HEART CONDITIONS IN SPORT

Transcription

1 HEART CONDITIONS IN SPORT Dr. Anita Green CHD Risk Factors Smoking Hyperlipidaemia Hypertension Obesity Physical Inactivity Diabetes 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 Physical Activity Benefits Reduces likelihood of Coronary artery disease Dyslipidaemia Hypertension Obesity Type 2 diabetes mellitis? Smoking

2 Exercise Effects Hyperlipidaemia Lower total 65%MHR Hypertension Significant drop in 60 to 70%MHR Lower triglyceride Increase 75 to 85%MHR (mainly with associated weight reduction) Achieve with 3 times per week Levels drop around 10mm systolic and 6mm diastolic - significant benefits Exercise Effects on Obesity Overweight/obese 66% Australian males 46% Australian females Levels are increasing Genetic potential High calorie food availability Inactivity Recommend accumulated activity then low intensity activity Exercise Effects on Diabetes Mellitus Type 1 (10% diabetics) Type 2 (90% diabetics) Exercise not shown to improve glycaemic control Benefits - increased fitness (aerobic and muscular) and well being (normalise) Primary goal is safe participation Most >40yo and sedentary 80% overweight/obese Problem is insulin resistance Acute benefits of exercise last 24 to 48hrs thus need regular daily activity (Glut 4) Resistance training may improve control

3 Physical Activity in Management Obesity - + dietary modification (waist:hip) Hypertension - mild to moderate (initial trial of nondrug therapy) Dyslipidaemia - initial 3m trial + modify diet - increase HDL, decrease LDL & total cholesterol Type 2 Diabetes - initial sole treatment - may control without drugs with appropriate diet Palpitations History Palpitations in athletes usually benign History of more concern if o near syncope / syncope o Chest pain o Family history of premature cardiac disease / sudden death Investigation Exercise induced o stress test +/- ECHO Palpitations at rest o Holter monitor 24 hrs o Home arrhythmia monitor up to 28days o Electrophysiological studies Syncope 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

4 Sudden Cardiac Death (SCD) <35 years old Hypertrophic cardiomyopathy (HOCM) Congenital anomalies of coronary arteries Marfan s syndrome Myocarditis Valvular heart disease Coronary artery disease Long QT syndrome NORMAL HOCM Hypertrophic Cardiomyopathy About 35% of sudden cardiac deaths in young athletes Familial Asymmetrical ventricular wall thickening Sudden collapse and cardiac death first symptom in many Some prodromal symptoms o Exertional dyspnoea o Chest pain o Palpitations o Presyncope / syncope 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

5 Marfan s Syndrome Aortic root dilation - rupture = cause death Assess and follow on ECHO B blockers Low intensity sports May need aortic +/- mitral valve replacement Prevention Sudden Cardiac Death Screening not justified Syncope / dyspnoea / chest pain with exertion New arrhythmia New murmur First degree relative with history of SCD First degree relative with HCM / Marfan s / familial cardiomyopathy Exercise prescription - sedentary person with cardiac risk factors Sudden Cardiac Death >35 years old Coronary artery disease Valvular heart disease (Aortic / Mitral) HOCM

6 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 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 Ischaemic Chest Pain Examination Often unremarkable PR / rhythm BP Carotid & peripheral pulses Murmurs Failure Investigation ECG Serial troponins [Ventilation / perfusion (VQ scan) exclude PE] Maximal exercise stress test (MEST) Myocardial perfusion stress test (MPS) Stress echocardiogram CT coronary angiogram (CTCA) Cardiac MRI

7 Exercise Stress Testing Assess potential CAD as cause for chest pain Extension of clinical and risk factor assessment Stratification of risk Intermediate risk patients 25 to 75% of CAD Sensitivity = 68% Specificity = 77% Maximal Exercise Stress Testing Treadmill vs bike Bruce protocol ramped 3 min stages Modified Bruce / Naughton 6 to 12 mins Aim 100% predicted max HR (need min 90%) Exercise Testing Indications Screening of higher risk individuals risk factor profile, age / family history Diagnosis of chest pain / dyspnoea Assess severity of CAD, arrhythmias Assess adequacy of medication Assess Post Infarction - Sub-max at Day 5+ - Maximal at ~ 6wks

8 Exercise Stress Testing - Limitations Not useful as a screening test high false positive Divided opinion on stress test those commencing vigorous exercise program tests static narrowing Chest pain + Low pre test probability CAD <25% - high false positive Chest pain + High pre test probability CAD >75% - coronary angiogram Exercise Stress Test Contraindications Recent Infarction < 5days Unstable Angina Severe Aortic Stenosis / HOCM Severe Hypertension Uncontrolled Arrhythmias Conduction Defects Significant Cardiac Failure Indications for Terminating Max heart rate achieved Severe angina Severe dyspnoea Dizziness ST depression >2mm ST elevation Significant arrhythmia BP > or = 250mm Hg Significant fall in BP Risks of Maximal Stress Testing Risks per 10,000 tests Myocardial infarction = 3.5 Serious arrythmia = 4.5 Death = 0.5

9 Myocardial Perfusion Scan Nuclear Medicine -Technetium Isotope (Sestamibi / Tetrafosmin) Perfusion scan o Maximal exercise stress test o Adenosine / Persantin stress test o Dobutamine stress test Gated heart pool scan o Regional wall motion abnormalities o Ejection fraction Myocardial Perfusion Scan Unable to exercise to maximal heart rate o Orthopaedic problems o Deconditioning o Pulmonary disease o Peripheral arterial disease Resting ECG abnormalities unable to interpret o Paced rhythm o Left bundle branch block o ST depression > 1mm Normal Nuclear Medicine Images Cross-Section Sagittal View Stress Stress Rest Rest

10 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 o opening / closing / velocities o exclude significant Aortic Stenosis and Pulmonary Hypertension Stress Echocardiogram - Indications Non pharmacologic o Still need to be able to exercise o ECG changes at rest o Positive maximal exercise test in lower risk patient o Advantage over MPS - no radiation Pharmacologic Dobutamine o Cannot exercise low ejection fraction o Add contrast bubbles if echo quality limited

11 Cardiac Catheterisation High risk patient with chest pain Positive stress test If significant lesions treatment options o Angioplasty o Stent o Coronary bypass grafting 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