Following viral myocarditis, which athlete can re-enter his active sports career? ESC Congress 2011 Paris F. Carré University Rennes 1-Pontchaillou Hospital Inserm U642, Rennes - F-35000
The author declares that he has no conflict of interest concerning this lecture
Myocarditis definition Inflammatory disease of the myocardium Acute and/or chronic arrhythmogenic substrate Dennert RHJ et al Eur Heart J 2008; 12: 450-6
Myocarditis classification +++ Viral myocarditis Enteroviruses coxsackie B Parvovirus B19 Adenovirus Human herpes virus 6 Epstein-Barr-Virus CM virus Rarely Common cold viruses rhinovirus coronavirus Olimulder, MAGM, etal. Neth Heart J 2009;17:481-6. Circ J 2011; 75: 734 743
Acute Myocarditis evolution Total and spontaneous recovery in 50% Chronic myocarditis in 20% Myocarditis induced dilated cardiomyopathy in 20%
Myocarditis and sport 1- Why myocarditis and sport? 2- Difficult diagnosis in athlete 3- Sport participation with myocarditis 4- Prevention of myocarditis in athlete
Myocarditis and sport 1- Why myocarditis and sport? 2- Difficult diagnosis in athlete 3- Sport participation with myocarditis 4- Prevention of myocarditis in athlete
The cardiac arrhythmogenic triangle Arrhythmogenic substrate Trigger Environmental conditions Autonomic nervous system, dehydratation, hypoxia, acidosis Modified from Coumel P., 1984 catecholamines
Causes of sport s related SD observed in young competitive athletes SD is reported 1-2/100 000 athletes 35 y.o. Myocarditis 5-22 % Wesslen L et al Eur Heart J 1996; 17: 902-10 Frick M et al Herz 2009 ;34:299-304 Link MS, Estes M III Prog Cardiovasc Dis, 2008;1:44-57 McCaffrey FM, Am. J. Dis. Child. 1991; 145: 177 83 Causes de MS dans les Sportifs 13% 14% n=126 11% 9% n=112 8% 4% 3% 1% n=326 36% 37% Congenital Anatomical - + congenital Anatomic Cardiomyopathies Myocadiopathies Arrhythmias Arrhythmias Infectious Atherosclerosis n=309 Infectious Degenerative Undetermined Degenerative Acquired Acquired 31% 35% "Normal Normal heart" heart Review of Bille K et al Eur J Cardiovasc Prev Rehab 2006.
Myocarditis and sport 1- Why myocarditis and sport? 2- Difficult diagnosis in athlete 3- Sport participation with myocarditis 4- Prevention of myocarditis in athlete
Myocarditis diagnostic (1) Symptoms Asymptomatic Flu-like symptoms Gastrointestinal symptoms Cardiac symptoms none chest pain dyspnea palpitations, syncope heart failure fulminant Subtle clinical discomfort + recent infectious event Circ J 2011; 75: 734 743 Frick M et al Herz 2009 ;34:299-304
Myocarditis diagnostic (2) Clinical signs Fever Cardiac rhythm disturbance Hypotension Auscultation abnormality Heart failure Blood biochemistry signs Transient elevation of C-reactive protein elevation MB form creatine kinase Cardiac troponin T and I Viral antibody titer «cardiac fatigue» in athlete? Circ J 2011; 75: 734 743
Myocarditis diagnostic (3) ECG signs Resting ECG Sensitive tool Timely repeated Conduction disturbances Abnormal ST-T waves Morgera T Am Heart J 1992; 124:455 66. Circ J 2011; 75: 734 743 «Athlete s heart?
Myocarditis diagnostic (3) ECG signs Holter monitoring Exercise test Arrhythmias? Urhausen A et al Circulation 2003, 108:e21-e22
Myocarditis diagnostic (4) Echocardiography signs Transient wall thickening Reduced cardiac chamber size Reduced wall motion Pericardial effusion Urhausen A et al Circulation 2003, 108:e21-e22 Circ J 2011; 75: 734 743 Sskouri HNGW et al. J Am Coll Cardiol 2006;48:2085-93
Cardiac Magnetic Resonance signs (Se 86 % - Spe 95%) Cine CMR Early and late contrast enhancement-cmr T2 acquisitions Myocarditis diagnostic (4) Acute myocarditis (EBV) T2 weighted images Acute myocarditis Spotty epicardial areas lateral free wall (PVB19) midwall IV septum(hhv6) Chronic myocarditis Chronic myocarditis scar fibrosis Sparrow Pj RadioGraphics 2009; 29:805 23 Friedrich MG et al. J Am Coll Cardiol 2009;53:1475-87 Olimulder, MAGM, etal. Neth Heart J 2009;17:481-6.
Myocarditis diagnostic (5) Cardiac Catheterization Endomyocardial Biopsy Gold standard for diagnosis Myocardial degeneration, myocyte necrosis, inflammatory infiltrates, interstitial myocardial edema, fibrosis But adverse events and false negative results Wesslen L et al. Eur Heart J 1996;17:902-10
Myocarditis and sport 1- Why myocarditis and sport? 2- Difficult diagnosis in athlete 3- Sport participation with myocarditis 4- Prevention of myocarditis in athlete
Recommandations for sport participation in case of myocarditis Eur Heart J 2005;26:1422-45 J Am Coll cardiol 2005;45:1312-75
Recommandations for sport participation in case of myocarditis Acute myocarditis or myopericarditis Possible diagnosis no strenous exercicse until definite diagnosis Definite diagnosis adapted treatment and no significant exercise C-MRI Pelliccia A et al. Eur Heart J 2005;26:1422-45
Chronic myocarditis and sport If symptoms no strenuous exercise, no competition C-MRI sequellae without symptoms? Professional cyclist 26 y.o. Asymptomatic ventricular premature beats
Normal echocardiography C-MRI
Exercise test 150 watts
Exercise test : HR 193 bpm- BP 210/65 mmhg 460 watts- VO 2 = 4,2 l/min 74 ml/min/kg Maximal exercise
Myocarditis and sport 1- Why myocarditis and sport? 2- Difficult diagnosis in athlete 3- Sport participation with myocarditis 4- Prevention of myocarditis in athlete
Prevention of myocarditis in athletes Wesslen et al. Eur Heart J.1996; 7: 902 7
Myocarditis more frequent in athletes? Elite athletes are not clinically immune deficient, but may be less resistant to common minor illnesses, such as URTI Gleeson M J Appl Physiol 103:693-699, 2007.
Purpose of preventions 1- Stop elite sport for 4 weeks after an unspecific and proven infection rarely implemented 2- Stop sport and CV evaluation in case of subtle discomforts with suspected viral infection in spring and summer which exams? Cost-benefit ratio of myocarditis diagnosis in athletes? Walsh NP et al Exerc Immunol Rev. 2011;17:64-103.
Guidelines for return to exercise after infections One day without fever and with improvement of URTI or GI symptoms before returning to exercise Progressive improvement in training intensity. Check the individual tolerance to increased exercise intensity If recovery is incomplete take an extra day off Stop again physical exercise and consult your physician if fever and/or if any symptom reoccur
Conclusions True myocarditis diagnosis stop sport practice (6 months) True resumption OK for all competitive spot Myocarditis in athlete induce several questions 1- Lot of unknown myocarditis in athletes 2- True diagnostic athlete s heart? 3- True disease resumption no gold parameter 4- Which attitude in case of asymptomatic myocardial scar on C-MRI?