Myocardial Fibrosis in Competitive Triathletes Detected by Contrast-Enhanced CMR Correlates With Exercise-Induced Hypertension and Competition History
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Objectives This study analyzed the presence of myocardial fibrosis detected by late gadolinium-enhancement (LGE) cardiac magnetic resonance (CMR) in correlation with the performance of competitive triathletes objectified by an exercise test and individual competition history. Background Myocardial fibrosis detected by LGE CMR has been reported to occur in 0% to 50% of asymptomatic athletes. However, the cause and mechanisms of myocardial fibrosis are unclear. Methods Eighty-three asymptomatic triathletes undergoing >10 training h per week (43 ± 10 years of age; 65% male) and 36 sedentary controls were studied by using LGE and extracellular volume (ECV) CMR. Parameters of physical fitness were measured by spiroergometry. Triathletes reported their lifetime competition results. Results LGE CMR revealed focal nonischemic myocardial fibrosis in 9 of 54 (17%) male triathletes (LGE+) but in none of the female triathletes (p < 0.05). LGE+ triathletes had higher peak exercise systolic blood pressure (213 ± 24 mm Hg) than LGE- triathletes (194 ± 26 mm Hg; p < 0.05). Furthermore, left ventricular mass index was higher in LGE+ triathletes (93 ± 7 g/m 2) than in LGE- triathletes (84 ± 11 g/m 2; p < 0.05). ECV in LGE- myocardium was higher in LGE+ triathletes (26.3 ± 1.8%) than in LGE- triathletes (24.4 ± 2.2%; p < 0.05). LGE+ triathletes completed longer cumulative distances in swimming and cycling races and participated more often in middle and Iron Man distances than LGE- triathletes. A cycling race distance of >1,880 km completed during competition had the highest accuracy to predict LGE, with an area under the curve value of 0.876 (p < 0.0001), resulting in high sensitivity (89%) and specificity (79%). Multivariate analysis identified peak exercise systolic blood pressure (p < 0.05) and the swimming race distance (p < 0.01) as independent predictors of LGE presence. Conclusions Myocardial fibrosis in asymptomatic triathletes seems to be associated with exercise-induced hypertension and the race distances. There appears to be a safe upper limit, beyond which exercise may result in myocardial fibrosis.
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Exercise-induced hypertension was not independently associated with myocardial fibrosis in VENTOUX.
“Tahir et al4 found exercise-induced hypertension was independently associated with myocardial fibrosis in triathletes; however, this was not replicated in VENTricular arrhythmia and cardiac fibrOsis in endUrance eXperienced athletes.”
From Ventricular Arrhythmia and Cardiac Fibrosis in Endurance Experienced Athletes (VENTOUX) (2025) · cites this paper as [4]
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Cites
Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes
La Gerche, A., Burns, A. T., Mooney, D. J., Inder, W. J., Taylor, A. J., Bogaert, J., MacIsaac, A. I., Heidbüchel, H., & Prior, D. L. (2012) · European Heart Journal · doi:10.1093/eurheartj/ehr397 · Cited by 776 · see citing works
Frisancho-Kiss, S., Davis, S. E., Nyland, J. F., Frisancho, J. A., Cihakova, D., Barrett, M. A., Rose, N. R., & Fairweather, D. (2007) · The Journal of Immunology · doi:10.4049/jimmunol.178.11.6710 · Cited by 212 · cited 1× · see citing works
“Furthermore, it has been shown that testosterone can amplify acute and chronic viral myocarditis in mice without altering viral replication (31).”
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Research works printed but not linked: 27
- Nocon M, Hiemann T, Müller- Riemenschneider F, Thalau F, Roll S, Willich SN. Association of physical activity with all-cause and cardiovascular mortality: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil 2008;15:239-46.
- Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation 2009;119: 1085-92.
- Marijon E, Tafflet M, Celermajer DS, et al. Sports-related sudden death in the general pop- ulation. Circulation 2011;124:672-81.
- La Gerche A, Baggish AL, Knuuti J, et al. Car- diac imaging and stress testing asymptomatic athletes to identify those at risk of sudden car- diac death. J Am Coll Cardiol Img 2013;6: 993-1007.
- Scharhag J, Schneider G, Urhausen A, Rochette V, Kramann B, Kindermann W. Athlete's heart: right and left ventricular mass and function in male endurance athletes and untrained in- dividuals determined by magnetic resonance im- aging. J Am Coll Cardiol 2002;40:1856-63.
- Steding K, Engblom H, Buhre T, et al. Relation between cardiac dimensions and peak oxygen uptake. J Cardiovasc Magn Reson 2010;12:8.
- Breuckmann F, Möhlenkamp S, Nassenstein K, et al. Myocardial late gadolinium enhancement: prevalence, pattern, and prognostic relevance in marathon runners. Radiology 2009;251:50-7.
- Wilson M, O'Hanlon R, Prasad S, et al. Diverse patterns of myocardial fibrosis in lifelong, veteran endurance athletes. J Appl Physiol 2011;110: 1622-6.
- Bohm P, Schneider G, Linneweber L, et al. Right and left ventricular function and mass in male elite master athletes: a controlled contrast- enhanced cardiovascular magnetic resonance study. Circulation 2016;133:1927-35.
- McDiarmid AK, Swoboda PP, Erhayiem B, et al. Athletic cardiac adaptation in males is a conse- quence of elevated myocyte mass. Circ Cardiovasc Imaging 2016;9:e003579.
- Abdullah SM, Barkley KW, Bhella PS, et al. Lifelong physical activity regardless of dose is not associated with myocardial fibrosis. Circ Car- diovasc Imaging 2016;9:e005511.
- van de Schoor FR, Aengevaeren VL, Hopman MTE, et al. Myocardial fibrosis in athletes. Mayo Clin Proc 2016;91:1617-31.
- Kellman P, Wilson JR, Xue H, et al. Extracel- lular volume fraction mapping in the myocardium, part 2: initial clinical experience. J Cardiovasc Magn Reson 2012;14:1-1.
- Ugander M, Oki AJ, Hsu LY, et al. Extracellular volume imaging by magnetic resonance imaging provides insights into overt and sub-clinical myocardial pathology. Eur Heart J 2012;33: 1268-78.
- Kammerlander AA, Marzluf BA, Zotter- Tufaro C, et al. T1 mapping by CMR imaging: from histological validation to clinical implication. J Am Coll Cardiol Img 2016;9:14-23.
- Diao K-Y, Yang Z-G, Xu H-Y, et al. Histologic validation of myocardial fibrosis measured by T1 mapping: a systematic review and meta-analysis. J Cardiovasc Magn Reson 2016;18:92.
- Schelbert EB, Piehler KM, Zareba KM, et al. Myocardial fibrosis quantified by extracellular volume is associated with subsequent hospitali- zation for heart failure, death, or both across the spectrum of ejection fraction and heart failure stage. J Am Heart Assoc 2015;4:e002613.
- Kellman P, Hansen MS. T1-mapping in the heart: accuracy and precision. J Cardiovasc Magn Reson 2014;16:2.
- Radunski UK, Lund GK, Stehning C, et al. CMR in patients with severe myocarditis: diagnostic value of quantitative tissue markers including extracellular volume imaging. J Am Coll Cardiol Img 2014;7:667-75.
- Rudolph A, Abdel-Aty H, Bohl S, et al. Noninvasive detection of fibrosis applying contrast-enhanced cardiac magnetic resonance in different forms of left ventricular hypertrophy relation to remodeling. J Am Coll Cardiol 2009; 53:284-91.
- Mahrholdt H, Wagner A, Deluigi CC, et al. Presentation, patterns of myocardial damage, and clinical course of viral myocarditis. Circulation 2006;114:1581-90.
- Cocker MS, Abdel-Aty H, Strohm O, Friedrich MG. Age and gender effects on the extent of myocardial involvement in acute myocarditis: a cardiovascular magnetic resonance study. Heart 2009;95:1925-30.
- Moon JCC, Sachdev B, Elkington AG, et al. Gadolinium enhanced cardiovascular magnetic resonance in Anderson-Fabry disease. Evidence for a disease specific abnormality of the myocardial interstitium. Eur Heart J 2003;24:2151-5.
- Florian A, Ludwig A, Rösch S, Yildiz H, Sechtem U, Yilmaz A. Myocardial fibrosis imaging based on T1-mapping and extracellular volume fraction (ECV) measurement in muscular dystrophy patients: diagnostic value compared with conven- tional late gadolinium enhancement (LGE) imaging. Eur Heart J Cardiovasc Imaging 2014;15:1004-12.
- Moon JC, Sheppard M, Reed E, Lee P, Elliott PM, Pennell DJ. The histological basis of late gadolinium enhancement cardiovascular magnetic resonance in a patient with Anderson- Fabry disease. J Cardiovasc Magn Reson 2006;8: 479-82.
- Karlstedt E, Chelvanathan A, Da Silva M, et al. The impact of repeated marathon running on cardiovascular function in the aging population. J Cardiovasc Magn Reson 2012;14:58.
- Imai K, Hayashi Y, Kono M. Testosterone- induced focal myocarditis in rats. I. Morphological and biochemical studies with special reference to pathogenetical mechanism and species differ- ences. J Toxicol Sci 1978;3:215-28.
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Franklin, B. A., Thompson, P. D., Al-Zaiti, S. S., Albert, C. M., Hivert, M.-F., Levine, B. D., Lobelo, F., Madan, K., Sharrief, A. Z., Eijsvogels, T. M. H., et al. (2020) · Circulation · doi:10.1161/cir.0000000000000749 · Cited by 410 · see citing works
Sudden Cardiac Death in Young Athletes
Finocchiaro, G., Westaby, J., Sheppard, M. N., Papadakis, M., & Sharma, S. (2024) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2023.10.032 · Cited by 115 · see citing works
Caselli, S., Serdoz, A., Mango, F., Lemme, E., Vaquer Seguì, A., Milan, A., Attenhofer Jost, C., Schmied, C., Spataro, A., & Pelliccia, A. (2019) · European Heart Journal · doi:10.1093/eurheartj/ehy810 · Cited by 109 · see citing works
The effects of endurance exercise on the heart: panacea or poison?
Parry-Williams, G., & Sharma, S. (2020) · Nature Reviews Cardiology · doi:10.1038/s41569-020-0354-3 · Cited by 102 · see citing works
Ventricular Arrhythmia and Cardiac Fibrosis in Endurance Experienced Athletes (VENTOUX)
Javed, W., Botis, I., Goh, Z. M., Shabi, M., Brown, B., Tomoaia, R., Farooq, M., Levelt, E., Graham, L., Gierula, J., et al. (2025) · Circulation: Cardiovascular Imaging · doi:10.1161/circimaging.125.018470 · Cited by 21 · see citing works
“Tahir et al 4 found exercise-induced hypertension was independently associated with myocardial fibrosis in tri-athletes; however, this was not replicated in VENTricular arrhythmia and cardiac fibrOsis in endUrance eXperi-enced athletes.”
MACEIRA, A., VALENZUELA, P. L., SANTOS-LOZANO, A., GARCÍA-GONZÁLEZ, M. P., ORTEGA, L. H., DÍAZ-GONZALEZ, L., BORAITA, A., BARRANCO-GIL, D., & LUCIA, A. (2023) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000003043 · Cited by 9 · see citing works
De Paepe, J., D’Ambrosio, P., De Bosscher, R., Bekhuis, Y., Pauwels, R., Dausin, C., Janssens, K., Mitchell, A., Elliott, A., Van De Heyning, C. M., et al. (2026) · European Journal of Preventive Cardiology · doi:10.1093/eurjpc/zwaf715 · Cited by 2 · see citing works
- Authors
- Tahir, E., Starekova, J., Muellerleile, K., von Stritzky, A., Münch, J., Avanesov, M., Weinrich, J. M., Stehning, C., Bohnen, S., Radunski, U. K., Freiwald, E., Blankenberg, S., Adam, G., Pressler, A., Patten, M., & Lund, G. K.
- Affiliations
- University Medical Center Hamburg-Eppendorf (DE)
- Philips (Germany) (DE)
- TUM Klinikum (DE)
- Corresponding author
- Lund, Gunnar K.
- ORCID
- Venue
- JACC: Cardiovascular Imaging
- Publisher
- Elsevier BV
- Published
- 2018-09
- Volume
- 11
- Issue
- 9
- Pages
- 1260-1270
- ISSN
- 1876-7591 (ISSN-L)
- 1936-878X
- OpenAlex
- W2772902268
- Cited by
- 168
- References
- 3
- Citations by year
- 2026: 10 · 2025: 17 · 2024: 16 · 2023: 13 · 2022: 24 · 2021: 23 · 2020: 36 · 2019: 19 · 2018: 8 · 2017: 1
- FWCI
- 13.70
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- JACC. Cardiovascular imaging (publishedVersion)
- PubMed (publishedVersion)
- mediaTUM – the media and publications repository of the Technical University Munich (Technical University Munich) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Effects of Exercise
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiomyopathy and Myosin Studies
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Keywords
- myocardial fibrosis, triathletes, exercise-induced hypertension, late gadolinium enhancement, extracellular volume, competition history, race distance, endurance athletes
- MeSH terms
- Adolescent, Adult, Aged, Bicycling, Competitive Behavior, Contrast Media, Female, Fibrosis, Heart Diseases, Humans, Hypertension, Male, Meglumine, Middle Aged, Myocardium, Organometallic Compounds, Physical Endurance, Predictive Value of Tests, Risk Factors, Running, Swimming, Case-Control Studies, Risk Assessment, Magnetic Resonance Imaging, Cine, Young Adult, Athletes
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