Herz und Sport Matthias Wilhelm

Universitätsklinik für Kardiologie, Interdisziplinäres Zentrum für Sportmedizin

The FIFA World Cup 2006 in Germany started on June 9, 2006, and ended on July 9, 2006. 1, Germany vs Costa Rica 2, Germany vs Poland 3, Germany vs Ecuador 4, Germany vs Sweden 5, Germany vs Argentina 6, Germany vs Italy 7, Germany vs Portugal (3rd place) 8, Italy versus France (final).

Objectives

•  Athlete’s heart – Normal vs. abnormal

•  Pre-participation screening – Gut feeling vs. evidence

•  Can you have too much of a good thing? – Morbidity vs. longevity

•  Exercise as (cardiac) medicine? – Effectiveness vs. efficacy

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Henschen S. Mitt Med Klin Upsala 1899;2:15-8.

“Skiing causes an enlargement of the heart which can perform more work

than a normal heart.”

The athlete’s heart

The effects of exercise training: a study of the Harward University crews.

Darling EA. Boston Med Surg J. 1899;161:229-33.

Impact of different clinical variables on LV end-

diastolic cavity dimensions in a large population of male and female elite

athletes.

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Impact of type of sport on the cardiovascular response

Dynamic Static

VO2

CO

HR

SV

Long distance runner Sprinter

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Strenght athlete Endurance athlete

Concentric hypertrophy in

strength-trained athletes:

Anabolic steroid abuse?

?Non-athlete

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Control subject Triathlete

TRIMP 1200 1600 2000 2800

Non-athletes, 29±6years VO2 peak 40.3±1.6 ml/min/kg, increase 21% in 12 months

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Young, competitive rowers 19±1years acute augmentation phase (90 days) Chronic maintenance phase (39 months)

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Maron et al., NEJM 2003 15

Afro-Caribbean Caucasian premier league soccer player leisure time athlete

„ethnic variant“ of early

repolarization

Hypertrophic cardiomyopathy

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Professional track cyclist with an abnormal ECG, no symptoms

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Peak power 339 watts (154 % pred.) VO2 peak 60.6 ml/min/kg (143 % pred.) BP at rest 150/80 mmHg, BP at peak exercise 230/80mmHg 24h BP 146/77 mmHg

LV wall max. 15 mm, no GLE

RVT 0.5

Professional track cyclist with an abnormal ECG, no symptoms

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Professional track cyclist with an abnormal ECG, no symptoms

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VO2 50 ml/min/kg VO2 75 ml/min/kg VO2 50 ml/min/kg VO2 75 ml/min/kg

ECV color maps

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Sudden cardiac death in sports

normal HCM ARVC

LV LV

LV

RV RV

RV

•  «Substrate» for ventricular arrhythmias under exertion

•  Abnormal resting ECGs>80% ECG screening

PPS H&P+ECG PPS H&P

Association is not

causality!

ARVC

Veneto region of Italy 21 years FU, 2,368,590 athlete years, 55 SCDs in athletes Mean age 23±7 years, 9% females

ARVC

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Titel der Präsentation / Name Referent/-in 25

Klinik- bzw. Direktionsname

Trends of sports-related sudden cardiac death in Switzerland - an autopsy study I B. Asatryan I SSC 2016 Lausanne

Department of Cardiology, Inselspital, Bern University Hospital, Switzerland

38% IHD, 24% AMI

Swissregard.ch: SCD related

to competitive sports n=21

Asatryan B et al., submitted

Distribution of underlying causes of srSCD

D’Silva et al. Eur Cardiol Rev, 2015;10:48–53

Australia and New Zealand years 2010 to 2012 all SCDs age group 1 to 35 years annual incidence 1.3/100,000 expert panel evaluation of autopsies

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Europace 2016, DOI 10.1093/europace/euw243

Europace 2016, DOI 10.1093/europace/euw243 28

Uberoi et al. Circulation. 2011;124:746-57

Corrado et al. Eur Heart J. 2010;31:243-59

Drezner et al. Br J Sports Med. 2013;47:122-4 29

2010 2013 2014

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Revised Seattle Criteria

Corrado D, 1st International Course in Sports Cardiology, St George’s University of London, 2015 31

Prevalence of Abnormal Electrocardiograms in Swiss Elite Athletes Using Modern Screening Criteria T. Perrin,1,* MD, L.D. Trachsel,1,* MD, S. Schneiter,1 MSc, A. Menafoglio,2 MD, S. Albrecht,3 MD, T. Pirrello,3 MD, P. Eser,1 MSc PhD, L. Roten,1 MD, B. Gojanovic,4 MD, M. Wilhelm,1 MD.

Swiss Medical Weekly 2016, accepted 32

ESC 2010/Uberoi 2011 criteria 3.9% abnormal ECG 2.7% abnormal H&P Costs: CHF 147 per athlete CHF 14,315 per finding

Br J Sports Med. 2014;48:1157-1161 33

Anthony Van Loo Defender SV Roeselare

Hypertrophic cardiomyopathy, plays soccer with an ICD

Competitive sports and structural heart disease?

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Respecting athlete’s autonomy - lessons to be learned from Gerald

Asamoah German soccer player from Ghana

1998 at the age of 20 years Asamoah collapsed and hypertrophic cardiomyopathy (IVS 20 mm) was diagnosed

Several physicians suggested disqualification from professional sports

Asamoah refused and continued playing under medication in the German Premier Soccer League, requirement of the German Soccer Federation: an AED at the field

Participation at the World Championships 2002 and 2006 for the German team

2007 Asamoah Foundation for Children with Heart Disease

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Leisure-time PA

Athletic exercise training

100 120 140

?

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Strenuous exercise (volume &

intensity) –

trigger AND promoter of CVD and

SCD?

<56 km/wk 56-72 km/wk >72 km/wk

4:28±0:39 4:05±0:41 3:45±0:21

pre post

“cardiac fatigue”

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Endurances sports and risk of AFib

Adapted from L. Mont, ESC 2014

Eur Heart J. 2013 Dec;34:3624-31

Vasaloppet 1989 to 1991

Mont et al., Europace 2009 Coumel et al., European Heart Journal

1994

Triangle of Coumel

Why does long-term endurance sport practice

promotes atrial fibrillation?

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Only male rats ?! «motivated» by mild electrical stimuli to run 28 m/min (1.86 km/h)

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Mean age 48/50 years AFib w/o RF Orienteers 5.3% Controls 0.9% OR 5.8 (95% CI 1.3 to 26.4)

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ARVC genes, myocarditis, drugs? 47

Figure 1 Schematic representation of ARVC course from desmosomal-gene mutation to phenotypic expression and cardiac arrest due to ventricular fibrillation.

Europace 2016, DOI 10.1093/europace/euw243 48

Vasaloppet 1989 to 1991

“Among male participants of a 90 km cross-country skiing event, a

faster finishing time and a high number of completed races were

associated with higher risk of arrhythmias. This was mainly driven

by a higher incidence of AF and bradyarrhythmias. No

association with ventricular arrhythmias or

cardiac arrest was found.” Eur Heart J. 2013 Dec;34:3624-31

2013

Association is not causality!

?

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Efficacy (ˈɛfɪkəsi) The ability to produce a desired or intended result.

Effectiveness (ɪˈfɛktɪvnəs) The degree to which something is successful in producing a desired result.

N Engl J Med 2000;342:454-60 54

Heart 2012;98:637-44 55

“…The overall increase in fitness (0.52 METs) was only a third the mean estimate reported in a recent systematic review (1.55 METs). …The exercise training volume prescribed was also only a third that reported in most international studies. …These low training volumes and small increases in cardiorespiratory fitness may partially explain the reported inefficacy of UK cardiac rehabilitation to reduce patient mortality…“ 56

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“… Exercise adherence decreased from a median of 95 minutes per week during months 4 through 6 of follow-up to 74 minutes per week during months 10 through 12…”

“…It is not easy for participants in an exercise training program, particularly for patients such as those in this study who have chronic symptomatic heart failure and multiple comorbid conditions, to continue exercise training during long-term follow-up. Although the study invested substantial effort and resources into optimizing adherence, we understand that lack of compliance is likely due to many factors, including a limitation of the disease state and concomitant comorbid conditions, diminishing motivation, or other factors, some of which are not easily modifiable….”

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Br J Sports Med 2013; doi:10.1136/bjsports-2013-092576

>80% VO2max

<50% VO2max

Circulation 2007; 115:3086

+46% 1.7 MET

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Take home messages

•  Athlete’s heart – DD sometimes difficult

•  Pre-participation screening – No evidence but good gut feeling

•  Can you have too much of a good thing? – Good genes often prevent serious

disease

•  Exercise as (cardiac) medicine? – Yes, but it has to be taken regularly

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Nothing’s as it seems

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45 yo marathon runner (personal best 2:35

1999 in Berlin) with dyspnea and palpitations

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Treadmill VO2 peak 38.3 ml/min/kg (99% pred.)

Bicycle ergometer VO2 peak 46.7 ml/min/kg (121 % pred.)

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Pectus excavatum

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Treadmill

Bicycle ergometer

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•  Section “Sports Cardiology”

•  Contact: Vincent Gabus, MD, CHUV vincent.gabus@chuv.ch

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