Potential Adverse Cardiovascular Effects From Excessive Endurance Exercise

doi:10.1016/j.mayocp.2012.04.005

Mayo Clinic Proceedings

Volume 87, Issue 6, June 2012, Pages 587-595

https://doi.org/10.1016/j.mayocp.2012.04.005 Get rights and content

Abstract

A routine of regular exercise is highly effective for prevention and treatment of many common chronic diseases and improves cardiovascular (CV) health and longevity. However, long-term excessive endurance exercise may induce pathologic structural remodeling of the heart and large arteries. Emerging data suggest that chronic training for and competing in extreme endurance events such as marathons, ultramarathons, ironman distance triathlons, and very long distance bicycle races, can cause transient acute volume overload of the atria and right ventricle, with transient reductions in right ventricular ejection fraction and elevations of cardiac biomarkers, all of which return to normal within 1 week. Over months to years of repetitive injury, this process, in some individuals, may lead to patchy myocardial fibrosis, particularly in the atria, interventricular septum, and right ventricle, creating a substrate for atrial and ventricular arrhythmias. Additionally, long-term excessive sustained exercise may be associated with coronary artery calcification, diastolic dysfunction, and large-artery wall stiffening. However, this concept is still hypothetical and there is some inconsistency in the reported findings. Furthermore, lifelong vigorous exercisers generally have low mortality rates and excellent functional capacity. Notwithstanding, the hypothesis that long-term excessive endurance exercise may induce adverse CV remodeling warrants further investigation to identify at-risk individuals and formulate physical fitness regimens for conferring optimal CV health and longevity.

Section snippets

Sudden Cardiac Death and Endurance ET

Over the past 35 years, the number of Americans participating in a marathon annually has risen 20-fold; in 2010, an estimated half-million runners completed a marathon in the United States.¹⁰ Sudden cardiac death (SCD) among marathoners is very rare, with 1 event per 100,000 participants.6, 7, 11, 12 Although that per-participant risk has not changed over the decades, absolute mortality rates have increased as the number of participants has risen. The final 1 mile of the marathon course

Animal Studies

In an elegant animal model of excessive endurance ET, rats were trained (in part by prodding with electrical shocks to maintain high-intensity effort) to run strenuously and continuously for 60 minutes daily for 16 weeks, and then they were compared with control sedentary rats.8, 24 The running rats developed hypertrophy of the left ventricle (LV) and the right ventricle (RV), diastolic dysfunction, and dilation of the left atria and the right atria (RA); they also showed increased collagen

Athlete's Heart

Chronic ET imposes increased hemodynamic demands that alter the loading conditions of the heart, particularly among athletes participating in sports requiring sustained elevations in cardiac work, such as long-distance running, rowing, swimming, and cycling.²⁶ Highly trained individuals develop cardiac adaptations including enlarged LV and RV volumes, increased LV wall thickness and cardiac mass, and increased left atrial size.21, 22, 23 In the general population, these structural changes are

Biomarker Evidence for Cardiac Damage With Extreme Endurance ET

Running is a prototypical natural PA and often plays an integral and important role in an active, healthy lifestyle.9, 34, 35, 36 However, uninterrupted very long distance running as is generally done while training for and participating in marathons and other extreme endurance events may produce adverse CV effects in susceptible individuals. Serologic markers of cardiac damage, including cardiac troponin, creatine kinase MB, and B-type natriuretic peptide, have been documented to increase in

Adverse Structural Remodeling

Accumulating evidence suggests that the adverse effects of both short-term intense PA and cumulative endurance exercise are most apparent in the right-sided cardiac chambers. Cardiac output at rest is approximately 5 L/min but typically increases 5-fold to about 25 L/min during vigorous ET.²¹ Long-term daily sessions of hours of continuous strenuous PA cause dilation of the RA and RV. During the postexercise period, the cardiac geometric dimensions are restored, but with this recurrent stretch

Coronary Artery Changes

Veteran endurance marathon runners in one study had coronary arteries that, at resting baseline, were similar in size to those of sedentary controls, but the marathoners had greater coronary artery dilating capacity.⁵² Mohlenkamp et al³⁰ studied 108 middle-aged German long-term marathon runners and compared them with matched nonrunner controls. They observed a greater atherosclerotic burden in the marathoners as documented by higher coronary artery calcium (CAC) scores. Additionally, during

Pathophysiology of Long-Term Extreme ET

Figure 7 shows the pathophysiology and possible adverse CV consequences (fibrosis, atrial arrhythmias, VAs, and SCD) associated with endurance ET and competition, such as marathon running. Individuals who do long-term ET and race over very long distances induce sustained (often for 1 to several hours daily) elevations in heart rate, blood pressure, cardiac output, and cardiac chamber volumes.⁹ Heavy and sustained ET generates large quantities of free radicals⁵⁵ that likely outstrip the

Proarrhythmic Effects of Excessive Endurance ET

Although it has been recognized that elite-level endurance athletes commonly have electrocardiographic abnormalities and atrial and ventricular ectopy,28, 44, 54 these functional adaptations traditionally have not been thought to predispose to serious arrhythmias or SCD. However, it appears that adverse cardiac remodeling induced by excessive ET can create an arrhythmogenic substrate, and rhythm abnormalities may be the most common CV problems encountered by veteran endurance athletes.29, 31, 54

Risk Stratification For Endurance Athletes

Currently, we have no proven screening methods for detecting potential CV pathologic changes associated with extreme endurance ET. A logical strategy for now might be to deploy postcompetition cardiac biomarkers, echocardiography, and/or advanced imaging such as cardiac MRI to identify individuals at risk for and/or with subclinical adverse structural remodeling and substrate for arrhythmias, but the cost would likely be prohibitive.⁶⁵ Computed tomography for CAC scoring may be useful,

Conclusion

In some individuals, long-term excessive endurance ET may cause adverse structural and electrical cardiac remodeling, including fibrosis and stiffening of the atria, RV, and large arteries. This theoretically might provide a substrate for atrial and ventricular arrhythmias and increase CV risk. Further investigation is warranted to identify the exercise threshold for potential toxicity, screening for at-risk individuals, and ideal ET regimens for optimizing CV health. For now, on the basis of

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La seule participation à un programme de RC n’était pas associée à un risque plus faible de survenue de FA. Toutefois, des valeurs initiales plus élevées de CCR et une plus grande amélioration des valeurs de la CCR ont exercé un effet protecteur proportionnel aux valeurs.

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ReviewPotential Adverse Cardiovascular Effects From Excessive Endurance Exercise

Abstract

Section snippets

Sudden Cardiac Death and Endurance ET

Animal Studies

Athlete's Heart

Biomarker Evidence for Cardiac Damage With Extreme Endurance ET

Adverse Structural Remodeling

Coronary Artery Changes

Pathophysiology of Long-Term Extreme ET

Proarrhythmic Effects of Excessive Endurance ET

Risk Stratification For Endurance Athletes

Conclusion

Mayo Clin Proc

Lancet

Lancet

Am J Cardiol

J Am Coll Cardiol

Int J Cardiol

Mayo Clin Proc

Cardiol Clin

Am J Med

Prog Cardiovasc Dis

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Metabolism

Int J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Psychol Sport Exer

Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association

Circulation

Increased life expectancy of world class male athletes

Med Sci Sports Exerc

Reduced disability and mortality among aging runners: a 21-year longitudinal study

Arch Intern Med

Running and all-cause mortality risk: is more better?

Med Sci Sports Exerc

Exercise duration as a determinant of vascular function and antioxidant balance in patients with coronary artery disease

Heart

Exercise-induced arrhythmogenic right ventricular cardiomyopathy: fact or fallacy?

Eur Heart J

USA Marathoning: 2007 OverviewMarathonGuide.com Web site

Competing risks of mortality with marathons: retrospective analysis

BMJ

Cardiac arrest during long-distance running races

N Engl J Med

The fittest person in the morgue?

Histopathology

Sudden death during the triathlon

JAMA

Incidence of sudden cardiac death in National Collegiate Athletic Association athletes

Circulation

Acute coronary thrombosis in Boston marathon runners

N Engl J Med

Review
Potential Adverse Cardiovascular Effects From Excessive Endurance Exercise