© 2015 John Wiley & Sons A/S.
Scand J Med Sci Sports 2015: ••: ••–•• doi: 10.1111/sms.12474
Published by John Wiley & Sons Ltd
Cardiovascular health in former elite male athletes J. K. Johansson1, U. M. Kujala2, S. Sarna3, H. Karanko1, P. J. Puukka1, A. M. Jula1 Department of Chronic Disease Prevention, National Institute for Health and Welfare, Turku, Finland, 2Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland, 3Department of Public Health, University of Helsinki, Helsinki, Finland Corresponding author: Jouni Johansson, MD, Department of Chronic Disease Prevention, National Institute for Health and Welfare, Peltolantie 3, 20720 Turku, Finland. Tel: +358 50 3586060, Fax: +358 20 7547201, E-mail: [email protected]
1
Accepted for publication 17 March 2015
To increase our knowledge on the effects of previous and current physical activity on cardiovascular health, we studied a group of Finnish male former elite athletes (endurance, n = 49; power, n = 50) and their 49 age and area-matched controls, aged 64–89 years. Body mass index (BMI), fasting serum glucose, lipids, blood pressure, and ultrasonography of cardiac and carotid artery structure and function were measured. Former endurance athletes smoked less, had lower prevalence of hypertension, and had higher intensity and volume of leisure time physical activity (LTPA) than the controls. No difference was detected in cardiac or carotid artery structure and function between these groups. Former athletes
performing high-intensity LTPA were slightly younger (possible selection bias), had lower BMI and waist circumference, lower use of antihypertensives, lower prevalence of diabetes, lower pulse wave velocity, and higher carotid artery elasticity than former athletes not performing high-intensity LTPA. In conclusion, former athletes had a higher intensity and volume of LTPA than the controls. Athletes performing vigorous LTPA had more elastic arteries than athletes performing moderately or no LTPA. Vigorous LTPA through the whole lifetime associates with good cardiovascular health, although the previous medical history may play an important role.
According to observational data, low physical activity has been suggested to account worldwide for 2.8% of the disability-adjusted life years, and it is one of the most remarkable individual factors contributing to global disease burden (Lim et al., 2012). Observational follow-up studies suggest that physical activity may protect against cardiovascular diseases such as coronary heart disease, stroke, and hypertension (Rogers et al., 1996; Paffenbarger et al., 2001), and decrease cardiovascular mortality (Paffenbarger et al., 2001; Shortreed et al., 2013). Health benefits seem to increase along with the degree of physical activity (Paffenbarger et al., 2001; Lim et al., 2012) and participation in vigorous exercise has been found to be associated with lower incidence of cardiovascular diseases (Schnohr et al., 2006; Shortreed et al., 2013). Intervention studies have shown that endurance training lowers blood pressure (BP) (Hagberg et al., 1989; Rogers et al., 1996). In addition, it has been shown that endurance athletes have higher life expectancy than population in general (Sarna et al., 1993; Paffenbarger et al., 2001; Teramoto & Bungum, 2010). The increased life expectancy may partly be explained by positive cumulative effects of physical activity on averting cardiovascular diseases, genetic pleiotropy, and partly by the healthier lifestyle of those exercising vigorous sports than the population in general (Paffenbarger et al., 2001;
Schnohr et al., 2006; Kujala, 2011; Shortreed et al., 2013). Although various studies on beneficial health effects of long-term physical activity exist, less is known about the impact of vigorous physical activity on old-age cardiovascular health in former elite athletes. In addition, there has been disagreement about the effects of both volume and intensity of physical exercise on left ventricular (LV) function of heart, and the results have been controversial (Pelliccia et al., 2002; Luthi et al., 2008; Teske et al., 2009; Baggish & Wood, 2011; Bhella et al., 2014; Knackstedt et al., 2014). The objective of the study was to investigate the impact of physical activity on cardiovascular health in surviving former elite male athletes as compared with their controls who were healthy at young adulthood. We hypothesized that a lifelong leisure time physical activity (LTPA) would be associated with a better cardiovascular health in later life. Methods Study design The study design, and the criteria for inclusion and exclusion are described in detail elsewhere (Sarna et al., 1993; Laine et al., 2014). The study population consists of male athletes who had represented Finland between the years 1920 and 1965 at least once in an international or intercountry competition and their age- and
1
Johansson et al. Original study populaon N=4136 - 2424 former athletes - 1712 controls Dropouts N=2953 - 1548 former athletes died - 1162 controls died - 243 lost to follow-up (no replies)
Study parcipants in the year 2008 N=1183 - 747 former athletes - 436 controls
Clinical study parcipants in the year 2008 N=599 - 392 former athletes - 207 controls
Clinical study nonparcipants in the year 2008 N=584 - 355 former athletes - 229 controls
Subgroup of randomly selected parcipants in the year 2008, echocardiographic study N=148 - 49 endurance athletes - 50 power sports athletes - 49 controls
Fig. 1. Flowchart describing participants and nonparticipants of the study. area-matched controls. The study participants were area-matched using six different provinces in Finland. They were Southern Finland, Western Finland, Eastern Finland, Oulu region, Lapland region, and Åland region. The control group consisted of Finnish men who were classified as completely healthy at the compulsory medical examination, which all Finnish men undergo at about 20 years of age as a part of the national military service. A flowchart describing the study participants and nonparticipants is presented in Fig. 1. The questionnaires were sent to all surviving cohort members in 1985, 1995, and 2001. Identical questions on physical activity and chronic diseases were used in the year 1985 and the following years. In 2008, an invitation to participate to follow-up was sent to all former elite athletes (n = 747, of which 392 participated in the study) and controls (n = 436, of which 207 participated) who were alive and who had answered at least one of the questionnaires (in 1985, 1995, or 2001). The athletes were classified as follows: endurance athletes (long-distance running, middle-distance running, and crosscountry skiing) and power sports (boxing, wrestling, shot put, weightlifting, javelin, hammer, and discus). In 2008, a clinical examination including measurements of body mass index (BMI), fasting serum glucose, lipids, BP, echocardiographic ultrasound of heart, intima media thickness (IMT), and pulse wave velocity (PWV) was performed for a subgroup (echocardiographic subgroup) of randomly selected 2008 cohort of elite athletes (50 study subjects from endurance sports group and 50 from power sports group of 392 elite athlete participants) and controls (50 study subjects from the control group of 207 participants). Forty-nine endurance athletes, 50 power sports athletes, and 49 subjects from the control group agreed to participate in the echocardiographic subgroup study. The ethics committee of the Hospital District of Helsinki and Uusimaa approved the study, and all participants gave their informed consent. Data on diseases were collected by using structured questionnaires and from Finnish registers (hospital inpatient discharge register, reimbursable medication register, and disability pension register) (Kujala et al., 1994).
intensity (MET) × duration (h) × times (n) of LTPA, modified from a previous publication (Kujala et al., 1998). MET intensity was defined as follows according to international recommendations (Ainsworth et al., 2000): 1 MET, if subject reported to read, watch television, or perform tasks not requiring physical activity; 4 MET, if subject reported that the physical activity was on average as intensive as walking; 8 MET, if on average as intensive as jogging; 10 MET, if on average as intensive as running. Subjects who did not report to participate in any leisure physical activity or did not report any intensity, duration, or frequency of activity were given MET index of 1 MET h/week. The mean values of MET intensity and MET hours per week (volume) were calculated and shown in Table 1 for elite sports groups and controls. Study subjects were divided in three categories according to the average intensity of LTPA (Table 2, Supporting Information Tables S1 and S2) and according to their MET hours per week (volume) (Table 3). Smoking was defined as smoking daily or occasionally. Diabetes mellitus was defined as a fasting serum glucose level higher or equal to 7.0 mmol/L or the use of insulin injections and/or oral hypoglycemic agents. Presence of hypercholesterolemia was defined as fasting serum total cholesterol level higher or equal to 7.0 mmol/L or the use of lipid-modifying agents. All biochemical samples were fasting samples of 12 h. Alcohol intake was evaluated with a questionnaire and the amount of alcoholic drinks was converted to grams of absolute ethanol per week (Kaprio et al., 1987). Trained study nurses performed the physical examinations including assessment weight, height, waist circumference, and BP, as well as blood sampling. The device for measuring body weight was performed using a digital scale, accuracy 0.1 kg (Seca delta model 707 patient scale, Seca, Hamburg, Germany). Height was measured without shoes on with a measuring tape against the wall to an accuracy of 0.1 cm. BMI was calculated as body weight divided by (height)2 (kg/m2). Waist circumference was measured with the participants in a relaxed standing posture. Waist circumference was measured midway between the anterior superior iliac spine and lower edge of the rib cage.
Definitions
Measurement of BP
Current volume of LTPA was assessed using metabolic equivalents (MET) hours per week. MET hours per week was calculated as
Seated BP was measured by a trained nurse with a conventional calibrated mercury sphygmomanometer after a 5-min rest, with
2
Former elite athletes and controls Table 1. Baseline characteristics
Variable Age (years) BMI (kg/m2) Waist circumference (cm) Current smokers (%) Antihypertensive medication (%) Diabetes (%) Hypercholesterolemia (%) Hypertension (%) Alcohol consumption (g/week) Current LTPA volume (MET hours per week)‡ Current LTPA intensity (MET)‡ Blood pressure (mmHg) Systolic Diastolic Heart rate (beats/min) Carotid IMT (mm) Beta stiffness index Young’s elastic modulus (mmHg) Carotid artery compliance (%/10 mmHg) Endothelial function (Δmm) Pulse wave velocity (m/s) IVSTd (mm) PWTd (mm) LVIDd, mm RWT Left ventricular mass index (g/m) E/A (m/s) Ejection fraction (%) Fractional shortening (%) Cardiac index (L/min/m2) Cardiac output (L/min) Cardiovascular event (MI, stroke, PCI, CABG) (%)
Endurance sports (n = 49) 74.9 (5.3) 24.8 (3.4) 94.1 (10.3) 4.1* 26.5** 6.1 28.6 57.1* 46.5 (70.4) 20.4 (16.4)*** 5.7 (2.9)* 141.8 (22.4) 79.0 (9.5) 66.3 (10.8) 0.93 (0.18) 14.7 (7.2) 996.2 (655.2) 0.75 (0.35) 0.18 (0.18) 10.0 (2.9) 11.1 (2.0) 9.4 (1.3) 54.8 (4.6) 0.38 (0.06) 128.6 (28.0) 0.82 (0.22) 71.1 (7.5) 34.6 (5.5) 4.4 (1.4) 8.4 (2.7) 16.3
Power sports (n = 50) 73.7 (5.0) 27.6 (3.8)*,†† 99.6 (11.9)† 2.0** 44.0 6.0 24.0 72.0 40.7 (43.5) 15.2 (12.5) 4.2 (2.1) 144.8 (19.5) 80.5 (9.1) 63.8 (10.2) 0.97 (0.39) 16.7 (11.1) 1140.4 (801.1) 0.66 (0.25) 0.20 (0.20) 10.4 (3.1) 10.8 (2.1) 9.7 (1.8) 56.1 (6.9) 0.37 (0.06) 137.3 (56.5) 0.85 (0.27) 72.6 (5.7) 35.4 (4.4) 4.3 (1.3) 8.5 (3.0) 22.0
Controls (n = 49)
P
74.2 (5.0) 25.9 (3.4) 97.6 (9.7) 20.4 53.1 14.3 40.8 79.6 50.9 (59.0) 9.9 (9.3) 2.1 (2.7)
0.49 7.0 mmol/L or use of lipid lowering drugs. Diabetes mellitus was defined as a fasting serum glucose level higher or equal to 7.0 mmol/L or the use of insulin injections, oral hypoglycemic agents, or both. RWT = (IVSTd + PWTd)/LVId; IVSTd, interventricular septal thickness at end diastole; IMT, intima media thickness; MET, metabolic equivalent; MI, myocardial infarction; LTPA, leisure time physical activity; LVIDd, left ventricular internal dimension at end diastole; PWTd, posterior wall thickness in diastole; PCI, percutaneous coronary intervention; CABG, coronary artery bypass surgery; RWT, relative wall thickness; E/A, early to late ventricular filling velocity ratio.
cuff around the right arm. The cuff was deflated at 2 mmHg/ heartbeat. Systolic BP and diastolic BP were defined according to Korotkoff sounds I and V. Heart rate was measured by a trained nurse with 30 s palpation on the right side arteria radialis.
Echocardiographic measurements Both M-mode and two-dimensional echocardiography was performed using ATL HDI 5000 device with multi-hertz (P4-2) sector transducer (ATL Inc., Bothell, Washington, USA). All measurements were performed blindly off-line by one trained physician according to the recommendations of the American Society of Echocardiography (ASE) (Sahn et al., 1978). Tracings used to determine LV dimensions were recorded at the level of chordae tendinae just below the mitral valve, with the transducer placed primarily in the fourth intercostal space at the left sternal border.
Measurements were made from three to six cardiac cycles with a Kurta XGT-digitizing tablet (Kurta Corp., Phoenix, Arizona, USA). Left ventricular internal dimension (LVID), interventricular septal thickness (IVST), and posterior wall thickness (PWT) were measured at end diastole (d) and end systole. LV mass (LVM) was calculated as follows: LVM (ASE) = 1,05 × [(LVIDd + IVSTd + PWTd)3 − LVIDd3] (Troy et al., 1972). Corrected LVM was calculated by the Deveraux equation: LVM = 0.8 × LVM (ASE) + 0.6 (Devereux et al., 1986). Left ventricular mass index (LVMI) was calculated as the ratio of LVM and person’s height.
Measurement of carotid IMT High-resolution B-mode carotid ultrasound examination of the right common carotid artery (CCA) was performed according to a
3
Johansson et al. Table 2. Characteristics of the elite athletes by average leisure time physical activity intensity
Variable
Leisure time physical activity intensity category n = 13 1 MET
Athlete group (%) Endurance sports (n = 49) Power sports (n = 50) Current LTPA volume (MET hours per week)‡ Age (years) BMI (kg/m2) Waist circumference (cm) Current smokers (%) Antihypertensive medication (%) Diabetes (%) Hypercholesterolemia (%) Hypertension (%) Alcohol consumption (g/week) Blood pressure (mmHg) Systolic Diastolic Heart rate (beats/min) Carotid IMT (mm) Beta stiffness index Young’s elastic modulus (mmHg) Carotid artery compliance (%/10 mmHg) Endothelial function (Δmm) Pulse wave velocity (m/s) IVSTd (mm) PWTd (mm) LVIDd (mm) RWT Left ventricular mass index (g/m) E/A (m/s) Ejection fraction (%) Fractional shortening (%) Cardiac index (L/min/m2) Cardiac output (L/min) Cardiovascular event (MI, stroke, PCI, CABG) (%)
n = 48 4 MET
38.5 61.5 1.1 (1.1) 78.4 (4.5) 29.7 (4.5) 107.7 ((12.6) 0.0 61.5 46.2 38.5 76.9 46.7 (34.1)
50.0 50.0 9.9 (5.7)** 73.2 (5.2)** 26.2 (3.8)** 97.5 (10.6)** 4.2 33.3 10.4** 29.2 58.3 50.1 (72.4)
153.7 (31.5) 79.7 (7.3) 59.3 (9.6) 1.00 (0.18) 26.6 (18.2) 1807.6 (1205.7) 0.43 (0.25) 0.15 (0.19) 14.0 (3.9) 11.5 (3.2) 10.0 (2.6) 61.1 (7.8) 0.35 (0.07) 170.5 (92.4) 0.96 (0.30) 69.8 (9.2) 33.5 (6.6) 4.6 (1.6) 9.4 (3.4) 30.8
139.6 (17.6) 78.8 (9.4) 66.2 (10.7) 0.93 (0.20) 15.6 (9.6)** 1086.0 (816.0)* 0.74 (0.35)* 0.23 (0.19) 10.3 (3.2)** 11.3 (2.0) 9.7 (1.5) 53.5 (4.9)*** 0.39 (0.07) 127.5 (31.6)** 0.86 (0.28) 72.9 (6.7) 35.7 (5.1) 4.1 (1.3) 7.9 (2.8) 20.8
P n = 38 8–10 MET 52.6 47.4 32.7 (11.0)***/††† 74.3 (4.7)* 25.0 (2.8)*** 92.3 (9.4)*** 2.6 29.0* 7.9** 18.4 68.4 34.4 (39.4) 144.6 (19.6) 81.0 (9.9) 65.3 (10.2) 0.97 (0.42) 13.6 (4.0)** 897.6 (319.9)** 0.71 (0.23) 0.16 (0.18) 9.3 (1.8)*** 10.4 (1.5) 9.3 (1.2) 56.0 (5.0)* 0.35 (0.05)†† 127.0 (25.2)** 0.79 (0.16) 71.7 (5.5) 34.6 (4.1) 4.7 (1.3) 8.8 (2.6) 13.2
0.67
Scand J Med Sci Sports 2015: ••: ••–•• doi: 10.1111/sms.12474
Published by John Wiley & Sons Ltd
Cardiovascular health in former elite male athletes J. K. Johansson1, U. M. Kujala2, S. Sarna3, H. Karanko1, P. J. Puukka1, A. M. Jula1 Department of Chronic Disease Prevention, National Institute for Health and Welfare, Turku, Finland, 2Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland, 3Department of Public Health, University of Helsinki, Helsinki, Finland Corresponding author: Jouni Johansson, MD, Department of Chronic Disease Prevention, National Institute for Health and Welfare, Peltolantie 3, 20720 Turku, Finland. Tel: +358 50 3586060, Fax: +358 20 7547201, E-mail: [email protected]
1
Accepted for publication 17 March 2015
To increase our knowledge on the effects of previous and current physical activity on cardiovascular health, we studied a group of Finnish male former elite athletes (endurance, n = 49; power, n = 50) and their 49 age and area-matched controls, aged 64–89 years. Body mass index (BMI), fasting serum glucose, lipids, blood pressure, and ultrasonography of cardiac and carotid artery structure and function were measured. Former endurance athletes smoked less, had lower prevalence of hypertension, and had higher intensity and volume of leisure time physical activity (LTPA) than the controls. No difference was detected in cardiac or carotid artery structure and function between these groups. Former athletes
performing high-intensity LTPA were slightly younger (possible selection bias), had lower BMI and waist circumference, lower use of antihypertensives, lower prevalence of diabetes, lower pulse wave velocity, and higher carotid artery elasticity than former athletes not performing high-intensity LTPA. In conclusion, former athletes had a higher intensity and volume of LTPA than the controls. Athletes performing vigorous LTPA had more elastic arteries than athletes performing moderately or no LTPA. Vigorous LTPA through the whole lifetime associates with good cardiovascular health, although the previous medical history may play an important role.
According to observational data, low physical activity has been suggested to account worldwide for 2.8% of the disability-adjusted life years, and it is one of the most remarkable individual factors contributing to global disease burden (Lim et al., 2012). Observational follow-up studies suggest that physical activity may protect against cardiovascular diseases such as coronary heart disease, stroke, and hypertension (Rogers et al., 1996; Paffenbarger et al., 2001), and decrease cardiovascular mortality (Paffenbarger et al., 2001; Shortreed et al., 2013). Health benefits seem to increase along with the degree of physical activity (Paffenbarger et al., 2001; Lim et al., 2012) and participation in vigorous exercise has been found to be associated with lower incidence of cardiovascular diseases (Schnohr et al., 2006; Shortreed et al., 2013). Intervention studies have shown that endurance training lowers blood pressure (BP) (Hagberg et al., 1989; Rogers et al., 1996). In addition, it has been shown that endurance athletes have higher life expectancy than population in general (Sarna et al., 1993; Paffenbarger et al., 2001; Teramoto & Bungum, 2010). The increased life expectancy may partly be explained by positive cumulative effects of physical activity on averting cardiovascular diseases, genetic pleiotropy, and partly by the healthier lifestyle of those exercising vigorous sports than the population in general (Paffenbarger et al., 2001;
Schnohr et al., 2006; Kujala, 2011; Shortreed et al., 2013). Although various studies on beneficial health effects of long-term physical activity exist, less is known about the impact of vigorous physical activity on old-age cardiovascular health in former elite athletes. In addition, there has been disagreement about the effects of both volume and intensity of physical exercise on left ventricular (LV) function of heart, and the results have been controversial (Pelliccia et al., 2002; Luthi et al., 2008; Teske et al., 2009; Baggish & Wood, 2011; Bhella et al., 2014; Knackstedt et al., 2014). The objective of the study was to investigate the impact of physical activity on cardiovascular health in surviving former elite male athletes as compared with their controls who were healthy at young adulthood. We hypothesized that a lifelong leisure time physical activity (LTPA) would be associated with a better cardiovascular health in later life. Methods Study design The study design, and the criteria for inclusion and exclusion are described in detail elsewhere (Sarna et al., 1993; Laine et al., 2014). The study population consists of male athletes who had represented Finland between the years 1920 and 1965 at least once in an international or intercountry competition and their age- and
1
Johansson et al. Original study populaon N=4136 - 2424 former athletes - 1712 controls Dropouts N=2953 - 1548 former athletes died - 1162 controls died - 243 lost to follow-up (no replies)
Study parcipants in the year 2008 N=1183 - 747 former athletes - 436 controls
Clinical study parcipants in the year 2008 N=599 - 392 former athletes - 207 controls
Clinical study nonparcipants in the year 2008 N=584 - 355 former athletes - 229 controls
Subgroup of randomly selected parcipants in the year 2008, echocardiographic study N=148 - 49 endurance athletes - 50 power sports athletes - 49 controls
Fig. 1. Flowchart describing participants and nonparticipants of the study. area-matched controls. The study participants were area-matched using six different provinces in Finland. They were Southern Finland, Western Finland, Eastern Finland, Oulu region, Lapland region, and Åland region. The control group consisted of Finnish men who were classified as completely healthy at the compulsory medical examination, which all Finnish men undergo at about 20 years of age as a part of the national military service. A flowchart describing the study participants and nonparticipants is presented in Fig. 1. The questionnaires were sent to all surviving cohort members in 1985, 1995, and 2001. Identical questions on physical activity and chronic diseases were used in the year 1985 and the following years. In 2008, an invitation to participate to follow-up was sent to all former elite athletes (n = 747, of which 392 participated in the study) and controls (n = 436, of which 207 participated) who were alive and who had answered at least one of the questionnaires (in 1985, 1995, or 2001). The athletes were classified as follows: endurance athletes (long-distance running, middle-distance running, and crosscountry skiing) and power sports (boxing, wrestling, shot put, weightlifting, javelin, hammer, and discus). In 2008, a clinical examination including measurements of body mass index (BMI), fasting serum glucose, lipids, BP, echocardiographic ultrasound of heart, intima media thickness (IMT), and pulse wave velocity (PWV) was performed for a subgroup (echocardiographic subgroup) of randomly selected 2008 cohort of elite athletes (50 study subjects from endurance sports group and 50 from power sports group of 392 elite athlete participants) and controls (50 study subjects from the control group of 207 participants). Forty-nine endurance athletes, 50 power sports athletes, and 49 subjects from the control group agreed to participate in the echocardiographic subgroup study. The ethics committee of the Hospital District of Helsinki and Uusimaa approved the study, and all participants gave their informed consent. Data on diseases were collected by using structured questionnaires and from Finnish registers (hospital inpatient discharge register, reimbursable medication register, and disability pension register) (Kujala et al., 1994).
intensity (MET) × duration (h) × times (n) of LTPA, modified from a previous publication (Kujala et al., 1998). MET intensity was defined as follows according to international recommendations (Ainsworth et al., 2000): 1 MET, if subject reported to read, watch television, or perform tasks not requiring physical activity; 4 MET, if subject reported that the physical activity was on average as intensive as walking; 8 MET, if on average as intensive as jogging; 10 MET, if on average as intensive as running. Subjects who did not report to participate in any leisure physical activity or did not report any intensity, duration, or frequency of activity were given MET index of 1 MET h/week. The mean values of MET intensity and MET hours per week (volume) were calculated and shown in Table 1 for elite sports groups and controls. Study subjects were divided in three categories according to the average intensity of LTPA (Table 2, Supporting Information Tables S1 and S2) and according to their MET hours per week (volume) (Table 3). Smoking was defined as smoking daily or occasionally. Diabetes mellitus was defined as a fasting serum glucose level higher or equal to 7.0 mmol/L or the use of insulin injections and/or oral hypoglycemic agents. Presence of hypercholesterolemia was defined as fasting serum total cholesterol level higher or equal to 7.0 mmol/L or the use of lipid-modifying agents. All biochemical samples were fasting samples of 12 h. Alcohol intake was evaluated with a questionnaire and the amount of alcoholic drinks was converted to grams of absolute ethanol per week (Kaprio et al., 1987). Trained study nurses performed the physical examinations including assessment weight, height, waist circumference, and BP, as well as blood sampling. The device for measuring body weight was performed using a digital scale, accuracy 0.1 kg (Seca delta model 707 patient scale, Seca, Hamburg, Germany). Height was measured without shoes on with a measuring tape against the wall to an accuracy of 0.1 cm. BMI was calculated as body weight divided by (height)2 (kg/m2). Waist circumference was measured with the participants in a relaxed standing posture. Waist circumference was measured midway between the anterior superior iliac spine and lower edge of the rib cage.
Definitions
Measurement of BP
Current volume of LTPA was assessed using metabolic equivalents (MET) hours per week. MET hours per week was calculated as
Seated BP was measured by a trained nurse with a conventional calibrated mercury sphygmomanometer after a 5-min rest, with
2
Former elite athletes and controls Table 1. Baseline characteristics
Variable Age (years) BMI (kg/m2) Waist circumference (cm) Current smokers (%) Antihypertensive medication (%) Diabetes (%) Hypercholesterolemia (%) Hypertension (%) Alcohol consumption (g/week) Current LTPA volume (MET hours per week)‡ Current LTPA intensity (MET)‡ Blood pressure (mmHg) Systolic Diastolic Heart rate (beats/min) Carotid IMT (mm) Beta stiffness index Young’s elastic modulus (mmHg) Carotid artery compliance (%/10 mmHg) Endothelial function (Δmm) Pulse wave velocity (m/s) IVSTd (mm) PWTd (mm) LVIDd, mm RWT Left ventricular mass index (g/m) E/A (m/s) Ejection fraction (%) Fractional shortening (%) Cardiac index (L/min/m2) Cardiac output (L/min) Cardiovascular event (MI, stroke, PCI, CABG) (%)
Endurance sports (n = 49) 74.9 (5.3) 24.8 (3.4) 94.1 (10.3) 4.1* 26.5** 6.1 28.6 57.1* 46.5 (70.4) 20.4 (16.4)*** 5.7 (2.9)* 141.8 (22.4) 79.0 (9.5) 66.3 (10.8) 0.93 (0.18) 14.7 (7.2) 996.2 (655.2) 0.75 (0.35) 0.18 (0.18) 10.0 (2.9) 11.1 (2.0) 9.4 (1.3) 54.8 (4.6) 0.38 (0.06) 128.6 (28.0) 0.82 (0.22) 71.1 (7.5) 34.6 (5.5) 4.4 (1.4) 8.4 (2.7) 16.3
Power sports (n = 50) 73.7 (5.0) 27.6 (3.8)*,†† 99.6 (11.9)† 2.0** 44.0 6.0 24.0 72.0 40.7 (43.5) 15.2 (12.5) 4.2 (2.1) 144.8 (19.5) 80.5 (9.1) 63.8 (10.2) 0.97 (0.39) 16.7 (11.1) 1140.4 (801.1) 0.66 (0.25) 0.20 (0.20) 10.4 (3.1) 10.8 (2.1) 9.7 (1.8) 56.1 (6.9) 0.37 (0.06) 137.3 (56.5) 0.85 (0.27) 72.6 (5.7) 35.4 (4.4) 4.3 (1.3) 8.5 (3.0) 22.0
Controls (n = 49)
P
74.2 (5.0) 25.9 (3.4) 97.6 (9.7) 20.4 53.1 14.3 40.8 79.6 50.9 (59.0) 9.9 (9.3) 2.1 (2.7)
0.49 7.0 mmol/L or use of lipid lowering drugs. Diabetes mellitus was defined as a fasting serum glucose level higher or equal to 7.0 mmol/L or the use of insulin injections, oral hypoglycemic agents, or both. RWT = (IVSTd + PWTd)/LVId; IVSTd, interventricular septal thickness at end diastole; IMT, intima media thickness; MET, metabolic equivalent; MI, myocardial infarction; LTPA, leisure time physical activity; LVIDd, left ventricular internal dimension at end diastole; PWTd, posterior wall thickness in diastole; PCI, percutaneous coronary intervention; CABG, coronary artery bypass surgery; RWT, relative wall thickness; E/A, early to late ventricular filling velocity ratio.
cuff around the right arm. The cuff was deflated at 2 mmHg/ heartbeat. Systolic BP and diastolic BP were defined according to Korotkoff sounds I and V. Heart rate was measured by a trained nurse with 30 s palpation on the right side arteria radialis.
Echocardiographic measurements Both M-mode and two-dimensional echocardiography was performed using ATL HDI 5000 device with multi-hertz (P4-2) sector transducer (ATL Inc., Bothell, Washington, USA). All measurements were performed blindly off-line by one trained physician according to the recommendations of the American Society of Echocardiography (ASE) (Sahn et al., 1978). Tracings used to determine LV dimensions were recorded at the level of chordae tendinae just below the mitral valve, with the transducer placed primarily in the fourth intercostal space at the left sternal border.
Measurements were made from three to six cardiac cycles with a Kurta XGT-digitizing tablet (Kurta Corp., Phoenix, Arizona, USA). Left ventricular internal dimension (LVID), interventricular septal thickness (IVST), and posterior wall thickness (PWT) were measured at end diastole (d) and end systole. LV mass (LVM) was calculated as follows: LVM (ASE) = 1,05 × [(LVIDd + IVSTd + PWTd)3 − LVIDd3] (Troy et al., 1972). Corrected LVM was calculated by the Deveraux equation: LVM = 0.8 × LVM (ASE) + 0.6 (Devereux et al., 1986). Left ventricular mass index (LVMI) was calculated as the ratio of LVM and person’s height.
Measurement of carotid IMT High-resolution B-mode carotid ultrasound examination of the right common carotid artery (CCA) was performed according to a
3
Johansson et al. Table 2. Characteristics of the elite athletes by average leisure time physical activity intensity
Variable
Leisure time physical activity intensity category n = 13 1 MET
Athlete group (%) Endurance sports (n = 49) Power sports (n = 50) Current LTPA volume (MET hours per week)‡ Age (years) BMI (kg/m2) Waist circumference (cm) Current smokers (%) Antihypertensive medication (%) Diabetes (%) Hypercholesterolemia (%) Hypertension (%) Alcohol consumption (g/week) Blood pressure (mmHg) Systolic Diastolic Heart rate (beats/min) Carotid IMT (mm) Beta stiffness index Young’s elastic modulus (mmHg) Carotid artery compliance (%/10 mmHg) Endothelial function (Δmm) Pulse wave velocity (m/s) IVSTd (mm) PWTd (mm) LVIDd (mm) RWT Left ventricular mass index (g/m) E/A (m/s) Ejection fraction (%) Fractional shortening (%) Cardiac index (L/min/m2) Cardiac output (L/min) Cardiovascular event (MI, stroke, PCI, CABG) (%)
n = 48 4 MET
38.5 61.5 1.1 (1.1) 78.4 (4.5) 29.7 (4.5) 107.7 ((12.6) 0.0 61.5 46.2 38.5 76.9 46.7 (34.1)
50.0 50.0 9.9 (5.7)** 73.2 (5.2)** 26.2 (3.8)** 97.5 (10.6)** 4.2 33.3 10.4** 29.2 58.3 50.1 (72.4)
153.7 (31.5) 79.7 (7.3) 59.3 (9.6) 1.00 (0.18) 26.6 (18.2) 1807.6 (1205.7) 0.43 (0.25) 0.15 (0.19) 14.0 (3.9) 11.5 (3.2) 10.0 (2.6) 61.1 (7.8) 0.35 (0.07) 170.5 (92.4) 0.96 (0.30) 69.8 (9.2) 33.5 (6.6) 4.6 (1.6) 9.4 (3.4) 30.8
139.6 (17.6) 78.8 (9.4) 66.2 (10.7) 0.93 (0.20) 15.6 (9.6)** 1086.0 (816.0)* 0.74 (0.35)* 0.23 (0.19) 10.3 (3.2)** 11.3 (2.0) 9.7 (1.5) 53.5 (4.9)*** 0.39 (0.07) 127.5 (31.6)** 0.86 (0.28) 72.9 (6.7) 35.7 (5.1) 4.1 (1.3) 7.9 (2.8) 20.8
P n = 38 8–10 MET 52.6 47.4 32.7 (11.0)***/††† 74.3 (4.7)* 25.0 (2.8)*** 92.3 (9.4)*** 2.6 29.0* 7.9** 18.4 68.4 34.4 (39.4) 144.6 (19.6) 81.0 (9.9) 65.3 (10.2) 0.97 (0.42) 13.6 (4.0)** 897.6 (319.9)** 0.71 (0.23) 0.16 (0.18) 9.3 (1.8)*** 10.4 (1.5) 9.3 (1.2) 56.0 (5.0)* 0.35 (0.05)†† 127.0 (25.2)** 0.79 (0.16) 71.7 (5.5) 34.6 (4.1) 4.7 (1.3) 8.8 (2.6) 13.2
0.67
