Exercise－Induced Cardiac T roponin Elevations： From Underlying Mechanisms to Clinical Relevance

運(yùn)動(dòng)誘導(dǎo)的心臟T肌鈣蛋白升高：從基礎(chǔ)機(jī)制到臨床相關(guān)性

Circulation． 2021 Dec 14；144（24）：1955－1972．

doi： 10．1161／CIRCULATIONAHA．121．056208． Epub 2021 Dec 13．

翻譯：苗 、丹妮，貓  排版：叮當(dāng)丸子麻

ABSTRACT： Serological assessment of cardiac troponins （cT n） is the gold standard to assess myocardial injury in clinical practice． A greater magnitude of acutely or chronically elevated cT n concentrations is associated with lower event－free survival in patients and the general population． Exercise training is known to improve cardiovascular function and promote longevity， but exercise can produce an acute rise in cT n concentrations， which may exceed the upper reference limit in a substantial number of individuals． Whether exercise－induced cT n elevations are attributable to a physiological or pathological response and if they are clinically relevant has been debated for decades． Thus far， exercise－induced cT n elevations have been viewed as the only benign form of cT n elevations． However， recent studies report intriguing findings that shed new light on the underlying mechanisms and clinical relevance of exercise－induced cT n elevations． We will review the biochemical characteristics of cT n assays， key factors determining the magnitude of postexercise cT n concentrations， the release kinetics， underlying mechanisms causing and contributing to exercise－induced cT n release， and the clinical relevance of exercise－induced cT n elevations． We will also explain the association with cardiac function， correlates with （subclinical） cardiovascular diseases and exercise－induced cT n elevations predictive value for future cardiovascular events． Last， we will provide recommendations for interpretation of these findings and provide direction for future research in this field．

摘要：心臟肌鈣蛋白血清學(xué)評(píng)估（cTn）是臨床評(píng)價(jià)心肌損傷的金標(biāo)準(zhǔn)。在患者和一般人群中，較大程度的急性或慢性升高的cTn濃度與較低的無(wú)事件生存率相關(guān)。眾所周知，運(yùn)動(dòng)訓(xùn)練可改善心血管功能并延長(zhǎng)壽命，但運(yùn)動(dòng)可導(dǎo)致cT n濃度急性升高，在相當(dāng)數(shù)量的個(gè)體中可能超過(guò)參考上限。運(yùn)動(dòng)誘導(dǎo)的cT升高是否可歸因于生理或病理反應(yīng)，以及它們是否與臨床相關(guān)，已經(jīng)爭(zhēng)論了幾十年。迄今為止，運(yùn)動(dòng)誘導(dǎo)的cT升高被認(rèn)為是唯一的良性cT升高形式。然而，最近的研究報(bào)告了有趣的發(fā)現(xiàn)，揭示了運(yùn)動(dòng)誘導(dǎo)cT升高的潛在機(jī)制和臨床相關(guān)性。我們將回顧cT n測(cè)定的生化特征，決定運(yùn)動(dòng)后cTn濃度大小的關(guān)鍵因素，釋放動(dòng)力學(xué)，導(dǎo)致和促成運(yùn)動(dòng)誘導(dǎo)cTn釋放的潛在機(jī)制，以及運(yùn)動(dòng)誘導(dǎo)cTn升高的臨床相關(guān)性。我們還將解釋其與心功能的關(guān)系，與（亞臨床）心血管疾病的相關(guān)性，以及運(yùn)動(dòng)誘發(fā)的cTn升高對(duì)未來(lái)心血管事件的預(yù)測(cè)價(jià)值。最后，我們將提供解釋這些發(fā)現(xiàn)的建議，并為該領(lǐng)域的未來(lái)研究提供方向。

Key Words： apoptosis細(xì)胞凋亡 ? athletes運(yùn)動(dòng)員 ? cardiomegaly心臟肥大， exercise－induced 運(yùn)動(dòng)誘發(fā)? heart心臟 ? heart injuries心臟損傷 ? necrosis壞死

Cardiac troponins （cTn） are proteins that facilitate the contraction of cardiomyocytes after the influx of calcium into the cell． Because of their cardiac－specific isoforms， serological assessment of cT n is the gold standard to assess myocardial injury in clinical practice．1 A greater magnitude of chronically or acutely elevated cT n concentration is associated with lower event－free survival in patients2，3 and the general population．4

心肌肌鈣蛋白（Ctn）是鈣離子內(nèi)流后促進(jìn)心肌細(xì)胞收縮的蛋白質(zhì)。由于其心臟特異性亞型，在臨床實(shí)踐中，對(duì)ctn的血清學(xué)評(píng)估是評(píng)估心肌損傷的金標(biāo)準(zhǔn)。1在患者2、3和普通人群中，慢性或急性升高的ctn濃度越大，無(wú)事件存活率越低。4

Exercise training improves cardiovascular function， lowers the risk for cardiovascular events， and promotes longevity． However， a bout of exercise can produce an acute rise in cTn concentrations，5 which may exceed the upper reference limit in a substantial number of individuals and meet the criteria for myocardial injury．1 Multiple studies over the past 3 decades have reported elevated cTn concentrations after exercise of different types， durations， and intensities and among subjects of different ages， sex， and health and training status．5–7 However， the clinical significance of such findings was not clear because of the descriptive nature， small sample size， and cross－sectional design of the studies， as well as a lack of long－term follow－up and mechanistic studies．

運(yùn)動(dòng)訓(xùn)練改善心血管功能，降低心血管事件的風(fēng)險(xiǎn)，并促進(jìn)長(zhǎng)壽。然而，一次運(yùn)動(dòng)可引起cT n濃度的急性升高，在大量個(gè)體中可能超過(guò)參考上限，符合心肌損傷的標(biāo)準(zhǔn)1在過(guò)去30年的多項(xiàng)研究中，不同類型、持續(xù)時(shí)間和強(qiáng)度的運(yùn)動(dòng)后，以及不同年齡、性別、健康狀況和訓(xùn)練狀態(tài)的受試者的cT n濃度均有所升高。5－7然而，由于研究的描述性、小樣本量和橫斷面設(shè)計(jì)，以及缺乏長(zhǎng)期隨訪和機(jī)制研究，這些發(fā)現(xiàn)的臨床意義尚不明確。

Recent studies shed new light on the underlying mechanisms and clinical relevance of exercise－induced

最近的研究對(duì)運(yùn)動(dòng)誘發(fā)的潛在機(jī)制和臨床意義有了新的認(rèn)識(shí)cTn升高。例如，耐力運(yùn)動(dòng)可損害心肌細(xì)胞肌膜的完整性，8這可能導(dǎo)致cT n片段泄漏到循環(huán)中。9此外，運(yùn)動(dòng)引起的cT n濃度升高的幅度與隱匿性阻塞性冠狀動(dòng)脈疾病10以及中年和老年個(gè)體死亡率和主要不良心血管事件風(fēng)險(xiǎn)的增加有關(guān)。11

This narrative review will summarize recent insights into factors determining the magnitude of exerciseinduced cT n release， the underlying mechanisms responsible for these elevations， and the clinical relevance and considerations for the interpretation of exercise－induced elevations in cT n concentrations．

這篇敘述性綜述將總結(jié)最近關(guān)于決定運(yùn)動(dòng)誘導(dǎo)cTn釋放強(qiáng)度的因素，導(dǎo)致這些升高的潛在機(jī)制，以及解釋運(yùn)動(dòng)誘導(dǎo)cTn濃度升高的臨床相關(guān)性和考慮因素。

ASSESSMENT OF CARDIAC TROPONINS Molecular Basis心臟肌鈣蛋白分子基礎(chǔ)評(píng)估

T roponin （Tn） is an intracellular protein complex that is part of the contractile apparatus of cardiac and skeletal muscle． T n consists of 3 subunits （ie， I， T， and C） of which cardiac－ and muscle－specific isoforms for I and T exist． Within cardiomyocytes， the cTn protein complex is attached to tropomyosin， a structural protein that is wrapped around the thin filament． With the influx of calcium， calcium ions bind to the T nC subunit， leading to a conformational change of the cT n complex， allowing the myosin head to bind to the actin filament， and leading to cardiomyocyte contraction （Figure 1）． In addition to tropomyosin－bound cT n， cT n molecules are also present in an early releasable pool， and this fraction of cT n may be significantly larger than previously estimated （5％–10％）．12

轉(zhuǎn)鐵蛋白（T－roponin，Tn）是一種細(xì)胞內(nèi)蛋白質(zhì)復(fù)合物，是心肌和骨骼肌收縮器的一部分。Tn由3個(gè)亞基（即I、T和C）組成，其中存在I和T的心臟和肌肉特異性異構(gòu)體。在心肌細(xì)胞內(nèi)，CTn蛋白復(fù)合體附著在原肌球蛋白上，原肌球蛋白是一種包裹在細(xì)絲上的結(jié)構(gòu)蛋白。隨著鈣離子的流入，鈣離子與T－NC亞基結(jié)合，導(dǎo)致CT－n復(fù)合物的構(gòu)象改變，使肌球蛋白頭部與肌動(dòng)蛋白細(xì)絲結(jié)合，導(dǎo)致心肌細(xì)胞收縮（圖1）。除了與原肌球蛋白結(jié)合的CTn，CTn分子也存在于早期可釋放池中，這部分CTn可能比先前估計(jì)的要大得多（5％－10％）。12

Analytic Considerations分析考慮

The first commercial cT n assays became available in 1996， but the rapid evolution of assay technology has tremendously improved the analytic sensitivity．13 High sensitivity cT n assays are characterized by a low analytic coefficient of variation （coefficient of variation ＜10％） at the 99th percentile or upper reference limit （URL） established in apparently healthy individuals， and they have the ability to quantify cT n levels in ＞50％ of those healthy individuals．13 Men typically have higher resting cT n levels，11，14 underlining the importance of sex－specific URLs．

1996年，第一批商業(yè)化的ct n檢測(cè)方法問(wèn)世，但檢測(cè)技術(shù)的快速發(fā)展極大地提高了分析靈敏度。13高靈敏度ct n檢測(cè)的特點(diǎn)是，在表面健康的人身上建立的第99個(gè)百分位數(shù)或參考上限（URL）處的分析變異系數(shù)很低（變異系數(shù)＜10％），而且它們有能力量化那些＞50％的健康人的ct n水平。13男性通常有更高的靜息ct n水平，11，14強(qiáng)調(diào)了性別特異性的重要性。

More than 20 immunoassays are commercially available for cardiac troponin I （cT nI）， ranging from contemporary， high－sensitivity to point－of－care assays， each using their own monoclonal antibodies specific to different epitopes of cT nI． Despite efforts by international workgroups， the standardization of cT nI measurements remains limited．15

市場(chǎng)上有20多種心肌肌鈣蛋白I（cT－nI）免疫分析方法可供選擇，從現(xiàn)代的高靈敏度檢測(cè)到定點(diǎn)檢測(cè)，每種方法都使用自己的針對(duì)cT－nI不同表位的單克隆抗體。盡管國(guó)際工作組做出了努力，cT nI測(cè)量的標(biāo)準(zhǔn)化仍然有限。15

Circulating cTn Forms 循環(huán)cTn形式

Different cT n forms and fragments have been identified in the circulation， caused either by intracellular or extracellular processes．16，17 The fragmentation process is not completely understood but may depend on degradation， phosphorylation， ubiquitination， complex formation， and binding to specific anti－cT n immunoglobulins． For patients with myocardial infarction， cardiac troponin T （cT nT） has predominantly been found intact （37 kDa） in the first hours after presentation， and as primary （29 kDa） and secondary fragments （15–20 kDa） thereafter．17 The primary fragment is cleaved at the N－terminal end of cT nT， whereas the secondary fragments are further cleaved at the C－terminal end．17 ，18 Patients with endstage renal disease had only small cT nT fragments with molecular weights comparable to the secondary fragments as seen with myocardial infarction．19 It remains to be determined whether these secondary cT n forms are comparable between patients with end－stage renal disease and myocardial infarction or whether they represent different types of disease－specific fragments． It also remains a topic of discussion how cT n forms （either intact or fragments） are cleared from the blood circulation， but it is thought that smaller proteins pass through the glomerular membrane for clearance．20 After an acute myocardial infarction， however， extrarenal clearance turned out to dominate in studies on rats．21 Extrarenal clearance might be associated with scavenger receptor clearance； however， this topic has not been fully elucidated．

在循環(huán)中發(fā)現(xiàn)了不同的Ctn形式和片段，可能是由細(xì)胞內(nèi)或細(xì)胞外過(guò)程引起的。16，17裂解過(guò)程尚不完全清楚，但可能依賴于降解、磷酸化、泛素化、復(fù)合物的形成以及與特定的抗Ct n免疫球蛋白的結(jié)合。對(duì)于心肌梗死患者，心肌肌鈣蛋白T（Ct NT）在出現(xiàn)后的第一個(gè)小時(shí)內(nèi)主要被發(fā)現(xiàn)完整（37 KDa），此后作為初級(jí)片段（29 KDa）和次級(jí)片段（15－20 kDa）。17初級(jí)片段在Ct NT的N端被切割，而次級(jí)片段在C端被進(jìn)一步切割。18例終末期腎病患者僅有小的Ct nt片段，其分子量與心肌梗死的繼發(fā)性片段相當(dāng)。19這些繼發(fā)性Ct n形式在終末期腎病和心肌梗死患者中是否具有可比性，或者它們是否代表不同類型的疾病特異性片段仍有待確定。Ct n的形成（完整或碎片）如何從血液循環(huán)中清除也仍然是一個(gè)討論的話題，但人們認(rèn)為較小的蛋白通過(guò)腎小球膜進(jìn)行清除。20然而，在急性心肌梗死后，腎外清除在大鼠的研究中占主導(dǎo)地位。21腎外清除可能與清道夫受體清除有關(guān)；然而，這一主題尚未完全闡明。

EXERCISE－INDUCED CARDIAC TROPONIN ELEVATIONS 運(yùn)動(dòng)性心肌肌鈣蛋白升高

Brief Historical Perspective短暫的歷史觀點(diǎn)

The majority of studies examining the possibility of myocardial injury after exercise have used cT n as the marker of choice． However， initial evidence supporting the concept of exercise－induced cardiac injury was based on studies measuring serum CK－MB （creatine kinase myocardial band）．22 Although CK－MB was widely adopted for the clinical diagnosis and management of acute coronary syndromes， it was subsequently shown to lack cardiac tissue specificity and sensitivity， especially among athletes in whom skeletal muscle CK－MB concentrations were higher （8．9±1．3％ versus 3．3±0．7％ in the gastrocnemius muscle of marathoners compared with untrained controls）， and released in response to exercise－induced muscle injury．22 Accordingly， cT n replaced CK－MB as the gold－standard marker for myocardial injury following the Redefinition of Myocardial Infarction in 2000． Since the development of the first－generation cT n assays， ＞200 studies examining the effect of exercise on cT n release have been published．

大多數(shù)研究運(yùn)動(dòng)后心肌損傷可能性的研究都使用ctn作為選擇標(biāo)記物。然而，支持運(yùn)動(dòng)性心臟損傷概念的初步證據(jù)是基于測(cè)定血清肌酸激酶同工酶（CK－MB）的研究22雖然CK－MB被廣泛用于急性冠脈綜合征的臨床診斷和治療，但隨后發(fā)現(xiàn)它缺乏心臟組織特異性和敏感性，特別是在那些骨骼肌CK－MB濃度較高的運(yùn)動(dòng)員（馬拉松運(yùn)動(dòng)員腓腸肌CK－MB濃度較高（8．9±1．3％比3．3±0．7％，馬拉松運(yùn)動(dòng)員腓腸肌CK－MB濃度高于未經(jīng)訓(xùn)練的對(duì)照組的3．3±0．7％），并在運(yùn)動(dòng)性肌肉損傷后釋放CK－MB）。22因此，在重新定義心肌后，Ct－MB取代CK－MB成為心肌損傷的金標(biāo)準(zhǔn)標(biāo)志物。自第一代CT－n檢測(cè)方法問(wèn)世以來(lái)，已發(fā)表了200多篇關(guān)于運(yùn)動(dòng)對(duì)CT－n釋放的影響的研究。

Findings from the initial descriptive studies using a simple preexercise， postexercise measurement design， coupled with the results of subsequent meta－analyses，6 suggest that circulating cT nI and cT nT concentrations are above the URL in ＞50％ of athletes after endurance activities． In addition， evidence suggests that running events may be more likely to cause cT n elevation than cycling events．6 However， direct comparisons are not available． The mechanism is also unclear but may relate to the higher intensity of running versus cycling． Additional studies and further meta－analyses have replicated these initial findings， in general， and have also documented postexercise cT n elevations in a variety of populations including children， adolescents， postmenopausal women， and athletic animals．5 cT n elevation has also been associated with numerous exercise stimuli including endurance running， prolonged marching， basketball， high－intensity treadmill running， high－intensity cycling， and clinical exercise tests．23

最初的描述性研究采用簡(jiǎn)單的運(yùn)動(dòng)前、運(yùn)動(dòng)后測(cè)量設(shè)計(jì)，再加上隨后的薈萃分析結(jié)果，6表明，在耐力運(yùn)動(dòng)后，＞50％的運(yùn)動(dòng)員循環(huán)中的ctni和ctnt濃度在URL以上。此外，有證據(jù)表明，跑步項(xiàng)目可能比自行車項(xiàng)目更有可能導(dǎo)致Ctn升高。6然而，沒(méi)有直接的比較。其機(jī)制也不清楚，但可能與跑步比騎自行車的強(qiáng)度更高有關(guān)。更多的研究和進(jìn)一步的薈萃分析總體上重復(fù)了這些最初的發(fā)現(xiàn)，還記錄了各種人群運(yùn)動(dòng)后的ct n升高，包括兒童、青少年、絕經(jīng)后婦女和運(yùn)動(dòng)動(dòng)物。5 ct n升高還與許多運(yùn)動(dòng)刺激有關(guān)，包括耐力跑、長(zhǎng)征、籃球、高強(qiáng)度跑步機(jī)跑步、高強(qiáng)度騎自行車和臨床運(yùn)動(dòng)測(cè)試。23

Figure 1． cTn復(fù)合體在心肌細(xì)胞收縮中起著重要作用。

當(dāng)動(dòng)作電位到達(dá)心肌細(xì)胞時(shí)，鈣離子進(jìn)入細(xì)胞，導(dǎo)致鈣離子與T－NC亞基結(jié)合后的構(gòu)象變化。因此，肌球蛋白結(jié)合位點(diǎn)暴露，使肌球蛋白頭與肌動(dòng)蛋白細(xì)絲結(jié)合，促進(jìn)心肌細(xì)胞收縮。注意，大多數(shù)ct n復(fù)合體與肌動(dòng)蛋白細(xì)絲結(jié)合，但也存在于早期可釋放池中。CT顯示心肌肌鈣蛋白。

Predictors： Exercise Duration and Intensity預(yù)測(cè)因素：運(yùn)動(dòng)持續(xù)時(shí)間和強(qiáng)度

Numerous investigators have tried to examine which factors contribute to the release of cardiac－specific biomarkers． Age， training experience， blood pressure， environmental factors， exercise intensity， and exercise duration are among the predictors potentially associated with the magnitude of postexercise cT n concen－trations14，24–26 （Figure 2）． The variance explained by multivariate prediction models is low （r2＜35％）， however， and appears to be driven primarily by the intensity and duration of exercise． Early studies suggested that the magnitude of cT n release was positively related to the duration of exercise．24 However， a meta－analysis of 26 studies published in 2007 with exercise durations from 0．5 to 22 hours showed that postexercise cT n was inversely associated with exercise duration．6 Specifically， more athletes had a cT n concentration greater than the URL after marathon running than after substantially longer ultraendurance events． These data suggest that exercise intensity， rather than duration， may be the more potent stimulus for cT n release，27 because marathons are run at a higher intensity than ultraendurance events． In a recent study that documented a direct relationship among exercise heart rate， a surrogate for exercise intensity， and the prevalence of cT n after exercise，7 the importance of exercise intensity was also suggested．

許多研究人員試圖研究哪些因素會(huì)導(dǎo)致心臟特異性生物標(biāo)志物的釋放。年齡、訓(xùn)練經(jīng)歷、血壓、環(huán)境因素、運(yùn)動(dòng)強(qiáng)度和運(yùn)動(dòng)持續(xù)時(shí)間是潛在地與運(yùn)動(dòng)后Ct n濃度的大小相關(guān)的預(yù)測(cè)因素。測(cè)試14、24－26（圖2）。然而，多變量預(yù)測(cè)模型解釋的方差很低（R2＜35％），而且似乎主要是由運(yùn)動(dòng)強(qiáng)度和持續(xù)時(shí)間驅(qū)動(dòng)的。24然而，一項(xiàng)對(duì)2007年發(fā)表的26項(xiàng)研究的薈萃分析顯示，運(yùn)動(dòng)后的Ctn與運(yùn)動(dòng)持續(xù)時(shí)間呈負(fù)相關(guān)。6具體地說(shuō)，更多的運(yùn)動(dòng)員在馬拉松賽跑后的Ctn濃度高于URL，而在超耐力項(xiàng)目后的Ctn濃度明顯高于URL。這些數(shù)據(jù)表明，運(yùn)動(dòng)強(qiáng)度，而不是持續(xù)時(shí)間，可能是更有效的刺激Ctn釋放的因素，27因?yàn)轳R拉松比超耐力項(xiàng)目的強(qiáng)度更高。最近的一項(xiàng)研究記錄了運(yùn)動(dòng)心率（運(yùn)動(dòng)強(qiáng)度的替代指標(biāo)）和運(yùn)動(dòng)后ctn患病率之間的直接關(guān)系，7還提出了運(yùn)動(dòng)強(qiáng)度的重要性。

To directly examine the effect of exercise duration and intensity， a recent study compared cT nI release following cycling at low （50％–60％ lactate threshold for 60 minutes）， moderate （60％–70％ lactate threshold for 4 hours）， and high intensities （80％–90％ lactate threshold for 60 minutes）．28 cT nI was elevated after both moderate－ and high－intensity exercise but not after the low－intensity stimulus． Furthermore， cT n concentrations were significantly higher after the short－duration， high－intensity exercise than after the long－duration， moderate－intensity exercise．28 A similar study compared running at a moderate （60 minutes at 70％ of peak heart rate） or high intensity （2 series of 12×30－second repeated sprints at 90％ peak heart rate）．29 cT nT was statistically higher 4 hours after the high－intensity than the moderate－intensity exercise． Also， a field study among 177 cyclists participating in a 91－km mountain bike race showed that the time spent performing high－intensity exercise （heart rate ＞150 bpm） was an independent predictor of postexercise cT nI and cT nT concentrations．30 In aggregate， these data suggest that postexercise cT n elevations are related to overall cardiac workload， the product of both duration and intensity．

為了直接檢驗(yàn)運(yùn)動(dòng)持續(xù)時(shí)間和強(qiáng)度的影響，最近的一項(xiàng)研究比較了低強(qiáng)度（50％－60％乳酸閾值，60分鐘）、中等強(qiáng)度（60％－70％乳酸閾值，4小時(shí)）和高強(qiáng)度（80％－90％乳酸閾值，60分鐘）騎自行車后Ctni的釋放。28 CT nI在中強(qiáng)度和高強(qiáng)度運(yùn)動(dòng)后升高，但在低強(qiáng)度刺激后沒(méi)有升高。此外，短時(shí)間大強(qiáng)度運(yùn)動(dòng)后的Ctn濃度明顯高于長(zhǎng)時(shí)間中強(qiáng)度運(yùn)動(dòng)后。28類似的研究比較了中等強(qiáng)度（60min，峰值心率的70％）和大強(qiáng)度（2組12×30s重復(fù)沖刺，峰值心率為90％）。29大強(qiáng)度運(yùn)動(dòng)后4h，CtNT顯著高于中強(qiáng)度運(yùn)動(dòng)。此外，對(duì)177名參加91公里山地自行車比賽的自行車手進(jìn)行的實(shí)地研究表明，進(jìn)行高強(qiáng)度運(yùn)動(dòng)（心率＞150 bpm）的時(shí)間是運(yùn)動(dòng)后Ctni和Ct nt濃度的獨(dú)立預(yù)測(cè)因子。30總體而言，這些數(shù)據(jù)表明運(yùn)動(dòng)后Ctn升高與總體心臟負(fù)荷有關(guān)，這是持續(xù)時(shí)間和強(qiáng)度的乘積。

Figure 2． 運(yùn)動(dòng)誘導(dǎo)肌鈣蛋白釋放大小的驅(qū)動(dòng)因素。

各因素對(duì)運(yùn)動(dòng)后肌鈣蛋白濃度的影響在不同研究中差異很大，所有因素的預(yù)測(cè)價(jià)值都有限（r2＜35％）。運(yùn)動(dòng)強(qiáng)度和持續(xù)時(shí)間似乎對(duì)運(yùn)動(dòng)后濃度的影響最大，可能反映了整體心臟負(fù)荷。

Influence of Exercise Training 運(yùn)動(dòng)訓(xùn)練的影響

The heart remodels in response to exercise training， prompting several studies to examine the relationship of fitness or training status to postexercise cT n release．24，31 Event completion times or years of training were used as surrogates of fitness． More experienced marathon runners were less likely to have cT n elevations after the events than less experienced runners in several studies， but other studies have failed to confirm this relationship．26，32

運(yùn)動(dòng)訓(xùn)練對(duì)心臟重塑的影響，促使多項(xiàng)研究探討運(yùn)動(dòng)訓(xùn)練狀態(tài)與運(yùn)動(dòng)后心臟重塑的關(guān)系，并以24、31次運(yùn)動(dòng)完成時(shí)間或運(yùn)動(dòng)年限作為運(yùn)動(dòng)訓(xùn)練的代理。在一些研究中，經(jīng)驗(yàn)豐富的馬拉松運(yùn)動(dòng)員比經(jīng)驗(yàn)不足的運(yùn)動(dòng)員在賽后不太可能有胸高，但是其他研究未能證實(shí)這種關(guān)系

Two recent studies have examined whether exercise training alters postexercise cT n release． One assessed cT nT concentrations at rest and after a 60－minute maximal run， before and after a 14－week training program in the intervention and control group．33 Before training， the 60－minute maximal run produced a heterogeneous cT nT response in both groups with 71％ of subjects exceeding the URL． Baseline and postexercise cT nT were higher after training in the intervention group than in the control group．33 This may be because of a higher workload in the intervention group during the second maximal run as evidenced by a substantially higher speed （12．1±0．9 versus 10．7±0．9 km／h， P＜0．05）． The second study randomly assigned 48 young sedentary obese women to 12 weeks of high－intensity interval training， moderateintensity continuous training， or no training and measured cT nT levels after the same absolute and relative （60％ of Vo2max） exercise stimulus．34 T raining significantly increased workload at 60％ Vo2max． Before training， cT nT increased in all groups after exercise． After training， resting and postexercise cT nT concentrations at the same relative intensity were similar to pretraining values． However， cT nT did not increase after exercise at the same absolute intensity． These results suggest that exercise training reduces cT n increase after the same absolute， but not relative， intensity exercise． These studies collectively suggest that the magnitude of postexercise cT n release is affected by a combination of both training status and exercise intensity， because trained individuals require a greater absolute exercise stimulus to achieve the same relative stimulus．

最近的兩項(xiàng)研究檢查了運(yùn)動(dòng)訓(xùn)練是否會(huì)改變運(yùn)動(dòng)后的CT n釋放。其中一人評(píng)估了干預(yù)和對(duì)照組在14周訓(xùn)練計(jì)劃之前和之后的靜息和60分鐘最大跑后的CT NT濃度。33在訓(xùn)練前，60分鐘最大跑在兩組中都產(chǎn)生了不同的CT NT反應(yīng)，71％的受試者超過(guò)了URL。33這可能是因?yàn)楦深A(yù)組在第二次最大跑時(shí)的負(fù)荷較大，表現(xiàn)為速度明顯較高（12．1±0．9比10．7±0．9 km／h，P＜0．05）。在訓(xùn)練后，干預(yù)組的基礎(chǔ)和運(yùn)動(dòng)后Ct NT均高于對(duì)照組。33這可能是因?yàn)楦深A(yù)組在第二次最大跑中的工作量較大，明顯高于對(duì)照組（12．1±0．9對(duì)10．7±0．9 km／h）。第二項(xiàng)研究隨機(jī)將48名久坐不動(dòng)的年輕肥胖女性分為高強(qiáng)度間歇訓(xùn)練、中等強(qiáng)度持續(xù)訓(xùn)練和不訓(xùn)練3組，分別在相同的絕對(duì)和相對(duì)（60％最大攝氧量）運(yùn)動(dòng)刺激下測(cè)定CTNT水平。34T訓(xùn)練在60％最大攝氧量時(shí)顯著增加了工作量。運(yùn)動(dòng)前各組運(yùn)動(dòng)后CT－NT均升高，與運(yùn)動(dòng)前比較差異無(wú)顯著性（P＞0．05）。訓(xùn)練結(jié)束后，相同相對(duì)強(qiáng)度的靜息和運(yùn)動(dòng)后ct－NT濃度與訓(xùn)練前相近。但在相同絕對(duì)強(qiáng)度的運(yùn)動(dòng)后，CT NT并沒(méi)有升高。這些結(jié)果提示，在相同的絕對(duì)運(yùn)動(dòng)強(qiáng)度下，運(yùn)動(dòng)訓(xùn)練可以降低Ctn的升高，但不能降低相對(duì)運(yùn)動(dòng)強(qiáng)度下的Ctn升高。這些研究表明，運(yùn)動(dòng)后Ctn釋放的大小受到訓(xùn)練狀態(tài)和運(yùn)動(dòng)強(qiáng)度的共同影響，因?yàn)橛?xùn)練者需要更大的絕對(duì)運(yùn)動(dòng)刺激才能獲得相同的相對(duì)刺激。

Kinetics of cTn Concentrations CTn濃度的動(dòng)力學(xué)研究

The kinetics of cT n concentrations after an acute myocardial infarction （AMI） are well described． Peak values of cT nI and cT nT occur ≈10 to 12 hours after an STsegment–elevation AMI35 and remain elevated for 4 to 10 days， although the pattern and magnitude of cT n elevations is highly variable among patients because of both the size of the AMI and the rapidity of cT n washout influenced by reperfusion．

本文較好地描述了急性心肌梗死（AMI）35后CTn濃度的動(dòng)態(tài)變化。CT ni和Ct NT峰值出現(xiàn)在ST段抬高后10～12小時(shí)，并持續(xù)升高4～10天，但由于心肌梗死的大小和再灌注對(duì)CT n消失速度的影響，不同患者的CT n升高模式和幅度差異很大。

The kinetics of exercise－induced cT n concentrations are less clear． Middleton et al36 attempted to describe cT n kinetics during and after marathon exercise and reported a biphasic release pattern． Subsequently， several other studies assessed time－dependent changes in cT n concentrations up to 72 hours after exercise， of which the findings are summarized in T able S1 （cT nT） and T able S2 （cT nI）． Differences in exercise duration， exercise intensity， and mode of exercise across studies exclude the possibility to perform a structured metaanalysis． Limited data are available to support or refute the potential of a biphasic release during exercise， but some important observations can nonetheless be made regarding postexercise concentrations． First， concentrations of cT n appear to progressively increase after exercise cessation with peak values typically occurring between 2 and 6 hours after exercise （Figure 3A）． Second， the magnitude of cT n increase varies greatly among individuals，37 with some individuals demonstrating no or only very small changes in cT n concentrations， but others reporting values exceeding several times the URL Figure 3B． On average， peak postexercise cT n concentrations are ≈1 to 3 times the URL． The median change from baseline to postexercise concentrations was 10－fold （interquartile range： 5－ to 19－fold） in marathon runners．37 Third， exercise－induced elevations in cT n concentrations are transient， with values returning to baseline after 48 to 72 hours postexercise． The early peak and smaller magnitude of exercise－related cT n elevations postexercise contrast with the greater magnitude and later peaking of cT n in AMI．

運(yùn)動(dòng)性CTn濃度的動(dòng)態(tài)變化尚不清楚。Middleton等人36試圖描述馬拉松運(yùn)動(dòng)期間和之后的Ct n動(dòng)力學(xué)，并報(bào)告了一種雙相釋放模式。隨后，其他幾項(xiàng)研究評(píng)估了運(yùn)動(dòng)后72小時(shí)內(nèi)CTn濃度隨時(shí)間的變化，其中的發(fā)現(xiàn)總結(jié)為T(mén)ableS1（Ctnt）和TableS2（Ctni）。不同研究中運(yùn)動(dòng)持續(xù)時(shí)間、運(yùn)動(dòng)強(qiáng)度和運(yùn)動(dòng)方式的差異排除了進(jìn)行結(jié)構(gòu)化薈萃分析的可能性。有限的數(shù)據(jù)可以支持或駁斥運(yùn)動(dòng)中雙相釋放的可能性，但仍然可以對(duì)運(yùn)動(dòng)后的濃度進(jìn)行一些重要的觀察。首先，停止運(yùn)動(dòng)后，Ctn濃度似乎逐漸升高，峰值通常出現(xiàn)在運(yùn)動(dòng)后2至6小時(shí)（圖3A）。其次，CTn的增加幅度在不同的個(gè)體之間差異很大，37有些人的CTn濃度沒(méi)有變化或只有很小的變化，但另一些人報(bào)告的值超過(guò)了URL圖3B的幾倍。平均而言，運(yùn)動(dòng)后峰值Ctn濃度是≈的1到3倍。馬拉松跑步者從運(yùn)動(dòng)前到運(yùn)動(dòng)后濃度的中位數(shù)變化是10倍（四分位數(shù)范圍：5到19倍）。37第三，運(yùn)動(dòng)誘導(dǎo)的Ctn濃度升高是短暫的，運(yùn)動(dòng)后48到72小時(shí)后恢復(fù)到基線水平。運(yùn)動(dòng)后運(yùn)動(dòng)相關(guān)的Ctn升高較早且幅度較小，與AMI患者運(yùn)動(dòng)后Ctn升高幅度較大且峰值較晚形成鮮明對(duì)比。

UNDERL YING MECHANISMS 底層機(jī)制

The mechanisms responsible for postexercise cT n increases remain controversial． cT n elevations were initially interpreted as irreversible damage， because the heart was considered a postmitotic organ whose cardiomyocytes could not be repaired or replaced． Hence， cT n release was considered pathognomonic of necrosis．38，39 There is increasing evidence， however， that cardiac mitosis does occur in adults at a rate of 0．5％ to 1％ of cardiomyocytes per year．40，41 This rate of mitosis may increase with exercise training．42，43 T ransient increases in cT n occur not only after exercise， but also after atrial pacing44 and pharmacological stress testing，45 even in healthy individuals， highlighting the probability that not all cT n release is attributable to cardiomyocyte necrosis． The European Society of Cardiology’s Study Group on Biomarkers identified 3 possible causes for elevated cT n concentrations46： （1） reversible injury attributable to cell wounds， cytoplasmatic blebbing， or extracellular vesicle release； （2） injury attributable to apoptosis； and （3） irreversible injury attributable to myocardial necrosis （Figure 4）． There are few direct data to support or reject a single release mechanism for exercise－induced elevations of cT n concentrations， but available evidence is presented in the following．

運(yùn)動(dòng)后Ctn升高的機(jī)制仍存在爭(zhēng)議。CTn升高最初被解釋為不可逆轉(zhuǎn)的損傷，因?yàn)樾呐K被認(rèn)為是有絲分裂后的器官，其心肌細(xì)胞不能修復(fù)或替換。因此，CT n的釋放被認(rèn)為是死亡的病原體。38，39然而，越來(lái)越多的證據(jù)表明，心臟有絲分裂確實(shí)發(fā)生在成年人中，每年有0．5％到1％的心肌細(xì)胞。40，41這種有絲分裂的比率可能會(huì)隨著運(yùn)動(dòng)訓(xùn)練而增加。42，43 T的短暫增加不僅發(fā)生在運(yùn)動(dòng)之后，也發(fā)生在心房起搏44和藥物應(yīng)激試驗(yàn)之后，45甚至在健康的個(gè)體中，這突顯了并不是所有的CT釋放都可歸因于心肌細(xì)胞壞死。42，43的短暫增加不僅發(fā)生在運(yùn)動(dòng)后，而且發(fā)生在心房起搏44和藥物應(yīng)激試驗(yàn)之后，45甚至在健康的人中也是如此，這突顯了并不是所有的Ct釋放都可歸因于心肌細(xì)胞壞死。歐洲心臟病學(xué)會(huì)的生物標(biāo)記物研究小組確定了導(dǎo)致Ct n濃度升高的3種可能原因46：（1）可歸因于細(xì)胞損傷、胞漿氣泡或細(xì)胞外小泡釋放的可逆性損傷；（2）可歸因于細(xì)胞凋亡的損傷；以及（3）可歸因于心肌壞死的不可逆損傷（圖4）。很少有直接數(shù)據(jù)支持或拒絕運(yùn)動(dòng)誘導(dǎo)的Ctn濃度升高的單一釋放機(jī)制，但現(xiàn)有證據(jù)如下所示。

圖3．運(yùn)動(dòng)誘導(dǎo)的cTn濃度升高的建議模式。

A1耐力運(yùn)動(dòng)后 ct n 濃度的動(dòng)力學(xué)示意圖。運(yùn)動(dòng)過(guò)程中 ct n 濃度的變化尚不清楚（虛線） ，但累積數(shù)據(jù)顯示 ct n 濃度在運(yùn)動(dòng)停止后繼續(xù)上升，在運(yùn)動(dòng)后2ー6小時(shí)達(dá)到峰值。運(yùn)動(dòng)后24到72小時(shí)內(nèi)完全恢復(fù)正常。第99百分位數(shù)或正常參考上限以紅色顯示。B1，個(gè)人（n ＝ 151）在馬拉松后 ct ni 濃度的瀑布圖，突出了在進(jìn)行類似耐力運(yùn)動(dòng)回合的運(yùn)動(dòng)員個(gè)人之間的巨大差異。數(shù)據(jù)來(lái)自波士頓37和恩德霍文26馬拉松比賽的參賽者。兩個(gè)曲線圖中的值都表示為CTn分析的URL的倍數(shù)。CT顯示心肌肌鈣蛋白。

Reversible Cardiac Injury可逆性心臟損傷

Macromolecules can exchange over the plasma membranes of viable cardiomyocytes and such release seems to occur through transient disruptions in the plasma membrane．47 Stressing the cardiomyocytes by contraction， β－adrenergic stimulation，4 7，4 8 stretching，49，50 or brief ischemia51，52 increases the rate of macromolecule release． These studies did not observe cardiomyocyte death on histological examination， but apoptosis could have occurred． In contrast， plasma membrane injury does not necessarily lead to cardiomyocyte death because （1） the cytoplasm is a macromolecular gel with restricted diffusion，53 （2） dystrophin complexes stabilize the membrane by forming links between the extracellular matrix and the contracting sarcomere，54 and （3） cell wound repair can restore small membrane holes after reoxygenation．48，54 Cardiomyocytes are therefore more resilient than previously thought．

大分子可以在活心肌細(xì)胞的質(zhì)膜上交換，這種釋放似乎是通過(guò)質(zhì)膜的短暫破壞發(fā)生的通過(guò)收縮、β－腎上腺素能刺激、4 7、4 8延伸、49、50或短暫缺血增加心肌細(xì)胞的大分子釋放率。組織學(xué)檢查未見(jiàn)心肌細(xì)胞死亡，但可能發(fā)生凋亡。相比之下，質(zhì)膜損傷不一定會(huì)導(dǎo)致心肌細(xì)胞死亡，因?yàn)椋?）細(xì)胞質(zhì)是一種擴(kuò)散受限的大分子凝膠，53（2）營(yíng)養(yǎng)不良蛋白復(fù)合物通過(guò)在細(xì)胞外基質(zhì)和收縮的肌節(jié)之間形成連接來(lái)穩(wěn)定膜，54和（3）細(xì)胞創(chuàng)面修復(fù)可以恢復(fù)小膜復(fù)氧后的洞。48，54心肌細(xì)胞因此比以前認(rèn)為的更有彈性。

The heart supplies most of the increased total body oxygen demand of exercise by increasing heart rate and stroke volume， which， in turn， increases myocardial oxygen demand， coronary blood flow， and cardiac preload and afterload． These responses increase cardiomyocyte stress and may alter membrane permeability， leading to passive diffusion of cT n from the cell to the extracellular space． This hypothesis has been examined in an explorative pilot study （n＝11） using cardiac MRI of myocardial tissue water diffusivity （MD）．8 MD is a quantitative measure of cardiomyocyte integrity and an increase in MD is indicative of increased cell membrane permeability． Marathon running increased cT nI concentrations and myocardial MD， thus demonstrating increased cell membrane permeability． Postmarathon cT nI values correlated directly with MD （r＝0．66， P＝0．03），8 suggesting that higher postexercise cT nI concentrations result， at least， in part， from greater cardiomyocyte membrane permeability． Both cT nI and MD returned to prerace values within 2 weeks after the marathon， indicating that these exerciseinduced changes were transient．

心臟通過(guò)增加心率和每搏輸出量提供運(yùn)動(dòng)增加的大部分身體需氧量，進(jìn)而增加心肌需氧量、冠脈血流量以及心臟前負(fù)荷和后負(fù)荷。這些反應(yīng)增加了心肌細(xì)胞的應(yīng)激反應(yīng)，并可能改變細(xì)胞膜的通透性，導(dǎo)致Ctn從細(xì)胞內(nèi)被動(dòng)擴(kuò)散到細(xì)胞外間隙。這一假說(shuō)已經(jīng)在一項(xiàng)探索性的先導(dǎo)性研究中得到驗(yàn)證（n＝11），使用心臟MRI的心肌組織水分?jǐn)U散率（MD）。8 MD是心肌細(xì)胞完整性的定量測(cè)量，MD的增加表明細(xì)胞膜通透性增加。馬拉松運(yùn)動(dòng)增加心肌CTni濃度和心肌MD，從而顯示細(xì)胞膜通透性增加。馬拉松后Ctni值與MD呈正相關(guān)（r＝0．66，P＝0．03），8提示運(yùn)動(dòng)后Ctni濃度升高，至少部分是由于心肌細(xì)胞膜通透性增加所致。Ctni和MD在馬拉松后2周內(nèi)均恢復(fù)到賽前水平，表明這些運(yùn)動(dòng)誘導(dǎo)的改變是短暫的。

The increase in membrane permeability after cardiomyocyte stress suggests that cT n molecules can leak from cardiomyocytes into the circulation， and this may be aided by degradation of cT n complexes． Ischemia is known to degrade cT n complexes． For example， ischemia reduces the size of cT nI and cT nT fragments in isolated rat hearts from 24 to 15 kDa and from 35 to 25 kDa， respectively，55 making them more readily able to pass through the membrane． Only small， degraded， cT nT fragments （＜18 kDa） were found in postrace serum samples obtained from 10 marathon runners．9 These findings suggest that smaller fragments may leak into the circulation with the cardiac stress associated with exercise or ischemia， whereas larger fragments might only escape with destruction of the membrane after myocardial infarction．

心肌細(xì)胞應(yīng)激后細(xì)胞膜通透性增加，提示CTn分子可從心肌細(xì)胞滲漏到循環(huán)中，這可能與CTn復(fù)合物的降解有關(guān)。已知缺血可使CTn復(fù)合體退化。例如，缺血減少了離體心臟的CT－Ni和CT－NT片段的大小。大鼠的心臟大小分別為24到15 kDa和35到25 kDa，55使它們更容易通過(guò)膜。在10名馬拉松運(yùn)動(dòng)員的賽后血清樣本中僅發(fā)現(xiàn)小的降解的CT NT片段（＜18 kDa）。9這些發(fā)現(xiàn)提示，在運(yùn)動(dòng)或缺血引起的心臟應(yīng)激時(shí)，較小的片段可能會(huì)泄漏到循環(huán)中，而較大的片段可能只有在心肌梗死后膜被破壞時(shí)才會(huì)逃逸。

Taken together， it is possible that exercise－induced cT n elevations are attributable， at least， in part， to reversible membrane damage of viable cardiomyocytes （T able 1）． Whether this is the only mechanism responsible for exercise－induced cT n elevations， or occurs next to apoptosis or necrosis， is unknown． The magnitude of cT n release across individuals is extremely variable， even after the same exercise．37 It is possible that several mechanisms contribute to this variability and that the dominant mechanism differs between individuals with low and high magnitudes of postexercise cT n elevations （Figure 3B）． Furthermore， it is unknown whether the putative changes in membrane permeability are entirely physiological or are an early marker of cardiac vulnerability and subsequent cardiac events．

綜合考慮，運(yùn)動(dòng)誘導(dǎo)的Ctn升高可能至少部分歸因于存活心肌細(xì)胞的可逆性膜損傷（Table1）。目前尚不清楚這是導(dǎo)致運(yùn)動(dòng)性ctn升高的唯一機(jī)制，還是僅次于凋亡或壞死的機(jī)制。即使在相同的運(yùn)動(dòng)之后，個(gè)體間的CTn釋放的大小也是非常不同的。37可能有幾種機(jī)制導(dǎo)致了這種差異，運(yùn)動(dòng)后Ctn升高幅度低和高的個(gè)體之間的主導(dǎo)機(jī)制不同（圖3B）。此外，尚不清楚膜通透性的假定變化是完全生理性的，還是心臟易損性和隨后的心臟事件的早期標(biāo)志。

圖4．運(yùn)動(dòng)誘導(dǎo)cTn釋放的潛在潛在機(jī)制的示意圖概述。

可歸因于細(xì)胞損傷的心肌細(xì)胞膜通透性增加、細(xì)胞外小泡釋放和胞吐速率增加可被認(rèn)為是可逆性的心臟損傷，導(dǎo)致心肌肌鈣蛋白濃度的生理性升高。同樣，心肌細(xì)胞周轉(zhuǎn)率的增加可能會(huì)一過(guò)性地增加心肌肌鈣蛋白濃度。較高的凋亡率，尤其是壞死率，應(yīng)該歸類為心肌細(xì)胞的（微�。�損傷，這代表了對(duì)運(yùn)動(dòng)的一種病理反應(yīng)，這可能會(huì)對(duì)健康產(chǎn)生長(zhǎng)期的影響。CT顯示心肌肌鈣蛋白。

Apoptosis 細(xì)胞凋亡

Apoptosis or programmed cell death is part of normal cell turnover． Apoptotic processes can be activated through stress caused by oxidative overload， ischemia， and processes in other cells such as the detection of intracellular pathogens． Apoptosis should not produce cT n elevations， because intracellular content is not released when the apoptotic cell is fragmented and engulfed by other cells．

細(xì)胞凋亡或程序性細(xì)胞死亡是正常細(xì)胞周轉(zhuǎn)的一部分。凋亡過(guò)程可以通過(guò)氧化超負(fù)荷、缺血引起的應(yīng)激，以及細(xì)胞內(nèi)病原體檢測(cè)等其他細(xì)胞過(guò)程被激活。凋亡不應(yīng)產(chǎn)生cT n升高，因?yàn)楫?dāng)?shù)蛲黾?xì)胞被其他細(xì)胞吞噬并破碎時(shí)，細(xì)胞內(nèi)的內(nèi)容不會(huì)釋放。

表1． 關(guān)于運(yùn)動(dòng)引起肌鈣蛋白濃度升高的基本機(jī)制的現(xiàn)有證據(jù)摘要

However， cTn could be released during the destruction of apoptotic bodies or as cardiomyocyte apoptosis transitions to secondary necrosis．20

然而，CTn可能在凋亡小體破壞或心肌細(xì)胞凋亡向繼發(fā)性死亡轉(zhuǎn)變過(guò)程中釋放。20

Few studies have explored the effects of exercise on apoptosis． T welve weeks of exercise training reduced age－induced apoptosis in the left ventricle of rats， measured by less DNA fragmentation， terminal deoxynucleotidyl transferase dUTP nick end labeling–positive staining， and caspase－3 cleavage．56 A subsequent study demonstrated that exercise reduces the age－related increase in apoptotic signaling markers．57 A large study （n＝64）58 of young （6－month－old） and middle－aged （12－monthold） mice randomly assigned the animals to cages with or without a functioning running wheel． Caspase－independent， Fas－dependent， and mitochondrial－dependent apoptotic pathways were reduced in both the young and middle－aged running mice．58 These findings agree with evidence in humans that exercise training is cardioprotective and helps preserve cardiac function during aging．

很少有研究探討運(yùn)動(dòng)對(duì)細(xì)胞凋亡的影響。12周的運(yùn)動(dòng)訓(xùn)練減少了年齡誘導(dǎo)的大鼠左心室細(xì)胞凋亡，通過(guò)減少DNA片段化、末端脫氧核苷酸轉(zhuǎn)移酶dUTP缺口末端標(biāo)記陽(yáng)性染色和caspase－3裂解來(lái)衡量。56隨后的研究表明，運(yùn)動(dòng)減少了與年齡相關(guān)的凋亡信號(hào)標(biāo)記物的增加。57一項(xiàng)大型研究（n＝64）58對(duì)年輕（6個(gè)月大）和中年（12個(gè)月大）的小鼠隨機(jī)分配到籠子里，放在籠子里或不放在籠子里。在年輕和中年跑步小鼠中，caspase非依賴、Fas依賴和線粒體依賴的凋亡通路均減少。58這些發(fā)現(xiàn)與人類的證據(jù)一致，即運(yùn)動(dòng)訓(xùn)練具有心臟保護(hù)作用，并有助于在衰老期間保護(hù)心臟功能。

The acute effects of exercise on apoptosis are not well studied． A study （n＝18） of young mice （2－monthold） assessed apoptosis at baseline or immediately after 8， 24， 48， and 72 hours of running at 60％ to 70％ of Vo2peak （n＝3 animals per time point）．59 Exercise pro duced a transient 150％ increase in the rate of myocardial apoptosis at 24 hours after exercise， in part， because of catecholaminergic， but not oxidative， stress． These findings suggest that， in animals， exercise acutely increases the rate of apoptosis， whereas apoptotic rates are reduced with chronic exercise training．

運(yùn)動(dòng)對(duì)細(xì)胞凋亡的急性影響還沒(méi)有得到很好的研究。一項(xiàng)針對(duì)小鼠（2個(gè)月大）的研究（n＝18）評(píng)估了在基線或跑步8、24、48和72小時(shí)后即刻的細(xì)胞凋亡，VO2峰值的60％到70％（n＝3只動(dòng)物／時(shí)間點(diǎn)）。59運(yùn)動(dòng)導(dǎo)致運(yùn)動(dòng)后24小時(shí)心肌細(xì)胞凋亡率短暫增加150％，部分原因是兒茶酚胺能，而不是氧化應(yīng)激。這些發(fā)現(xiàn)表明，在動(dòng)物中，運(yùn)動(dòng)顯著增加了細(xì)胞凋亡率，而長(zhǎng)期運(yùn)動(dòng)訓(xùn)練則降低了細(xì)胞凋亡率。

The acute increase in left ventricular preload during exercise could contribute to increased apoptosis．60 Isolated rat hearts exposed to increased preload demonstrate intramyocardial cT nI proteolysis and cT nI release in the absence of ischemia．61 This cT nI degradation was blocked by antibodies that prevent the activation of endogenous calpains． Calpains are involved in cell signaling and cell cycle progression． Therefore， cellular calcium entry and proteolysis of cT nI may produce stretch－induced cardiomyocyte apoptosis．62 These findings have been confirmed in an in vivo swine model． Acute hemodynamic overload produced by phenylephrine infusion provoked transient left ventricular （L V） dysfunction， stretch－induced cardiomyocyte injury， elevated cT nI concentrations， and apoptosis in the absence of ischemia．63 Another study in swine evaluated changes in cT nI and apoptosis after 10 minutes of left anterior descending coronary artery occlusion with subsequent reperfusion for 24 hours．64 Brief ischemia produced a delayed cT nI release， with significant cT nI elevations starting 30 minutes after reperfusion． The cT nI elevations persisted for 24 hours． There was a concomitant， transient increase in apoptosis， with a 6－fold increase 1 hour after reperfusion， which normalized at 24 hours．64 In humans， 30， 60， and 90 seconds of balloon－induced coronary artery occlusion to induce ischemia increased cT n concentrations in patients without coronary artery disease （CAD）， which continued to increase up to the end of sampling， 4 hours after ischemia．65 After 90 seconds of ischemia， patients had larger and quicker increases in cT n． cT nI and cT nT were ＞URL 3 hours after brief ischemia in 11％ to 25％ and 75％ of patients， respectively．65 These findings indicate that isolated apoptosis can occur after increased preload or brief ischemia， conditions that may also occur during exercise．

運(yùn)動(dòng)中左心室前負(fù)荷的急劇增加可能導(dǎo)致細(xì)胞凋亡的增加。60只暴露于增加前負(fù)荷的離體大鼠心臟在沒(méi)有缺血的情況下表現(xiàn)出心肌內(nèi)的Ctni蛋白水解和Ctni釋放。61這種Ctni的降解被阻止內(nèi)源性Calain激活的抗體阻斷。鈣蛋白酶參與細(xì)胞信號(hào)和細(xì)胞周期進(jìn)程。因此，Ctni的細(xì)胞鈣內(nèi)流和蛋白水解可能導(dǎo)致?tīng)繌堈T導(dǎo)的心肌細(xì)胞凋亡。62這些發(fā)現(xiàn)已在活體豬模型中得到證實(shí)。注射苯腎上腺素產(chǎn)生的急性血流動(dòng)力學(xué)超負(fù)荷引起一過(guò)性左心室（L V）功能障礙、牽張誘導(dǎo)的心肌細(xì)胞損傷、Ctni濃度升高和無(wú)缺血情況下的細(xì)胞凋亡。63另一項(xiàng)在豬身上的研究評(píng)估了左冠狀動(dòng)脈前降支閉塞10分鐘后Ctni和細(xì)胞凋亡的變化。64短暫缺血導(dǎo)致Ctni釋放延遲，再灌注30分鐘后Ctni顯著升高。Ctni升高區(qū)持續(xù)了24小時(shí)。隨之而來(lái)的是細(xì)胞凋亡的短暫增加，在再灌注1小時(shí)后增加6倍，并在24小時(shí)恢復(fù)正常。64在人類，球囊閉塞冠狀動(dòng)脈誘導(dǎo)缺血30、60和90秒后，無(wú)冠狀動(dòng)脈疾�。–AD）患者的CT－n濃度升高，一直持續(xù)到取樣結(jié)束，在缺血4小時(shí)后。65在缺血90秒后，患者的CT－Ni和CT－NT在短暫缺血3小時(shí)后升高更大、更快，CT－Ni和CT－NT在短暫缺血后3小時(shí)均＞URL。65這些發(fā)現(xiàn)表明，在增加前負(fù)荷或短暫缺血后，可能會(huì)出現(xiàn)孤立的細(xì)胞凋亡，這些情況也可能發(fā)生在運(yùn)動(dòng)過(guò)程中。

An alternative explanation to increased cT n levels with exercise is that exercise increases cardiomyocyte turnover． C／EBPβ is a member of the bHLH gene family of DNA－binding transcription factors and decreases cardiomyocyte growth and proliferation．42 Exercise training decreased the expression of C／EBPβ in mice with swim training． Furthermore， the mice with reduced cardiac C／ EBPβ levels were resistant to cardiac failure produced by pressure overload． These results indicate that exercise training decreases C／EBPβ， thereby decreasing its inhibition of cardiomyocyte turnover and increasing cardiac resilience to external stress． This hypothesis is supported by the observation that 8 weeks of running increased new cardiomyocytes 4．6－fold in adult mice， without evidence of systolic dysfunction or increased apoptosis．66 Both studies demonstrate that exercise activates the endogenous regenerative capacity of the mammalian heart， suggesting that replaced cardiomyocytes could release cT n into the circulation if this process is accelerated by an acute bout of exercise．

運(yùn)動(dòng)導(dǎo)致肌鈣蛋白水平升高的另一種解釋是，運(yùn)動(dòng)增加了心肌細(xì)胞的更新?lián)Q代。C／eBPβ是bHLH基因家族中的一員，可抑制心肌細(xì)胞的生長(zhǎng)和增殖。42運(yùn)動(dòng)訓(xùn)練降低游泳訓(xùn)練小鼠心肌c／eBPβ的表達(dá)。此外，心臟C／EBPβ水平降低的小鼠對(duì)壓力超負(fù)荷引起的心力衰竭具有抵抗力。這些結(jié)果表明，運(yùn)動(dòng)訓(xùn)練降低了C／EBPβ，從而降低了其對(duì)心肌細(xì)胞周轉(zhuǎn)的抑制作用，提高了心臟對(duì)外界應(yīng)激的抵抗力。這一假設(shè)得到以下觀察的支持：8周的跑步使成年小鼠的新心肌細(xì)胞增加了4．6倍，沒(méi)有收縮功能障礙或細(xì)胞凋亡增加的證據(jù)。66兩項(xiàng)研究都表明，運(yùn)動(dòng)可以使新的心肌細(xì)胞數(shù)量增加4．6倍，而沒(méi)有收縮功能障礙或細(xì)胞凋亡增加的證據(jù)激活哺乳動(dòng)物心臟的內(nèi)源性再生能力，這表明如果急性運(yùn)動(dòng)加速了這一過(guò)程，被替換的心肌細(xì)胞可能會(huì)將Ctn釋放到循環(huán)中。

The association between exercise and apoptosis appears dependent on the time frame． Exercise training reduces apoptotic rates56–58 and increases cardiomyocyte growth and proliferation．42，66 In contrast， （supra） physiological challenges to untrained animals， such as forced running，59 volume overload，61，63 or ischemia，64 increase apoptosis with associated increases in cT n concentrations （T able 1）． Whether these findings can be extrapolated to humans is not presently clear．

運(yùn)動(dòng)和細(xì)胞凋亡之間的聯(lián)系似乎取決于時(shí)間框架。運(yùn)動(dòng)訓(xùn)練降低了凋亡率56－58，并增加了心肌細(xì)胞的生長(zhǎng)和增殖。42，66相比之下，對(duì)未經(jīng)訓(xùn)練的動(dòng)物的生理挑戰(zhàn)，如強(qiáng)迫跑步，59容量超負(fù)荷，61，63或缺血，64會(huì)增加細(xì)胞凋亡，并伴隨著Ctn濃度的增加（Table1）。目前還不清楚這些發(fā)現(xiàn)是否可以外推到人類身上。

Cardiomyocyte Necrosis心肌細(xì)胞壞死

Myocardial necrosis is the most frequent cause of cT n elevations unrelated to exercise． Cardiomyocyte metabolism shifts from aerobic to anaerobic pathways to produce A TP during myocardial ischemia． This shift to anaerobic metabolism eventually disrupts the sarcolemma． Ischemia ＞15 minutes irreversibly damages the cardiomyocyte，1 allowing intracellular proteins to enter the circulation． There is an old hypothesis67 that， after AMI， there is first an immediate and substantial release of cT n from an early releasable pool， followed by a smaller peak of cT n caused by the slower process of degrading myofibrils．1 Although this hypothesis has been disputed，12 the exact mechanism of cT n release remains to be unraveled． As discussed earlier， the cT n release after exercise is smaller， appears to peak sooner， and resolves faster than that observed with AMI． These differences make it unlikely that necrosis causes exercise－induced cT n elevations but does not exclude the possibility that a small degree of necrosis could produce elevated cT n concentrations in vulnerable individuals after exercise．

心肌壞死是CT升高最常見(jiàn)的原因，與運(yùn)動(dòng)無(wú)關(guān)。心肌缺血時(shí)，心肌細(xì)胞代謝從有氧途徑轉(zhuǎn)變?yōu)闊o(wú)氧途徑，從而產(chǎn)生A－TP。這種向無(wú)氧代謝的轉(zhuǎn)變最終會(huì)破壞肌膜。缺血＞15分鐘對(duì)心肌細(xì)胞造成不可逆轉(zhuǎn)的損害，1使細(xì)胞內(nèi)蛋白進(jìn)入循環(huán)。有一種古老的假說(shuō)67，即急性心肌梗死后，首先從早期的可釋放池中立即大量釋放Ctn，然后是由于較慢的肌原纖維降解過(guò)程引起的Ctn的較小峰值。1盡管這一假說(shuō)一直存在爭(zhēng)議，12 Ctn釋放的確切機(jī)制仍有待解開(kāi)。正如前面所討論的，運(yùn)動(dòng)后的Ctn釋放較小，似乎更早達(dá)到峰值，而且消退得比觀察到的急性心肌梗死更快。這些差異使得壞死不太可能導(dǎo)致運(yùn)動(dòng)誘導(dǎo)的CTn升高，但不排除輕微的壞死可能導(dǎo)致運(yùn)動(dòng)后脆弱個(gè)體的CTn濃度升高。

Acute cardiac necrosis cannot be definitely determined in vivo． Cardiac MRI studies of participants in the Manitoba，68 London，69 and Detroit70 marathons found no myocardial edema or late gadolinium enhancement despite increased cT n concentrations after exercise． The absence of myocardial edema or scar argue against cardiac necrosis， but cardiac MR is not sensitive enough to detect a small degree of necrosis． Only 40 mg of rat myocardial necrosis increases cT nT and cT nI ＞URL，71 but this would not be detected by cardiac MRI． It could be speculated that long－term exercise training could produce myocardial damage from repetitive single exercise sessions． This hypothesis is supported by the observation that lifelong endurance athletes have more late gadolinium enhancement （LGE） than their physically inactive peers and that the amount of LGE increases with the number of race completions and years of training．72 Thus， although no direct evidence exists of myocardial necrosis after exercise， it cannot be excluded as contributing to exercise－induced cT n increases in some cases （T able 1）．

在活體內(nèi)不能確定急性心肌壞死。對(duì)馬尼托巴省68、倫敦69、底特律70馬拉松參賽者的心臟MRI研究發(fā)現(xiàn)，盡管運(yùn)動(dòng)后CTn濃度升高，但沒(méi)有心肌水腫或晚期釓增強(qiáng)。無(wú)心肌水腫或疤痕不利于心臟壞死，但心臟MR不夠敏感，不能發(fā)現(xiàn)少量的壞死。只有40 mg的大鼠心肌壞死使CtNT和CtNi＞URL，71但心臟MRI不能檢測(cè)到這一點(diǎn)。可以推測(cè)，長(zhǎng)期的運(yùn)動(dòng)訓(xùn)練可能會(huì)因重復(fù)的單次運(yùn)動(dòng)而造成心肌損傷。這一假說(shuō)得到以下觀察的支持，即終身耐力運(yùn)動(dòng)員比不運(yùn)動(dòng)的同齡人有更多的晚期釓增強(qiáng)（LGE），并且LGE的量隨著比賽完成次數(shù)和訓(xùn)練年限的增加而增加。72因此，盡管沒(méi)有直接證據(jù)表明運(yùn)動(dòng)后心肌壞死，但在某些情況下不能排除它是運(yùn)動(dòng)誘導(dǎo)的Ctn增加的原因（T Abable 1）。

Noncardiac Explanations 非心血管解釋

Several alternative hypotheses have been suggested to contribute to exercise－induced elevations of cT n concentrations （T able 1）． First， exercise－induced hemoconcentration may impact postexercise cT n concentrations， but the percentage change of fluid balance markers is （very） small relative to the increases in cT n concentrations． Also， any hemoconcentration is expected to be quickly restored with postexercise rehydration， which is contradictory to the progressive increase in cT n concentrations up to 2 to 6 hours after exercise． Evidence also suggests that hemodilution may occur after endurance exercise，73 so the role of hemoconcentration in elevated cT n concentrations after exercise is likely limited if not negligible．

已經(jīng)提出了幾種可供選擇的假說(shuō)，以促進(jìn)運(yùn)動(dòng)誘導(dǎo)的CTn濃度的升高（T表1）。首先，運(yùn)動(dòng)誘導(dǎo)的血液濃縮可能會(huì)影響運(yùn)動(dòng)后的Ctn濃度，但相對(duì)于Ctn濃度的升高，液體平衡標(biāo)記物的百分比變化（非常）很小。此外，任何血液濃度都有望在運(yùn)動(dòng)后補(bǔ)充水分后迅速恢復(fù)，這與運(yùn)動(dòng)后2至6小時(shí)內(nèi)CTn濃度的進(jìn)行性升高相矛盾。證據(jù)還表明，血液稀釋可能發(fā)生在耐力運(yùn)動(dòng)后，73所以血液濃度在運(yùn)動(dòng)后升高的ctn濃度中的作用可能是有限的，如果不是可以忽略的話。

Second， prolonged exercise and dehydration are associated with a compromised kidney function， but exerciseinduced increases in cT n concentrations far exceed the modest reduction in renal function observed immediately after exertion． Cystatin C increased 21％ to 25％ immediately after a marathon run， indicating a similar relative decrease in renal function．74 This reduction in renal function may reduce renal cT n clearance and contribute to increased cT n concentrations， but cT n concentrations increase a median 1000％ postmarathon，37 whereas renal function quickly recovers （＜24 hours），74 demonstrating that the contribution of attenuated renal function to the magnitude of exercise－induced cT n elevations is limited．

第二，長(zhǎng)時(shí)間的運(yùn)動(dòng)和脫水與腎功能受損有關(guān)，但運(yùn)動(dòng)引起的Ctn濃度的升高遠(yuǎn)遠(yuǎn)超過(guò)運(yùn)動(dòng)后立即觀察到的腎功能的輕微下降。74這種腎功能下降可能會(huì)降低腎臟的Ctn清除率，并導(dǎo)致Ctn濃度升高，但馬拉松后Ctn濃度升高的中位數(shù)為1000％，37而腎功能迅速恢復(fù)（＜24小時(shí)），74表明腎功能減弱對(duì)運(yùn)動(dòng)性Ctn升高幅度的貢獻(xiàn)是有限的，但Ctn濃度在馬拉松后升高的中位數(shù)為1000％，37而腎功能迅速恢復(fù)（＜24小時(shí)），74表明腎功能減弱對(duì)運(yùn)動(dòng)誘導(dǎo)的Ctn升高幅度的貢獻(xiàn)是有限的，但在馬拉松結(jié)束后，Ctn濃度升高的中位數(shù)為1000％，37而腎功能迅速恢復(fù)（＜24小時(shí)）。

Third， increases in cT n were hypothesized to be attributable to the cross－reactivity of the assay with skeletal T n or skeletal muscle damage with cT n release． Cross－reactivity of cT n assays with skeletal T n has been reported for cT nT75 and for certain assays of cT nI．76 For cT nT， it was estimated that cross－reactivity is limited to 0．003％ （package insert Roche Diagnostics ［201703， V9．0 English］） to 0．02％75 and for cT nI， 0．04％ to 0．44％．76 Nevertheless， in a clinical setting of rhabdomyolysis， no association between CK and cT nT or cT nT was reported．77 In patients with neuromuscular diseases， endstage renal disease， and even in healthy human skeletal muscle samples， cT nT but not cT nI was detected．78 Similarly， blood cT nT concentrations were often ＞URL in patients with skeletal myopathies， whereas cT nI was rarely elevated．79 Thus， skeletal muscle injury could conceivably contribute to exercise－induced cT nT increases but likely could not contribute to cT nI increases． We are also unaware of data showing increases in cT n， either T or I in muscle samples from exercise－trained subjects．

第三，Ctn的升高被認(rèn)為是由于測(cè)定與骨骼Tn或骨骼肌損傷與Ctn釋放的交叉反應(yīng)所致。已經(jīng)報(bào)道了CT nT75的CT n測(cè)定與骨骼Tn的交叉反應(yīng)，以及CT nt的某些CT nI．76測(cè)定的交叉反應(yīng)，估計(jì)交叉反應(yīng)限制在0．003％（Package Insert Roche Diagnostics［201703，V9．0 English］）至0．02％75和Ctni的0．04％至0．44％．76。然而，在橫紋肌溶解癥的臨床環(huán)境中，CK與CT nt或CT nt之間沒(méi)有關(guān)聯(lián)。78同樣，骨骼性肌病患者的血液CT NT濃度通常＞URL，而Ct ni很少升高。79因此，可以想見(jiàn)，骨骼肌損傷可能導(dǎo)致運(yùn)動(dòng)性CT NT升高，但很可能不會(huì)導(dǎo)致Ct ni升高。我們也不知道有數(shù)據(jù)顯示運(yùn)動(dòng)訓(xùn)練受試者的肌肉樣本中的Ctn增加，無(wú)論是T還是I。

CLINICAL RELEVANCE 臨床相關(guān)性

Exercise－induced increases in cT n have traditionally been interpreted as the only benign form of cT n release， because these elevations are mild， occur often， in apparently healthy individuals， and are not related to cardiac symptoms． However， cT n concentrations taken at rest in large populations and clinical studies predict mortality and cardiovascular morbidity，2，4 even within the normal range．3 The prognostic value of exercise－induced increases in cT n has rarely been studied80，81 but may have clinical relevance in some populations as discussed later on in this article．

傳統(tǒng)上，運(yùn)動(dòng)引起的Ctn升高被認(rèn)為是唯一良性的Ctn釋放形式，因?yàn)檫@些升高是溫和的，經(jīng)常發(fā)生在表面上健康的人身上，而且與心臟癥狀無(wú)關(guān)。然而，靜息狀態(tài)下的ctn濃度在大量人群和臨床研究中預(yù)測(cè)死亡率和心血管發(fā)病率，2，4甚至在正常范圍內(nèi)。3運(yùn)動(dòng)誘導(dǎo)的Ctn升高的預(yù)后價(jià)值很少被研究80，81，但可能在本文后面討論的一些人群中具有臨床相關(guān)性。

Postexercise cTn and Cardiac Function 運(yùn)動(dòng)后cTn與心功能

A number of studies have examined the association between postexercise reductions in cardiac function and cT n concentrations．7 Reductions in cardiac function after exercise are typically mild and transient and occur mostly after prolonged endurance events such as marathons， triathlons， and ultraraces． A meta－analysis using echocardiography found reductions in LV ejection fraction and diastolic function after such races．7 Postexercise cT n concentrations correlated directly with reductions in diastolic function measured as E／A ratio， but no association between cT n and change in LV ejection fraction was found， because only a few studies reported a significant association and not with the standard echocardiographic parameters． This is probably because of the limited number of studies （4／22） investigating the association between cT n and LV ejection fraction．7

多項(xiàng)研究研究了運(yùn)動(dòng)后心功能下降與ct－n濃度之間的關(guān)系。7運(yùn)動(dòng)后心功能下降通常是輕微和短暫的，大多發(fā)生在馬拉松、鐵人三項(xiàng)和超長(zhǎng)距離等長(zhǎng)期耐力活動(dòng)之后，7運(yùn)動(dòng)后的心功能下降通常是輕微的和短暫的，主要發(fā)生在馬拉松、鐵人三項(xiàng)和超長(zhǎng)距離比賽之后。使用超聲心動(dòng)圖的薈萃分析發(fā)現(xiàn)，運(yùn)動(dòng)后左心室射血分?jǐn)?shù)和舒張功能下降。7運(yùn)動(dòng)后ctn濃度與以E／A比值測(cè)量的舒張功能下降直接相關(guān)，但沒(méi)有發(fā)現(xiàn)ctn與左心室射血分?jǐn)?shù)的變化相關(guān)，因?yàn)橹挥袔醉?xiàng)研究報(bào)道了顯著的相關(guān)性，而與標(biāo)準(zhǔn)的超聲心動(dòng)圖參數(shù)無(wú)關(guān)。這可能是因?yàn)檠芯緾Tn和左心室射血分?jǐn)?shù)之間關(guān)系的研究數(shù)量有限（4／22）。7

Exercise appears to affect right ventricular （RV） more than L V function， possibly because the relative increase in RV wall stress with exercise is greater than in the L V．82 Eight studies measured RV function and exercise－induced cT n concentrations （T able S3）． Only 4 of 8 studies reported a significant reduction in RV systolic function． Of those 4 studies， only 2 reported associations between RV systolic function and postexercise cT n concentrations， which found an association between exercise－induced cT n and the reduction in RV ejection fraction （r＝0．49， P＝0．00283）， and RV basal （r＝0．68）， mid （r＝0．70）， and apical （r＝0．72） strain （P＜0．001 for all）．25 The only 2 studies reporting postexercise reductions in RV function and associations with postexercise cT n found a direct correlation， but the absence of an association in the other studies may not have been reported． Potential explanations for discrepant outcomes between studies likely relate to the selection of endurance races， the timing of blood drawings， and the inclusion of less sensitive measures of systolic function （strain analyses were more likely to reveal reductions in cardiac function25 because both studies that used RV strain found reductions in RV function）．

運(yùn)動(dòng)對(duì)右室功能的影響似乎大于對(duì)左心室功能的影響，可能是因?yàn)檫\(yùn)動(dòng)對(duì)右室壁應(yīng)力的相對(duì)增加大于左心室。82 項(xiàng)研究測(cè)量了右室功能和運(yùn)動(dòng)誘導(dǎo)的CTn濃度（TableS3）。8項(xiàng)研究中只有4項(xiàng)報(bào)告右室收縮功能顯著降低。在這4項(xiàng)研究中，只有2項(xiàng)研究報(bào)道了右室收縮功能與運(yùn)動(dòng)后Ctn濃度之間的關(guān)系，這兩項(xiàng)研究發(fā)現(xiàn)運(yùn)動(dòng)誘導(dǎo)的Ctn與RV射血分?jǐn)?shù)的降低（r＝0．49，P＝0．00283）、RV基礎(chǔ)應(yīng)變（r＝0．68）、MID（r＝0．7）和心尖應(yīng)變（r＝0．72）（均P＜0．001）有關(guān)。25僅有2項(xiàng)研究報(bào)告運(yùn)動(dòng)后RV功能的降低與運(yùn)動(dòng)后Ctn的關(guān)系，但這兩項(xiàng)研究的缺失與運(yùn)動(dòng)后的Ctn之間存在直接關(guān)聯(lián)，但這兩項(xiàng)研究均未發(fā)現(xiàn)運(yùn)動(dòng)誘導(dǎo)的Ctn與RV基礎(chǔ)應(yīng)變（r＝0．68）、MID應(yīng)變（r＝0．7）和心尖應(yīng)變（r＝0．72）之間的相關(guān)性。研究結(jié)果不一致的潛在解釋可能與耐力比賽的選擇、血液繪圖的時(shí)間以及包含不太敏感的收縮功能測(cè)量有關(guān)（應(yīng)變分析更有可能顯示心功能下降25，因?yàn)槭褂糜倚氖覒?yīng)變的兩項(xiàng)研究都發(fā)現(xiàn)右心室功能減退）。

Overall， some evidence suggests that postexercise cT n concentrations are associated with decreased LV diastolic function and possibly with LV and RV systolic function， but this was observed in only a few studies， and the strength of the association was moderate． An important caveat of available evidence is that studies have only examined associations between cT n concentrations and cardiac function using a single postexercise assessment， most often acquired immediately after exercise cessation． Because cT n kinetics appear to show a delayed peak after exercise， a single postexercise cT n may obscure the true association between cT n and cardiac function．

總而體來(lái)說(shuō)，一些證據(jù)表明，運(yùn)動(dòng)后Ctn濃度與左心室舒張功能下降有關(guān)，并可能與左心室和右室收縮功能有關(guān)，但這只在少數(shù)研究中觀察到，而且這種聯(lián)系的強(qiáng)度是中等的�，F(xiàn)有證據(jù)的一個(gè)重要警告是，研究只使用單一的運(yùn)動(dòng)后評(píng)估來(lái)檢查CTn濃度和心功能之間的關(guān)系，通常是在運(yùn)動(dòng)停止后立即獲得的。由于運(yùn)動(dòng)后CTn動(dòng)力學(xué)表現(xiàn)出一個(gè)延遲的峰值，單一的運(yùn)動(dòng)后Ctn可能掩蓋了Ctn與心功能之間的真實(shí)聯(lián)系。

Is Exercise－Induced cTn an Indicator of Subclinical Disease？運(yùn)動(dòng)性肌鈣蛋白是亞臨床疾病的指標(biāo)嗎？

How and why exercise－induced cT n increases occur in ostensibly healthy people is unclear， but increases in cT n may reflect subclinical myocardial vulnerability． Epidemiological and clinical studies demonstrate that individuals with cardiovascular risk factors （CVRFs） and diseases （CVDs） have higher resting cT n concentrations11，84，85 than their healthy counterparts． Similarly， after short and prolonged exercise， individuals with CVD and CVRF showed larger cT n increases than their healthy peers．11，84 For example， patients with heart failure have higher baseline， exercise－induced cT nT concentrations than healthy controls after a short－graded bicycle exercise test．84 Among 725 long－distance walkers with an average age of 61 years， resting cT nI concentrations were higher （P＜0．001）， but the proportion of concentrations ＞URL was similar （P＝0．86）， in individuals with CVD （n＝104， 7 ［2–15］ ng／L， 1．0％ ＞URL）， CVRF （n＝186， 3 ［0–9］ ng／L， 1．7％）， and healthy controls （n＝435， 1 ［0–5］ ng／L， 1．2％）． After 30 to 55 km of walking， cT nI concentrations increased in all groups （P＜0．001）， but patients with CVD more often had a postexercise cT n concentration ＞URL （16％） compared with individuals with CVRF （10％） and controls （6％； P＝0．003）．11

在表面上健康的人中，運(yùn)動(dòng)誘導(dǎo)的Ctn升高是如何以及為什么發(fā)生的尚不清楚，但Ctn的升高可能反映了亞臨床心肌的脆弱性。流行病學(xué)和臨床研究表明，有心血管危險(xiǎn)因素（CVRF）和疾�。–VD）的人的靜息Ctn濃度高于健康人11，84，84。以心力衰竭患者為例，在短強(qiáng)度自行車運(yùn)動(dòng)試驗(yàn)后，心力衰竭患者的運(yùn)動(dòng)誘導(dǎo)CtnT濃度高于健康對(duì)照組。84在725名平均年齡為61歲的長(zhǎng)距離步行者中，靜息Ctni濃度高于健康對(duì)照組（P＜0．001），但濃度＞URL的比例相似（P＝0．86．0 5），心力衰竭患者（n＝10 4，7例）中，靜息CtnI濃度較高（P＜0．05），但濃度＞URL的比例相似（P＝0．86），CVD患者的靜息CtnI濃度高于健康對(duì)照組（P＜0．05），但濃度＞URL的比例相似（P＝0．86）。3［0～9］ng／L，1．7％），健康對(duì)照組（n＝435，1［0～5］ng／L，1．2％）。步行30～55 km后，各組Ctni濃度均升高（P＜0．001），但Cvd組運(yùn)動(dòng)后Ctn濃度＞URL（16％）高于腦血管病組（10％）和對(duì)照組（6％；P＝0．003）。11

cT n elevations may indicate demand ischemia， so several studies have explored the association between the magnitude of exercise－induced cT n increases and significant CAD， but the results are inconsistent．86–88 Several studies have found no increase in cT n after a shortduration （＜15 minutes） clinical exercise test in individuals with CAD．89 Other studies have reported significant cT n increases after clinical exercise or dobutamine stress tests． A recent meta－analysis including studies published between 2008 and 2016 found only minor increases in cT n concentrations after clinical exercise stress tests， with no difference in exercise－induced elevations of cT n concentrations between patients with inducible and noninducible ischemia （cT nT： 0．5 ［0–0．9］ ng／L versus 1．1 ［0–2．2］ ng／L， P＝0．29； cT nI： 2．4 ［0．2–4．7］ ng／L versus 1．8 ［0．6–3．0］ ng／L， P＝0．61）．90 Similar findings were reported for pharmacological stress testing．90 Overall， these findings may be attributable to （1） exercise intensity or duration at the ischemia threshold being insufficient to produce cT n elevations sufficient to discriminate between those with and without severe CAD or myocardial ischemia； （2） cT n concentrations being measured too early after exercise and missing the cT n peak （Figure 3A）； or （3） the lack of an association between myocardial ischemia and exercise－induced cT n elevations．

CTn升高可能表明需求缺血，因此幾項(xiàng)研究探索了運(yùn)動(dòng)引起的CT n升高幅度與顯著的CAD之間的關(guān)系，但結(jié)果并不一致。86－88幾項(xiàng)研究發(fā)現(xiàn)，在短時(shí)間（＜15分鐘）的臨床運(yùn)動(dòng)試驗(yàn)后，冠心病患者的CTn沒(méi)有升高。89其他研究報(bào)告了在臨床運(yùn)動(dòng)或多巴酚丁胺負(fù)荷試驗(yàn)后CT n顯著升高。最近的一項(xiàng)薈萃分析（包括2008年至2016年發(fā)表的研究）發(fā)現(xiàn)，在臨床運(yùn)動(dòng)負(fù)荷試驗(yàn)后，Ctn濃度僅有輕微升高，在誘導(dǎo)性和非誘導(dǎo)性缺血患者之間運(yùn)動(dòng)誘導(dǎo)的Ctn濃度升高沒(méi)有差異（Ct NT：0．5［0－0．9］ng／L對(duì)1．1［0－2．2］ng／L，P＝0．29；CT－Ni：2．4［0．2－4．7］ng／L對(duì)1．8［0．6－3．0］ng／L，P＝0．61）。90藥理應(yīng)激試驗(yàn)也有類似的發(fā)現(xiàn)。90總體來(lái)說(shuō)，這些發(fā)現(xiàn)可能歸因于（1）運(yùn)動(dòng)強(qiáng)度或缺血閾值持續(xù)時(shí)間不足以產(chǎn)生足以區(qū)分有無(wú)嚴(yán)重冠心病或心肌缺血者的Ctn升高；（2）運(yùn)動(dòng)后測(cè)量Ctn濃度太早，錯(cuò)過(guò)了Ctn峰值（圖3A）；（3）心肌缺血與運(yùn)動(dòng)性ctn升高之間缺乏相關(guān)性。

Observations among long－distance runners and cyclists largely confirm the findings from clinical studies with the majority of studies showing no association between cT n concentrations and CAD （T able 2）． For example， no relation was found between postexercise cT nT concentrations and coronary artery calcification scores （r＝–0．013， P＝0．95） in 27 participants of the Paavo Nurmi marathon．91 Also， postexercise cT nI concentrations were not different between marathon runners with coronary artery calcification scores greater than or less than the median score （P＞0．99）．92 The North Sea Race Endurance Exercise Study （n＝120） also found no relation between cT n concentrations 3 hours after a 91－km mountain bicycle race， although cyclists with occult obstructive CAD （n＝9） had significantly higher cT nI and cT nT concentrations 24 hours after exercise than controls．10 The delayed cT n release in individuals with obstructive CAD may relate to impaired blood flow through the obstructed coronary arteries as is also seen with AMI． Future studies that evaluate whether postexercise cT n is a marker for occult CAD should include multiple time points of assessment．

對(duì)長(zhǎng)跑運(yùn)動(dòng)員和騎自行車的人的觀察在很大程度上證實(shí)了臨床研究的結(jié)果，大多數(shù)研究表明CTn濃度與CAD之間沒(méi)有關(guān)聯(lián)（表2）。例如，在27名參加帕沃－努爾米馬拉松比賽的運(yùn)動(dòng)員中，運(yùn)動(dòng)后CT＿（Nt）濃度與冠狀動(dòng)脈鈣化積分之間沒(méi)有相關(guān)性（r＝－0．013，P＝0．95）。此外，冠脈鈣化積分大于或小于中位數(shù)的馬拉松運(yùn)動(dòng)員運(yùn)動(dòng)后CT＿（Nt）濃度也沒(méi)有差異（P＞0．99）。92北海耐力運(yùn)動(dòng)研究也發(fā)現(xiàn)91公里山地自行車比賽后3小時(shí)的CT＿n濃度之間也沒(méi)有關(guān)系。9例隱匿性梗阻性CAD患者運(yùn)動(dòng)后2 4h的CT ni和CT NT濃度明顯高于對(duì)照組。10梗阻性CAD患者的Ctn釋放延遲可能與梗阻性冠脈血流障礙有關(guān)，在AMI患者中也有同樣的表現(xiàn)。（2）隱性梗阻性CAD患者運(yùn)動(dòng)后24h的Ctn和Ctnt濃度明顯高于對(duì)照組（P＜0．01）。未來(lái)評(píng)估運(yùn)動(dòng)后Ctn是否是隱匿性CAD的標(biāo)記物的未來(lái)研究應(yīng)該包括多個(gè)時(shí)間點(diǎn)的評(píng)估。

Myocardial fibrosis has also been reported in ostensibly healthy endurance athletes． Only 2 studies to our knowledge have investigated the association between postexercise cT n concentrations and the presence of LGE （T able 2）． German marathon runners with LGE （n＝9） had higher cT nI concentrations immediately postmarathon than those without LGE （n＝65）．92 In contrast， triathletes with （n＝10， 49±8 years） and without LGE （n＝20， 42±10 years）， showed no difference in postexercise cT nT concentrations collected at 2．4±1．1 hours posttriathlon （40±26 versus 65±103 ng／L）．93 These 2 studies included only 19 individuals with LGE， so it is impossible to determine whether a relation exists．

表面上健康的耐力運(yùn)動(dòng)員中也有心肌纖維化的報(bào)道。據(jù)我們所知，只有2項(xiàng)研究調(diào)查了運(yùn)動(dòng)后Ctn濃度與LGE存在之間的關(guān)系（表2）。有LGE的德國(guó)馬拉松運(yùn)動(dòng)員（n＝9）在馬拉松后即刻的Ctni濃度高于無(wú)LGE的運(yùn)動(dòng)員（n＝65）。92相反，有LGE的鐵人三項(xiàng)運(yùn)動(dòng)員（n＝10，49±8年）和無(wú)LGE的鐵人三項(xiàng)運(yùn)動(dòng)員（n＝20，42±10年）在運(yùn)動(dòng)后2．4±1．1小時(shí)的Ct－nt濃度沒(méi)有差異（40±26對(duì)65±103 ng／L）。93這兩項(xiàng)研究只包括19名有LGE的人，因此不可能確定。

In summary， CVRF and CVD are associated with higher resting and postexercise cT n concentrations． Most exercise studies have found no association between postexercise cT n elevations and CAD severity or myocardial fibrosis， but few studies have been performed and they used different exercise intensities， durations， and blood sampling protocols．

綜上所述，CVRF和CVD與較高的靜息和運(yùn)動(dòng)后Ctn濃度相關(guān)。大多數(shù)運(yùn)動(dòng)研究都沒(méi)有發(fā)現(xiàn)運(yùn)動(dòng)后Ctn升高與冠心病嚴(yán)重程度或心肌纖維化之間的關(guān)系，但很少有研究進(jìn)行，他們使用了不同的運(yùn)動(dòng)強(qiáng)度、持續(xù)時(shí)間和采血方案。

Prognostic Value in Patients 患者的預(yù)后價(jià)值

We are aware of only 2 exercise stress test studies evaluating the prognostic value of exercise－induced cT n concentrations80，81 （T able 3）． Neither found a predictive relationship． There was no difference in 4 hours postexercise cT nT concentrations between patients with unstable angina who did （n＝23） or did not （n＝46） develop recurrent angina at 6－month follow－up．80 Another study reported no difference in the incidence of a composite end point （death， myocardial infarction， acute revascularization， hospitalization for unstable angina， or heart failure） in patients with CAD with 8 to 12 and 24－h(huán)our postex ercise cT nI concentrations greater than versus less than the URL （27％ versus 17％， P＞0．05） during 36 （15–49） months of follow up．81 The absence of an association of exercise cT n with subsequent symptoms may be attributable to the short duration of exercise， sample size， sampling times， only a small number of clinical events， or the absence of a clinically important relationship．

我們知道只有2項(xiàng)運(yùn)動(dòng)負(fù)荷試驗(yàn)研究評(píng)估了運(yùn)動(dòng)誘導(dǎo)的Ctn濃度80，81的預(yù)后價(jià)值（T表3）。兩人都沒(méi)有發(fā)現(xiàn)可預(yù)測(cè)的關(guān)系。在6個(gè)月的隨訪中，23名不穩(wěn)定型心絞痛患者和46名未復(fù)發(fā)心絞痛患者在運(yùn)動(dòng)后4小時(shí)的ct－nt濃度沒(méi)有差異。80另一項(xiàng)研究報(bào)道，在8－12和24小時(shí)ct－ni濃度大于或小于URL的冠心病患者中，復(fù)合終點(diǎn)（死亡、心肌梗死、急性血運(yùn)重建、不穩(wěn)定心絞痛住院或心力衰竭）的發(fā)生率沒(méi)有差異（27％比17％，P＜0．05）。81缺乏運(yùn)動(dòng)Ctn與后續(xù)癥狀的關(guān)聯(lián)可能是由于運(yùn)動(dòng)持續(xù)時(shí)間短、樣本量小、采樣時(shí)間短、僅有少量臨床事件或缺乏臨床上重要的關(guān)系所致。（2）在36（15－49）個(gè)月的隨訪中，Ctn與隨后的癥狀之間沒(méi)有關(guān)聯(lián)，這可能是由于運(yùn)動(dòng)持續(xù)時(shí)間短、樣本量大、采樣時(shí)間短、臨床事件數(shù)量少，或者沒(méi)有臨床上重要的關(guān)系。

Prognostic Value in Exercising Individuals 運(yùn)動(dòng)個(gè)體的預(yù)后價(jià)值

In contrast with a paucity of exercise／cT n studies in the clinical setting， a plethora of studies exist that follow endurance exercise events， but to our knowledge only 3 studies have assessed the prognostic value of these cT n elevations （T able 3）． cT nI concentrations increased from baseline to postexercise in 7 4 male marathon runners （57±6 years）， with 36．5％ of the runners demonstrating postexercise cT nI concentrations ＞URL． During 6 years of follow－up， 6 CAD events occurred， evenly split between individuals with postmarathon cT nI concentrations greater than and less than the median value．92

與臨床上運(yùn)動(dòng)／CTn研究相對(duì)較少的是，有大量研究跟蹤耐力運(yùn)動(dòng)事件，但據(jù)我們所知，只有3個(gè)研究評(píng)估了這些CT nI升高的預(yù)后價(jià)值（TABL3）。74名男性馬拉松運(yùn)動(dòng)員（57±6歲）運(yùn)動(dòng)后CTni濃度從運(yùn)動(dòng)前到運(yùn)動(dòng)后逐漸升高，36．5％的跑步者運(yùn)動(dòng)后Ctni濃度＞URL。在6年的隨訪中，發(fā)生了6個(gè)CAD事件，平均分布在馬拉松后Ctni濃度大于或小于中位數(shù)的個(gè)體之間。92

Our group previously followed 725 long－distance walkers （61．4 ［54．4–69．1］ years）， 9％ of whom had a cT nI concentration ＞URL ±10 minutes after walking 30 to 55 km．11 During a median follow－up of 43 （23– 77） months， 62 participants experienced a composite end point of death （n＝29， 47％）， myocardial infarction （n＝6， 10％）， stroke （n＝17 ， 27％）， heart failure diagnosis （n＝4， 6％）， revascularization （n＝5， 8％）， or resuscitated sudden cardiac arrest （n＝1， 2％）． Of individuals with postexercise cT nI ＞URL， 27％ experienced an end point compared with 7％ of those with cT nI URL， even when markedly elevated．

我們的小組之前跟蹤了725名長(zhǎng)距離步行者（61．4［54．4－69．1］年），其中9％的人在步行30到55公里后10分鐘內(nèi)Ctni濃度＞URL。11在平均43（23－77）個(gè)月的隨訪中，62名參與者經(jīng)歷了復(fù)合終點(diǎn)死亡（n＝29，47％），心肌梗死（n＝6，10％），中風(fēng)（n＝17，27％），心力衰竭診斷（n＝4，6％），血管重建（n＝4，6％）。2％）。在運(yùn)動(dòng)后Ctni＞URL的個(gè)體中，27％的人經(jīng)歷了終點(diǎn)，而Ctni＜URL的個(gè)體中有7％的人經(jīng)歷了終點(diǎn)（粗風(fēng)險(xiǎn)比5．21［95％CI，2．96－9．17］）。在調(diào)整了年齡、性別以及是否存在CVD和CVRF后，危險(xiǎn)比為3．21（95％CI，1．79－5．77）。在調(diào)整基線CtnI后，這一數(shù)字進(jìn)一步下降到2．48（95％CI，1．29－4．78）。當(dāng)將死亡率與其他終點(diǎn)分開(kāi)時(shí)（圖5），死亡率與ctni的增加沒(méi)有顯著關(guān)聯(lián)（完全調(diào)整的風(fēng)險(xiǎn)比，1．09［0．38－3．10］），而主要的心血管不良結(jié)局有很強(qiáng)的相關(guān)性（完全調(diào)整的風(fēng)險(xiǎn)比，3．75［1．56－9．02］）。這可能是由于獨(dú)立結(jié)果的統(tǒng)計(jì)能力較低，或者是因?yàn)闄z查了所有原因而不是心血管死亡率。研究隊(duì)列不是運(yùn)動(dòng)人群，而是來(lái)自普通人群的體力活動(dòng)個(gè)體，包括患有腦血管病和腦血管病的老年人。因此，這些數(shù)據(jù)不適用于Ctn值＞URL的年輕運(yùn)動(dòng)員隊(duì)列，即使明顯升高。

Preliminary data examined postexercise cT n concentrations in 991 healthy participants （46 ［40–53］ years） in the North Sea Race 91－km bike race．94 Participants were followed for 5 years， and 12 （1．2％） experienced a cardiovascular event during follow－up． The prevalence of cT n ＞URL for cT nI and cT nT at 3 and 24 hours after exercise were 83％ and 92％， and 17％ and 27％， respectively． Postexercise cT n concentrations ＞URL were not associated with cardiovascular events at 3 （log－rank test， cT nI： P＝0．11， cT nT： P＝0．35） or 24 hours （cT nI： P＝0．45， cT nT： P＝0．06）．94 The low event rate may have contributed to the absence of an association， but the near－significant result for cT nT at 24 hours is noteworthy．

初步數(shù)據(jù)分析了參加北海91公里自行車賽的991名健康參與者（46［40－53］歲）的運(yùn)動(dòng)后Ctn濃度。94名參與者被跟蹤5年，其中12名（1．2％）在隨訪期間經(jīng)歷了心血管事件。Ctn＞URL在Ctni和Ct Nt中的患病率（3％）運(yùn)動(dòng)后24h分別為83％和92％，17％和27％。運(yùn)動(dòng)后3小時(shí)（對(duì)數(shù)秩檢驗(yàn)，CT ni：P＝0．11，CT NT：P＝0．35）或24小時(shí)（CT ni：P＝0．45，CT NT：P＝0．06）的心血管事件與Ctn濃度＞URL無(wú)關(guān)。94低的事件發(fā)生率可能是導(dǎo)致兩者無(wú)相關(guān)性的原因之一，但值得注意的是24小時(shí)Ct NT的接近顯著的結(jié)果。

Together， these 3 studies suggest that exaggerated postexercise cTn elevations may not be benign and may portend cardiovascular events in older individuals． It is unknown whether these findings can be extrapolated to younger subjects and to athletes performing vigorous activities．

總之，這3項(xiàng)研究表明，運(yùn)動(dòng)后CTn的升高可能不是良性的，可能預(yù)示著老年人的心血管事件。目前還不清楚這些發(fā)現(xiàn)是否可以推斷到更年輕的受試者和進(jìn)行劇烈運(yùn)動(dòng)的運(yùn)動(dòng)員。

表2．冠狀動(dòng)脈粥樣硬化、心肌纖維化和運(yùn)動(dòng)誘導(dǎo)的cTn釋放之間的相關(guān)性

CAC indicates coronary artery calcification冠狀動(dòng)脈鈣化； CAD， coronary artery disease冠心病； cTnI， cardiac troponin I心肌肌鈣蛋白I； CVD， cardiovascular disease心血管疾病

； hs－cTnT， high sensitivity cardiac troponin T高敏心肌肌鈣蛋白T； hs－cTnI， high sensitivity cardiac troponin I高敏心肌肌鈣蛋白I； and URL， upper reference limit參考上限

．Clinical Management and Considerations 臨床管理與思考

Exercise－induced cTn elevations can lead to clinical confusion in the emergency department when individuals present postexercise with elevated cT n concentrations．

運(yùn)動(dòng)性CTn升高可能導(dǎo)致急診科的臨床混亂，當(dāng)個(gè)人在運(yùn)動(dòng)后出現(xiàn)CTn濃度升高時(shí)。

表3．評(píng)估運(yùn)動(dòng)性cTn釋放的預(yù)后價(jià)值的研究綜述

cTnI indicates cardiac troponin I心肌肌鈣蛋白I； CVD， cardiovascular disease心血管疾��；HRadjusted， adjusted hazard ratio； HRmax估計(jì)的最大心率， estimated maximal heart rate； hs－cTnI， high sensitivity cardiac troponin I高敏心肌肌鈣蛋白I； hs－cTnT， high sensitivity cardiac troponin T高敏心肌肌鈣蛋白T； MACE， major adverse cardiovascular outcome主要不良心血管結(jié)果； and URL， upper reference limit參考上限

Several clinical approaches have been suggested5 and remain appropriate． Clinicians should follow usual clinical protocols but be especially cognizant that exercise can increase cT n concentrations far above the URL and thus can explain cT n elevations after exercise． Patients presenting postexercise with any clinical concern for an acute coronary syndrome （with elevated cT n or not） should undergo the appropriate evaluation including 12－lead ECG， serial cT n testing， and some form of either noninvasive or invasive risk stratification as dictated by the overall clinical picture． However， assessment of CAD （eg， with coronary artery calcification scoring） is not indicated solely on the basis of lone postexercise cT n elevations．

已經(jīng)推薦了幾種臨床方法，并且仍然是合適的。臨床醫(yī)生應(yīng)該遵循通常的臨床規(guī)程，但要特別認(rèn)識(shí)到，運(yùn)動(dòng)可以使Ctn濃度遠(yuǎn)遠(yuǎn)高于URL，從而可以解釋運(yùn)動(dòng)后Ctn升高的原因。運(yùn)動(dòng)后出現(xiàn)任何臨床癥狀的急性冠脈綜合征患者（無(wú)論是否有Ctn升高）都應(yīng)該接受適當(dāng)?shù)脑u(píng)估，包括12導(dǎo)聯(lián)心電圖、系列Ctn測(cè)試，以及根據(jù)總體臨床情況進(jìn)行某種形式的無(wú)創(chuàng)或有創(chuàng)風(fēng)險(xiǎn)分層。然而，冠心病的評(píng)估（例如，冠狀動(dòng)脈鈣化評(píng)分）并不僅僅基于運(yùn)動(dòng)后單獨(dú)的ctn升高。

Clinicians who oversee mass sporting events are not recommended to do on－site cT n testing outside of a clear research agenda unless future research supports its added value． If postexercise cT n elevations are found， the clinical significance is unclear， although some studies suggest that postexercise cT n elevations may portend future cardiac events in a small number of individuals．

監(jiān)督大眾體育賽事的臨床醫(yī)生不建議在明確的研究議程之外進(jìn)行現(xiàn)場(chǎng)ct n測(cè)試，除非未來(lái)的研究支持其附加值。如果發(fā)現(xiàn)運(yùn)動(dòng)后Ctn升高，其臨床意義尚不清楚，盡管一些研究表明運(yùn)動(dòng)后Ctn升高可能預(yù)示著少數(shù)人未來(lái)的心臟事件。

圖5．基于Aengevaeren等人的數(shù)據(jù)，運(yùn)動(dòng)后肌鈣蛋白I的風(fēng)險(xiǎn)比＞死亡率和MACE的正常參考上限，以及死亡率和MACE11

在43［23－77］個(gè)月的隨訪中，對(duì)725名年長(zhǎng)的長(zhǎng)距離步行者在步行30到55公里后10分鐘測(cè)量了t－roponin I，他們經(jīng)歷了62次事件、29次死亡和33次。MACE提示發(fā)生了嚴(yán)重的心血管不良事件。

FUTURE DIRECTIONS 未來(lái)方向

Many studies have used 1 phlebotomy time point after exercise， and this time point often varies among studies， whereas only a few studies have investigated cT n release during exercise． Future studies should use similar time points for similar outcome measures． It appears that peak cTn values are achieved at 2 to 6 hours after a bout of endurance exercise． More research is needed to determine whether a specific postexercise time point may be predictive of future mortality and cardiovascular outcome．

許多研究都使用了運(yùn)動(dòng)后1個(gè)采血時(shí)間點(diǎn)，而這個(gè)時(shí)間點(diǎn)在不同的研究中往往不同，而只有少數(shù)研究研究了運(yùn)動(dòng)過(guò)程中CTn的釋放。未來(lái)的研究應(yīng)該對(duì)類似的結(jié)果測(cè)量使用類似的時(shí)間點(diǎn)。耐力運(yùn)動(dòng)后2～6小時(shí)可達(dá)峰值。需要更多的研究來(lái)確定特定的運(yùn)動(dòng)后時(shí)間點(diǎn)是否可以預(yù)測(cè)未來(lái)的死亡率和心血管結(jié)果。

There is evidence that both physiological and reversible， and pathological and irreversible myocardial injury， as well， might contribute to the exercise－induced cT n response， and this may be mediated by the population being studied． Mechanisms may also differ between populations because exercise－induced cT n release may be more likely related to reversible myocardial injury in healthy individuals， whereas irreversible myocardial injury might be more common in individuals with underlying CVD． Cellular and animal models， novel imaging techniques， and novel biomarker assays are needed to examine these possibilities． For example， a study using diffusion－weighted MRI could assess whether the larger exercise－induced elevations in cT n concentrations in individuals with CVRF are attributable to larger decreases in cardiomyocyte integrity． Assessing the types and sizes of cT n fragments and the appearance of apoptotic biomarkers would contribute to this analysis． Future work examin ing exercise－induced cT n release in healthy participants， and those with underlying cardiovascular disease， should examine the influence of coronary blood flow， because the differential response between these populations may be explained by the degree of coronary occlusion or vessel reactivity and the corollary impact on the washout of cT n stimulated by exercise．

有證據(jù)表明，生理性和可逆性以及病理性和不可逆性心肌損傷都可能參與運(yùn)動(dòng)性CTn反應(yīng)，這可能是由被研究人群介導(dǎo)的。機(jī)制也可能因人群不同而不同，因?yàn)檫\(yùn)動(dòng)誘導(dǎo)的ctn釋放可能更可能與健康個(gè)體的可逆性心肌損傷有關(guān)，而不可逆性心肌損傷可能更常見(jiàn)于潛在的CVD患者。需要細(xì)胞和動(dòng)物模型、新的成像技術(shù)和新的生物標(biāo)記物分析來(lái)檢查這些可能性。例如，一項(xiàng)使用彌散加權(quán)MRI的研究可以評(píng)估患有CVRF的個(gè)體在運(yùn)動(dòng)誘導(dǎo)的Ctn濃度較大程度上的升高是否可歸因于心肌細(xì)胞完整性的較大下降。評(píng)估CTn片段的類型和大小以及凋亡生物標(biāo)志物的出現(xiàn)將有助于這一分析。未來(lái)研究健康受試者和有潛在心血管疾病的受試者的運(yùn)動(dòng)誘導(dǎo)的CTn釋放的工作應(yīng)檢查冠脈血流的影響，因?yàn)檫@些人群之間的不同反應(yīng)可能由冠狀動(dòng)脈閉塞或血管反應(yīng)性的程度以及運(yùn)動(dòng)對(duì)Ctn的清除的必然影響來(lái)解釋。

Large prospective studies in clinical and recreational athletic populations with prolonged follow－up are needed to determine whether exercise－induced cT n predicts future cardiovascular events． Subsequent studies can then determine if altering the cT n response by exercise training or pharmacological treatment （eg， statins or aspirin） can alter cardiovascular outcomes．

需要在臨床和休閑運(yùn)動(dòng)人群中進(jìn)行大規(guī)模前瞻性研究，并進(jìn)行長(zhǎng)期隨訪，以確定運(yùn)動(dòng)誘發(fā)的CT是否可以預(yù)測(cè)未來(lái)的心血管事件。隨后的研究可以確定通過(guò)運(yùn)動(dòng)訓(xùn)練或藥物治療（例如：他汀類藥物或阿司匹林）改變CTn反應(yīng)是否能改變心血管結(jié)果。

CONCLUSIONS

Exercise of different types， durations， and intensities commonly increases cT n． cT n transiently increases after the performance of endurance exercise with peak values typically 2 to 6 hours after exercise． The underlying mechanisms are not clearly defined， but evidence supports the hypothesis that sarcolemmal permeability from reversible cardiac injury permits cT n fragments from an early releasable pool to leak from the cardiomyocyte． Evidence also suggests increased apoptosis or accelerated cardiomyocyte turnover attributable to myocardial stress or brief ischemia． Few studies have investigated the predictive value of exercise－induced cT n for cardiovascular events， but older long－distance walkers with a postexercise cT n concentration ＞URL experienced increased cardiovascular events． These findings need to be confirmed and the prognostic significance of cT n in younger athletic subjects needs to be determined．

不同類型、持續(xù)時(shí)間和強(qiáng)度的運(yùn)動(dòng)通常會(huì)增加Ctn，耐力運(yùn)動(dòng)后Ctn有一過(guò)性增加，峰值一般在運(yùn)動(dòng)后2～6h。其潛在的機(jī)制尚不清楚，但有證據(jù)支持這樣的假設(shè)，即可逆性心臟損傷引起的肌膜通透性允許早期可釋放池中的Ctn片段從心肌細(xì)胞中滲出。也有證據(jù)表明，心肌應(yīng)激或短暫缺血增加了心肌細(xì)胞凋亡或加速了心肌細(xì)胞的周轉(zhuǎn)。很少有研究調(diào)查運(yùn)動(dòng)誘導(dǎo)的Ctn對(duì)心血管事件的預(yù)測(cè)價(jià)值，但運(yùn)動(dòng)后Ctn濃度＞URL的老年長(zhǎng)距離步行者發(fā)生更多的心血管事件。這些發(fā)現(xiàn)需要得到證實(shí)，CT＿n在年輕運(yùn)動(dòng)受試者中的預(yù)后意義需要確定。

       原文標(biāo)題 : 【文獻(xiàn)閱讀】運(yùn)動(dòng)誘導(dǎo)的心臟T肌鈣蛋白升高:從基礎(chǔ)機(jī)制到臨床相關(guān)性