Skip to main content

Advertisement

SpringerLink
Log in

Exercise and Competitive Sport: Physiology, Adaptations, and Uncertain Long-Term Risks

  • Sports Cardiology (M Emery, Section Editor)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

The benefits of regular and moderate exercise training on cardiovascular outcomes have been well established. In addition, strenuous exercise training leads to corollary cardiac structural and functional adaptations that are sport-specific and facilitate athletic performance. In this review, the normal physiologic and hemodynamic changes that occur during exercise and the subsequent differential exercise-induced cardiac remodeling patterns that develop will be discussed. Paradoxically, recent data have raised concern about the long-term impact of higher doses of physical activity and exercise on mortality and cardiovascular health outcomes. We will discuss important aspects of these controversial data and review the supporting evidence as well as the limitations of prior research. Specifically, we will address the association between high levels of exercise and relative reductions in overall mortality, increased risk of atrial fibrillation, arrhythmogenic cardiac remodeling, and accelerated coronary artery calcifications. For the practitioner, this review aims to detail these contemporary sports cardiology controversies and highlights the critical need to incorporate shared decision making with the athlete in dealing with the uncertainties that exist. Finally, we will discuss key “athlete-specific” variables that should be considered in the design of future important research in this arena.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Paffenbarger RS Jr, Hyde RT, Wing AL, Lee IM, Jung DL, Kampert JB. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. N Engl J Med. 1993;328(8):538–45.

    Article  PubMed  Google Scholar 

  2. Sattelmair J, Pertman J, Ding EL, Kohl HW 3rd, Haskell W, Lee IM. Dose response between physical activity and risk of coronary heart disease: a meta-analysis. Circulation. 2011;124(7):789–95.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Sofi F, Capalbo A, Cesari F, Abbate R, Gensini GF. Physical activity during leisure time and primary prevention of coronary heart disease: an updated meta-analysis of cohort studies. Eur J Cardiovasc Prev Rehabil. 2008;15(3):247–57.

    Article  PubMed  Google Scholar 

  4. Wen CP, Wai JP, Tsai MK, Yang YC, Cheng TY, Lee MC, et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet. 2011;378(9798):1244–53.

    Article  PubMed  Google Scholar 

  5. Lee DC, Brellenthin AG, Thompson PD, Sui X, Lee IM, Lavie CJ. Running as a Key Lifestyle Medicine for Longevity. Prog Cardiovasc Dis. 2017;pii: S0033-0620(17)30048–8.

  6. Baggish AL, Wood MJ. Athlete’s heart and cardiovascular care of the athlete: scientific and clinical update. Circulation. 2011;123(23):2723–35.

    Article  PubMed  Google Scholar 

  7. Pluim BM, Zwinderman AH, van der Laarse A, van der Wall EE. The athlete’s heart. A meta-analysis of cardiac structure and function. Circulation. 2000;101(3):336–44.

    Article  CAS  PubMed  Google Scholar 

  8. Baggish AL, Wang F, Weiner RB, Elinoff JM, Tournoux F, Boland A, et al. Training-specific changes in cardiac structure and function: a prospective and longitudinal assessment of competitive athletes. J Applied Physiol (1985). 2008;104(4):1121–8.

    Article  Google Scholar 

  9. •• Andersen K, Farahmand B, Ahlbom A, Held C, Ljunghall S, Michaelsson K, et al. Risk of arrhythmias in 52 755 long-distance cross-country skiers: a cohort study. Eur Heart J. 2013;34(47):3624–31. This study is the largest cohort study of high-level endurance athletes demonstrating an association between endurance exercise and atrial fibrillation. Importantly, those athletes who competed in the most number of cross-country skiing events and who were the fastest were most at risk.

    Article  PubMed  Google Scholar 

  10. •• La Gerche A, Burns AT, Mooney DJ, Inder WJ, Taylor AJ, Bogaert J, et al. Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes. Eur Heart J. 2012;33(8):998–1006. In this study of 40 elite endurance athletes, an association was observed between reduced RV systolic function and increased cardiac biomarkers immediately after completion of an ultra-endurance exercise event. Additionally, a small number of athletes studied at baseline showed fibrosis in the right ventricle on cardiac MRI of unclear significance.

    Article  PubMed  Google Scholar 

  11. • Mohlenkamp S, Lehmann N, Breuckmann F, Brocker-Preuss M, Nassenstein K, Halle M, et al. Running: the risk of coronary events : prevalence and prognostic relevance of coronary atherosclerosis in marathon runners. Eur Heart J. 2008;29(15):1903–10. This study found increased coronary artery calcium scores in veteran marathon runners compared to relatively matched non-marathon running controls. Four marathon runners had coronary events within 2 years of follow-up.

    Article  PubMed  Google Scholar 

  12. Levine BD. Can intensive exercise harm the heart? The benefits of competitive endurance training for cardiovascular structure and function. Circulation. 2014;130(12):987–91.

    Article  PubMed  Google Scholar 

  13. O’Keefe JH, Lavie CJ. Run for your life ... at a comfortable speed and not too far. Heart. 2013;99(8):516–9.

    Article  PubMed  Google Scholar 

  14. Reynolds G. Can too much exercise harm the heart? New York Times. 2015. (http://well.blogs.nytimes.com/2015/12/30/can-too-much-exercise-harm-the-heart/?_r=0).

  15. Rosenbaum L. Extreme exercise and the heart. The New Yorker. 2014. (http://www.newyorker.com/tech/elements/extreme-exercise-and-the-heart).

  16. Rowell L. Human circulation: regulation during physical stress. New York: Oxford University Press; 1986.

    Google Scholar 

  17. Maron BJ, Zipes DP. Introduction: eligibility recommendations for competitive athletes with cardiovascular abnormalities-general considerations. J Am Coll Cardiol. 2005;45(8):1318–21.

    Article  PubMed  Google Scholar 

  18. Weiner RB, Wang F, Isaacs SK, Malhotra R, Berkstresser B, Kim JH, et al. Blood pressure and left ventricular hypertrophy during American-style football participation. Circulation. 2013;128(5):524–31.

    Article  PubMed  Google Scholar 

  19. Morganroth J, Maron BJ, Henry WL, Epstein SE. Comparative left ventricular dimensions in trained athletes. Ann Intern Med. 1975;82(4):521–4.

    Article  CAS  PubMed  Google Scholar 

  20. Lin J, Wang F, Weiner RB, DeLuca JR, Wasfy MM, Berkstresser B, et al. Blood pressure and LV remodeling among American-style football players. JACC Cardiovasc Imaging. 2016;9(12):1367–76.

    Article  PubMed  Google Scholar 

  21. Kim JH, Sher S, Wang F, Berkstresser B, Shoop JL, Galante A, et al. Impact of American-style football participation on vascular function. Am J Cardiol. 2015;115(2):262–7.

    Article  PubMed  Google Scholar 

  22. Arem H, Moore SC, Patel A, Hartge P, Berrington de Gonzalez A, Visvanathan K, et al. Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship. JAMA Intern Med. 2015;175(6):959–67.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Armstrong MEG, Green J, Reeves GK, Beral V, Cairns BJ. Response to letter regarding article, “Frequent physical activity may not reduce vascular disease risk as much as moderate activity: large prospective study of women in the United Kingdom”. Circulation. 2015;132(18):e225.

    Article  PubMed  Google Scholar 

  24. • Lee DC, Pate RR, Lavie CJ, Sui X, Church TS, Blair SN. Leisure-time running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol. 2014;64(5):472–81. In this epidemiologic analysis, the authors found low-dose running significantly reduced all-cause and cardiovascular mortality. In addition, metrics of running dose were stratified into quintiles, and there were minimal differences in mortaliy benefit across quintiles.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Schnohr P, O'Keefe JH, Marott JL, Lange P, Jensen GB. Dose of jogging and long-term mortality: the Copenhagen City Heart Study. J Am Coll Cardiol. 2015;65(5):411–9.

    Article  PubMed  Google Scholar 

  26. Kim JH, Baggish AL. Physical activity, endurance exercise, and excess—can one overdose? Curr Treat Options Cardiovasc Med. 2016;18(11):68.

    Article  PubMed  Google Scholar 

  27. Chakravarty EF, Hubert HB, Lingala VB, Fries JF. Reduced disability and mortality among aging runners: a 21-year longitudinal study. Arch Intern Med. 2008;168(15):1638–46.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Clarke PM, Walter SJ, Hayen A, Mallon WJ, Heijmans J, Studdert DM. Survival of the fittest: retrospective cohort study of the longevity of Olympic medallists in the modern era. BMJ. 2012;345:e8308.

    Article  PubMed  Google Scholar 

  29. Farahmand BY, Ahlbom A, Ekblom O, Ekblom B, Hallmarker U, Aronson D, et al. Mortality amongst participants in Vasaloppet: a classical long-distance ski race in Sweden. J Intern Med. 2003;253(3):276–83.

    Article  CAS  PubMed  Google Scholar 

  30. Marijon E, Tafflet M, Antero-Jacquemin J, El Helou N, Berthelot G, Celermajer DS, et al. Mortality of French participants in the Tour de France (1947-2012). Eur Heart J. 2013;34(40):3145–50.

    Article  PubMed  Google Scholar 

  31. Sarna S, Sahi T, Koskenvuo M, Kaprio J. Increased life expectancy of world class male athletes. Med Sci Sports Exerc. 1993;25(2):237–44.

    Article  CAS  PubMed  Google Scholar 

  32. Iwasaki YK, Nishida K, Kato T, Nattel S. Atrial fibrillation pathophysiology: implications for management. Circulation. 2011;124(20):2264–74.

    Article  CAS  PubMed  Google Scholar 

  33. Elosua R, Arquer A, Mont L, Sambola A, Molina L, Garcia-Moran E, et al. Sport practice and the risk of lone atrial fibrillation: a case-control study. Int J Cardiol. 2006;108(3):332–7.

    Article  PubMed  Google Scholar 

  34. Heidbuchel H, Anne W, Willems R, Adriaenssens B, Van de Werf F, Ector H. Endurance sports is a risk factor for atrial fibrillation after ablation for atrial flutter. Int J Cardiol. 2006;107(1):67–72.

    Article  PubMed  Google Scholar 

  35. Karjalainen J, Kujala UM, Kaprio J, Sarna S, Viitasalo M. Lone atrial fibrillation in vigorously exercising middle aged men: case-control study. BMJ. 1998;316(7147):1784–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Molina L, Mont L, Marrugat J, Berruezo A, Brugada J, Bruguera J, et al. Long-term endurance sport practice increases the incidence of lone atrial fibrillation in men: a follow-up study. Europace. 2008;10(5):618–23.

    Article  PubMed  Google Scholar 

  37. Abdulla J, Nielsen JR. Is the risk of atrial fibrillation higher in athletes than in the general population? A systematic review and meta-analysis. Europace. 2009;11(9):1156–9.

    Article  PubMed  Google Scholar 

  38. Wilhelm M, Roten L, Tanner H, Wilhelm I, Schmid JP, Saner H. Atrial remodeling, autonomic tone, and lifetime training hours in nonelite athletes. Am J Cardiol. 2011;108(4):580–5.

    Article  PubMed  Google Scholar 

  39. Mozaffarian D, Furberg CD, Psaty BM, Siscovick D. Physical activity and incidence of atrial fibrillation in older adults: the cardiovascular health study. Circulation. 2008;118(8):800–7.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Scharf M, Brem MH, Wilhelm M, Schoepf UJ, Uder M, Lell MM. Cardiac magnetic resonance assessment of left and right ventricular morphologic and functional adaptations in professional soccer players. Am Heart J. 2010;159(5):911–8.

    Article  PubMed  Google Scholar 

  41. Marcus FI, McKenna WJ, Sherrill D, Basso C, Bauce B, Bluemke DA, et al. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria. Circulation. 2010;121(13):1533–41.

    Article  PubMed  PubMed Central  Google Scholar 

  42. James CA, Bhonsale A, Tichnell C, Murray B, Russell SD, Tandri H, et al. Exercise increases age-related penetrance and arrhythmic risk in arrhythmogenic right ventricular dysplasia/cardiomyopathy-associated desmosomal mutation carriers. J Am Coll Cardiol. 2013;62(14):1290–7.

    Article  PubMed  Google Scholar 

  43. Sharma S, Zaidi A. Exercise-induced arrhythmogenic right ventricular cardiomyopathy: fact or fallacy? Eur Heart J. 2012;33(8):938–40.

    Article  PubMed  Google Scholar 

  44. Benito B, Gay-Jordi G, Serrano-Mollar A, Guasch E, Shi Y, Tardif JC, et al. Cardiac arrhythmogenic remodeling in a rat model of long-term intensive exercise training. Circulation. 2011;123(1):13–22.

    Article  PubMed  Google Scholar 

  45. Ector J, Ganame J, van der Merwe N, Adriaenssens B, Pison L, Willems R, et al. Reduced right ventricular ejection fraction in endurance athletes presenting with ventricular arrhythmias: a quantitative angiographic assessment. Eur Heart J. 2007;28(3):345–53.

    Article  PubMed  Google Scholar 

  46. Douglas PS, O'Toole ML, Hiller WD, Hackney K, Reichek N. Cardiac fatigue after prolonged exercise. Circulation. 1987;76(6):1206–13.

    Article  CAS  PubMed  Google Scholar 

  47. Neilan TG, Januzzi JL, Lee-Lewandrowski E, Ton-Nu TT, Yoerger DM, Jassal DS, et al. Myocardial injury and ventricular dysfunction related to training levels among nonelite participants in the Boston marathon. Circulation. 2006;114(22):2325–33.

    Article  PubMed  Google Scholar 

  48. Scharhag J, George K, Shave R, Urhausen A, Kindermann W. Exercise-associated increases in cardiac biomarkers. Med Sci Sports Exerc. 2008;40(8):1408–15.

    Article  PubMed  Google Scholar 

  49. Whyte GP, George K, Sharma S, Lumley S, Gates P, Prasad K, et al. Cardiac fatigue following prolonged endurance exercise of differing distances. Med Sci Sports Exerc. 2000;32(6):1067–72.

    Article  CAS  PubMed  Google Scholar 

  50. Wilson M, O'Hanlon R, Prasad S, Deighan A, Macmillan P, Oxborough D, et al. Diverse patterns of myocardial fibrosis in lifelong, veteran endurance athletes. J Appl Physiol (1985). 2011;110(6):1622–6.

    Article  CAS  Google Scholar 

  51. Bohm P, Schneider G, Linneweber L, Rentzsch A, Kramer N, Abdul-Khaliq H, 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(20):1927–35.

    Article  PubMed  Google Scholar 

  52. Baggish AL, Yared K, Wang F, Weiner RB, Hutter AM Jr, Picard MH, et al. The impact of endurance exercise training on left ventricular systolic mechanics. Am J Physiol Heart Circ Physiol. 2008;295(3):H1109–h16.

    Article  CAS  PubMed  Google Scholar 

  53. Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A. Growing epidemic of coronary heart disease in low- and middle-income countries. Curr Probl Cardiol. 2010;35(2):72–115.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Aikawa E, Nahrendorf M, Figueiredo JL, Swirski FK, Shtatland T, Kohler RH, et al. Osteogenesis associates with inflammation in early-stage atherosclerosis evaluated by molecular imaging in vivo. Circulation. 2007;116(24):2841–50.

    Article  CAS  PubMed  Google Scholar 

  55. Ross R. The pathogenesis of atherosclerosis: a perspective for the 1990s. Nature. 1993;362(6423):801–9.

    Article  CAS  PubMed  Google Scholar 

  56. Weber C, Noels H. Atherosclerosis: current pathogenesis and therapeutic options. Nat Med. 2011;17(11):1410–22.

    Article  CAS  PubMed  Google Scholar 

  57. Budoff MJ, Shaw LJ, Liu ST, Weinstein SR, Mosler TP, Tseng PH, et al. Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol. 2007;49(18):1860–70.

    Article  PubMed  Google Scholar 

  58. Schwartz R, Schwartz JG, Wickstrom KK, Peichel G, Gerberich RF, et al. Increased coronary artery plaque volume among male marathon runners. Mo Med. 2014;111:85–94.

    Google Scholar 

  59. • Aengevaeren VL, Mosterd A, Braber TL, NHJ P, Doevendans PA, Grobbee DE, et al. The relationship between lifelong exercise volume and coronary atherosclerosis in athletes. Circulation. 2017;136:138–48. In this study, middle-aged runners with the highest lifetime exercise volume had higher CAC scores, prevalence of CAC, and plaque compared to runners with the lowest exercise exposure. Among those with plaque, participants in the most active group had less mixed plaque and were more likely to have only calcified plaques compared to the least active group.

    Article  CAS  PubMed  Google Scholar 

  60. •• Merghani A, Maestrini V, Rosmini S, Cox AT, Dhutia H, Bastiaenen R, et al. Prevalence of subclinical coronary artery disease in masters endurance athletes with a low atherosclerotic risk profile. Circulation. 2017;136:126–37. In this observational study, master athletes with low atherosclerotic risk had the same percentage of normal CAC as a healthy-matched control cohort. The master athlete cohorts were more likely, however, to have a CAC of > 300 compared to controls. Plaques found in master athletes were more likely to be calcific compared to those of controls.

    Article  CAS  PubMed  Google Scholar 

  61. Hagstrom E, Michaelsson K, Melhus H, Hansen T, Ahlstrom H, Johansson L, et al. Plasma-parathyroid hormone is associated with subclinical and clinical atherosclerotic disease in 2 community-based cohorts. Arterioscler Thromb Vasc Biol. 2014;34(7):1567–73.

    Article  PubMed  Google Scholar 

  62. Scott JP, Sale C, Greeves JP, Casey A, Dutton J, Fraser WD. The effect of training status on the metabolic response of bone to an acute bout of exhaustive treadmill running. J Clin Endocrinol Metab. 2010;95(8):3918–25.

    Article  CAS  PubMed  Google Scholar 

  63. Zerath E, Holy X, Douce P, Guezennec CY, Chatard JC. Effect of endurance training on postexercise parathyroid hormone levels in elderly men. Med Sci Sports Exerc. 1997;29(9):1139–45.

    Article  CAS  PubMed  Google Scholar 

  64. Criqui MH, Denenberg JO, Ix JH, McClelland RL, Wassel CL, Rifkin DE, et al. Calcium density of coronary artery plaque and risk of incident cardiovascular events. JAMA. 2014;311(3):271–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  65. Kim JH, Malhotra R, Chiampas G, d'Hemecourt P, Troyanos C, Cianca J, et al. Cardiac arrest during long-distance running races. N Engl J Med. 2012;366(2):130–40.

    Article  CAS  PubMed  Google Scholar 

  66. Lamppa R. 2015 state of the sport—U.S. race trends. Running USA, 2015. (http://www.runningusa.org/annual-reports).

  67. Baggish AL, Hale A, Weiner RB, Lewis GD, Systrom D, Wang F, et al. Dynamic regulation of circulating microRNA during acute exhaustive exercise and sustained aerobic exercise training. J Physiol. 2011;589(Pt 16):3983–94.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Baggish AL, Park J, Min PK, Isaacs S, Parker BA, Thompson PD, et al. Rapid upregulation and clearance of distinct circulating microRNAs after prolonged aerobic exercise. J Appl Physiol (1985). 2014;116(5):522–31.

    Article  CAS  Google Scholar 

  69. Kim JH, Banton S, Awad M, Yadalam A, Sher S, Tran V, et al. Training-related metabolic adaptations in American-style football participants. Ann Sports Med Res. 2015;2(8):1048.

    Google Scholar 

  70. Lewis GD, Farrell L, Wood MJ, Martinovic M, Arany Z, Rowe GC, et al. Metabolic signatures of exercise in human plasma. Sci Transl Med. 2010;2(33):33ra7.

    Article  Google Scholar 

Download references

Acknowledgements

Dr. Kim is supported by the National Institutes of Health (K23 HL128795).

Author information

Authors and Affiliations

  1. Division of Cardiology, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road, NE, Suite 502, Atlanta, GA, 30322, USA

    Patrick T. Gleason MD & Jonathan H. Kim MD

Authors
  1. Patrick T. Gleason MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jonathan H. Kim MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jonathan H. Kim MD.

Ethics declarations

Conflict of Interest

Patrick T. Gleason and Jonathan H. Kim each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Sports Cardiology

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gleason, P.T., Kim, J.H. Exercise and Competitive Sport: Physiology, Adaptations, and Uncertain Long-Term Risks. Curr Treat Options Cardio Med 19, 79 (2017). https://doi.org/10.1007/s11936-017-0578-7

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11936-017-0578-7

Keywords

Search

Navigation