Dr Navin Chandra Clinical Research Fellow in Cardiology St George s University of London

Transcription

1 Dr Navin Chandra Clinical Research Fellow in Cardiology St George s University of London

2 Cardiac Adaptation in Athletes Athletic training for prolonged periods may result in physiological adaptations of cardiac structure and function Increases in left ventricular (LV) wall thickness and left ventricular cavity size are well documented

3 Left Ventricular Hyper-Trabeculation Left ventricular hyper-trabeculation has not previously been documented in athletes It is a recognised feature in: LEFT VENTRICULAR NON-COMPACTION (LVNC) Hypertrophic cardiomyopathy (apical) Dilated cardiomyopathy Neuromuscular disorders with cardiac involvement Peri-partum cardiomyopathy Cardiomyopathy remains the most common cause of sudden cardiac death in young athletes

4 Left Ventricular Non-Compaction - Prominent trabeculations - Ventricular arrhythmias - Progressive LV dysfunction - Systemic emboli a rare & novel cardiomyopathy with diagnostic difficulty often misdiagnosed as other forms of cardiomyopathy implications as LVNC may be under-diagnosed as a cause for SCD in athletes

5 Demographics of Cardiac Adaptation A number of factors are associated with physiological cardiac adaptation in athletes: Age Sex Body size Type of sporting discipline Ethnicity Afro-Caribbean (black) athletes demonstrate marked changes in cardiac dimensions Our group has observed a small number of cases of LV hypertrabeculation in athletes of black ethnicity and those engaged in endurance sports

6 Aims & Objectives The aim of this study was to evaluate: the prevalence and significance of LV hyper-trabeculation in athletes whether this is related to ethnicity? whether it is related to type of training? is it associated with ECG abnormalities? is it associated with other echocardiographic abnormalities?

7 Methods Between Nov 2008 and Jan 2010, 256 highly trained male athletes Cardiac evaluation with a health questionnaire, physical examination, 12-lead ECG and echocardiography ECGs were analysed for specific abnormalities as described in the European Society of Cardiology (ESC) sports cardiology consensus Standard echocardiographic views and measurements made in accordance with ESC guidelines

8 Method: Definitions LV hyper-trabeculation was defined as: The presence of 3 or more prominent trabeculations in the LV wall Seen in the parasternal short axis view: at the papillary muscle level and/or the apical level Seen at the apex in the 4-chamber view

9 Results: Demographics Of the 256 athletes evaluated: Mean age = 19.1yrs ± 4.3yrs (range:16-35years) Afro-Caribbean athletes = 38 (15.0%) Participating in 20 different sporting disciplines Endurance trained athletes = 53 (20.7%) Training duration = 13.3hrs ± 2.1hrs per week (range 10-26hrs) Asymptomatic, normotensive & no significant past medical or family history

10 Results: Athletes with LV Hyper-Trabeculation LV hyper-trabeculation was identified in 5 (2%) athletes 4 out of 5 = black ethnicity 0 out of 5 = endurance athletes All 4 black athletes had an abnormal 12-lead ECG All 5 athletes had otherwise normal echocardiograms None fulfilled diagnostic criteria for any form of cardiomyopathy ATHLETE AGE ETHNICITY SPORT ECG 1 21 Black Football T-wave inversion II, III, AVF 2 19 Black Boxing LVH, T-wave inversion I, AVL, V Black Cricket LVH, T-wave inversion II, III, AVF 4 24 Black Rugby LVH, T-wave inversion III, AVF 5 23 White Tennis Normal

11 Results: ECGs

12 Results: Echocardiography Para-sternal short axis view: Papillary muscle level

13 Results: Echocardiography Para-sternal short axis view: apical level Apical 4-chamber view

14 Conclusions This study demonstrates that LV hyper-trabeculation in isolation is a rare finding in highly trained male athletes (~2%) It is more common in black athletes (10.5% vs 0.6%) It does not appear to be associated with endurance training It is associated with an abnormal ECG It is not associated with left ventricular systolic and diastolic dysfunction

15 Conclusions: Black Athletes >10% of all black athletes demonstrated LV hyper-trabeculation 35.5% of black patients with heart failure demonstrate LV hypertrabeculation Significantly higher than the prevalence of LVNC Suggests that LV hyper-trabeculation may be an epiphenomenon in response to chronic increases in pre-load & after-load associated with regular exercise rather than a manifestation of pathology

16 Conclusions: Black Athletes However, the association between LV hyper-trabeculation & repolarisation abnormalities on 12-lead ECG cannot be ignored BUT, repolarisation abnormalities are also more common in black athletes Parameter Black Athletes n = 904 (%) White athletes n = 1823 (%) p-values ST-segment elevation < ST-segment depression NS T-wave inversions < Deep T-wave inversions <

17 Study Limitations The precise significance of this morphological anomaly requires: larger sample size familial evaluation more detailed imaging longitudinal follow up Greater numbers of endurance athletes and Afro- Caribbean athletes No data on female athletes, adolescent athletes or recreational/non-athletes

18 Acknowledgements Fellow authors: Michael Papadakis, Jennifer Duschl, David Foldes, Rebecca Howes & Sanjay Sharma Cardiac Risk in the Young for providing ECG & echocardiography equipment St George s University of London & University Hospital Lewisham