Sports activity in asymptomatic

patients with ischaemic heart

disease?

Europrevent,

Geneva,

110415

Mats Börjesson,

Assoc prof, MD, FESC

Sahlgrenska University Hospital/Östra,

Göteborg, Sweden

Asymptomatic individuals with IHD

in sporting activity

• Normally not patients…

• Do they exist?

• How do we find them?

• Are they eligible for

sports?

• Restrictions?

Do they exist?

Case report

• 46-year old married man, lawyer

• No earlier known disease

• Recreational cyclist since many years, licensed for cycling competition since one year

Case presentation

• Several day race in France, extreme conditions

• After finishing a leg of the race he suffers acute chest pain and MI is diagnosed. He underwent acute PCI with a STENT placement in the LAD.

• After returning to Sweden he had some more chest pain at recovery: two additonal coronary angios have been normal.

• Medication: ASA, clopidogrel, statins, low dose beta-blocker

• He eventually resumed cycle-training without symptoms, and then wants to resume cycling competititon….

??

La Marmotte 2006-07-08Col de la Croix de Fer – Col de Telegraph – Col de Galibier

Puls 154/172 (snitt/max) Temp 17-28 C (25 C vid 2100 möh vid MI)

Ischemic Heart Disease -most common cause of SCD in

>35 y olds

Ref: Virmani R,

Pathology annual, 1985

SCD etiology: Iceland (left) vs Sweden

(12-35 and 15-35 years, respectively)

2%2%2%1%

4%

7%

10%

10%

10% 12%

18%

22%

Structurally normal heart

IHD

HCM

DCM

Myocarditis

Diss aortic aneurysm

ARVD

Coronary anomaly

Post op CHD

Valvular disease

Conductionsystem

Other

25%

17%

13%13%

9%

7%

4%

4%

2%2% 2%

IHD

Structurally normal heart

HCM

Arrythmia

Myocarditis

Pulmonary embolism

Long QT2

DCM

Valve disese

Coronary anomali

Other

IHD

Structurally normal heart

HCM

Arrythmia

Myocarditis

Pulmonary embolism

Long QT2

DCM

Valve disese

Coronary anomali

Other

24%

16%

13%13%

9%

7%

4%4%

4%

2% 2%

Athletes and coronary

artery disease

• SCD increases transiently during vigorous physical activity

• PA causes dilatation in normal coronaries, but may cause

vasoconstriction in atherosclerotic segments (Gordon, J Clin

Invest -89)

• Aggravating factors during exercise

-catecholamine release

-platelet adhesion/activation (Cadroy, J Appl Phys -02)

-electrolyte disturbances (i.e. potassium)

-heat/cold/altitude related complications (O´Donnell,NEJM -72)

-doping/drugs (Heesch, Heart -00, Kennedy, Med J Aust -93)

* The level of physical activity? Risk of competition?

Older athletes: risk group

• ”Master athletes”: Defined as >35 years of age (40), may be significantly older

• Organized form of competitive sports, specifically designed for

older athletes (over 50 sports:

running, cycling, skiing..)

”..unique psychological and physiological

stresses that competition places on such

athletes, particularly those with cardio- vascular

disease” : AHA 2001

Biomarker release stratified by age, 30 km race (Sahlen A, Am J Cardiol 2009;104:1434-40)

• Pro-BNP

Predisposing Factors and Consequences of Elevated Biomarker

Levels in Long-Distance Runners Aged >55 YearsAnders Sahlén, MDa,*, Thomas P. Gustafsson, MSc, Lic Med Scb, Jan E. Svensson, MD, PhDb,

Tony Marklund, BScc, Reidar Winter, MD, PhDd, Cecilia Linde, MD, PhDa, and

Frieder Braunschweig, MD, PhDa

Cardiac biomarkers play an important role in the diagnosis of cardiovascular disease.

Elevated levels can be seen in the context of strenuous exercise. We studied this phenomenonin senior endurance runners. We included 185 participants (61.1 � 5 years; 29%

women) at a 30-km cross-country race who were self-reportedly in excellent health. Before

and after the race, the creatinine, N-terminal pro-brain natriuretic peptide (NT-proBNP),

and troponin T were analyzed, and participation in the number of previous races and the

race duration were recorded. NT-proBNP increased from 53 ng/L (interquartile range 31 to

89) to 121 ng/L (interquartile range 79 to 184) and troponin T from undetectable to 0.01�g/L (interquartile range 0.01 to 0.04). The independent predictors of a large NT-proBNP

increase were (1) greater levels present at baseline, (2) a greater increase in creatinine (both

p <0.001), (3) older age (p � 0.01), and (4) a longer race duration (p <0.05). Troponin T

elevation was independently predicted by (1) older age (p � 0.01), (2) a greater increase in

creatinine, and (3) participation in fewer previous races (both p <0.05). Of the 15 runners

with an elevated (>194 ng/L) baseline NT-proBNP level (8.1% of 185), 4 were found to

have serious cardiovascular disease (2.2% of whole sample). Of these 4 patients, 1 died from

sudden cardiac death within months after the race. In conclusion, biomarker elevation

occurs commonly in senior runners. A high baseline NT-proBNP is predictive of a large

release during exercise, suggesting that the factors that control the at rest levels also

determine its release with exertion. Troponin T elevation was seen in less-experienced

participants. A small group of very ill runners were identified by NT-proBNP

analysis. © 2009 Elsevier Inc. All rights reserved. (Am J Cardiol 2009;104:1434 –1440)

Asymptomatic athletes may have

severe underlying CV-disease

How de we find them?

AHA recommendations for

screening of masters athletes(Circulation 2001;103:327-34)

• ALL master athletes should undergo screening by

personal and family history and physical ex

• Standard 12-lead ECG for all >40 (men and women)

• Those >40 (men), >50 (women) with 1 more risk factor

(lipids, HT, smoker, diabetes, pos fam history of CAD)

should undergo maximal exercise-testing

• Exercise-test in ALL >65 and in those with symptoms of

CAD

Screening recommendations

according to:

1 Intensity-level of intended PA;

2. Risk profile;

3. Habitual exercise level

Individual risk profile

• Initially, by a self-evaluation

-AHA/ACSM questionnaire

-revised PAR-Q

• Secondarily, a risk stratification

by a physician (if necessary)

-by SCORE

Table 2

Revised physical activity readiness questionnaire (PAR-Q)

(adopted from Balady, Circulation 1998;97:2283-93)

1 Has a doctor ever said that you have a heart condition and recommended only

medically supervised activity? Yes/ No

2 Do you have chest pain brought on by physical activity? Yes/ No

3 Have you developed chest pain in the past month? Yes/ No

4 Have you on 1 or more occasions lost consciousness or fallen over as a result of

dizziness? Yes/ No

5 Do you have a bone or joint problem that could be aggra vated by the proposed

physical activity? Yes/ No

6 Has a doctor ever recommended medication for your blood pressure or a heart

condition? Yes/ No

7 Are you aware, through your own experience or a doctor«s advice, of any other

physical reason that would prohibit you from exercising without medical

supervision? Yes/ No

First line- self assessment, alternative 2

The fitness level adds info

Are they eligible for sports?

Ref: Börjesson M et al, EJCPR 2006; 13: 137-49.

1. Athletes with known IHD

Includes athletes with:

I. Unstable angina

II. Stable angina

III. Post ACB/PCI patients

IV. Post MI

V. Silent ischemia (unequivocal evidence of

ischemia on stress testing/Holter, but

without clinically evident symptoms

Risk stratification of IHD pats

• LOW PROBABILITY FOR EXERCISE-INDUCED EVENTS

-ejection fraction >50% (echo)

-normal exercise capacity (for age)

-absence of exercise-induced ischemia

-absence of complex ventricular arrhythmias

-absence of significant coronary stenosis (>70%) of major

coronaries, or >50% of LAD

(ref: adjusted from Maron BJ, Circulation 2001;103:327-34)

• HIGH PROBABILITY FOR EXERCISE-INDUCED EVENTS

-Ejection fraction <50% (echo/SPECT), or

-exercise induced ischemia (>1mm in 2 leads),

-exercise induced inadequate dyspnea/syncope,

-complex ventricular arrhythmia (rest/stress),or

-significant coronary stenosis, as above, on coronary angiography

Angiography does not fully predict the risk of

plaque rupture

‘Safe’ plaque ‘Unsafe’ plaque

Angiographic

appearance

Recommendations for

participation in competitive

sports

• Definitive IHD+

high probability of cardiac events:

-no competitive sports

• Definitive IHD+

low probability of cardiac events:

-only sports IA-B

Table 1. Classification of sports

A. Low Dynamic B. Moderate Dynamic C. High Dynamic

I. Low Static Archering

Bowling

Cricket

Golf

Riflery

Table tennis

Tennis (doubles)

Volleyball

Baseball*

Badminton

Walking

Running (marathon)

Cross-country skiing

(classic)

II. Moderate Static Auto racing*DivingEquestrian*Motorcycling*Gymnastics*Karate/Judo*

Sailing

Fencing

Field events (jumping)

Figure skating*

Lacrosse*Running (sprint)

Basketball*

Biathlon

Ice hockey*

Field hockey*

Football*

Socce r*

Cross-country skiing

(skating)

Running (mid/long)

Swimming

Squash*

Tennis (single)

Team handball*

III. High Static Bobsledding *Field events (throwing)

Luge*Rock Climbing*Waterskiing*Weight lifting*

Windsurfing*

Body building*Downhill skiing*Wrestling*

Boxing*

Canoeing, Kayaking

Cycling*Decathlon

Rowing

Speed skating

Symbols: *Dange r of bodily collision. Increased risk if syncope occu rs.

Adapted and modified after Mitchell et al. (Classification of Sports. JACC 1994;24:864-6).

Table 1. Classification of sports

A. Low Dynamic B. Moderate Dynamic C. High Dynamic

I. Low Static Archering

Bowling

Cricket

Golf

Riflery

Table tennis

Tennis (doubles)

Volleyball

Baseball*

Badminton

Walking

Running (marathon)

Cross-country skiing

(classic)

II. Moderate Static Auto racing*DivingEquestrian*Motorcycling*Gymnastics*Karate/Judo*

Sailing

Fencing

Field events (jumping)

Figure skating*

Lacrosse*Running (sprint)

Basketball*

Biathlon

Ice hockey*

Field hockey*

Football*

Socce r*

Cross-country skiing

(skating)

Running (mid/long)

Swimming

Squash*

Tennis (single)

Team handball*

III. High Static Bobsledding *Field events (throwing)

Luge*Rock Climbing*Waterskiing*Weight lifting*

Windsurfing*

Body building*Downhill skiing*Wrestling*

Boxing*

Canoeing, Kayaking

Cycling*Decathlon

Rowing

Speed skating

Symbols: *Dange r of bodily collision. Increased risk if syncope occu rs.

Adapted and modified after Mitchell et al. (Classification of Sports. JACC 1994;24:864-6).

Recommendations for

leisure-time PA

• Encouraged and should be prescribed

• Provided at safe level of exercise:

-10 beats below anginal threshold with HR-monitor (ischemia-threshold in silent angina)

-and/or below ventilatory threshold

-RPE by Borg an alternative, for example if on beta-blockade)

2. Athletes without evidence

of IHD, but with >1 risk

factor for IHD

Risk stratification

• In asymptomatic subjects, the total IHD-risk level can be estimated from the presence of major risk factors, according to the SCORE (systematic coronary risk evaluation)-system

-blood pressure

-age

-sex

-smoking

-total cholesterol

(Third Joint European Task Force for cardiovasc prevention)

• In addition, diabetes and family

history are added

Risk stratification-2

• THE HIGH RISK PROFILE FOR DEVELOPING A

CARDIAC EVENT:

-Presence of risk factors, resulting in a 10-year risk >5%

in SCORE

and/or

-markedly raised tot-cholesterol >8 mmol/l,

LDL>6 mmol/l or BP >180/110 mmHg and/or

-diabetes mellitus type 1/2 with microalbuminuria

-family history of premature cardiovascular

disease in 1 first degree relative

• THE LOW RISK PROFILE:

Evaluation- high risk profile

• FIRST, try to rule out silent ischemia by maximal exercise

testing (limitations)

• THEN…separate

1. Negative X-test: The absolute risk is

considered low

2. Positive X-test: The risk for future cardiac events is

increased

Further evaluation by stress echo/ myocardial

scintigraphy and/or coronary angio-graphy to rule

out/confirm the presence of IHD is needed

Evaluation-low risk profile

• Use of exercise-testing in healthy asymptomatic

athletes (<35y men; <45y women) without

classical risk factors is not routinely

recommended

Recommendations for

participation in (risk) patients

• No known IHD+ high risk profile+ positive exercise test

-sports IA-IB only (same as known IHD)

• No known IHD+ high risk profile+ negative exercise test

-individual decision, (avoid extreme sports)

• No known IHD+ low risk profile

-all competitive sports

• Regular follow-up recommended….and leisure-time PA!

Summary: (ERCP 2006;13:137-149)

Asymptomatic athletes in

Vasaloppet- follow-up study:

1970-2005: 698.000 racers, 13 SCD (expected 1,7) -1/50.000 racers

73500 competitors in Vasaloppet 1989-98,

mean 4 year follow-up

73.500 skiers

1989-98

Vasaloppet- net effect. . .

3 extra SCD during the race

440 less deaths in 4 years follow-up after the race

Future challenges

•The ultimate goal must be to achieve all the

benefits of PA and still avoid the negative

effects

ex. helmet for cyclists

•To better identify high risk individuals with

underlying IHD

•To refine the recommendations regarding

eligibility in competitive sports

”If we could give every individual

the right amount of nourishment

and exercise, not too little and not

too much, we would have found

the safest way to health”

(Hippocrates 400 BC)

Thank you!