ABC | Volume 115, Nº1, July 2020

Viewpoint Silva Diastolic function in athletes Arq Bras Cardiol. 2020; 115(1):134-138 were within the normal limits, setting up a supernormal mitral flow pattern often found in youth and athletes. Example 2: 48-year-old male bodybuilder and runner. Initial 3D echo study did not show any significant abnormalities. The diastolic evaluation showed an E/A ratio of 1.12, a septal and lateral e’ velocity of 0.05 and 0.07 m/s, respectively, an E/e’ ratio of 10.3, indexed left atrium volume of 17.9 mL/m 2 and tricuspid regurgitation peak velocity of 2 m/s (Figure 3). After analysis of these data, according to the 2016 guideline, only one criterium, out of four, was not normal (mitral septal and lateral annulus velocity), which should lead to a normal diastolic function. However, attention was drawn to abnormal mitral annulus velocity in an asymptomatic athlete. After a more careful anamnesis, the patient reported that he was on anabolic androgenic steroids (testosterone propionate 30 mg, testosterone phenpropionate 60 mg, testosterone isocaproate 60 mg, testosterone decanoate 100 mg – Durateston®). After evaluation of the myocardial deformation with speckle tracking, we found an abnormal global longitudinal strain value of -15.4%. (Figure 4). This finding completely modifies the diastolic function analysis on this patient. Documented systolic disfunction lead to the second algorithm of 2016 guideline (patients with depressed LVEFs and patients with myocardial disease and normal LVEF after consideration of clinical and other 2D data). Such a low strain value points to some degree of myocardial impairment caused by the steroids, compromising both systolic and diastolic functions. According to this guideline, we should not expect to have systolic disfunction without, at least, some degree of diastolic disfunction, due to the intricated relationship between them. This has not been a new concept. Since 2008 Lester et al. 7 reported that: “traditionally, parameters of diastolic function have been derived fromDoppler and those of systolic function from two-dimensional variables. This may create the illusion that individuals have isolated diastolic dysfunction”. Thus, instead of normal diastolic function, according to the 2016 guideline, this athlete already has mild diastolic disfunction. Extremely active people and competitive athlete populations are increasing day by day. 8 Recent reports extrapolate the causes of cardiac remodeling induced by exercises beyond the ventricular structure, including now changes in diastolic function, 9 right ventricle morphology, 8 and left atrium structure. 10-12 All forms of vigorous physical exercise, whether in professional athletes or in highly active people, involve a combination of static and dynamic exercises. Static and dynamic refer to the skeletal muscular activity pattern and its consequence in the cardiovascular system. Static activity is characterized by vigorous short contractions of certainmuscular groups. During pure static activity events (or predominantly), like in weightlifting/throwers, we find an acute increase in vascular resistance and blood pressure. The main purpose of cardiovascular system in these athletes is to preserve the cardiac output in face of the sudden and exaggerated increase in afterload. In contrast, dynamic exercises (endurance) are characterized by repetitive contractions and relaxations, often rhythmic, of big muscular groups that require an increase in the oxidative metabolism. The dynamic activity intensity can be quantified by the oxygen consumption (VO 2 ). The primary response of the cardiovascular system to dynamic exercise is to increase the cardiac output to ensure the arrival of nutrients to the active muscular bed. Increase of cardiac output is reached by increasing both stroke volume and heart rate and decreasing peripheral vascular resistance. Figure 1 – Left: Apical four-chamber view on 2D echo. Right: Doppler mitral flow on a young athlete. LAA: left atrial appendage; RA: right atrium; LA: left atrium; E/A VM: mitral valve E/A ratio; T.Des. VM: mitral valve deceleration; RV: right ventricle; LV: left ventricle.. Mitral flow LV RV LA RA LAA A B 135