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Strenuous Endurance Exercise and the Heart: Physiological versus Pathological Adaptations

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Although the benefits of regular physical activity on cardiovascular health are well established, the effects of strenuous endurance exercise (SEE) have been a matter of debate since ancient times. In this article, we aim to provide a balanced overview of what is known about SEE and the heart—from epidemiological evidence to recent cardiac imaging findings. Lifelong SEE is overall cardioprotective, with endurance master athletes showing in fact a youthful heart. Yet, some lines of research remain open, such as the need to elucidate the time‐course and potential relevance of transient declines in heart function (or increases in biomarkers of cardiac injury) with SEE. The underlying mechanisms and clinical relevance of SEE‐associated atrial fibrillation, myocardial fibrosis, or high coronary artery calcium scores also remain to be elucidated. © 2022 American Physiological Society. Compr Physiol 12: 4067–4085, 2022.

Figure 1. Figure 1. Comparison of the left ventricular structure in chimpanzees and two representative human groups: sedentary westerners and Tarahumara subsistence farmers. Abbreviations: LV, left ventricle; WT, wall thickness; LVL, left ventricle length. Adapted, with permission, from Shave RE, et al., 2019 193.
Figure 2. Figure 2. Main causes of sudden cardiac death in athletes. Adapted, with permission, from Peterson DF, et al., 2020 163.
Figure 3. Figure 3. Structural adaptations of the left ventricle (LV) in endurance‐ and strength‐trained athletes compared with the pathological changes found in nonathletes with structural cardiac disease.
Figure 4. Figure 4. Benefits and potential risks associated with lifelong strenuous endurance exercise.
Figure 5. Figure 5. Acute and hypothetical long‐term cardiac adaptations induced by strenuous endurance exercise (SEE). As opposed to endurance training with “optimal” recovery, which could lead to physiological cardiac remodeling (i.e., enhanced cardiac structure and function), “excess” endurance training with insufficient recovery may cause cardiac injury and proarrhythmogenic remodeling. Abbreviations: cTn‐I, cardiac troponin, I isoform; RV, right ventricle.
Figure 6. Figure 6. Physiological adaptations associated with regular endurance training that might protect against the incidence of cardiac events associated with high coronary artery calcium (CAC) scores and atherosclerotic plaques. Abbreviation: CVD, cardiovascular disease.

Figure 1. Comparison of the left ventricular structure in chimpanzees and two representative human groups: sedentary westerners and Tarahumara subsistence farmers. Abbreviations: LV, left ventricle; WT, wall thickness; LVL, left ventricle length. Adapted, with permission, from Shave RE, et al., 2019 193.

Figure 2. Main causes of sudden cardiac death in athletes. Adapted, with permission, from Peterson DF, et al., 2020 163.

Figure 3. Structural adaptations of the left ventricle (LV) in endurance‐ and strength‐trained athletes compared with the pathological changes found in nonathletes with structural cardiac disease.

Figure 4. Benefits and potential risks associated with lifelong strenuous endurance exercise.

Figure 5. Acute and hypothetical long‐term cardiac adaptations induced by strenuous endurance exercise (SEE). As opposed to endurance training with “optimal” recovery, which could lead to physiological cardiac remodeling (i.e., enhanced cardiac structure and function), “excess” endurance training with insufficient recovery may cause cardiac injury and proarrhythmogenic remodeling. Abbreviations: cTn‐I, cardiac troponin, I isoform; RV, right ventricle.

Figure 6. Physiological adaptations associated with regular endurance training that might protect against the incidence of cardiac events associated with high coronary artery calcium (CAC) scores and atherosclerotic plaques. Abbreviation: CVD, cardiovascular disease.
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How to Cite

Pedro L. Valenzuela, Aaron Baggish, Adrián Castillo‐García, Alejandro Santos‐Lozano, Araceli Boraita, Alejandro Lucia. Strenuous Endurance Exercise and the Heart: Physiological versus Pathological Adaptations. Compr Physiol 2022, 12: 4067-4085. doi: 10.1002/cphy.c210045