Sports Cardiology & Preliminary Results From the Masters Athlete Screening Study Hollyburn Country Club, Presenter Series October 19 th , 2016 Dr. Saul Isserow - MBBCh, FRCPC, FACC Medical Director, Sports CardiologyBC Barb Morrison - PhD student, MSc, BHK, CEP Research and Project Coordinator, Sports CardiologyBC
Outline • Dr. Saul Isserow • What is Sports Cardiology • Background - Why Study Masters Athletes? • Barb Morrison • Preliminary Results of the Masters Screening Study
What is Sports Cardiology? • “Aims to elucidate the cardiovascular effects of regular exercise and delineate its benefits and risks, so that safe guidance can be provided to all individuals engaging in sports and/or physical activity in order to attain the maximum potential benefit at the lowest possible risk” Heidbuchel, Eur J Prev Cardiology, 2013
www.SportsCardiologyBC.org
Evoluti on of Physica l Activity
Evoluti on of Physica l Activity
Good Reasons to Exercise Regularly • Reduction in MI and sudden death • Physical & mental well-being • Positive feedback from successes • Earning a living • Peer group • Weight loss
Phidippides (530 BC - 490 BC) Athenian herald: Professional-running courier Ran 40km from Marathon to Athens to announce Greek victory over Persia ‘Nikomen’ – We have won Collapses and dies Luc-Olivier Merson, 1869
Why Study Masters Athletes? • Middle-aged individuals are exercising more and living longer • Paradoxically, exercise can act as a trigger for a sudden cardiac arrest in those with underlying disease • Suggestions that there are potential harmful effects of chronic endurance exercise (i.e. AFIB, CAD) • Cardiovascular screening can prevent SCD, yet the optimal method in this population has yet to be determined
Canaccord Genuity CEO Paul Reynolds dies after incident during Hawaii triathlon The Globe and Mail Published Thursday, Apr. 02 2015, 7:04 AM EDT
Increasing Number of Masters Athletes • 54% were older than 65 years of age.. . Chugh S, Weiss B JACC, 2015.
Exercise Paradox
Does Exercise Increase the Risk of SCD? § Small absolute increase in relative risk of SCD during exercise § In the long-run, physical activity is protective
Physiologic changes of exercise and potential sequelae Thompson, Circulation. 2007 May 1;115(17):2358-68.
Causes of Sports-Related SCD -Number participating in 1. Underlying cardiovascular disease 2. Sport sport -Intensity of sport (physiological requirements) Primary cause of SCD in > 35 years is Coronary Artery Disease 3. Gender • Greater predominance in males vs. females (up to 30 fold more frequent) Marijon et al. Circulation. 2011
Greater incidence of sports-related SCD in non-competitive and older athletes 94% of sports- related deaths in overall population (majority of SDs were > 35 years) 1 6 % of sports related deaths in Eloi Marijon et al. Circulation. 2011 the young athlete
Optimal Amount of Exercise? é Troponin post exercise - AF (5 fold é ) - ? Myocardial fibrosis ê Obesity - ? é RV ê BP dysfunction ê Diabetes ê Risk of CAD - ? é CAD ê Risk of AF é Coronary reserve in CAD Arem et al., JAMA Intern Med. 2015 Merghani et al, Trends in Cardiovascular Medicine. 2016.
Running 1-3 times/week provided same level of risk reduction as higher frequency or intensity of running
Detection of Coronary Artery Disease: Can you name 10 Risk Factors? Non-Modifiable Modifiable • Age (↑) • Hypertension • Gender (Male) • Diabetes • Ethnicity (First Nations, • Dyslipidaemia South East Asian) • Smoking • Genetics • Physical Inactivity • Family History • Obesity and Abdominal • 1st degree male <55 years or Girth 1st degree female <65 years • Psychosocial • Alcohol Consumption
Framingham Risk Score (FRS): Calculating risk 3 Categories: Low risk (<10%) Moderate risk 10-19% risk High risk >20% risk For individuals 30-59 , double their score if cardiovascular disease is present in a 1st degree male <55 years or 1st degree female <65 years FHx: multiply Framingham risk by 2
What is the 10-year risk of a 60 year old man with normal lipids, non-smoker, normal blood pressure? • A – 5% • B – 10% • C – 15% • D – 20%
What if that same patient is now 70 FRS = 18.4%
50 male marathon runners (mean age: 52.7, range 45 -67 years) • Marathons completed: 1-72, median 7, mean 13.8 •
Results Summary • 50% of male marathon runners had mild- moderate CAD despite favorable risk profile • One had significant CAD • Reported atypical chest pain • Exercise stress test failed to detect those with CAD • Traditional risk factors did not differ between those with and without CAD Tsifilikas et al. 2015. RoFo
Potential Explanations • Jim Fixx dilemma • Excessive exercise versus previous bad habits • Metabolic and mechanical stresses • Potentially lead to accelerated atherosclerosis from oxidative stress • Increased sustained levels of catecholamines • Belief that exercise trumps a bad diet and smoking
Atrial Fibrillation
AF Prevalence • Prevalence increases with age: • persistent or paroxysmal AF • ~0.5% in subjects aged 45-54 years • ~1% at 55-64 years • ~4% at 65-74 years • diagnosed in 1% of the population by age 60 • >10% when older than 80 year • Most common treated arrhythmia seen in ATHLETES
Prevalence of AF in athletes • Dependent on: • Age • Sport • Length of prior training • Intensity of prior training • Sex
AF Risk Factors Wyse, JACC 2014
AF Risk Factors
AF Risk Factors
U-shaped curve? >5x jog/wk è 53% é risk of AF
Exercise and AF • Regular moderate exercise has TREMENDOUS health benefits • High-performance endurance athletes and Olympic athletes live longer than the general population
DESIGN RATIONALE Detection of: Coronary Artery Disease 1. Atrial Fibrillation 2. Valve Disease 3. Inherited Heart Disease 4.
Cardiovascular Imaging • Use as a first line tool in screening may not be appropriate due to concerns of cost-effectiveness, accessibility, and radiation exposure • Echocardiograms • PRO: No direct adverse effects • PRO: Useful for detecting cardiomyopathies, coronary anomalies • CON: Time, accessibility • CON: Does not detect coronary artery disease • Stress echo does • CT Angiography and Coronary Artery Calcium Scoring • PRO: High sensitivity for detecting mild to moderate disease • Will the results alter treatment decision making (i.e. take a statin)? • Does it reduce morbidity and mortality? • CON: Radiation exposure, cost • Cardiac Magnetic Resonance Imaging (CMR) • Limited availability, high cost, and low pre-test probability
Exercise Treadmill Test CONS PROS • Does not (always) detect mild- Predictive value of coronary artery • moderate plaque that is disease é as risk factors é vulnerable to plaque rupture Prognostic tool in risk stratifying • • Poor sensitivity in population based on: with low pre-test probability (i.e. Blood pressure response active individuals) • Complex ventricular ectopy • Exercise capacity • • False - positives à over Heart rate profile (failure to reach • treatment target heart rate, slow heart rate recovery)
Preliminary Results: Pre-Participation Screening and Cardiovascular Risk Assessment in Masters Athletes
What's Up Doc? • Participant Dave • 60 year old male • Received highest health category on his life insurance medical including ECG and blood work • No family Hx of CAD, never smoked • Physically fit, walks the dog and does the P90x workout daily • Just got back from the Olympics • Just finished walking his dog in the forest on Bowen Island, had chest pain à St. Paul's à 100% LAD blockage à 3 stents in 4 hrs
800+ Masters Athletes Initial Screen (UBC Hospital, Fortius, other allied health centres) Framingham Risk Score, History and Personal Symptoms Questionnaire, Physical Exam, Resting ECG, Physical Activity, Lifestyle and Psychosocial Stress Questionnaire Negative Positive Exercise Treadmill Test and/or cardiologist consult No Further Testing Abnormal Normal Further Testing (echo, No Further Testing CACS, CTA, MIBI) Cardiovascular No significant Disease à Clinical CVD Care Everyone à Annual Follow-Up for 5 Years
Criteria for Exercise Treadmill Test (summary) • Personal Symptoms • Positive Family History • Abnormal Physical Examination • Abnormal resting ECG (ECG Specific Criteria: “Seattle Criteria”) • If FRS ≥ 10 and/or has a markedly raised single cardiovascular risk factor • Age ≥ 65
Criteria for Cardiology Consult and/or Further Testing (i.e. echo, CCT, holter) • If stress test is positive or inconclusive • An abnormal physical exam • Family history of congenital heart • ECG suggestive of cardiomyopathy • FRS > 20
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