Efficacy of beta-blocker therapy in symptomatic athletes with exercise-induced intra-ventricular gradients

Abstract

BackgroundUpright exercise stress echocardiography (SE) induces significant intraventricular gradient (IVG) and systolic anterior motion (SAM) in a large proportion of symptomatic athletes, who may therefore benefit from a negative inotropic therapy.The purpose of the present study was to assess the effect of chronic oral β blocker therapy on the occurrence of exercise-induced IVG and mitral valve SAM, in symptomatic athletes.MethodsWe enrolled 35 symptomatic athletes (age = 23 ± 11 years) with IVG (>30 mmHg) during SE off therapy. All repeated SE on chronic oral beta-blocker therapy (atenolol up to 50 mg, bisoprolol up to 10 mg, or metoprolol up to 100 mg daily according to physician-driven choice).ResultsOn therapy, there was during SE a reduction in IVG (35 off vs 17 on beta blocker, p < 0.01), decrease of IVG (102 ± 34 mmHg off vs 69 ± 24 mmHg on beta blocker, p < 0.01), peak heart rate (178 ± 15 bpm off vs 157 ± 9 bpm on beta blocker), SAM (24 off vs 9 on beta blocker, p < 0.001), symptoms during SE (17 off vs 2 on beta blocker p < 0.001), ST segment depression (13 off vs 2 on beta blocker, p < 0.001).ConclusionsIn athletes with positive screening on medical evaluation for sports practice and IVG on exertion, treatment with oral beta blockers improved symptoms in the large majority of patients. Symptomatic benefit was mirrored by objective evidence of improvement of echocardiographic signs of obstruction (IVG and SAM) and reduction of ischemia-like electrocardiographic changes.

Decreased carotid and vertebral arterial blood-flow velocity in response to orthostatic unload in patients with severe aortic stenosis

“…Several studies have reported the importance of upright positioning during exercise in the detection of provocable (latent) or labile left ventricular (LV) outflow tract gradients in hypertrophic cardiomyopathy [3][4][5][6][7][8][9][10][11][12]. Also, passive orthostatic tests (without exercise) are helpful in diagnostic evaluation in other diseases predisposing to LV outflow tract gradients [8,12].…”

Symptomatic Exercise-induced Intraventricular Gradient in Competitive Athlete

“…1,2 This condition is usually associated to global or segmental left ventricular hypertrophy or an abnormal implantation of the papillary muscles, but the pathophysiological mechanisms are not well established. Three potential mechanisms are purposed for the development of IVG:…”

“…The development of significant exercise-induced IVG (>30mmHg at rest or >50mmHg with exercise) is uncommon, but can lead to several and unspecific symptoms such as dizziness, thoracic pain, or even ventricular repolarization changes and arrhythmias during exercise test. 1 , 2 This condition is usually associated to global or segmental left ventricular hypertrophy or an abnormal implantation of the papillary muscles, but the pathophysiological mechanisms are not well established. Three potential mechanisms are purposed for the development of IVG:…”

Clinical applications of exercise stress echocardiography in the treadmill with upright evaluation during and after exercise

“…We conducted an open-label, prospective, non-randomized study to provide proof of concept that exercise stress echocardiogram can be a guide to tailored treatment in athletes with positive screening [61] and that develop IVG and mitral valve SAM on exertion. We evaluated 52 athletes that developed IVG and 35 (32 had exercise-related symptoms or positive exercise electrocardiography) repeated the exercise stress echocardiogram under treatment with ß blockers Thirty athletes (85%) showed improvement with a significant reduction of IVG and of the prevalence of SAM were shown (Figure 10).…”