New scientific advances in Sports Cardiology-

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1 New scientific advances in Sports Cardiology- Highlights from EuroPRevent Prague 2010 ESC meeting, Stockholm Mats Börjesson, MD, Assoc prof, Univ lecturer Sahlgrenska University Hospital/Östra, Göteborg, Sweden

2 Symposium Cardiovascular adaptation to exercise in children Chairmen: E Meijboom, Lausanne E Kouidi, Thessaloniki F Quattrini M Papadakis G Whyte H Heidbuchel

3 Physiological Upper limits of cardiac dimensions in adolescent athletes M. Papadakis St George s University of London, UK University Hospital Lewisham, London, UK

4 Factors influencing cardiac adaptation to exercise Gender Size Genetic Sporting Discipline Athlete s Heart Cardiac Pathology Ethnicity AGE

5 Left ventricular cavity size in adolescent athletes 900 elite athletes vs. 250 sedentary controls athletes controls 17% Makan J et al. Heart 2005;91:

6 Left ventricular hypertrophy in adolescent athletes 720 elite athletes vs. 250 sedentary controls 0.4% Sharma S et al. JACC 2002;40:

7 Conclusion Adolescent athletes exhibit similar cardiac adaptation to adult athletes with increased chamber size and wall thickness BUT to a lesser degree compared to adult athletes Most athletes exhibit modest increase in cardiac dimensions A small proportion of athletes exhibit substantial increase in cardiac size which overlap with cardiomyopathies

8 Genetic Determinants of Functional Capacity: Can Potential Olympic Champion Runners be Selected in Childhood? Professor Gregory P Whyte PhD FACSM Research Institute for Sport & Exercise Science Liverpool John Moores University

9 The Performance Gene? ACE I/D (Montgomery et al., Circ 1998;96: ; Coates, Int J Biochem Cell Biol. 2003;35: ) Increased I allele in endurance rowers (n = 64). I allele related to running distance (n = 65; 35 endurance, 30 sprint) Increased D allele in short distance swimmers (n = 35) * 2 larger studies have reported no association (Taylor et al., 1999; Rankinen et al., 2000)

10 The Performance Gene? Other Candidates CKMM $ (Echegaray and Rivera, Sp Med 2001;31: ) not found in elite athletes AGT M235T $ (McCole at al., Physiol Genomics 2002;10:63-69) elite endurance athletes (n = 24) β 2 -adrenergic receptor gene ADRB2 gene $ (Moore at al., Metabolism 2001;50: ) elite post-menopausal endurance athletes (n = 24) Bradykinin β 2 receptor gene BDKBR2 (Williams et al., JAP 2004;96: ) elite track athletes (n = 81) ACTN3 (fast-fibre-specific Z line protein α-actinin-3) (North et al., Nat Genet 1999;21: ) (n = 301; 107 sprint/power; 194 endurance) $ Independent replication of results however; all variants have been shown not to be related to performance in other studies!

11 Can Potential Olympic Champion Runners be Selected in Childhood? Summary: To date, there is no evidence that any of the identified gene variants have any substantial predictive value for prospectively identifying potential elite athletes

12 Symposium Vexing issues in sports Cardiology Chairmen: E Solberg, Oslo M Borjesson, V Frolunda D Corrado F Carre S Sharma A Pelliccia

13 Vexing issues in sports cardiology Should young athletes implanted with internal cardioverter defibrillators be allowed to continue to participate in high intensity sports? Domenico Corrado, MD, PhD Department of Cardiac, Thoracic and Vascular Sciences University of Padova, Italy EUROPREVENT 2019 Prague May 5-7, 2010

14 Reasons of restriction from intense sports participation in patients with an ICD Increased frequency of ventricular arrhythmias Potential failure of shock to convert a life-threatening arrhythmia Increased frequency of inappropriate shock Injury to patients due to momentary loss of control because of the arrhythmia of the shock itself Sports-related damage to the device or lead system

15 Inappropriate Shock: consequences Shock is painful: anxiety/aversion of the ICD therapy Inappropriate shock may be potentially lifethreatening (trigger of malignant arrhythmias)

16 Safety of Sports Participation in Patients with ICD: A Survey of Heart Rhythm Society Members Lampert et al; JCE 2006; 17: 11-15

17 Conclusions Reasons for restriction of competition sports in young competitive athletes with cardiomyopathy and ICD go beyond the increased risk of arrhythmias, inappropriate interventions, injury to patient and damage of the system. Sports participation is a mortality issue because plays a major role in the disease progression, substrate worsening and adverse outcome

18 EuroPrevent 2010 François Carré, Gaelle Kervio, Nathalie Ville, Université Rennes 1 Hôpital Pontchaillou Inserm U 642 PRAGUE 5-7 May

19 Automatic result Manual tangent method U wave must be excluded Incorrect measurement of QT - 70 % of cardiologists - 33 % of heart rhythm specialists (Viskin S,, et al. Heart Rhythm 2005) How to measure QT duration? Lead II or V5 ++ Physiological modulators of QT duration J N Johnson, M J Ackerman Br J Sports Med 2009 Age and gender effect Correction for heart rate Autonomic modulation Athlete s heart Cardiac hypertrophy Illicit and prohibited drugs?

20 Why an increased QT duration in athletes? Prolongation cardiac repolarization? Autonomic balance rats PS Cyclists S Tibbits et al Carré F et al. 2000

21 QTC duration in athletes, sports specificity effect Parame ter HR (bpm) RR (ms) QT Static (n=177) 62.6 ± 13.1 (38 108) 998 ± 194 ( ) ± 33.7 ( ) Mixed (n=245) 60.2 ± 12.3 (34 105) 1036 ± 206 ( ) ± 33.0 ( ) Dynamic (n=377) 58.0 ± 11.5 (36 92) ** 1074 ± 208 ( ) ** ± 36.1 ( ) QTcb ± 24.4 ( ) ± 25.5 ( ) ± 26.5 ( ) dynamic static mixed Males athletes ** p<0.01 Kervio G et al 2007 The mean QT and QTc values are not influenced by sport s specificty

22 QT duration limits in athletes 5130 athletes 3514 males 1676 females Limits males Females ESC (> ) 129 (3.7%) 31 (1.9%) Bethesda ( ) 16 (0.46%) 9 (0.54%) Basavarajaiah (>500) 2 (0.06%) 1 (0.06%) Basavarajaiah et al Eur Heart J % Corrado et al JAMA % Sedentary people 0.04 % (Goldenberg J J Am Coll Cardiol 2008;

23 Sanjay Sharma BSc (Hons), MD, FRCP (UK), FESC Professor of Clinical Cardiology and Director of the Inherited Cardiac Diseases and Sports Cardiology. Conflicts/Disclosures: None

24 Size Age Ethnicity Gender Anabolic Drugs Type of sport ECG Inherited Cardiomyopathy or ion channel disorder

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26 904 asymptomatic black male athletes Normotensive No obvious FH of cardiomyopathy West African (70%), East African (20%), North African (10% Participating at regional or National level 22 different sporting disciplines Mean age 22.8 (range 14-35) BSA 1.91 ± 0.16 m -2 (range )

27 Parameter Black Athletes (n = 904) White athletes (n = 1823) P- values ST Segment Elevation (%) < ST segment depression (%) NS T wave inversions (%) < Deep T wave inversions (%) <

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29 Parameter Black Athletes (n = 904) Sedentary Individuals (n = 119) P- values ST Segment Elevation (%) NS ST segment depression (%) NS T wave inversions (%) < Deep T wave inversions (%) <

30 V4 V5 V6

31 Black athletes exhibit marked repolarisation changes compared with white athletes. Amongst black athletes, repolarisation changes are more prevalent and pronounced in males than females Deep T wave inversions in V1-V4 are common and appear benign. Deep T wave inversions in the inferior lateral leads require further assessment for cardiac pathology. The significance of minor T wave inversions in the inferior and later leads remains to be elucidated.

32 Preparticipation CV screening of competitive athletes: saving lives or destroying lives? Antonio Pelliccia, MD Institute of Sports Medicine and Science Rome, Italy

33 Why we perform CV Screening? to reduce the risk of sudden cardiac death (or disease progression) and start appropriate treatment, if necessary by timely identification and selective withdrawal from competitive sport of athletes with silent cardiac disease. AHA 2005; ESC 2005

34 Comparison of Italian and US Sudden Deaths in Competitive Athletes Corrado et al. JAMA 2006; 296: Maron et al. Am J Cardiol 2009

35 The disqualification controversies: Criteria for accurate and individualized risk stratification in most cardiomyopathies are incompletely defined; Sport activity as independent and powerful risk determinant is not completely proven; Cause of immediate loss of social, economic and psychological benefits vs. potential future health benefits.

36 Abnormal findings Diagnosis of HCM in young athletes Genotype positive, phenotyp e negative Abnormal ECG LV Hypertrophy Sudden death can occur at any time! Adolesce Adulthood nce ECG is altered in HCM patients prior the appearance of LVH!

37 University Potsdam, Germany

38 Preparticipation Screening System Elite Sports Schools Brandenburg preparticipation screening system for elite sports schools children at 7th (8th and 10th) year of school history, physical examination ECG at rest and during exercise echocardiography at 7th and 9th year of school routine blood parameters corresponding to preparticipation screening in olympic athletes funded (and wanted!) by the state government

39 Subjects [n] ECG findings normal minor alterations mildly abnormal distinctly abnormal Boys Girls

40 Predictive values ECG sensitivity 38 % Young athletes (Sports School) specificity 64 % positive predictive accuracy 13 % negative predictive accuracy 88 % sensitivity 51 % Italien athletes* specificity 61 % positive predictive accuracy 7 % negative predictive accuracy 96 % *: Pelliccia et al. Circulation 2000;102:

41 Conclusion Same distribution of ECG patterns in young athletes as in adult athletes No differences in the amount of ECG patterns between boys and girls, probably reflects missing differences in growth induced by sex hormones at older ages High negative predictive value of ECG in preparticipation screening Due to the low sensitivity of ECG and false positive ECGs, echocardiography is an important tool to rule out structural cardiac abnormalities even in young athletes URL LV wall thickness years: 8-9 mm (Girls), 9-10 mm (Boys) years: 9-10 mm (Girls), 11 mm (Boys) URL LV EDD : ~ 53 mm / mm/m² / 33 mm/m

42 Symposium Too old to play Chairmen: K-P Mellwig, Bad Oeynhausen D Dugmore, Stockport S Hood H Bjornstad M Sheppard M Borjesson

43 WHAT ARE THE LONG- TERM CARDIAC IMPLICATIONS OF PARTICIPATING IN HIGH INTENSITY SPORT? HANS BJØRNSTAD HAUKELAND UNIVERSITY HOSPITAL, BERGEN

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45 MATERIAL&METHODS 30 TOP ENDURANCE ATHLETES (skiers,runners), 50%FEMALES * MEAN AGE 25 YEARS, 12 INTERNATIONAL CHAMPIONS, 10 INTERNATIONAL LEVEL, 8 NATIONAL LEVEL (Start of systematic training at 13 years) 100% FOLLOW UP 15 YEARS Clin.,ECG, 24h ECG, echo (also with doppler on follow up)

46 Conclusion: changes 6-12 years after stopping active career LV volume unchanged Relative wall thickness reduced LV ejection fraction increased LV diastolic function normal* Left atrium slightly enlarged* Aortic root * Heart rate sign. reduced only at night AV and SA blocks disappeared (High HRV *) (VPBs: no significant change**) *): Not baseline data **):Different methods

47 Is there a role for preparticipation screening in middle-aged athletes? Mats Börjesson, MD, Assoc prof, Univ lecturer Sahlgrenska University Hospital/Östra, Göteborg, Sweden

48 EACPR recommendations Cardiovascular evaluation of adult/senior individuals engaged in leisure-time or competitive sport activities Position Stand from the Sections of Sports Cardiology and Exercise Physiology, within the European Association for Cardiovascular Prevention and Rehabilitation (EACPR) Borjesson M, Urhausen A, Kouidi E, Dugmore D, Sharma S, Halle M, Heidbuchel H, Bjornstad H, Gielen S, Mezzani A, Corrado D, Pelliccia A, Vanhees L- EJCPR 2010

49 The goal is to achieve all the benefits of PA and avoid the negative effects at the same time

50 Screening recommendations according to: 1 Intensity-level of intended PA; 2. Risk profile; 3. Habitual exercise

51 The middle aged athletes of Vasaloppet? : racers, 13 SCD (expected 1,7) -1/ racers

52 73500 competitors in Vasaloppet , mean 4 year follow-up

53 Vasaloppet- net effect skiers extra SCD during the race 240 less deaths in 4 years follow-up after the race

54 Symposia Exercise recommendations in athletes Chairmen: A Pelliccia, Rome A Deligiannis, Thessaloniki A Hirth S Sharma L Vanhees N Panhuysen-Goedkoop

55 Exercise Guidelines in Cardiomyopathy Sanjay Sharma MD, FRCP, FESC Professor of Clinical Cardiology

56 Hypertrophic Cardiomyopathy

57 Individuals with Unequivocal HCM or High Probability of HCM Bethesda Guidelines (American) Participation in class 1A sport (low intensity and low dynamic) ESC Guidelines No competitive sports if symptoms or any risk factors for sudden death Class IA sport (low intensity and low dynamic) in those with no symptoms or risk factors

58 Diagnosis of HCM is Based on Echocardiography Left ventricular Hypertrophy ( 13 mm in adults and > 11 mm in adolescents) in association with a nondilated LV cavity

59 Exercise Guidelines for Athletes with Isolated ECG Abnormalities in the absence of other phenotypic features of HCM or Familial HCM Bethesda Guidelines Can participate in all sports ESC Guidelines Can participate in all sports

60 Arrhythmogenic Right Ventricular Cardiomyopathy

61 Individuals with Unequivocal ARVC or High Probability of ARVC ESC Guidelines Participation in Class IA sport (low intensity and low dynamic) in most athletes Bethesda Guidelines (American) Participation in class 1A sport in all athletes

62 Take home message: Male Athletes Female Athletes max-lvwt > 14 mm > 11 mm LVED > 60 mm > 55 mm LA > 45 mm > 42 mm Ao > 40 mm > 36 mm should be further assessed for underlying cardiac pathology The vast majority of clinical dilemmas can be resolved with systematic clinical evaluation