Athletes with cardiac disease; dead and buried or chance for resurrection?

Transcription

1 Athletes with cardiac disease; dead and buried or chance for resurrection? EuroPRevent 2011 Geneva F. Carré University Rennes 1-Pontchaillou Hospital Inserm U642, Rennes - F-35000

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3 Risk of physical activity in cardiac diseases 3 p<0.001 Relative risk of sudden death = ,3 0,9 Athletes Sedentary y.o Corrado et al. J Am Coll Cardiol 2003

4 Non traumatic sudden death during sport < 35 years old De Noronha SV et al Heart 2009;95: Maron1996 Intense exercise can induce acute cardiac event worse cardiac disease

5 ESC recommandations Eur Heart J 2005;26:

6 US recommandations 36 th Bethesda conference J Am Coll cardiol 2005;45:

7 Interest and limit of the recommandations Needed because SD and sport s disqualification are mainly due to cardiovascular diseases Consensus more than recommandations No specific study on athletes Good sense and personal experience Absolute risk is known but what about individual risk?

8 Two main questions concerning CV disease and sport s participation in athlete 1 True diagnostic of cardiac disease in an athlete 2 Individual risk during sport participation CV disease aggravation SD or cardiac event risk Treatment efficacy

9 Two main questions concerning CV disease and sport s participation in athlete 1 True diagnostic of cardiac disease in an asymptomatic athlete 2 Individual risk during sport participation CV disease aggravation SD or cardiac event risk Treatment efficacy

10 Athlete s heart: a multifactorial adaptation Training specificities Anthropometry Gender Age Ethnicity Genetic Doping

11 Athlete s heart «limits» DCM? EDLVD mm Complex ventricular arrhythmias myocarditis? Athlete s heart? Cardiomyopathy Adapted from Maron BJ et al. JACC 2005;45 HCM? ARVD? «abnormal» ECG LV WT mm HCM?

12 Hypertrophic cardiomyopathy

13 HCM Soccer player Professional cyclist ECG easy but ECG is abnormal in % of HCM V 4 V 5 V 6

14 ECG variants in athletes : ethnicity effects in Men Soccer players African Caucasian Japanese North African n=96 n=118 n=68 n=49 Isolated R or S wave 35 mm 10% 4% 9% 2% Diphasic T waves 17% 2% 6% 4% Inverted T waves 4% 0% 0% 0%

15 ECG variants in athletes : ethnicity effects in Women 2 % of deep inverted T waves 0 % of deep inverted T waves Rawlins J et al Circulation 2010;121:

16 Echocardiogram easy but

17 Cardiac remodelling and training specificties

18 LV wall thickness in athletes and ethnicity MEN 3% 3% Basavarajaiah S et al. J Am Coll Cardiol 2008;51:

19 LV wall thickness in athletes and ethnicity WOMEN Rawlins J et al. Circulation 2010;121

20 Athlete s heart or HCM? Adapted from 36 th Bethesda conference Maron BJ et al. JACC 2005;45 + MRI -

21 Black basket ball woman player Apical hypertrophic cardiomyopathy

22 Caucasian woman long distance runner (1)

23 Caucasian long distance runner (2) History, echocardiography, cardiac MRI, exercise test, 24 H Holter : no abnormality

24 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%)

25 Swimmer, 17 y.o. Training 16h/week Detraining 4 months

26 Two main questions concerning CV disease and sport s participation in athlete 1 True diagnostic of cardiac disease 2 Individual risk during sport participation CV disease aggravation SD or cardiac event risk Treatment efficacy

27 CV disease aggravation Dilated laminocardiomyopathies and competition Pasotti M et al. J Am Coll Cardiol 2008;52: Risk factors Competitive sport participation NYHA III-IV Risk factors Mutation specificity Competitive sport participation Valvular diseases?

28 Individual cardiac event risk? ATHLETE Mechanism Area Adrenergic Antecedent Pathology Symptoms Treatment Training level Psychological EXPOSED

29 Patient patterns History Cardiac disease and treatment Exercise related symptoms Sport history and aims Physical exam Complementary exams 12 leads ECG Echocardiography CPX with drugs Exercise echocardiography Holter with exercise session MRI, T wave alternans, Late potential ECG Others

30 Individual cardiac event risk? ATHLETE Mechanism Area Adrenergic Antecedent Pathology Symptoms Treatment Training level Psychological EXPOSED Sport Intensity Duration Competition Environment

31 Sport classification from Mitchell et al 2005 ESC reommandations EHJ 2005

32 Cardiovascular effects of competition Psychological impact Intensity Caution with stop watch, ball sports, points sports P. Fages Thèse rennes 1984

33 Mitchell s classification limits Age Skill Modulation of intensty Duration of exercise Environment Psychological profile Individual profile of athlete

34 Low risk subject? CARDIAC DISEASE Low absolute risk «Good» specific criteria PATIENT No symptom at rest and during exercise No significant arrhythmia at rest and during exercise Good myocardial function Adapted fitness level Adapted training level Good technical skill Good drug observance if needed PHYSICAL ACTIVITY Adapted intensity Good practice and education

35 Treatment efficacy Drugs Arterial hypertension Ablation WPW Supraventricular tachycardia Atrial fibrillation Atrial flutter Ventricular tachycardia

36 Take home messages Intense exercise increases cardiac complications risk in case of cardiac disease Arrhythmia is the main cause of exercise related sudden death In all case all adapted cardiovascular explorations are needed Current recommandations can be seen as guidelines Two main questions arise in Athletes the true diagnostic the individual risk level which is dificult to accuretely define Sometimes common decision between «experts» is needed In all cases, the final decision must be argumented and explained to the athlete