L essentiel de 2013 Exercice Readaptation et Sport (GERS) Dr Marie Christine Iliou

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1 PARIS Janvier 2014 L essentiel de 2013 Exercice Readaptation et Sport (GERS) Dr Marie Christine Iliou

2 Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Affiliation/Financial Relationship Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit Company ResMed Servier, Astra-Zeneca, Boehringer, Novartis,

3 E xercise R ehabilitation S ports

4 Exercise Meta epidemiological study (16 meta-analyses) Exercise vs Drugs on mortality outcomes participants randomized In Secondary prevention on Coronary Heart Disease and prediabetes : no statistically differences among any exercise and drugs: the OR of mortality was reduced similarly «For example, regulators should consider requiring pharmaceuticals sponsors of new drugs to include exercise interventions as an active comparator arm» Naci H, Ioannidis J. BMJ 2013;347;f5577

5 Exercise test report Reason for terminating exercise Patient effort defined by % PMHR Effort capacity (METs) HR and BP at resting, exercise and recovery Peak and recovery ST modifications

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7 Powers S. Physiolology 2014; 29:27-38

8 Rehabilitation post MI Oldridge N. Future Cardiol 2012;8:729-51

9 In France 2011 (post MI) Patients hospitalisés en SSR dans les 6 mois Réadaptation cardiaque Autres finalités Hommes Femmes p Global Hommes Femmes p Global N Age moyen (ans) 57,7 62,6 *** 58,6 76,1 82,4 *** 79,7 PMSI MCO SSR CV % Tous âges % 26,9 13,5 *** 22,7 6,1 18,6 *** 10,0 For ACS ans (%) 42,5 32,3 *** 40,6 1,0 2,7 * 1, ans (%) 35,4 28,6 *** 34,2 2,4 3,4 * 2, ans (%) 24,8 18,0 *** 23,0 5,4 9,9 *** 6, ans (%) 11,3 8,5 *** 10,1 10,9 23,1 *** 16,2 85 ans (%) 3,0 1,9 * 2,3 23,5 32,9 *** 29,3 De Peretti C. BEH 2014

10 Regional disparities De Peretti C. BEH 2014

11 Post CABG 846 pts, 69 % CR Follow up 10 years Absolute risk reduction of 12.7% RR reduction in all-cause mortality of 46%

12 Exercise training is safe after coronary stenting 3132 patients, 5016 stents (1.2/1000 patients, 0.8/106 patient-hours of exercise) Iliou MC, GERS, Eur J Prev Cardiol 2013

13 Dose response? 544 eligible pts for CR (MI,CABG, PCI): 52 % at least 1 session Follow up : 14 years All cause mortality in non attenders :4.3 % vs 2.1 % in attenders OR mortality 3 2,5 2 1,5 1 Attenders, n of sessions performed 0,5 0 < 25 % 25-50% % > 75 % Beauchamps A, Heart 2013;99:620

14 Effets of exercise in HF BNP VE/VCO 2 Cipriano G. Heart Fail Rev 2013

15 Interval Training vs Continu Pic VO2 FE VG Haykowsky M. Am J Cardiol 2013

16 Sensitivity Prognostic value of Peak VO2 after CR 285 Heart failure patients FU : 12 months Mortality, Tx, HF Mortality PVO22 PVO21 PVO22 PVO Specificity Specificity Tabet JY. Int J Cardiol 2013

17 What challenges in CR? LVAD patients Preserved LV EF patients Congenital and Pumonary Hypertension Improve long term adherence Telemedicine?

18 Sports Athlete's ECG Athlete's Echocardiography Risks

19 Normal findings in athletes

20 Ethnicity and repolarization 20-25% of afro-caribbean athletes

21 Abnormal ECG findings (Seattle criteria) Drezner J. Br J Sports Med 2013;47:

22 Ventricular arrhythmias in athletes Evaluation 17± 5 ans ECG rest Echo rest Ex test ECG HA Holter ECG MRI Steriotis A et al. Am J cardiol 2013;111:557-62

23 Ventricular arrhythmias in athletes 17± 5 ans Steriotis A et al. Am J cardiol 2013;111:557-62

24 Echography = Trabeculations in athletes Cross sectional echocardiographic study in 1146 Athletes (20.9 ±6 years) 415 Healthy Controls 75 LV non compaction Increased trabeculation 18.3% A - 7% C, p< Echo criteria LV NC 8.1 % athletes Gati S, et al. Heart 2013;99:

25 Trabeculations in athletes 0.9% echo LV NC + LVEF < 50% + negative T waves MRI normal Follow up 48.6±14.6 months = no AE High sport is not CI But need a regular CV FU Gati S, et al. Heart 2013;99:

26 Risks of High Intensity training? AF promotion by endurance exercise Rats 8-12 weeks high intensity endurance training (1h/d), detraining 4-8 weeks Guasch E at al. JACC 2013 ;62

27 Potential mechanistic contributors Atrial dilation Autonomic changes Fibrosis

28 Lower mortality in elite cyclist 786 French cyclists participant in the Tour de France (29,7% des participants) 26 % death 41 % reduction / general population Standardized mortality ratio Marijon E. Eur Heart J 2013; 34,

29 Athlete s Longevity Scharhag J, et al. Dtsch Arztebl Int 2013; 110:

30 Sports in cardiac patients, needs to change the recommendations?

31 Take-home messages Moderate Exercise is beneficial at all of ages Cardiac Rehabilitation : benefits +++ => Refer your patients! Sport : some long term risks remains debated

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33 Impact of athlete s ECG learning on practitioner s performance General improvement By disease