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Cited by 776Cardiovascular Effects of ExerciseCardiovascular and exercise physiologyCardiomyopathy and Myosin Studies

Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes

Open access
La Gerche, André, Burns, Andrew T., Mooney, Don J., Inder, Warrick J., Taylor, Andrew J., Bogaert, Jan, MacIsaac, Andrew I., Heidbüchel, Hein +1 more·2012·European Heart Journal
DOI 10.1093/eurheartj/ehr397
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Abstract

AIMS: Endurance training may be associated with arrhythmogenic cardiac remodelling of the right ventricle (RV). We examined whether myocardial dysfunction following intense endurance exercise affects the RV more than the left ventricle (LV) and whether cumulative exposure to endurance competition influences cardiac remodelling (including fibrosis) in well-trained athletes. METHODS AND RESULTS: Forty athletes were studied at baseline, immediately following an endurance race (3-11 h duration) and 1-week post-race. Evaluation included cardiac troponin (cTnI), B-type natriuretic peptide, and echocardiography [including three-dimensional volumes, ejection fraction (EF), and systolic strain rate]. Delayed gadolinium enhancement (DGE) on cardiac magnetic resonance imaging (CMR) was assessed as a marker of myocardial fibrosis. Relative to baseline, RV volumes increased and all functional measures decreased post-race, whereas LV volumes reduced and function was preserved. B-type natriuretic peptide (13.1 ± 14.0 vs. 25.4 ± 21.4 ng/L, P = 0.003) and cTnI (0.01 ± .03 vs. 0.14 ± .17 μg/L, P < 0.0001) increased post-race and correlated with reductions in RVEF (r = 0.52, P = 0.001 and r = 0.49, P = 0.002, respectively), but not LVEF. Right ventricular ejection fraction decreased with increasing race duration (r = -0.501, P < 0.0001) and VO(2)max (r = -0.359, P = 0.011). Right ventricular function mostly recovered by 1 week. On CMR, DGE localized to the interventricular septum was identified in 5 of 39 athletes who had greater cumulative exercise exposure and lower RVEF (47.1 ± 5.9 vs. 51.1 ± 3.7%, P = 0.042) than those with normal CMR. CONCLUSION: Intense endurance exercise causes acute dysfunction of the RV, but not the LV. Although short-term recovery appears complete, chronic structural changes and reduced RV function are evident in some of the most practiced athletes, the long-term clinical significance of which warrants further study.

AI snapshot

Written from the paper’s full text.

TL;DR

In 40 well-trained endurance athletes, intense endurance exercise caused acute right ventricular (RV) dysfunction and dilation while left ventricular (LV) function was preserved, with most RV recovery by 1 week. A minority showed septal delayed gadolinium enhancement (DGE) and greater cumulative exercise exposure, suggesting possible chronic RV-predominant remodelling.

Key findings

  • Post-race RV volumes increased and all RV functional measures decreased, whereas LV volumes decreased and LV function was preserved; RVEF fell by 9% relative to baseline (P < 0.0001) and mostly recovered by 1 week, except RVSRs remained depressed.
  • Post-race BNP (13.1 ± 14.0 vs. 25.4 ± 21.4 ng/L, P = 0.003) and cTnI (0.01 ± 0.03 vs. 0.14 ± 0.17 mg/L, P < 0.0001) increased and correlated with reductions in RVEF (r = 0.52, P = 0.001 and r = 0.49, P = 0.002, respectively), but not LVEF.
  • RVEF decreased with increasing race duration (r = −0.501, P < 0.0001) and VO2max (r = −0.359, P = 0.011); race completion time and VO2max independently explained 34% of the variance in ΔRVEF (P = 0.001).
  • DGE localized to the interventricular septum in 5 of 39 athletes (12.8%); those athletes had greater cumulative exercise exposure and lower RVEF (47.1 ± 5.9 vs. 51.1 ± 3.7%, P = 0.042) than those with normal CMR.

Methods

  • Prospective study of 40 well-trained athletes competing in a marathon, endurance triathlon, alpine cycling race, or ultratriathlon; assessments were at baseline, immediately post-race, and 6–11 days after the race.
  • Evaluation included cardiac troponin I, B-type natriuretic peptide, echocardiography (three-dimensional volumes, ejection fraction, systolic strain rate), and cardiac magnetic resonance imaging with delayed gadolinium enhancement for myocardial fibrosis.
  • Statistical analysis used paired t-tests, ANOVA, factorial repeated-measures ANOVA, and forward stepwise multivariable analysis; the sample size of 40 was prospectively determined to have 90% power to detect a 10% relative reduction in RVEF.

Limitations

  • Stated: DGE within the RV free wall was not assessed because adequate nulling of normal RV free wall myocardium was visualized in only a minority of athletes; athletic remodelling may cause fibrosis to be under-appreciated with relative-enhancement techniques.
  • Stated: the cohort was relatively small and underpowered for clinical sequelae; biomarker assessment at a single time point may limit interpretation; conclusions about exercise duration are tempered by confounders such as training levels, exercise modality, race conditions, and motivation.
  • Evident from text: the study reports no long-term clinical outcomes, and prognostic implications from other clinical conditions should not be extrapolated to this healthy athletic cohort.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1093/eurheartj/ehr397

Cites

51 of 51 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

13 of 33 cited sources checked · 9 supported · 0 flagged · accuracy not yet measured

  • Premisecitation
    § Introduction

    Right ventricular function may be more profoundly affected by intense endurance exercise than left ventricular function.

    “However, right ventricular (RV) function may be more profoundly affected by intense endurance exercise 6 -10”
    Quote in the paperSubstantial claim2 of 5 sources checked
    • cites [6] 2008, Biochemical and functional abnormalities of left and right ventricular function after ultra-endurance exercise, Heart source
    • cites [7] 2010, Acute cardiac effects of marathon running, J Appl Physiol source
    • cites [8] 2009, Relation of biomarkers and cardiac magnetic resonance imaging after marathon running, Am J Cardiol source
    • cites [9] 2006, Myocardial injury and ventricular dysfunction related to training levels among nonelite participants in the Boston marathon, Circulation source
    • cites [10] 1990, Different effects of prolonged exercise on the right and left ventricles, J Am Coll Cardiol source
  • Interpretationcitation
    § Chronic myocardial remodelling and the effect of exercise 'dose'

    The inability to discern normal nulled RV free wall myocardium in a majority of athletes more likely reflects limitations in spatial resolution of the CMR technique rather than abnormal enhancement.

    “While this could be interpreted as abnormal enhancement, it is more likely to reflect the limitations in spatial resolution of the technique, a sentiment echoed by a panel of experts who deemed that DGE assessment in the RV free wall was too unreliable to be included in the recent revision of diagnostic criteria for arrhythmogenic RV cardiomyopathy.35”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [35] 2010, Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria, Circulation source
  • Premisecitation
    § Chronic myocardial remodelling and the effect of exercise 'dose'

    Intense endurance exercise may be associated with an excess in arrhythmic disorders.

    “However, there is also emerging evidence that intense endurance exercise may be associated with an excess in arrhythmic disorders, the mechanisms for which remain unexplained.38 -41”
    Quote in the paperSubstantial claim2 of 4 sources checked
    • cites [38] 2008, Sinus node disease and arrhythmias in the long-term follow-up of former professional cyclists, Eur Heart J

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [39] 2011, Strenuous endurance exercise: is more better for everyone? Our genes won't tell us, Br J Sports Med source
    • cites [40] 2011, Marathon rat: myocardial remodeling in an animal model of vigorous endurance exercise and implications for humans, Circulation source
    • cites [41] 2010, Arrhythmias and sport practice, Heart source
  • Premisecitation
    § Chronic myocardial remodelling and the effect of exercise 'dose'

    Recent data suggest that exercise-induced proarrhythmic substrates may develop in the RV while sparing the LV.

    “Studies focussing on the LV of athletes have failed to provide these mechanistic insights, 4 but recent data have suggested that exercise-induced proarrhythmic substrates may develop in the RV while sparing the LV.12,13,15”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites [12] 2007, Reduced right ventricular ejection fraction in endurance athletes presenting with ventricular arrhythmias: a quantitative angiographic assessment, Eur Heart J source
    • cites [13] 2003, High prevalence of right ventricular involvement in endurance athletes with ventricular arrhythmias. Role of an electrophysiologic study in risk stratification, Eur Heart J source
    • cites [15] 2011, Cardiac arrhythmogenic remodeling in a rat model of long-term intensive exercise training, Circulation source
  • Premisecitation
    § Chronic myocardial remodelling and the effect of exercise 'dose'

    Trained athletes during intense exercise demonstrate considerable increases in pulmonary pressures.

    “The considerable increases in pulmonary pressures demonstrated in trained athletes during intense exercise 29,30,34 suggest a similar physiological stress, albeit only transient.”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [29] 2011, Disproportionate exercise load and remodeling of the athlete's right ventricle, Med Sci Sports Exerc source
    • cites [30] 2010, Pulmonary transit of agitated contrast is associated with enhanced pulmonary vascular reserve and right ventricular function during exercise, J Appl Physiol source
    • cites [34] 1999, Range of tricuspid regurgitation velocity at rest and during exercise in normal adult men: implications for the diagnosis of pulmonary hypertension, J Am Coll Cardiol source
  • Classified as probably not a substantial claim. 10
  • May combine two claims. 25
  • The quote only partly states this claim. 2

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation
    § Chronic myocardial remodelling and the effect of exercise 'dose'

    Intense endurance exercise promoted RV-specific fibrosis in rats, which increased vulnerability to ventricular tachycardia following programmed stimulation.

    “Benito et al. 15 recently documented that intense endurance exercise promoted RV-specific fibrosis in rats which increased vulnerability to ventricular tachycardia following programmed stimulation.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [15] 2011, Cardiac arrhythmogenic remodeling in a rat model of long-term intensive exercise training, Circulation source

      The chamber-specific remodeling section reports right-ventricular fibrosis after intensive training, with no observed left-ventricular difference. The ventricular-arrhythmia section reports greater inducibility during programmed stimulation in exercise rats (42% versus 6%). But the discussion says fibrosis *could play a role* in that susceptibility; it does not establish that the fibrosis caused the increase. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Chronic myocardial remodelling and the effect of exercise 'dose'

    Exercise is a powerful intervention in the prevention and treatment of cardiovascular disease across a wide range of exercise volumes and intensities, including among competitive athletes.

    “Exercise is a powerful intervention in the prevention and treatment of cardiovascular disease for which compelling evidence exists across a wide range of exercise volumes and intensities, including among competitive athletes.4,26,37”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [4] 2010, Long-term clinical consequences of intense, uninterrupted endurance training in olympic athletes, J Am Coll Cardiol source

      The Conclusions (page not provided) report that prolonged, intense endurance training in young Olympic athletes was not associated with cardiovascular events or deterioration in left ventricular function. That supports a limited point about competitive athletes, but the study enrolled athletes free of cardiovascular disease and does not establish exercise as a prevention or treatment intervention across a wide range of volumes and intensities. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [26] 2010, Physical activity and cardiovascular health: lessons learned from epidemiological studies across age, gender, and race/ethnicity, Circulation source
    • cites [37] 1993, Increased life expectancy of world class male athletes, Med Sci Sports Exerc

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation
    § Chronic myocardial remodelling and the effect of exercise 'dose'

    DGE was observed in 6 of 12 elite veteran athletes but not in 17 young novice athletes or 20 older non-athletes.

    “More recently, Wilson et al. 18 observed DGE in 6 of 12 elite veteran athletes but not in 17 young novice athletes or 20 older non-athletes.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [18] 2011, Diverse patterns of myocardial fibrosis in lifelong, veteran endurance athletes, J Appl Physiol source

      The Results report LGE in 6 of 12 veteran athletes and none in the 17 young athletes or 20 age-matched controls. But the Methods describe the young athletes as experienced endurance competitors with 11–31 years of training, not novices. The paper calls the imaging finding LGE rather than DGE. (LLM, conf=0.90)

      Experimental — accuracy not yet measured

  • The quote only partly states this claim.

    Findingown data
    § Post-race changes in ventricular function

    All functional measures of the right ventricle decreased post-race relative to baseline.

    “all measures of systolic RV function were reduced post-race.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Discussion

    Focal gadolinium enhancement and increased right ventricular remodelling were more prevalent in athletes with a longer history of competitive sport.

    “Also, focal gadolinium enhancement and increased RV remodelling were more prevalent in those athletes with a longer history of competitive sport”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Interventricular dependence

    An early diastolic 'septal bounce' on M-mode echocardiography occurred in 26 of 40 athletes post-race and was not present at baseline.

    “the occurrence of an early diastolic 'septal bounce' on M-mode echocardiography in 26 of 40 athletes which was not present at baseline”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Correlation between functional and biochemical evidence of myocardial injury

    B-type natriuretic peptide and cardiac troponin I correlated with reductions in right ventricular ejection fraction (r = 0.52, P = 0.001 and r = 0.49, P = 0.002, respectively).

    “Significant correlations were evident between the change in RVEF and post-race troponin (r ¼ 0.494, P ¼ 0.002) and BNP levels (r ¼ 0.518, P ¼ 0.001).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Assessment of cardiac fibrosis by cardiac magnetic resonance imaging

    Athletes with delayed gadolinium enhancement had 16% greater right ventricular end-diastolic volume and 25% greater right ventricular end-systolic volume than those without delayed gadolinium enhancement (P = 0.029 and 0.003, respectively).

    “those with DGE had 16% greater RVEDV and 25% greater RVESV than those athletes in whom there was no DGE (P ¼ 0.029 and 0.003, respectively).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Correlation between functional and biochemical evidence of myocardial injury

    B-type natriuretic peptide and cardiac troponin I did not correlate with left ventricular ejection fraction.

    “There was no correlation between changes in LVEF and post-race cTnI (r ¼ 20.065, P ¼ 0.702) or BNP (r ¼ 0.250, P ¼ 0.125).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Effect of race duration

    Race completion time and VO2max remained as independent predictors in the multivariable analysis (b = 0.459, P = 0.002 and b = 0.294, P = 0.036, respectively), together explaining 34% of the variance in change in right ventricular ejection fraction (P = 0.001).

    “Race completion time and VO 2 max remained as independent predictors in the multivariable analysis (b ¼ 0.459, P ¼ 0.002 and b ¼ 0.294, P ¼ 0.036, respectively), together explaining 34% of the variance in △RVEF (P ¼ 0.001).”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data
    § Abstract

    Athletes with delayed gadolinium enhancement had greater cumulative exercise exposure than those with normal cardiac magnetic resonance imaging.

    “athletes who had greater cumulative exercise exposure”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Conclusion and clinical implications

    There was a significant interaction between event type and time point with a greater reduction in function in those completing the longest event (ultra-triathlon).

    “There was a significant interaction between event type and time point (P-value) with a greater reduction in function in those completing the longest event (ultra-triathlon).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Conclusion and clinical implications

    Right ventricular volumes increased in the post-race setting while left ventricular volumes decreased, resulting in a decrease in right ventricular ejection fraction but not left ventricular ejection fraction.

    “Right ventricular volumes increased in the post-race setting while left ventricular volumes decreased resulting in a decrease in right ventricular ejection fraction but not left ventricular ejection fraction.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given
    § Conclusion and clinical implications

    These athletes had been competing in endurance sport for longer and had greater structural remodelling of the RV.

    “These athletes had been competing in endurance sport for longer and had greater structural remodelling of the RV.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Chronic myocardial remodelling and the effect of exercise 'dose'

    Acute injury and chronic remodelling of the myocardium both disproportionately affect the RV.

    “In addition, we demonstrate that the acute injury and chronic remodelling of the myocardium both disproportionately affect the RV”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Chronic myocardial remodelling and the effect of exercise 'dose'

    In all cases, focal DGE was confined to the interventricular septum and commonly at the site of RV attachment.

    “In all cases, focal DGE was confined to the interventricular septum and commonly at the site of RV attachment.”
    • Also stated in: § Conclusion and clinical implications · plain
      “Images of five athletes in whom focal delayed gadolinium enhancement (DGE) was identified in the interventricular septum (indicated with arrows) when compared with an athlete with a normal study (top left).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Conclusion and clinical implications

    Ejection fraction, fractional area change, and systolic strain rate decreased in the post-race setting.

    “Ejection fraction (A), fractional area change (B), and systolic strain rate (C ) decreased in the post-race setting.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Conclusion and clinical implications

    Functional abnormalities were confined to the RV and were largely reversible 1 week following the event.

    “Functional abnormalities were confined to the RV and were largely reversible 1 week following the event.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Statistical analysis

    A tolerance of >0.5 was set to avoid collinearity between the five entered variables (race duration, VO2max, age, weekly training, and career training).

    “A tolerance of .0.5 was set to avoid collinearity between the five entered variables (race duration, VO 2 max, age, weekly, and career training).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given
    § Study design

    Written informed consent was obtained from all subjects and the protocol was approved by the St Vincent's Hospital Human Research Ethics Committee in accordance with the Declaration of Helsinki.

    “Written informed consent was obtained from all subjects and the protocol was approved by the St Vincent's Hospital Human Research Ethics Committee in accordance with the Declaration of Helsinki.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data
    § Discussion

    Intense endurance exercise causes an acute reduction in right ventricular function that correlates with increases in biomarkers of myocardial injury.

    “Intense endurance exercise causes an acute reduction in RV function that increases with race duration and correlates with increases in biomarkers of myocardial injury.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data
    § Discussion

    Repetitive ultra-endurance exercise may lead to more extensive right ventricular change and possible myocardial fibrosis.

    “suggesting that repetitive ultra-endurance exercise may lead to more extensive RV change and possible myocardial fibrosis.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Echocardiography

    All reported values are the average of three repeated measures from separate cardiac cycles.

    “All reported values are the average of three repeated measures from separate cardiac cycles.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Statistical analysis

    The sample size of 40 was prospectively determined to have a 90% power of detecting a 10% relative reduction in right ventricular ejection fraction averaged across all four endurance events.

    “The sample size of 40 was prospectively determined to have a 90% power of detecting a 10% relative reduction in RVEF averaged across all four endurance events”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data
    § Cardiac magnetic resonance imaging

    Delayed gadolinium enhancement within the right ventricular free wall was not assessed because adequate nulling of normal right ventricular free wall myocardium was visualized in only a minority of athletes.

    “Delayed gadolinium enhancement within the RV free wall was not assessed because adequate nulling of normal RV free wall myocardium (the reference against which abnormal enhancement is compared) was visualized in only a minority of athletes.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data
    § Abstract

    Intense endurance exercise causes acute dysfunction of the right ventricle, but not the left ventricle.

    “Intense endurance exercise causes acute dysfunction of the RV, but not the LV.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Post-race changes in load, myocardial substrates, and metabolites should confound right ventricular and left ventricular measures similarly.

  • May combine two claims.

    Interpretationown data
    § Discussion

    Intense endurance exercise causes an acute reduction in right ventricular function that increases with race duration.

    “Intense endurance exercise causes an acute reduction in RV function that increases with race duration”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The four endurance events represent a progressive increase in exercise duration.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductcitation
    § Cardiac magnetic resonance imaging

    To be deemed significant, delayed gadolinium enhancement had to be independently identified by both clinicians and mean signal intensities in the region of hyperenhancement were required to be more than two standard deviations higher than the mean signal intensity of a region of adjacent myocardium.

    “To be deemed significant, DGE had to be independently identified by both clinicians and, in addition, mean signal intensities in the region of hyperenhancement were required to be more than two standard deviations (SDs) higher than the mean signal intensity of a region of adjacent myocardium”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given
    § Cardiac magnetic resonance imaging

    Delayed gadolinium enhancement was qualitatively assessed by two experienced clinicians after comparing pre- and post-contrast short-axis slices to exclude artefacts.

    “Delayed gadolinium enhancement (DGE) was qualitatively assessed by two experienced clinicians after comparing pre-and post-contrast short-axis slices to exclude artefacts.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data
    § Evidence for isolated right ventricular injury

    Greater reductions in right ventricular function occurred in those athletes competing for a longer duration, suggesting that the heart has a finite capacity to maintain the increased work demands of exercise.

    “Greater reductions in RV function occurred in those athletes competing for a longer duration, suggesting that the heart has a finite capacity to maintain the increased work demands of exercise.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The four endurance events represent a progressive increase in exercise duration.

  • May combine two claims.

    Interpretationreasoning
    § Biochemical markers are associated with changes in right ventricular function

    B-type natriuretic peptide may provide a measure of both acute right ventricular load and the resultant fatigue which occurs when this load is sustained.

    “Thus, BNP may provide a measure of both acute RV load and the resultant fatigue which occurs when this load is sustained.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § Biochemical markers are associated with changes in right ventricular function

    B-type natriuretic peptide release during intense exercise is associated with greater relative increases in right ventricular systolic pressures, but not left ventricular pressures.

    “We have previously demonstrated that BNP release during intense exercise is associated with greater relative increases in RV systolic pressures, but not LV pressures.30”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [30] 2010, Pulmonary transit of agitated contrast is associated with enhanced pulmonary vascular reserve and right ventricular function during exercise, J Appl Physiol source

  • May combine two claims.

    Premisecitation
    § Evidence for isolated right ventricular injury

    Ventricular load increases with exercise intensity and is greater for the right ventricle than the left ventricle.

    “It has been demonstrated that ventricular load increases with exercise intensity and is greater for the RV than the LV, 29”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [29] 2011, Disproportionate exercise load and remodeling of the athlete's right ventricle, Med Sci Sports Exerc source
33 of 33

  • The paper relies on this without support.

    The four endurance events represent a progressive increase in exercise duration.

    “The four events were selected to represent a progressive increase in exercise duration”

  • The paper relies on this without support.

    Post-race changes in load, myocardial substrates, and metabolites should confound right ventricular and left ventricular measures similarly.

    “Comparisons with the LV are most instructive, given that post-race changes in load, myocardial substrates, and metabolites should confound RV and LV measures similarly.”

  • The paper relies on this without support.

    Athletic training results in relatively uniform cardiac remodelling.

    “Secondly, athletic training results in relatively uniform cardiac remodelling and it is possible that cardiac fibrosis may be under-appreciated with current techniques that assess relative enhancement.”

  • The paper relies on this without support.

    Focal delayed gadolinium enhancement on cardiac magnetic resonance indicates myocardial fibrosis.

    “However, there remained a significant minority of athletes in whom there was evidence of myocardial fibrosis in the interventricular septum.”
4 of 4

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Conclusion excludes a reported LV functional abnormality

    Major

    The conclusion says functional abnormalities were confined to the RV, but the results explicitly report impaired post-race LV diastolic filling.

  • Post-race troponin median is below the reported range

    Minor

    The reported post-race median of 0.018 mg/L is below the reported minimum of 0.020 mg/L.

2 of 2

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Authors
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.
Affiliations
  • St Vincent's Hospital Melbourne (AU)
  • The University of Melbourne (AU)
  • Baker Heart and Diabetes Institute (AU)
  • Universitair Ziekenhuis Leuven (BE)
ORCID
Venue
European Heart Journal
Publisher
Oxford University Press (OUP)
Published
2011-12-06
Volume
33
Issue
8
Pages
998-1006
ISSN
  • 0195-668X (ISSN-L)
  • 1522-9645
DOI
10.1093/eurheartj/ehr397
OpenAlex
W2148325692
Semantic Scholar
7d299222e3e0cabc4deedc38d9035410d00d5777
Cited by
776
References
48
Citations by year
2026: 34 · 2025: 41 · 2024: 36 · 2023: 38 · 2022: 62 · 2021: 42 · 2020: 82 · 2019: 48 · 2018: 62 · 2017: 61 · 2016: 64 · 2015: 62 · 2014: 71 · 2013: 38 · 2012: 30
FWCI
28.72
Type
journal article
Language
en
Open access
Locations
  • European Heart Journal (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Effects of Exercise
  • Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiomyopathy and Myosin Studies
Keywords
endurance athletes, right ventricular dysfunction, cardiac remodeling, myocardial fibrosis, arrhythmogenic cardiomyopathy, endurance exercise, right ventricular ejection fraction, late gadolinium enhancement, cardiac troponin I, brain natriuretic peptide, exercise-induced myocardial injury
MeSH terms
Adult, Female, Fibrosis, Humans, Male, Middle Aged, Myocardium, Physical Endurance, Stroke Volume, Biomarkers, Exercise, Ventricular Dysfunction, Right, Magnetic Resonance Angiography, Troponin I, Ventricular Remodeling, Athletes

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