Study, country, study design and level of evidence, quality score	Population	Methods	Outcome	Additional notes	Interpretation
Nottin et al27 France Pre-post = level 4 D&B score = 11/15	N = 23 (all males) Mean age: 40 ± 9 yrs Characteristics: trained individuals (mean training, 12 ± 3 hours/week for 12 ± 6 yrs)	El: ultra-long triathlon (3.8 km swim, 186 km cycle, 42.2 km run) MD: 858 minutes MP: before and 40 ± 15 minutes after race completion OMs: LV systolic apical and basal rotation, apical and basal rotation rate, twist, time to peak twist, time to peak systolic apical and basal rotation, diastolic apical and basal rotation rate, untwisting rate, time to peak untwisting rate MT: 2D echocardiogram with STA	LV systolic apical and basal rotation, and diastolic untwisting rate decreased Time to peak twist, times to peak systolic apical and basal rotation, and time to peak untwisting rate increased	LV twist increased but not significantly (P = 0.09) Twist at aortic valve closure decreased Loss of rapid LV untwisting during isovolumic relaxation time	Ultra-long triathlon induces impaired systolic and diastolic twisting function
Chan-Dewar et al26 United Kingdom Pre-post = level 4 D&B score = 11/15	N = 14 (all males) Mean age: 32 ± 10 yrs Characteristics: nonelite runners (range of personal best marathon times: 157–268 minutes; range of training mileage in month prior to race: 10–60 miles)	El: marathon (42.2 km) MD: 229 ± 38 minutes MP: before and within 60 minutes after race completion OMs: LV systolic apical and basal rotation, apical and basal rotation rate, twist, diastolic apical and basal rotation rate in subendocardium and subepicardium MT: 2D echocardiogram with STA	Systolic apical rotation rate in the subendocardium increased	Irregular trends in remaining indexes of twisting function	Marathon running induces sporadic changes in twisting function in the subendocardium and subepicardium
Oxborough et al25 United Kingdom Pre-post = level 4 D&B score = 10/15	N = 17 (all males) Mean age: 33 ± 6 yrs Characteristics: recreational runners	El: marathon (42.2 km) MD: 209 ± 19 minutes MP: before, within 60 minutes, and after 6 hours of race completion OMs: LV systolic apical and basal rotation, twist, diastolic apical and basal untwisting rate, untwisting rate MT: 2D echocardiogram with STA	LV diastolic apical and basal rotation rate and untwisting rate decreased	LV twist decreased slightly but not significantly Twist at aortic valve closure decreased Twist remained elevated during early diastole	Marathon running impairs diastolic twisting function and induces slight depressions in systolic function
Hanssen et al30 Germany Pre-post = level 4 D&B score = 11/15	N = 28 (all males) Mean age: 41 ± 5 yrs Characteristics: amateur marathon runners (completed ≥ 1 marathon; mean training mileage 10 weeks prior to race: 43 ± 17 km/week)	El: marathon (42.2 km) MD: 245 ± 55 minutes MP: before, within 1 hour of race completion, and 1 day after race completion OMs: LV systolic apical and basal rotation, apical and basal rotation rate, twist, diastolic apical and basal rotation rate MT: cardiac MRI	LV twist and twisting rate increased	LV systolic apical rotation remained elevated during early diastole	Marathon running enhances systolic twisting function but impairs diastolic twisting function
Nottin et al28 France Pre-post = level 4 D&B Score = 9/15	N = 20 (all males) Mean age: 25 ± 5 yrs Characteristics: healthy	El: continuous cycling (cadence: 70–80 rpm; HR > 150 bpm) MD: 120 minutes MP: before, within 30–45 minutes after protocol completion OMs: LV systolic apical and basal rotation, apical and basal rotation rate, twist, twisting rate, diastolic apical and basal rotation rate, untwisting rate MT: 2D echocardiogram with STA	Time to peak systolic apical rotation rate and time to peak diastolic untwisting rate increased	Reduction in rapid LV untwisting during early diastole	Prolonged cycling impairs diastolic twisting function and slightly reduces systolic twisting function

Abbreviations: 2D, two-dimensional; D&B score, Downs and Black13 score; El, exercise intervention; HR, heart rate; MD, mean exercise duration; MP, measurement period; MRI, magnetic resonance imaging; MT, measurement technique; OM, outcome measure; STA, speckle tracking analysis; yrs, years.