Pre-participation screening is warranted: Pro
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1 Controversies on marathon and beyond Pre-participation screening is warranted: Pro DOMENICO CORRADO, MD, PhD Department of Cardiac, Thoracic and Vascular Sciences University of Padova, Italy ESC 2011 Paris, August 27-31, 2011
2 DECLARATION OF CONFLICT OF INTEREST Nothing to declare
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 and sudden cardiac death Marathon running has become an increasingly popular endurance sport activity, involving hundreds of thousands individuals each year worldwide. Running a marathon can lead to sudden cardiac death, a s it has been documented since 2500 years ago.
5 SCD during a marathon running documented since 2500 years ago Luc-Oliver Merson 1869
6 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 apparently healthy individuals. Instinctively, everyone wonders what caused marathon runner to die during race and what intervention might have prevented SD.
7 Incidence of SCD during Marathon Author Events Study population Study period SCD rate BJ Maron (JACC,1998) Marine Corps(WA) Twin Cities (MN) Marathons 215,413 Marathon runners 30 years ( ) 0.5/ 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/
8 Cardiovascular causes of sudden death associated with sports 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 Adults (age > 35 years): Atherosclerotic coronary artery disease
9 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
10 Leading causes of sudden cardiovascular death in young competitive athletes HCM ARVC/D
11 A 21 years old basket player with HCM identified at PPS Corrado et al. Circulation (Abstr) 2004
12 Corrado et al. Eur Heart J 2005
13 Cardiovascular conditions causing disqualification from competitive sports in 879 athletes over 2 consecutive screening periods ( and ) at the Center for Sports Medicine in Padua, Italy NUMBER OF DISQUALIFIED ATHETES* CARDIOVASCULAR CAUSES OF DISQUALIFICATION Total Study Period ( ) N=879 (%) Early screening Period ( ) N=455 (%) Late screening Period ( ) N=424 (%) P-value Rhythm and conduction abnormalities 345 (39) 166 (36) 179 (42.2) ventricular arrhythmias 173 (19.6) 81 (18) 92 (21.6) supraventricular arrhythmias 73 (8.3) 39 (8.6) 34 (8.0) WPW Syndrome 55 (6.3) 29 (6.3) 26 (6.1) LBBB or RBBB & LAD 26 (3.0) 8 (1.7) 18 (4.2) second Degree AV Block 13 (1.5) 7 (1.5) 6 (1.4) long QT Syndrome 5 (0.6) 2 (0.4) 3 (0.7) 0.93 Systemic hypertension: 205 (23) 118 (25.9) 87 (20.5) 0.96 Valvular disease (including MVP): 184 (21) 106 (23.3) 78 (18.4) 0.09 Cardiomyopathies 60 (6.8) 20 (4.4) 40 (9.4) hypertrophic 30 (3.4) 14 (3.0) 16 (3.8) arrhythmogenic right ventricular 16 (1.8) 2 (0.4) 14 (3.3) dilated 14 (1.6) 4 (0.9) 10 (2.4) 0.21 Coronary artery disease 11 (1.3) 2 (0.4) 9 (2.1) 0.05 Other 74 (8.4) 43 (9.5) 31 (7.3) 0.42
14 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:
15 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:
16 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
17 Profile of middle-aged/senior victims of SCD during Marathon running 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
18 Sudden death 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 myocardial infarction. A C B
19 Consideration on preparticipation screening of adults/senior individuals In this age group marathon is associated with an increased risk of coronary events including SCD Screening by exercise testing offers the potential to detect myocardial ischemia in asymptomatic individuals with CAD Exercise testing has a low predictive value for CAD in the general asymptomatic population, but it may identify CAD patients with markedly increased risk for coronary events.
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21 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 Mats Borjesson et al. EJCPR 2011
22 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 Mats Borjesson et al. EJCPR 2011 Maximal exercise testing Negative Positive Further evaluation, Appropriate treatment and individually prescribed physical activity
23 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 Eligible Low risk Mats Borjesson et al. EJCPR 2011 High risk Maximal exercise testing Negative Positive Further evaluation, Appropriate treatment and individually prescribed physical activity*
24 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. The available evidence indicates that ECG screening has to be considered an efficient health strategy for prevention of SCD of young competitors. Identification of middle-aged/senior runners with coronary artery disease at risk of SCD is difficult and the utility of preparticipation screening by means of exercise testing remains unproven. However, cardiovascular medical evaluation is recommended by most Associations of Cardiology and Sports Medicine as a prudent measure before entering master sport training programs.
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27 Endurance sports and SCD Preamble Story Epidemiology Causes and mechanisms Prevention strategies
28 Endurance sports and SCD Preamble Story Epidemiology Causes and mechanisms Prevention strategies
29 Endurance sports and SCD Preamble Story Epidemiology Causes and mechanisms Prevention strategies
30 Endurance sports and SCD Preamble Story Epidemiology Causes and mechanisms Prevention strategies
31 Endurance sports and SCD Preamble Story Epidemiology Causes and mechanisms Prevention strategies
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
35 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
36 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
Endurance sports and sudden cardiac death
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