Previous studies have noted reversible cardiac dysfunction during marathon races, but few data are available concerning ultradistance trail running. The aim of this study was to assess echocardiographic parameters during ultradistance trail running. We performed an observational study in 66 participants to the 80-km Ecotrail of Paris Ile de France. All subjects had echocardiographic examinations before the race and on arrival, and 28 of them underwent serial echocardiographic examinations during the race (21 and 53 km). A single experienced physician performed all echocardiographic examinations, and the same protocol was always used (conventional 2-dimensional and Doppler left ventricular parameters and longitudinal strain). All echocardiographic parameters of left ventricular (LV) systolic function were significantly decreased on arrival (p ≤0.002). A significant reduction of LV systolic function was observed in 48% of study subjects on arrival. No significant modification was observed at 21 or at 53 km, and only global longitudinal strain was significantly decreased (p = 0.0008). At arrival, mitral E/A ratio and average mitral tissue Doppler imaging e’ wave were significantly decreased (p = 0.0001 and p = 0.0004, respectively), but these changes were observed from 21 km. In conclusion, ultradistance trail running can lead to abnormalities of LV systolic and diastolic functions in amateur runners. Diastolic dysfunction arises earlier than systolic dysfunction. Left ventricular systolic dysfunction occurred in 48% of the study subjects and was detected early by assessment of longitudinal strain.
The practice of endurance sport has increased in recent years. In 2001, about 480,000 runners had completed a marathon in the United States. The cardiovascular benefits of moderate exercise are well established, whereas the effects of prolonged and intense exercise are unclear. The athlete’s heart is mainly defined as left ventricular (LV) hypertrophy (LVH), but the beneficial or deleterious effects of cardiac remodeling are still debated. After the Boston Marathon, systolic and diastolic dysfunctions were observed and these echocardiographic examinations in “classic races” (i.e., marathon or semi-marathon) have only been performed before and after the race. In the last few years, ultradistance trail running has grown increasingly popular, but few data are available. The aim of our study was to assess cardiac function by repeated echocardiographic examinations during ultradistance trail running.
Methods
We performed an observational study in 66 participants in the 80-km Ecotrail of Paris Ile de France. These 66 volunteers were electronically recruited using an announcement on the race’s Web site ( www.traildeparis.com ). The protocol was approved by the race’s organization committee, and we obtained the consent of all volunteers. All subjects were included before the start of the race. Entry criteria included age >18 years, male gender, and completion of an ultra-endurance race (distance >50 km) during the last 12 months. Subjects with a medical history and in whom significant heart disease was observed at the first echocardiographic examination were excluded. No subject presented with previous heart disease or hypertension.
All subjects (n = 66) underwent a baseline echocardiographic examination (<24 hours) before the race and on arrival, and 28 subjects underwent additional serial echocardiographic examinations at intermediate checkpoints of the race (21 and 53 km). The echocardiographic examinations performed during the race required a 5-minute stop at each checkpoint to allow recordings. Calculation of echocardiographic parameters was performed after the race. Hemodynamic, respiratory, and echocardiographic parameters were recorded before the race and on arrival in all subjects and at each intermediate checkpoint for 28 subjects.
All echocardiographic examinations were performed by a single experienced physician (NM) using a VIVID I (GE Medical Systems, Horten, Norway). All echocardiographic examinations were digitally recorded and interpreted in a blinded fashion and independently by a physician blinded to the clinical status and the race results. All measurements were performed according to the recommendations and were averaged over 3 cardiac cycles.
Several 2-dimensional (2D) views were routinely recorded: parasternal long-axis view, parasternal short-axis view, and apical 2-, 3-, and 4-chamber views. The following 2D measurements were routinely assessed : (1) end-diastolic measurements of the interventricular septum, posterior wall, and left ventricle, allowing calculation of LV mass ; (2) end-systolic LV and left atrial diameters; (3) fractional shortening using the Teichholz’s method; (4) aorta diameter and aortic outflow tract in the parasternal long-axis view; (5) LV ejection fraction using Simpson’s method; and (6) left atrial diameter.
The following Doppler parameters were routinely determined: (1) E and A waves of the mitral inflow and mitral E wave deceleration time; (2) aortic ejection flow (peak of aortic ejection flow and velocity-time integral of aortic flow), allowing the measurement of cardiac output, (3) Doppler tissue imaging of the lateral and septal mitral annulus in the apical 4-chamber view, allowing average measurement of mitral e’, a’, and S waves and of the E/e’ ratio; and (4) Doppler tissue imaging of the lateral tricuspid annulus in the apical 4-chamber view, allowing measurement of tricuspid e’, a’, and S waves.
Regional and global LV functions were also studied using the longitudinal strain assessed by 2D speckle tracking. For this analysis of myocardial deformation, loops were recorded in standard B mode, using 70- to 80-Hz cadence images. The software tracks the positional changes of natural myocardial acoustic markers. Using 2D strain, we routinely assessed the left ventricle with (1) the calculation of global longitudinal strain (GLS) from the apical 2, 3, and 4 cavities and (2) the calculation of longitudinal deformation of each left ventricular section.
Continuous variables are presented as means ± SD and ranges, unless otherwise specified. Categorical data are presented as absolute values and percentages. Continuous and categorical variables were compared using the chi-square test, repeated-measures analysis of variance, and the Fisher’s exact test, as appropriate. A value of p <0.05 was considered statistically significant. Statistical analyses were performed with SPSS, version 8.0 (SPSS Inc., Chicago, Illinois).
The investigators had full access to and take full responsibility for the integrity of the data. All investigators have read and agreed to the report as written.
Results
The study population consisted of 66 male subjects participating in the Ecotrail (80 km). Among cardiovascular risk factors, 2 subjects were treated for hypercholesterolemia. No cardiovascular risk factor, such as hypertension or smoking, was found. Characteristics of the population are presented in Table 1 . Of the 66 subjects, 49 (74%) reached the finish line. Of the 28 subjects who underwent serial echocardiographic examinations during the race, 21 had the complete studies; 2 subjects abandoned the race between 21 and 53 km and 5 between 53 and 80 km. Body weight did not significantly decrease during the race, from 72.3 ± 8.0 kg before to 71.5 ± 7.8 kg on arrival (p = 0.76), whereas blood pressure significantly decreased and heart and respiratory rates significantly increased ( Table 2 ).
| Variable | Median ± CI | Range |
|---|---|---|
| Age (years) | 42.8 ± 9.4 | 24-62 |
| Height (cm) | 177 ± 6 | 165-192 |
| Weight (kg) | 70 ± 7 | 56-90 |
| Body surface area (m 2 ) | 1.81 ± 0.10 | 1.58-2.04 |
| Body mass index (kg / m 2 ) | 22.5 ± 1.8 | 18.9-27.6 |
| Baseline heart rate (bpm) | 67 ± 8 | 45-78 |
| Baseline systolic blood pressure (mmHg) | 133 ± 18 | 106-168 |
| Baseline diastolic blood pressure (mmHg) | 74 ± 15 | 51-99 |
| Training (hours / week) | 7.0 ± 2.7 | 3-16 |
| Training (km / week) | 69 ± 26.3 | 25-150 |
| Mean duration of the race (hours.min) | 9.55 ± 1.19 | 7.02-12.30 |
| Average speed of the race (km/h) | 8.2 ± 1.1 | 6.4-11.4 |
| Variable | Baseline (n = 66) | Arrival (n = 49) | p value |
|---|---|---|---|
| Heart rate (beats/min) | 67 ± 8 | 82 ± 11 | < 0.0001 |
| Systolic blood pressure (mmHg) | 133 ± 18 | 108 ± 10 | < 0.0001 |
| Diastolic blood pressure (mmHg) | 70 ± 13 | 58 ± 8 | 0.001 |
| Respiratory rate (breaths/min) | 16 ± 4 | 24 ± 8 | 0.0001 |
| End-diastolic measurements: | |||
| Interventricular septum (mm) | 9.8 ± 1.2 | 9.3 ± 1.1 | 0.31 |
| Posterior wall (mm) | 8.8 ± 1 | 7.9 ± 0.9 | 0.09 |
| Left ventricular diameter (mm) | 51.1 ± 3.9 | 50.4 ± 4.1 | 0.38 |
| Aortic diameter (mm) | 34 ± 2.5 | 34.3 ± 3.2 | 0.64 |
| Left ventricular mass (g) | 174 ± 41 | 161 ± 45 | 0.06 |
| End-systolic measurements: | |||
| Left ventricular diameter (mm) | 31.8 ± 4.2 | 35.8 ± 3.9 | 0.01 |
| Left atrial diameter (mm) | 37.4 ± 3.7 | 37.1 ± 4 | 0.74 |
| Left ventricular ejection fraction (%) | 70.0 ± 2.9 | 64.0 ± 4.1 | < 0.0001 |
| Shortening fraction (%) | 37.7 ± 5.9 | 28.9 ± 6.1 | < 0.0001 |
| Doppler measurements | |||
| Aortic ejection flow (m/s) | 1.1 ± 0.11 | 1 ± 0.12 | 0.83 |
| Aortic velocity-time integral (cm) | 21.5 ± 3 | 19.1 ± 3.2 | 0.04 |
| Cardiac output (L/min) | 4.33 ± 0.85 | 4.90 ± 0.91 | 0.02 |
| Mitral E wave (m/s) | 0.86 ± 0.22 | 0.62 ± 0.20 | 0.03 |
| Mitral A wave (m/s) | 0.54 ± 0.13 | 0.57 ± 0.12 | 0.59 |
| Mitral E/A ratio | 1.72 ± 0.67 | 1.04 ± 0.42 | 0.0001 |
| Mitral E wave deceleration time (ms) | 186 ± 31 | 191 ± 27 | 0.15 |
| Average mitral TDI e’ wave (m/s) | 0.14 ± 0.02 | 0.12 ± 0.02 | 0.0004 |
| Average mitral a’ wave (m/s) | 0.10 ± 0.02 | 0.10 ± 0.03 | 0.73 |
| Average mitral S wave (m/s) | 0.11 ± 0.03 | 0.09 ± 0.02 | 0.002 |
| Mitral E/e’ ratio | 5.6 ± 1.2 | 5.8 ± 1.4 | 0.83 |
| Tricuspid TDI e’ wave (m/s) | 0.15 ± 0.04 | 0.14 ± 0.03 | 0.71 |
| Tricuspid TDI a’ wave (m/s) | 0.16 ± 0.06 | 0.16 ± 0.05 | 0.86 |
| Tricuspid TDI S wave (m/s) | 0.16 ± 0.04 | 0.13 ± 0.02 | 0.0002 |
| Two-dimensional strain measurements | |||
| Global peak systolic strain (%) | −22.2 ± 2.0 | −19.7 ± 2.7 | 0.0008 |
| A3C peak systolic strain (%) | −22.9 ± 1.9 | −21.2 ± 1.9 | 0.003 |
| A4C peak systolic strain (%) | −21.0 ± 2.3 | −18.5 ± 3.0 | 0.0004 |
| A2C peak systolic strain (%) | −22.1 ± 2.6 | −19.7 ± 2.8 | 0.001 |
Echocardiographic parameters at baseline and on arrival for all subjects are presented in Table 2 . Concerning the conventional echocardiographic parameters, no difference was observed among the cardiac chambers except for end-systolic LV diameter (p = 0.01). All echocardiographic parameters of systolic function were decreased: LV ejection fraction (p <0.0001), LV shortening fraction (p <0.0001), average mitral S wave (p = 0.002), tricuspid tissue Doppler imaging (TDI) S wave (p = 0.0002), and global peak systolic strain (p = 0.0008). Concerning the diastolic function assessment, significant decreases of mitral E/A ratio and average mitral TDI e’ wave were observed (p = 0.0001 and p = 0.0004, respectively).
Echocardiographic parameters in the subgroup of 28 subjects who underwent serial echocardiographic examinations are presented in Table 3 . The same echocardiographic characteristics were observed at baseline and on arrival. At 21 km, no significant difference was observed for LV systolic function parameters, whereas at 53 km GLS was significantly reduced (−19.4 ± 3% vs −22.1 ± 2.1% at baseline, p = 0.0008) but not LV ejection fraction (70.4 ± 2.5% at baseline vs 67.3 ± 2.9%, p = 0.21). At arrival, all LV systolic function parameters were significantly decreased. Significant changes in transmitral velocities were observed from 21 km to arrival (mitral E/A ratio: 1.64 ± 0.70 at baseline vs 1.03 ± 0.37 at 21 km, p = 0.0002).
| Variable | Baseline (n = 28) | km 21 (n = 26) | km 53 (n = 24) | km 80 (arrival) (n = 21) |
|---|---|---|---|---|
| Heart rate (beats/min) | 63 ± 9 | 101 ± 13 | 95 ± 13 | 82 ± 11 |
| End-diastolic measurements: | ||||
| Interventricular septum (mm) | 9.9 ± 1.3 | 9.3 ± 1.2 | 9.2 ± 1.1 | 9.3 ± 1 |
| Posterior wall (mm) | 9 ± 1.2 | 8.1 ± 0.8 | 8.1 ± 0.8 | 7.8 ± 1 |
| Left ventricular diameter (mm) | 50.9 ± 3.6 | 48.9 ± 4.1 | 50.6 ± 3.8 | 50.2 ± 4 |
| Aortic diameter (mm) | 34 ± 2.7 | 34.3 ± 2.9 | 34.7 ± 2.6 | 34.5 ± 3.1 |
| Left ventricular mass (g) | 179 ± 38 | 150 ± 28 | 162 ± 38 | 156 ± 40 |
| End-systolic measurements: | ||||
| Left ventricular diameter (mm) | 31.9 ± 4.4 | 30.8 ± 5.3 | 32.9 ± 4.4 | 35.5 ± 4 |
| Left atrial diameter (mm) | 37.8 ± 3.3 | 36.1 ± 4 | 36.4 ± 3.4 | 36.9 ± 3.8 |
| Left ventricular ejection fraction (%) | 70.4 ± 2.5 | 69 ± 3.4 | 67.3 ± 2.9 | 64.8 ± 3.8 |
| Shortening fraction (%) | 37.6 ± 6.1 | 37.3 ± 7.4 | 35.1 ± 7.5 | 29.2 ± 6.1 |
| Doppler measurements | ||||
| Aortic ejection flow (m/s) | 1.1 ± 0.1 | 1.1 ± 0.2 | 1.1 ± 0.20 | 1 ± 0.13 |
| Aortic velocity-time integral (cm) | 21.9 ± 3.2 | 19.7 ± 3 | 19 ± 3.1 | 19 ± 3.1 |
| Cardiac output (L/min) | 4.35 ± 0.87 | 6.27 ± 1.14 | 5.66 ± 1.02 | 4.84 ± 0.80 |
| Mitral E wave (m/s) | 0.79 ± 0.15 | 0.72 ± 0.19 | 0.73 ± 0.20 | 0.66 ± 0.16 |
| Mitral A wave (m/s) | 0.52 ± 0.14 | 0.73 ± 0.19 | 0.71 ± 0.15 | 0.58 ± 0.13 |
| Mitral E/A ratio | 1.64 ± 0.70 | 1.03 ± 0.37 | 1.07 ± 0.40 | 1.17 ± 0.29 |
| Mitral E wave deceleration time (ms) | 181 ± 32 | 197 ± 40 | 193 ± 36 | 194 ± 30 |
| Average mitral TDI e’ wave (m/s) | 0.14 ± 0.03 | 0.12 ± 0.04 | 0.12 ± 0.03 | 0.12 ± 0.02 |
| Average mitral TDI a’ wave (m/s) | 0.10 ± 0.03 | 0.13 ± 0.03 | 0.12 ± 0.03 | 0.10 ± 0.02 |
| Average mitral TDI S wave (m/s) | 0.11 ± 0.02 | 0.13 ± 0.02 | 0.11 ± 0.01 | 0.09 ± 0.01 |
| Mitral E/e’ ratio | 5.7 ± 1.2 | 5.9 ± 1.2 | 5.8 ± 1.1 | 5.8 ± 2.0 |
| Tricuspid TDI e’ wave (m/s) | 0.15 ± 0.03 | 0.22 ± 0.06 | 0.21 ± 0.05 | 0.16 ± 0.04 |
| Tricuspid TDI a’ wave (m/s) | 0.16 ± 0.05 | 0.24 ± 0.06 | 0.25 ± 0.05 | 0.16.± 0.06 |
| Tricuspid TDI S wave (m/s) | 0.15 ± 0.02 | 0.16 ± 0.02 | 0.14 ± 0.02 | 0.13 ± 0.02 |
| Two-dimensional strain measurements | ||||
| Global peak systolic strain (%) | −22.1 ± 2.1 | −21.2 ± 3 | −19.4 ± 3 | −19.8 ± 2.8 |
| A3C peak systolic strain (%) | −23.1 ± 2.4 | −21.8 ± 3.8 | −19.7 ± 3.5 | −21.3 ± 3.2 |
| A4C peak systolic strain (%) | −20.8 ± 2 | −18.5 ± 3.7 | −20 ± 3.4 | −18.3 ± 2.9 |
| A2C peak systolic strain (%) | −22.2 ± 2.9 | −20 ± 3 | −22 ± 3.4 | −19.9 ± 3.4 |
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