweenDuring a timeframe between 2010 to and 2013, 1364 elite athletes aged 14-35 years old were assessedAs with a health questionnaire, electrocardiogram (ECG) and echocardiogram. Of these black females comprised of only 40 (3%) athletes. Given that the aim of this study was to specifically assess gender differences in left ventricular geometry in a large cohort we confined our analysis only to white athletes. The final study group consisted of As part of this study, we evaluated 1083 consecutive Caucasian elite athletes of which 40% were female. The mean age of the cohort was (mean age 22 6 years old. , females 40%). aged 14-35 years who were assessed with a health questionnaire, electrocardiogram (ECG) and echocardiogram. Athletes participated in 40 different sporting disciplines, which were subdivided into static, dynamic or mixed as per the Mitchell classificationADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jacc.2005.02.015", "ISSN" : "0735-1097", "PMID" : "15837288", "author" : [ { "dropping-particle" : "", "family" : "Mitchell", "given" : "Jere H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haskell", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Snell", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Camp", "given" : "Steven P", "non-dropping-particle" : "Van", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of the American College of Cardiology", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "2005", "4", "19" ] ] }, "page" : "1364-7", "title" : "Task Force 8: classification of sports.", "type" : "article-journal", "volume" : "45" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=997505ec-02ca-465c-9c6c-ad54277afe4a" ] } ], "mendeley" : { "formattedCitation" : "(11)", "plainTextFormattedCitation" : "(11)", "previouslyFormattedCitation" : "(11)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(11).  Electrocardiogram Standard 12-lead ECGs were performed as described elsewhereADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0195-668X", "PMID" : "6210548", "author" : [ { "dropping-particle" : "", "family" : "Clementy", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bergere", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bricaud", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "European heart journal", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "1982", "4" ] ] }, "page" : "37-47", "title" : "Electrocardiography and vectocardiography in the evaluation of left ventricular hypertrophy due to pressure overload.", "type" : "article-journal", "volume" : "3 Suppl A" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=ec3ad89b-aca6-410c-9604-fc7b1eb9cf72" ] } ], "mendeley" : { "formattedCitation" : "(12)", "plainTextFormattedCitation" : "(12)", "previouslyFormattedCitation" : "(12)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(12). Sokolow-Lyon voltage criteria for left ventricular hypertrophy (LVH) were defined as the sum of S in V1+ R in V5or V6e" 35mm. ST-segment shift was considered significant if e"0.1 mV in e"2 contiguous leads. Biphasic T-wave inversion was considered abnormal if the negative deflection of the T-wave exceeded e""0.1 mV. T-wave inversion (TWI) e"0.1 mV in e"2 contiguous leads was considered abnormal. Deep T-wave inversions were defined as a T-wave deflection e""0.2 mV. An abnormal Q wave was defined as a Q wave with duration e" 40 msec or a Q/R ratio > 0.25. The normal frontal cardiac axis was considered to be >"30 but <120. Left atrial (LA) enlargement was defined by a P wave duration e" 0.12s in the frontal plane associated with a terminal P negativity in lead V1 of duration e" 0.04s and depth e" 1 mm. The ECG was interpreted according to the  refined criteriaADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1161/CIRCULATIONAHA.113.006179", "ISBN" : "1524-4539 (Electronic)\r0009-7322 (Linking)", "ISSN" : "0009-7322", "PMID" : "24619464", "abstract" : "BACKGROUND: Recent efforts have focused on improving the specificity of the European Society of Cardiology (ESC) criteria for ECG interpretation in athletes. These criteria are derived predominantly from white athletes (WAs) and do not account for the effect of Afro-Caribbean ethnicity or novel research questioning the relevance of several isolated ECG patterns. We assessed the impact of the ESC criteria, the newly published Seattle criteria, and a group of proposed refined criteria in a large cohort of black athletes (BAs) and WAs. METHODS AND RESULTS: Between 2000 and 2012, 1208 BAs were evaluated with history, examination, 12-lead ECG, and further investigations as appropriate. ECGs were retrospectively analyzed according to the ESC recommendations, Seattle criteria, and proposed refined criteria which exclude several specific ECG patterns when present in isolation. All 3 criteria were also applied to 4297 WAs and 103 young athletes with hypertrophic cardiomyopathy. The ESC recommendations raised suspicion of a cardiac abnormality in 40.4% of BAs and 16.2% of WAs. The Seattle criteria reduced abnormal ECGs to 18.4% in BAs and 7.1% in WAs. The refined criteria further reduced abnormal ECGs to 11.5% in BAs and 5.3% in WAs. All 3 criteria identified 98.1% of athletes with hypertrophic cardiomyopathy. Compared with ESC recommendations, the refined criteria improved specificity from 40.3% to 84.2% in BAs and from 73.8% to 94.1% in WAs without compromising the sensitivity of the ECG in detecting pathology. CONCLUSION: Refinement of current ECG screening criteria has the potential to significantly reduce the burden of false-positive ECGs in athletes, particularly BAs.", "author" : [ { "dropping-particle" : "", "family" : "Sheikh", "given" : "Nabeel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Papadakis", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ghani", "given" : "Saqib", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zaidi", "given" : "Abbas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gati", "given" : "Sabiha", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Adami", "given" : "Paolo Emilio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Carre", "given" : "F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schnell", "given" : "Fr\u00e9d\u00e9ric", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wilson", "given" : "Mathew", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Avila", "given" : "Paloma", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McKenna", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sharma", "given" : "Sanjay", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Carr\u00e9", "given" : "Fran\u00e7ois", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schnell", "given" : "Fr\u00e9d\u00e9ric", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wilson", "given" : "Mathew", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Avila", "given" : "Paloma", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McKenna", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sharma", "given" : "Sanjay", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Circulation", "id" : "ITEM-1", "issue" : "16", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "1637-1649", "title" : "Comparison of Electrocardiographic Criteria for the Detection of Cardiac Abnormalities in Elite Black and White Athletes", "type" : "article-journal", "volume" : "129" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=246e8bd3-3e90-45d8-92a3-7e59a96b5592" ] } ], "mendeley" : { "formattedCitation" : "(13)", "plainTextFormattedCitation" : "(13)", "previouslyFormattedCitation" : "(13)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(13). T wave inversion between V1-V3 was considered as a normal juvenile ECG pattern in asymptomatic athletes < 16 years old. Echocardiogram Two-dimensional echocardiography was performed using either a GE Vivid I (Tirat, Israel), Philips Sonos 7500, Philips iE33 or Philips CPX50 (Bothel, Washington). Standard views were obtained as previously describedADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.euje.2005.12.014", "ISBN" : "2047-2404, 2047-2412", "ISSN" : "2047-2404, 2047-2412", "PMID" : "16458610", "abstract" : "Quantification of cardiac chamber size, ventricular mass and function ranks among the most clinically important and most frequently requested tasks of echocardiography. Over the last decades, echocardiographic methods and techniques have improved and expanded dramatically, due to the introduction of higher frequency transducers, harmonic imaging, fully digital machines, left-sided contrast agents, and other technological advancements. Furthermore, echocardiography due to its portability and versatility is now used in emergency rooms, operating rooms, and intensive care units. Standardization of measurements in echocardiography has been inconsistent and less successful, compared to other imaging techniques and consequently, echocardiographic measurements are sometimes perceived as less reliable. Therefore, the American Society of Echocardiography, working together with the European Association of Echocardiography, a branch of the European Society of Cardiology, has critically reviewed the literature and updated the recommendations for quantifying cardiac chambers using echocardiography. This document reviews the technical aspects on how to perform quantitative chamber measurements of morphology and function, which is a component of every complete echocardiographic examination.", "author" : [ { "dropping-particle" : "", "family" : "Lang", "given" : "Roberto M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bierig", "given" : "Michelle", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Devereux", "given" : "Richard B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Flachskampf", "given" : "Frank A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Foster", "given" : "Elyse", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pellikka", "given" : "Patricia A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Picard", "given" : "Michael H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roman", "given" : "Mary J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seward", "given" : "James", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shanewise", "given" : "Jack", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Solomon", "given" : "Scott", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spencer", "given" : "Kirk T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sutton", "given" : "Martin St John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "St John Sutton", "given" : "Martin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sutton", "given" : "Martin St John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Eur J Echocardiogr", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "79-108", "title" : "Recommendations for chamber quantification", "type" : "article-journal", "volume" : "7" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=45c5d6f3-67b5-4c75-8ec6-619e2029015a" ] } ], "mendeley" : { "formattedCitation" : "(14)", "plainTextFormattedCitation" : "(14)", "previouslyFormattedCitation" : "(14)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(14). Assessment of diastolic function included traditional pulsed-wave Doppler across the mitral valve and tissue Doppler velocity imaging of the septal and lateral mitral valve annulusADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1093/ejechocard/jep007", "ISSN" : "1532-2114", "PMID" : "19270053", "author" : [ { "dropping-particle" : "", "family" : "Nagueh", "given" : "Sherif F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Appleton", "given" : "Christopher P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gillebert", "given" : "Thierry C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marino", "given" : "Paolo N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Oh", "given" : "Jae K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Smiseth", "given" : "Otto A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Waggoner", "given" : "Alan D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Flachskampf", "given" : "Frank A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pellikka", "given" : "Patricia A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Evangelisa", "given" : "Arturo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2009", "3" ] ] }, "page" : "165-93", "title" : "Recommendations for the evaluation of left ventricular diastolic function by echocardiography.", "type" : "article-journal", "volume" : "10" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=47afee76-9a06-4dca-b80b-8228f6705ed4" ] } ], "mendeley" : { "formattedCitation" : "(15)", "plainTextFormattedCitation" : "(15)", "previouslyFormattedCitation" : "(15)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(15). Digitized images of 2 beats were stored and analyzed by cardiologists and expert sonographers blinded to the clinical characteristics offline in accordance with the European Society of Echocardiography guidelines. Left ventricular (LV) internal diameter, septal wall thickness and posterior wall thickness were measured from two-dimensional (2D) images in the parasternal long-axis view in end-diastole. When measuring septal thickness, care was taken to exclude right ventricular septal bands. In measuring the LV posterior wall thickness, care was taken to exclude posterior wall chordae. Indexed LV cavity size was considered increased if > 31 mm/m2. Relative wall thickness (RWT) was defined as the ratio of the sum of the interventricular septum and posterior wall thickness in end diastole to the LV end-diastolic diameter. A RWT was considered to be abnormal if >0.42ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.euje.2005.12.014", "ISBN" : "2047-2404, 2047-2412", "ISSN" : "2047-2404, 2047-2412", "PMID" : "16458610", "abstract" : "Quantification of cardiac chamber size, ventricular mass and function ranks among the most clinically important and most frequently requested tasks of echocardiography. Over the last decades, echocardiographic methods and techniques have improved and expanded dramatically, due to the introduction of higher frequency transducers, harmonic imaging, fully digital machines, left-sided contrast agents, and other technological advancements. Furthermore, echocardiography due to its portability and versatility is now used in emergency rooms, operating rooms, and intensive care units. Standardization of measurements in echocardiography has been inconsistent and less successful, compared to other imaging techniques and consequently, echocardiographic measurements are sometimes perceived as less reliable. Therefore, the American Society of Echocardiography, working together with the European Association of Echocardiography, a branch of the European Society of Cardiology, has critically reviewed the literature and updated the recommendations for quantifying cardiac chambers using echocardiography. This document reviews the technical aspects on how to perform quantitative chamber measurements of morphology and function, which is a component of every complete echocardiographic examination.", "author" : [ { "dropping-particle" : "", "family" : "Lang", "given" : "Roberto M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bierig", "given" : "Michelle", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Devereux", "given" : "Richard B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Flachskampf", "given" : "Frank A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Foster", "given" : "Elyse", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pellikka", "given" : "Patricia A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Picard", "given" : "Michael H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roman", "given" : "Mary J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seward", "given" : "James", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shanewise", "given" : "Jack", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Solomon", "given" : "Scott", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spencer", "given" : "Kirk T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sutton", "given" : "Martin St John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "St John Sutton", "given" : "Martin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sutton", "given" : "Martin St John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Eur J Echocardiogr", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "79-108", "title" : "Recommendations for chamber quantification", "type" : "article-journal", "volume" : "7" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=45c5d6f3-67b5-4c75-8ec6-619e2029015a" ] } ], "mendeley" : { "formattedCitation" : "(14)", "plainTextFormattedCitation" : "(14)", "previouslyFormattedCitation" : "(14)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(14). LV mass calculation was based on a prolate ellipse model of the left ventricle in accordance with American Society of Echocardiography (ASE) formula: LV mass = [0.8 x 1.04[(LV end-diastolic diameter + interventricular septum + posterior wall thickness)3 - (LV end-diastolic diameter)3]] + 0.6 g. An abnormal LV mass was defined as > 95 g/m2 in women and > 115 g/m2 in menADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.euje.2005.12.014", "ISBN" : "2047-2404, 2047-2412", "ISSN" : "2047-2404, 2047-2412", "PMID" : "16458610", "abstract" : "Quantification of cardiac chamber size, ventricular mass and function ranks among the most clinically important and most frequently requested tasks of echocardiography. Over the last decades, echocardiographic methods and techniques have improved and expanded dramatically, due to the introduction of higher frequency transducers, harmonic imaging, fully digital machines, left-sided contrast agents, and other technological advancements. Furthermore, echocardiography due to its portability and versatility is now used in emergency rooms, operating rooms, and intensive care units. Standardization of measurements in echocardiography has been inconsistent and less successful, compared to other imaging techniques and consequently, echocardiographic measurements are sometimes perceived as less reliable. Therefore, the American Society of Echocardiography, working together with the European Association of Echocardiography, a branch of the European Society of Cardiology, has critically reviewed the literature and updated the recommendations for quantifying cardiac chambers using echocardiography. This document reviews the technical aspects on how to perform quantitative chamber measurements of morphology and function, which is a component of every complete echocardiographic examination.", "author" : [ { "dropping-particle" : "", "family" : "Lang", "given" : "Roberto M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bierig", "given" : "Michelle", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Devereux", "given" : "Richard B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Flachskampf", "given" : "Frank A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Foster", "given" : "Elyse", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pellikka", "given" : "Patricia A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Picard", "given" : "Michael H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roman", "given" : "Mary J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seward", "given" : "James", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shanewise", "given" : "Jack", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Solomon", "given" : "Scott", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spencer", "given" : "Kirk T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sutton", "given" : "Martin St John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "St John Sutton", "given" : "Martin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sutton", "given" : "Martin St John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Eur J Echocardiogr", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "79-108", "title" : "Recommendations for chamber quantification", "type" : "article-journal", "volume" : "7" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=45c5d6f3-67b5-4c75-8ec6-619e2029015a" ] } ], "mendeley" : { "formattedCitation" : "(14)", "plainTextFormattedCitation" : "(14)", "previouslyFormattedCitation" : "(14)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(14). LV volumes and LVEF were assessed from the apical views, using the biplane method of discs. LV systolic function was considered to be reduced if the ejection fraction (EF) was < 50%ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1093/ehjci/jev014", "ISSN" : "2047-2412", "PMID" : "25712077", "abstract" : "The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.", "author" : [ { "dropping-particle" : "", "family" : "Lang", "given" : "Roberto M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Badano", "given" : "Luigi P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mor-Avi", "given" : "Victor", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Afilalo", "given" : "Jonathan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Armstrong", "given" : "Anderson", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ernande", "given" : "Laura", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Flachskampf", "given" : "Frank A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Foster", "given" : "Elyse", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goldstein", "given" : "Steven A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kuznetsova", "given" : "Tatiana", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lancellotti", "given" : "Patrizio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Muraru", "given" : "Denisa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Picard", "given" : "Michael H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rietzschel", "given" : "Ernst R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rudski", "given" : "Lawrence", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spencer", "given" : "Kirk T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tsang", "given" : "Wendy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Voigt", "given" : "Jens-Uwe", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "European heart journal cardiovascular Imaging", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2015", "3" ] ] }, "page" : "233-70", "title" : "Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.", "type" : "article-journal", "volume" : "16" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=6afb245c-565a-4766-83d1-2376be2dbf0f" ] } ], "mendeley" : { "formattedCitation" : "(16)", "plainTextFormattedCitation" : "(16)", "previouslyFormattedCitation" : "(16)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(16). Based upon the guidelines from the European and American Society of Echocardiography Cardiology guidelinesADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1093/ehjci/jev014", "ISSN" : "2047-2412", "PMID" : "25712077", "abstract" : "The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.", "author" : [ { "dropping-particle" : "", "family" : "Lang", "given" : "Roberto M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Badano", "given" : "Luigi P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mor-Avi", "given" : "Victor", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Afilalo", "given" : "Jonathan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Armstrong", "given" : "Anderson", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ernande", "given" : "Laura", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Flachskampf", "given" : "Frank A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Foster", "given" : "Elyse", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goldstein", "given" : "Steven A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kuznetsova", "given" : "Tatiana", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lancellotti", "given" : "Patrizio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Muraru", "given" : "Denisa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Picard", "given" : "Michael H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rietzschel", "given" : "Ernst R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rudski", "given" : "Lawrence", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spencer", "given" : "Kirk T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tsang", "given" : "Wendy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Voigt", "given" : "Jens-Uwe", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "European heart journal cardiovascular Imaging", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2015", "3" ] ] }, "page" : "233-70", "title" : "Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.", "type" : "article-journal", "volume" : "16" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=6afb245c-565a-4766-83d1-2376be2dbf0f" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.euje.2005.12.014", "ISBN" : "2047-2404, 2047-2412", "ISSN" : "2047-2404, 2047-2412", "PMID" : "16458610", "abstract" : "Quantification of cardiac chamber size, ventricular mass and function ranks among the most clinically important and most frequently requested tasks of echocardiography. Over the last decades, echocardiographic methods and techniques have improved and expanded dramatically, due to the introduction of higher frequency transducers, harmonic imaging, fully digital machines, left-sided contrast agents, and other technological advancements. Furthermore, echocardiography due to its portability and versatility is now used in emergency rooms, operating rooms, and intensive care units. Standardization of measurements in echocardiography has been inconsistent and less successful, compared to other imaging techniques and consequently, echocardiographic measurements are sometimes perceived as less reliable. Therefore, the American Society of Echocardiography, working together with the European Association of Echocardiography, a branch of the European Society of Cardiology, has critically reviewed the literature and updated the recommendations for quantifying cardiac chambers using echocardiography. This document reviews the technical aspects on how to perform quantitative chamber measurements of morphology and function, which is a component of every complete echocardiographic examination.", "author" : [ { "dropping-particle" : "", "family" : "Lang", "given" : "Roberto M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bierig", "given" : "Michelle", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Devereux", "given" : "Richard B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Flachskampf", "given" : "Frank A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Foster", "given" : "Elyse", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pellikka", "given" : "Patricia A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Picard", "given" : "Michael H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roman", "given" : "Mary J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seward", "given" : "James", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shanewise", "given" : "Jack", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Solomon", "given" : "Scott", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spencer", "given" : "Kirk T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sutton", "given" : "Martin St John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "St John Sutton", "given" : "Martin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sutton", "given" : "Martin St John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stewart", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Eur J Echocardiogr", "id" : "ITEM-2", "issue" : "2", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "79-108", "title" : "Recommendations for chamber quantification", "type" : "article-journal", "volume" : "7" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=45c5d6f3-67b5-4c75-8ec6-619e2029015a" ] } ], "mendeley" : { "formattedCitation" : "(14,16)", "plainTextFormattedCitation" : "(14,16)", "previouslyFormattedCitation" : "(14,16)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(14,16) , Lleft ventricular geometry was classified into 4 groups based on the relative wall thickness (RWT) and LV mass as represented in Figure 1: 1) normal (normal LV mass/normal RWT); 2) concentric hypertrophy (increased LV mass/increased RWT); 3) eccentric hypertrophy (increased LV mass/normal RWT); 4) concentric remodelling (normal LV mass/increased RWT). Ethical approval/consent Ethical approval was granted by the National Research Ethics Service, Essex 2 Research Ethics Committee in the UK. Written consent was obtained from individuals e"16 years and from a parent/guardian for those <16 years. Further evaluation Athletes with abnormalities in the history, 12-lead ECG, and echocardiography underwent further assessment including exercise ECG, ambulatory monitoring, signal-averaged ECG, and cardiac magnetic resonance imaging.Specific triggers for additional evaluation included: 1) symptoms suggestive of cardiac disease; 2) family history of hereditary cardiac disease or of premature (d" 50 years old) sudden cardiac death; 3) ECG abnormalities according to refined criteria; 4) structural and functional abnormalities on the echocardiogram, including a (a) LV wall thickness > 11 mm in females and > 12 mm in males, (b) dilated LV with EF < 50% and (c) abnormal diastolic function, e.g. average septal/lateral E < 10 cm/s or E/E ratio > 15. Statistical analysis Statistical analysis was performed using the PASW software (PASW 18.0 Inc, Chicago, IL). Results are expressed as mean SD for continuous variables or as number of cases and percentage for categorical variables. Comparison between groups was performed using students t-tests for continuous variables with adjustment for unequal variance if needed and chi-square tests or Fisher Exact Tests for categorical variables. Intra- and inter-observation variability, was assessed by selecting 80 random studies which were blindly reanalyzed by a separate investigator. Intra- and inter-reader variability was quantified using mean differences as well as Pearsons correlation and intraclass correlation coefficients. RESULTS Athlete demographics The mean age of the athletes was 22 6 years and 996 (92%) athletes were aged > 16 years old. The average hours of exercise were 21 8 per week and was similar between males and females. Males had a greater BSA than females (2.0 0.2 vs 1.7 0.2, p<0.001). Athletes engaged in 40 different sporting disciplines (62% mixed, 28% pure dynamic, 10% pure static), with no significant differences according to gender. The top 5 sports represented were swimming (n=123, 11%), cricket (n=95, 9%), football (n=89, 8%), rowing (n=89, 8%), rugby (n=72, 6%). Left ventricular geometry The echocardiographic characteristics of the study population are shown in Table 1. The majority of athletes showed normal LV geometry (69% males vs 71% in females, p=0.54). Females exhibited a lower absolute LV mass and RWT compared to males. A RWT > 0.42 was observed in 8% of females and 12% of males (p=0.04). None of the female athletes showed a RWT >0.48 compared to 1.3% of males (p=0.04) (Figure 2). Average LV mass indexed for BSA was higher in males and almost a quarter of males and females had an increased indexed LV mass. None of the females showed a maximal wall thickness > 12 mm compared to 2.5% of males (p<0.001). Females demonstrated a lower absolute left ventricular end-diastolic diameter (LVEDD) compared with males. A LVEDD >54 mm was present in only 7% of females vs 47% of males, p<0.001, but females showed a higher LVEDD indexed for BSA. 18% of females showed an increased indexed LVEDD (>31 mm/m2) compared to 10% of males (p<0.001). There was a modest relationship between RWT and LV mass in females and males (r=0.30, p<0.001 and r=0.24, p<0.001 respectively). An important minority of athletes showed concentric hypertrophy/remodelling which was less common in females (7% vs 12%, p=0.009). There were no significant gender differences relating to the LV geometry in athletes competing in static or mixed sport. In contrast females competing in dynamic sports, exhibited a higher prevalence of eccentric hypertrophy compared to males (22% vs 16%, p<0.001). Only 4% of females competing in dynamic sports showed concentric hypertrophy/remodelling compared to 15% of males (p<0.001) (Figure 3). None of the athletes with concentric LVH/remodelling showed abnormal indices of diastolic function. Electrocardiogram Ninety-seven (9%) athletes had an abnormal ECG according to the refined criteria. ECG abnormalities were predominantly driven by abnormal TWI (anterior n=68, 6%; inferior n=40, 4%). Although there were quantitative differences in the percentage of otherwise normal ECGs between females and males, tThere were no significant differences in the prevalence of abnormal ECGs characterised as distinctly abnormal between between females and males (n=48, 11% vs n=49, 8%, p=0.11). The QRS duration was similar in the two genders (82 12 vs. 87 13 ms in females and males respectively, p=0.156), but females very rarely exhibited a QRS >100 ms (3% vs 33%, p<0.001). Left axis deviation (LAD) was more common in males (0.4% in females vs. 4% in males, p<0.001). The presence of LA enlargement was slightly more frequent in males but did not reach without reaching the statistical significance (5% vs 2.5%, p=0.06). Females had a higher prevalence of anterior TWI (n=39, 9% vs n=29, 4%, p=0.05) whereas males had higher prevalence of inferior TWI (n=31, 5% vs n=9, 2%, p=0.02). There were no significant differences in the prevalence of abnormal ECG between athletes with normal LV geometry compared with those with abnormal geometry (8% vs 10%, p=0.33). Among athletes with abnormal geometry, there were no significant differences in the prevalence of abnormal ECG between athletes who exhibited concentric hypertrophy/remodelling and those with eccentric hypertrophy (11% vs 10%, p=0.63). In relation to a potential diagnosis of pathological LV hypertrophy, none of the athletes with concentric LVH/remodelling showed TWI in the lateral leads, ST depression or pathological Q waves. Five athletes had inferior TWI, 6 had anterior TWI that was confined to V1-V2 and to V1-V3 in 3 cases. Five athletes showed left atrial enlargement in isolation and 8 showed left axis deviation in isolation. Diagnosis and subsequent investigations Thirty-four athletes (3.1%) revealed minor congenital/valvular abnormalities at echocardiography [bicuspid aortic valve,n= 6 (0.6%); mitral valve prolapse,n= 2 (0.2%); patent foramen ovale (PFO),n= 11 (1%); possible PFO, n=2 (0.2%); mild aortic regurgitation, n=8 (0.7%); mild mitral regurgitation, n=2 (0.2%); possible cor triatratum, n=2 (0.2%); mild pulmonary stenosis, n=1 (0.1%)]. One athlete (0.1%) was diagnosed with the Wolff-Parkinson-White ECG pattern. A further 64 athletes (6%) revealed features at initial evaluation that, after ECG and echocardiogram, warranted further investigation to exclude cardiac disease. These included 1 athlete with a family history of cardiomyopathy in a first degree relative and 8 athletes with possible cardiac symptoms. Forty-two athletes (3.8%) had an abnormal ECG, including 3 with a prolonged QT interval, 31 with T wave inversion and 8 with ventricular extrasystolesectopics (VEs). Thirteen athletes revealed structural abnormalities at the echocardiogram that overlapped with cardiomyopathy, including 2 athletes with LV enlargement and mildly reduced LV systolic function (EF 48% in both cases), 2 mild LV hypertrophy (> 13 mm) and 9 athletes with significant right ventricular enlargement and mild systolic dysfunction. Athletes with structural abnormalities at the echocardiogram and, T wave inversion, multiple VEs, family history and symptoms were investigated comprehensively to exclude pathology. All 64 athletes underwent an exercise stress test and a 24 Holter and 45 athletes (1 with family history of cardiomyopathy, 31 with abnormal T wave inversion and 13 that showed structural features overlapping with cardiomyopathy) were subject to CMR. followed a full diagnostic work-up including exercise test, 24h Holter and CMR, while the ones with prolonged QT were investigated with exercise test and 24h Holter. None of the athletes showed any features of cardiomyopathy on further assessments. Inter-observer reliability The average difference between 2 independent readers (inter-observer variability based on 80 echocardiograms) was of 1.8 0.4 mm for LVEDD (Kappa inter-observer coefficient of 0.86), 0.6 0.2 mm for IVS (Kappa inter-observer coefficient of 0.79) and 0.5 0.2 for PW (Kappa inter-observer coefficient of 0.79). DISCUSSION Data relating to cardiac adaptation in female athletes is relatively limited particularly with respect to changes in LV geometry associated with exercise. As previously reported in a smaller cohort of exclusively male athletesADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/heartjnl-2014-305904", "ISSN" : "1468-201X", "PMID" : "24916049", "abstract" : "AIMS: This study evaluated (a) global LV adaption to endurance versus resistance training in male athletes, (b) LV assessment using by modern imaging technologies and (c) the impact of scaling for body size on LV structural data.\\n\\nMETHODS: A prospective cross-sectional design assessed the LV in 18 elite endurance-trained (ET), 19 elite resistance-trained (RT) and 17 sedentary control (CT) participants. Standard 2D, tissue Doppler and speckle tracking echocardiography assessed LV structure and function. Indexing of LV structures to body surface area (BSA) was undertaken using ratio and allometric scaling.\\n\\nRESULTS: Absolute and scaled LV end-diastolic volume (ET: 43.7\u00b16.8; RT: 34.2\u00b17.4; CT 32.5\u00b18.9\u2005mL/m(1.5); p<0.05) and LV mass (ET: 29.8\u00b16.6; RT: 25.4\u00b18.7; CT 25.9\u00b16.4\u2005g/m(2.7); p\u2009<\u20090.05) were significantly higher in ET compared with RT and CT. LV wall thickness were not different between ET and RT. 65% of ET and 95% of RT had normal geometry. Stroke volume was higher in ET compared with both RT and CT (p<0.05). Whilst regional tissue velocity data were not different between groups, longitudinal and basal circumferential strain (\u03b5) was reduced in RT compared with ET.\\n\\nCONCLUSIONS: In this comprehensive evaluation of the male athlete's heart (AH), normal LV geometry was predominant in both athlete groups. In the ET, 30% demonstrated an eccentric hypertrophy with no concentric hypertrophy in RT. Cardiac \u03b5 data in RT require further evaluation, and any interpretation of LV size should appropriately index for differences in body size.", "author" : [ { "dropping-particle" : "", "family" : "Utomi", "given" : "Victor", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Oxborough", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ashley", "given" : "Euan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lord", "given" : "Rachel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fletcher", "given" : "Sarah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stembridge", "given" : "Mike", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shave", "given" : "Rob", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hoffman", "given" : "Martin D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Whyte", "given" : "Greg", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Somauroo", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sharma", "given" : "Sanjay", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "George", "given" : "Keith", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Heart (British Cardiac Society)", "id" : "ITEM-1", "issue" : "16", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "1264-71", "title" : "Predominance of normal left ventricular geometry in the male 'athlete's heart'.", "type" : "article-journal", "volume" : "100" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=0a0d3db2-d204-4e3c-9b62-7636ef6d7aea" ] } ], "mendeley" : { "formattedCitation" : "(8)", "plainTextFormattedCitation" : "(8)", "previouslyFormattedCitation" : "(8)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(8), this study reinforces the concept that LV geometry is also normal in most female athletes. Importantly, this study shows the effect of gender on LV geometry according to sporting discipline. Whereas 15% of male athletes engaged in dynamic exercise exhibit concentric LV hypertrophy or remodelling, females predominantly develop eccentric LV hypertrophy. LV geometry in athletes In 1975 Morganroth et al. ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0003-4819", "PMID" : "1119766", "abstract" : "Little is known about the structure of athletes' hearts of anatomic variations associated with training. Echocardiograms of 56 active athletes were obtained. Mean left ventricular end-diastolic volume and mass were increased in athletes involved in isotonic exercise, such as swimming (181 ml, 308 g) and running (160 ml, 302 g), compared with controls (101 ml, 211 g); wall thickness was normal (less than or equal to 12 mm). Athletes involved in isometric exercise, such as werstling and shot putting, had normal mean left ventricular end-diastolic volumes (110 ml, 122 ml), but increased wall thickness (13 to 14 mm) and mass (330 g, 348 g). Thus, athletes participating in isotonic exercise had increased left ventricular mass with cardiac changes similar to those in chronic volume overloads. Athletes participating in isometric exercise had increased left ventricular mass with cardiac changes similar to those in chronic pressure loads, recognizing greater left ventricular mass and volume in well-trained athletes aids in interpreting values deviating from \"normal\" limits.", "author" : [ { "dropping-particle" : "", "family" : "Morganroth", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Maron", "given" : "B J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Henry", "given" : "W L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Epstein", "given" : "S E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of internal medicine", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "1975", "4" ] ] }, "page" : "521-4", "title" : "Comparative left ventricular dimensions in trained athletes.", "type" : "article-journal", "volume" : "82" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=7d666d61-6ba3-46ba-bfc3-a8cf4ffeb9bb" ] } ], "mendeley" : { "formattedCitation" : "(17)", "plainTextFormattedCitation" : "(17)", "previouslyFormattedCitation" : "(17)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(17) described LV adaptation in athletes using echocardiography and concluded that athletes involved in isotonic(static) exercise had a greater LV mass due to a greater LV end-diastolic volume, while athletes involved in isometric(dynamic) exercise were found to have a greater LV wall thickness than non-athletes. These findings have been challenged by at least two studies in male athletes. Spence et al.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1113/jphysiol.2011.217125", "ISSN" : "1469-7793", "PMID" : "21969450", "abstract" : "The principle that 'concentric' cardiac hypertrophy occurs in response to strength training, whilst 'eccentric' hypertrophy results from endurance exercise has been a fundamental tenet of exercise science. This notion is largely based on cross-sectional comparisons of athletes using echocardiography. In this study, young (27.4 \u00b1 1.1 years) untrained subjects were randomly assigned to supervised, intensive, endurance (END, n = 10) or resistance (RES, n = 13) exercise and cardiac MRI scans and myocardial speckle tracking echocardiography were performed at baseline, after 6 months of training and after a subsequent 6 weeks of detraining. Aerobic fitness increased significantly in END (3.5 to 3.8 l min(-1), P < 0.05) but was unchanged in RES. Muscular strength significantly improved compared to baseline in both RES and END ( = 53.0 \u00b1 1.1 versus 36.4 \u00b1 4.5 kg, both P < 0.001) as did lean body mass (2.3 \u00b1 0.4 kg, P < 0.001 versus 1.4 \u00b1 0.6 kg P < 0.05). MRI derived left ventricular (LV) mass increased significantly following END (112.5 \u00b1 7.3 to 121.8 \u00b1 6.6 g, P < 0.01) but not RES, whilst training increased end-diastolic volume (LVEDV, END: +9.0 \u00b1 5.0 versus RES +3.1 \u00b1 3.6 ml, P = 0.05). Interventricular wall thickness significantly increased with training in END (1.06 \u00b1 0.0 to 1.14 \u00b1 0.06, P < 0.05) but not RES. Longitudinal strain and strain rates did not change following exercise training. Detraining reduced aerobic fitness, LV mass and wall thickness in END (P < 0.05), whereas LVEDV remained elevated. This study is the first to use MRI to compare LV adaptation in response to intensive supervised endurance and resistance training. Our findings provide some support for the 'Morganroth hypothesis', as it pertains to LV remodelling in response to endurance training, but cast some doubt over the proposal that remodelling occurs in response to resistance training.", "author" : [ { "dropping-particle" : "", "family" : "Spence", "given" : "Angela L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Naylor", "given" : "Louise H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Carter", "given" : "Howard H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Buck", "given" : "Christopher L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dembo", "given" : "Lawrence", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Murray", "given" : "Conor P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Watson", "given" : "Philip", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Oxborough", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "George", "given" : "Keith P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Green", "given" : "Daniel J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of physiology", "id" : "ITEM-1", "issue" : "Pt 22", "issued" : { "date-parts" : [ [ "2011", "11", "15" ] ] }, "page" : "5443-52", "title" : "A prospective randomised longitudinal MRI study of left ventricular adaptation to endurance and resistance exercise training in humans.", "type" : "article-journal", "volume" : "589" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=e7b4234f-5907-464d-9bf3-c3bd271f28ee" ] } ], "mendeley" : { "formattedCitation" : "(18)", "plainTextFormattedCitation" : "(18)", "previouslyFormattedCitation" : "(18)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(18) studied 23 male subjects randomly assigned to endurance dynamic or resistance static training using cardiac MRI and speckle tracking echocardiography and showed that eccentric cardiac hypertrophy was frequently observed in dynamic sportsresponse to endurance exercise (in line with the Morganroth hypothesis), whereas resistance trainingstatic training was not associated with any substantive LV remodelling. Utomi et al.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/heartjnl-2014-305904", "ISSN" : "1468-201X", "PMID" : "24916049", "abstract" : "AIMS: This study evaluated (a) global LV adaption to endurance versus resistance training in male athletes, (b) LV assessment using by modern imaging technologies and (c) the impact of scaling for body size on LV structural data.\\n\\nMETHODS: A prospective cross-sectional design assessed the LV in 18 elite endurance-trained (ET), 19 elite resistance-trained (RT) and 17 sedentary control (CT) participants. Standard 2D, tissue Doppler and speckle tracking echocardiography assessed LV structure and function. Indexing of LV structures to body surface area (BSA) was undertaken using ratio and allometric scaling.\\n\\nRESULTS: Absolute and scaled LV end-diastolic volume (ET: 43.7\u00b16.8; RT: 34.2\u00b17.4; CT 32.5\u00b18.9\u2005mL/m(1.5); p<0.05) and LV mass (ET: 29.8\u00b16.6; RT: 25.4\u00b18.7; CT 25.9\u00b16.4\u2005g/m(2.7); p\u2009<\u20090.05) were significantly higher in ET compared with RT and CT. LV wall thickness were not different between ET and RT. 65% of ET and 95% of RT had normal geometry. Stroke volume was higher in ET compared with both RT and CT (p<0.05). Whilst regional tissue velocity data were not different between groups, longitudinal and basal circumferential strain (\u03b5) was reduced in RT compared with ET.\\n\\nCONCLUSIONS: In this comprehensive evaluation of the male athlete's heart (AH), normal LV geometry was predominant in both athlete groups. In the ET, 30% demonstrated an eccentric hypertrophy with no concentric hypertrophy in RT. Cardiac \u03b5 data in RT require further evaluation, and any interpretation of LV size should appropriately index for differences in body size.", "author" : [ { "dropping-particle" : "", "family" : "Utomi", "given" : "Victor", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Oxborough", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ashley", "given" : "Euan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lord", "given" : "Rachel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fletcher", "given" : "Sarah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stembridge", "given" : "Mike", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shave", "given" : "Rob", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hoffman", "given" : "Martin D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Whyte", "given" : "Greg", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Somauroo", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sharma", "given" : "Sanjay", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "George", "given" : "Keith", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Heart (British Cardiac Society)", "id" : "ITEM-1", "issue" : "16", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "1264-71", "title" : "Predominance of normal left ventricular geometry in the male 'athlete's heart'.", "type" : "article-journal", "volume" : "100" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=0a0d3db2-d204-4e3c-9b62-7636ef6d7aea" ] } ], "mendeley" : { "formattedCitation" : "(8)", "plainTextFormattedCitation" : "(8)", "previouslyFormattedCitation" : "(8)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(8) compared LV mass and its determinants, as well as the pattern of LV remodelling in ultra-endurance (dynamic sports, n=18) and resistance-trained (static sports) male athletes (n=19) and age-matched sedentary controls.recently showed that Nnormal LV geometry was predominant in both athlete groupsa cohort of athletes engaging in dynamic (n=18) and static (n=19) sports, with and 30% of the ultra-endurance athletesathletes participating in dynamic sports demonstrateding eccentric hypertrophy., but none of the resistance-trained athletes showed concentric hypertrophy or remodelling. In contrast we observed that a significant proportion of athletes involved in dynamic, static or mixed training showed concentric remodelling/hypertrophy and the discrepancy with previous observations may be related to the fact that in our athletes the training hours per week were significantly higher. Athletes with concentric remodelling/hypertrophy, showed normal systolic and diastolic function. Moreover, none revealed ECG abnormalities characteristic of HCM including TWI in the lateral leads, ST depression or pathological Q waves. Female athletes heart The vast majority of the studies evaluating cardiac adaptation in athletes have focused on males, although the past 3 decades have observed an exponential increase in the number of women participating in competitive sportADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1161/CIRCULATIONAHA.114.010775", "ISSN" : "1524-4539", "PMID" : "25281664", "abstract" : "BACKGROUND It is unclear whether, and to what extent, the striking cardiac morphological manifestations of endurance athletes are a result of exercise training or a genetically determined characteristic of talented athletes. We hypothesized that prolonged and intensive endurance training in previously sedentary healthy young individuals could induce cardiac remodeling similar to that observed cross-sectionally in elite endurance athletes. METHODS AND RESULTS Twelve previously sedentary subjects (aged 29\u00b16 years; 7 men and 5 women) trained progressively and intensively for 12 months such that they could compete in a marathon. Magnetic resonance images for assessment of right and left ventricular mass and volumes were obtained at baseline and after 3, 6, 9, and 12 months of training. Maximum oxygen uptake ( max) and cardiac output at rest and during exercise (C2H2 rebreathing) were measured at the same time periods. Pulmonary artery catheterization was performed before and after 1 year of training, and pressure-volume and Starling curves were constructed during decreases (lower body negative pressure) and increases (saline infusion) in cardiac volume. Mean max rose from 40.3\u00b11.6 to 48.7\u00b12.5 mL/kg per minute after 1 year (P<0.00001), associated with an increase in both maximal cardiac output and stroke volume. Left and right ventricular mass increased progressively with training duration and intensity and reached levels similar to those observed in elite endurance athletes. In contrast, left ventricular volume did not change significantly until 6 months of training, although right ventricular volume increased progressively from the outset; Starling and pressure-volume curves approached but did not match those of elite athletes. CONCLUSIONS One year of prolonged and intensive endurance training leads to cardiac morphological adaptations in previously sedentary young subjects similar to those observed in elite endurance athletes; however, it is not sufficient to achieve similar levels of cardiac compliance and performance. Contrary to conventional thinking, the left ventricle responds to exercise with initial concentric but not eccentric remodeling during the first 6 to 9 months after commencement of endurance training depending on the duration and intensity of exercise. Thereafter, the left ventricle dilates and restores the baseline mass-to-volume ratio. In contrast, the right ventricle responds to endurance training with eccentric remodeling at all levels\u2026", "author" : [ { "dropping-particle" : "", "family" : "Arbab-Zadeh", "given" : "Armin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Perhonen", "given" : "Merja", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Howden", "given" : "Erin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Peshock", "given" : "Ronald M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zhang", "given" : "Rong", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Adams-Huet", "given" : "Beverly", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haykowsky", "given" : "Mark J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Levine", "given" : "Benjamin D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Circulation", "id" : "ITEM-1", "issue" : "24", "issued" : { "date-parts" : [ [ "2014", "12", "9" ] ] }, "page" : "2152-61", "title" : "Cardiac remodeling in response to 1 year of intensive endurance training.", "type" : "article-journal", "volume" : "130" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=6a0cc096-839e-4056-87e7-6ff6829821ae" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "1524-4539", "PMID" : "11864923", "abstract" : "BACKGROUND The clinical significance and long-term consequences of left ventricular (LV) hypertrophy associated with intensive athletic conditioning remain unresolved. METHODS AND RESULTS We prospectively evaluated 40 elite male athletes who had shown marked LV cavity enlargement of > or = 60 mm, wall thickness of > or = 13 mm, or both in a longitudinal fashion with serial echocardiograms, initially at peak training (age 24 +/- 4 years) and subsequently after a long-term deconditioning period (1 to 13 years; mean, 5.6 +/- 3.8). After detraining, LV cavity dimension decreased by 7% (61.2 +/- 2.9 to 57.2 +/- 3.1 mm; P<0.001), maximum wall thickness by 15% (12.0 +/- 1.3 to 10.1 +/- 0.8 mm; P<0.001), and mass normalized to height by 28% (194 +/- 25 to 140 +/- 21 g/m; P<0.001). However, individual subject analysis showed persistent substantial cavity dilatation (> or = 60 mm) in 9 athletes (22%); in contrast, wall thickness returned to normal in each athlete. Multiple regression analysis demonstrated that approximately 50% of the incomplete reduction in cavity dimension was explained by increased body weight and recreational physical activity performed during the follow-up period. No athlete had developed cardiac symptoms, impaired exercise performance, or evidence of LV dysfunction. CONCLUSIONS LV remodeling was evident after long-term detraining, with significant reduction in cavity size and normalization of wall thickness. Resolution of cavity enlargement was, however, incomplete in most cases, and substantial chamber dilatation persisted in >20% of athletes. The possibility that this residual LV hypertrophy, apparently part of the athlete's heart syndrome, may have future long-term clinical implications in some individuals cannot be excluded with certainty.", "author" : [ { "dropping-particle" : "", "family" : "Pelliccia", "given" : "Antonio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Maron", "given" : "Barry J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Luca", "given" : "Rosanna", "non-dropping-particle" : "De", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Paolo", "given" : "Fernando M", "non-dropping-particle" : "Di", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spataro", "given" : "Antonio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Culasso", "given" : "Franco", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Circulation", "id" : "ITEM-2", "issue" : "8", "issued" : { "date-parts" : [ [ "2002", "2", "26" ] ] }, "page" : "944-9", "title" : "Remodeling of left ventricular hypertrophy in elite athletes after long-term deconditioning.", "type" : "article-journal", "volume" : "105" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=ffb57698-b36a-4306-9f2a-60e21a258911" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1016/j.jacc.2014.03.062", "ISSN" : "1558-3597", "PMID" : "25236519", "abstract" : "BACKGROUND Sedentary aging has deleterious effects on the cardiovascular system, including decreased left ventricular compliance and distensibility (LVCD). Conversely, Masters level athletes, who train intensively throughout adulthood, retain youthful LVCD. OBJECTIVES The purpose of this study was to test the hypothesis that preservation of LVCD may be possible with moderate lifelong exercise training. METHODS Healthy seniors (n = 102) were recruited from predefined populations, screened for lifelong patterns of exercise training, and stratified into 4 groups: \"sedentary\" (<2 sessions/week); \"casual\" (2 to 3 sessions/week); \"committed\" (4 to 5 sessions/week); and \"competitive\" Masters level athletes (6 to 7 sessions/week). Right heart catheterization and echocardiography were performed while preload was manipulated using lower body negative pressure and rapid saline infusion to define LV pressure-volume relationships and Frank-Starling curves. RESULTS Peak oxygen uptake and LV mass increased with escalating doses of lifelong exercise, with little change in systolic function. At baseline, LV distensibility was greater in committed (21%) and competitive (36%) exercisers than in sedentary subjects. Group LV stiffness constants (sedentary: 0.062 \u00b1 0.039; casual: 0.079 \u00b1 0.052; committed: 0.055 \u00b1 0.033; and competitive: 0.035 \u00b1 0.033) revealed: 1) increased stiffness in sedentary subjects compared to competitive athletes, whereas lifelong casual exercise had no effect; and 2) greater compliance in committed exercisers than in sedentary or casual exercisers. CONCLUSIONS Low doses of casual, lifelong exercise do not prevent the decreased compliance and distensibility observed with healthy, sedentary aging. In contrast, 4 to 5 exercise sessions/week throughout adulthood prevent most of these age-related changes. As LV stiffening has been implicated in the pathophysiology of many cardiovascular conditions affecting the elderly, this \"dose\" of exercise training may have important implications for prevention of cardiovascular disease.", "author" : [ { "dropping-particle" : "", "family" : "Bhella", "given" : "Paul S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hastings", "given" : "Jeffrey L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fujimoto", "given" : "Naoki", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shibata", "given" : "Shigeki", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Carrick-Ranson", "given" : "Graeme", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Palmer", "given" : "M Dean", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boyd", "given" : "Kara N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Adams-Huet", "given" : "Beverley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Levine", "given" : "Benjamin D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of the American College of Cardiology", "id" : "ITEM-3", "issue" : "12", "issued" : { "date-parts" : [ [ "2014", "9", "23" ] ] }, "page" : "1257-66", "title" : "Impact of lifelong exercise \"dose\" on left ventricular compliance and distensibility.", "type" : "article-journal", "volume" : "64" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=59404921-0c23-47ef-900f-cd3b6a0a5e04" ] }, { "id" : "ITEM-4", "itemData" : { "DOI" : "10.1016/j.jacc.2009.10.068", "ISSN" : "1558-3597", "PMID" : "20378081", "abstract" : "OBJECTIVES The aim of this study was to assess incidence of cardiac events and/or left ventricular (LV) dysfunction in athletes exposed to strenuous and uninterrupted training for extended periods of time. BACKGROUND Whether highly intensive and uninterrupted athletic conditioning over a long period of time might be responsible for cardiac events and/or LV dysfunction is unresolved. METHODS We assessed clinical profile and cardiac dimensions and function in 114 Olympic athletes (78% male; mean age 22 +/- 4 years), free of cardiovascular disease, participating in endurance disciplines, who experienced particularly intensive and uninterrupted training for 2 to 5 consecutive Olympic Games (total, 344 Olympic events), over a 4- to 17-year-period (mean 8.6 +/- 3 years). RESULTS Over the extended period of training and competition, no cardiac events or new diagnoses of cardiomyopathies occurred in the 114 Olympic athletes. Global LV systolic function was unchanged (ejection fraction: 62 +/- 5% to 63 +/- 5%; p = NS), and wall motion abnormalities were absent. In addition, LV volumes (142 +/- 26 ml to 144 +/- 25 ml; p = 0.52) and LV mass index (109 +/- 21 g/m(2) to 110 +/- 22 g/m(2); p = 0.74) were unchanged, and LV filling patterns remained within normal limits, although left atrial dimension showed a mild increase (37.8 +/- 3.7 mm to 38.9 +/- 3.2 mm; p < 0.001). CONCLUSIONS In young Olympic athletes, extreme and uninterrupted endurance training over long periods of time (up to 17 years) was not associated with deterioration in LV function, significant changes in LV morphology, or occurrence of cardiovascular symptoms or events.", "author" : [ { "dropping-particle" : "", "family" : "Pelliccia", "given" : "Antonio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kinoshita", "given" : "Norimitsu", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pisicchio", "given" : "Cataldo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Quattrini", "given" : "Filippo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dipaolo", "given" : "Fernando M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ciardo", "given" : "Roberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giacinto", "given" : "Barbara", "non-dropping-particle" : "Di", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Guerra", "given" : "Emanuele", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Blasiis", "given" : "Elvira", "non-dropping-particle" : "De", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Casasco", "given" : "Maurizio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Culasso", "given" : "Franco", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Maron", "given" : "Barry J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of the American College of Cardiology", "id" : "ITEM-4", "issue" : "15", "issued" : { "date-parts" : [ [ "2010", "4", "13" ] ] }, "page" : "1619-25", "title" : "Long-term clinical consequences of intense, uninterrupted endurance training in olympic athletes.", "type" : "article-journal", "volume" : "55" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=5085219b-7baa-4b7e-8c68-908efb4d29fb" ] } ], "mendeley" : { "formattedCitation" : "(3,19\u201321)", "plainTextFormattedCitation" : "(3,19\u201321)", "previouslyFormattedCitation" : "(3,19\u201321)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(3,1921). The physiological and morphological differences between males and females are likely to affect cardiac adaptation to exercise, but few studies have specifically investigated this issue. In the largest study of female athletes to date, Pelliccia e al.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0098-7484", "PMID" : "8667565", "abstract" : "UNLABELLED OBJECTIVES; To define the expression of \"athlete's heart\" in women by determining the alterations in cardiac dimensions associated with long-term intense conditioning in elite female athletes. DESIGN; Prospective cardiovascular assessment conducted from 1986 through 1993. Subjects were evaluated using 2-dimensional, M-mode, and Doppler echo-cardiographic studies. SETTING Institute of Sports Science, Italian National Olympic Committee, Rome, Italy. PARTICIPANTS A total of 600 elite female athletes (mean age, 21 years; range, 12-49 years) who had participated in vigorous training (mean duration, 9 years; range, 2-32 years) and had competed in 27 sports, including 211 athletes at the international level and 389 at the national level. A control group consisted of 65 sedentary volunteer women (mean age, 23.7 years; range, 14-41 years) who were free of cardiovascular disease and who did not participate in regular athletic training. MAIN OUTCOME MEASURES Left ventricular end-diastolic cavity dimension and wall thickness. RESULTS Athletes demonstrated larger left ventricular end-diastolic cavity dimension (mean +/- SD) (49 +/- 4 mm) and greater maximal wall thickness (8.2 +/- 0.9 mm) than controls (46 +/- 3 mm and 7.2 +/- 0.6 mm; P < .001). These dimensions were 6% and 14% larger in athletes. Among athletes, left ventricular cavity dimension was 40 mm to 66 mm, exceeded normal limits ( > 54 mm) in 47 women (8%), and was within the range consistent with primary dilated cardiomyopathy ( > or = 60 mm) in 4 athletes (1%). Training for endurance sports, such as cycling, cross-country skiing, and rowing had the greatest effect on cavity dimension. Left ventricular wall thickness was 6 mm to 12 mm in athletes and did not exceed normal limits or extend into the borderline gray zone with hypertrophic cardiomyopathy in any subject. Compared with data from 738 previously studied male athletes, female athletes showed significantly smaller left ventricular cavity dimension (11% less; P < .001) and wall thickness (23% less; P < .001). CONCLUSIONS Highly trained women athletes frequently demonstrate cardiac dimensional changes as an adaptation to physical training, although absolute left ventricular cavity size exceeding normal limits was evident in a minority (8%) of women athletes and was rarely (1% of athletes) within the range of dilated cardiomyopathy. Athletic training was not a stimulus for substantial increases in absolute left ventricular wall thickness, w\u2026", "author" : [ { "dropping-particle" : "", "family" : "Pelliccia", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Maron", "given" : "B J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Culasso", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spataro", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Caselli", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "JAMA", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "1996", "7" ] ] }, "page" : "211-5", "title" : "Athlete's heart in women. Echocardiographic characterization of highly trained elite female athletes.", "type" : "article-journal", "volume" : "276" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=714b9846-9984-4e29-95b6-a6498afbfdff" ] } ], "mendeley" : { "formattedCitation" : "(7)", "plainTextFormattedCitation" : "(7)", "previouslyFormattedCitation" : "(7)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(7) assessed 600 elite female athletes and showed that women did not exhibit a LV wall thickness > 12 mm and rarely revealed significant left ventricular cavity enlargement (LVEDD >54 mm). These results have important clinical implications especially in terms of screening, because they define the physiological upper limits of exercise cardiac adaptation in females. However absolute dimensions may not be particularly sensitive in distinguishing physiology from pathology, whereas LV geometry may be a more useful tool in this setting. Our study confirmed previous findings and showed that none of the females revealed a LV wall thickness >12 mm and only 7% exhibited a LVEDD >54 mm. Although absolute LV end-diastolic diameter in females was lower than in males, when the LV measurements were indexed for BSA, women exhibited a higher LV cavity size. Assessment of LV geometry in athletes engaged in dynamic sports showed that females exhibit predominantly eccentric LV hypertrophy whereas a significant proportion of males (15%) show concentric LV remodelling/hypertrophy. Possible mechanisms underlying the quantitative and geometric differences between males and females include higher circulating concentration of testosterone and a higher density of myocardial testosterone receptors in malesADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0804-4643", "PMID" : "14713281", "abstract" : "OBJECTIVE To test the hypothesis that lower endogenous testosterone levels are associated with higher blood pressure, left ventricular mass, and left ventricular hypertrophy. DESIGN Population-based cross-sectional study. METHODS Sex hormone levels, measured by immunoassay, anthropometric measurements and resting blood pressure were studied in 1548 men aged 25-84 Years; echocardiography was completed in 1264 of these men. Partial correlations and multiple regressions were used to estimate the associations between sex hormones, blood pressure and left ventricular mass by height. Analyses of variance and covariance were used to compare men with categorical hypertension and left ventricular hypertrophy. RESULTS In age-adjusted partial correlations, total testosterone and sex hormone-binding globulin (SHBG) were each inversely associated with systolic blood pressure (SBP) (P<0.001). Men with categorical hypertension (SBP> or =140 or diastolic blood pressure (DBP)> or =90 mmHg) had lower levels of total and free testosterone and SHBG before (P<0.001, P=0.011 and P<0.001, respectively) and after (P<0.001, P=0.035 and P=0.002, respectively) adjusting for body mass index (BMI). Total testosterone and SHBG were each inversely associated with left ventricular mass (P<0.001), and men with left ventricular hypertrophy had significantly lower levels of total testosterone (P=0.042) and SHBG (P=0.006); these associations were no longer significant after adjusting for BMI. CONCLUSION The results of the present study are consistent with the hypothesis that lower levels of testosterone in men are associated with higher blood pressure, left ventricular mass, and left ventricular hypertrophy. The reduced associations after adjusting for BMI suggest that the association of low testosterone levels with blood pressure and left ventricular mass is mediated by obesity.", "author" : [ { "dropping-particle" : "", "family" : "Svartberg", "given" : "Johan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "M\u00fchlen", "given" : "Denise", "non-dropping-particle" : "von", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schirmer", "given" : "Henrik", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barrett-Connor", "given" : "Elizabeth", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sundfjord", "given" : "Johan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jorde", "given" : "Rolf", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "European journal of endocrinology / European Federation of Endocrine Societies", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2004", "1" ] ] }, "page" : "65-71", "title" : "Association of endogenous testosterone with blood pressure and left ventricular mass in men. The Troms\u00f8 Study.", "type" : "article-journal", "volume" : "150" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=940b707a-44ba-497e-aba4-de7198eeac72" ] } ], "mendeley" : { "formattedCitation" : "(22)", "plainTextFormattedCitation" : "(22)", "previouslyFormattedCitation" : "(22)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(22). Recent data suggest that testosterone and its highly active metabolite dihydrotestosterone (DHT) has a pro-hypertrophic effect on murine cardiac myocytes. point toward a prohypertrophic effect of testosterone and its highly active metabolite dihydrotestosterone (DHT) on isolated cardiomyocytes and in miceADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0009-7322", "PMID" : "9697826", "abstract" : "BACKGROUND The role of androgens in producing cardiac hypertrophy by direct action on cardiac myocytes is uncertain. Accordingly, we tested the hypothesis that cardiac myocytes in adult men and women express an androgen receptor gene and that myocytes respond to androgens by a hypertrophic response. METHODS AND RESULTS We used reverse transcription-polymerase chain reaction methods to demonstrate androgen receptor transcripts in multiple tissues and [3H]phenylalanine incorporation and atrial natriuretic peptide secretion as markers of hypertrophy in cultured rat myocytes. Messenger RNA encoding androgen receptors was detected in myocytes of male and female adult rats, neonatal rat myocytes, rat heart, dog heart, and infant and adult human heart. Both testosterone and dihydrotestosterone produced a robust receptor-specific hypertrophic response in myocytes, determined by indices of protein synthesis and atrial natriuretic peptide secretion. CONCLUSIONS Androgen receptors are present in cardiac myocytes from multiple species, including normal men and women, in a context that permits androgens to modulate the cardiac phenotype and produce hypertrophy by direct, receptor-specific mechanisms. There are clinical implications for therapeutic or illicit use of androgens in humans.", "author" : [ { "dropping-particle" : "", "family" : "Marsh", "given" : "J D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lehmann", "given" : "M H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ritchie", "given" : "R H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gwathmey", "given" : "J K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Green", "given" : "G E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schiebinger", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Circulation", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "1998", "7", "21" ] ] }, "page" : "256-61", "title" : "Androgen receptors mediate hypertrophy in cardiac myocytes.", "type" : "article-journal", "volume" : "98" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=687d5b0a-4e04-4373-b94d-e4f63f228122" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1152/ajpheart.01087.2002", "ISSN" : "0363-6135", "PMID" : "12560213", "abstract" : "Premenopausal women are much less prone to develop cardiovascular disease than men of similar age, but this advantage no longer applies after menopause. We previously found that male mice have a significantly higher rate of cardiac rupture than females during the acute phase of myocardial infarction (MI); however, the effects of sexual hormones on chronic remodeling are unknown. We hypothesized that estrogen (E) may protect the heart from chronic remodeling and deterioration of function post-MI, whereas testosterone (T) may have adverse effects. Mice (4 wk old) of both genders were divided into four groups: female groups consisted of 1) sham ovariectomy (S-Ovx) + placebo (P) (S-Ovx + P), 2) S-Ovx + T, 3) Ovx + P, and 4) Ovx + T; and male groups consisted of 1) sham castration (S-Cas)+ P (S-Cas + P), 2) S-Cas + 17beta-estradiol (E), 3) Cas + P, and 4) Cas + E. MI was induced 6 wk later. Echocardiography was performed to assess cardiac function and left ventricular dimensions (LVD). Myocyte cross-sectional area (MCSA) was measured at the end of the study. In females, both testosterone and ovariectomy decreased ejection fraction (EF) and increased LVD, and when combined they aggravated cardiac function and remodeling further. Testosterone significantly increased MCSA. In males, castration or estrogen increased EF and reduced LVD, whereas castration significantly reduced MCSA. Our data suggest that estrogen prevents deterioration of cardiac function and remodeling after MI, but testosterone worsens cardiac dysfunction and remodeling and has a pronounced effect when estrogen levels are reduced.", "author" : [ { "dropping-particle" : "", "family" : "Cavasin", "given" : "Maria A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sankey", "given" : "Steadman S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yu", "given" : "Ai-Li", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Menon", "given" : "Shreevidya", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yang", "given" : "Xiao-Ping", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "American journal of physiology. Heart and circulatory physiology", "id" : "ITEM-2", "issue" : "5", "issued" : { "date-parts" : [ [ "2003", "5" ] ] }, "page" : "H1560-9", "title" : "Estrogen and testosterone have opposing effects on chronic cardiac remodeling and function in mice with myocardial infarction.", "type" : "article-journal", "volume" : "284" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=95351325-5bc6-4c45-b4bd-84e3e2c078f8" ] } ], "mendeley" : { "formattedCitation" : "(23,24)", "plainTextFormattedCitation" : "(23,24)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(23,24) Additionally anti-androgenic therapy has been shown to is supposed to even reverse pathological cardiac hypertrophy in murine modelsADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1161/CIRCULATIONAHA.114.012066", "ISSN" : "1524-4539", "PMID" : "25632043", "abstract" : "BACKGROUND In comparison with men, women have a better prognosis when experiencing aortic valve stenosis, hypertrophic cardiomyopathy, or heart failure. Recent data suggest that androgens like testosterone or the more potent dihydrotestosterone contribute to the development of cardiac hypertrophy and failure. Therefore, we analyzed whether antiandrogenic therapy with finasteride, which inhibits the generation of dihydrotestosterone by the enzyme 5-\u03b1-reductase, improves pathological ventricular remodeling and heart failure. METHODS AND RESULTS We found a strongly induced expression of all 3 isoforms of the 5-\u03b1-reductase (Srd5a1 to Srd5a3) in human and mouse hearts with pathological hypertrophy, which was associated with increased myocardial accumulation of dihydrotestosterone. Starting 1 week after the induction of pressure overload by transaortic constriction, mice were treated with finasteride for 2 weeks. Cardiac function, hypertrophy, dilation, and fibrosis were markedly improved in response to finasteride treatment in not only male, but also in female mice. In addition, finasteride also very effectively improved cardiac function and mortality after long-term pressure overload and prevented disease progression in cardiomyopathic mice with myocardial G\u03b1q overexpression. Mechanistically, finasteride, by decreasing dihydrotestosterone, potently inhibited hypertrophy and Akt-dependent prohypertrophic signaling in isolated cardiac myocytes, whereas the introduction of constitutively active Akt blunted these effects of finasteride. CONCLUSIONS Finasteride, which is currently used in patients to treat prostate disease, potently reverses pathological cardiac hypertrophy and dysfunction in mice and might be a therapeutic option for heart failure.", "author" : [ { "dropping-particle" : "", "family" : "Zwadlo", "given" : "Carolin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmidtmann", "given" : "Elisa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Szaroszyk", "given" : "Malgorzata", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kattih", "given" : "Badder", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Froese", "given" : "Natali", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hinz", "given" : "Hebke", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmitto", "given" : "Jan Dieter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Widder", "given" : "Julian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Batkai", "given" : "Sandor", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "B\u00e4hre", "given" : "Heike", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kaever", "given" : "Volkhard", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Thum", "given" : "Thomas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bauersachs", "given" : "Johann", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Heineke", "given" : "Joerg", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Circulation", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "2015", "3", "24" ] ] }, "page" : "1071-81", "title" : "Antiandrogenic therapy with finasteride attenuates cardiac hypertrophy and left ventricular dysfunction.", "type" : "article-journal", "volume" : "131" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=2df25526-25cc-4f6e-8655-103902e87188" ] } ], "mendeley" : { "formattedCitation" : "(25)", "plainTextFormattedCitation" : "(25)", "previouslyFormattedCitation" : "(25)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(25). Higher peak exercise related systolic blood pressure may also play an important role in the development of LV hypertrophy in malesADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/S0167-5273(00)00417-4", "ISSN" : "01675273", "PMID" : "11150625", "abstract" : "Background: Long term athletic training is associated with an increase in left ventricular diastolic cavity dimensions, wall thickness, and mass. These changes are described as the \"athlete's heart\". In comparison to men, athletic training in women athletes is not a stimulus for substantial increase in left ventricular wall thickness. Although many variables are related to these gender differences in cardiac morphology, some factors such as 24-h blood pressure and the level of training have not been studied yet. Therefore pairs in sport dancing, in which the level of training of both partners is the same, were chosen as models in order to evaluate whether 24-h blood pressure contributes to sex-related differences in an athlete's heart. Methods: Fifteen pairs in the national sport dancing team and 30 control subjects (15 males, 15 females) were studied. In all subjects casual and 24-h ambulatory blood pressures, echocardiography, and maximal stress testing were performed. Results: Female in comparison to male dancers had significantly lower M-mode (P<0.004) and 2-D left ventricular mass index (P<0.001), 24-h systolic blood pressure (P<0.003), day systolic blood pressure (P<0.002), casual systolic blood pressure (P<0.025), and achieved significantly lower peak systolic blood pressure at stress testing (P<0.004). Multiple stepwise regression analysis showed that the best predictors of 2-D left ventricular mass index are maximal work load and peak exercise systolic blood pressure, 24-h systolic blood pressure, day, and casual systolic blood pressure. Conclusions: Lower left ventricular mass index in female dancers can be partly explained by lower systolic blood pressures during 24-h and at exercise. \u00a9 2001 Elsevier Science Ireland Ltd.", "author" : [ { "dropping-particle" : "", "family" : "Zemva", "given" : "Ale\u0161", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rogel", "given" : "Polona", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "International Journal of Cardiology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2001" ] ] }, "page" : "49-54", "title" : "Gender differences in athlete's heart: Association with 24-h blood pressure. A study of pairs in sport dancing", "type" : "article-journal", "volume" : "77" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=9931ad67-7b6b-407e-96b7-1bd427702d52" ] } ], "mendeley" : { "formattedCitation" : "(26)", "plainTextFormattedCitation" : "(26)", "previouslyFormattedCitation" : "(26)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(26). Finally it is also possible that there are both quantitative and qualitative differences to the pattern of training among men that may promote increased hypertrophy. Although the absolute prevalence of abnormal ECGs was similar in male and female athletes, we observed significant differences in the ECG patterns, suggesting the need of a gender-based approach for interpreting the in athletes ECG. interpretation . At odds with recent reports, this study revealed that some athletes do develop concentric remodelling/hypertrophy, especially males. Concentric LVH/remodelling is observed in only 4% of female athletes, involved in purely dynamic exercise. This study also demonstrated that none of female athletes exhibit a RWT >0.48 or a LV mass >145 g/m2. Although none of the female athletes with concentric LVH/remodelling in this study showed other features of pathological LVH, these cut-off values may be an important starting point for the differential diagnosis with hypertrophic cardiomyopathy in a female athlete with cardiac symptoms or abnormal ECG. Limitations The present study has some limitations. We indexed cardiac dimensions for BSA, but this may be not the most accurate method of scaling LV size in athletes. Other studies have considered height, lean body mass and allometric scalingADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0009-7322", "PMID" : "9843460", "abstract" : "BACKGROUND It is unclear whether increased left ventricular (LV) mass in overweight individuals is related to their adiposity or to greater fat-free mass (FFM). METHODS AND RESULTS We compared echocardiographic LV mass to FFM and adipose body mass by bioelectric impedance and to anthropometric measurements in 3107 American Indian participants in the Strong Heart Study. In men and women, the relations of LV mass and FFM (r=0.37 and 0.38, P<0.001) were closer (P<0.05 to <0.001) than they were with adipose mass, waist/hip ratio, body mass index, systolic blood pressure, height, or height2.7. Regression analyses showed that in men LV mass had the strongest independent relation with FFM, followed by systolic blood pressure and age (all P<0.001); in women, LV mass was related to FFM more strongly than it was to systolic blood pressure, age (all P<0. 001), and diabetes (P=0.012). Adipose mass had no independent relation to LV mass. When waist/hip ratio or body mass index were substituted for adipose mass, LV mass was independently related to FFM (P<0.001) and body mass index (P=0.02) but not to waist/hip ratio in men and was independently related to FFM and waist/hip ratio (both P<0.001) but not to body mass index in women. Using 97.5 percentile gender-specific partitions for LV mass/FFM in reference individuals, we found that LV hypertrophy occurred in 20.8% of Strong Heart Study participants with hypertension, overweight, or diabetes compared with 10.5% and 16.7% by LV mass indexed for body surface area or height2.7. CONCLUSIONS LV mass is more strongly related to FFM than to adipose mass, waist/hip ratio, body mass index, or height-based surrogates for lean body weight; LV mass/FFM criteria may increase sensitivity to detect LV hypertrophy.", "author" : [ { "dropping-particle" : "", "family" : "Bella", "given" : "J N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Devereux", "given" : "R B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roman", "given" : "M J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Grady", "given" : "M J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Welty", "given" : "T K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lee", "given" : "E T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fabsitz", "given" : "R R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "V", "family" : "Howard", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Circulation", "id" : "ITEM-1", "issue" : "23", "issued" : { "date-parts" : [ [ "1998", "12", "8" ] ] }, "page" : "2538-44", "title" : "Relations of left ventricular mass to fat-free and adipose body mass: the strong heart study. The Strong Heart Study Investigators.", "type" : "article-journal", "volume" : "98" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=71b4bc5c-ded9-47ea-8e8e-fe20826f52f5" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0143-5221", "PMID" : "11115417", "abstract" : "Empirically derived relationships between body size variables and cardiac dimensions have not been published previously for a large sample of male and female athletes. This process would inform scaling practice and facilitate intra- and inter-group comparisons of cardiac data. Therefore we investigated the relationships of body mass (BM), height and body surface area (BS) with a range of cardiac dimensions derived by echocardiography in 464 male and female elite junior athletes (age range 14-18 years; sporting allocation included rowers, cyclists, footballers, tennis players, swimmers and a miscellaneous group). Initial linearity checks suggested that most of the relationships between the body size variables and cardiac dimensions were non-linear, thus precluding the simple ratio standard approach to scaling. Multiple log-log least-squares linear regression confirmed commonality of slopes (between males and females, across the age range and between sporting groups) for all relationships involving BM and BS. Subsequent analyses of the slope exponent (b) for left ventricular dimensions supported previous data and were dimensionally consistent (LVM-BM, b=0.91+/-0.11; LVM-BS, b=1.44+/-0.19; where LVM is left ventricular mass), except for left ventricular internal dimension in diastole (LVIDd) (LVIDd-BM, b=0.25+/-0.04). Data for the left atria internal dimension (LA) were also dimensionally consistent (LA-BM, b=0.29+/-0.09); however, this was not the case for the right ventricular internal dimension in diastole (RVIDd) (RVIDd-BM, b=0.76+/-0.14). It is possible that these results were due to a study-specific limitation in the data range (LVIDd) and the geometric peculiarities of RVIDd compared with LVIDd. The gender/age/sporting groupxbody size interaction factor for virtually all relationships between height and cardiac dimensions was significant (P<0.05), and thus whole-group b exponents could not be generated. Generally these data support previous small-sample research with athletes, and suggest that allometric scaling, as opposed to simple ratio scaling, should be adopted in studies of cardiac dimensions in athletes. This should allow, with minimal mathematical difficulty, the production of body-size-independent cardiac indices to be evaluated in laboratory or clinical work. Further research is required to develop normative 'allometrically derived' cardiac indices, and care should be taken to determine relationships in specific population groups as well a\u2026", "author" : [ { "dropping-particle" : "", "family" : "George", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sharma", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Batterham", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Whyte", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McKenna", "given" : "W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical science (London, England : 1979)", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2001", "1" ] ] }, "page" : "47-54", "title" : "Allometric analysis of the association between cardiac dimensions and body size variables in 464 junior athletes.", "type" : "article-journal", "volume" : "100" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=aaefa071-dc0e-46ab-8592-520578a68764" ] } ], "mendeley" : { "formattedCitation" : "(27,28)", "plainTextFormattedCitation" : "(27,28)", "previouslyFormattedCitation" : "(27,28)" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }(27,28). However the majority of guidelines from both American and European guidelines suggest reference values normalized per BSA. Our study was conducted on a cohort of highly trained elite athletes (21 8 hours per week of exercise) and these results may not be applicable to recreational athletes. Finally, due to our inability to access a substantial number of black female athletes during the study period, we focused solely on white athletes and the results should not be extrapolated to black athletes. CONCLUSIONS Gender has an important effect on cardiac adaptation to exercise. Although the majority of elite athletes manifest normal LV geometry, males show a higher prevalence of concentric hypertrophy/remodelling than females. Conversely a significant proportion of females generally adapt by developing eccentric hypertrophy, particularly those engaged in dynamic sports. REFERENCES: ADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY  1. George KP., Warburton DER., Oxborough D., et al. Upper limits of physiological cardiac adaptation in ultramarathon runners. J Am Coll Cardiol 2011;57(6):7545. Doi: 10.1016/j.jacc.2010.05.070. 2. Arbab-Zadeh A., Perhonen M., Howden E., et al. Cardiac remodeling in response to 1 year of intensive endurance training. Circulation 2014;130(24):215261. Doi: 10.1161/CIRCULATIONAHA.114.010775. 3. Pelliccia A., Maron BJ., De Luca R., Di Paolo FM., Spataro A., Culasso F. Remodeling of left ventricular hypertrophy in elite athletes after long-term deconditioning. Circulation 2002;105(8):9449. 4. Drezner J a., Ashley E., Baggish AL., et al. Abnormal electrocardiographic findings in athletes: recognising changes suggestive of primary electrical disease. Br J Sports Med 2013;47(3):13752. Doi: 10.1136/bjsports-2012-092069. 5. Corrado D., Schmied C., Basso C., et al. Risk of sports: do we need a pre-participation screening for competitive and leisure athletes? Eur Heart J 2011;32(8):93444. Doi: 10.1093/eurheartj/ehq482. 6. Chandra N., Bastiaenen R., Papadakis M., Sharma S. Sudden cardiac death in young athletes: practical challenges and diagnostic dilemmas. J Am Coll Cardiol 2013;61(10):102740. Doi: 10.1016/j.jacc.2012.08.1032. 7. Pelliccia A., Maron BJ., Culasso F., Spataro A., Caselli G. Athletes heart in women. Echocardiographic characterization of highly trained elite female athletes. JAMA 1996;276(3):2115. 8. Utomi V., Oxborough D., Ashley E., et al. Predominance of normal left ventricular geometry in the male athletes heart. Heart 2014;100(16):126471. Doi: 10.1136/heartjnl-2014-305904. 9. Yalin F., Shiota T., Odabashian J., et al. Comparison by real-time three-dimensional echocardiography of left ventricular geometry in hypertrophic cardiomyopathy versus secondary left ventricular hypertrophy. Am J Cardiol 2000;85(8):10358. 10. Bos JM., Theis JL., Tajik AJ., Gersh BJ., Ommen SR., Ackerman MJ. Relationship between sex, shape, and substrate in hypertrophic cardiomyopathy. Am Heart J 2008;155(6):112834. Doi: 10.1016/j.ahj.2008.01.005. 11. Mitchell JH., Haskell W., Snell P., Van Camp SP. Task Force 8: classification of sports. J Am Coll Cardiol 2005;45(8):13647. Doi: 10.1016/j.jacc.2005.02.015. 12. Clementy J., Bergere P., Bricaud H. Electrocardiography and vectocardiography in the evaluation of left ventricular hypertrophy due to pressure overload. Eur Heart J 1982;3 Suppl A:3747. 13. Sheikh N., Papadakis M., Ghani S., et al. Comparison of Electrocardiographic Criteria for the Detection of Cardiac Abnormalities in Elite Black and White Athletes. Circulation 2014;129(16):163749. Doi: 10.1161/CIRCULATIONAHA.113.006179. 14. Lang RM., Bierig M., Devereux RB., et al. Recommendations for chamber quantification. Eur J Echocardiogr 2006;7(2):79108. Doi: 10.1016/j.euje.2005.12.014. 15. Nagueh SF., Appleton CP., Gillebert TC., et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr 2009;10(2):16593. Doi: 10.1093/ejechocard/jep007. 16. Lang RM., Badano LP., Mor-Avi V., et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015;16(3):23370. Doi: 10.1093/ehjci/jev014. 17. Morganroth J., Maron BJ., Henry WL., Epstein SE. Comparative left ventricular dimensions in trained athletes. Ann Intern Med 1975;82(4):5214. 18. Spence AL., Naylor LH., Carter HH., et al. A prospective randomised longitudinal MRI study of left ventricular adaptation to endurance and resistance exercise training in humans. J Physiol 2011;589(Pt 22):544352. Doi: 10.1113/jphysiol.2011.217125. 19. Arbab-Zadeh A., Perhonen M., Howden E., et al. Cardiac remodeling in response to 1 year of intensive endurance training. Circulation 2014;130(24):215261. Doi: 10.1161/CIRCULATIONAHA.114.010775. 20. Bhella PS., Hastings JL., Fujimoto N., et al. Impact of lifelong exercise dose on left ventricular compliance and distensibility. J Am Coll Cardiol 2014;64(12):125766. Doi: 10.1016/j.jacc.2014.03.062. 21. Pelliccia A., Kinoshita N., Pisicchio C., et al. Long-term clinical consequences of intense, uninterrupted endurance training in olympic athletes. J Am Coll Cardiol 2010;55(15):161925. Doi: 10.1016/j.jacc.2009.10.068. 22. Svartberg J., von Mhlen D., Schirmer H., Barrett-Connor E., Sundfjord J., Jorde R. Association of endogenous testosterone with blood pressure and left ventricular mass in men. The Troms Study. Eur J Endocrinol 2004;150(1):6571. 23. Marsh JD., Lehmann MH., Ritchie RH., Gwathmey JK., Green GE., Schiebinger RJ. Androgen receptors mediate hypertrophy in cardiac myocytes. Circulation 1998;98(3):25661. 24. Cavasin MA., Sankey SS., Yu A-L., Menon S., Yang X-P. Estrogen and testosterone have opposing effects on chronic cardiac remodeling and function in mice with myocardial infarction. Am J Physiol Heart Circ Physiol 2003;284(5):H15609. Doi: 10.1152/ajpheart.01087.2002. 25. Zwadlo C., Schmidtmann E., Szaroszyk M., et al. Antiandrogenic therapy with finasteride attenuates cardiac hypertrophy and left ventricular dysfunction. Circulation 2015;131(12):107181. Doi: 10.1161/CIRCULATIONAHA.114.012066. 26. Zemva A., Rogel P. Gender differences in athletes heart: Association with 24-h blood pressure. A study of pairs in sport dancing. Int J Cardiol 2001;77(1):4954. Doi: 10.1016/S0167-5273(00)00417-4. 27. Bella JN., Devereux RB., Roman MJ., et al. Relations of left ventricular mass to fat-free and adipose body mass: the strong heart study. The Strong Heart Study Investigators. Circulation 1998;98(23):253844. 28. George K., Sharma S., Batterham A., Whyte G., McKenna W. Allometric analysis of the association between cardiac dimensions and body size variables in 464 junior athletes. Clin Sci (Lond) 2001;100(1):4754.  Figure legends Figure 1. LV geometry according to RWT and LV mass (adapted from HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/25712077" LangRM, Badano LP, Mor-Avi V et al. Recommendationsfor cardiacchamberquantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015;16:23370. doi:10.1093/ehjci/jev014). Figure 2. LV mass/RWT relationship and thresholds in males and females. Figure 3. LV geometry in males and females according to type of sport (A). Concentric hypertrophy/remodelling and eccentric hypertrophy in athletes involved in dynamic sport (p<0.001 in females vs males) (B). Table 1. DemographicType of sport and echocardiographic characteristics of the study population. Total (N=1083)Females (N=439)Males (N=644)PType of sportMixed (n;%)672 (62)263 (60)419 (65)0.11Dynamic (n;%)301 (28)131 (30)170 (26)  ),-12=>KLSTU^rsxǻǴ|sh H*mH sH h]AhJheUH*mH sH heUhJh H*mH sH hjh hShJhSH*mH sH  h A F N O j . / O Z [ ^ v |       ! , . / 0 2 F G H I S T ^ q t u ṷ̈hihxChh;HhY hhYhlh+, hhhCh hCh hC5himh h@ hKh6hKh%uhD> hP=hP=hP= h@ 5h>h656 :;<=>Cft$@Ol$&(13>@kŻ𷭻h&hl zhv hKhhe hch>h&5HhFh hHhFh hihq^cHdhK EHhK Ehq^&HhK Ehq^h cHdhFhihYhlh66   678>?D`nrstu|}~  35@CFTVghi  ÿÿûǷ䳷h8-hWh6hnhxLh+,hI he h k!h k! h2h k! he hKhqhhKhv h&hl zh;HE <NdxB_`afpɲ}yok^Q}hl zhRcHdh$Fh~hRcHdh$Fh~Hh$FhRhKahl z hRhl zHh$FhRhRhRhl zhRcHdh$FHh#FhRhR,Hh#FhRhRh cHdhFHhFh h@ 5h>h>5hhxChGh k!h6hqh8-hW  &489DUWdkst"#t<<º¦zvzh6ujhY^Uhy hFhhhFh 5hFhg"|5 h5'jhY^hY^5UmHnHsH uhqhq5hq"hKahyMhR5cHdh,Fhph:hh"0h6hlhKahvhdhRhi &)#tլ֬ެ'90TTVVE[Z[B^D^T^~^dgd3q6dgd"\^dgdl(dgdH'dgdqdhgdR<<<<<<:=;=X=Z===============tttttttu$u[u`uaueufuguhuuuuuȸؤ~z~vrvn~n~nhQXh?9hyh6hbh3 h?9mH sH hhmHnHsH uh6umH sH jhY^UmH sH hfmH sH h6mH sH hmH sH h6mH sH hymH sH hFhFmH sH hhY^jhY^UhhmHnHu*uuuuuuuuuuuuuuvv-v^v_v&/7AƆԆՆ*;<Xtz~HhFhHhF'hFVHhFh.h h.cHdhFHhFh.HhFh.h hUh3 hhmHnHuh6ujhY^Uh_hphy h3 hbhbhQXhl(1$234"#%.K^anȴxdWC&Hh Ehjh.cHdhFhl(hjcHdh E&Hh Ehjh.cHdhF&Hhi,Eh0Bh.cHdhF&Hh Ehjh0BcHdhi,E&Hhh,Eh0Bh.cHdhF&Hh Ehjh.cHdhFHh EhjhhmHnHuh6ujhY^Uh hUh hcHdhF !AQT\huvwҬӬԬլ֬ެҭ֭辶wocZcVLHhF'hFVhR$hj!{5mH sH h]h]5mH sH h0h05h09hzl5mH sH h#mH sH hz[_mH sH hymH sH h0mH sH hQXmH sH h0h0mH sH h mH sH hl(h h@ h0h0Hhj,Eh0Bhl(h0BcHdhj,Eh &Hhj,Eh0Bh.cHdhFۭ֭ܮRY`aftuz} İİsoaSHh F'hRmH sH Hh EhSmH sH hqhqhScHdh EHhF'hmH sH Hh EhSmH sH Hh EhSHh F'hR&Hh EhShRcHdh F'&Hh EhShYcHdh#F'Hh#F'hYhUhz[_hyhR$hR$hFVcHdhF' .5:ENn{'0ǹǝiUH;hR$h{DcHdhF'hqh{DcHdhF'&Hh EhSh{DcHdhF'.Hh EhSh{DcHdhF'mH sH HhF'h0mH sH HhF'h{DmH sH HhF'h{DmH sH HhF'h{DmH sH HhF'h{DmH sH HhF'h{DmH sH HhF'h0mH sH Hh F'h0mH sH Hh F'h{DmH sH 02;@LMV\eͿՙ}eXNXNXNDHhF'hHhg2EhHhg2Ehqh.Hhg2EhhcHdhF'mH sH HhF'hmH sH Hhg2EhmH sH HhF'hmH sH .Hh EhSh{DcHdhF'mH sH Hh EhSmH sH hymH sH h]mH sH !hqh{DcHdhF'mH sH !h]h{DcHdhF'mH sH Ʊʱ˱̱ܱݱ "#678@A±~m~\~\~QD7hxCh{DcHdhF'h;Hh{DcHdhF'h]h]mH sH !hhScHdh EmH sH !hQXhScHdh EmH sH !h]hScHdh EmH sH !hj!{hScHdh EmH sH !h]hScHdh EmH sH !hqhScHdh EmH sH hqmH sH Hh EhSmH sH &Hhh2EhhcHdhF'&Hhg2EhhcHdhF'ANcrzʲ˲!"#$%&'(89tu,-عؒ{sg^UNFBFh6ujhY^U hhh5mH sH h095mH sH hh5mH sH h]mH sH jh{D0JUsHh]h]mH sH h;M[*hhh{DcHdhF'mHnHuh6uh{DcHdhF'"jhY^h{DUcHdhF'hz[_h{DcHdhF'h;M[h{DcHdhF'hxCh{DcHdhF'hjh{DcHdhF'-125(,hjHLR8@Z\^v dq¾ƾ—Ÿhqh6uh:F<h#hj!{hQX hO=UhO=Uhz[_h_hO=UhFh hhhO=UhUH* hO=UhUhU hhjhY^UhhmHnHu6<=qr)*ijqr 2:LQYuļĮا؃xphhmH sH hmH sH h]h"\^mH sH h]mH sH hhmHnHuh6ujhY^Uh"\^ h"\^h"\^hhmHnHsH uh6umH sH jhY^UmH sH h"\^mH sH h]h]mH sH  hihihd5mH sH h]h]5mH sH (/02AE,01;SYu\ ] a b c k t {   žݦ|thjmH sH hhmHnHsH uh6umH sH jhY^UmH sH h"\^mH sH h;M[mH sH humH sH hFmH sH  hz[_hz[_h"mH sH hpmH sH h;HmH sH hz[_mH sH h3[mH sH hlmH sH h]h]mH sH -           , - F G ` a b f h          !"#$UVZ[~{tptptph3q6 h3q6h3q6h^@^B^D^}up hs|:5hmH sH hy%mH sH Hh*FhRmH sH hh_mH sH hh4FmH sH h4FmH sH hRVTmH sH hj!{mH sH hhmH sH  hg"|5hO=UhO=U5hUg hUghUgh?h3q6h52hHXh|q%hoh&*D^T^f^~^^^^^^^^^^^^^^___ _8_:_<_>_x_____________"`%`&`'`(`+`/`2`3`4`5`8`;`A`D`[`````````ֻ鷳h'hd7mH sH h-75 hnh&h&hd7hRVTho h14h14h!h|q%hRnh14h& hqhqhlhqhqhq5 h525 hO=U5=``````````` a aaa a#a&a*a,a4a5a8a;a@aHaKaNaSaTadaeagahaaaa0bAbCbIbRbsbtbvbbbbbbbbbbbbbbc cƾܺܶhh52h](huEh&rhbNhf#h|q%hch2h2hm5h2h25 h6h6 hRh4Fh6h?hRhwmhSChN?hh4Fhd7;~^haacGeLfBhUhl'nooqwwxxxYq@]dgd`dgd?$dgdT5%dgddgdRVTdgd|q%dgd52dgdH'dgd6 ccccTc}c~cccccccdddd!d"dKdPdQdhdndoduddddddddddddddddddeee!e2e4eDeEeFeGeSeYeeeeeeeѹݭ h*nh*nh*nhRVThAKh2hKhh3thZhFhh&hhoh.hf#hch>hr8h6h?hbNh52 hr8h52gHgIgTgUgVgWghgggggggggggggAhBhChShUhhhhhhhi iͽ鵭ݒhoCoNoOoPo|ooooooooooooopp.p1pCpZp[p^p_pcpdppppppppppppppppppp[qȼȵĵĵĵĵĵĵh9rhh^l] hh^lh hK*ehX h^lh^lh>;hUghUg5 hy!5h6h03hHh-75h?hhw.hT5%A[qgqiqqqqqqqqqqqqqqqqqr,rJrPrZr[rjrrrrrrrrrrrrss!s&s(s2s5s>sBsGsXs\s^scsps}ss˿尷ǨǨ巤巨巚hMh+cHdhF'HhF'h+hHh6hss hMhMhMh|S`hkhK*ehzh( h^lh^lh>;h` hh95hw.hpVRh'vh? hh^lh|x5ssssssstt$t(t)t8tLtTtct{tttttttttttttt uu#u$u6uauuŻukaHhF'hSp!Hhz2Eh! #Hhy2Eh! #&Hhy2Eh! #hSp!cHdhF'HhF'hSp!Hh2Eh! #&Hhy2EhNdhSp!cHdhF'Hhy2EhNdhj h^lh^lhhzhHhC h|q%5h;h|q%5hKKhuh|x h|xh|xh95 h^lh^l&Hhy2Eh! #h+cHdhF'&Hh2Eh! #h+cHdhF'&Hhz2Eh! #h+cHdhF'&Hhz2Eh! #hSp!cHdhF'&Hhz2Eh! #hSp!cHdhF'HhF'hSp!HhF'h+HhF'hSp!HhF'hSp!HhF'hSp!wwwwwxxx#x$x%x&x8xLxXx`xaxfxgxhxixyxxxxxxxxxxxxxxxxxy'y=y>yKyZy[ybyeyfyryyyȽȽخȽخةh~c<hNMh!)hh]AhXhZxhhO=UhO=U5 hO=U5hh]AmH sH h|q%hy%h|q%mH sH hTmH sH hmH sH h]AmH sH hh|q%mH sH h|q%mH sH h;h|q%5mH sH 2yyyyyyyyyy *,1;@GR]^_sŊ !(7?ILXYqyм̸차䜕 hwhwhx0h hwhphp5hg"|hh'vh&hj9h_h1mhph~c<hhmHnHuh6ujhY^Uh=nh/h]AhdhM: />?MYai•Εו -z{%&*+,346;Zdlozŧʧ̧ҧ 𻷻𣟣ϣϣ hhh&hKIhq^cHdhP Eh?$hKIhhhmHnHuh6ujhY^Uhh`hpHhP Ehq^hwhwhBcHdh2E hwhwhhBhwh 1 79AHIabcfklvŨƨǨӨԨξ۾ۺzlblRlhh^JmHnHtH uh6u^JnH tH jhY^U^JnH tH h?$^JnH tH hHh.@opqy~ټZ\]ty}Ͻ߽*:=RǺѺѺ||||h& holhxhx holh1mh`h`5h?*h=Sh;>Qhh6hbh`h?$h?$hDcHdh.Yfuv̒žrcrcrcXG!h_S/h(6]aJmHnHuhYAh(B*phhYAh(0J>*B*phhYAh(0J>*B*\phGhYAh(0J5>*B*CJOJQJ\^JaJfHphq hY^jhY^Uh(hK$eh"vx hhRhhR5 hR5hRhR5 h5 hC5 hh5jhY^5UhVhVmHnHu!"#$%4)ghw  d$IfgdH'  dgdH'dgdndgdH'dgdcޓߓ'()0123nr ûÛ~zvrme` hY5hchc5 h(5hSChF1!hR hhih7Jah` hh hh'{hh'{5h(h# hhnhL hK5hLhL5 hhRh(aJmHnHuhmaJmHnHu!h_S/h(5\aJmHnHuh_S/h(aJmHnHu#!"(=fgh•Õȕɕѕҕ֕ؕļĴİzpfp\\fHh Eh)!Hh Eh)!Hh Eh)!Hh EhN5Hh Ehtf htfhtf htfh)! hnhtfh<htf5 htf5hchnh~5hnh:5hnhc5 hnhchchx 5 hY5 h<5Hh Ehtf5h<htf5cHdh E kd$$Iflsrj u# 339 t0644 la5p2yttf  d$IfgdH'  d$Ifgd '  d$Ifgd)!kd$$Iflsrj u# 339 t0644 la5g Ep2yttfɕҕו  d$Ifgd)!  d$Ifgd וؕ'  d$Ifgd kd$$Iflsrj u# 339 t0644 la5g Ep2yttf "#$%&ƼƲ䒈wpf\\\Hh EhN5Hh Eh)! htfhtfhtfh)!h)! htfh)!Hh Eh.3Hh Eh)!UHh EhN5Hh Eh)!Hh EhtfHh EhN5Hh EhN5Hh Eh)!Hh Eh)! hnhtfHh EhN5Hh Eh)!   d$Ifgd)!  d$Ifgd 0.17Static (n;%)100 (10)45 (10)55 (8)0.3EchocardiogramLVEDD (mm)525494545<0.001LVEDD/BSA (mm/m2)27.82.828.62.727.22.7<0.001IVS (mm)9.41.48.71.210.01.3<0.001Maximal LVWT > 12 mm (n;%)26(2.5) /26(40)<0.001PW (mm)9.21.28.41.29.61.2<0.001RWT0.360.040.350.040.360.04<0.001RWT>0.42 (n;%)109(10)34(8)75(12)0.04LV mass/BSA (g/m2)9422831710121<0.001Increased LV mass/BSA (n;%) (n;%)260(24)105(24)155(24)0.942LVEF < 50% (n;%)2(0.1) /2(0.3)0.68E wave (m/s)0.890.180.930.170.860.18<0.001E/A2.10.62.290.722.030.61<0.001E' lateral (cm/s) 18.84193.718.64.20.19E/E'4.91.55.11.24.81.2<0.001Pattern of LV geometryNormal (n;%)756(70)314(71)442(69)0.52Eccentric (n;%)216(20)91(21)125(19)0.46Concentric LVH (n;%)45(4)14(3)31(5)0.14Concentric remodelling (n;%)66(6)20(4)46(7)0.05 Abbreviations: BSA: body surface area; IVS: interventricular septum; LA: left atrial; LVEDD: left ventricular end-diastolic diameter; LVEF: left ventricular ejection fraction; LVH: left ventricular hypertrophy; LVWT: left ventricular wall thickness; PW: posterior wall; RWT: relative wall thickness.      PAGE \* MERGEFORMAT 1 This bit should be in the results section. '  d$Ifgd kd$$Iflsrj u# 339 t0644 la5g Ep2yttf%,0  d$IfgdN5  d$Ifgd)!  d$Ifgd &')*+,./1@px  #$()-.2378<=Aھ{t{{t{ hnhzhz hnh=h= hnh?h? hnh  hnhhh hr8h(h< hnh<h<h<5Hh Eh.3Hh EhN5 hnhtfHh EhN5Hh EhN5Hh EhN5-01@'  d$Ifgd kd$$Iflsrj u# 339 t0644 la5g Ep2yttf@ABCD  d$Ifgd DEPU,  d$Ifgd kd$$Iflsrj u# 339 t0644 la5p2yttfUZ_f  d$Ifgd fgy,  d$Ifgd kd$$Iflsrj u# 339 t0644 la5p2yttf  d$Ifgd ,  d$Ifgd kd$$Iflsrj u# 339 t0644 la5p2yttf  d$Ifgd ,  d$Ifgdr8kd$$Iflsrj u# 339 t0644 la5p2yttf  d$Ifgd ,  d$Ifgd kd$$Iflsrj u# 339 t0644 la5p2yttf '  d$Ifgd '(,6,  d$Ifgd kdz $$Iflsrj u# 339 t0644 la5p2yttf6@JQ  d$Ifgd QRai,  d$Ifgd kdj $$Iflsrj u# 339 t0644 la5p2yttfiov{  d$Ifgd {|,  d$Ifgd kdZ $$Iflsrj u# 339 t0644 la5p2yttf  d$Ifgd ,  d$Ifgd kdJ $$Iflsrj u# 339 t0644 la5p2yttf  d$Ifgd ,  d$Ifgd kd: $$Iflsrj u# 339 t0644 la5p2yttf   d$Ifgd   d$Ifgd $.,  d$Ifgd kd*$$Iflsrj u# 339 t0644 la5p2yttf.8BI  d$Ifgd ABHJMNQRUVZ[_`deijpr| %&(,-hh6h hb5 hnhbhbh hnhzhz hnh=h?h= hnh?LIJNV,  d$Ifgd kd$$Iflsrj u# 339 t0644 la5p2yttfV`jq  d$Ifgd   d$Ifgdzqr,  d$Ifgd kd $$Iflsrj u# 339 t0644 la5p2yttf  d$Ifgd   d$Ifgd=,  d$Ifgdbkd$$Iflsrj u# 339 t0644 la5p2yttf  d$Ifgdb,  d$Ifgdbkd$$Iflsrj u# 339 t0644 la5p2yttf  d$Ifgdb,  d$Ifgdbkd$$Iflsrj u# 339 t0644 la5p2yttf   d$Ifgdb &,  d$Ifgdbkd$$Iflsrj u# 339 t0644 la5p2yttf&-5:  d$Ifgdb-459;JPUVX[\abfhs~#MpѽhFjhFUh(CJaJhCJaJh CJaJh+@h<CJaJhX+h<CJaJh<CJaJh+@h<5CJaJh<5CJaJ$hzhtf5CJaJcHdh Ehzhb hnhbh3:;PV,  d$Ifgdbkd$$Iflsrj u# 339 t0644 la5p2yttfV\bg  d$Ifgdbgh,  d$Ifgdbkd$$Iflsrj u# 339 t0644 la5p2yttf  d$Ifgdb,  dhgdkd$$Iflsrj u# 339 t0644 la5p2yttf!"#$%&  dhgd [$\$gd~$a$ dgdd !"#$%&ºh+@h<CJaJhY^h{Dh{DmH sH h{DmH sH jh{D0JUhwjhY^UmHnHuhFVmHnHuhBEzjhY^UhFjhFU21h:p8. A!"#$% $$If5!vh#v #v3#v#v9:V ls t065 53559a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5g Ep2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5g Ep2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5g Ep2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5g Ep2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttf$$If5!vh#v #v3#v#v9:V ls t065 53559/ a5p2yttfj 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH J`J 8Normal dCJ_HaJmH sH tH DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List Z@Z 0 Balloon Text dCJOJQJaJmHsHtHNoN 0Balloon Text CharCJOJQJ^JaJ`^@` ~0 Normal (Web)ddd[$\$CJOJPJQJaJtH 6U`!6 ]0 Hyperlink >*B*phj3j c Table Grid7:V0<@B< d0Header B#mHsH:oQ: d0 Header Char CJaJtH < @b< d0Footer B#mHsH:oq: d0 Footer Char CJaJtH B'`B @0Comment ReferenceCJaJD@D @0 Comment TextCJaJmHsH>o> @0Comment Text ChartH @j@@ @0Comment Subject5\JoJ @0Comment Subject Char 5\tH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  Sanjay Sharma%SSF',/~ ***- #  <u֭ 0A- 9S7ZD^` ce i@m[qsuwy R 6V+YYx&A-&KMNOPQRSUVWXYZ[\]^_`abcdefhijklmnopqrstvwxyz{|}~^]~!ו0@DUf'6Qi{.IVq &:Vg&LTgu~444445ll^n}}3"ʪ!t,1afPU e%j%%GGjzzw|څ߅tܩ>Y]qd'l''99:EE Khhkk aQXQQQQQQQQQQQQQQQQQQQQQQQQX $&-!L  # @%(    s >TextBox 4#" ?PK!8[Content_Types].xmlAN0EH%N@%邴K@`dOdlyLhoDX3'AL:*/@X*eRp208J妾)G,R}Q)=HiҺ0BL):T뢸WQDY;d]6O&8* VCLj"󃒝 yJ.;[wIC_ :{IOA !>Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!4 drs/e2oDoc.xmlRN!}7vWnmD_@Y, a{Z[oƗr8sffvlp5?)'1nU)gkDN|/GW Z8z_6F_VY#QPC"3&mW!4>T`|P`Y<貢bq>spo.-tr^B!=M֏[ȫ0_Dx[$3v~?PK!Ӭf drs/downrev.xmlLAN0EH$v]ӐTR8qHSX9ԡNN$ؠ@"KEKDs`^WPK-!8[Content_Types].xmlPK-!8! /_rels/.relsPK-!4 .drs/e2oDoc.xmlPK-!Ӭf drs/downrev.xmlPK B S  ?  Ot_GoBackkk 8%^fgsx+5fm5<3:MMb[d[[[bbb"be|o||JJJK‹L%R OOPPX-Y__ ccyjj )̈́քׄ_R͆φȇʇHJ׉ى79ln‹333333333333333333333333333333333tzҥ֥ץץإإ٥٥ڥڥۥۥ\didjdjdkdkdqdqdrdrdsdsdtdtdududvdvdwdwdXGmGnGnGoGoGpGpGwGxG}GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG‹ BDgdP^`OJPJQJ^Jo(-^`OJQJ^Jo(o p^p`OJQJo( @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o P^P`OJQJo(BDglL\n        u(2\QR-)5I eNOAK^qeD:hqK_cGq Kl{&.= B8Uc3 ,9 }G 2c e @ Z ]w z juEY^^Z> B(>9e ZX+&?14SY +>/6xLx(RaXV l )!F1!U^! k!Sp!y!;"! #f#R$?$%L1%T5%|q%&i &)&x&'DP'`'H'tO(l(!){Q*++,ge._S/0x0"052N2C3:i34N5-75956.6IM63q6e7899l:9?9]W9j9+:97:s|::<5<:F<~c<P=N??+@?@YA]AABB0BCSC#D-)D5EuEF4FQRRpVRfkScTTRVTO=UWUxUxU 9VoWHXY!Y\YY[FZ\}]$]"\^q^,_z[_`|S`7Ja%bzbddK$eK*e~Eeg?f(g~ghh(h>hj{j\5k9klolzlm1mn o%bo@topgTp$q)qQCqr&r9r3Br3tBat6u{HuJuvtu vCwkPw{rk@ij)eUt[+wNw&X]f+v, i6imm$I  =*LLqv3T= b#SJMNdPMRU r8F#)w.:e=n *6Ud z%"x FKR"]g9FGUv !fj{D>].,7Uc.3nhRn~tf v3[?!ZpK5o(kQXZxRcssvk oo%uz/p?GXU 7Yy%GZP`r Ib#8$A]l09u^wmSFV..Q'{:GR #BK~8-03T_2*Pv . AiKad5&=^RsVzYY+` 0SF+m>!tUbso 0?n{E=S?*xC ^ #5'A8Sw\<`aU(T-g]({DL\UgbNwiDl6;6Zo=^l*nIT-W|x^Q`~"1C^'vmOz>;lD'yMhs6KKAbe:MvDIQX ~DV8Srne.@XD:bd<Enabled>1</Enabled><ScanUnformatted>1</ScanUnformatted><ScanChanges>1</ScanChanges><Suspended>1</Suspended></ENInstantFormat><ENLayout><Style>J Amer College Cardiology</Style><LeftDelim>{</LeftDelim><RightDelim>}</RightDelim><FontName>Calibri</FontName><FontSize>11</FontSize><ReflistTitle></ReflistTitle><StartingRefnum>1</StartingRefnum><FirstLineIndent>0</FirstLineIndent><HangingIndent>720</HangingIndent><LineSpacing>0</LineSpacing><SpaceAfter>0</SpaceAfter><HyperlinksEnabled>1</HyperlinksEnabled><HyperlinksVisible>0</HyperlinksVisible></ENLayout><Libraries><item db-id="d2p2srwwve2pzre2s0q5a9905pxtzrp5tzst">Paper LV geometry<record-ids><item>1</item><item>2</item><item>3</item><item>4</item><item>5</item><item>6</item><item>7</item><item>16</item><item>17</item><item>18</item><item>19</item><item>20</item><item>21</item><item>22</item><item>24</item><item>25</item><item>26</item><item>29</item><item>30</item><item>31</item><item>32</item><item>33</item></record-ids></item></Libraries>@WkWkWkWkIJKOP@@VX@^@0@Unknown Sanjay SharmaGherardo Finocchiaro Licenced UserGherardo G.Cx Times New Roman5Symbol3. .Cx Arial_ Times-RomanTimes New Roman7.@Calibri5. .[`)TahomaO  MS MinchoMS Gothic?= .Cx Courier New;WingdingsA$BCambria Math"1CF'\CEaq*MEas*M!0ik :qHP  $P{2! xx  Licenced User Sanjay Sharma Oh+'0x  ( 4 @ LX`hpLicenced UserNormalSanjay Sharma23Microsoft Office Word@4('@6a{@|Nق@4_Eaq*՜.+,D՜.+,L hp  SGULMi  TitleTitolo CK+;k+ s    G;gw k  _PID_HLINKSMendeley Document_1Mendeley User Name_1Mendeley Citation Style_1Mendeley Recent Style Id 0_1Mendeley Recent Style Name 0_1Mendeley Recent Style Id 1_1 Mendeley Recent Style Name 1_1 Mendeley Recent Style Id 2_1 Mendeley Recent Style Name 2_1 Mendeley Recent Style Id 3_1 Mendeley Recent Style Name 3_1Mendeley Recent Style Id 4_1Mendeley Recent Style Name 4_1Mendeley Recent Style Id 5_1Mendeley Recent Style Name 5_1Mendeley Recent Style Id 6_1Mendeley Recent Style Name 6_1Mendeley Recent Style Id 7_1Mendeley Recent Style Name 7_1Mendeley Recent Style Id 8_1Mendeley Recent Style Name 8_1Mendeley Recent Style Id 9_1Mendeley Recent Style Name 9_1A "0N,http://www.ncbi.nlm.nih.gov/pubmed/25712077 E _ENREF_4True(gherardobis@yahoo.it@www.mendeley.com<http://www.zotero.org/styles/jacc-cardiovascular-imagingDhttp://www.zotero.org/styles/american-political-science-association(American Political Science Association@http://www.zotero.org/styles/american-sociological-association$American Sociological Association<http://www.zotero.org/styles/canadian-journal-of-cardiology Canadian Journal of Cardiology4http://www.zotero.org/styles/chicago-author-date4Chicago Manual of Style 16th edition (author-date)0http://www.zotero.org/styles/future-cardiologyFuture Cardiology(http://www.zotero.org/styles/harvard1,Harvard Reference format 1 (author-date)$http://www.zotero.org/styles/heartHeart$http://www.zotero.org/styles/ieeeIEEE<http://www.zotero.org/styles/jacc-cardiovascular-imaging JACC: Cardiovascular ImagingDhttp://www.zotero.org/styles/modern-humanities-research-associationLModern Humanities Research Association 3rd edition (note with bibliography)  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~ Root Entry F` Data 1TableVGWordDocument 4~SummaryInformation(DocumentSummaryInformation8MsoDataStoreڝ`Q`SBEZLJX==2ڝ`Q`Item  HPropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q