Endurance sports and sudden cardiac death

Transcription

1 Symposium: Endurance training and ventricular arrhythmias Endurance sports and sudden cardiac death DOMENICO CORRADO, MD, PhD Department of Cardiac, Thoracic and Vascular Sciences University of Padova, Italy EHRA Europace 2011 Madrid (Spain), June 26-29, 2011

2 Endurance sports and SCD Preamble Story Epidemiology Causes and mechanisms Prevention strategies

3 Regular exercise and prevention of sudden coronary death Regular exercise is recommended by the medical community because it prevents development, progression and complication of atherosclerotic coronary artery disease by favourable effects on: - classical risk factors, including components of the metabolic syndrome (weight, insulin sensitivity, lipid metabolism and blood pressure); - endothelial dysfunction; - autonomic balance; - blood coagulation; - coronary artery plaque (and myocardial electrical?) stability

4 Endurance sports Sports whose the goal is prolonged athletic output over an extended distance or for an extended period of time. Aerobic by nature. Not action, but training and motivation based

5 Endurance sports and sudden cardiac death Marathon running has become an increasingly popular endurance sport activity, involving hundreds of thousands individuals each year worldwide. Vigorous exertion may act as a trigger of acute myocardial infarction and sudden death.

6 Endurance sports and SCD Preamble Story Epidemiology Causes and mechanisms Prevention strategies

7 SCD during a marathon running documented since 2500 years ago Luc-Oliver Merson 1869

8 Endurance sports and SCD Preamble Story Epidemiology Causes and mechanisms Prevention strategies

9 Endurance sports and sudden cardiac death Although SD of a marathon runner according to the statistics may a negligible event, it probably is not for the family and friends of the SD victim. The unexpected demise of the athlete is always a tragic event which has a tremendous impact on the media, because it strikes down young and apparently healthy individuals. Instinctively, everyone wonders what caused marathon runner to die during race and what intervention might have prevented SD.

10 Rate of SCD during Marathon Author Events Study population Study period SCD rate BJ Maron (JACC,1998) Marine Corps(WA) Twin Cities (MN) 215,413 Marathon runners 30 years ( ) 0.5/ Marathons DT Pedoe (2004) London (UK) Marathon 539,312 Marathon runners 20 years ( ) 1.5/ DA Redelmeier (BMJ 2007) 26 (USA) Marathons 3,292,268 Marathon runners 30 years ( ) 0.8/ KM Harris (JAMA 2010) USA Triathlon 922,810 Triathlon competitors 3 years ( ) 1.5/

11 Endurance sports and SCD Preamble Story Epidemiology Causes and mechanisms Prevention strategies

12 Cardiovascular causes of sudden death associated with sports Adults (age > 35 years): Atherosclerotic coronary artery disease Young competitive athletes (age 35 years): Hypertrophic cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy Congenital anomalies of coronary arteries Myocarditis Aortic rupture Valvular disease Preexcitation syndromes and conduction diseases Ion channel diseases Congenital heart disease, operated or unoperated

13 Profile of SCD victims during race Middle-aged adult man Asymptomatic No prior documentation of heart disease Cardiac arrest due to FV Post-mortem: atherosclerotic plaque lesions obstructing one epicardial coronary vessel(s) in 71% to 87% Contributing factors: hyponatremia and heat related extreme dehydration

14 SCD of a 47-year old marathon runner Obstructive atherosclerotic coronary artery disease of both left (anterior descending branch) and right coronary arteries (A,B) C) Histology of the myocardium shows replacement type fibrosis due to previous myocardial infarction. A C B

15 How Exercise Provokes Plaque Rupture and Coronary Thrombosis? Exercise coronary artery spasm in diseased segments plaque rupture Exercise changes in cardiac dimensions twisting of the epicardial coronaries plaque rupture Exercise increased blood pressure (shear forces) plaque disruption Exercise augmenting catecholamine-induced platelet aggregation

16 Endurance sports and SCD Preamble Story Epidemiology Causes and mechanisms Prevention strategies

17 Pre-participation basal 12- lead ECG has been proven to be life-saving in young competitive athletes (<35 years) in whom SCD is mostly caused by ECG detectable genetic cardiomyopathies

18 Annual Incidence Rates of Sudden Cardiovascular Death in Screened Competitive Athletes and Unscreened Nonathletes Aged 12 to 35 Years in the Veneto Region of Italy ( ) Sudden death per person-years 4,5 4 3,5 3 2,5 2 1,5 1 0, P for trend < Athletes Nonathletes Years Corrado et al JAMA 2006;296:

19 Sudden death per athlete-years 1,60 1,40 1,20 1,00 0,80 0,60 0,40 0,20 0,00 Mortality trend for sudden death from Cardiomyopathies RR=0.10 P for trend =0.002 Pre-screening ( ) Early-screening ( ) Late-screening ( ) Corrado et al JAMA 2006;296:

20 A 21 years old basket player with HCM identified at PPS Corrado et al. Circulation (Abstr) 2004

21 Pre-participation basal 12-lead ECG appears to be a non accurate test for screening coronary artery disease in older athletes engaged in leisure-time sports such as Marathon running

22 Rationale for screening adults/senior individuals Because of its established prognostic value, widespread availability and low cost, exercise testing is the best available test for screening coronary artery disease in asymptomatic middle-aged/senior Marathon runners. Exercise testing has a low predictive value for CAD in the general asymptomatic population, but in a patient population with risk factor for CAD it may identify patients with markedly increased risk for coronary events. The risk may differ in relation to individual age, level of fitness, sports intensity, and underlying coronary artery disease

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24 Cardiovascular evaluation of adult/senior individuals engaging in physical activity and sports I) Individual risk profile (risk factors for CAD) Self-assessment (questionnaires) ESC risk score (age, sex, BP, cholesterol and smoking Other (family Hx, diabetes, BMI >28) II) Current level of habitual physical activity Sedentary individuals Active individuals III) Intensity of intended physical activity: Low intensity Moderate intensity High intensity Borjesson et al. EJCPR 2011(online)

25 SEDENTARY Low intensity activity Modete-High intensity activity Self-assessment of risk NO on every question YES on every question Screening by physician: Hx, Phys.exam., RISK SCORE, ECG Low risk High risk Eligible Borjesson et al. EJCPR 2011(online) Maximal exercise testing Negative Positive Further evaluation, Appropriate treatment and individually prescribed physical activity

26 ACTIVE Adult/senior Low intensity activity Moderate intensity activity High intensity activity Self-assessment of risk NO on every question YES on every question Screening by physician: Hx, Phys.exam., RISK SCORE, ECG Low risk High risk Maximal exercise testing Negative Positive Eligible Borjesson et al. EJCPR 2011(online) Further evaluation, Appropriate treatment and individually prescribed physical activity

27 Prevalence of coronary artery calcification in relation to cardiovascular risk factors in marathon runners and its role for myocardial damage and coronary events Möhlenkamp S et al. European Heart Journal 2008;29:

28 Screening limitations in middle-aged/senior competitors justify the increasing efforts for implementing programs of cardiac arrest management by using inthe-field AED. As recommended by the recent consensus document of the ESC Sport Cardiology section regarding Cardiovascular Safety at Sports Arenas, basic cardiac life support including AED should be considered the minimum acceptable level of care at any mass gathering event, with mobile emergency responders able to deliver first defibrillation within 5 minutes of a witnessed.

29 Conclusions While several studies have reported an acute increase of the SD risk during running events, the benefits of regular exercise appear to outweigh the risks. Exercise test screening for middle-aged/senior leisure marathon runners has not proven to reduce SD; however, it appears to be prudent in the light of our current understanding of the cardiovascular risks and benefits of exercise in this age group. Competitors are recommended to take actions in order to avoid dehydration, sodium loss and the impact of heat on their body. Prompt defibrillation at the race by automated AED may be a valuable back-up for preventing unpredictable SD.

30 The end

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32 SCD in athletes: age groups Age Young Athletes ( 35 yrs) Older athletes (>35 yrs) Sports A variety of sports (ball games) Jogging and running Level Competitive activity Individual exercise annual SCD rate Pathology 1-4/100,000 athletes 1:50,000-1:15,000 athl. Large spectrum of cardiac disease (genetic and congenital) Atherosclerotic coronary artery disease

33 EXERCISE AND SUDDEN CORONARY DEATH Relationship between physical exercise and the risk of sudden coronary death in middle aged and older population Increased risk of acute coronary events in persons who did not exercise regularly. Relative Risk of Sudden Cardiac Death During Exercise* Sedentary men Active men *Siscovick DS. NEJM 1984;311:874 Habitual sport activity may offer protection over the long- term from the overall risk of myocardial infarction and sudden coronary death

34 IMMEDIATE POST-EXERCISE ACUTE EXERCISE STRESS Abrupt Cessation of Activity Venous Return Arterial Vasodilatation Sympathetic Activity + Vagal Stimulation Na + /K + Imbalance Catecholamines Cardiac Output HR, SBP Blood Pressure Coronary Perfusion (CHD) MVO 2 Ischemia Myocardial Irritability Altered Depolarization/Repolarization Altered Conduction Velocity Ventricular Ectopic Activity