年長耐力運動員的心臟：慢性冠狀動脈壓力作用 (下) | The heart of the ageing endurance athlete: the role of chronic coronary stress

年長耐力運動員的心臟：慢性冠狀動脈壓力作用 (下) | The heart of the ageing endurance athlete: the role of chronic coronary stress

 

年長耐力運動員的心臟：

慢性冠狀動脈壓力作用

The heart of the ageing endurance athlete: the role of chronic coronary stress

Gemma Parry-Williams, Sabiha Gati, and Sanjay Sharma

Received 15 June 2020; revised 24 September 2020; editorial decision 16 January 2021; accepted 9 March 2021; online publish-ahead-of-print 22 March 2021

 

大師級別運動員冠狀動脈鈣化的性別差異

對於大師級別女性運動員的冠狀動脈粥樣硬化模式所知甚少。一項對於26名長壽女性馬拉松運動員的研究顯示，與對照組相比，運動組每年至少跑一次馬拉松並持續10-25年，結果顯示鈣化負擔較低且斑塊較少；然而，運動員的動脈粥樣硬化風險因素也較低。有斑塊的運動員相對年齡較高，而且也是參與馬拉松比賽時間最長的運動個體[48]。有研究將46名女性運動員與38名年齡及佛萊明風險分數符合的對照組相比，CAC分數或斑塊形態的患病率並無差異[22]。這些較小規模的研究發現，女性運動員可能會受益於決經前雌激素的保護作用；然而，更年期對於女性運動員的CAC盛行率影響尚待釐清。

 

耐力運動與亞臨床梗塞

在> 40%的大師級別男性運動員和>30%的大師級別女性運動員中觀察到影響右心室插入點的局灶性纖維化，這被認為是是持續反覆的右心室壓力和容量超負荷的良性後果，在肺動脈高壓中也有類似發現[49]。據報導，有11-17%的大師級別運動員發生了影響內膜下層、中壁或心外膜下區域的嚴重心肌纖維化，且僅發生於男性。心肌纖維化的病因和機制尚待了解；然而，心內膜下層型態暗示了缺血性損傷，心外膜下型態則於炎症後反應相符。在與152名耐力運動員及92名對照組的研究中，與對照組相比，11%的大師級別運動員出現心肌纖維化。當中有1/3表現出與過往心肌梗塞相符的纖維化，其餘2/3標線出非缺血性瘢痕於中壁或心外膜下分布，是常見於急性或癒合型心肌炎的特徵[22]。盡管這也可能是長期高強度訓練獲得的心肌病變程序。不過在患有與心肌梗塞相符瘢痕的運動員中，只有一半有出現冠狀動脈狹窄，且在每個個案中狹窄度≤50%。

 

Möhlenkamp等人[37]表示，除了完成的馬拉松次數之外，更高的CAC百分為數顯示了延遲顯影（late gadolinium enhancement /LGE）的存在。這些結果顯示，大師級別的心內膜下纖維化可能代表了需求性缺血、微栓塞和冠狀動脈痙攣引發的亞臨床心肌梗塞。在6年的隨訪中，有LGE的冠狀動脈事件發生率為57%，沒有的則為8%[50]。表示除了冠狀動脈鈣化外還有LGE會增加不良後果的風險。

 

心肌纖維化是一項重要發現，因為其與室性心律失常有關且增加了一般人群的死亡率[51]。迄今為止的研究尚未表示，與對照組相比，大師級別運動員擁有更高的室性心律失常患病率[52]，也沒有任何與大師級別運動員心肌纖維化、室性心律失常和不良事件之間的直接關聯[37]。我們對於缺血性纖維化型態的大師級別運動員心律失常的相對有限經驗顯示，非持續性室性心搏過速發生率高於無纖維化的運動員（43%對上7%），當中共三名室性心搏過速運動員皆顯示了≥50%左前降支動脈狹窄[22]。需要更進一步的大規模縱向研究來調查心肌瘢痕對運動員的精確影響。

 

結論

定期進行體育訓練對於維持最佳健康和長壽至關重要，應進行全球性鼓勵。越來越多的證據顯示，與年齡和佛萊明風險相符的對照組相比，部分運動員表現出較高的CAC分數、較高的斑塊負擔與心肌纖維化，這些機制和意義尚未釐清。目前有限的數據顯示高CAC分數與高級別運動員的全因死亡率沒有相關性。

 

未來發展方向

需要針對男性運動員進行大型前瞻性縱向研究，以調查運動員CAC、冠狀動脈斑塊和心肌纖維化的原因和意義。炎症在這些發現中的潛在作用也值得進一步探索。對於女性年長運動員心臟的進一步剖析、了解更年期影響，並解釋男女性之間的生理差異，將能極大地擴展我們目前對於運動對年長運動員心臟影響的理解。

 

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