1. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE 16 th FINA World Sports Medicine Conference The Athletes’ Heart: From Physiology to Pathology Professor Gregory P Whyte PhD FACSM Research Institute for Sport & Exercise Science Liverpool John Moores University

2. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE VO 2max = Q max * a-vO 2diffmax

3. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE THE ATHLETES’ HEART

4. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE

5. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE

6. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE

7. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE SCD in the Young Sharma, S., Whyte, G. & McKenna, W.J. (1997) Sudden cardiac death from cardiovascular disease in young athletes: fact or fiction? BJSM 31: 269-276 CommonUncommon HCM*Myocarditis ICLVHCAD CAAMarfan’s ARVC**MVP Ionchannelopathies * Most common cause of ERSCD, ** Most common cause of ERSCD in Northern Italy N.B. Some athletes with underlying CV disease are capable of high levels of performance

8. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE

9. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE Exercise Induced Cardiac Damage Positive cTnT samples following the London marathon (scale is log-plotted due to the spread of data) 0.1  g/L cut- off 0.03  g/L cut- off 0.05  g/L cut- off cT nT  g /L Shave et al. Heart, 2005

10. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE Dysfunction & Damage Myocardial injury followed by repair as a result of myocyte hypertrophy (super-compensation) »Physiological Signal for Adaptation Myocardial injury followed by scarring leading to fibrotic replacement associated with arrhythmia generation »Pathologic process of myocardial replacement

11. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE Arrhythmia Ector et al., EHJ 2007;28:345-353 »RV dysfunction leading to RV arrhythmia »Whyte et al., EHJ 2007 [first on-line] Heidbuchel et al., EHJ 2003;24(16):1473-1480 »RV abnormalities acting as a substrate for arrhythmogenic focus in athletes presenting with VT »‘EXERCISE INDUCED VENTRICULAR DYSPLASIA’ »Poor prognosis; incidence of SCD = 25% Jensen-Urstad et al., Heart 1998;79:161-164. »Increased prevalence of complex ventricular arrhythmia, profound bradyarrhythmia (bradycardia < 40bpm) [N=11] Northcote et al., BMJ 1986;55:198-203. »60 deaths, 2 cardiac arrhythmia Northcote et al., Br Heart J 1989;61:155-160. »Heart block and bradyarrhythmias more prevalent in veterans

12. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE

13. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE Cardiac Inflammation & Exercise Chen et al., JAP 2000;88(5):1749-1755 Rats: 8% BM attached to tail and forced to swim for 3.5h/5h Histologic evidence of localised myocyte damage demonstrated by interstitial inflammatory infiltrates consisting of neutrophils, lymphocytes and histiocytes (5h swim)

14. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE Exercise & Reactive Scar Tissue Formation in Humans Virmani et al., Am J Med 1982;72:874-882. »SCD in 30 Joggers »25% (7/30) no identifiable cause – 3 cardiac hypertrophy, 6 myocytolysis and contraction band necrosis (CV?) McKechnie et al., S Afr Med J 1979;56:261-265 »PE in 2 ultramarathon runners secondary to dysfunction? Rowe, WJ, Chest 1991;99:1306-1308 »62 year old world record marathon runner (cause of death: lymphoma) »Circadian variation in coronary vasospasm – ‘Prinz-metal’s »Heart weight 360g. Small patchy non-transmural scar in LV posterior wall. Focal fibrosis of L papillary muscles consistent with remote ischemic insult (normal coronaries & microvasculature) »ISCHEMIA ASSOCIATED WITH CV? Wesslen et al., EHJ 1996;17(6):902-910. »16 SCD Swedish orienteers (5 active myocarditis, 4 ARVC-like alterations)

15. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE Myocardial Fibrosis in a Lifelong Endurance Runner (RH): 2C & 4C LGE images

16. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE Persistent Elevation in cTnT at Rest - RS

17. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE SCD in a Marathon Runner (RC) Whyte et al. BJSM, 2008

18. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE

19. Research Institute for Sport & Exercise Sciences FACULTY OF SCIENCE THANK YOU