Advertisement
Canadian Journal of Cardiology

The Potential Cardiotoxic Effects of Exercise

  • André La Gerche
    Correspondence
    Corresponding author: A/Prof André La Gerche, Sports Cardiology, Baker IDI Heart and Diabetes Institute, Level 4 Alfred Centre, 99 Commercial Rd, Melbourne 3004, Australia. Tel.: +1-9288-4423; fax: +61-39288-4422.
    Affiliations
    Baker IDI Heart and Diabetes Institute, and Department of Cardiology, Alfred Hospital, Melbourne, Australia; and the Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
    Search for articles by this author
Published:February 24, 2016DOI:https://doi.org/10.1016/j.cjca.2015.11.010

      Abstract

      The emerging controversy related to the potential cardiotoxic effects of high doses of intense exercise need to be considered among the much stronger evidence that supports the pleomorphic benefits of exercise as a whole. However, there is fairly compelling evidence to support the association between long-term sport practice and an increased prevalence of atrial fibrillation and the fact that this relates to a chronic altered atrial substrate. This article was designed to challenge the reader with speculative science that suggests that exercise might promote permanent structural changes in the myocardium which can, in some individuals, predispose to arrhythmias. In terms of long-term health outcomes, it would seem that these small risks are outweighed by the many other benefits of exercise, including a likely decrease in atherosclerotic vascular events, although some recent results have brought into question whether the protective benefits of exercise on vascular events also extends to high-intensity exercise training. Above all else, in this article we sought to highlight current controversies to stimulate research on the many unanswered questions. In particular, there is a lack of adequately powered prospective studies from which we can measure health outcomes and their relationship to exercise-induced cardiac remodelling.

      Résumé

      La nouvelle controverse relative aux possibles effets cardiotoxiques de l’exercice intensif pendant de longues périodes doit être revue à la lumière des preuves beaucoup plus probantes appuyant les nombreux bienfaits offerts par l’exercice physique en général. Il existe des preuves assez concluantes à l’effet que les sports intenses pratiqués à long terme augmentent la prévalence de la fibrillation auriculaire liée à une modification du substrat auriculaire et cet article a pour but de mettre le lecteur au défi en lui présentant l’hypothèse selon laquelle l’exercice serait susceptible d’entraîner des modifications structurelles permanentes du myocarde qui pourraient prédisposer certaines personnes à l’arythmie. Ces risques, somme toute limités, seraient toutefois amplement compensés par les bienfaits généraux de l’exercice physique, notamment la réduction des accidents vasculaires liés à l’athérosclérose, et ce, même si les résultats de certaines études récentes semblent remettre en question les bienfaits vasculaires de l’exercice intensif. Dans cet article, nous avons avant tout cherché à faire ressortir la controverse actuelle afin de stimuler l’amorce de travaux de recherche visant à fournir des réponses aux nombreuses questions qui demeurent toujours en suspens. Il y a notamment une pénurie d’études prospectives suffisamment importantes pour pouvoir mesurer les effets de l’exercice sur la santé et son association avec le remodelage cardiaque induit par l’exercice.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Khan K.M.
        • Thompson A.M.
        • Blair S.N.
        • et al.
        Sport and exercise as contributors to the health of nations.
        Lancet. 2012; 380: 59-64
        • Sallis R.
        • Franklin B.
        • Joy L.
        • et al.
        Strategies for promoting physical activity in clinical practice.
        Prog Cardiovasc Dis. 2015; 57: 375-386
        • Bauman A.E.
        • Reis R.S.
        • Sallis J.F.
        • et al.
        Correlates of physical activity: why are some people physically active and others not?.
        Lancet. 2012; 380: 258-271
        • Corrado D.
        • Basso C.
        • Rizzoli G.
        • Schiavon M.
        • Thiene G.
        Does sports activity enhance the risk of sudden death in adolescents and young adults?.
        J Am Coll Cardiol. 2003; 42: 1959-1963
        • Marijon E.
        • Tafflet M.
        • Celermajer D.S.
        • et al.
        Sports-related sudden death in the general population.
        Circulation. 2011; 124: 672-681
        • Blair S.N.
        • Kohl 3rd, H.W.
        • Paffenbarger Jr., R.S.
        • et al.
        Physical fitness and all-cause mortality. A prospective study of healthy men and women.
        JAMA. 1989; 262: 2395-2401
        • La Gerche A.
        • Prior D.L.
        • Heidbuchel H.
        Strenuous endurance exercise: is more better for everyone? Our genes won’t tell us.
        Br J Sports Med. 2011; 45: 162-164
        • Armstrong M.E.
        • Green J.
        • Reeves G.K.
        • Beral V.
        • Cairns B.J.
        Frequent physical activity may not reduce vascular disease risk as much as moderate activity: large prospective study of women in the United Kingdom.
        Circulation. 2015; 131: 721-729
        • Shiroma E.J.
        • Sesso H.D.
        • Moorthy M.V.
        • Buring J.E.
        • Lee I.M.
        Do moderate-intensity and vigorous-intensity physical activities reduce mortality rates to the same extent?.
        J Am Heart Assoc. 2014; 3: e000802
        • La Gerche A.
        • McMullen J.R.
        Let’s keep running... exercise, basic science and the knowledge gaps.
        Heart. 2015; 101: 742-744
        • Sarna S.
        • Sahi T.
        • Koskenvuo M.
        • Kaprio J.
        Increased life expectancy of world class male athletes.
        Med Sci Sports Exerc. 1993; 25: 237-244
        • Kujala U.M.
        • Tikkanen H.O.
        • Sarna S.
        • et al.
        Disease-specific mortality among elite athletes.
        JAMA. 2001; 285: 44-45
        • Marijon E.
        • Tafflet M.
        • Antero-Jacquemin J.
        • et al.
        Mortality of French participants in the Tour de France (1947-2012).
        Eur Heart J. 2013; 34: 3145-3150
        • Chahal H.S.
        • Elizabeth Mostofsky E.
        • Mittleman M.A.
        • et al.
        Aerobic fitness and risk of ventricular arrhythmia following physical exertion.
        Can J Cardiol. 2016; ([in press])
        • Abdulla J.
        • Nielsen J.R.
        Is the risk of atrial fibrillation higher in athletes than in the general population? A systematic review and meta-analysis.
        Europace. 2009; 11: 1156-1159
        • Claessen G.
        • Colyn E.
        • La Gerche A.
        • et al.
        Long-term endurance sport is a risk factor for development of lone atrial flutter.
        Heart. 2011; 97: 918-922
        • Biffi A.
        • Maron B.J.
        • Verdile L.
        • et al.
        Impact of physical deconditioning on ventricular tachyarrhythmias in trained athletes.
        J Am Coll Cardiol. 2004; 44: 1053-1058
        • Baldesberger S.
        • Bauersfeld U.
        • Candinas R.
        • et al.
        Sinus node disease and arrhythmias in the long-term follow-up of former professional cyclists.
        Eur Heart J. 2008; 29: 71-78
        • Heidbuchel H.
        • Hoogsteen J.
        • Fagard R.
        • et al.
        High prevalence of right ventricular involvement in endurance athletes with ventricular arrhythmias. Role of an electrophysiologic study in risk stratification.
        Eur Heart J. 2003; 24: 1473-1480
        • Schnell F.
        • Claessen G.
        • La Gerche A.
        • et al.
        Subepicardial delayed gadolinium enhancement in asymptomatic athletes: let sleeping dogs lie?.
        Br J Sports Med. 2016; 50: 111-117
        • Karjalainen J.
        • Kujala U.M.
        • Kaprio J.
        • Sarna S.
        • Viitasalo M.
        Lone atrial fibrillation in vigorously exercising middle aged men: case-control study.
        BMJ. 1998; 316: 1784-1785
        • Grimsmo J.
        • Grundvold I.
        • Maehlum S.
        • Arnesen H.
        High prevalence of atrial fibrillation in long-term endurance cross-country skiers: echocardiographic findings and possible predictors–a 28-30 years follow-up study.
        Eur J Cardiovasc Prev Rehabil. 2010; 17: 100-105
        • Molina L.
        • Mont L.
        • Marrugat J.
        • et al.
        Long-term endurance sport practice increases the incidence of lone atrial fibrillation in men: a follow-up study.
        Europace. 2008; 10: 618-623
        • Mont L.
        • Sambola A.
        • Brugada J.
        • et al.
        Long-lasting sport practice and lone atrial fibrillation.
        Eur Heart J. 2002; 23: 477-482
        • Elosua R.
        • Arquer A.
        • Mont L.
        • et al.
        Sport practice and the risk of lone atrial fibrillation: a case-control study.
        Int J Cardiol. 2006; 108: 332-337
        • Heidbuchel H.
        • Anne W.
        • Willems R.
        • et al.
        Endurance sports is a risk factor for atrial fibrillation after ablation for atrial flutter.
        Int J Cardiol. 2006; 107: 67-72
        • Thelle D.S.
        • Selmer R.
        • Gjesdal K.
        • et al.
        Resting heart rate and physical activity as risk factors for lone atrial fibrillation: a prospective study of 309 540 men and women.
        Heart. 2013; 99: 1755-1760
        • Biffi A.
        • Pelliccia A.
        • Verdile L.
        • et al.
        Long-term clinical significance of frequent and complex ventricular tachyarrhythmias in trained athletes.
        J Am Coll Cardiol. 2002; 40: 446-452
        • Corrado D.
        • Basso C.
        • Leoni L.
        • et al.
        Three-dimensional electroanatomical voltage mapping and histologic evaluation of myocardial substrate in right ventricular outflow tract tachycardia.
        J Am Coll Cardiol. 2008; 51: 731-739
        • Dello Russo A.
        • Pieroni M.
        • Santangeli P.
        • et al.
        Concealed cardiomyopathies in competitive athletes with ventricular arrhythmias and an apparently normal heart: role of cardiac electroanatomical mapping and biopsy.
        Heart Rhythm. 2011; 8: 1915-1922
        • La Gerche A.
        • Claessen G.
        • Dymarkowski S.
        • et al.
        Exercise-induced right ventricular dysfunction is associated with ventricular arrhythmias in endurance athletes.
        Eur Heart J. 2015; 36: 1998-2010
        • Wyse D.G.
        • Van Gelder I.C.
        • Ellinor P.T.
        • et al.
        Lone atrial fibrillation: does it exist?.
        J Am Coll Cardiol. 2014; 63: 1715-1723
        • Wilhelm M.
        • Roten L.
        • Tanner H.
        • et al.
        Atrial remodeling, autonomic tone, and lifetime training hours in nonelite athletes.
        Am J Cardiol. 2011; 108: 580-585
        • Luthi P.
        • Zuber M.
        • Ritter M.
        • et al.
        Echocardiographic findings in former professional cyclists after long-term deconditioning of more than 30 years.
        Eur J Echocardiogr. 2008; 9: 261-267
        • Guasch E.
        • Benito B.
        • Qi X.
        • et al.
        Atrial fibrillation promotion by endurance exercise: demonstration and mechanistic exploration in an animal model.
        J Am Coll Cardiol. 2013; 62: 68-77
        • Aschar-Sobbi R.
        • Izaddoustdar F.
        • Korogyi A.S.
        • et al.
        Increased atrial arrhythmia susceptibility induced by intense endurance exercise in mice requires TNFalpha.
        Nat Commun. 2015; 6: 6018
        • La Gerche A.
        • Inder W.J.
        • Roberts T.J.
        • et al.
        Relationship between Inflammatory cytokines and indices of cardiac dysfunction following intense endurance exercise.
        PLoS One. 2015; 10: e0130031
        • Hill J.A.
        • Olson E.N.
        Cardiac plasticity.
        N Engl J Med. 2008; 358: 1370-1380
        • Pelliccia A.
        • Maron B.J.
        • De Luca R.
        • et al.
        Remodeling of left ventricular hypertrophy in elite athletes after long-term deconditioning.
        Circulation. 2002; 105: 944-949
        • La Gerche A.
        • Burns A.T.
        • Taylor A.J.
        • et al.
        Maximal oxygen consumption is best predicted by measures of cardiac size rather than function in healthy adults.
        Eur J Appl Physiol. 2012; 112: 2139-2147
        • Spence A.L.
        • Carter H.H.
        • Naylor L.H.
        • Green D.J.
        A prospective randomized longitudinal study involving 6 months of endurance or resistance exercise. Conduit artery adaptation in humans.
        J Physiol. 2013; 591: 1265-1275
        • Shave R.
        • Baggish A.
        • George K.
        • et al.
        Exercise-induced cardiac troponin elevation: evidence, mechanisms, and implications.
        J Am Coll Cardiol. 2010; 56: 169-176
        • Middleton N.
        • Shave R.
        • George K.
        • et al.
        Left ventricular function immediately following prolonged exercise: a meta-analysis.
        Med Sci Sports Exerc. 2006; 38: 681-687
        • Elliott A.D.
        • La Gerche A.
        The right ventricle following prolonged endurance exercise: are we overlooking the more important side of the heart? A meta-analysis.
        Br J Sports Med. 2015; 49: 724-729
        • La Gerche A.
        • Burns A.T.
        • Mooney D.J.
        • et al.
        Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes.
        Eur Heart J. 2012; 33: 998-1006
        • Oxborough D.
        • Shave R.
        • Warburton D.
        • et al.
        Dilatation and dysfunction of the right ventricle immediately after ultraendurance exercise: exploratory insights from conventional two-dimensional and speckle tracking echocardiography.
        Circ Cardiovasc Imaging. 2011; 4: 253-263
        • Neilan T.G.
        • Januzzi J.L.
        • Lee-Lewandrowski E.
        • et al.
        Myocardial injury and ventricular dysfunction related to training levels among nonelite participants in the Boston marathon.
        Circulation. 2006; 114: 2325-2333
        • Mousavi N.
        • Czarnecki A.
        • Kumar K.
        • et al.
        Relation of biomarkers and cardiac magnetic resonance imaging after marathon running.
        Am J Cardiol. 2009; 103: 1467-1472
        • Trivax J.E.
        • Franklin B.A.
        • Goldstein J.A.
        • et al.
        Acute cardiac effects of marathon running.
        J Appl Physiol. 2010; 108: 1148-1153
        • Heidbuchel H.
        • Prior D.L.
        • La Gerche A.
        Ventricular arrhythmias associated with long-term endurance sports: what is the evidence?.
        Br J Sports Med. 2012; 46: i44-i50
        • La Gerche A.
        • Heidbuchel H.
        • Burns A.T.
        • et al.
        Disproportionate exercise load and remodeling of the athlete’s right ventricle.
        Med Sci Sports Exerc. 2011; 43: 974-981
        • Lewis G.D.
        • Bossone E.
        • Naeije R.
        • et al.
        Pulmonary vascular hemodynamic response to exercise in cardiopulmonary diseases.
        Circulation. 2013; 128: 1470-1479
        • Aaron C.P.
        • Tandri H.
        • Barr R.G.
        • et al.
        Physical activity and right ventricular structure and function. The MESA-Right Ventricle Study.
        Am J Respir Crit Care Med. 2011; 183: 396-404
        • La Gerche A.
        • Robberecht C.
        • Kuiperi C.
        • et al.
        Lower than expected desmosomal gene mutation prevalence in endurance athletes with complex ventricular arrhythmias of right ventricular origin.
        Heart. 2010; 96: 1268-1274
        • Sawant A.C.
        • Bhonsale A.
        • Te Riele A.S.
        • et al.
        Exercise has a disproportionate role in the pathogenesis of arrhythmogenic right ventricular dysplasia/cardiomyopathy in patients without desmosomal mutations.
        J Am Heart Assoc. 2014; 3: e001471
        • Benito B.
        • Gay-Jordi G.
        • Serrano-Mollar A.
        • et al.
        Cardiac arrhythmogenic remodeling in a rat model of long-term intensive exercise training.
        Circulation. 2011; 123: 13-22
        • O’Hanlon R.
        • Wilson M.
        • Wage R.
        • et al.
        Troponin release following endurance exercise: is inflammation the cause? A cardiovascular magnetic resonance study.
        J Cardiovasc Magn Reson. 2010; 12: 38
        • Breuckmann F.
        • Mohlenkamp S.
        • Nassenstein K.
        • et al.
        Myocardial late gadolinium enhancement: prevalence, pattern, and prognostic relevance in marathon runners.
        Radiology. 2009; 251: 50-57
        • Mohlenkamp S.
        • Lehmann N.
        • Breuckmann F.
        • et al.
        Running: the risk of coronary events: prevalence and prognostic relevance of coronary atherosclerosis in marathon runners.
        Eur Heart J. 2008; 29: 1903-1910
        • Wilson M.
        • O’Hanlon R.
        • Prasad S.
        • et al.
        Diverse patterns of myocardial fibrosis in lifelong, veteran endurance athletes.
        J Appl Physiol. 2011; 110: 1622-1626
        • Kokkinos P.
        • Myers J.
        Exercise and physical activity: clinical outcomes and applications.
        Circulation. 2010; 122: 1637-1648
        • Mohlenkamp S.
        • Leineweber K.
        • Lehmann N.
        • et al.
        Coronary atherosclerosis burden, but not transient troponin elevation, predicts long-term outcome in recreational marathon runners.
        Basic Res Cardiol. 2014; 109: 391
        • Schnohr P.
        • O’Keefe J.H.
        • Marott J.L.
        • Lange P.
        • Jensen G.B.
        Dose of jogging and long-term mortality: the Copenhagen City Heart Study.
        J Am Coll Cardiol. 2015; 65: 411-419