Exercise-induced Arrhythmias Research Articles

Physical Therapy and the Arrhythmias: The potential benefits and challenges of their kinship

Cardiovascular disease is the primary cause of mortality in the United States, and cardiac arrhythmias are a common cause of hospital admission with significant mortality and morbidity. Cardiovascular diseases significantly burden the healthcare system, with high costs associated with hospitalization, medication, and ongoing management. By finding cost-effective methods to prevent and treat cardiovascular diseases, healthcare resources can be allocated more efficiently, ultimately improving health outcomes and reducing the burden on the healthcare system. Exercise therapy is a low-cost intervention that can be done without expensive equipment or medical procedures. Exercise therapy can help decrease risk factors for heart disease, including high blood pressure, obesity, and high cholesterol, by improving overall fitness and reducing chronic inflammation. Over time, there have been concerns about exercise-induced arrhythmia because it can reduce physical activity among patients with arrhythmia. In this review, we emphasized the beneficial effects of physical activity on arrhythmia patients.

Study of Correlation of TMT Results with Angiogram Findings in Coronary Artery Disease Predictability in Patients with Angina Equivalents in DAE Hospital

Introduction Coronary artery disease is leading cause of mortality and morbidity worldwide. The early detection and treatment of CAD is vital to prevent complications with non invasive tests like stress tests Exercise treadmill testing (ETT) is a wellvalidated, inexpensive test that can be used for the evaluation of patients with suspected coronary artery diseases (CAD). In addition to identifying patients who have exercise-induced ECG changes suggestive of ischemia, ETT also provides important data on exercise capacity, blood pressure, and heart rate response to exercise, symptoms, and the presence of exercise-induced arrhythmias. In a person at high risk for coronary heart disease (e.g., advanced age, multiple coronary risk factors), an abnormal TMT is very predictive of the presence of coronary heart disease (> 90% accurate). In the present study ,we studied the patients with changing risk factor profiles along with increasing incidence of CAD in younger population (even as young as 30-35 years), in females versus males by TMT and also the correlation of TMT results with angiogram findings in the predictability of CAD

Association among cardiopulmonary and metabolic rehabilitation, arrhythmias, and myocardial ischemia responses of patients with HFpEF or HFmrEF.

There's limited evidence of the potential benefits of cardiopulmonary and metabolic rehabilitation (CPMR) in patients with heart failure with preserved ejection fraction (HFpEF) or mildly reduced ejection fraction (HFmrEF) and coronary artery disease (CAD). The aim of this study was to investigate the impact of CPMR on the myocardial ischemia response (MIR), exercise-induced arrhythmias (EIA), New York Heart Association (NYHA) functional class, heart rate recovery (HRR), Borg CR10 perceived symptoms, and the SF-36 physical and mental health summary scores. A prospective cohort study was conducted with 106 patients undergoing 12 weeks of CPMR who completed two exercise tests pre- and post-CPMR: 1) maximum incremental test (CPX) and 2) submaximal constant load test (SUB). After CPMR, the effects on MIR, EIA, NYHA functional class, and HRR during both tests were analyzed. There was a significant change in NYHA functional classes after CPMR, with 96% of the patients in class I (vs 62% pre-CPMR, P<0.0001), 4% in class II (vs 32%), and none in class III (vs 6%). There was a significant reduction in the frequency of EIA (P<0.05) and MIR (P<0.001) and a significantly improved performance on both CPX and SUB tests (P<0.0001). Lastly, there was significant progress in the recovery metrics like HRR (P<0.0001), the Borg CR10 (P<0.0001), and the SF-36 summary scores (P<0.0001). The CPMR resulted in a significant decrease in EIA, delayed ischemia threshold in CPX and SUB tests, increased functional capacity, and improved quality of life.

INDUCTION OF CARDIAC ARRHYTHMIAS DURING BICYCLE ERGOMETRY IN THE DIAGNOSIS OF CORONARY HEART DISEASE

HighlightsThe frequency of arrhythmias during bicycle ergometry was compared in patients with and without coronary heart disease. Their diagnostic significance in diagnosing this disease was analyzed separately for men and women. AbstractAim. To determine the diagnostic significance of exercise-induced cardiac arrhythmias (CAs) during bicycle ergometry (BEM) in patients with suspected coronary heart disease (CHD).Methods. For the retrospective study, 384 case histories of patients discharged from the cardiology department between 2011 and 2020 were selected according to the inclusion and exclusion criteria. The data of BEM and coronary angiography were studied. The correlation between the occurrence of induction of different types of CAs during BEM and the presence of coronary artery blood flow abnormalities was investigated. Indicators of the diagnostic significance of CAs in the diagnosis of coronary artery disease, such as sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) results, were determined separately for men and women. The statistical significance of the results was assessed.Results. Statistically significant specificity and PPV for the induction of ventricular arrhythmias (VAs) without taking into account rare single monomorphic ventricular extrasystoles (VEs) in the diagnosis of CHD in men were 83.5% and 73.1%, respectively. The same indicators for VAs, excluding all single VEs, were 95.3% and 82.6% in men.Conclusion. The induction of VAs in men on BEM, with the exception of rare single monomorphic VEs, is diagnostically significant in the detection of CHD and allows us to qualify the result of BEM as “positive”. The induction of other CAs on BEM has not shown diagnostic significance in the detection of CHD.

The Fragmented QRS Complex in Lead V1: Time for an Update of the Athlete’s ECG?

Differentiating between ECG patterns related to athletes' heart remodeling and pathological findings is a challenge in sports cardiology. As the significance of fragmented complex in athletes remains uncertain, this study aimed to assess the presence of fragmented QRS in lead V1 (fQRSV1) among young athletes and its association with heart adaptations and arrhythmias. Young athletes referred for annual pre-participation screening receiving a maximal exercise testing and transthoracic echocardiography from January 2015 to March 2021 were included. The study included 684 young athletes. The prevalence of fQRSV1 was 33%. Subjects with fQRSV1 had higher exercise capacity and indexes of right ventricular function and remodeling. Among highly trained athletes, the fQRSV1 group demonstrated also increased left ventricular wall thickness. No significant association existed between fQRSV1 and exercise-induced arrhythmias, even in highly trained athletes. The high prevalence of fQRSV1 in young athletes is associated with training-induced heart adaptations but not exercise-induced ventricular arrhythmias.Graphical The fragmented QRS complex in lead V1 in young athletes. PPS = preparticipation screening; EST = exercise stress test; fQRSV1 = fragmented QRS in lead V1; PSBs = premature supraventricular beats; PVBs = premature ventricular beats.

Exercise-Induced Electrocardiography Changes in Pulmonary Arterial Hypertension

Cardiopulmonary exercise testing (CPET) is an important tool in assessing the functional status of patients with pulmonary arterial hypertension (PAH). During CPET, continuous electrocardiography (ECG) is used as a marker of exercise-induced ischemia or arrhythmia. We hypothesize that ECG changes with exercise may be an early indicator of clinical worsening in PAH and could predict adverse outcomes. Clinical, hemodynamic, and CPET data of 155 children and young adult patients with PAH who underwent CPET between 2012 and 2019 in our pulmonary hypertension (PH) center were included in this retrospective analysis. ECGs were analyzed for ST depressions and T-wave inversions, along with coincident hemodynamic data. These data were correlated with adverse outcomes divided into 2 categories: severe worsening (death or receiving lung transplant) and mild to moderate worsening (PAH medication escalation, hospitalization, shunt creation, or listing for lung transplant). The median age was 19years (range 7 to 40years), 69% were female, and the average follow-up time was 5years (range 1 to 8years). A total of 63 patients (41%) had at least 1 adverse outcome. A total of 39 patients (25%) demonstrated significant ST-T-wave changes with exercise. Patients with ST-T-wave changes were 20% more likely to die or need lung transplant than those without. The multiple linear regression found that ST-T-wave changes were a predictor of elevated mean pulmonary arterial pressure (mPAP) found on catheterization (R=0.489, p=0.003), although not of pulmonary vascular resistance index (R=-0.112, p=0.484). An mPAP of 55mm Hg was the most sensitive and specific point in identifying when ST-T-wave changes with exercise begin to appear. In conclusion, ST-T-wave changes on exercise ECG are significantly associated with adverse outcomes in PH in a medium-term follow-up study, and the presence of ST-T-wave changes correlates with higher mPAP. These ECG changes with exercise may be used as early indicators of clinical worsening in PH and predictors of adverse outcomes.

Associations between Medical Disorders and Racing Outcomes in Poorly Performing Standardbred Trotter Racehorses: A Retrospective Study.

Poor performance in racehorses is commonly associated with subclinical diseases. This study aims to evaluate the associations between medical disorders and racing results in Standardbred trotters. The clinical records of 248 poorly performing Standardbreds were retrospectively reviewed, and their racing results were extracted from an online database, concerning the periods 3 months before and 6 months after hospitalization and the entire lifetime. Generalized linear models were used to evaluate the effects of different disorders on racing outcomes. Airway neutrophilia was associated with limiting lifetime starts and wins pre- and post-hospitalization, while mastocytosis was associated with less wins in the post-hospitalization period. Therefore, lower airway inflammation showed both short- and long-term impacts on racing performance. Severe upper airway obstructions and gastric ulcers showed associations with less placings in the post-discharge period but no long-term influence on performance. The significance of exertional rhabdomyolysis was indeterminable, yet interference with the number of starts in the post-discharge period was reported and associated with lower total career earnings. Exercise-induced pulmonary hemorrhage and cardiac arrhythmias were not associated with worse racing outcomes: therefore, their role in poor performance remains unclear.

Multisystem Inflammatory Syndrome in Children (MIS-C): Reduced Exercise Duration and Capacity at Six Month Follow-Up.

Myocarditis is common in Multisystem Inflammatory Syndrome in Children (MIS-C), and the mechanism may differ from idiopathic/viral myocarditis as MIS-C involves a hyper-inflammatory state weeks after COVID-19. We sought to evaluate exercise stress testing (EST) in these patients as EST may help guide return-to-play recommendations. Retrospective cohort study evaluating ESTs (standard Bruce treadmill protocol) from MIS-C patients from 2020 to 2022, compared to myocarditis patients and age, sex, and weight matched controls from 2005 to 2019. ESTs included 22 MIS-C patients (mean age 11.9 years) with 14 cardiopulmonary and 8 cardiovascular tests, 33 myocarditis (15.5 years), and 44 controls (12.0 years). Percent-predicted peak VO2 was abnormal (< 80% predicted) in 11/14 (79%) MIS-C patients, 13/33 (39%) myocarditis, and 17/44 (39%) controls (p = 0.04). Exercise duration was shorter in MIS-C than myocarditis or control cohorts (p = 0.01). Isolated atrial or ventricular ectopy was seen in 8/22 (36%) MIS-C, 9/33 (27%) myocarditis, and 5/44 (11%) controls (p = 0.049). No arrhythmias/complex ectopy or evidence of ischemia were noted, though non-specific ST/T wave abnormalities occurred in 4/22 (18%) MIS-C, 5/33 (15%) myocarditis, and 3/44 (7%) controls. Exercise duration and percent-predicted peak VO2 were significantly reduced in MIS-C at mean 6-month follow-up compared to pre-COVID era idiopathic/viral myocarditis and control cohorts. This may be secondary to deconditioning during the pandemic and/or chronic cardiopulmonary or autonomic effects of COVID/MIS-C. Although there were no exercise-induced arrhythmias in our MIS-C patients, larger cohort studies are warranted. EST in MIS-C follow-up may help evaluate safety and timing of return to play and potentially mitigate further deconditioning.

Cardiac electrophysiological remodeling associated with enhanced arrhythmia susceptibility in a canine model of elite exercise.

The health benefits of regular physical exercise are well known. Even so, there is increasing evidence that the exercise regimes of elite athletes can evoke cardiac arrhythmias including ventricular fibrillation and even sudden cardiac death (SCD). The mechanism of exercise-induced arrhythmia and SCD is poorly understood. Here, we show that chronic training in a canine model (12 sedentary and 12 trained dogs) that mimics the regime of elite athletes induces electrophysiological remodeling (measured by ECG, patch-clamp, and immunocytochemical techniques) resulting in increases of both the trigger and the substrate for ventricular arrhythmias. Thus, 4 months sustained training lengthened ventricular repolarization (QTc: 237.1±3.4 ms vs. 213.6±2.8 ms, n=12; APD90: 472.8±29.6 ms vs. 370.1±32.7 ms, n=29 vs. 25), decreased transient outward potassium current (6.4±0.5 pA/pF vs. 8.8±0.9 pA/pF at 50 mV, n=54 vs. 42), and increased the short-term variability of repolarization (29.5±3.8 ms vs. 17.5±4.0 ms, n=27 vs. 18). Left ventricular fibrosis and HCN4 protein expression were also enhanced. These changes were associated with enhanced ectopic activity (number of escape beats from 0/hr to 29.7±20.3/hr) in vivo and arrhythmia susceptibility (elicited ventricular fibrillation: 3 of 10 sedentary dogs vs. 6 of 10 trained dogs). Our findings provide in vivo, cellular electrophysiological and molecular biological evidence for the enhanced susceptibility to ventricular arrhythmia in an experimental large animal model of endurance training.

The incidence of cardiac arrhythmias during exercise stress testing: a focus on patients with severe obesity undergoing sleeve gastrectomy.

Obesity is associated with a higher risk of cardiac arrhythmias. Sleeve gastrectomy (SG) is a common bariatric surgery with beneficial effects on weight loss and comorbidities. The study aimed to investigate the prevalence of arrhythmias during maximal exercise testing in patients with moderate-severe obesity and to evaluate the impact of SG on these arrhythmic events. All patients with moderate or severe obesity who were considered suitable candidates for SG between June 2015 and September 2020 were recruited. Each patient underwent three incremental, maximal, ECG-monitored cardiopulmonary exercise test 1 month before and 6 and 12 months after SG; the frequency and complexity of ventricular premature beats (VPBs) and atrial premature beats (APBs) have been evaluated during rest, exercise and recovery phases. Fifty patients with severe obesity (BMI 46.39 ± 7.89 kg/m2) were included in the study. After SG, patients presented a decreased BMI (34.15 ± 6.25 kg/m2 at 6 months post-SG and 31.87 ± 5.99 kg/m2 at 12 months post-SG). At 6 months post-SG, an increase in VPBs, mainly during the recovery phase, was observed. At 12 months post-SG, a reduction in VPBs compared with the 6 months evaluation was showed. Although in the early post-surgical phase the risk of exercise-induced arrhythmias may be higher, SG does not seem to increase the occurrence of arrhythmias in the long-term. No life-threating arrhythmias were found during post-SG evaluations.

Abstract 13630: Association Between Arrhythmia Burden During Clinical Exercise Testing and All-Cause Mortality

Introduction: Arrhythmias commonly occur during clinical exercise stress testing (EST), however there are limited data on prognostic significance, particularly differences between individuals with minor versus significant arrhythmia burden. Hypothesis: We hypothesized that significant but not minor arrhythmia burden during EST would be predictive of future all-cause mortality. Methods: Adults who underwent clinically indicated EST at Mayo Clinic Rochester between September 1993 and April 2017 were included and followed-up until March 2021 using the National Death Index to ascertain survival status. Expert clinician coding pertaining to arrhythmia burden during EST were used to group individuals (see Table 1 ). Cox proportional hazard models adjusted for known predictors of exercise-induced arrhythmias, were used to test the association of arrhythmia burden with all-cause mortality. Results: A total of 30796 individuals were included (age: 55±14yrs; female: 36%; Table 1 ). Mean follow-up was 8.8±3.6yrs, with a total of 2516 deaths. Arrhythmia during EST was associated with all-cause mortality compared with no arrhythmia (HR: 1.72; 95% CI: 1.58-1.88; p&lt;0.001), however significant arrhythmia showed greater association compared with minor arrhythmia (HR: 2.07; 95% CI: 1.81-2.38; p&lt;0.001). Both minor and significant arrhythmia during EST were significant predictors of all-cause mortality compared with no arrhythmia ( Figure, Table 2 ), however, after model adjustments, only significant arrhythmia was associated with all-cause mortality (HR: 1.40; 95% CI: 1.21-1.63; p&lt;0.001) ( Table 2 ). Conclusions: After multivariate adjustment, significant arrhythmia burden during EST showed a 40% increased future risk of all-cause mortality, Conversely, adjusting for age and sex attenuated the effect of minor arrhythmia burden during EST on incidence of death. These results highlight the clinical significance of arrhythmia burden during exercise testing.

Arrhythmia Burden and Heart Rate Response During Exercise in Anderson-Fabry Disease.

Patients with Anderson-Fabry disease (AFD) have an elevated incidence of resting arrhythmias and ischemic heart disease, but their exercise arrhythmia burden and ischemic changes are not well understood. In addition, little research has been done on heart rate recovery in these patients. We retrospectively reviewed charts of patients with AFD who underwent maximal effort cardiopulmonary exercise testing (CPET) (n=44; 38.2 ± 13.8 yr; 23 men) from 2012 through 2018. Electrocardiographic, Holter monitoring, echocardiographic, cardiac magnetic resonance imaging, and patient demographic data were collected. No patient had adverse events that necessitated CPET termination, whereas 25 (57%) had ectopy during CPET, including 3 (7%) with frequent premature atrial contractions and 5 (11%) with frequent premature ventricular contractions. The ectopic burden was higher during resting electrocardiographic monitoring before exercise. In addition, 7 patients (16%) had pathologic ST-segment or T-wave changes on CPET, defined as ST-segment changes ≥2 mm. Among the patients who had concurrent cardiac magnetic resonance findings with their CPET (n=27), ST-segment or T-wave changes were associated with left ventricular myocardial mass (r=0.43, P=0.02). Chronotropic incompetence was seen during CPET in 28 patients (64%); however, only 2 patients (4%) had abnormal heart rate recovery at 1 minute. This study shows that patients with AFD can safely undergo exercise testing but have a high incidence of exercise-induced arrhythmias and ischemic changes. Ischemic electrocardiographic changes during exercise testing are associated with myocardial mass. Despite the chronotropic incompetence associated with AFD, heart rate recovery appears to be generally preserved in these patients.

Algorithm for the management of patients with ventricular arrhythmias recorded during wakefulness

Aim. To study the clinical and electrocardiographic characteristics of exerciseinduced arrhythmias and develop an algorithm for managing patients with exerciseinduced ventricular arrhythmias (VA).Material and methods. For the period from 2015 to 2019 203 patients with VA during periods of wakefulness were selected from the database of patients who performed Holter monitoring; 167 of them were selected, who underwent a treadmill test (TT) according to the standard Bruce protocol. During TT, the qualitative and quantitative characteristics of VA were assessed. Further examination and treatment were carried out according to the proposed algorithm.Results. In 80 patients (48% of all those who underwent TT), regardless of VA presence in the pretest, arrhythmias had an exercise nature and appeared and/or progressed during exercise. These patients were included in the present study to assess the causal relationship of VA with any disease. Following the algorithm, coronary artery disease was verified in 15 people, stage I-II hypertension — in 25, and minor heart defects — in 21. Of the remaining 19 patients without association of exercise-induced VA with any disease during the initial examination, 5 patients were diagnosed with arrhythmogenic cardiomyopathy/right ventricular dysplasia during prospective follow-up. In the remaining 14, VAs were considered idiopathic.Conclusion. The presented algorithm can accelerate both the search for the causes of exercise-induced VA and the choice of personalized treatment.

New protocol for diagnosing exercise-induced arrhythmias and conduction disturbances in early and preschool age children

Aim. To develop a protocol for diagnosing exercise-induced arrhythmias and conduction disturbances in children aged 3-6 years without structural heart disease.Material and methods. The study included 20 patients (11 boys) aged 58,7±2,12 months with ventricular arrhythmias (VA) and/or atrioventricular (AV) block according to single electrocardiographic (ECG) records and/or 24-hour ECG monitoring. All patients underwent a thorough clinical and paraclinical examination, including exercise stress testing using original and Bruce protocols. The termination criteria were the first of following events: achievement of the heart rate set by the study aim; the appearance and/or aggravation of potentially dangerous arrhythmias and conduction disorders (single premature ventricular contraction (PVCs) with increasing frequency, and/or early PVCs, and/or paired PVCs, and/ or ventricular tachycardia (VT), and/or AV block); registration of allorhythmia (bigeminy) within 10 seconds.Results. The termination criteria using the original protocol were achieved in all patients (n=20, 100%) compared to the standard Bruce protocol (n=5, 25,0%), p&lt;0,001. The number of steps passed was significantly higher using original protocol (5,0 [5,00-6,00]) than when using the standard protocol Bruce 2,0 [2,03,0], p&lt;0,05. Exercise tolerance was significantly higher when using the original protocol than the standard Bruce protocol (p&lt;0,05). The probability of reaching the termination criteria using the original protocol were 116 times greater than using the standard Bruce protocol (odds ratio, 116, 95% confidence interval: 5,932250, p=0,0017). VAs were registered in 20,0% (n=4) of patients using the original protocol, while AV blocks — in 20,0% (n=4). Among the five patients who achieved the termination criteria using the standard Bruce protocol, VAs were recorded in 10,0% (n=2) of patients, while AV blocks — in 5,00% (n=1).Conclusion. The use of exercise test with an original protocol makes it possible to achieve the termination criteria, increases its information content and diagnostic significance. It makes it possible to determine the nature of VAs and AV conduction dosorders.

Exercise-induced arrhythmias.

A 38-year-old man presents with exercise-induced palpitations. Since childhood, he has never enjoyed exercising because of palpitations that limited his ability to keep up with other children. At the age of 16, his symptoms were thought to be related to atrial tachycardia that was ablated at the base of the left atrial appendage. Although his symptoms improved after ablation, they never completely abated and he has limited his exercise. He has no family history of heart disease or sudden cardiac death.

Prevalence of exercise-induced arrhythmias in young athletes with fragmented QRS pattern in lead V1

Abstract Funding Acknowledgements Type of funding sources: None. Background Resting 12-lead electrocardiogram (ECG) in apparently health athletes has specific pattern, typically associate to heart remodelling in response to regular exercise. (1,2) Moreover, these adaptations were correlated to typical ventricular arrhythmias, not associated with underlying cardiac abnormalities.(3) Recently, also fragmented QRS complex in lead V1 (fQRSV1), representing right ventricular (RV) activation, seems related to training-induced RV remodelling in athletes, where its prevalence is greater.(4) Purpose Evaluate presence of fQRSV1pattern at resting ECG in a population of young athletes and its relationship with training-associated structural heart adaptations and exercise-induced ventricular arrhythmias. Methods This study retrospectively enrolled subjects who consecutively undergo to annual pre-participation screening and also to transthoracic echocardiography assessment, from January 2015 to September 2020. For each participant, medical history, physical examination, resting ECG, maximal standardized exercise test and echocardiographic evaluation were collected. All ECG were reviewed by two independent physicians to evaluate fQRSV1 pattern. Results 684 young athletes (mean age 14.87±1.96 years, 36% female) were included and the overall prevalence of fQRSV1was 27%. Figure 1 shows an example of fQRSV1 pattern. Principal subject characteristics and evaluations data are shown in Table 1. fQRSV1 subjects presented a significantly wider QRS interval (p=0.004) and lower heart rate at rest (p=0.001). Exercise workload expressed in METs and exercise duration were higher in subjects with fQRSV1 (p=0.002 and p=0.023, respectively). Echocardiographic data showed that subjects with fQRSV1differ in morphological and functional right ventricular (RV) characteristics, especially had a higher indexed RV end diastolic diameter (p=0.019) and higher TAPSE (p=0.013). Patients with fQRSV1did not show an increased occurrence of supraventricular or ventricular arrhythmias, regardless of morphology, neither for isolated nor for repetitive events. Conclusion Overall prevalence of fQRSV1 pattern in young athletes is comparable with the one studied in other population of adult athletes in previous studies. Adolescent athletes with fQRSV1 present structural heart characteristic that differ from subjects without this ECG pattern, especially in RV feature. No differences in prevalence of any type of exercise-induced arrhythmias was shown, especially in common ventricular arrhythmias consistent with origin from the right ventricular outflow tract, previously described in healthy athletes.

The incidence of cardiac arrhythmias during exercise stress testing among patients with obesity undergoing sleeve gastrectomy

Abstract Funding Acknowledgements Type of funding sources: None. Background Obesity is associated with higher rate of cardiovascular morbidity and mortality, anatomical and functional cardiac alteration.(1) In particular, several studies found an association between increased body weight and arrhythmic events.(2) Sleeve Gastrectomy (SG) is recognized as significant treatment option for obesity, with beneficial effect in both weight loss and comorbidities.(3) Moreover, this treatment results in positively decrease in some basal parameters currently associated with increased risk of arrhythmic events, even if little is known about real incidence of cardiac arrhythmias, especially during exercise, before and after bariatric surgery.(4) Purpose To investigate the prevalence of arrhythmic events during maximal exercise testing in patients with moderate-severe obesity and to evaluate how SG affects the number of arrhythmic events. Methods All patients with moderate or severe obesity who were considered suitable candidates for SG after multidisciplinary evaluations were consecutively included in this study. Each patient underwent an incremental, maximal, ECG-monitored cardiopulmonary exercise testing (CPET) before and 6-months after SG. Presence and complexity of atrial premature beats (APBs) and ventricular premature beats (VPBs) has been evaluated at rest, during exercise and during recovery phase. Results 318 patients with morbidly obesity (BMI 44.20±6.79 kg/m2, age 48.9±10.7 years) were included in the study. After SG, patients presented lower heart rate at rest (80.75±12.60 versus 64.84±9.89 bpm, p&amp;lt;0.001) and an increased exercise time (831.30±195.32 versus 941.13±222.16 s, p&amp;lt;0.001). The analysis of the arrhythmic events during the complete test showed a slight significant difference between pre-SG and post-SG, only regarding number of patients presenting APBs (p=0.038). However, the incidence of arrhythmic events was significantly increased during the recovery phase in post-SG evaluation, both by number of patients with at least one arrhythmic episode and by number of arrhythmic events per minute (Table I). Patients affected by severe obesity had a higher risk occurrence of arrhythmias during CPET, notably atrial premature beats (p=0.038), when compared to patients with moderate obesity. No differences were found among post-SG patients. Men presented more frequently VPBs compared to women, both in pre-SG (p=0.048) and post-SG evaluation (p&amp;lt;0.001). No gender differences were observed in APBs (Figure 1). Conclusion Patients affected by severe obesity show an increased prevalence of atrial premature beats, even if no episode of exercise-induce atrial fibrillation has been described. In the early post-surgical phase, the risk of exercise-induced arrhythmias may be higher during the recovery phase, although SG does not seem to increase the occurrence of life-threating arrhythmias.

Exercise Causes Arrhythmogenic Remodeling of Intracellular Calcium Dynamics in Plakophilin-2-Deficient Hearts.

Exercise training, and catecholaminergic stimulation, increase the incidence of arrhythmic events in patients affected with arrhythmogenic right ventricular cardiomyopathy correlated with plakophilin-2 (PKP2) mutations. Separate data show that reduced abundance of PKP2 leads to dysregulation of intracellular Ca2+ (Ca2+i) homeostasis. Here, we study the relation between excercise, catecholaminergic stimulation, Ca2+i homeostasis, and arrhythmogenesis in PKP2-deficient murine hearts. Experiments were performed in myocytes from a cardiomyocyte-specific, tamoxifen-activated, PKP2 knockout murine line (PKP2cKO). For training, mice underwent 75 minutes of treadmill running once per day, 5 days each week for 6 weeks. We used multiple approaches including imaging, high-resolution mass spectrometry, electrocardiography, and pharmacological challenges to study the functional properties of cells/hearts in vitro and in vivo. In myocytes from PKP2cKO animals, training increased sarcoplasmic reticulum Ca2+ load, increased the frequency and amplitude of spontaneous ryanodine receptor (ryanodine receptor 2)-mediated Ca2+ release events (sparks), and changed the time course of sarcomeric shortening. Phosphoproteomics analysis revealed that training led to hyperphosphorylation of phospholamban in residues 16 and 17, suggesting a catecholaminergic component. Isoproterenol-induced increase in Ca2+i transient amplitude showed a differential response to β-adrenergic blockade that depended on the purported ability of the blockers to reach intracellular receptors. Additional experiments showed significant reduction of isoproterenol-induced Ca2+i sparks and ventricular arrhythmias in PKP2cKO hearts exposed to an experimental blocker of ryanodine receptor 2 channels. Exercise disproportionately affects Ca2+i homeostasis in PKP2-deficient hearts in a manner facilitated by stimulation of intracellular β-adrenergic receptors and hyperphosphorylation of phospholamban. These cellular changes create a proarrhythmogenic state that can be mitigated by ryanodine receptor 2 blockade. Our data unveil an arrhythmogenic mechanism for exercise-induced or catecholaminergic life-threatening arrhythmias in the setting of PKP2 deficit. We suggest that membrane-permeable β-blockers are potentially more efficient for patients with arrhythmogenic right ventricular cardiomyopathy, highlight the potential for ryanodine receptor 2 channel blockers as treatment for the control of heart rhythm in the population at risk, and propose that PKP2-dependent and phospholamban-dependent arrhythmogenic right ventricular cardiomyopathy-related arrhythmias have a common mechanism.

Arrhythmogenesis of Sports: Myth or Reality?

Regular exercise confers health benefits with cardiovascular mortality risk reduction through a variety of mechanisms. At a population level, evidence suggests that undertaking more exercise has greater benefits. In the modern era of sport, there has been an exponential rise in professional and amateur athletes participating in endurance events, with a progressively better understanding of the associated cardiac adaptations, collectively termed ‘athletes heart’. However, emerging data raise questions regarding the risk of potential harm from endurance exercise, with an increased risk of arrhythmia from adverse cardiac remodelling. Cross-sectional studies have demonstrated that athletes may exhibit a higher burden of AF, conduction tissue disease, ventricular arrhythmias, a cardiomyopathy-like phenotype and coronary artery disease. In an attempt to separate myth from reality, this review reports on the evidence supporting the notion of ‘too much exercise’, the purported mechanisms of exercise-induced cardiac arrhythmia and complex interplay with sporting discipline, demographics, genetics and acquired factors.

Effects of caffeinated energy drinks on cardiovascular responses during exercise in healthy adults: a systematic review and meta-analysis of randomized controlled trials.

The impact of caffeinated energy drinks (CEDs) on the cardiovascular (CV) response to exercise has not been well described. A systematic review and meta-analysis was conducted on the acute effects of CEDs on CV responses during dynamic, aerobic exercise in 296 healthy adult males (224) and females (72) in 21 randomized controlled trials. During exercise, there was an increase in heart rate (HR) (mean difference (MD), 2.86bpm, 95% CI, 2.39-3.34bpm, I2=0%, p<0.00001), and systolic blood pressure (SBP) (MD, 9.02mm Hg, 95% CI, 4.25-13.79mm Hg, I2=0%, p=0.0002) with consumption of CEDs, compared with controls, but diastolic blood pressure was similar. Insufficient data were available to evaluate rate pressure product (HR × SBP) and exercise-induced arrhythmia. Though changes to HR during exercise were modest, the significant increase in exercise SBP highlights the importance of directly assessing CV effects of CEDs with exercise, especially in individuals prone to hypertension. Novelty: Exercise SBP in healthy adults is significantly increased during exercise with the consumption of CEDs compared with controls, despite limited data. The direct assessment of CV effects of CEDs with exercise highlights the particular relevance to individuals prone to hypertension.