The Noninvasive Cardiac Evaluation of Lon.g-Distance Runners* Brent M. Parker, M.D.; 00 Ben R. Londeree, Ed.D.;t Gerald V. Cupp, M.D.;t and ]erzy P. Dubiel, M.D.§
Twelve long-distance runnen were evaluated by physical eDmination, electrocardiopam, vectorcanliopam, chest x-ny film, and ecbocanliopam; and the results were compared to the ftndlnp in 12 normal control mbjects. The athletes showed a sipiftcmtly blgber frequency of pllop rbytb- with a third or fourth heart IOUlld. Electrocanliop'apblc and vectorcanllopapblc abnormalities consisting of rfaht or left ventricular hypertrophy, bndycanlia, and altentlons in the ST-T wave were allo preaent
in the runnen. Echocardiopapbic eumination of the athletes revealed increased wall tbiclmem, left ventricular muscular llUlllll, dlastolk volume, and ventricular function. It is eflllential that the physician who eumines athletes be aware of the spectrum of apparently abnormal findings in this group. Echocardlocnpblc studies sboald prove useful in establisblng the presence or absence of some fora. of cardiac disea8e in athletes.
when the well-conditioned athlete is examined, there may be a number of alterations from normal that suggest the presence of heart disease. Many physicians, unaware of these changes, have subjected athletes to unnecessary evaluations or restriction of activity. This is especially true for such complaints as fatigue or pain in the chest. 1 These problems have led some to suggest that athletes should avoid physicians.2 The purpose of this report is to present the physical, electrocardiographic, vectorcardiographic, echocardiographic, and radiologic findings in 12 longdistance runners, as compared to a control group of untrained men.
averaged 408 Cooper points weekly by running an average of 9.7 miles daily at a mean rate of 6 min/mile. The duration of training ranged from two to ten years, with a mean of seven years. The control group was comprised of 12 white male medical personnel of similar age who had no athletic training. Their weight averaged 78.9 kg ( 174 lb), and the mean estimated maximum consumption of oxygen was 46.7 ± 6.7. ml/kg/min. Cardiac physical examination was performed independently by two physicians, and recumbent arterial pressure was recorded after 15 to 20 minutes at rest. Electrocardiograms were evaluated for standard factors. The criteria of Romhilt et al• were utilimd for a diagnosis of left venbicular hypertrophy, and the height of the R wave in lead~ was used as a criterion for right venbicular hypertrophy. The vectorcardiograms were recorded using Frank's lead system. The criteria of Romhilt et aJll for left ventricular hypertrophy and of Chou et aJ6 for right venbicular hypertrophy were employed. Chest x-ray films were obtained in ten runners and seven control subjects, and the cardiotboracic ratio was calculated.. The echocardiograms were obtained with an ultrasonic scope (Smith-Kline Ekoline 20) in the routine manner. Three sets of standard measurements (Fig 1 ) from different areas of the echocardiogram were performed by each of two independent observers, and the average was used in the 6nal calculations. Left ventricular end-diastolic and end-systolic volumes,7 stroke volume, cardiac output, ejection fraction,7,8 the ratio of the thickness of the diastolic septal wall over that of the left venbicular wall, the mean rate of shortening of the circumferential 6bers,s and the left ventricular massto were calculated from the echocardiographic measurements. Statistical analyses of obtained data were performed using Student's ~test for nonpaired variables and x 2 analysis.
MATERIALS AND METHODS
Subfects
The group under study consisted of 12 white male longdistance runners, aged 19 to 40 years. Their weight averaged 67 .2 kg (148 lb), and their mean maximum consumption of oxygen was 73.7 ± 6.3 ml/kg/min. Six runners were from the University of Missouri's cross-country team that was Big Eight Conference Co-Champion, and six runners were from the Columbia (Mo) Track Club. The criterion for inclusion in the group under study was an accumulation of at least 200 Cooper3 points per week for one year or longer. The group •From the Cardiology Division,, Deparbnent of Medicine, University of Missouri Medical Center and the Harry S. Truman Veterans AdminiRtration Hospital and the Human Performance Laboratory, Department of Health and Physical Education, University o!Missouri, Columbia. ••Professor of Medicine. t Associate Professor of Health and Physical Education. :J:Fellow in Cardiology. Currently at Boone County Hospital, Columbia, Mo. §Fellow in Cardiology. Manuscript received April 27; revision accepted July 18 Reprint requests: Dr. Parker, Di1'i8ion of Cardiology, UrMveraity of Mis~"OUrl, Columbia 65201
376 PARKER ET AL
fu:sULTS
The results of physical examination, chest x-ray films, ECGs, and vectorcardiograms are shown in Tables 1 to 3. Statistically significant differences were apparent in the incidence of bradycardia, galCHEST, 73: 3, MARCH, 1978
FIGURE 1. Echocardiogram diagrammatically showing measurements made. RV, Right venbicle; DST, diastolic septal thickness; Dd, diastolic diameter; Sd, systolic diameter; PWTd, posterior wall thickness in diastole; and PWT•• posterior wall thickness in systole.
lop rhythms, alterations in the cardiac apex and carotid pulse, the voltage of the QRS complex on the ECG and vectorcardiogram, and abnormalities of the ST segment and T wave. A systolic cardiac murmur was heard more often (not statistically significant) in runners ( 6/ 12 or 50 percent) than in control subjects ( 2/ 12 or 17 percent). The murmurs were soft (grade 1/6 and 2/6) and were heard at the pulmonic area. The murmurs in the two persons in the control group were similar. Review of individual ECGs revealed left ventricular hypertrophy in four runners and no control subjects. We did not observe electrocardiographic right ventricular hypertrophy or incomplete right bundlebranch block. Analysis of the vectorcardiographic data in individual runners indicated increased voltage of the QRS complex in 11 runners, abnormalities of the T loop in two runners, left ventricular hypertrophy in four runners, and right ventricular hypertrophy in three runners. Two of those with left ventricular hypertrophy as determined by the vectorcardiogram also had left ventricular hypertrophy by the ECG. Increased voltage of the QRS complex was present in one subject in the control group, and two others had abnormalities of the T loop. As seen in Table 4, many significant differences were found between the echocardiograms of the athletes and control subjects. Since the athletes were smaller, correction for body size would augment the differences seen. When the formula of Teichholz et al8 was used, the volumes in athletes moved toward normal but remained significantly above those of the control subjects. CHEST, 73: 3, MARCH, 1978
When correlations between measurements studied, statistically significant relationships noted between gallop rhythms with a fourth sound ( S4) and the cardiothoracic ratio ( r =
were were heart 0.65)
Table 1-l'laraical and Roe..,.e-....plde Fintlln••
Data No. of subjects
Athletes
Controls P Value•
12
12
Age, yr Range Mean± SD
19-40 26±7
29±4
NS
Heart rate, beats per minute Range Mean± SD
50±5
45-77 61 ±11
Twelve long-distance runnen were evaluated by physical eDmination, electrocardiopam, vectorcanliopam, chest x-ny film, and ecbocanliopam; and the results were compared to the ftndlnp in 12 normal control mbjects. The athletes showed a sipiftcmtly blgber frequency of pllop rbytb- with a third or fourth heart IOUlld. Electrocanliop'apblc and vectorcanllopapblc abnormalities consisting of rfaht or left ventricular hypertrophy, bndycanlia, and altentlons in the ST-T wave were allo preaent
in the runnen. Echocardiopapbic eumination of the athletes revealed increased wall tbiclmem, left ventricular muscular llUlllll, dlastolk volume, and ventricular function. It is eflllential that the physician who eumines athletes be aware of the spectrum of apparently abnormal findings in this group. Echocardlocnpblc studies sboald prove useful in establisblng the presence or absence of some fora. of cardiac disea8e in athletes.
when the well-conditioned athlete is examined, there may be a number of alterations from normal that suggest the presence of heart disease. Many physicians, unaware of these changes, have subjected athletes to unnecessary evaluations or restriction of activity. This is especially true for such complaints as fatigue or pain in the chest. 1 These problems have led some to suggest that athletes should avoid physicians.2 The purpose of this report is to present the physical, electrocardiographic, vectorcardiographic, echocardiographic, and radiologic findings in 12 longdistance runners, as compared to a control group of untrained men.
averaged 408 Cooper points weekly by running an average of 9.7 miles daily at a mean rate of 6 min/mile. The duration of training ranged from two to ten years, with a mean of seven years. The control group was comprised of 12 white male medical personnel of similar age who had no athletic training. Their weight averaged 78.9 kg ( 174 lb), and the mean estimated maximum consumption of oxygen was 46.7 ± 6.7. ml/kg/min. Cardiac physical examination was performed independently by two physicians, and recumbent arterial pressure was recorded after 15 to 20 minutes at rest. Electrocardiograms were evaluated for standard factors. The criteria of Romhilt et al• were utilimd for a diagnosis of left venbicular hypertrophy, and the height of the R wave in lead~ was used as a criterion for right venbicular hypertrophy. The vectorcardiograms were recorded using Frank's lead system. The criteria of Romhilt et aJll for left ventricular hypertrophy and of Chou et aJ6 for right venbicular hypertrophy were employed. Chest x-ray films were obtained in ten runners and seven control subjects, and the cardiotboracic ratio was calculated.. The echocardiograms were obtained with an ultrasonic scope (Smith-Kline Ekoline 20) in the routine manner. Three sets of standard measurements (Fig 1 ) from different areas of the echocardiogram were performed by each of two independent observers, and the average was used in the 6nal calculations. Left ventricular end-diastolic and end-systolic volumes,7 stroke volume, cardiac output, ejection fraction,7,8 the ratio of the thickness of the diastolic septal wall over that of the left venbicular wall, the mean rate of shortening of the circumferential 6bers,s and the left ventricular massto were calculated from the echocardiographic measurements. Statistical analyses of obtained data were performed using Student's ~test for nonpaired variables and x 2 analysis.
MATERIALS AND METHODS
Subfects
The group under study consisted of 12 white male longdistance runners, aged 19 to 40 years. Their weight averaged 67 .2 kg (148 lb), and their mean maximum consumption of oxygen was 73.7 ± 6.3 ml/kg/min. Six runners were from the University of Missouri's cross-country team that was Big Eight Conference Co-Champion, and six runners were from the Columbia (Mo) Track Club. The criterion for inclusion in the group under study was an accumulation of at least 200 Cooper3 points per week for one year or longer. The group •From the Cardiology Division,, Deparbnent of Medicine, University of Missouri Medical Center and the Harry S. Truman Veterans AdminiRtration Hospital and the Human Performance Laboratory, Department of Health and Physical Education, University o!Missouri, Columbia. ••Professor of Medicine. t Associate Professor of Health and Physical Education. :J:Fellow in Cardiology. Currently at Boone County Hospital, Columbia, Mo. §Fellow in Cardiology. Manuscript received April 27; revision accepted July 18 Reprint requests: Dr. Parker, Di1'i8ion of Cardiology, UrMveraity of Mis~"OUrl, Columbia 65201
376 PARKER ET AL
fu:sULTS
The results of physical examination, chest x-ray films, ECGs, and vectorcardiograms are shown in Tables 1 to 3. Statistically significant differences were apparent in the incidence of bradycardia, galCHEST, 73: 3, MARCH, 1978
FIGURE 1. Echocardiogram diagrammatically showing measurements made. RV, Right venbicle; DST, diastolic septal thickness; Dd, diastolic diameter; Sd, systolic diameter; PWTd, posterior wall thickness in diastole; and PWT•• posterior wall thickness in systole.
lop rhythms, alterations in the cardiac apex and carotid pulse, the voltage of the QRS complex on the ECG and vectorcardiogram, and abnormalities of the ST segment and T wave. A systolic cardiac murmur was heard more often (not statistically significant) in runners ( 6/ 12 or 50 percent) than in control subjects ( 2/ 12 or 17 percent). The murmurs were soft (grade 1/6 and 2/6) and were heard at the pulmonic area. The murmurs in the two persons in the control group were similar. Review of individual ECGs revealed left ventricular hypertrophy in four runners and no control subjects. We did not observe electrocardiographic right ventricular hypertrophy or incomplete right bundlebranch block. Analysis of the vectorcardiographic data in individual runners indicated increased voltage of the QRS complex in 11 runners, abnormalities of the T loop in two runners, left ventricular hypertrophy in four runners, and right ventricular hypertrophy in three runners. Two of those with left ventricular hypertrophy as determined by the vectorcardiogram also had left ventricular hypertrophy by the ECG. Increased voltage of the QRS complex was present in one subject in the control group, and two others had abnormalities of the T loop. As seen in Table 4, many significant differences were found between the echocardiograms of the athletes and control subjects. Since the athletes were smaller, correction for body size would augment the differences seen. When the formula of Teichholz et al8 was used, the volumes in athletes moved toward normal but remained significantly above those of the control subjects. CHEST, 73: 3, MARCH, 1978
When correlations between measurements studied, statistically significant relationships noted between gallop rhythms with a fourth sound ( S4) and the cardiothoracic ratio ( r =
were were heart 0.65)
Table 1-l'laraical and Roe..,.e-....plde Fintlln••
Data No. of subjects
Athletes
Controls P Value•
12
12
Age, yr Range Mean± SD
19-40 26±7
29±4
NS
Heart rate, beats per minute Range Mean± SD
50±5
45-77 61 ±11
