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Exercise-induced arrhythmogenic right ventricular cardiomyopathy: fact or fallacy?

Sanjay Sharma, Abbas Zaidi
DOI: http://dx.doi.org/10.1093/eurheartj/ehr436 First published online: 7 December 2011

This editorial refers to ‘Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes’, by A. La Gerche et al., doi:10.1093/eurheartj/ehr397

The cardiovascular benefits of regular exercise are established; individuals exercising regularly have an average life expectancy of 7 years longer than their sedentary counterparts.1 Indeed exercise is regarded as one of the most potent and cost-effective treatments dispensed by health professionals in the management of an adverse risk profile for generalized atherosclerosis. Such benefits are achievable with relatively modest doses of exercise amounting to 6–10 METS (metabolic equivalents) per day2 and are devoid of the side effects associated with usual drug therapy. Analogously to pharmacological treatments, it is recognized that exercise exhibits an inverted J-shaped dose–benefit response with respect to musculoskeletal injuries; however, the concept that intensive exercise may exert a detrimental effect in individuals with normal hearts is rarely entertained and has never been investigated in large cohorts. The majority of highly trained athletes exercise intensively for several hours per day, resulting in workloads of 200–300 METS per week which is 5–10 times greater than the exercise recommendations for preventing coronary atherosclerosis.

Cross-sectional studies in athletes demonstrate modest increases in cardiac size with preserved indices of systolic and diastolic function and high scores during objective assessment of functional capacity.3 Adverse cardiac events in athletes are also low and most frequently confined to those harbouring hereditary or congenital cardiac abnormalities.4 These facts support the widely held notion that exercise is beneficial irrespective of the dose and, contrary to the haemodynamic circumstances associated with cardiac pathologies, the paradigm has evolved that ‘the athlete's big heart is beautiful’.

The past three decades have witnessed somewhat of a paradox consisting of an increase in obesity and cardiac morbidity due to lack of habitual exercise as well as a …