Download Chest Pain In A Collegiate Basketball Player

Outline
Sports Cardiology In Endurance Athletes
AKOMA CME Conference
5-10-14 Anchorage AK
Christine E. Lawless, MD, MBA, FACC, FACSM, CAQSM
Founder, ACC Sports and Exercise Cardiology Council
President-Sports Cardiology Consultants LLC
University of Chicago
University of Nebraska

Numbers of athletes are increasing
Exercise physiology of endurance
sports
 Interpreting cardiac tests in
endurance athletes
 Risks of endurance sports
 How sports cardiologists minimize
risk

Disclosures: None relevant
Many Health Benefits of
exercise for all ages


Current United States (US) physical activity
guidelines:
 Healthy adults : 2.5 hours of moderate
activity/wk
 Children : 60 minutes of daily physical activity,
with 20-30 minutes of vigorous activity 3 days
per week for both age groups
Numbers of athletes in USAINCREASING

Participation doubled
in all demographic
groups over past 10
yrs

Established heart
disease: Living
longer; may
contemplate sports
and exercise
Ref: Swift, Fletcher, Thompson, Pate, Jansen, Thorpe and US
DHHS website
Over age 35 years- drawn to
endurance exercise

Marathon finishers
up from 353,000 in
2000 to over
500,000 in 2011

USA Triathlon
memberships up
from 21,341 to
more than 146,000
during the same
period
Risks of exercise

Paradoxically, despite its favorable
effects on well-being and survival,
exercise can acutely be associated
with:

risk of myocardial infarction
aortic dissection
 arrhythmias
 Sudden cardiac arrest (SCA) and/or
death (SCD)

1
Exercise physiology
Acute Exercise Response
VO2 max = CO x A-V O2 diff
VO2 max = (HR x SV) x A-V
O2 diff
Any Part Equation can
Reduce Performance
Effects Exercise Training
 VO2 max
•
Primarily SV
•
•
Reduced HR
Cross country skiing: Lesson in sports
cardiology, and evaluating an athlete

CV Demands:
 Endurance
 Altitude (Interaction
w/ external athletic
environment
 O2 desaturation worse with altitude,
as low as 80%
 Use of both arms
and legs
•
Heart Rate
Stroke Volume
Arterial O2 Content
Venous O2 Content
Cross country skiing: Lesson in sports
cardiology, and evaluating an athlete

CV Adaptations
 VO2max 87ml/kg/min
(highest recorded
96ml/kg/min- B. Daehlie
 Max HR of 185 bpm
 SV 200ml
 CO 40 L/min
 Up to 40% increases in
all chamber
measurements in
ECHO/MRI
http://www.cardiosource.org/Science-And-Quality/Hot-
http://www.cardiosource.org/Science-And-Quality/Hot-
Topics/2014/02/Sports-Cardiology-of-Cross-Country-Skiing.aspx.
Topics/2014/02/Sports-Cardiology-of-Cross-Country-Skiing.aspx.
2
Interpreting cardiac tests
ECG findings/adaptation
Enhanced Parasympathetic
Tone
Resting Bradycardia
Sinus Arrhythmia
AV Conduction Delay
1st, 2nd, 3rd
Early Repolarization
T Wave Changes
28 year old 2:17 marathoner - chest discomfort
16 year old miler
Vaso-Vagal Syncope is More
Common in Endurance Athletes
WPW Pattern is More
Common
In Endurance Athletes
Huston NEJM
1985
 Large
Venous Capacity
Vagal Tone
 Reduced Sympathetic Tone
 High
Be Careful of + Tilt Tables in AthletesUp to 66% can be positive
3
The Limits of LV Cavity
Cardiac Enlargement
 Global
1300 Elite Italian Athletes
LVID Increased
45% > 55 mm
14% > 60 mm
 Largest LVID
Female = 66 mm
Male = 70 mm
 HR r= 0.37; BSA r = 0.76

(LV, RV, LA, RA)
 Mild
 Marked

Enlargement 
Disease
Pelliccia Annals IM 1999
Distribution of Left Atrial Dimensions in
1,823 Elite Athletes
220
200
180
20% (40mm)
male
female
140
11% (45mm)
120
100
80
60
40
947 Italian Athletes
209 Women
16 Athletes LVWT > 12 mm
Rowing + Canoeing - 7% of Those
Athletes
1 Athlete > 16 mm
All Women < 11 mm
20
Pelliccia NEJM 1991
0
23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Distribution of max. LV wall thickness in
738 male and 600 female elite athletes
(Pelliccia, NEJM 91 and JAMA 95)
300
Left Ventricular Ejection
Fraction: ? Normal
MEN
250
WOMEN
200
N° Athletes
No. Athletes
160
The Limits of Normal Wall
Thickness
150
100
Tour De France Cyclists11% have LVEF less than
52%
50
0
5
6 7 8 9 10 11 12 13 14 15 16
Max. Wall Thickness (mm)
4
RV
Weight lifting: Pressure overload
 LV
cavity not
increased
 Wall thickness not
increased, but out
of proportion to
cavity dimension
Risks of exercise

Paradoxically, despite its favorable
effects on well-being and survival,
exercise can acutely be associated
with:

risk of myocardial infarction +/SCA/SCD
 aortic dissection
 arrhythmias
 Sudden cardiac arrest (SCA) and/or
death (SCD)
In Young Athletes
How Dangerous Is Exercise
For Healthy Adults?
1 Death/Year/Per
Thompson
15,640
(per 100,000 )
Women
Men
High School 0.12
College 0.28
High School 0.66
College 1.45
JAMA 247:2535,1982
Siscovick
NEJM 311:874,1984
18,000
( 1 / 133,333 men & 1/769,230
women )
Van Camp 1995
5
Medical perspective- XC skiing
Incidence and etiology of SCD in athletes
•
•
•
•
•
SCD rare ( Swiss Engadine Ski Marathon,
1:120,000 skiing hours)
Swedish Vasaloppet racers showed more
than 7 X greater risk of SCD acutely
Over a 10 year period , standardized
mortality ratios of 0.48 [95% confidence
interval (CI) 0.44-0.53]
Acute increase in SCD outweighed by long
term benefit
Higher incidence of atrial fibrillation
LaGerche JACC 2013
Relative Risk of MI onset
Sports Cardiology of XC Skiing http://www.cardiosource.org/.2-19- 2014.
Exercise Also Increases
the Risk of Myocardial
Infarction
Mittleman et al, NEJM 1993
Most MIs Are Caused by Lesions
of Minimal Stenosis
Falk E. et al Circulation. 1995;92 ;657-671.
14%
18%
Stenosis Prior to MI
50%-70%
<50%
68%

16
0
12
0
80
40
Giroud
et al
1992
Nobuyoshi
et al
1991
0
Little
et al
1988
60
50
40
30
20
10
0
>70%
Ambrose
et al
1988
MI 100
Patien 90
ts
80
(No.) 70
Screening Exercise Tests
200
May Be Falsely Positive
Because of Left Ventricular
Enlargement ??
 Can Be Dismissed if Good Exercise
Tolerance, No Symptoms, Good Heart
Rate Response, Rapid Resolution in
Recovery
 Nuclear Imaging May Show Inferior
Defect
 Due to Large Hearts & Diaphragmatic
Attenuation ??

6
Exercise Testing for Asymptomatic
Persons Without Known CAD
Screening Exercise Tests
Are Not Good Predictors of Sudden
Death or Acute MI in Asymptomatic
Individuals
Exercise Advice ?
 36th
Bethesda Conference 2005
Determining
Athletic Eligibility in Athletes with
Heart Disease Are Very Restrictive
 Prohibit Competitive Athletics with
High Risk Lesions (CAD, HCM,
Marfan)
 Flexibility Depending on the
Perceived Risk For the Athlete…but
 The “I Gotta Sleep Too Rule”
•
Class 2 - Conflict or Divergence
of Opinion
•
Evidence/Opinion Favors - Diabetes
Pre Vigorous Exercise
•
Usefulness Less Established - Men
>45, Women >55 Pre Vigorous
Exercise
The Most Frequent Problem
High Powered, Exercise – Addicted
Lawyers, Bankers, Stock Brokers
 Wanting to Return to Climbing,
Competition, Whatever
 After an ACS

Typical baby boomer athlete (Dr Lawless)

Born post WWIIbetween 1946 and
1964

A weekend warrior

Or, an athlete who
resumes sports
after years of no
training or the
athlete who starts a
sport late in life
Return to previous activity
after event???

60 y/o male attending cardiac rehab after
CX stent for MI
 Asymptomatic, MVO2 32.4ml/kg/min, max
HR 134 bpm (10:15 min Bruce protocol)
 LVEF 52%, nuclear stress- small fixed
defect lateral wall, no evidence of
reversible ischemia
 His question: Is it OK to return to
competitive open wheel race car driving at
145mph?
7
Demands of open wheel driving
Med Sci Sports Exerc 2002 Dec;34(12):2085-90
Br J Sports Med 2009
Patient Information
• 21-year-old male
• Six years prior – diagnosed with mild aortic
insufficiency
• Otherwise a healthy individual.
• No history of:
–
–
–
–
–
Hypertension
Diabetes
Dyslipidemia
COPD
Smoking
Family History:
• Suggestive
• Father died at age 38 of a “heart attack”
Weight Lifting Exercise
• Weightlifter
• Exercises daily
• Primarily anaerobic
exercise
• Lifts up to 75-100% of body
weight
• Weight: 201 lb (91 kg), Height: 72 in (184 cm)
Clinical Presentation
In June, 1999:
• Presented to an outside institution with acute
severe substernal chest pain with shortness
of breath
• The pain developed during strenuous
exercise (lifting weights)
Computed Tomography
• Dilated ascending
aorta from the
sinuses to the
proximal arch,
• Maximal size 5.2 cm
• Aortic dissection
was suspected, but
a clear dissection
flap was not visible
C
C ompres
ompres ss ed
ed 8
8:1
:1
IIM
M :: 3
31
1 SE
SE :: 1
10
04
4
PP age:
age: 3
31
1 of
of 1
10
00
0
8
Transesophageal Echocardiography
• Dilatation of the ascending aorta from the
sinuses to the proximal arch
• Maximal size 5.3 cm
• Bicuspid aortic valve
• Moderate aortic insufficiency, no stenosis
• Normal left ventricular ejection fraction
• Fluid in the pericardium
• No signs of aortic dissection
Intraoperative findings
• Bloody fluid in the pericardium –
moderate amount (no
hemodynamic effect)
• Ascending aorta appeared
severely dilated
• Tubular type aneurysm
• Severe ecchymosis in the wall of
the aorta
• Upon entry of the aorta – a large
stellate laceration (3 cm) of the
internal surface of the aorta was
found in the right lateral location.
Evidence of Intramural Hematoma of the Ascending Aorta
Intramural Hematoma
Surgical procedure
• Composite graft
replacement of the
ascending aorta, aortic
valve, and hemiarch on
cardiopulmonary bypass
and deep hypothermic
circulatory arrest
Cardiopulmonary bypass time
– 174 min
Aortic cross-clamp time
– 108 min
DHCA time at 18 degrees Celsius – 31 min
Elefteriades JA. Thoracic aortic aneurysm: Reading the enemy's playbook. Curr Probl Cardiol. 2008;33(5):203-277
Postoperative Course
• Early:
– Benign, diuresing well, hemodynamically stable.
– No atrial fibrillation
– Discharged home on 5th postoperative day
• Late:
– 15 years postoperatively the patient is doing well
– Continues physical training and weight lifting
Patient wants to return to weightlifting
• What advice to give to patient?
– Restrict anaerobic physical exercise to less than 50%
of body weight.
– Allow complete return to preoperative levels of
physical activity.
– Allow complete return to preoperative levels of
physical activity and screen the size of
arch/descending/thoracoabdominal aorta.
9
Five years postoperatively
Outline

Numbers of athletes are increasing
Exercise physiology of endurance
sports
 Interpreting cardiac tests in
endurance athletes
 Risks of endurance sports
 How sports cardiologists minimize
risk

Thank you!
Thanks to Dr Paul Thompson
(Hartford Hospital, CT) for use
of some slides
10