Endurance Exercise and Cardiovascular Health

Transcription

1 Endurance Exercise and Cardiovascular Health Professor Sanjay Sharma St George s University of London St George s Hospital NHS Trust Conflicts/Disclosures: None

2 Objectives Discuss the cardiovascular benefits of exercise. Provide an overview of the range of cardiovascular adaptation to regular intensive exercise ( Athlete s Heart ). Evaluate the dose-benefit relationship between exercise and cardiovascular health.

3 Benefits of Exercise

4 Physical activity and Cardiovascular Disease The first study to show an association between physical activity and risk of heart disease. Morris et al. (1953) Lancet

5 Risk Hazard of Coronary Artery Disease in Relation to Physical Activity 44,452 professional males Follow up of 475,755 person years Tenesescue M et al JAMA 2002

6 Benefits of Exercise

7 Current Physical Activity Guidelines Adults: 30 mins of moderate intensity physical activity at least 5 days per week or 25 min vigorous activity 3 days per week Children: at least 60 minutes per day of moderate intensity physical activity. (Chief Medical Officers Report 2004)

8 Endurance Athletes

9 Impact of Athletic Training

10 Athlete s Heart ELECTRICAL Bradycardia Repolarisation anomalies STRUCTURAL Increased chamber wall thickness and cavity size Voltage criteria for chamber enlargement FUNCTIONAL Enhanced diastolic filling Augmentation of stroke volume Increased peak oxygen consumption

11 Right axis deviation Incomplete RBBB SV1 ER RV6 Sinus bradycardia 45 bpm SV1 + RV6 > 3.5 mv = LVH

12 Athlete s Heart versus Normal Heart Normal Athlete

13 Determinants of Cardiac Dimensions Ethnicity Size Type of sport Gender Anabolic Drugs Age Cardiac Dimensions Inherited Cardiomyopathy or ion channel disorder

14 Left Ventricular Cavity Dimensions in Highly Trained Athletes 48%

15 Large body surface area Long standing endurance athlete Adult Males Large cardiac dimensions and marked repolarisation changes Black athletes

16 LV Wall Thickness in Highly Trained Athletes 1.6% WA 13 % BA Papadakis M et al. EHJ. 2010

17 Repolarisation Changes on the ECG in Black Athletes

18 44 Italian Olympian males with LVH (> 13 mm) and enlarged LV cavity (> 60 mm). De-trained for a mean of 53 months. LV wall thickness and LV mass normalised.

19 Sudden Cardiac Death in Sport

20 The Ugly Side of Exercise-Sudden Cardiac Death 90% during or just after exercise 90% in males 80% don t have prodromal symptoms

21 Maron BJ Circulation 2009;119: Normal heart Causes of SCD in Sport Cardiomyopathies Valvular heart disease Acquired disease Congenital Coronary artery disease and aortopathy

22 Risk in Relation to Running Times COSTUMES 5 hours plus LOW RISK MIDDLE AGED MALE RUNNER 4 hour group HIGH RISK GROUP ELITE/CLUB < 3 hours LOW RISK

23 Triggers for Sudden Cardiac Death Dehydration Adrenergic surges Electrolyte imbalance Acid/base disturbance

24 Can Too Much Exercise Damage the Normal Heart?

25 Mass Endurance Events Endurance athletes exercise x the daily recommended exercise. 2 million marathon participants each year. Can you get too much of a good thing?

26 Reverse J Relationship Between Physical Activity and Mortality Schnohr et al. JACC. 2015; 65: Lee DC et al. JACC. 2015; 64: Armstrong et al. Circulation. 2015; 131:

27 1098 joggers v 3950 healthy non joggers. Schnohr et al. JACC 2015 Jogging hours, over 2-3 times per week and a slow to moderate pace (6-10 MET equivalents) was associated with the best results for reduction in all cause mortality.

28 Duck Chul-Li et al. JACC year observational study. 55,137 individuals. Mean age 44 years old. Runners had a 30% all cause reduction in mortality and a 45% reduction in CVD events.

29 Transient Cardiac Injury Post Marathon Running Raised cardiac troponin levels post race (EXERCISE INDUCED CARDIAC DAMAGE) Impaired left ventricular function (EXERCISE INDUCED CARDIAC FATIGUE)

30 Can Too Much Exercise Be Cardiotoxic? Troponin Troponin Troponin

31 SEROLOGICAL MARKERS Troponin Release High BNP concentrations PATHOLOGY HISTOLOGICAL CHANGES Adverse cardiac remodelling Cardiac Dysfunction + Arrhythmias Myocardial inflammation Myocardial fibrosis

32 Animal model of Endurance Training Enlarged Atria and RVH/LVH Fibrosis A Exercised for 60mins daily for 16 weeks E Diastolic dysfunction Compared with sedentary rats VT in 42 %

33 Mohlenkamp et al. EHJ. 2008; 29: 1903 Breuckmann et al. Radiology. 2009; 1: 50-57

34 Let s Examine the Flip Side!

35 1098 joggers v 3950 healthy non joggers. Schnohr et al. JACC 2015 Jogging hours, over 2-3 times per week and a slow to moderate pace (6-10 MET equivalents) was associated with the best results for reduction in all cause mortality.

36 Duck Chul-Li et al. JACC year observational study. 55,137 individuals including 13,016 joggers. Mean age 44 years old. Runners had a 30% all cause reduction in mortality and a 45% reduction in CVD events. Running is beneficial for health. There was no dose threshold for increased mortality.

37 661,137 male and females Median age 62 years (21-98) 116,686 deaths. Median FU 14.2 years 20% 31% 37% 39% 39%

38 Significance of Raised Cardiac Troponins?

39 Animal model of Endurance Training Enlarged Atria and RVH/LVH Fibrosis A Exercised for 60mins daily for 16 weeks E Diastolic dysfunction Compared with sedentary rats VT in 42 %

40 8 weeks detraining Fibrosis resolves on detraining

41 Runners had lower CAC score compared to non runners. Mohlenkamp et al. EHJ. 2008; 29: % were either smokers or reformed smokers. Breuckmann et al. Radiology. 2009; 1: % runners had scars consistent with a previous myocardial infarction. 3 had severe coronary artery disease. Data based on athletes who presented with ventricular tachycardia or syncope!

42 The Veteran Athletes Heart Project Veteran athletes n=152 >40 years >10 years of competitive endurance exercise Free of CVS risk factors Veteran controls n= 92 >40 years Exercise 50 mins/week Free of CVS risk factors Health questionnaire ECG/SAECG Echocardiogram Cardiopulmonary exercise testing Holter monitoring Cardiac MRI CT Coronary angiography Genetics Myocardial fibrosis markers

43 Coronary Artery Calcium Scores in Male Veteran Athletes and Male Controls Exercise 31 ± 12.6 years Median 13 marathons 77.5% marathon runners 16 national champions, 5 world champions Males Controls Athletes P Parameter Age 52.5 ± ± Framingham risk score 4.29 ± ± CAC score 0 32 (59%) 55 (52%) 0.5 CAC score 100 Ag Units 4 (7.4%) 20 (18.9%) 0.06 >50th percentile 12 (22.2%) 29 (27.4%) 0.57 >70th percentile 10 (14.8%) 16 (15.1%) 0.5 Merghani A/Sharma S Circulation 2017

44 Coronary Artery Calcium Score in Male Veteran Athletes and Male Controls 11.5% male athletes had a CAC > 300 AU compared with none of the controls. Merghani A/Sharma S Circulation 2017

45 Coronary Plaques in Male Veteran Athletes v Male Controls Coronary plaques were present in 47 (44.3%) male athletes compared with 12 (22.2%) controls; p = (7.5%) athletes had a luminal stenosis 50% compared with none of the controls

46 Plaque Morphology Veteran athletes had a higher prevalence of calcific plaques compared with controls (72% v 31%); p = Merghani A/Sharma S Circulation 2017

47 Myocardial Fibrosis in Veteran Athletes 17 males (16%) had evidence of myocardial fibrosis on CMR. 7 had a pattern consistent with myocardial infarction.

48 Athletes Live Longer than Non Athletes

49 Atrial Fibrillation in Veteran Athletes

50 Relationship Between Atrial Fibrillation and Physical Activity Good, Bad or Therapy

51 Atrial Fibrillation in Athletes Age Endurance sport Tall stature Male sex AF in athletes Exercise time 1500 hours over a life time Abdulla et al. Europace 2009

52 AF in Athletes Trigger?Increased pulmonary vein ectopy Modulators Increased vagal tone: Bradycardia Shortening and dispersion of the atrial refractory period Gastro-oesophageal reflux Endurance sport practice Substrate Pressure and volume overload: Atrial stretch Myocyte Hypertrophy Atrial dilatation Inflammatory response Atrial fibrosis

53 Characteristics of AF Affect males Occur at rest; usually wake athletes from sleep. Very symptomatic. Sensed as a marked reduction of functional capacity during an attempt at training. May last between seconds and > 48 hours at a time. Not usually precipitated by exercise

54 Studied participants in the Vasalopett (90k) cross country ski race between % Male. 10% aged under 60 years old. Followed up until December 2005 (7-16 years). 959 had significant arrhythmias (AF, A flutter and bradyarrhythmias) which correlated with the number of races completed and faster finishing times; HR 1.30 each.

55 Events Exercise and the Heart Obesity BP Diabetes risk of CAD risk of AF Coronary reserve in CAD Functional capacity and prognosis in HF? SIGNIFICANCE? RV dysfunction Myocardial fibrosis Recommended level of exercise 150 mins/week Troponin post exercise AF ( ) CAC Sedentary >35 MET HOUR/WEEK