SPORT AND ARRHYTHMIA Sports and Physical Exercise in Special Clinical Settings Chairmen: P. Delise, F. Giada. Myocarditis
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1 SPORT AND ARRHYTHMIA Sports and Physical Exercise in Special Clinical Settings Chairmen: P. Delise, F. Giada Myocarditis Brian Olshansky MD Professor Emeritus, University of Iowa Electrophysiologist, Mason City, Iowa USA
2 MY CONFLICTS OF INTEREST ARE Medtronic consultant Boston Scientific DSMB, consultant, research Amarin DSMB, consultant Biocontrol consultant, research Sanofi-Aventis - DSMB Boehringer Ingelheim consultant, research On-X - consultant Biotronik - consultant Lundbeck consultant Daiichi Sankyo consultant, speaker
3 A Case of Intractable VF 300 µgm/min)
4 A Case of Intractable VF Bharati S. J Cardiovasc Electrophysiol 1992;3:
5 A Case of Intractable VF Myocarditis of the AV node Fibrosis of the septum Diagnosis: Chronic myocarditis of the septum Bharati S. J Cardiovasc Electrophysiol 1992;3:
6 Corrado D. Cardiovasc Res 2001;50: Sudden Cardiac Death Young People Apparently Normal Heart
7 Myocarditis Schultz JC. Mayo Clin Proc 2009;84:
8 Toxins Position Statement - ESC Working Group Amphetamines, anthracyclines, cocaine, ethanol, cyclophosphamide, fluorouracil, lithium, hemetine, catecholamines, interleukin-2, trastuzumab, clozapine Chemicals - copper, iron, lead, carbon monoxide, arsenic, phosphorus, sodium azide Radiation, electric shock Other - scorpion sting, snake/spider bites, bee and wasp stings, pheochromocytoma, beri beri Caforio ALP. Eur Heart J 2013;34:
9 Infectious Etiologies Position Statement - ESC Working Group Bacterial, mycobacterial, spirochete, fungal, protozoal, parasitic, rickettsial RNA virus: Coxsackie A and B, echo, polio, influenza A/B, respiratory syncytial, mumps, measles, rubella, hepatitis C, dengu, yellow fever, Chikungunya, Junin, Lassa fever, rabies, HIV-1 DNA virus: adeno, parvo, B19, cytomegalovirus, herpes-6, Epstein-Barr, varicella-zoster, herpes simplex, variola, vaccinia Caforio ALP. Eur Heart J 2013;34:
10 Immune-Mediated Position Statement - ESC Working Group Tetanus toxoid, vaccines, serum sickness Drugs: penicillin, cefaclor, colchicine, etc. Heart transplant rejection Autoantigens: lymphocytic or giant cell Autoimmune: lupus, rheumatoid arthritis, Churg-Strauss, Kawasaki s disease, inflammatory bowel, scleroderma, polymyositis, myasthenia, diabetes, thyrotoxicosis, sarcoidosis, Wegener s, rheumatic fever Caforio ALP. Eur Heart J 2013;34:
11 Caforio ALP. Eur Heart J 2013;34:
12 Time Course of Myocarditis Edema Gadolinium enhancement Kindermann J. Am Coll Cardiol 2012;59:779 92
13 Maron BJ. Circulation 2007;115: Causes of Sudden Death Young Competitive Athletes Hypertrophic cardiomyopathy
14 Harmon KG. Circ Arrhythm Electrophysiol 2014;7: Sudden Death in NCAA and Other Populations
15 European Prospective Registry Sports-related sudden cardiac death Total population Age 35 Mean age: 46.8±16.2 years Bohm P. Eur J Preventive Cardiol 2015 in press
16 Assessment of the Athlete Recommendations for competitive sports participation in athletes History upper respiratory/gi symptoms, palpitations, fatigability, exertional dyspnea, syncope. Flu-like illness or epidemiological circumstances supporting viral infection ECG Frequent, complex ventricular and/or supraventricular arrhythmias, ST-T changes, bundle branch block, AV block Caforio ALP. Eur Heart J 2013;34: Pelliccia A. Eur Heart J 2005;26:
17 Caforio ALP. Eur Heart J 2013;34: Diagnostic Criteria Recommendations for competitive sports participation in athletes ECG abnormalities Elevated troponin (T/I) Functional/structural abnormalities on imaging (echo/angiography/mri) Tissue characterization MRI -> edema and/ or classical myocarditis Angiography, myocardial biopsy
18 Caforio ALP. Eur Heart J 2013;34: Echocardiography Recommendations for competitive sports participation in athletes Global LV enlargement and dysfunction Mildly enlarged LV, borderline dysfunction Localized wall motion abnormality (apex) Pericardial effusion
19 Zagrosek A. J Am Coll Cardiol Img 2009;2:131 8 Lesion Reversibility by MRI Partial reversibility Complete reversibility
20 Proposed MRI Criteria Regional/global myocardial increase in T2-weighted image signal intensity Increased global early enhancement ratio between myocardium and skeletal muscle in gadoliniumenhanced T1-weighted images Focal lesion(s) with nonischemic distribution in inversion recovery-prepared gadolinium-enhanced T1-weighted images (c/w injury or scar) Left ventricular dysfunction or pericardial effusion Friedrich MG. White Paper. J Am Coll Cardiol 2009;53:
21 Recommendations Competitive Sports Participation Active myocarditis! History, PE, ECG, Echo! No competitive sports After resolution (6-months post-onset)! History, PE, ECG, Echo, exercise test, Holter! No symptoms or arrhythmias, normal LV function! All competitive sports Pellicia A. Eur J Cardiovasc Prev Rehabil 2006;13:
22 Exercise in Myocarditis? Avoidance prudent based on animal data Mice-> Coxsackie B3 inoculation, exercised to exhaustion Exercise nearly doubled lesion size and tripled T cytotoxic, T suppressor cells and doubled T cytotoxic, suppressor/t helper cell ratio Thus, exercise during acute infection may contribute to disease progression Gatmaitan BG J Exp Med 1970;131: Ilback N-G. Am Heart J 1989;117:1298
23 Coxsackie B3 Myocarditis Worsened by Exercise Coxsackie B-3 myocarditis induced in mice had an acute mortality of 5.5% Acutely, when mice were forced to swim, half died most while swimming but, after the acute phase, swimming led to a 13.8% mortality Myocardial Coxsackie replication increased 530X with swimming during the acute phase Gatmaitan BG. J Exp Med 1970;131:
24 Exercise - Not a Good Thing Mortality in Coxsackie B3 infected Mice Cabinian AE. J Lab Clin Med 1990;115:454-62
25 Exercise and Myocarditis A Bad Combination INF infected with coxsackie B3 EX - exercise AB anti-thymocyte antibodies CYA cyclosporine A Cabinian AE. J Lab Clin Med 1990;115:454-62
26 Asymptomatic Athletes Schnell F. Br J Sports Med 2015;0:1 8
27 Asymptomatic Arrhythmias Schnell F. Br J Sports Med 2015;0:1 8
28 T-Wave Changes Schnell F. Br J Sports Med 2015;0:1 8
29 Delayed Hyperenhancement MRI Asymptomatic Athletes Schnell F. Br J Sports Med 2015;0:1 8
30 Asymptomatic Myocarditis Isolated large areas of subepicardial delayed enhancement in an asymptomatic athlete is not benign and requires careful evaluation at exercise and strict follow-up These findings question whether extreme exercise during silent myocarditis may facilitate fibrosis generation and adverse remodeling Schnell F. Br J Sports Med 2015;0:1 8
31 Conclusion Myocarditis, a cause for death among athletes, may be more common than thought Diagnosis is clinical but may be missed Restriction from sports for at least 6 months until complete resolution is present
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