The preceding Images in Cardiovascular Medicine article by Parikh and colleagues¹—limited in narrative and references by Texas Heart Institute Journal specifications for Images submissions—shows that weightlifting can lead to catastrophe. Presented here is more information on the possible dangers of weightlifting, with a focus on the cardiovascular sequelae.

Weightlifting is associated with 3 categories of injury: musculoskeletal,^2,3 neurologic,^4–7 and cardiovascular.^8–22 Common to all 3 categories are poor conditioning or technique, inadequate strength or endurance, improperly selected resistance, insufficient warm-up or stretching, loss of balance, and fatigue.² Musculoskeletal ailments are reported frequently. Noteworthy neurologic effects, such as subarachnoid hemorrhage,⁴ brain stem dysfunction,⁵ and acute paraplegia,^1,12 are apparently rare.

Among the cardiovascular sequelae, aortic dissection receives substantial attention^8–12; the internal carotid artery,^13–16 coronary arteries,^17–19 and celiac artery²⁰ can also dissect. In addition, implanted pacemaker leads can fracture.^21,22 The chief culprit is vascular stress, applied to the arterial walls through exceptionally elevated blood pressure. Indeed, the intra-arterial blood pressure can soar as high as 480/350 mmHg at the moment of maximal weightlifting effort.^23,24 Investigators attribute this 4-fold rise to mechanical compression of the blood vessels, increased cardiac output, and the same pressor effects that are seen in the Valsalva maneuver.²³ Other contributory factors are emotional stress,²⁵ structural aberrations of the arterial walls, and defective connective tissue in the surrounding extracellular matrix.¹⁶

Certain individuals are at special risk and should lift weights cautiously, if at all: people with chronic systemic hypertension; the elderly, with their comparatively inelastic arteries; persons who have congenital or acquired disease of the aorta; and anyone with a heritable disorder of the connective tissue, such as Marfan syndrome, Ehlers-Danlos syndrome, Turner syndrome, pseudoxanthoma elasticum, osteogenesis imperfecta, and autosomal dominant polycystic kidney disease.^10,12,16

Despite its potential for grievous bodily harm, weightlifting—when properly undertaken—yields distinct benefits and is relatively safe for most participants.