{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T19:16:31Z","timestamp":1787685391832,"version":"build-2784847793"},"reference-count":96,"publisher":"MDPI AG","issue":"16","license":[{"start":{"date-parts":[[2024,8,22]],"date-time":"2024-08-22T00:00:00Z","timestamp":1724284800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Environmental factors such as extreme temperatures, humidity, wind, pollution, altitude, and diving can significantly impact athletes\u2019 cardiovascular systems, potentially hindering their performance, particularly in outdoor sports. The urgency of this issue is heightened by the increasing prevalence of climate change and its associated conditions, including fluctuating pollution levels, temperature variations, and the spread of infectious diseases. Despite its critical importance, this topic is often overlooked in sports medicine. This narrative review seeks to address this gap by providing a comprehensive, evidence-based evaluation of how athletes respond to environmental stresses. A thorough assessment of current knowledge is essential to better prepare athletes for competition under environmental stress and to minimize the harmful effects of these factors. Specifically, adaptative strategies and preventative measures are vital to mitigating these environmental influences and ensuring athletes\u2019 safety.<\/jats:p>","DOI":"10.3390\/jcm13164961","type":"journal-article","created":{"date-parts":[[2024,8,23]],"date-time":"2024-08-23T12:38:43Z","timestamp":1724416723000},"page":"4961","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":18,"title":["Effects of Environmental Conditions on Athlete\u2019s Cardiovascular System"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2631-8642","authenticated-orcid":false,"given":"Andrea","family":"Segreti","sequence":"first","affiliation":[{"name":"Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy"},{"name":"Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Universit\u00e0 Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy"},{"name":"Department of Movement, Human and Health Sciences, University of Rome \u201cForo Italico\u201d, Piazza Lauro de Bosis, 15, 00135 Roma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6374-1821","authenticated-orcid":false,"given":"Mihail","family":"Celeski","sequence":"additional","affiliation":[{"name":"Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy"},{"name":"Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Universit\u00e0 Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3021-9463","authenticated-orcid":false,"given":"Emiliano","family":"Guerra","sequence":"additional","affiliation":[{"name":"Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124 Modena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0051-5253","authenticated-orcid":false,"given":"Simone Pasquale","family":"Crispino","sequence":"additional","affiliation":[{"name":"Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy"},{"name":"Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Universit\u00e0 Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-2021-9261","authenticated-orcid":false,"given":"Francesca","family":"Vespasiano","sequence":"additional","affiliation":[{"name":"Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy"},{"name":"Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Universit\u00e0 Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-5621-9316","authenticated-orcid":false,"given":"Lorenzo","family":"Buzzelli","sequence":"additional","affiliation":[{"name":"Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy"},{"name":"Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Universit\u00e0 Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2870-7185","authenticated-orcid":false,"given":"Chiara","family":"Fossati","sequence":"additional","affiliation":[{"name":"Department of Movement, Human and Health Sciences, University of Rome \u201cForo Italico\u201d, Piazza Lauro de Bosis, 15, 00135 Roma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rocco","family":"Papalia","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic and Trauma Surgery, Universit\u00e0 Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy"},{"name":"Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5808-9405","authenticated-orcid":false,"given":"Fabio","family":"Pigozzi","sequence":"additional","affiliation":[{"name":"Department of Movement, Human and Health Sciences, University of Rome \u201cForo Italico\u201d, Piazza Lauro de Bosis, 15, 00135 Roma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesco","family":"Grigioni","sequence":"additional","affiliation":[{"name":"Cardiology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy"},{"name":"Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Universit\u00e0 Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,8,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Bowler, D.E., Buyung-Ali, L.M., Knight, T.M., and Pullin, A.S. (2010). A systematic review of evidence for the added benefits to health of exposure to natural environments. BMC Public Health, 10.","DOI":"10.1186\/1471-2458-10-456"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1146\/annurev-publhealth-032013-182443","article-title":"Nature and health","volume":"35","author":"Hartig","year":"2014","journal-title":"Annu. Rev. Public Health"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Burtscher, M., Gatterer, H., Burtscher, J., and Mairb\u00e4url, H. (2018). Extreme Terrestrial Environments: Life in Thermal Stress and Hypoxia. A Narrative Review. Front. Physiol., 9.","DOI":"10.3389\/fphys.2018.00572"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1016\/j.ccm.2005.05.001","article-title":"Breathing at depth: Physiologic and clinical aspects of diving while breathing compressed gas","volume":"26","author":"Tetzlaff","year":"2005","journal-title":"Clin. Chest Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1111\/j.1600-0838.1995.tb00035.x","article-title":"Intrapersonal and interpersonal factors in athletic performance","volume":"5","year":"1995","journal-title":"Scand. J. Med. Sci. Sports"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"100118","DOI":"10.1016\/j.joclim.2022.100118","article-title":"Endurance athletes and climate change","volume":"6","author":"Nowak","year":"2022","journal-title":"J. Clim. Chang. Health"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e760","DOI":"10.1002\/wcc.760","article-title":"Impacts of climate change on organized sport: A scoping review","volume":"13","author":"Orr","year":"2022","journal-title":"Wiley Interdiscip. Rev. Clim. Chang."},{"key":"ref_8","first-page":"3422","article-title":"Effects of global climate changes on sports and athletes","volume":"18","author":"Geri","year":"2022","journal-title":"J. Rom. Sports Med. Soc."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"2193","DOI":"10.47772\/IJRISS.2024.801160","article-title":"Interrogating the Impact of Climate Change on Multiple Outdoor Sports Activities: A Critical Review","volume":"8","author":"Ngota","year":"2024","journal-title":"Int. J. Res. Innov. Soc. Sci."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"735","DOI":"10.1089\/ars.2017.7488","article-title":"Environmental Stressors and Their Impact on Health and Disease with Focus on Oxidative Stress","volume":"28","author":"Daiber","year":"2018","journal-title":"Antioxid. Redox Signal."},{"key":"ref_11","first-page":"873","article-title":"Athlete\u2019s heart or heart disease in the athlete? Evaluation by cardiopulmonary exercise testing","volume":"63","author":"Segreti","year":"2023","journal-title":"J. Sports Med. Phys. Fit."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Segreti, A., Celeski, M., Monticelli, L.M., Perillo, A., Crispino, S.P., Di Gioia, G., Cammalleri, V., Fossati, C., Mega, S., and Papalia, R. (2023). Mitral and Tricuspid Valve Disease in Athletes. J. Clin. Med., 12.","DOI":"10.3390\/jcm12103562"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e82","DOI":"10.1111\/j.1600-0838.2010.01160.x","article-title":"Participation and performance trends in ultra-triathlons from 1985 to 2009","volume":"21","author":"Knechtle","year":"2011","journal-title":"Scand. J. Med. Sci. Sports"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"770","DOI":"10.1136\/bjsports-2012-091296","article-title":"International Olympic Committee consensus statement on thermoregulatory and altitude challenges for high-level athletes","volume":"46","author":"Bergeron","year":"2012","journal-title":"Br. J. Sports Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"596","DOI":"10.1016\/j.echo.2023.02.004","article-title":"Application of Allometric Methods for Indexation of Left Ventricular End-Diastolic Volume to Normal Echocardiographic Data and Assessing Gender and Racial Differences","volume":"36","author":"Nabeshima","year":"2023","journal-title":"J. Am. Soc. Echocardiogr."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"121923","DOI":"10.1016\/j.lfs.2023.121923","article-title":"Exercise in cold: Friend than foe to cardiovascular health","volume":"328","author":"Feng","year":"2023","journal-title":"Life Sci."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1002\/cphy.c140081","article-title":"Cold Stress Effects on Exposure Tolerance and Exercise Performance","volume":"6","author":"Castellani","year":"2015","journal-title":"Compr. Physiol."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"El Helou, N., Tafflet, M., Berthelot, G., Tolaini, J., Marc, A., Guillaume, M., Hausswirth, C., and Toussaint, J.F. (2012). Impact of environmental parameters on marathon running performance. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0037407"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1323","DOI":"10.1007\/s40279-014-0212-8","article-title":"Adaptation to heat and exercise performance under cooler conditions: A new hot topic","volume":"44","author":"Corbett","year":"2014","journal-title":"Sports Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"695","DOI":"10.1016\/j.csm.2005.03.002","article-title":"Environmental illness in athletes","volume":"24","author":"Seto","year":"2005","journal-title":"Clin. Sports Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1249\/FIT.0000000000000352","article-title":"Maximizing Safety When Exercising in the Cold","volume":"22","author":"Bushman","year":"2018","journal-title":"ACSM\u2019s Health Fit. J."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"S171","DOI":"10.1249\/00005768-198810001-00015","article-title":"The effect of body cooling on oxygen transport during exercise","volume":"20","author":"Pendergast","year":"1988","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1080\/23328940.2015.1008890","article-title":"Responses of the hands and feet to cold exposure","volume":"2","author":"Cheung","year":"2015","journal-title":"Temperature"},{"key":"ref_24","first-page":"48p","article-title":"Shivering intensity in humans during immersion in cold water [proceedings]","volume":"290","author":"Golden","year":"1979","journal-title":"J. Physiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1186\/2046-7648-3-12","article-title":"Moving in extreme environments: Open water swimming in cold and warm water","volume":"3","author":"Tipton","year":"2014","journal-title":"Extrem. Physiol. Med."},{"key":"ref_26","first-page":"21","article-title":"A Review of the Association between Environmental Factors and Athletic Performance","volume":"1","year":"2021","journal-title":"J. Specif. Sport Sci."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Pellicer-Caller, R., Vaquero-Crist\u00f3bal, R., Gonz\u00e1lez-G\u00e1lvez, N., Abenza-Cano, L., Horcajo, J., and de la Vega-Marcos, R. (2023). Influence of Exogenous Factors Related to Nutritional and Hydration Strategies and Environmental Conditions on Fatigue in Endurance Sports: A Systematic Review with Meta-Analysis. Nutrients, 15.","DOI":"10.3390\/nu15122700"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"225","DOI":"10.1080\/0265673021000058357","article-title":"Cardiovascular responses to heat stress and their adverse consequences in healthy and vulnerable human populations","volume":"19","author":"Donaldson","year":"2003","journal-title":"Int. J. Hyperth."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1883","DOI":"10.1002\/cphy.c100082","article-title":"Integrated physiological mechanisms of exercise performance, adaptation, and maladaptation to heat stress","volume":"1","author":"Sawka","year":"2011","journal-title":"Compr. Physiol."},{"key":"ref_30","first-page":"8216","article-title":"Evaluation of the impact of hot environmental conditions on physical activity among soccer players","volume":"26","author":"Liu","year":"2022","journal-title":"Eur. Rev. Med. Pharmacol. Sci."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2286","DOI":"10.1161\/CIRCULATIONAHA.105.540773","article-title":"Effects of heat stress on thermoregulatory responses in congestive heart failure patients","volume":"112","author":"Cui","year":"2005","journal-title":"Circulation"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1016\/S1440-2440(03)80005-1","article-title":"Heat cramps: Fluid and electrolyte challenges during tennis in the heat","volume":"6","author":"Bergeron","year":"2003","journal-title":"J. Sci. Med. Sport."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"8034","DOI":"10.3390\/ijerph120708034","article-title":"Limitations to Thermoregulation and Acclimatization Challenge Human Adaptation to Global Warming","volume":"12","author":"Hanna","year":"2015","journal-title":"Int. J. Environ. Res. Public Health"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1123\/ijspp.5.4.559","article-title":"How hot is too hot?: Some considerations regarding temperature and performance","volume":"5","author":"Dugas","year":"2010","journal-title":"Int. J. Sports Physiol. Perform."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1111\/j.1600-0838.2010.01219.x","article-title":"Effect of hot environmental conditions on physical activity patterns and temperature response of football players","volume":"20","author":"Kurdak","year":"2010","journal-title":"Scand. J. Med. Sci. Sports"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"320","DOI":"10.2165\/00007256-200737040-00012","article-title":"Marathon performance in thermally stressing conditions","volume":"37","author":"Montain","year":"2007","journal-title":"Sports Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"799","DOI":"10.1152\/jappl.2000.89.2.799","article-title":"Exercise in the heat is limited by a critical internal temperature","volume":"89","author":"Walters","year":"2000","journal-title":"J. Appl. Physiol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"306","DOI":"10.2165\/00007256-200737040-00009","article-title":"Physiological regulation of marathon performance","volume":"37","author":"Coyle","year":"2007","journal-title":"Sports Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"463","DOI":"10.1016\/j.jacc.2014.05.025","article-title":"Life-threatening events during endurance sports: Is heat stroke more prevalent than arrhythmic death?","volume":"64","author":"Yankelson","year":"2014","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_40","first-page":"329","article-title":"National Athletic Trainers\u2019 Association position statement: Exertional heat illnesses","volume":"37","author":"Binkley","year":"2002","journal-title":"J. Athl. Train."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1038\/460208a","article-title":"Toxicology for the twenty-first century","volume":"460","author":"Hartung","year":"2009","journal-title":"Nature"},{"key":"ref_42","unstructured":"World Health Organization (2021). Regional Office for Europe: Review of Evidence on Health Aspects of Air Pollution: REVIHAAP Project: Technical Report, World Health Organization, Regional Office for Europe. Available online: https:\/\/apps.who.int\/iris\/handle\/10665\/341712."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1581","DOI":"10.1016\/S0140-6736(14)60617-6","article-title":"Outdoor air pollution and asthma","volume":"383","author":"Guarnieri","year":"2014","journal-title":"Lancet"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1519\/JSC.0b013e31815ef98b","article-title":"Ultrafine and fine particulate matter inhalation decreases exercise performance in healthy subjects","volume":"22","author":"Rundell","year":"2008","journal-title":"J. Strength Cond. Res."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1130","DOI":"10.1289\/ehp.1002921","article-title":"Particulate matter exposures, mortality, and cardiovascular disease in the health professionals follow-up study","volume":"119","author":"Puett","year":"2011","journal-title":"Environ. Health Perspect."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1080\/08958370601051727","article-title":"Inhalation of ultrafine and fine particulate matter disrupts systemic vascular function","volume":"19","author":"Rundell","year":"2007","journal-title":"Inhal. Toxicol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1204","DOI":"10.1161\/CIRCRESAHA.116.309279","article-title":"Exposure to Fine Particulate Air Pollution Is Associated With Endothelial Injury and Systemic Inflammation","volume":"119","author":"Pope","year":"2016","journal-title":"Circ. Res."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"692","DOI":"10.1161\/01.RES.0000243586.99701.cf","article-title":"Environmental cardiology: Studying mechanistic links between pollution and heart disease","volume":"99","author":"Bhatnagar","year":"2006","journal-title":"Circ. Res."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"2331","DOI":"10.1161\/CIR.0b013e3181dbece1","article-title":"Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the American Heart Association","volume":"121","author":"Brook","year":"2010","journal-title":"Circulation"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"e11562","DOI":"10.7717\/peerj.11562","article-title":"Marathon race performance increases the amount of particulate matter deposited in the respiratory system of runners: An incentive for \u201cclean air marathon runs\u201d","volume":"9","author":"Zoladz","year":"2021","journal-title":"PeerJ"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1249\/MSS.0b013e3181b84a85","article-title":"Effect of air pollution on marathon running performance","volume":"42","author":"Marr","year":"2010","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"967","DOI":"10.1080\/02640410400000272","article-title":"Athens 2004: The pollution climate and athletic performance","volume":"22","author":"Donaldson","year":"2004","journal-title":"J. Sports Sci."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1136\/bjsports-2011-090823","article-title":"Effect of air pollution on athlete health and performance","volume":"46","author":"Rundell","year":"2012","journal-title":"Br. J. Sports Med."},{"key":"ref_54","first-page":"274","article-title":"Effects of living at higher altitudes on mortality: A narrative review","volume":"5","author":"Burtscher","year":"2014","journal-title":"Aging Dis."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1089\/ham.2006.7.245","article-title":"Lipid profile, waist circumference, and body mass index in a high altitude population","volume":"7","author":"Mohanna","year":"2006","journal-title":"High Alt. Med. Biol."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1093\/ije\/29.1.65","article-title":"High density lipoprotein cholesterol increases with living altitude","volume":"29","year":"2000","journal-title":"Int. J. Epidemiol."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"798","DOI":"10.1136\/jech-2015-206210","article-title":"Independent at heart: Persistent association of altitude with ischaemic heart disease mortality after consideration of climate, topography and built environment","volume":"70","author":"Faeh","year":"2016","journal-title":"J. Epidemiol. Community Health"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"1298","DOI":"10.1056\/NEJM197106102842305","article-title":"Adaptation to high altitude","volume":"284","author":"Lenfant","year":"1971","journal-title":"N. Engl. J. Med."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"456","DOI":"10.1016\/j.pcad.2010.03.004","article-title":"Physiological adaptation of the cardiovascular system to high altitude","volume":"52","author":"Naeije","year":"2010","journal-title":"Prog. Cardiovasc. Dis."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1249\/JSR.0b013e3181d404ac","article-title":"The athlete and high altitude","volume":"9","author":"Derby","year":"2010","journal-title":"Curr. Sports Med. Rep."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"e20188","DOI":"10.1016\/j.heliyon.2023.e20188","article-title":"Effect of altitude training on the aerobic capacity of athletes: A systematic review and meta-analysis","volume":"9","author":"Chen","year":"2023","journal-title":"Heliyon"},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1177\/1941738116630948","article-title":"Athletes at High Altitude","volume":"8","author":"Khodaee","year":"2016","journal-title":"Sports Health"},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1016\/j.pcad.2010.02.008","article-title":"The risk of cardiovascular events during leisure time activities at altitude","volume":"52","author":"Burtscher","year":"2010","journal-title":"Prog. Cardiovasc. Dis."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1016\/j.hlc.2017.01.010","article-title":"Risk and Protective Factors for Sudden Cardiac Death During Leisure Activities in the Mountains: An Update","volume":"26","author":"Burtscher","year":"2017","journal-title":"Heart Lung Circ."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"1224","DOI":"10.1161\/01.CIR.96.4.1224","article-title":"Effect of high-altitude exposure in the elderly: The Tenth Mountain Division study","volume":"96","author":"Levine","year":"1997","journal-title":"Circulation"},{"key":"ref_66","doi-asserted-by":"crossref","unstructured":"Wolff, S., Picco, J.M., D\u00edaz-Gonz\u00e1lez, L., Valenzuela, P.L., Gonzalez-D\u00e1vila, E., Santos-Lozano, A., Matile, P., Wolff, D., Boraita, A., and Lucia, A. (2021). Exercise-Induced Cardiac Fatigue in Recreational Ultramarathon Runners at Moderate Altitude: Insights From Myocardial Deformation Analysis. Front. Cardiovasc. Med., 8.","DOI":"10.3389\/fcvm.2021.744393"},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1111\/j.1600-0838.2005.00440.x","article-title":"The human diving response, its function, and its control","volume":"15","author":"Foster","year":"2005","journal-title":"Scand. J. Med. Sci. Sports"},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"R1","DOI":"10.1152\/ajpregu.00165.2017","article-title":"Highs and lows of hyperoxia: Physiological, performance, and clinical aspects","volume":"315","author":"Brugniaux","year":"2018","journal-title":"Am. J. Physiol. Regul. Integr. Comp. Physiol."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"1084","DOI":"10.1136\/heartjnl-2021-319601","article-title":"Cardiovascular considerations for scuba divers","volume":"108","author":"Tso","year":"2022","journal-title":"Heart"},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"276","DOI":"10.1152\/japplphysiol.90984.2008","article-title":"The underwater environment: Cardiopulmonary, thermal, and energetic demands","volume":"106","author":"Pendergast","year":"2009","journal-title":"J. Appl. Physiol."},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"719","DOI":"10.1161\/HYPERTENSIONAHA.108.127530","article-title":"Cardiovascular regulation during apnea in elite divers","volume":"53","author":"Heusser","year":"2009","journal-title":"Hypertension"},{"key":"ref_72","doi-asserted-by":"crossref","unstructured":"Dumi\u0107, J., Cvetko, A., Abramovi\u0107, I., \u0160upraha Goreta, S., Perovi\u0107, A., Njire Brati\u010devi\u0107, M., Kifer, D., Sin\u010di\u0107, N., Gornik, O., and \u017darak, M. (2022). Changes in Specific Biomarkers Indicate Cardiac Adaptive and Anti-inflammatory Response of Repeated Recreational SCUBA Diving. Front. Cardiovasc. Med., 9.","DOI":"10.3389\/fcvm.2022.855682"},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"505","DOI":"10.1097\/JSM.0b013e318257c9cc","article-title":"Effects of lightweight outdoor clothing on the prevention of hypothermia during low-intensity exercise in the cold","volume":"22","author":"Burtscher","year":"2012","journal-title":"Clin. J. Sport. Med."},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1123\/ijspp.6.4.443","article-title":"The challenge of performing aerobic exercise in tropical environments: Applied knowledge and perspectives","volume":"6","author":"Hue","year":"2011","journal-title":"Int. J. Sports Physiol. Perform."},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"545","DOI":"10.2165\/11630550-000000000-00000","article-title":"Pre-cooling and sports performance: A meta-analytical review","volume":"42","author":"Wegmann","year":"2012","journal-title":"Sports Med."},{"key":"ref_76","doi-asserted-by":"crossref","first-page":"89","DOI":"10.2165\/11596870-000000000-00000","article-title":"Keeping your cool: Possible mechanisms for enhanced exercise performance in the heat with internal cooling methods","volume":"42","author":"Siegel","year":"2012","journal-title":"Sports Med."},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1016\/j.autneu.2016.02.002","article-title":"Cardiovascular adaptations supporting human exercise-heat acclimation","volume":"196","author":"Travers","year":"2016","journal-title":"Auton. Neurosci."},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"336","DOI":"10.1309\/AJCP30OGLSLWLEIY","article-title":"Exertional dysnatremia in collapsed marathon runners: A critical role for point-of-care testing to guide appropriate therapy","volume":"132","author":"Siegel","year":"2009","journal-title":"Am. J. Clin. Pathol."},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1111\/sms.12408","article-title":"Adaptations and mechanisms of human heat acclimation: Applications for competitive athletes and sports","volume":"25","author":"Racinais","year":"2015","journal-title":"Scand. J. Med. Sci. Sports"},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"470","DOI":"10.1249\/JSR.0000000000000878","article-title":"ACSM Expert Consensus Statement on Exertional Heat Illness: Recognition, Management, and Return to Activity","volume":"20","author":"Roberts","year":"2021","journal-title":"Curr. Sports Med. Rep."},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"302","DOI":"10.2165\/00007256-199112050-00003","article-title":"The induction and decay of heat acclimatisation in trained athletes","volume":"12","author":"Armstrong","year":"1991","journal-title":"Sports Med."},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1007\/s40279-014-0277-4","article-title":"Adaptation to hot environmental conditions: An exploration of the performance basis, procedures and future directions to optimise opportunities for elite athletes","volume":"45","author":"Guy","year":"2015","journal-title":"Sports Med."},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"3488","DOI":"10.1519\/JSC.0b013e3181fb3e15","article-title":"Effect of body cooling on subsequent aerobic and anaerobic exercise performance: A systematic review","volume":"24","author":"Ranalli","year":"2010","journal-title":"J. Strength Cond. Res."},{"key":"ref_84","doi-asserted-by":"crossref","unstructured":"Gerrett, N., Kingma, B.R.M., Sluijter, R., and Daanen, H.A.M. (2019). Ambient Conditions Prior to Tokyo 2020 Olympic and Paralympic Games: Considerations for Acclimation or Acclimatization Strategies. Front. Physiol., 10.","DOI":"10.3389\/fphys.2019.00414"},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1111\/j.1749-6632.2009.05101.x","article-title":"Heat acclimation-mediated cross-tolerance in cardioprotection: Do HSP70 and HIF-1alpha play a role?","volume":"1188","author":"Horowitz","year":"2010","journal-title":"Ann. N. Y. Acad. Sci."},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"H2271","DOI":"10.1152\/ajpheart.2001.280.5.H2271","article-title":"Effects of body temperature during exercise training on myocardial adaptations","volume":"280","author":"Harris","year":"2001","journal-title":"Am. J. Physiol. Heart Circ. Physiol."},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"1873","DOI":"10.1152\/physrev.00038.2020","article-title":"Exercise under heat stress: Thermoregulation, hydration, performance implications, and mitigation strategies","volume":"101","author":"Eijsvogels","year":"2021","journal-title":"Physiol. Rev."},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1016\/j.autneu.2016.02.009","article-title":"Human physiological responses to cold exposure: Acute responses and acclimatization to prolonged exposure","volume":"196","author":"Castellani","year":"2016","journal-title":"Auton. Neurosci."},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"3395","DOI":"10.1172\/JCI68993","article-title":"Cold acclimation recruits human brown fat and increases nonshivering thermogenesis","volume":"123","author":"Hoeks","year":"2013","journal-title":"J. Clin. Investig."},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"3404","DOI":"10.1172\/JCI67803","article-title":"Recruited brown adipose tissue as an antiobesity agent in humans","volume":"123","author":"Yoneshiro","year":"2013","journal-title":"J. Clin. Investig."},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"E438","DOI":"10.1210\/jc.2013-3901","article-title":"Increased brown adipose tissue oxidative capacity in cold-acclimated humans","volume":"99","author":"Blondin","year":"2014","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"59","DOI":"10.2165\/00007256-198502010-00006","article-title":"Adaptation to exercise in the cold","volume":"2","author":"Shephard","year":"1985","journal-title":"Sports Med."},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"2099","DOI":"10.1113\/JP273395","article-title":"Four-week cold acclimation in adult humans shifts uncoupling thermogenesis from skeletal muscles to brown adipose tissue","volume":"595","author":"Blondin","year":"2017","journal-title":"J. Physiol."},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"1509","DOI":"10.1056\/NEJMoa0810780","article-title":"Identification and importance of brown adipose tissue in adult humans","volume":"360","author":"Cypess","year":"2009","journal-title":"N. Engl. J. Med."},{"key":"ref_95","doi-asserted-by":"crossref","unstructured":"Mabhida, S.E., Mashatola, L., Kaur, M., Sharma, J.R., Apalata, T., Muhamed, B., Benjeddou, M., and Johnson, R. (2021). Hypertension in African Populations: Review and Computational Insights. Genes, 12.","DOI":"10.3390\/genes12040532"},{"key":"ref_96","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.envint.2012.02.004","article-title":"Short-term effects of air pollution on respiratory morbidity at Rio de Janeiro\u2014Part II: Health assessment","volume":"43","author":"Sousa","year":"2012","journal-title":"Environ. Int."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/16\/4961\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T15:41:27Z","timestamp":1760110887000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/16\/4961"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,8,22]]},"references-count":96,"journal-issue":{"issue":"16","published-online":{"date-parts":[[2024,8]]}},"alternative-id":["jcm13164961"],"URL":"https:\/\/doi.org\/10.3390\/jcm13164961","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,8,22]]}}}