Sports and Physical Exercise in Special Clinical Settings ...€¦ · Sports and Physical Exercise...
Transcript of Sports and Physical Exercise in Special Clinical Settings ...€¦ · Sports and Physical Exercise...
Myocarditis
Brian Olshansky MD Professor Emeritus, University of Iowa
Electrophysiologist, Mason City, Iowa USA
SPORT AND ARRHYTHMIA Sports and Physical Exercise in Special Clinical Settings
Chairmen: P. Delise, F. Giada
MY CONFLICTS OF INTEREST ARE Medtronic – consultant Boston Scientific – DSMB, consultant, research Amarin – DSMB, consultant Biocontrol – consultant, research Sanofi-Aventis - DSMB Boehringer Ingelheim – consultant, research On-X - consultant Biotronik - consultant Lundbeck – consultant Daiichi Sankyo – consultant, speaker
A Case of Intractable VF
Bharati S. J Cardiovasc Electrophysiol 1992;3:437-441
Myocarditis of the AV node
Fibrosis of the septum Diagnosis: Chronic myocarditis of the septum
Toxins
Amphetamines, anthracyclines, cocaine, ethanol, cyclophosphamide, fluorouracil, lithium, hemetine, catecholamines, interleukin-2, trastuzumab, clozapine Chemicals - copper, iron, lead, carbon monoxide, arsenic, phosphorus, sodium azide Radiation, electric shock Other - scorpion sting, snake/spider bites, bee and wasp stings, pheochromocytoma, beri–beri
Position Statement - ESC Working Group
Caforio ALP. Eur Heart J 2013;34:2636–2648
Infectious Etiologies
Bacterial, mycobacterial, spirochete, fungal, protozoal, parasitic, rickettsial RNA virus: Coxsackie A and B, echo, polio, influenza A/B , respiratory syncytial, mumps, measles, rubella, hepatitis C, dengu, yellow fever, Chikungunya, Junin, Lassa fever, rabies, HIV-1 DNA virus: adeno, parvo, B19, cytomegalovirus, herpes-6, Epstein-Barr, varicella-zoster, herpes simplex, variola, vaccinia
Position Statement - ESC Working Group
Caforio ALP. Eur Heart J 2013;34:2636–2648
Immune-Mediated
Tetanus toxoid, vaccines, serum sickness Drugs: penicillin, cefaclor, colchicine, etc. Heart transplant rejection Autoantigens: lymphocytic or giant cell Autoimmune: lupus, rheumatoid arthritis, Churg-Strauss, Kawasaki’s disease, inflammatory bowel, scleroderma, polymyositis, myasthenia, diabetes, thyrotoxicosis, sarcoidosis, Wegener’s, rheumatic fever
Caforio ALP. Eur Heart J 2013;34:2636–2648
Position Statement - ESC Working Group
Time Course of Myocarditis
Kindermann J. Am Coll Cardiol 2012;59:779–92
Edema
Gadolinium enhancement
Causes of Sudden Death Young Competitive Athletes
Maron BJ. Circulation 2007;115:1643-1455
Hypertrophic cardiomyopathy
European Prospective Registry
Bohm P. Eur J Preventive Cardiol 2015 in press
Sports-related sudden cardiac death
Age ≤35 Total population
Mean age: 46.8±16.2 years
Assessment of the Athlete
History – upper respiratory/GI symptoms, palpitations, fatigability, exertional dyspnea, syncope. Flu-like illness or epidemiological circumstances supporting viral infection ECG – Frequent, complex ventricular and/or supraventricular arrhythmias, ST-T changes, bundle branch block, AV block
Pelliccia A. Eur Heart J 2005;26:1422–1445
Recommendations for competitive sports participation in athletes
Caforio ALP. Eur Heart J 2013;34:2636–2648
Diagnostic Criteria
ECG abnormalities Elevated troponin (T/I) Functional/structural abnormalities on imaging (echo/angiography/MRI) Tissue characterization – MRI -> edema and/or classical myocarditis Angiography, myocardial biopsy
Caforio ALP. Eur Heart J 2013;34:2636–2648
Recommendations for competitive sports participation in athletes
Echocardiography
Global LV enlargement and dysfunction Mildly enlarged LV, borderline dysfunction Localized wall motion abnormality (apex) Pericardial effusion
Recommendations for competitive sports participation in athletes
Caforio ALP. Eur Heart J 2013;34:2636–2648
Lesion Reversibility by MRI
Zagrosek A. J Am Coll Cardiol Img 2009;2:131–8
Partial reversibility
Complete reversibility
Proposed MRI Criteria
Regional/global myocardial increase in T2-weighted image signal intensity Increased global early enhancement ratio between myocardium and skeletal muscle in gadolinium-enhanced T1-weighted images Focal lesion(s) with nonischemic distribution in inversion recovery-prepared gadolinium-enhanced T1-weighted images (c/w injury or scar) Left ventricular dysfunction or pericardial effusion
Friedrich MG. White Paper. J Am Coll Cardiol 2009;53:1475-1487
Recommendations
Active myocarditis ! History, PE, ECG, Echo ! No competitive sports
After resolution (6-months post-onset) ! History, PE, ECG, Echo, exercise test, Holter ! No symptoms or arrhythmias, normal LV function ! All competitive sports
Pellicia A. Eur J Cardiovasc Prev Rehabil 2006;13:876–885
Competitive Sports Participation
Exercise in Myocarditis?
Mice-> Coxsackie B3 inoculation, exercised to exhaustion Exercise nearly doubled lesion size and tripled T cytotoxic, T suppressor cells and doubled T cytotoxic, suppressor/T helper cell ratio Thus, exercise during acute infection may contribute to disease progression
Avoidance prudent based on animal data
Ilback N-G. Am Heart J 1989;117:1298 Gatmaitan BG J Exp Med 1970;131:1121–36
Coxsackie B3 Myocarditis Worsened by Exercise
Coxsackie B-3 myocarditis induced in mice had an acute mortality of 5.5% Acutely, when mice were forced to swim, half died most while swimming but, after the acute phase, swimming led to a 13.8% mortality Myocardial Coxsackie replication increased 530X with swimming during the acute phase
Gatmaitan BG. J Exp Med 1970;131:1121–36
Exercise - Not a Good Thing
Cabinian AE. J Lab Clin Med 1990;115:454-62
Mortality in Coxsackie B3 infected Mice
Exercise and Myocarditis A Bad Combination
INF – infected with coxsackie B3 EX - exercise AB – anti-thymocyte antibodies CYA – cyclosporine A
Cabinian AE. J Lab Clin Med 1990;115:454-62
Asymptomatic Myocarditis
“Isolated large areas of subepicardial delayed enhancement in an asymptomatic athlete is not benign and requires careful evaluation at exercise and strict follow-up” “These findings question whether extreme exercise during silent myocarditis may facilitate fibrosis generation and adverse remodeling”
Schnell F. Br J Sports Med 2015;0:1–8