Outline. Many Health Benefits of exercise for all ages. Over age 35 years- drawn to endurance exercise. Risks of exercise

Size: px

Start display at page:

Download "Outline. Many Health Benefits of exercise for all ages. Over age 35 years- drawn to endurance exercise. Risks of exercise"

Scott Norris
5 years ago
Views:

Outline Sports Cardiology In Endurance Athletes AKOMA CME

Lawless, MD, MBA, FACC, FACSM, CAQSM Founder, ACC Sports and

Consultants LLC University of Chicago University of Nebraska

endurance sports Interpreting cardiac tests in endurance athletes

Disclosures: None relevant Many Health Benefits of exercise for

physical activity, with 2-3 minutes of vigorous activity 3 days

Pate, Jansen, Thorpe and US DHHS website Numbers of athletes in

over past 1 yrs Established heart disease: Living longer; may

endurance exercise Marathon finishers up from 353, in 2 to over

146, during the same period Risks of exercise Paradoxically,

1 Outline Sports Cardiology In Endurance Athletes AKOMA CME Conference Anchorage AK Christine E. Lawless, MD, MBA, FACC, FACSM, CAQSM Founder, ACC Sports and Exercise Cardiology Council President-Sports Cardiology Consultants LLC University of Chicago University of Nebraska Numbers of athletes are increasing Exercise physiology of endurance sports Interpreting cardiac tests in endurance athletes Risks of endurance sports How sports cardiologists minimize risk Disclosures: None relevant Many Health Benefits of exercise for all ages Current United States (US) physical activity guidelines: Healthy adults : 2.5 hours of moderate activity/wk Children : 6 minutes of daily physical activity, with 2-3 minutes of vigorous activity 3 days per week for both age groups Ref: Swift, Fletcher, Thompson, Pate, Jansen, Thorpe and US DHHS website Numbers of athletes in USA- INCREASING Participation doubled in all demographic groups over past 1 yrs Established heart disease: Living longer; may contemplate sports and exercise Over age 35 years- drawn to endurance exercise Marathon finishers up from 353, in 2 to over 5, in 211 USA Triathlon memberships up from 21,341 to more than 146, during the same period Risks of exercise Paradoxically, despite its favorable effects on well-being and survival, exercise can acutely be associated with: risk of myocardial infarction aortic dissection arrhythmias Sudden cardiac arrest (SCA) and/or death (SCD) 1

Exercise physiology Acute Exercise Response VO 2 max = CO x A-V O 2

2 max Primarily SV Reduced HR Any Part Equation can Reduce Performance

country skiing: Lesson in sports cardiology, and evaluating an athlete

environment O2 desaturation - worse with altitude, as low as 8% Use of

Topics/214/2/Sports-Cardiology-of-Cross-Country-Skiing.aspx.

chamber measurements in ECHO/MRI http://www.cardiosource.

2 Exercise physiology Acute Exercise Response VO 2 max = CO x A-V O 2 diff VO 2 max = (HR x SV) x A-V O 2 diff Effects Exercise Training VO 2 max Primarily SV Reduced HR Any Part Equation can Reduce Performance Heart Rate Stroke Volume Arterial O 2 Content Venous O 2 Content Cross country skiing: Lesson in sports cardiology, and evaluating an athlete CV Demands: Endurance Altitude (Interaction w/ external athletic environment O2 desaturation - worse with altitude, as low as 8% Use of both arms and legs Topics/214/2/Sports-Cardiology-of-Cross-Country-Skiing.aspx. Cross country skiing: Lesson in sports cardiology, and evaluating an athlete CV Adaptations VO2max 87ml/kg/min (highest recorded 96ml/kg/min- B. Daehlie Max HR of 185 bpm SV 2ml CO 4 L/min Up to 4% increases in all chamber measurements in ECHO/MRI Topics/214/2/Sports-Cardiology-of-Cross-Country-Skiing.aspx. 2

Interpreting cardiac tests ECG findings/adaptation Enhanced

Conduction Delay 1 st, 2 nd, 3 rd Early Repolarization T Wave

old miler Vaso-Vagal Syncope is More Common in Endurance

Huston NEJM 1985 Large Venous Capacity High Vagal Tone Reduced

3 Interpreting cardiac tests ECG findings/adaptation Enhanced Parasympathetic Tone Resting Bradycardia Sinus Arrhythmia AV Conduction Delay 1 st, 2 nd, 3 rd Early Repolarization T Wave Changes 28 year old 2:17 marathoner - chest discomfort 16 year old miler Vaso-Vagal Syncope is More Common in Endurance Athletes WPW Pattern is More Common In Endurance Athletes Huston NEJM 1985 Large Venous Capacity High Vagal Tone Reduced Sympathetic Tone Be Careful of + Tilt Tables in Athletes- Up to 66% can be positive 3

Enlargement Disease The Limits of LV Cavity 13 Elite Italian

of Left Atrial Dimensions in 1,823 Elite Athletes male female 2% (

41 42 43 44 45 46 47 48 49 5 The Limits of Normal Wall Thickness 947

- 7% of Those Athletes 1 Athlete > 16 mm All Women < 11 mm Pelliccia

LV wall thickness in 738 male and 6 female elite athletes

4 N Athletes No. Athletes Cardiac Enlargement Global (LV, RV, LA, RA) Mild Marked Enlargement Disease The Limits of LV Cavity 13 Elite Italian Athletes LVID Increased 45% > 55 mm 14% > 6 mm Largest LVID Female = 66 mm Male = 7 mm HR r=.37; BSA r =.76 Pelliccia Annals IM Distribution of Left Atrial Dimensions in 1,823 Elite Athletes male female 2% ( 4mm) 11% ( 45mm) The Limits of Normal Wall Thickness 947 Italian Athletes 29 Women 16 Athletes LVWT > 12 mm Rowing + Canoeing - 7% of Those Athletes 1 Athlete > 16 mm All Women < 11 mm Pelliccia NEJM 1991 Distribution of max. LV wall thickness in 738 male and 6 female elite athletes (Pelliccia, NEJM 91 and JAMA 95) 3 Left Ventricular Ejection Fraction:? Normal MEN WOMEN Max. Wall Thickness (mm) Tour De France Cyclists- 11% have LVEF less than 52% 4

exercise can acutely be associated with:

311:874,1984 Women In Young Athletes (per

5 RV Weight lifting: Pressure overload LV cavity not increased Wall thickness not increased, but out of proportion to cavity dimension Risks of exercise Paradoxically, despite its favorable effects on well-being and survival, exercise can acutely be associated with: risk of myocardial infarction +/- SCA/SCD aortic dissection arrhythmias Sudden cardiac arrest (SCA) and/or death (SCD) How Dangerous Is Exercise For Healthy Adults? 1 Death/Year/Per Thompson 15,64 JAMA 247:2535,1982 Siscovick 18, NEJM 311:874,1984 Women In Young Athletes (per 1, ) Men High School.12 High School.66 College.28 College 1.45 ( 1 / 133,333 men & 1/769,23 women ) Van Camp

Ambrose et al 1988 Little et al 1988 Nobuyoshi et al 1991 Giroud et al 1992 Relative Risk of MI onset Incidence and

hours) Swedish Vasaloppet racers showed more than 7 X greater risk of SCD acutely Over a 1 year period, standardized

53] Acute increase in SCD outweighed by long term benefit Higher incidence of atrial fibrillation LaGerche JACC 213

Exercise Also Increases the Risk of Myocardial Infarction Mittleman et al, NEJM 1993 Most MIs Are Caused by Lesions

Stenosis Prior to MI MI 1 Patien 9 >7% ts 8 5%-7% (No.

6 Ambrose et al 1988 Little et al 1988 Nobuyoshi et al 1991 Giroud et al 1992 Relative Risk of MI onset Incidence and etiology of SCD in athletes Medical perspective- XC skiing SCD rare ( Swiss Engadine Ski Marathon, 1:12, skiing hours) Swedish Vasaloppet racers showed more than 7 X greater risk of SCD acutely Over a 1 year period, standardized mortality ratios of.48 [95% confidence interval (CI) ] Acute increase in SCD outweighed by long term benefit Higher incidence of atrial fibrillation LaGerche JACC 213 Sports Cardiology of XC Skiing Exercise Also Increases the Risk of Myocardial Infarction Mittleman et al, NEJM 1993 Most MIs Are Caused by Lesions of Minimal Stenosis Falk E. et al Circulation. 1995;92 ; Stenosis Prior to MI MI 1 Patien 9 >7% ts 8 5%-7% (No.) 7 <5% % 18% 68% Screening Exercise Tests May Be Falsely Positive Because of Left Ventricular Enlargement?? Can Be Dismissed if Good Exercise Tolerance, No Symptoms, Good Heart Rate Response, Rapid Resolution in Recovery Nuclear Imaging May Show Inferior Defect Due to Large Hearts & Diaphragmatic Attenuation?? 6

Screening Exercise Tests Are Not Good Predictors of Sudden Death or Acute MI in Asymptomatic

Divergence of Opinion Evidence/Opinion Favors - Diabetes Pre Vigorous Exercise Usefulness Less

36 th Bethesda Conference 25 Determining Athletic Eligibility in Athletes with Heart Disease Are

Flexibility Depending on the Perceived Risk For the Athlete but The I Gotta Sleep Too Rule The

Return to Climbing, Competition, Whatever After an ACS Typical baby boomer athlete (Dr Lawless)

years of no training or the athlete who starts a sport late in life Return to previous activity

4ml/kg/min, max HR 134 bpm (1:15 min Bruce protocol) LVEF 52%, nuclear stress- small fixed

7 Screening Exercise Tests Are Not Good Predictors of Sudden Death or Acute MI in Asymptomatic Individuals Exercise Testing for Asymptomatic Persons Without Known CAD Class 2 - Conflict or Divergence of Opinion Evidence/Opinion Favors - Diabetes Pre Vigorous Exercise Usefulness Less Established - Men >45, Women >55 Pre Vigorous Exercise Exercise Advice? 36 th Bethesda Conference 25 Determining Athletic Eligibility in Athletes with Heart Disease Are Very Restrictive Prohibit Competitive Athletics with High Risk Lesions (CAD, HCM, Marfan) Flexibility Depending on the Perceived Risk For the Athlete but The I Gotta Sleep Too Rule The Most Frequent Problem High Powered, Exercise Addicted Lawyers, Bankers, Stock Brokers Wanting to Return to Climbing, Competition, Whatever After an ACS Typical baby boomer athlete (Dr Lawless) Born post WWIIbetween 1946 and 1964 A weekend warrior Or, an athlete who resumes sports after years of no training or the athlete who starts a sport late in life Return to previous activity after event??? 6 y/o male attending cardiac rehab after CX stent for MI Asymptomatic, MVO2 32.4ml/kg/min, max HR 134 bpm (1:15 min Bruce protocol) LVEF 52%, nuclear stress- small fixed defect lateral wall, no evidence of reversible ischemia His question: Is it OK to return to competitive open wheel race car driving at 145mph? 7

Demands of open wheel driving Med Sci Sports Exerc 22 Dec;34(12):285-9 Br J

with mild aortic insufficiency Otherwise a healthy individual.

Father died at age 38 of a heart attack COPD Smoking Weight: 21 lb (91 kg),

Primarily anaerobic exercise Lifts up to 75-1% of body weight Clinical

severe substernal chest pain with shortness of breath The pain developed

ascending aorta from the sinuses to the proximal arch, Maximal size 5.

8 Demands of open wheel driving Med Sci Sports Exerc 22 Dec;34(12):285-9 Br J Sports Med 29 Patient Information 21-year-old male Six years prior diagnosed with mild aortic insufficiency Otherwise a healthy individual. No history of: Hypertension Family History: Diabetes Suggestive Dyslipidemia Father died at age 38 of a heart attack COPD Smoking Weight: 21 lb (91 kg), Height: 72 in (184 cm) Weight Lifting Exercise Weightlifter Exercises daily Primarily anaerobic exercise Lifts up to 75-1% of body weight Clinical Presentation In June, 1999: Presented to an outside institution with acute severe substernal chest pain with shortness of breath The pain developed during strenuous exercise (lifting weights) Computed Tomography Dilated ascending aorta from the sinuses to the proximal arch, Maximal size 5.2 cm Aortic dissection was suspected, but a clear dissection flap was not visible C ompressed 8 :1 I M : 3 1 SE : 1 4 P age: 3 1 of 1 8

$3 cm Bicuspid aortic valve Moderate aortic insufficiency, no stenosis Normal left ventricular ejection fraction Fluid in the pericardium No signs of aortic dissection Intraoperative findings Bloody$ fluid in the pericardium moderate amount (no hemodynamic effect) Ascending aorta appeared severely dilated Tubular type aneurysm Severe ecchymosis in the wall of the aorta Upon entry of the aorta a

fluid in the pericardium moderate amount (no hemodynamic effect) Ascending aorta appeared severely dilated Tubular type aneurysm Severe ecchymosis in the wall of the aorta Upon entry of the aorta a

Evidence of Intramural Hematoma of the Ascending Aorta Intramural Hematoma Surgical procedure Composite graft replacement of the ascending aorta, aortic valve, and hemiarch on cardiopulmonary bypass

9 Transesophageal Echocardiography Dilatation of the ascending aorta from the sinuses to the proximal arch Maximal size 5.3 cm Bicuspid aortic valve Moderate aortic insufficiency, no stenosis Normal left ventricular ejection fraction Fluid in the pericardium No signs of aortic dissection Intraoperative findings Bloody fluid in the pericardium moderate amount (no hemodynamic effect) Ascending aorta appeared severely dilated Tubular type aneurysm Severe ecchymosis in the wall of the aorta Upon entry of the aorta a large stellate laceration (3 cm) of the internal surface of the aorta was found in the right lateral location. Evidence of Intramural Hematoma of the Ascending Aorta Intramural Hematoma Surgical procedure Composite graft replacement of the ascending aorta, aortic valve, and hemiarch on cardiopulmonary bypass and deep hypothermic circulatory arrest Cardiopulmonary bypass time 174 min Aortic cross-clamp time 18 min DHCA time at 18 degrees Celsius 31 min Elefteriades JA. Thoracic aortic aneurysm: Reading the enemy's playbook. Curr Probl Cardiol. 28;33(5): Postoperative Course Early: Benign, diuresing well, hemodynamically stable. No atrial fibrillation Discharged home on 5 th postoperative day Late: 15 years postoperatively the patient is doing well Continues physical training and weight lifting Patient wants to return to weightlifting What advice to give to patient? Restrict anaerobic physical exercise to less than 5% of body weight. Allow complete return to preoperative levels of physical activity. Allow complete return to preoperative levels of physical activity and screen the size of arch/descending/thoracoabdominal aorta. 9

10 Five years postoperatively Outline Numbers of athletes are increasing Exercise physiology of endurance sports Interpreting cardiac tests in endurance athletes Risks of endurance sports How sports cardiologists minimize risk Thank you! Thanks to Dr Paul Thompson (Hartford Hospital, CT) for use of some slides 1

EVALUATION OF THE ATHLETE. Karen Stout, MD Professor, Medicine and Pediatrics University of Washington

EVALUATION OF THE ATHLETE. Karen Stout, MD Professor, Medicine and Pediatrics University of Washington EVALUATION OF THE 12 ATHLETE Karen Stout, MD Professor, Medicine and Pediatrics University of Washington NO DISCLOSURES OUTLINE Why evaluate athletes? What s the problem? What evaluation should be done?