the heart of the athlete william b baker md facc
TRANSCRIPT
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THE HEART OF THE ATHLETE
WILLIAM B BAKER MD FACC
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EXERCISE IS GOOD FOR YOU
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BENEFITS OF EXERCISE
• DISEASE PREVENTION• Cardiovascular• Diabetes• Osteoporosis, joint health
• FITNESS• WEIGHT CONTROL• ENJOYMENT• Personal Goals• Competition
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DEFINITIONS FOR THIS TALK
• EXERCISE: Any form of physical activity, done on a regular basis, with the purpose of achieving a specific goal• Low level to vigorous• Recreational (including “play”) to competative
• ATHLETE: Anyone who is exercising• YOUNG ATHLETE: Less than 35 years old• ADULT ATHLETE: Greater than 35 years old
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COULD YOUR “WORKOUT” CAUSE YOU CARDIOVASCULAR HARM?
• ANSWER: YES• THE RISK IS SMALL• THE CONSEQUENCES ARE SIGNIFICANT• WHAT THE RISK IS AND WHAT
CONDITIONS ARE RESPONSIBLE FOR THE RISK VARY BY AGE
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Who are we talking about, what are the numbers and what are we talking about
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THE YOUNG ATHLETE AND THE RISK
(US numbers)• All deaths related to exercise: 120/year (excluding
trauma)• Deaths caused by CVD: < 100/year• Approximately 1 CVD death/100,000/year• CVD death in affected athletes is not limited to
exercise times• At least 2-3 X more likely during exercise
• All the “conditions” that might harm athletes are just as prevalent in non-athletes. Athletes are at higher risk.
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THE YOUNG ATHLETEHOW MANY ARE AT RISK?
• 44 Million youths participate in “sports programs”
• 3.5 Million high school athletes• 500,000 college athletes in the US• 10,000 “pro-athletes” in the US
IF A CONDITION THAT CAN HARM AN ATHLETEAFFECTS 1 IN 500 YOUTHS, HOW MANY ARE AT RISK?
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THE ADULT ATHLETE• Harder to define the numbers and risk• Heart disease is common among adults• Exercise programs vary• No organized reporting program
• Marathoners: <1/100,000 on race day• Tri-athletes: 1.5/100,000 on race day• Recreational runners: 1/10,000/year or 1/396,000
hours of running• Nordic Skiers: 1/607,000 hours• Individuals with disease are 2 -3-X more likely to have
an event during exertion.
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THE YOUNG ATHLETEA SAMPLING OF THE CAUSES
• Structural Heart Disease• Hypertrophic Cardiomyopathy • Anomalous Origin of the Coronary Arteries• Arrhythmogenic Right Ventricular
Cardiomyopathy• Myocarditis/Cardiomyopathy• Valvular Disease
• The “Channelopathies”• Marfan Syndrome
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THE ADULT ATHLETEA SAMPLING OF THE CAUSES
• Coronary Artery Disease• Valvular Heart Disease• Cardiomyopathy• “Young Athlete” Disease
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THE YOUNG ATHLETE
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THE YOUNG ATHLETEand SUDDEN CARDIAC DEATH
• Rare events• Without warning• Devastating• Occur in healthy individuals• Attract attention
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MECHANISM OF SUDDEN DEATHVentricular Tachycardia and Ventricular Fibrillation
Normal EKG
Ventricular Tachycardia Polymorphic Ventricular TachycardiaVentricular Fibrillation
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THE YOUNG ATHLETEand SUDDEN CARDIAC DEATH
• The “Underlying Substrate”: Many of these conditions predispose to lethal arrhythmia
• There can be changes in the athlete’s heart that may increase the risk• Hypertrophy (the “muscular heart”)• LV and RV dilation (the “enlarged heart”)• Increased demand and “adrenalin”
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THE YOUNG ATHLETE
SPECIFIC EXAMPLES(An incomplete review)
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HANK GATHERS1967 - 1990
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HYPERTROPHIC CARDIOMYOPATHY
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HYPERTROPHIC CARDIOMYOPATHY
• Affects 1 in 500 individuals• Genetically determined• Sporadic or inherited• At least 11 genes, 1400 mutations
• Accounts for 35 – 40% of athletic deaths• Can be symptomatic/detectable before SCA• Increased risk with age• Ventricular arrhythmia is primary cause of death
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HYPERTROPHIC CARDIOMYOPATHY
• Treatment: Medical• Treatment: Implantable Defibrillator
• “Disqualified” from participation in in all but low effort sports (bowling, curling) regardless of symptoms, phenotype, treatment.
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The IMPLANTIBLE CARDIAC DEFIBRILLATOR (ICD)
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DISQUALIFIED?
The 36th Bethesda Conference
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THE 36TH BETHESDA CONFERENCE
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ANOMALOUS ORIGIN OF THE CORONARY ARTERIES
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ANOMALOUS ORIGIN OF THE CORONARY ARTERIES
• Accounts for 15 – 20% of sudden death in young athletes
• Can be symptomatic (< 50%)• Chest discomfort• Shortness of breath• Palpitations• Fainting
• Treatment: Medical or Surgical• May be “cleared” to participate if corrected
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ARRYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY
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ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY
• Prevalence: 1/1000 – 2000• Genetic, 30% inherited.• Accounts for 5% of sudden death in young
athletes• Can be symptomatic: palpitations, fainting• Treatment: medical, ICD• Disqualified from competitive sports
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MYOCARDITIS/CARDIOMYOPATHY
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MYOCARDITIS/CARDIOMYOPATHY
• Accounts for 5 -10% of sudden cardiac arrests in young athletes
• Causes: “viral”, inherited/genetic, idiopathic• Can be symptomatic: shortness of breath,
palpitations, fatigue/weakness, fainting, chest discomfort
• Treatment: Medical, time, ICD, transplant• Disqualified from most competitive sports.
May return if recover. ICD = no contact sports
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MARFAN SYNDROME
• Connective tissue disorder
• Genetic• 25% sporadic• Autosomal Dominant
• 1/3000 – 5000
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MARFAN SYNDROME
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COMMOTIO CORDIS
• Vulnerable moment• High force, specific area• Baseball, hockey, karate• Kids more vulnerable• 20% survival• Boys > girls• Prevention key• Training to avoid impact• ? vests
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INHERITED ARRHYTHMIAand
SUDDEN CARDIAC ARRESTThe “Channelopathies”
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WHAT IS A CHANNEL?
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THE CHANNELOPATHIES AND SUDDEN CARDIAC ARREST
(A SAMPLING)• Long QT Syndrome• Brugada Syndrome• Catecholaminergic Polymorphic Ventricular
Tachycardia• Short QT
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THE CHANNELOPATHIES AND SUDDEN CARDIAC ARREST
• Inherited/genetic conditions• Lead to Ventricular Tachycardia and
Ventricular Fibrillation• Evident (variably/intermittently) on EKG• Cause of Sudden Cardiac Arrest in both
athletes and non-athletes. Exercise does increase the risk in many of these conditions
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THE CHANNELOPATHIESTHE LONG QT SYNDROME
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THE CHANNELOPATHIES: LONG QT• Not rare: 3000 – 4000 deaths/y in children/adolescents• Inherited/genetic
• 12 types/genes, hundreds of different mutations• Variable “lethality”• AR associated with deafness
• Variable expression• Acquired form
• Medications/drugs• Electrolyte changes
• Increased risk of SCA with exercise, risk variable based on type• SCA in athletes: not rare, numbers not clear• EKG + , gene +, symptom + : Disqualified from competitive sports
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ACQUIRED LONG QT• Medications: www.qtdrugs.org
• Antiarrhythmics• Antibiotics: Levaquin, Zithromax (Z pack), erythromycin• Antidepressants: Tricyclics, Prozac, Celexa• Tamoxifen• diuretics• 140 other drugs
• Methadone• Combinations of drugs• Electrolytes: Low K+, Mg++, Ca++• Genetic + Drugs, ? Unmasked congenital form• Reversible
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ACQUIRED LONG QT AND EXERCISE
• ? Drug + exercise interaction• ? Electrolyte changes with exercise• Dehydration• Excessive “free water” intake• Losses with sweating• Diuretics• ? Greater risk with endurance events
• The Perfect Storm: Congenital substrate + drugs + exercise
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THE CANNELOPATHIESBRUGADA SYNDROME
• Genetic• Genetic testing variable• Na+ channel
• EKG variable• Provocative testing
• Multiple types• Male > Female• Avg age at DX: 41• Fever/hyperthermia trigger• Night time trigger• Treatment: ICD, limited medications• Caution advised for competitive
sports with no history of events• With history of events or ICD low
level sports only
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THE CHANNELOPATHIES: CATECHOLAMINERGIC POLYMORPHIC VT
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CPVT• Genetic, at least 2 gene mutations• Inherited• Emotional and physical triggers. Symptoms:
dizziness and syncope• Usually presents in childhood and adolescence• Treatment: Medical therapy, ICD + medical,
Sympathectomy, Medical therapy for gene + asymptomatic.
• Generally recommend against competitive sports, ICD precludes contact sports
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OTHER ARRHYTHMIAWOLFF PARKINSON WHITE
• 1/400• Often Incidental finding• Can present with symptoms• Often first diagnosed in
adulthood• Risk of V-fibrillation• Risk stratify asymptomatic
Pts• Ablation• OK to participate in
competitive sports once treated
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SCREENING YOUNG ATHLETES
• Recommendations vary widely internationally and within the US
• Recommendations vary widely based on level of participation
• Not clear if definitely reduces risk• Findings variable with time• Variable age of onset• These are relatively rare diseases
• Needs to be done regularly until adult age
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SCREENING GOAL
• To identify those at risk • Prevent injury and lethal events
TO ASSIST YOUNG ATHLETES AND THEIR FAMILIES IN MAKING
RATIONAL DECISIONS REGARDING THE RISK OF ATHLETIC PARTICIPATION
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THE PREPARTICIPATION EXAM
• Review for symptoms• Dizziness or fainting, shortness of breath,
palpitations, chest discomfort, can’t keep up
• Family History• Premature death• “Death under unusual circumstances”
• Physical exam• Murmurs, build, pulses
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WHAT ABOUT EKGs
• Not recommended routinely in US• Required in Europe• Controversial• Not clear it helps• Athletes often have EKG changes that are “normal”• False negatives, False positives• Cost of EKGs, Cost of additional testing, Cost of
disqualifying athletes• Estimated $80,000 to find one case
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LOWERING RISK IN THE YOUNG ATHLETE
• Preparticipation Exam• Parental involvement in children and adolescents• Coaches/trainer/athlete awareness• Symptom awareness• Workout/practice design• Hydration/electrolyte replacement• AEDs in close proximity when feasible and AED
training• CPR training of coaches/trainers/athletes
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SCREENING RELATIVES“BACKWARD AND FORWARD”
Can both include exclude disease
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THE ADULT ATHLETE
CARDIOVASCULAR DISEASE IS THE PRIMARY CAUSE OF DEATH IN ADULT
ATHLETES
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THE ADULT ATHLETE
• Primary Cause: Coronary Artery Disease• Cardiomyopathy• Vascular Disease• Arrhythmia• Valvular Heart Disease
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THE ADULT ATHLETE
The adult athlete can still have almost any of the conditions of the young athlete.
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CORONARY ARTERY DISEASE
STILL NUMBER ONE
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JIM FIXX1932 - 1984
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WHAT IS THE RISK?• 800,000 Heart attacks/year• 400,000 Sudden Cardiac Death• Sudden Death: First symptom in 50%• 2 – 3 X as likely to suffer a cardiac event during exercise in
those with disease• Numbers during exercise unknown
• Marathon Risk: 1/50,000 – 100,000/race• 2012: 550,000 finished a marathon• 2011: 500,00 started their first marathon
• Nobody is keeping track outside of organized events• Odds are there are many cardiac events during unorganized
exercise that are not reported
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WHAT IS THE RISK OF EXERCISE?
• Relatively infrequent• Not rare• Unexpected• No prior history of cardiac disease• Healthy• Devastating for “victims”, families,
communities
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DETERMINANTS OF EXERCISE RISK
Probability of Cardiac Disease
Intensity and Duration of Exercise
RISK INCREASES WITH INCREASED RISK OF UNDERLYING CVD, INTENSITY, DURATION
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MEASURING INTENSITY
The Metabolic Equivalent or MET
3.5 ml O2/kg/min
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MET
1. Sitting……………………………………………….1.02. Walking at 2.5 m/h……………………………2.93. Biking at 10 m/h……………………………….4.04. Elliptical……………………………………………5.55. Jogging…………………………………………….7.06. Swimming (moderate)……………………..8.0 7. Swimming (hard)…………………………….12.08. Running 8 min mile…………………………12.59. Bike Racing (not drafting) > 20m/h….16.0
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RATING OF PERCEIVED EXERTIONRPE
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EXERCISE INTENSITY• Light • Daily activities, gentle walk• RPE < 3, < 3 METs
• Moderate• Brisk walk, easy jog or bike• RPE 3 – 5, < 6 METs• “Talk Sing”
• Vigorous/Intense• Running, Biking, High Intensity Interval, “Boot Camp”• RPE 7 – 10, METs > 6• Fail “Talk Sing”
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EXERCISE DURATION
• Dehydration• Electrolyte changes• Increased inflammation• Hyperthermia• Pushing through
Most cardiac events during marathonsoccur past the 22.5 mile marker
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RECOMMENDED DURATION(health and fitness goal)
American Heart Association
150 min/week of moderate exercise
75 min/week of vigorous exercise
OK to break it up
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WHAT IS CORONARY ARTERY DISEASE?
HOW DO I CATCH IT?
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CARDIOVASCULAR DISEASE THE PRIMARY CULPRIT
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FACTORS INCREASING THE LIKLIHOOD OF CORONARY ARTERY DISEASE
• Age• High Blood Pressure• Abnormal Cholesterol Values• Family History• Smoking
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FACTORS INCREASING THE LIKLIHOOD OF CORONARY ARTERY DISEASE
NON-TRADITIONAL• Cholesterol variants• Lp(a)• Particle size
• Genetic• Vascular physiology/metabolism• Inflammation
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GLOBAL RISK
THE GREATER THE NUMBER OF RISK FACTORS, THE GREATER THE RISK
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THE HEART ATTACK
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ISCHEMIA
Increased HRIncreased
ContractilityIncreased
InflammationElectrolyte Changes
Dehydration
Demand > Supply
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ISCHEMIA AND SCD
DEMAND > SUPPLY ISCHEMIA
CHEST PAINSOB
PERFORMANCENON-LETHAL ARRYTHMIA
LETHAL ARRHYTHMIA
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WHAT’S THE TREATMENT
• PREVENTION PREVENTION PREVENTION • MEDICAL• REVASCULARIZATION
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OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISE
DILATED CARDIOMYOPATHYHYPERTROPHIC
CARDIOMYOPATY
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OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISE
AORTIC DISSECTION• Risk Factors: ASCVD,
especially hypertension• Sporadic, associated with
aneurysm, genetic• Sheer force• Increased risk with high
static component exercise
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OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISE
VALVULAR HEART DISEASE• Aortic stenosis• Aortic insufficiency• Mitral Valve Prolapse
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NONLETHAL ARRHYTHMIA
ATRIAL FIBRILLATIONSUPRAVENTRICULAR
TACHYCARDIA
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EXERCISE AND NONLETHAL ARRHYTHMIA
• European Heart Journal 2014• 52,000 Nordic Skiers• Mean age: 38• Twice the risk of non-athletes• Higher risk with more races• Higher risk with faster times• Mechanism: ? inflammation
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DETERMINING YOUR RISK
• AGE• CVD RISK FACTORS• HISTORY OF EXERCISE• SYMPTOMS• FAMILY HISTORY OF SUDDEN DEATH,
FAINTING, ARRHYTHMIA, DEATH UNDER UNUSUAL CIRCUMSTANCES
• CORONARY ARTERY CALCIUM SCORING
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WHO NEEDS SCREENING
• Everyone over 20 years old should know their risk factors for CVD and periodically re-evaluate them
• Everyone should discuss with their physician their exercise routine (Physicians rarely ask)
• A “baseline” history and exam is indicated as part of the risk evaluation for exercise
• It is reasonable for adults to have at least one baseline EKG
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RISK LEVEL
• Low Risk: man < 45, woman < 55, no CVD risk factors, no symptoms, no worrisome history
• Moderate Risk: man > 45, woman > 55, 1 or 2 CVD risk factors (not DM)
• High Risk: History or Symptoms of CVD, DM, age > 65, > 2 CVD risk factors
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RISK LEVEL
LOW MODERATE HIGH
HIGH
MOD
LOW
WHO NEEDS PRE-EXERCISE TESTING
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Match your type, intensity and duration of exercise to your goal
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IF YOU ARE EXERCISINGDON’T IGNORE SYMPTOMS WHETHER WITH
EXERCISE OR NOT
• Decreased performance• Chest discomfort• Shortness of breath• Irregular heart beats / palpitations• Dizziness or fainting
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CONCLUSIONS
• EXERCISE IS GOOD FOR YOU• EVERYBODY SHOULD EXERCISE• EXERCISE CARRIES A SMALL RISK OF A
CARDIAC EVENT THAT IS “AGE” SPECIFIC• GET APPROPRIATE “SCREENING”• DON’T IGNORE SYMPTOMS. THERE IS NO
LIFETIME WARRANTY FROM A SINGLE SCREENING