Exercise Cardiomyopathy

Transcription

1 Exercise Cardiomyopathy Aaron L. Baggish MD, F.A.C.C., F.A.C.S.M. Cardiovascular Performance Program Division of Cardiology Massachusetts General Hospital Boston, MA

2 Conflicts: None Athletic Affiliations: Funding Sources: National Institutes of Health American Heart Association American Society of Echocardiography Department of Defense National Football League Player s Association

3 A History of Our Pastimes 1940 s It wakes a sleepy man up. It sharpens the brain. It widens the smile. It quickens the steps It heightens the jump. Yes, it is the elixir of life JUST ASK YOUR DOCTOR

4 A History of Our Pastimes

5 A History of Our Pastimes 1960 s Free Love. Sex Therapy

6 A History of Our Pastimes

7 A History of Our Pastimes 2000 s

8 A History of Our Pastimes Running can take a toll on the heart that essentially eliminates the benefits of exercise. Running too far, too fast and for too many years may speed one s progress toward the finish line of life, concludes an editorial to be published next month in the British journal Heart.

9 A History of Our Pastimes What do you tell this poor chap who lies in bed and wonders if marathons and triathlons are speeding him toward an early demise? What does this chap tell the throngs of endurance athletes he works with to do now that running is bad for you?

10 Too much exercise? Is exercise destined to go the way tobacco use and liberal sexuality? Can too much exercise over too much time hurt your heart (and affect morbidity and mortality) and if so, what does this pathology look like?

11 The Athlete in CV Medicine Where do they come from and why? The Athlete Sudden Death Asymptomatic Symptomatic Athlete s Heart Vs. Pathology Syncope Arrhythmias ASHD HTN Stamina

12 Too much exercise? 1.) Atrial Fibrillation - YES 2.) Exercise Cardiomyopathy - MAYBE 3.) Coronary Artery Disease - UNLIKELY

13 Atrial Fibrillation

14 Atrial Fibrillation 1 st Author Reference Subjects Primary Finding Karjalainen BMJ 1998 Runners (n=100) 5.5 ( ) Mont EHJ 2002 Endurance (n=70) 71% with lone AF Elosua Int J Card 2006 Endurance (n=51) 2.87 ( ) Heidbuchel Int J Card 2006 Endurance (n=53) 1.81 ( ) Molina Europace 2008 Runnners (n=39) 8.8 ( ) Baldesberger EHJ 2008 Cyclist (n=67) 10% AF in athletes Mont Europace 2008 Endurance (n=48) 7.31 ( ) Aizer Am J Card 2009 PHS Database (n=16,921) 1.20 with 7 days/week ex.* Claessen Heart 2011 Non-sel. Flutter RFA (n=58) Sportsmen 50% of Lone Afl pop. Andersen EHJ 2013 Nordic Skiers (n=52,755) 1.29 ( )*

15 Atrial Fibrillation Retrospective Vasaloppet (90K) Sweden >50,000 participants >> Dec Assessment of arrhythmia events Race time / # of races > Arrhyth. AF the dominant rhtythm issue

16 Atrial Fibrillation Coronary Artery Disease MECHANISM of ATHLETIC AF - LA Dilation / Remodeling - Persistent vagotonia - Sympathetic Surges - Intermit. LA Hypertension - Chronic Inflammation - Genes - ETOH - Caffeine - Psychological Stress

17 Too much exercise? 1.) Atrial Fibrillation - YES 2.) Exercise Cardiomyopathy - MAYBE 3.) Coronary Artery Disease - UNLIKELY

18 Exercise CMP Harvard Athlete Initiative

19 Exercise CMP Am J Physiol Heart Circ Physiol 2008 LV Systolic Strain Changes with Rowing Training (n=20) AS AL AS A AS A MS ML S L S L BS BL I P I P (< -2) (-2 to 2) (2 to 4) (4 to 6) (> 6) (< -2) (-2 to 2) (2 to 4) (4 to 6) (> 6) (< -2) (-2 to 2) (2 to 4) (4 to 6) (> 6) Longitudinal ~ 20-25% Radial ~ 50-60% Circumferential ~ 20-25% Normal to Supranormal Strain.Focal Septal Dysfunction??

20 Exercise CMP The Ventricular Interdependence of Physiologic Remodeling Am J Physiol Heart Circ Physiol 2008;295:1109

21 Exercise CMP Whyte et al. JAP 2011 LaGerche et al. EHJ 2011

22 Exercise CMP 40 trained (>10 h of intense training / week) athletes Competitive, top 25% finish recent endurance event No cardiac symptoms of traditional risk factors No inducible ischemia on stress echo MRI/echo/biochem. At 3 time points (pre-finish-6 to 11 d)

23 Exercise CMP

24 Too much exercise? 1.) Atrial Fibrillation - YES 2.) Exercise Cardiomyopathy - MAYBE 3.) Coronary Artery Disease - UNLIKELY

25 CV Risk Factors with Exercise NEJM 2002 JAMA 1985 Circulation 2007 JAMA 2003

26 CAD 108 M (>50 y.) At least 5 marathons

27 CAD Middle-aged runners (59 y.) (n=50) >25 Consecutive TCM s No training history No race history No physiology

28 CAD Interpretation Options: 1.) Exercise (rec. marathon training) drives athero. 2.) CAD findings driven by established and studied risk factors.underappreciated in these studies 3.) CAD findings driven by overlooked, non-running risk factors

29 CAD Do you really think it was the running that caused these men s coronary disease??

30 CAD Missing Risk Issues: 1.) Diet (Fit vs. Healthy) 2.) Care-free 20 s-30 s 3.) Family Genes Without controlling for these, can we say anything about causality?

31 Endurance Athletes.People Too

32 Clinical Implications and Future Work CAD A. Fib Toxic Exposure CMP

33 Clinical Implications and Future Work 6 Rules of Common Sense for the clinic 1. Aggressive CVD risk factor management 2. Plan for Annual Periodicity 3. Prioritize Warm-ups & Cool Downs 4. Practice Careful Event Preparation 5. Respect a Virus 6. Listen to Warning Signs

34 Thank You!