Benjamin D Levine

University of Texas at Dallas, Richardson, Texas, United States

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Publications (456)2658.77 Total impact

  • Heart, Lung and Circulation 12/2015; 24:S80-S81. DOI:10.1016/j.hlc.2015.04.077 · 1.17 Impact Factor
  • Mildred A. Opondo · Satyam Sarma · Benjamin D. Levine
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    ABSTRACT: Athletes represent the extremes of human performance. Many of their remarkable abilities stem from a cardiovascular system that has adapted to meet the metabolic needs of exercising muscle. A large and compliant heart is a hallmark feature of athletes who engage in highly aerobic events. Despite high fitness levels, athletes may present with symptoms that limit performance. Understanding and dissecting these limitations requires a strong background in sports science and the factors that determine sports capabilities. This article reviews the basic principles of exercise physiology, cardiovascular adaptations unique to the "athlete's heart," and the utility of exercise testing in athletes. Copyright © 2015 Elsevier Inc. All rights reserved.
    Clinics in sports medicine 07/2015; 34(3). DOI:10.1016/j.csm.2015.03.004 · 2.58 Impact Factor
  • Satyam Sarma · Benjamin D Levine
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    ABSTRACT: Patients with heart failure with preserved ejection fraction (HFpEF) have similar degrees of exercise intolerance and dyspnea as patients with heart failure with reduced EF (HFrEF). The underlying pathophysiology leading to impaired exertional ability in the HFpEF syndrome is not completely understood and a growing body of evidence suggests "peripheral", i.e. non-cardiac, factors may play an important role. Changes in skeletal muscle function (decreased muscle mass, capillary density, mitochondrial volume, and phosphorylative capacity) are common findings in HFrEF. While cardiac failure and decreased cardiac reserve account for a large proportion of the decline in oxygen consumption in HFrEF, impaired oxygen diffusion and decreased skeletal muscle oxidative capacity can also hinder aerobic performance, functional capacity and VO2 kinetics. The impact of skeletal muscle dysfunction and abnormal oxidative capacity may be even more pronounced in HFpEF, a disease predominantly affecting the elderly and women, two demographic groups with a high prevalence of sarcopenia. In this review, we 1) describe the basic concepts of skeletal muscle oxygen kinetics and 2) evaluate evidence suggesting limitations in aerobic performance and functional capacity in HFpEF subjects may, in part be due to alterations in skeletal muscle oxygen delivery and utilization. Improving oxygen kinetics with specific training regimens may improve exercise efficiency and reduce the tremendous burden imposed by skeletal muscle upon the cardiovascular system. Copyright © 2014, Journal of Applied Physiology.
    Journal of Applied Physiology 06/2015; DOI:10.1152/japplphysiol.01127.2014 · 3.43 Impact Factor
  • Benjamin D Levine
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    ABSTRACT: Levine, Benjamin D. Going high with heart disease: The effect of high altitude exposure in older individuals and patients with coronary artery disease. High Alt Med Biol 16:89-96, 2015.-Ischemic heart disease is the largest cause of death in older men and women in the western world (Lozano et al., 2012 ; Roth et al., 2015 ). Atherosclerosis progresses with age, and thus age is the dominant risk factor for coronary heart disease in any algorithm used to assess risk for cardiovascular events. Subclinical atherosclerosis also increases with age, providing the substrate for precipitation of acute coronary syndromes. Thus the risk of high altitude exposure in older individuals is linked closely with both subclinical and manifest coronary heart disease (CHD). There are several considerations associated with taking patients with CHD to high altitude: a) The reduced oxygen availability may cause or exacerbate symptoms; b) The hypoxia and other associated environmental conditions (exercise, dehydration, change in diet, thermal stress, emotional stress from personal danger or conflict) may precipitate acute coronary events; c) If an event occurs and the patient is far from advanced medical care, then the outcome of an acute coronary event may be poor; and d) Sudden death may occur. Physicians caring for older patients who want to sojourn to high altitude should keep in mind the following four key points: 1). Altitude may exacerbate ischemic heart disease because of both reduced O2 delivery and paradoxical vasoconstriction; 2). Adverse events, including acute coronary syndromes and sudden cardiac death, are most common in older unfit men, within the first few days of altitude exposure; 3). Ensuring optimal fitness, allowing for sufficient acclimatization (at least 5 days), and optimizing medical therapy (especially statins and aspirin) are prudent recommendations that may reduce the risk of adverse events; 4). A graded exercise test at sea level is probably sufficient for most clinical decision making and will allow for assessment of exercise capacity, and provocable ischemia. Given these considerations, most older individuals with CHD should be able to tolerate exposure to high altitude safely, and with minimal increased risk.
    High altitude medicine & biology 06/2015; 16(2):89-96. DOI:10.1089/ham.2015.0043 · 1.82 Impact Factor
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    ABSTRACT: Cross-sectional studies in athletes suggest that endurance training augments cardiovascular structure and function with apparently different phenotypes in athletic males and females. It is unclear whether the longitudinal response to endurance training leads to similar cardiovascular adaptations between sexes. We sought to determine whether males and females demonstrate similar cardiovascular adaptations to 1-year of endurance training, matched for training volume and intensity. Twelve previously sedentary males (26±7, n=7) and females (31±6, n=5) completed 1-year of progressive endurance training. All participants underwent a battery of tests every 3 months to determine VO2 max and LV function and morphology (cardiac MRI). Pulmonary artery catheterization was performed before and after 1-year of training, and pressure/volume and Starling curves were constructed during decreases (lower body negative pressure) and increases (saline infusion) in cardiac volume. Males progressively increased VO2max, LV mass and mean wall thickness, before reaching a plateau from month 9 to 12 of training. In contrast, despite exactly the same training, the response in females was markedly blunted, with VO2max, LV mass and mean wall thickness plateauing after only 3 months of training. The response of LV end-diastolic volume was not influenced by sex (males +20% and females+18%). After training Starling curves were shifted upward and left; but the effect was greatest in males (interaction P=0.06). We demonstrate for the first time clear sex differences in response to 1-year of matched endurance training, such that the development of ventricular hypertrophy and increase in VO2max in females is markedly blunted compared to males. Copyright © 2015, Journal of Applied Physiology.
    Journal of Applied Physiology 04/2015; 119(1):jap.00092.2015. DOI:10.1152/japplphysiol.00092.2015 · 3.43 Impact Factor
  • The Journal of Heart and Lung Transplantation 04/2015; 34(4):S191. DOI:10.1016/j.healun.2015.01.522 · 5.61 Impact Factor
  • The Journal of Heart and Lung Transplantation 04/2015; 34(4):S62-S63. DOI:10.1016/j.healun.2015.01.160 · 5.61 Impact Factor
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    ABSTRACT: To assess the hemodynamic effects of exercise training in transposition of the great arteries (TGA) patients with systemic right ventricles (SRV). TGA patients have limited exercise tolerance and early mortality due to systemic (right) ventricular failure. Whether exercise training enhances or injures the SRV is unclear. 14 asymptomatic patients (34 ± 10y) with TGA and SRV were enrolled in a 12 week exercise training program (moderate and high intensity workouts). Controls were matched on age, gender, BMI and physical activity. Exercise testing pre- and post- training included: a) submaximal and peak; b) prolonged (60 min) submaximal endurance and c) high intensity intervals. Oxygen uptake (VO2; Douglas bag technique), cardiac output (Qc, foreign-gas rebreathing), ventricular function (echocardiography and cardiac MRI) and serum biomarkers were assessed. TGA patients had lower peak VO2 , Qc, and stroke volume (SV), a blunted Qc/VO2 slope, and diminished SV response to exercise (SV increase from rest: TGA = 15.2%, controls = 68.9%, p<0.001) compared with controls. After training, TGA patients increased peak VO2 by 6%±8.5%, similar to controls (interaction p = 0.24). The magnitude of SV reserve on initial testing correlated with Qc training response (r = 0.58, p = 0.047), though overall, no change in peak Qc was observed. Hs-troponin-T and NT pro-BNP were low and did not change with acute exercise or after training. TGA patients with SRVs in this study safely participated in exercise training and improved peak VO2 . Neither prolonged submaximal exercise, high intensity intervals, or short-term exercise training seem to injure the systemic right ventricle. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    The Journal of Physiology 03/2015; 593(11). DOI:10.1113/JP270280 · 4.54 Impact Factor
  • Journal of the American College of Cardiology 03/2015; 65(10):A1035. DOI:10.1016/S0735-1097(15)61035-X · 15.34 Impact Factor
  • Journal of the American College of Cardiology 03/2015; 65(10):A1508. DOI:10.1016/S0735-1097(15)61508-X · 15.34 Impact Factor
  • Abigail S L Stickford · Tiffany B VanGundy · Benjamin D Levine · Qi Fu
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    ABSTRACT: Patients with the postural orthostatic tachycardia syndrome (POTS) are primarily premenopausal women, which may be attributed to female sex hormones. We tested the hypothesis that hormonal fluctuations of the menstrual cycle alter sympathetic neural activity and orthostatic tolerance in POTS women. Ten POTS women were studied during the early follicular (EF) and mid-luteal (ML) phases of the menstrual cycle. Haemodynamics and muscle sympathetic nerve activity (MSNA) were measured while supine, and during 60° upright tilt for 45 min or until presyncope, cold pressor test (CPT), and Valsalva manoeuvres. Blood pressure and total peripheral resistance were higher during rest and tilting in the ML than EF phase; however heart rate, stroke volume, and cardiac output were similar between phases. There were no differences in MSNA burst frequency (8 ± 8 [SD] EF phase vs. 10 ± 10 bursts/min ML phase at rest; 34 ± 15 EF phase vs. 36 ± 16 bursts/min ML phase at 5 min tilt), burst incidence, or total activity, or in the cardiovagal and sympathetic baroreflex sensitivities between phases in any condition. The incidence of presyncope was also the same between phases. There were no differences in haemodynamic or sympathetic responses to CPT or Valsalva. These results suggest that the menstrual cycle does not affect sympathetic neural activity, but modulates blood pressure and vasoconstriction in POTS women during tilting. Thus, factors other than sympathetic neural activity are likely responsible for symptoms of orthostatic intolerance across the menstrual cycle in women with POTS. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    The Journal of Physiology 02/2015; 593(9). DOI:10.1113/JP270088 · 4.54 Impact Factor
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    Circulation Heart Failure 01/2015; 8(1):209-20. DOI:10.1161/CIRCHEARTFAILURE.113.001420 · 5.95 Impact Factor
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    ABSTRACT: Introduction. This controlled nonrandomized parallel groups trial investigated the effects on performance, VO2 and hemoglobin mass (tHbmass) of 4 preparatory in-season training interventions: living and training at moderate altitude for 3 and 4 weeks (Hi-Hi3, Hi-Hi), living high and training high and low (Hi-HiLo, 4 weeks), and living and training at sea level (SL) (Lo-Lo, 4 weeks). Methods. From 61 elite swimmers, 54 met all inclusion criteria and completed time trials over 50 and 400 m crawl (TT50, TT400), and 100 (sprinters) or 200 m (non-sprinters) at best stroke (TT100/TT200). and heart rate were measured with an incremental 4x200-m test. Training load was estimated using TRIMPc and session RPE. Initial measures (PRE) were repeated immediately (POST) and once weekly on return to SL (PostW1 to PostW4). tHbmass was measured in duplicate at PRE and once weekly during the camp with CO rebreathing. Effects were analyzed using mixed linear modeling. Results. TT100 or TT200 was worse or unchanged immediately POST, but improved by ~3.5% regardless of living or training at SL or altitude following at least 1 week of sea level recovery. Hi-HiLo achieved a greater improvement two (5.3%) and four weeks (6.3%) after the camp. Hi-HiLo also improved more in TT400 and TT50 two (4.2% and 5.2%, respectively) and four weeks (4.7% and 5.5%) from return. This performance improvement was not linked linearly to changes in or tHbmass. Conclusion. A well- implemented 3- or 4-week training camp may impair performance immediately, but clearly improves performance even in elite swimmers after a period of SL recovery. Hi-HiLo for 4 weeks improves performance in swimming above and beyond altitude and SL controls, through complex mechanisms involving altitude living and SL training effects.
    Medicine and science in sports and exercise 01/2015; DOI:10.1249/MSS.0000000000000626 · 4.46 Impact Factor
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    Rong Zhang · Wanpen Vongpatanasin · Benjamin D Levine
    JAMA Internal Medicine 01/2015; 175(1):144. DOI:10.1001/jamainternmed.2014.6971 · 13.25 Impact Factor
  • Satyam Sarma · Benjamin D Levine
    Circulation Cardiovascular Imaging 12/2014; 8(1). DOI:10.1161/CIRCIMAGING.114.002836 · 6.75 Impact Factor
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    ABSTRACT: To assess the effect of cardiorespiratory fitness on the association between the initiation of statin therapy and incident diabetes. In a prospective observational study, we studied 6519 generally healthy men and 2334 women with two preventive health examinations from December 15, 1998 through December 18, 2013 which included measurement of fitness levels, statin therapy, risk factors for diabetes, and incident diabetes. 93 cases of incident diabetes occurred during an average follow-up of 3.0 years. After multivariable adjustment, an increased odds of incident diabetes with statin use was observed in those patients with impaired fasting glucose at baseline (odds ratio [OR]: 2.15, [95% CI:1.26 to 3.67]), but not among individuals with normal glucose levels (OR:1.85, [95% CI: 0.76 to 4.52]). Cardiorespiratory fitness attenuated but did not eliminate the increased risk of incident diabetes with statin use. In a population of relatively healthy patients, statin use was not associated with incident diabetes in patients with normal fasting glucose at baseline. However, it was associated with incident diabetes in those patients with impaired fasting glucose at baseline, though this risk was substantially reduced by increasing fitness. In addition, increasing cardiorespiratory fitness was inversely associated with incident diabetes whether or not a patient was treated with a statin. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
    Atherosclerosis 12/2014; 239(1):43-49. DOI:10.1016/j.atherosclerosis.2014.12.051 · 3.97 Impact Factor
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    ABSTRACT: We thank Lipman [1] for his attention to detail and swift response to our recent publication [2], and believe his letter provides an educational opportunity regarding the management of exertional heat stroke (EHS) and thermal emergencies in general.Although the controversial [3, 4] Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Heat-Related Illness [5] cites a review article [6] which references a book chapter [7] suggesting a strict definition of heat stroke as “…greater than 40 Celsius”, recent literature suggests that use of an absolute temperature threshold for the treatment of EHS is not supported by current knowledge. Lipman’s contention that it is at this exact temperature where cell injury, apoptosis, and systemic symptoms occur is not accurate. There is simply no evidence of a binary threshold of temperature at which the EHS pathways mentioned are initiated. In the spirit of education, we wish to point the reader to the three following princ ...
    Sports Medicine 12/2014; 45(4). DOI:10.1007/s40279-014-0295-2 · 5.32 Impact Factor
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    ABSTRACT: Asians have a lower prevalence of hypertensive disorders of pregnancy than Caucasians. Since sympathetic overactivity and dysregulation of the renal-adrenal system (e.g., low aldosterone levels) have been found in preeclamptic women, we hypothesized that Asians have lower muscle sympathetic nerve activity (MSNA) and greater aldosterone concentrations during normal pregnancy than Caucasians. Blood pressure (BP), heart rate (HR), and MSNA were measured during supine and upright tilt (30° and 60° for 5 min each) in 9 Asians [32±1 (SE) yrs] and 12 Caucasians (29±1 yrs) prospectively during pre, early (≤8 wks of gestation) and late (32–36 wks) pregnancy, and post-partum (6–10 wks after delivery). Supine MSNA increased with pregnancy in both groups (P<0.001); it was significantly lower in Asians than Caucasians (14±3 vs. 23±3 bursts/min and 16±5 vs. 30±3 bursts/min in early and late pregnancy, respectively; P = 0.023). BP decreased during early pregnancy (P<0.001), but was restored during late pregnancy. HR increased during pregnancy (P<0.001) with no racial difference (P = 0.758). MSNA increased during tilting and it was markedly lower in Asians than Caucasians in late pregnancy (31±6 vs. 49±3 bursts/min at 60° tilt; P = 0.003). Upright BP was lower in Asians even in pre-pregnancy (P = 0.006), and this racial difference persisted during pregnancy. Direct renin and aldosterone increased during pregnancy (both P<0.001); these hormones were greater in Asians (P = 0.086 and P = 0.014). Thus, Asians have less sympathetic activation but more upregulated renal-adrenal responses than Caucasians during pregnancy. These results may explain, at least in part, why Asian women are at low risk of hypertensive disorders in pregnancy.This article is protected by copyright. All rights reserved
    The Journal of Physiology 12/2014; 593(5). DOI:10.1113/jphysiol.2014.282277 · 4.54 Impact Factor
  • Qi Fu · Benjamin D Levine
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    ABSTRACT: Patients with the Postural Orthostatic Tachycardia Syndrome (POTS) have orthostatic intolerance, as well as exercise intolerance. Peak oxygen uptake (VO2peak) is generally lower in these patients compared with healthy sedentary individuals, suggesting a lower physical fitness level. During acute exercise, POTS patients have an excessive increase in heart rate and reduced stroke volume for each level of absolute workload; however, when expressed at relative workload (%VO2peak), there is no difference in the heart rate response between patients and healthy individuals. The relationship between cardiac output and VO2 is similar between POTS patients and healthy individuals. Short-term (i.e., 3months) exercise training increases cardiac size and mass, blood volume, and VO2peak in POTS patients. Exercise performance is improved after training. Specifically, stroke volume is greater and heart rate is lower at any given VO2 during exercise after training versus before training. Peak heart rate is the same but peak stroke volume and cardiac output are greater after training. Heart rate recovery from peak exercise is significantly faster after training, indicating an improvement in autonomic circulatory control. These results suggest that patients with POTS have no intrinsic abnormality of heart rate regulation during exercise. The tachycardia in POTS is due to a reduced stroke volume. Cardiac remodeling and blood volume expansion associated with exercise training increase physical fitness and improve exercise performance in these patients. Copyright © 2014 Elsevier B.V. All rights reserved.
    Autonomic neuroscience: basic & clinical 11/2014; 188. DOI:10.1016/j.autneu.2014.11.008 · 1.37 Impact Factor

Publication Stats

10k Citations
2,658.77 Total Impact Points


  • 1991–2015
    • University of Texas at Dallas
      Richardson, Texas, United States
    • Duke University
      Durham, North Carolina, United States
  • 1989–2015
    • University of Texas Southwestern Medical Center
      • • Department of Internal Medicine
      • • Division of Cardiology
      • • Institute for Exercise and Environmental Medicine
      Dallas, Texas, United States
  • 2013
    • Brigham and Women's Hospital
      • Division of Sleep Medicine
      Boston, MA, United States
    • Indiana University Bloomington
      • Department of Kinesiology
      Bloomington, Indiana, United States
  • 2010–2012
    • Texas Health Resources
      Southlake, Texas, United States
  • 2006–2012
    • Children's Medical Center Dallas
      Dallas, Texas, United States
    • Qinghai University
      Hsi-ning-shih, Qinghai Sheng, China
    • University of Southern California
      • Department of Biomedical Engineering
      Los Angeles, CA, United States
  • 2011
    • John Peter Smith Hospital
      Fort Worth, Texas, United States
  • 1997–2010
    • New York Presbyterian Hospital
      New York, New York, United States
  • 2007
    • Radboud University Nijmegen
      Nymegen, Gelderland, Netherlands
  • 2004–2007
    • VU University Amsterdam
      Amsterdamo, North Holland, Netherlands
    • Stanford University
      • Department of Medicine
      Palo Alto, California, United States
    • Nihon University
      Edo, Tōkyō, Japan
  • 2005
    • Helen Hayes Hospital
      West Haverstraw, New York, United States
  • 2002
    • Pennsylvania State University
      • Department of Kinesiology
      University Park, MD, United States
    • University of Texas at Arlington
      Arlington, Texas, United States
    • Bethesda Hospital
      Jogjakarta, Daerah Istimewa Yogyakarta, Indonesia
    • Michigan Technological University
      • Department of Biomedical Engineering
      Houghton, MI, United States
  • 2001
    • University of Oslo
      Kristiania (historical), Oslo County, Norway
  • 1991–2001
    • Cleveland Clinic
      • Department of Cardiology
      Cleveland, Ohio, United States
  • 1999
    • Uniformed Services University of the Health Sciences
      • Department of Family Medicine
      Maryland, United States
  • 1992–1994
    • IT University of Copenhagen
      København, Capital Region, Denmark
    • University of Alaska Anchorage
      Anchorage, Alaska, United States