Cardiac Conditions in Sport & Exercise. Cardiac Conditions in Sport. USA - Sudden Cardiac Death (SCD) Dr Anita Green. Sudden Cardiac Death

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1 Cardiac Conditions in Sport & Exercise Dr Anita Green Cardiac Conditions in Sport Sudden Cardiac Death USA - Sudden Cardiac Death (SCD) <35 years old Hypertrophic cardiomyopathy (HOCM) ~ 30-40%++ Congenital anomalies of coronary arteries ~15% ARVC ~5% Marfan s syndrome ~5% Myocarditis ~5% Valvular heart disease Coronary artery disease SCD young competitive US athletes (median age, 17 years)

2 UK - Sudden Cardiac Death (SCD) <35 years old Hypertrophic cardiomyopathy (HOCM) ~ 30-40%+ Congenital anomalies of coronary arteries ~10% ARVC ~13%** SCD in athletes (median age, 29 years) Hypertrophic Cardiomyopathy (Video) About % of sudden cardiac deaths in young athletes Familial Asymmetrical ventricular wall thickening Hypertrophic Cardiomyopathy Sudden collapse and cardiac death first symptom in many Some prodromal symptoms Exertional dyspnoea Chest pain Palpitations Presyncope / syncope

3 HCM - Investigation Examination - frequently normal ECG - usually have LVH / ST or T wave changes CXR - may enlarged / freq normal ECHO - Left ventricular hypertrophy without dilation - >15mm diagnostic Recommend not play competitive sport Normal Echo (Video) HCM Echo (Video)

4 Arrhythmogenic right ventricular cardiomyopathy (ARVC) inherited condition muscle fibres are replaced by fat or scar tissue predispose to severe arrhythmias during exercise Congenital - Coronary Artery Anomalies (CAAs) anomalous aortic origin of a coronary artery (AAOCA) and anomalous origin of a coronary artery from the pulmonary artery. ALCA - ~ 85% of SCDs related to AAOCA (considered a more lethal anomaly) postulated that occlusion or compression of anomalous vessel during exercise leads to myocardial ischemia and subsequent lethal ventricular arrhythmia (ventricular tachycardia and fibrillation) Most often infection by common viruses During acute myocarditis, all aerobic exercise to be avoided Athletes with evidence of myocarditis - withdrawn from sport & training for 6 months may commence training again when all ventricle function returned to normal / show no signs of arrhythmia Myocarditis (Video)

5 Marfan ssyndrome (Video) Aortic root dilation: rupture - cause death Assess and follow on ECHO B blockers Low intensity sports May need aortic +/- mitral valve replacement Marfan ssyndrome (Video) Dilated Aorta Prevention - Sudden Cardiac Death Screening not justified Syncope / dyspnoea / chest pain with exertion First degree relative with history of SCD First degree relative with HCM / Marfan s / familial cardiomyopathy US Cardiologist Barry Maron (M.D) Panel chair for AHA/ACC guidelines mass screening of student athletes would be impractical and ineffective.

6 Sudden Cardiac Death (Video) >35 years old Coronary artery disease Valvular heart disease (Aortic / Mitral) HOCM Cardiac Conditions in Sport & Exercise Chest Pain Ischaemic Heart Disease Risk Factors Understanding Absolute Risk Ischaemic Chest Pain - History Age increased risk with age Site retrosternal / jaw / neck / arm / epigastric Type pressure/constricting/burning Aggravation activity/meal/cold/ stress - not mechanical Relieving rest/gtn not with postural change Associations nausea/vomiting/sweating

7 Chest Pain Non Traumatic Musculoskeletal o Costochondritis / Sternoclavicular joint o Thoracic spine referred o Intercostal muscle Gastrointestinal o Reflux o Peptic ulceration Cardiac o Ischaemic Respiratory o Pulmonary embolism Chest Pain - Summary Young athletes majority chest wall History - including family history Assessing chest pain - risk stratification Low risk - high false positive rate testing Intermediate risk - stress test High risk - consider angiogram Stratification of Risk Typical vs atypical pain Risk factors o Age o Sex o Family history Non Modifiable Lipid profile Smoking Blood pressure Modifiable Diabetes Obesity Physical inactivity Cerebro- / Reno- / Peripheral- vascular disease

8 CHD Risk Factors Smoking Diabetes Dyslipidaemia Hypertension Obesity Physical Inactivity Risks are cumulative (multiplicative) Lifestyles predispose to RF One RF may predispose to other RF Improving RF is effective in primary, secondary and tertiary prevention Improving one RF may improve others

9 Absolute Cardiovascular Risk Modfication Online CardioVascular Risk Calculator Palpitations History Palpitations in athletes usually benign History of more concern if Near syncope / syncope Chest pain Family history of premature cardiac disease / sudden death Investigations Exercise induced Stress test +/- ECHO Palpitations Holter monitor 24 to 48 hours Home arrhythmia monitor up to 28days Electrophysiological studies

10 Syncope (Collapse) Presyncope / syncope during exercise warrants investigation Post exercise is common and frequently physiological Increased suspicion with family history of cardiomyopathy / HCM / SCD Similar investigations to palpitations + Tilt table + Implantable loop recorder if no warning Tilt Test

11 Cardiac Conditions in Sport & Exercise Overview of a Cardiac Scientist s Role Common Career Path Cardiac Sciences Public / Private Hospitals Cardiology Private Clinics ECG / Holter monitoring Stress Testing Echocardiology Catheter Laboratory Electrophysiology Laboratory Maximal Exercise Stress Testing Treadmill Bruce protocol - ramped protocol Aim 100% predicted max HR Investigation Chest Pain Dyspnoea Palpitations

12 Exercise Testing Indications Screening of higher risk individuals (Exercise / Athletes) Diagnosis of chest pain / dyspnoea Assess severity of CAD / arrhythmias Assess adequacy of medication Risks of Maximal Stress Testing Risks per 10,000 tests Myocardial infarction = 3.5 Serious arrythmia = 4.5 Death = 0.5

13 Resting ECG ECG Study - 4 minutes ECG Study - 11 minutes

14 Myocardial Perfusion Scan Nuclear Medicine -Technetium Isotope Perfusion scan Maximal exercise stress test Adenosine stress test Dobutamine stress test Normal Nuclear Medicine Images Cross-Section Sagittal View Stress Stress Rest Rest

15 Nuclear Medicine Images of Defects Reversible Defect Fixed Defect Stress Stress Rest Rest Stress Echocardiogram Contractility of myocardium Regional wall motion abnormalities Ejection fraction increase with exercise Valve opening / closing / velocities exclude significant Aortic Stenosis

16 Indications Cardiac Catheterisation High risk patient with chest pain Positive stress test For significant lesions treatment options include Medical Angioplasty Stent Coronary bypass grafting Development of Acute Infarct Normal ECG

17 Development of Acute Infarct Development of Acute Infarct Development of Acute Infarct

18 Cardiac Catheterisation

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