Ischemic Heart Disease and Sport

Transcription

1 Ischemic Heart Disease and Sport Dr Benoît GERARDIN - Clinique Ambroise Paré, Neuilly Hôpital de Neuilly - RACcE (GRCI). - amateur sportsman Journées Européennes de la SFC - Janvier

2 Introduction Exercise : Many cardiovascular benefits (primary and secondary prevention). But the risk of sudden cardio-vascular events is ephermerally increased during vigourous physical exertion. Non traumatic sudden death during sport : 90% cardio-vascular. Physiopathology : cardiac outpout X 4-5/ rest, 6-8 in champions), 02 cardiac comsuption (X 2-4/rest) + humoral modifications (ionic, coagulation ), sympathetic nervous system activation Because excertion may worsen or reveal underlying cardiac anomaly. Physiopathology : Rupture of atherosclerotic plaque + thrombus. Myocardial bridge Congenital coronary abnormality.

3 Outline Introduction Sport in coronary patients. Sport in the global population.

4 Sport in coronary patients Goal = to benefit of sports activity and to avoid cardiac event induced by sport. What coronary patient? What sports activity? What sports activity for which coronary patient?

5 - General context : Sport in coronary patients What coronary patient? - Age. Extracardiac medical history. Comorbidities? - Former sportsman? - Coronary medical history: - Coronary events : type, when - Complete revascularisation? (CRO CRH) - LV function? (cardiac ventriculography echocardiography) - Ventricular arrythmia? (stress test Holter) - Physical capacity at distance of the acute phase. (stress test)

6 Low risk (<5%) Intermediate risk High risk (>10%) In-hospital evolution simple Complications LV function Normal EF : 30% - 50% EF <30% Residual ischemia NO Moderate Important Exertion ventricular arrythmia Sport in coronary patients. What coronary patient? In broad outline, coronary patients are divided in 3 groups according to the risk of mortality at 1 year : Non Moderate Oui Physical capacity ( distance of the acute phase) Other > 6 Mets 5-6 Mets < 5 Mets Survivor after sudden death MET (Metabolic Equivalent Task) = energy consumed during an activity. 1 MET = 1 kcal/kg/h.

7 Sport in coronary patients. What coronary patient? - Complete coronary revascularization? (angioplasty or surgery) - Time past since coronary angioplasty :. < 1 month : reendothelization => no intense physical activity.. 1 month 6 months (bare metal stents) to 1 year (drug eluting stents) : intimal proliferation with risk of restenosis => progressive resumption of the physical activity (no competition).. > 6 months (1 year) : «stable» healing. Level of capacity determined according to the global risk of the patient.

8 Sport in coronary patients. What sport? (Mitchell et al 2005)

9 Sport in coronary patients. What sport? 4 5 METS 1 MET = 1 kcal/kg/h METS

10 Sport in coronary patients. What sport? It is necessary to distinguish : - Other constraints. (climatic, altitude, remoteness ) - Leisure / competition. - Cycling and running : the biggest suppliers of sudden deaths (but population +++)

11 Sport in coronary patients. What sport for which coronary patient? Individually tailored +++. Key role of the stress test. (Watts/kg). If => residual ischemia : stay with a heart rate 10 /mn below thel ischemic threshold (heart rate monitor++). If => good LV, complete coronary revascularization, no arrythmia, stress test normal for 3 watts/kg : demanding sport possible. (for extreme cases VO2 max (altitude treks )).

12 Sport in coronary patients What sport for which coronary patient? 1 > 1 2 > 2-3 > 3 EE watts EE watts/kg

13 Sport in coronary patients. What sport for which coronary patient? Endurance activities (low increase of the blood pressure, peripheral resistance reduction) are prefered to resistance activities. But, the desire for a sport is the best guarantee for its practice. Good sport practice : «ne pas se mettre dans le rouge» (pro-arrythmic, ionic disorders, plaque rupture), the 10 golden rules of the «Club des cardiologues du Sport»

14 Sport in coronary patients. What sport for which coronary patient? Important items : 1/ Coronary heart disease = evolutive disease. Symptoms / Manage the other risk factors (tobacco +++, CL, overweight, diabetes, high blood pressure ). 3/ Good hydratation. 4/ Medications : avoid (if possible) diuretic and antiarrythmic Ic.

15 Sport in coronary patients. What sport for which coronary patient? Cardiac rehabilitation : Medical indication for all patients after MI or coronary bypass surgery. Warmly recommended for all the patients who want to practice sport : it is a garantee for the patient to reach the maximum of its physical capacity in its situation.

16 Sport in coronary patients. What sport for which coronary patient? Europeans recommendations : 1/ Competition (2005): Only for low risk patients, only for sports IA and IIA. 2/ Recreational sport (2006): - Index SCORE* < 5% : yes, with <10 beats/mn below the ischemic threshold. - Index SCORE > 5% : ban. * Index score < 5% : FE>50%, normal performance, no ischemy, no arrythmia, reisdual stenosis < 70%

17 Sport in coronary patients. What sport? (Mitchell et al 2005)

18 Sport in coronary patients. What sport for which coronary patient? 13 «experts» French experts opinion R. Brion et al coronary patients who want to come back to competition 7M, 1W y.o. LV dysfunction =0 Arrythmia = 0 100% 80% 60% 40% 20% 46% 77% 69% 54% 85% 77% 77% 54% 2 football 2 LD running 2 cycling 1 swimming 1 tennis 0% no consensus for any case!

19 Sport in coronary patients. Take home message : - There is a great benefit of the physical activity for the coronary patient; it must be encouraged - The maximal level of exertion is tailored individually. - Key role of the stress test. - Auto-control (symptoms, heart rate monitor, 10 golden rules). - The «zero risk» does not exist.

20 Outline Introduction Sport in coronary patients. Sport in the global population.

21 Sport in the global population. WHY? In France : à death / year during exercice. Mean age: 48 y.o. (1/3 of death in y.o.). Almost males (sex ratio from 2 to 3 before 35 y.à., > 9 after 35 y.o.). Especially in running and cycling. Etiologies :. > 35 y.o. : coronary heart disease +++ (> 80%).. < 35 y.o. : HCM, DVDA, QT anomaly (long), Brugada syndrom, myopericarditis, and in % coronary heart disease, congenital coronary abnormality, myocardial bridge.

22 Sport in the global population Sportsmen : Professional sportsmen and «high level sportsmen» = small population = specific screening. Other sportsmen : very important population = mass screening.

23 Sport in the global population. => SCREENING. Difficult :. important population of sportsmen : 10 millions «licence holders» and competitors (long distance running races : 2,5 million/ year with 63% > 35 y.o.).. asymptomatic + sport : population with low prevalence of coronary heart disease.. atherosclerotic plaque rupture is not predictible. => Cost. Public health concern.

24 Sport in the global population. => SCREENING. 1O millions «licence holders» - competitors 2400 (900 sudden death and 1500 MI)

25 Sport in the global population. => SCREENING. VNCI (SFC recommandation updated in 2009). Medical questioning +++ Medical history (family, personal) risk factors of CV disease. Symptoms (chest pain, syncopes, faintness, dyspnoea, palpitations, performance limitation +++). Physical examination. (rest heart rate, blood pressure (2 arms), murmur, peripheral pulses, Marfan) ECG : Asymptomatic cardiopathies diagnosed in 5% of the cases with the only medical examination, and in 60% of the cases if ECG added y.o. : every 3 years, then every 5 years after 20 y.o. until 35 y.o. - > 35 years : ECG

26 Sport in the global population. => SCREENING : ECG ECG : even at the high-level sportsman, the ECG is most of the time normal. Anomalies are not frequent => alloted to sport only if full cardiologic screening is normal.

27 Sport in the global population. => SCREENING : stress test? - Stress test : non systematic man > 35 y.o., woman > 45 y.o., especially if > 2 RF. - Consider sport activity wished. LIMITS +++: - low return in asymptomatics. - low detection of acute event risk.

28 Sport in the global population. => SCREENING : stress test? Relationship between stenosis and myocardial infarction

29 54 y.o. CRA VF 50 m before finish line Paris- Versailles Training 2 h/ week. Semi 2. Stress test (270 W) normal.

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31 Sport in the global population. => SCREENING : stress test? Asymptomatic amateur sportsman Medical examination including ECG. What sport? Low CV risk and no anomaly High CV risk and/or ECG ambiguous anomaly Patent ischemic ECG STRESS TEST normal positive No contraindication for sport Coronarography

32 Sport in the global population. => SCRENNING : coronary scan? - Calcic Score : only refine Framingham score => no individual interest. Ex : marathon runner 53 y.o.. Framingham Score : 4%. Agaston Score: 0 => 2% 130 =>12% > 400 : 16% - «Full» coronary scanner: - false positive - Reports with ambiguous responses. normal coronarographies +++ coronarographies with middle stenosis : medical attitude??? for a low rate of coronarographies with severe stenosis.

33 Sport in the global population. => SCREENING : coronary scan? => NO

34 Sport in the global population. SCREENING : congenital coronary abnormalities Very few abnormalities concerned : coronary course between the aorta and the pulmonary artery = rare. - Anomalous origine of coronary arteries: (anocor) < 5/ - «compressive» course : < 20 / of anocor => Then potentially dangerous anocor < 1 / Systematic screnning of anocor: only in professionnal sportsmen (echo : ostia ; if not seen => scan).

35 Sport in the global population. => SCREENING : myocardial bridge - Very common and no pathological. (when a myocardial bridge is observed during an autopsy, it is not necessary the cause of the death!!!). but exceptions!!!

36 Sport in the global population. => SCREENING : myocardial bridge Man 33 y.o. Training : 3 h/ week for years Semi Paris 2013 km 17 CRA : cardiac massage => rapid recover

37 Sport in the global population Take home message Coronary heart disease is less frequent in the sports population than in the sedentary population. But could be revealed by vigourous exertion. Screnning is difficult and necessarily faillible. -> Always questioning (symptoms+++), examination and ECG. -> Sometimes : stress test. -> No scan. During consultation, inform+++: faillible screening, alert symptoms, good sports practice.

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