Effects of Physical Activity on the Heart
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1 Effects of Physical Activity on the Heart Sharon L. Mulvagh MD FACC FASE FAHA FRCP(C) Professor of Medicine Director, Women s Heart Clinic Associate Director, Preventive Cardiology Mayo Clinic Rochester MN, USA 2014 MFMER slide-1
2 Disclosures I love running! 2014 MFMER slide-2
3 Learning objectives Review the effects of physical activity on the heart and cardiovascular system Understand the current debate regarding dose of exercise Provide guidelines for current patient recommendations 2014 MFMER slide-3
4 Question: Do you try to exercise vigorously at least 3 days per week or accumulate at least 30 minutes of moderate physical activity per day? 2014 MFMER slide-4
5 Does Exercise Prevent Cardiovascular Disease over a Lifetime in Healthy People? Harriette Thompson; 92 yo female completed San Diego Rock n Roll Marathon 2015 Time: 7:24:36 This is principally an epidemiologic question Large, long-term randomized clinical trials are not feasible 2014 MFMER slide-5
6 CHD and Physical Activity of Work Physical Activity at Work and CHD Deaths in 6,451 Longshoremen Low Medium 40 High CHD death Sudden death Paffenbarger RS et al. N Engl J Med. 1975;292: MFMER slide-6
7 Occupational Activity Church et al PLOS MFMER slide-7
8 Effect of Exercise on Coronary Artery Disease Progression 113 patients with stable angina randomized 12 month training program versus usual care T C T C T C Schuler G et al. Circulation 1992:86: MFMER slide MFMER slide-8
9 Exercise Training vs. PCI Rainer Hambrecht et al. Circulation. 2004;109: Copyright American Heart Association, Inc. All rights reserved MFMER slide-9
10 Effect of Exercise on Coronary Artery Disease Progression Schuler et al. doi: /eurheartj/eht111; April 7, MFMER slide MFMER slide-10
11 Benefits of Physical Activity on Coronary Risk Factors Improved blood lipids HDL-cholesterol Triglycerides Small, dense LDL-cholesterol Decreased blood pressure ~ 4/4 mmhg in normotensive subjects ~ 11/6 mmhg in hypertensive subjects Improved insulin resistance Reduced visceral adiposity Reduced hs-crp 2014 MFMER slide-11
12 Comparison of Coronary Arteries in Runners versus Inactive Men 11 inactive male volunteers 11 male ultradistance runners Haskell W et al. Circulation 1993:87: MFMER slide MFMER slide-12
13 Physical Activity, Mortality & Longevity 650,000 Adults (Swedes & US, >40 yo) 1.0 Hazard ratio of mortality Years of life gained Guidelines About Here Leisure time physical activity (MET-hr/wk) Vigorous activity ~4 hrs/week Moore et al PLoS Med MFMER slide-13-13
14 Is it possible to have too much of a good thing? 2014 MFMER slide-14
15 Potential adverse cardiovascular effects from excessive endurance exercise O Keefe JH, Mayo Clin Proc 2012; 87: MFMER slide-15
16 Leisure-Time Running Reduces All-Cause & CV Mortality Risk 55,137 adults, years of age (mean age 44) Lee D, Blair S. J Am Coll Cardiol. 2014;64(5): MFMER slide-16
17 Dose of Jogging and Long-Term Mortality The Copenhagen City Heart Study 1,098 healthy joggersl 3,950 healthy nonjoggers prospectively followed since 2001 Light joggers HR = 0.22; 95% CI = 0.10 to 0.47 Moderate joggers HR = 0.66; 95% CI = 0.32 to 1.38 Strenuous joggers HR = 1.97; 95% CI = 0.48 to 8.14 Schnohr P, J Am Coll Cardiol 2015;65: MFMER slide-17
18 Too Much Exercise? The FIT study, Detroit N= 37,855. no CVD, high fitness Mean age 50, 2/3 males No upper threshold for mortality benefit w/ increasing fitness, even in the most highly fit subjects Our data caution against any public health message that might dissuade patients from routine vigorous physical activity with the goal of reaching the highest levels of cardiorespiratory fitness Feldman et al JACC 2015 CP MFMER slide-18
19 Physical activity in Extreme Environments heart & vascular system 2014 MFMER slide-19
20 2014 MFMER slide-20
21 Molecular Mechanisms of Exercise Training Endothelial function and NO availability Endothelial repair by stem cells Reduced arterial stiffness Increased production of microrna Collateral growth Schuler G et al. doi: /eurheartj/eht111; April 7, MFMER slide MFMER slide-21
22 Schuler G et al. doi: /eurheartj/eht111; April 7, MFMER slide MFMER slide-22
23 The Athlete s Heart P Douglas, 1999 Increased heart chamber sizes Thicker heart muscle Improved relaxation of heart sucker heart Slow heart rate 2014 MFMER slide-23
24 Cardiac Structural Adaptation to Intensive Training Hypertrophy Eccentric ISOMETRIC Concentric Balanced Changes in cardiac dimensions: ISOTONIC RA/LA/LV dimensions Diastolic function: sucker vs. pusher heart Baggish A, J Applied Physiology 2008 Pluim et al. Circulation 1999 Barbier J et al. Eur J of Cardiovascular Prevention and Rehabilitation MFMER slide-24
25 CV Causes of Sudden Death 1,435 Young Competitive Athletes Older (Ages 31-65) Athletes Maron BJ: Circulation 2007;115:1643 Waller: Exercise and the Heart, MFMER slide-25
26 2014 MFMER slide-26
27 EXTREME PHYSICAL ACTIVITY The Marathon 2014 MFMER slide-27
28 Marathon Running Physiology Unique blend of intensity and duration Fast enough pace to require high VO2max < 5:00/mile in elite men; < 5:30/mile in elite women Long enough to cause problems with substrate availability Confounding problems Heat transfer and hydration in warm conditions Anything above 55 F 2014 MFMER slide-28
29 Effects of Marathon Running on the Heart of non-elite athletes MJ Wood 2006 Boston Marathon (30/yr) Portable echos Blood tests Population Characteristics 41 males, 19 females Mean age: 41years (21-65 years) Mean training mileage: mi/wk avg finish time: 4hr 5 mins (range 2 hr 55mins to 5hr 55mins) 2014 MFMER slide-29
30 Effects of Marathon Running on the Heart of non-elite athletes MJ Wood 2006 Transient alterations in systolic and diastolic function right > left ventricle Elevation of cardiac biomarkers used to diagnose MI, CHF These findings were directly associated with training mileage: <35-40 miles/wk Circulation Nov 2006; Eur Heart J May MFMER slide-30
31 42 y/o male runner Tissue Doppler Pre and Post Marathon (3:28 marathon) E a -10cm/s Ea -4.5cm/s Courtesy of Dr. MJ Wood 2014 MFMER slide-31
32 RV Strain Pre-marathon RV free wall ε Post-marathon RV free wall ε -30% -24% Courtesy of Dr. MJ Wood 2014 MFMER slide-32
33 Running: the Risk of Coronary Events Prevalence and prognostic relevance of CAD in marathon runners Essen Marathon Study, Germany: Eur Heart J, April healthy male runners >50 yo >5 marathons in 3 yrs Methods: FRS, CAC, MRI Conclusions: Fram Risk score underestimated CAC Higher CAC with more marathons As CAC so did heart scar on MRI Limitations: -no women selection bias: pre-existing disease? CAC MRI 2014 MFMER slide-33
34 Incidence of SCA 5.4 per million marathon participants 18.6 per million per NCAAathlete/yr 54% > 35 years old 57% female accessed Kim JH, N Engl J Med. 2012;366: Harmon KG, Circulation. 2015;May 14:[Epub ahead of print] MFMER slide-34
35 Sports-related SCA is more likely to be a witnessed event, suffer ventricular fibrillation, receive timely CPR and have higher survival to hospital discharge Marijon E, Circulation. 2015;131: Bystander CPR and use of AED for rapid cardiac defibrillation --strongest independent predictors for survival to hospital discharge among sports-related SCA patients-hands only CPR mass training pre-marathon events Kim JH, N Engl J Med. 2012;366: MFMER slide-35
36 Sports Paradox vigorous activity (>6 METs) acutely and transiently increases the risk of SCA and AMI (~5X) regular habitual exercise mitigates that risk relative risk of SCA and exercise: inversely related to habitual exercise level ~50 X higher in sedentary ~40% lower among men with highest level of habitual vigorous activity Mittleman MA N Engl J Med. 1993;329: Albert CM N Engl J Med. 2000;343: Siscovick DS, N Engl J Med. 1984;311: MFMER slide-40
37 Sudden Cardiac Arrest (SCA) During Sports Activity Overwhelmingly, the majority of sports-related SCAs have occurred in men (HR 18X) Potential explanations include: historically lower participation rates for women in events women tend to develop atherosclerosis ~10 yrs later than men gender differences atherosclerotic plaque morphology ventricular electrical activity autonomic factors Marijon E, Circulation. 2011;124: Kim JH, N Engl J Med. 2012;366: Harmon KG, Circulation. 2015;May 14:[Epub ahead of print] MFMER slide-41
38 What is the effective dose of exercise? 2012 MFMER slide MFMER slide-42
39 Physical Activity Recommendations: Given the extensive CV benefits of exercise >150 min/wk of moderate, or 75 min/wk of vigorous exercise training (or an equivalent combination of both) Minimum 30 min of moderate-intensity physical activity (continuous or in 10-minute increments), preferably most days of week Equivalent to ~1.5 miles/day of brisk walking Even 15 min/day or 90 min/wk is associated with a survival benefit compared with physical inactivity Haskell WL, Circulation. 2007;116(9): Fletcher GF,Circulation. 2013;128:8 Global Recommendations on Physical Activity for Health. World Health Organization. Available at: Physical Activity Guidelines for Americans. U.S. Department of Health and Human Services. Available at: MFMER slide-43
40 Recommendations for your patient Assess the potential impact of increased physical activity for the individual patient Start with a level of exercise appropriate to the baseline fitness and activity level of the patient Progressively advance the exercise prescription until risk factors are optimally controlled or limits of tolerance are reached 2014 MFMER slide-44
41 Implications of Recent Trials High intensity interval training more effective than continuous low-moderate intensity training Supervised training superior to home programs Both HF-ACTION and LOOK AHEAD had more frequent supervised sessions initially, tapering off to home program as study progressed 2012 MFMER slide MFMER slide-45
42 Exercise is great medicine, but sometimes it can be a hard pill to swallow Explains negative results in LOOK AHEAD and HF-ACTION COMPLIANCE ISSUES 2012 MFMER slide MFMER slide-46
43 Determinants of Health CDC MFMER slide-47
44 Behavior Changes When Observed Personal Activity Monitors Many Types 2012 MFMER slide MFMER slide-48
45 Incorporating Physical Activity into your workday: The Active Office Workout while you work! Dr. James Levine & Walking Workstation MFMER slide-49
46 MAYO ECHOLAB MSP AIRPORT 2014 MFMER slide-50
47 2014 MFMER slide-51
48 2014 MFMER slide-52
49 Hoffman et al., 2015, Cell Metabolism 22, 1 14;November 3, MFMER slide-53
50 Summary Effects of Physical Activity on the Heart Benefits on decreasing CV disease risk; 1 o & 2 o prevention Controversy regarding dose of exercise, potential adverse effects of extreme endurance exercise Perspective on SCA during sports activities; rare, but increasing due to increasing participation, predisposing factors; prevention gap Current physical activity recommendations for heart health IT solutions to improving adherence 2014 MFMER slide-54
51 The long-term benefits outweigh the shortterm risks related to physical activity. "If you survive exercise, which you almost certainly will, you will undoubtedly live longer and healthier" 2014 MFMER slide-55
52 Gracias! Thank 2014 MFMER slide-56
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