Cardiac Adaptation to Exercise chronic

1. Cardiac Adaptation to Exercise chronic • Morphological • Myocardial • Vascular • Functional • Neural

2. CRMS Chronic Cardiac Adaptation to Exercise Morphological Myocardial hypertrophy Coronaries

3. CRMS Chronic Cardiac Adaptation to Exercise Morphological • Myocardial hypertrophy • Eccentric • Concentric Coronaries

4. Hypertrophia-Hyperplasia • Hyperplasia constitutes an increase in the number of cells in an organ or tissue, which may then have increased volume. • Hypertrophy refers to an increase in the size of cells and, with such change, an increase in the size of the organ

5. CRMS Myocardial hypertrophy pressure overload Due to physical stimuli volume overload Due to hormonal chemical stimuli

6. CRMS Factors promoting Cardiac hypertrophy Mechanical Force

7. Volume Overload Increased parietal diastolic stress Addition of sarcomer in series Increase chamber size Eccentric Hypertrophy Pressure Overload Increased parietal systolic stress Addition of sarcomer in parallel Increase wall thickness Concentric Hypertrophy Development of Myocardial Hypertrophy Collagen CRMS

8. Exercise (Isometric-Isotonic) Overload Volume/pressure Adeguate Capillary density Myocite Hypertrophy Cardiac remodelling Increase contrattility CRMS Athletic Heart Effects of pressure/volume overload on cardiac structure and function

9. Effects of Training on Left Ventricle

10. Adaptation of the Heart to Exercise Training

11. Adaptation of the Heart to Exercise Normal Concentric Eccentric

13. CRMS Calculation of Left Ventricle Mass LVM(gr) =0,80x1,05x (IVS+PWT+LVID)3-LVID 3

14. Anatomical Section Through the Short Axis of Left Ventricle

15. Short Axis View of Left Ventricle in Normal Subject

16. Short Axis View of Left Ventriclein Athlete

17. Pathological Hypertrophy

18. CRMS Hypertrophy Modulating Factors • Age • Gender • Type of stimulus • Genetic heritage

19. Hypertrophy Modulating Factors • Age

20. CRMS Left Ventricular Mass in young athletes ( soccer players): a cross echocardiographic study Giorgio Galanti M.D, Paolo Manetti M.D., Maria Concetta Vono M.D., Loira Toncelli M.D., Paola Zilli M.D., Carlo Rostagno M.D., Vieri Boddi M.Sc.*, Natale Villari M.D**,Roberto Salti M.D.

21. Purpose - Regular exercising induces changes in left ventricular mass (LVM). While its effects in adults are well known, few data are so far available on those in adolescents. • Methods - group of 127 young male soccer players (aged 13.6±2.1 yr., mean ± standard deviation) was studied. They had been regularly playing soccer since they were six years old. Players were age-matched with 70 male sedentary adolescents. LVM was detected with echocardiography and body composition with bioelectrical impedance analysis. Pubertal stadiation was evaluated with the Tanner method and skeletal maturation with hand x-ray.

22. Results - Skeletal age, Tanner maturation and weight were comparable in the two groups, while height (p=0.002), fat-free mass (FFM, p<0.0005) and cellular body mass (p=0.002) were higher in athletes. Players showed increased LVM as compared with controls (159±49 vs. 137±42 g, p=0.002; confirmed by measures of LVM/body surface area: 97±19 g/m2 vs. 87±17 g/m2, p<0.0005, respectively). Starting from similar values, LVM progressively increased more in players than in controls after 12 yr. (Tanner 2), reaching statistical significance at 15.4 yr. (Tanner 5). In both athletes and controls LVM was directly correlated with all the anthropometric and cardiovascular parameters examined (p<0.0005). At multivariate analysis LVM was significantly correlated with skeletal age (b=8.54), height (b=1.77) in athletes, and with skeletal age (b=4.83) and FFM (b=1.83) in controls.

23. Conclusions • Our data suggest that exercise induces a physiological left ventricular hypertrophy in sportive population. • This hypertrophy becomes evident after sexual maturation was achieved.

24. CRMS Hypertrophy Modulating Factors Type of stimulus

25. Hypertrophy Modulating Factors Circulation Reasearch 2001

26. Hypertrophy Modulating Factors Genetic Heritage

27. Studied SubjetsAllelic Frequency Analysis • 42 elite soccer male players • (from 17 to 31 years old) • 45 age matched healthy • male controls • All were studied with echocardiography and DNA analysis G.Galanti et al. MSSE Nov:2000

28. Correlation between Left Ventricular Mass (LVM) and I/D Polimorphysm Athletes with increased LVM Athletes without increased LVM Genotype DD + ID 14 5 II 3 0 p<0,05 G.Galanti et al. MSSE Nov:2000

29. CRMS CONCLUSIONS • Increase of left ventricular mass is correlated with I/D polimorphism: The DD athletes had shown an increase while the II athletes had a reduction. • Increase of left ventricular mass is not correlated with A/C polimorphism: G.Galanti et al. MSSE Nov:2000

30. CRMS La scelta dello sport è geneticamente determinata? Association of angiotensin-converting enzyme gene I/D polymorphism with change in left ventricular mass in response to physical training Montgomery H, Clarkson P et al Circulation 1997, 96: 741-747)

31. CRMS Soggetti Studiati I soggetti studiati comprendevano 136 atleti allenati (età media 24±3.5 anni) tra i quali 121 erano calciatori(85 maschi, 36 femmine) e 15 ciclisti (maschi), confrontati con 155 controlli, sedentari, comparabili per sesso ed età.

32. CRMS Risultatifrequenza allelica La distribuzione del genotipo è risultata in accordo con l'equilibrio di Hardy-Weinberg e la frequenza allelica è risultata comparabile nei due gruppi. Non sono state evidenziate differenze significative comparando la distribuzione dei genotipi nei vari tipi di sport.

33. CRMS Athlete’s HeartDistinguishing normal from abnormal • Adeguate Hypertrophy • Normal Systolic Function • Normal Diastolic Function • Reversibility

34. CRMS Athlete’s HeartDistinguishing normal from abnormal • Adeguate Hypertrophy • Normal Systolic Function • Normal Diastolic Function • Reversibility

35. Types of Myocardial Hypertrophy Normal Adeguate Adeguate NonAdeguate

36. Variability of wall thickness in elite athletes N° Athl Wall Thickness mm Pelliccia.NEJM.1991

37. CRMS Athlete’s HeartDistinguishing normal from abnormal • Adeguate Hypertrophy • Normal Systolic Function • Normal Diastolic Function • Reversibility

38. Exercise Echocardiography

39. CRMS Modifications during Exercise Echocardiography • Increse Ejection fraction • Decreased Left Systolic Ventricular Volume • No significant modifications of Wall Stress

40. CRMS Athlete’s HeartDistinguishing normal from abnormal • Adeguate Hypertrophy • Normal Systolic Function • Normal Diastolic Function • Reversibility

41. DIASTOLIC FUNCTION IN ATHLETES

42. CRMS Athlete’s HeartDistinguishing normal from abnormal • Adeguate Hypertrophy • Normal Systolic Function • Normal Diastolic Function • Reversibility

43. Regression of Athlete’s Hypertrophy G.Galanti et al. Cardiologia 1989

44. CRMS Cardiac Adaptation to Exercise chronic Morphological • Myocardial hypertrophy • Eccentric • Concentric Coronaries

45. Coronary Arteries

46. Left Coronary in Athlete

47. Rigth Coronary in Athlete

48. Cardiac Adaptation to Exercisechronic Functional Heart Rate

49. H.R. b/min Cycloergometer Recovery Cardiovascular Response to Acute Exercise in trained subjects