Cardiovascular Response to Recreational Hockey in

Middle-Aged Men
Zack A. Goodman, MSca, Scott G. Thomas, PhDa, Robert C. Wald, MDb, and
Jack M. Goodman, PhDa,b,*

The present study examined the hemodynamic response to recreational pick-up hockey
relative to maximal exercise testing in middle-aged men. A total of 23 men with a mean age
of 53 – 7 years were studied. Graded exercise testing on a cycle ergometer determined
maximal oxygen consumption, blood pressure (BP), and heart rate (HR). Ambulatory BP
and Holter electrocardiographic monitoring was performed during one of their weekly
hockey games (mean duration [ 45 – 7.2 minutes): for “On-Ice” responses (PLAY; data
recorded while standing immediately after a shift; 8.0 – 1.4 shifts per game) and during
seated recovery (BENCH), 15 minutes after the game. On-Ice HRs and BPs were signifi-
cantly higher than values obtained during maximal cycle exercise, respectively (HR 174 –
8.9 vs 163 – 11.0 beats/min) (systolic blood pressure 202 – 20 vs 173 – 31 mm Hg; p <0.05).
Both systolic and diastolic blood pressures decreased significantly throughout the duration
of the game, whereas HR increased from 139 – 20 to 155 – 16 beats/min during the game.
The myocardial oxygen demand (myocardial time tension index) increased significantly
during PLAY concurrent with a decrease in estimated myocardial oxygen supply (diastolic
pressure time index), with the endocardial viability ratio during PLAY demonstrating a
significant decrease during the third quarter of the game (1.25 – 0.24) versus the first
quarter (1.56 – 0.30), which remained depressed 15 minutes post-game (p <0.05). In
conclusion, recreational pick-up hockey in middle-aged men is an extremely vigorous in-
terval exercise with increasing relative intensity as the game progresses. Hockey elicits peak
BPs and HRs that can exceed values observed during maximal exercise testing and is
characterized by progressive increases in myocardial oxygen demand and lowered supply
during PLAY and BENCH time. Given the progressive and high cardiovascular demands,
caution is warranted when estimating the cardiovascular demands of hockey from clinical
stress testing, particularly in those whom coronary reserve may be compromised. Ó 2017
Elsevier Inc. All rights reserved. (Am J Cardiol 2017;119:2093e2097)

Increased concern exists about adverse responses to
intensive exercise, particularly in the “weekend warrior”
who exercises infrequently and as a result may have less
cardioprotection than subjects engaged in regular and sus-
tained vigorous physical activity,1 which alone acutely in-
creases risk of an adverse cardiac event above that expected
at rest.2 Anecdotal reports of sudden cardiac deaths during
or shortly after recreational “pick-up” hockey in middle-
aged men are widespread, but incidence rates are un-
known. Limited data in this cohort indicate that hockey may
elicit heart rates exceeding 90% of predicted maximal heart
rate (HRmax).3 Under these conditions, the myocardial ox-
ygen supply/demand relation, particularly in the presence of
known or occult heart disease, may be challenged
a
Faculty of Kinesiology and Physical Education, University of Toronto,
Toronto, Ontario, Canada; and bDivision of Cardiology, UHN/Mt. Sinai
Hospital, University of Toronto, Toronto, Ontario, Canada. Manuscript
received January 16, 2017; revised manuscript received and accepted
March 31, 2017.
This study was supported by an internal grant provided by the Faculty
of Kinesiology and Physical Education, University of Toronto.
See page 2096 for disclosure information.
*Corresponding author: Tel: (416) 978-6095; fax: (416) 971-2118.
E-mail address: jack.goodman@utoronto.ca (J.M. Goodman).
uniquely.4,5 Measures of heart rate (HR) and blood pressure
(BP) would provide a more complete understanding of the
relative cardiac “cost” of pick-up hockey in this age group.
Therefore, the purpose of this study was to examine the
hemodynamic effects of a full game of recreational hockey
in middle-aged men, including patterns observed during
exertion and rest while on the bench. We hypothesized that
systolic blood pressure (SBP) and HR responses during
hockey progressively increase during the game, approaching
values seen during maximal exercise testing, and that esti-
mated myocardial oxygen demand would increase concur-
rent with diminished supply.
Methods
A total of 23 men aged 40 to 65 years were recruited for
the study from men’s recreational “pick up” hockey games
by postings at local rinks and by word of mouth. All par-
ticipants completed informed consent, with all experimental
procedures approved by the University of Toronto’s
research ethics board. Participants were then screened by
interview to exclude a history or symptoms of cardiovas-
cular disease, hypertension, or use of cardiovascular medi-
cations. Baseline measures of height (cm) and weight (kg),
BP at rest, and maximal exercise testing were performed on
a separate day but within 2 weeks of cardiovascular

0002-9149/17/$ - see front matter Ó 2017 Elsevier Inc. All rights reserved. www.ajconline.org
http://dx.doi.org/10.1016/j.amjcard.2017.03.241
2094 The American Journal of Cardiology (www.ajconline.org)
monitoring during hockey. Seated measures of BP and HR
were averaged from 5 consecutive readings in a quiet room
(BpTRU, Coquitlam, Canada) following recommended
procedures.6
Maximal oxygen consumption (VO2 peak) was deter-
mined by direct gas exchange (Moxus; AEI Technologies,
Pittsburg, California) using an electronically braked cycle
ergometer, as previously described.7 Criteria confirming a
maximal effort included a plateau in VO2 or attaining a
respiratory exchange ratio >1.15 and age-predicted
maximal HR, which was monitored continuously (Polar
RS800, Kempele, Finland) with BPpeak measured on the
right arm by the oscillometric technique using a semi-
automated motion-tolerant monitor (Tango M2; Suntech
Medical, Morrisville, North Carolina) with the arm relaxed.
Cardiovascular monitoring during hockey occurred in
one of 2 indoor arenas with similar environmental condi-
tions, between November and February (6 to 10 P.M.).
Ambulatory monitoring was established 20 to 30 minutes
before the game as participants dressed and continued
throughout the on-ice warm up (10 minutes), the game
(45 to 55 minutes), and recovery period in the dressing room
(15 to 20 minutes). A 3-lead electrocardiogram (ECG) was
obtained by a Holter recorder (Holter DR200/HE; NorthEast
Monitoring, Maynard, Massachusetts), with data analyzed
for frequency of any ectopic beats and segmental and in-
terval disturbances using proprietary software. BP was
recorded using a motion-tolerant ambulatory, automated BP
monitor (Accutraker II; SunTech Medical), secured on the
right arm under the padding and player’s jersey. This device
has been validated against intra-arterial measures.8
During the game, “on-ice” (PLAY) measures of BP and a
time marker were initiated immediately on the participant
returning to the bench door (within 3 seconds), whereas
subjects remained at standing position with feet shuffling
back and forth. The total time required to complete BP
measurements was approximately 45 seconds. Subjects then
assumed a seated position (BENCH) with another measure
completed after 60 seconds. Each player’s position, shift
number, and duration were recorded. Because pick-up
hockey is unregulated with varying attendance each week,
a wide variation in both the duration of shifts and bench
time was expected. To account for this and to facilitate
statistical analysis of trends, data from each game were
binned into 4 time segments, each representing 25% of the
game duration for each participant.
Myocardial oxygen demand was estimated using the
modified time tension index (MTTI)9 from the BP and HR
data recorded using the equation: MTTI ¼ SBP  OHR,
which has been correlated (r ¼ 0.80) to direct measures of
myocardial oxygen consumption (MVO2), particularly when
contractile state is elevated during exercise.4 The diastolic
pressure time index (DPTI) was also calculated as: (DBP-LV
diastolic BP)  duration of diastole, with LB diastolic BP
assumed to be 5 mm Hg.10 Diastolic duration was estimated
from the Holter ECG, magnified 10 on paper, defined as
the mean of 3 consecutive time intervals between the end of
the QRS complex to the end of the P-wave. The intra-
observer reliability was determined in a blinded fashion on
subset of 7 randomly selected participants, with an intraclass
correlation coefficient of 0.99. The endocardial viability ratio
(EVR) was calculated as an index of myocardial oxygen
supply and demand, using a modified equation, where
EVR ¼ DPTI/MTTI.4 For any given BP measurement, the
HR corresponding to 15 seconds after the onset of inflation
of the cuff was used for analysis of diastolic duration, to
account for the cuff-inflation time. All BP measures were
temporally aligned to the ECG data for determination of HR
from marker events, and a rolling average of data was then
determined for each quartile of the game.
All endpoints were compared at intervals throughout the
game representing pre-game, on-ice (PLAY), bench sitting
(BENCH), and post-game recovery using a repeated-
measure ANOVA with least-squares post hoc analysis.
Individual t tests with Bonferroni correction were used to
compare maximal cardiovascular endpoints from maximal
exercise testing and the highest recorded values during the
hockey game. All data were considered significant at
p <0.05.
Results
All subjects completed the study without adverse re-
sponses, with key subject characteristics results presented in
Table 1. None were taking cardiovascular medications or had
known chronic diseases. Maximal exercise testing to exhaus-
tion was completed in all subjects, with all achieving an res-
piratory exchange ratio >1.15; the mean HRmax achieved was
95% of the predicted maximal value,11 with the mean VO2peak
within the 40th to 50th percentile for their age group.12
Peak HR, SBP, and DBP obtained during PLAY were
significantly higher than those obtained during graded ex-
ercise testing (Table 1; p <0.05), with values obtained at all
time points similar regardless of player position. The mean
duration of the hockey games (excluding light warm-up)
was 45.5  7.2 minutes. A wide variation existed for the
number (mean ¼ 2.1  0.5) and duration (mean ¼ 150  30
seconds) of shifts per quartile; this was also the case for
BENCH durations (mean ¼ 140  12 seconds), and in both
cases, no differences existed between quartile or based on
player position (defense vs forward). Mean HRs during
PLAY for the entire game was 149  16 with a mean bench
HR of 126  19, yielding an overall (PLAY and BENCH)
mean HR of 137  22 beats/min. Data from each quartile of
PLAY and BENCH recordings are presented in Figure 1. As
expected, the mean HR during bench time was lower than
PLAY values throughout the game (Figure 1, p <0.05) with
a progressive upward drift of HR (p <0.05) observed for
both PLAY and BENCH values. The SBP (Figure 1) during
PLAY reached the highest levels after the second shift early
in the game and thereafter progressively decreased (p
<0.01); a similar pattern occurred for SBP during BENCH
time points (p <0.05) which were similar to PLAY values at
any time point. The DBP (Figure 1) was elevated above pre-
game levels during the first quartile of the game, decreasing
significantly (p <0.05) for both PLAY and BENCH values
as the game progressed, remaining above pre-game values.
The MTTI (Figure 1) during PLAY increased signifi-
cantly above resting levels, remaining elevated throughout
the game and higher than BENCH recordings, which failed
to return to pre-game (rest) values until the post-game. The
DPTI (Figure 1) decreased from the onset of the game
 Miscellaneous/Cardiovascular Responses to Hockey in Middle-Aged Men 2095

Table 1
Key subject characteristics
Subject Age (yr) VO2peak Body Body Mass Index Peak Heart Rate Peak Systolic Blood Pressure Peak Diastolic Blood Pressure
(ml/kg/min) Weight (kg) Kg/m2 Achieved (bpm) Achieved (mmHg) Achieved (mmHg)

Maximal On-Ice Maximal On-Ice Maximal On-Ice

Exercise Test Exercise Test Exercise Test

1 52 28.7 88.2 25.8 156 171 180 202 95 107

2 53 25.0 88.6 30.3 157 183 155 164 88 100
3 54 37.1 85.2 24.1 159 163 132 190 76 92
4 53 30.7 98 28.9 173 174 231 184 100 104
5 55 34.2 96.6 30.1 162 168 227 209 86 102
6 63 29.9 82.3 29.7 160 158 193 172 74 101
7 60 37.2 84.4 23.9 140 171 204 227 79 107
8 53 35.1 84.5 25.8 166 177 181 220 94 105
9 42 34.0 79.5 28.5 170 183 161 206 78 108
10 59 24.8 73.6 28.7 173 180 186 225 110 105
11 53 40.0 80 24.9 168 183 149 224 86 107
12 62 29.1 89.5 28.9 158 166 165 221 86 106
13 53 23.5 100.7 35.2 143 174 234 225 104 104
14 44 39.2 66 22.1 177 189 144 225 82 105
15 43 37.8 85.9 25.1 176 185 197 228 92 112
16 41 30.8 109.5 33.4 174 183 171 186 110 87
17 52 32.4 77.3 25.5 156 177 177 172 88 102
18 61 26.5 78.2 25.5 142 174 143 217 91 108
19 60 30.0 89.3 26.8 167 183 155 184 88 86
20 52 40.3 72.5 26.3 168 168 128 212 88 99
21 53 37.5 76.4 23.6 159 156 164 189 93 96
22 43 39.6 75.2 21.7 166 180 143 219 70 102
23 58 31.1 69 22.9 177 180 172 170 90 98
MeanSD 536.6 32.85.2 83.910.5 26.93.5 16211 1759 17330 20322 8910 1027

during PLAY and BENCH recordings (p <0.05), remaining
depressed 15 minutes post-game relative to pre-game read-
ings. The EVR (Figure 1) during PLAY was lower than
REST, remained stable throughout the game except for a
significant reduction in the third quartile of the game, and
post-game values also remaining below pre-game values
(p <0.05). Holter ECG revealed 1 subject had bundle
branch block without arrhythmias during the game, with
another who had 124 supraventricular ectopic beats during
the recording period. No clinically relevant ST-segment
changes were observed for any participant.
Discussion
To our knowledge, this is the first study that has exam-
ined both the HR and BP responses throughout a game of
recreational hockey in middle-aged men, capturing imme-
diately post-exercise and recovery data. There are 2 key
findings of our study. First, the cardiovascular demands of
recreational hockey in middle-aged men can greatly exceed
those observed during graded maximal exercise testing.
Second, the extent by which HR drifts higher during both
PLAY and BENCH time far exceeds the progressive de-
creases in SBP and DBP; this suggests that estimates of
myocardial oxygen demand increase while supply di-
minishes as the game progresses.
Our observation that effort during pick-up hockey can
often achieve or exceed 85% to 100% of predicted maximal
HR is consistent with a previous report.13 This reflects an
exercise intensity that far exceeds recommended targets for
vigorous aerobic exercise,14,15 with similar findings
observed for peak SBP. The progressive increase in HR
throughout the game may have been because of a combi-
nation of dehydration, increased core temperature, and
elevated catecholamines during exercise.16 Although we
could not monitor fluid status, it is known that hockey
equipment greatly elevates core temperature and skin blood
flow17; this would promote a reduced central venous pres-
sure and stroke volume and upward drift in HR.18
Clinical stress testing is commonly terminated at 85% of
predicted HRmax,19 an endpoint with considerable variation
(e.g., SD of 12 beats/min),20 often underestimating true
values. The present data suggest that both peak HR and SBP
during the game exceeds those achieved during maximal
exercise. Therefore, when trying to establish the intensity of
pick-up hockey, clinical exercise tests may under-represent
ceiling both HR and BP expected during pick-up hockey.
Although hockey has similarities to high-intensity interval
training,21 the recovery periods in hockey differ, in that they
are completely stationary, and our data indicate that each
“shift” of this high-intensity exercise often exceeds 2 mi-
nutes, which is a more demanding high-intensity interval
training regimen that may be suited to low-risk participants
with higher fitness levels.22
The trends of HR and BP as the game progresses have
direct implications for myocardial oxygen supply and de-
mand. Approximately 50% to 70% of the increased
myocardial oxygen demand during exercise is attributed to
increased HR,23 with LV work contributing a smaller
contribution, for which SBP is a major component. As the
2096 The American Journal of Cardiology (www.ajconline.org)

Figure 1. Cardiovascular responses to pick-up hockey in middle-aged men. (A) Heart rate, (B) SBP, (C) diastolic blood pressure, (D) myocardial time tension
index, (E) diastolic pressure time index, and (F) myocardial viability ratio. Pre-game and post-game data obtained in the dressing room 15 minutes before and
after the game, respectively. On-ice (PLAY) and recovery (BENCH) data shown reflect running averages from each quartile of play. “*,” Significantly different
than pre-game (p <0.05); “**,” significant difference between PLAY and BENCH throughout the game (p <0.05); “#,” significantly different than first and
second quartile; “†,” significantly different than corresponding Play (p <0.05).

game continued, the MTTI during PLAY remained elevated
throughout the game and while lower during recovery
(BENCH), MTTI failed to fully recover to resting values
until the post-game recovery time period. These data indi-
cate that the elevated myocardial oxygen demand during
PLAY is solely because of a progressive increase in HR,
whereas a reduction in the DPTI was because of reductions
in both diastolic filling time and in DBP, with only partial
relief in myocardial oxygen demand or restoration of its
supply observed between shifts, with persistence of this
imbalance seen in post-game time period as the EVR
remained lower than pre-game values.
Our data indicate that recreational hockey in this age
group becomes increasingly demanding on the cardiovas-
cular system as the game progresses, accompanied by a
sustained elevation in myocardial oxygen demand and lower
supply. Based on these findings, more frequent and longer
periods of rest between shifts may facilitate a more favor-
able myocardial supply/demand balance in subjects who
may have flow-limiting coronary reserve, particularly when
low fitness levels limit HR recovery during recovery.
Moreover, caution is warranted when using results from
clinical exercise testing conferring the upper limits of
exertion because they may underestimate the cardiovascular
demands imposed by pick-up hockey in middle-aged adults.
Our study is not without limitations. It is possible that
treadmill exercise testing may have yielded higher values
for both VO2 and BP compared with cycle ergometry.
However, subjects exercised to exhaustion, achieving at
least 95% of their age-predicted HR and secondary end-
points conferring maximal effort, well-beyond that which
is typically achieved during standard clinical stress
testing. Practical limitations precluded recording of BP
measures during skating, but standing BP recordings were
initiated within 3 seconds of participants returning to the
bench maintaining leg movement to mitigate orthostatic-
related reductions. Notwithstanding, it is possible that
BP during ice skating achieved higher values than re-
ported. It was not feasible to monitor fluid intake;
therefore, hydration state was not assessed and may have
influenced individual cardiovascular responses. Finally,
the use of ECG-derived estimates of diastolic time to
calculate an estimate of myocardial oxygen supply may
reduce precision, particularly without confirmation of
functional markers.
Acknowledgments: The authors would like to thank to the
participants who offered their time generously and kindly
allowed to interfere with their weekly hockey game.
Disclosures
The authors have no conflicts of interest to disclose.
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