Download Following viral myocarditis.

Following viral myocarditis,
which athlete can re-enter
his active sports career ?
ESC Congress 2011
Paris
F. Carré
University Rennes 1-Pontchaillou Hospital
Inserm U642,
Rennes - F-35000
The author declares that he
has no conflict of interest
concerning this lecture
Myocarditis definition
Inflammatory disease
of the myocardium
Acute and/or chronic
arrhythmogenic substrate
Dennert RHJ et al Eur Heart J 2008; 12: 450-6
Myocarditis classification
+++
Viral myocarditis
Enteroviruses
 coxsackie B
Parvovirus B19
Adenovirus
Human herpes virus 6
Epstein-Barr-Virus
CM virus
Rarely
Common cold viruses
rhinovirus
coronavirus
Olimulder, MAGM, etal. Neth Heart J 2009;17:481-6.
Circ J 2011; 75: 734 – 743
Acute Myocarditis evolution
Total and spontaneous recovery in 50%
Chronic myocarditis in 20%
Myocarditis induced dilated cardiomyopathy in 20%
Myocarditis and sport
1- Why myocarditis and sport ?
2- Difficult diagnosis in athlete
3- Sport participation with myocarditis
4- Prevention of myocarditis in athlete
Myocarditis and sport
1- Why myocarditis and sport ?
2- Difficult diagnosis in athlete
3- Sport participation with myocarditis
4- Prevention of myocarditis in athlete
The cardiac arrhythmogenic triangle
Arrhythmogenic
Trigger
substrate
Environmental conditions
Autonomic nervous system, dehydratation,
hypoxia, acidosis…
Modified from Coumel P., 1984
catecholamines
Causes of sport’s related SD observed in
young competitive athletes
SD is reported 1-2/100 000 athletes ≤ 35 y.o.
Wesslen L et al Eur Heart J 1996; 17: 902-10
Frick M et al Herz 2009 ;34:299-304
Link MS, Estes M III Prog Cardiovasc Dis, 2008;1:44-57
McCaffrey FM, Am. J. Dis. Child. 1991; 145: 177–83
Myocarditis  5- 22 %
Causes de MS dans les Sportifs
11%
9%
13%
14%
4%
8%
Anatomical -+congenital
Congenital
Anatomic
1%
3%
36%
37%
n=112
n=126
n=326
n=309
Myocadiopathies
Cardiomyopathies
Arrhythmias
Arrhythmias
Atherosclerosis
Infectious
Infectious
Degenerative
Undetermined
Degenerative
Acquired
Acquired
31%
35%
Review of Bille K et al Eur J Cardiovasc Prev Rehab 2006.
"Normal
heart"
“Normal
heart“
Myocarditis and sport
1- Why myocarditis and sport ?
2- Difficult diagnosis in athlete
3- Sport participation with myocarditis
4- Prevention of myocarditis in athlete
Myocarditis diagnostic (1)
Symptoms
Asymptomatic
fulminant
Flu-like symptoms
Gastrointestinal symptoms
Cardiac symptoms
none
chest pain
dyspnea
palpitations, syncope
heart failure
Subtle clinical discomfort + recent infectious event
Circ J 2011; 75: 734 – 743
Frick M et al Herz 2009 ;34:299-304
Myocarditis diagnostic (2)
Clinical signs
Fever
Cardiac rhythm disturbance
Hypotension
Auscultation abnormality
Heart failure
Blood biochemistry signs
Transient elevation of
C-reactive protein elevation
MB form creatine kinase
Cardiac troponin T and I
Viral antibody titer
« cardiac fatigue »
in athlete?
Circ J 2011; 75: 734 – 743
Myocarditis diagnostic (3)
ECG signs
Resting ECG
Sensitive tool
Timely repeated
Conduction disturbances
Abnormal ST-T waves
Morgera T Am Heart J 1992; 124:455–66.
Circ J 2011; 75: 734 – 743
« Athlete’s heart ?
Myocarditis diagnostic (3)
ECG signs
Holter monitoring
Exercise test
Arrhythmias ?
Urhausen A et al Circulation 2003, 108:e21-e22
Myocarditis diagnostic (4)
Echocardiography signs
Transient wall thickening
Reduced cardiac chamber size
Reduced wall motion
Pericardial effusion
Circ J 2011; 75: 734 – 743
Sskouri HNGW et al. J Am Coll Cardiol 2006;48:2085-93
Urhausen A et al Circulation 2003, 108:e21-e22
Myocarditis diagnostic (4)
Cardiac Magnetic Resonance signs
(Se 86 % - Spe 95%)
Cine CMR
Early and late contrast
enhancement-CMR
T2 acquisitions
Acute myocarditis (EBV)
T2 weighted images
Acute myocarditis
Spotty epicardial areas
lateral free wall (PVB19)
midwall IV septum(HHV6)
Chronic myocarditis
scar fibrosis
Friedrich MG et al. J Am Coll Cardiol 2009;53:1475-87
Olimulder, MAGM, etal. Neth Heart J 2009;17:481-6.
Chronic myocarditis
Sparrow Pj
RadioGraphics
2009; 29:805–23
Myocarditis diagnostic (5)
Cardiac Catheterization
Endomyocardial Biopsy
Gold standard for diagnosis
Myocardial degeneration,
myocyte necrosis,
inflammatory infiltrates,
interstitial myocardial edema,
fibrosis
But adverse events and
false negative results
Wesslen L et al. Eur Heart J 1996;17:902-10
Myocarditis and sport
1- Why myocarditis and sport ?
2- Difficult diagnosis in athlete
3- Sport participation with myocarditis
4- Prevention of myocarditis in athlete
Recommandations for sport participation
in case of myocarditis
Eur Heart J 2005;26:1422-45
J Am Coll cardiol 2005;45:1312-75
Recommandations for sport participation
in case of myocarditis
Acute myocarditis or myopericarditis
Possible diagnosis  no strenous exercicse
until definite diagnosis
Definite diagnosis  adapted treatment and
no significant exercise
C-MRI
Pelliccia A et al. Eur Heart J 2005;26:1422-45
Chronic myocarditis and sport
If symptoms  no strenuous exercise, no competition
C-MRI sequellae without symptoms ?
Professional cyclist 26 y.o.
Asymptomatic ventricular premature beats
Normal echocardiography
C-MRI
Exercise test
150 watts
Exercise test : HR 193 bpm- BP 210/65 mmHg
460 watts- VO2 = 4,2 l/min  74 ml/min/kg
Maximal exercise
Myocarditis and sport
1- Why myocarditis and sport ?
2- Difficult diagnosis in athlete
3- Sport participation with myocarditis
4- Prevention of myocarditis in athlete
Prevention of myocarditis in athletes
Wesslen et al. Eur Heart J.1996; 7: 902–7
Myocarditis more frequent in athletes ?
Elite athletes are not clinically
immune deficient, but may be
less resistant to common
minor illnesses, such as URTI
Gleeson M J Appl Physiol 103:693-699, 2007.
Purpose of preventions
1- Stop elite sport for 4 weeks after an unspecific and
proven infection  rarely implemented
2- Stop sport and CV evaluation in case of subtle
discomforts with suspected viral infection in spring
and summer  which exams ?
Cost-benefit ratio of myocarditis diagnosis in athletes ?
Walsh NP et al Exerc Immunol Rev. 2011;17:64-103.
Guidelines for return to
exercise after infections
One day without fever and with improvement of
URTI or GI symptoms before returning to exercise
Progressive improvement in training intensity.
Check the individual tolerance to increased
exercise intensity
If recovery is incomplete take an extra day off
Stop again physical exercise and consult your physician
if fever and/or if any symptom reoccur
Conclusions
True myocarditis diagnosis  stop sport practice (6
months)
True resumption  OK for all competitive spot
Myocarditis in athlete induce several questions
1- Lot of unknown myocarditis in athletes
2- True diagnostic  athlete’s heart ?
3- True disease resumption  no gold parameter
4- Which attitude in case of asymptomatic
myocardial scar on C-MRI ?