Focus on sport cardiology and exercise

This edition of the Journal is focused on risk stratification in sport cardiology, exercise. Also, the ominous consequence of unhealthy life-style is studied as well as of electronic cigarettes on vascular endothelial function. In adults who participate in competitive sports, the athlete’s heart is a common phenomenon. The majority of research on training-induced cardiac remodelling has, unfortunately, been done on adults, and the present recommendations mostly apply to adult athletes.1 A complete clinical examination, a personal and family history, and the use of an electrocardiogram (ECG) are all recommended in the most recent European documents for preparticipation screening of athletes.2 However, the adult criteria for ECG interpretation cannot be easily transferred to children, and the international criteria have shown poorer sensitivity in paediatric athletes when compared to the Seattle and ESC recommendations. Given the potential for early detection of life-threatening illnesses, managing therapy, and eligibility to sports events in the constantly expanding paediatric athlete population, an adequate interpretation of resting ECG and imaging in children participating in sports is essential. In this review, the authors provided a comprehensive description of the current evidence on training-induced remodelling in paediatric athletes and recommend a modification of the current ECG criteria for their application in children.3 Cardiovascular mortality among patients hospitalized for coronary artery disease (CAD)4 has been demonstrated to decrease with exercise-based cardiac rehabilitation,5 and physical activity is widely recognized as an essential and fundamental part of cardiac rehabilitation programmes. Coronary atheromatous plaque volume and composition are both strongly related to the risk of acute and recurrent coronary events and outcomes. However, the effects of physical exercise on coronary atheromatous plaques remain largely unknown. In this study Vesterbekkmo and co-workers assessed the effect of 6 months of supervised high-intensity interval training (HIIT) on coronary plaque geometry using intravascular ultrasound in patients with stable CAD following percutaneous coronary intervention.6 Sixty patients were randomly assigned to follow current preventive guidelines or two weekly supervised HIIT sessions at 85–95% of peak heart rate. Change in percent atheroma volume and total atheroma volume (TAV) normalized for segment length (TAVnorm) at 6-month follow-up were the study’s outcomes. After 6 months a significant improvement in coronary atheroma volume was seen in individuals who underwent supervised HIIT underlining once again the importance of exercise for the secondary prevention of CAD. Physical inactivity is a recognized cardiovascular disease (CVD) risk factor favouring atherosclerosis.7 The protective effect of regular exercise regardless of the age and risk category is the cornerstone of current guidelines on CVD prevention.8,9 Less is known about the association between exercise capacity, muscle strength, and the risk of developing sub-clinical atherosclerosis in adulthood. In this issue, Fortuin-de Smidt et al.10 fill this gap by presenting a unique longitudinal study on a large cohort of Swedish men evaluated at 18 years of age and followed up until the age of 60 years. Higher exercise capacity in early adulthood was associated with a 19% lower risk of presenting atherosclerotic carotid plaques in later adulthood, possibly mediated by a better burden of later CVD risk factors. Interestingly, muscle strength was not associated with sub-clinical atherosclerosis. The study further supports the promotion of physical activity among young people to reduce the burden of CVD. What is the impact of our lifestyle on the risk of experiencing ischemic heart disease (IHD)?11,12 And is there still time to improve our lifestyle if we are currently going in the wrong direction? In this issue Gao et al.13 help us in answering these simple but relevant questions, presenting a very large prospective cohort study based on the UK biobank. They defined five cardiovascular health-related lifestyle factors (smoking, physical activity, diet, sleep duration, and body mass index) making a score to quantify the associated risk of incident IHD during a median follow-up of 4.2 years. An intermediate or poor lifestyle conferred a 30 or 52% higher risk of IHD, respectively, when compared to people with an ideal lifestyle. More remarkably, a declined or improved lifestyle trajectory strengthened or attenuated the risk of IHD, respectively, regardless of the baseline lifestyle category. Such association was stronger among subjects with hypertension, diabetes, and hyperlipidaemia. The study makes the point on lifestyle-related IHD risk, providing a solid evidence for the empowering of social policies aimed at contrasting unhealthy behaviours. E-cigarettes are marketed as safer alternatives to traditional tobacco cigarettes and are frequently recommended as a way to reduce or quit smoking. There are numerous varieties of electronic cigarettes, also known as electronic nicotine delivery systems or electronic non-nicotine delivery systems. However, despite the fact that electronic cigarettes do not contain tobacco, they still contain nicotine (which is highly addictive) as well as substances such as glycerine and propylene glycol that may have adverse effects on pulmonary and cardiovascular health. In this study, the authors conducted a comprehensive literature review and meta-analysis to compare the effects of e-cigarettes on endothelial function with those of two control groups: traditional tobacco and nicotine-free vaping. Eight studies involving 372 participants were eligible for this review.14 Pairwise and network analysis were conducted for three different methodologies to assess vascular nitric oxide (NO) formation such as flow-mediated dilation (FMD), arterial pulse wave velocity (PWV), and the heart rate- corrected augmentation index (AIx75) Compared to nicotine-free vaping, nicotine-containing e-liquid raised a PWV and AIx75, which is consistent with a reduction in vascular NO generation, but had no effect on FMD.