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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