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Heart and Vascular Health for Cyclists: Screening & Management from Juniors to

Masters Athletes

Anne R. Albers MD, PhD, RVT, FACC, FASE, FAHA

OhioHealth Heart & Vascular Physicians

Columbus, Ohio

August 23, 2014

Disclosures

I have no disclosures.

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Heart and Vascular Health for Cyclists: Screening & Management from Juniors to Masters Athletes

1. Review issues / clinical cases

2. Understand cardiac screening guidelines/practice

3. Apply cardiovascular care guidelines

4. Provide resources

Objectives

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Classification of Sports ~ Peak Dynamic and Static

Components Achieved During Competition

Longmuir P E et al. Circulation 2013;127:2147-2159

Copyright © American Heart Association

MVC (Maximal Voluntary Contraction), *Risk of bodily collision

†Increased risk if syncope occurs

Exercise Physiology

Thompson PD et al. Circulation 2007;115:2358-2368

Junior or Masters Considerations

Age < 35 years 1. Congenital risk

2. Acquired risk

Age > 35 years 1. Acquired risk

Atherosclerotic Coronary Artery Disease (CAD)

2. Congenital risk

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2

Goals for Screening-All Ages

Normal Ok to participate

Abnormal Further evaluation, assessment, consideration

Risk Stratification + Risk Management

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Cardiac Arrest Sudden Cardiac Death (SCD)

♥ The heart abruptly stops pumping

♥ Ventricular fibrillation occurs instantly, stops regular

heart beats, makes a person faint

♥ 88% of cardiac arrests occur at home

♥ < 8% who suffer cardiac arrest outside the hospital

survive*

*Increased survival in running events has been reported; Increased survival in Out of Hospital Cardiac Arrest (OHCA) youth (< 35 years old)

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Ewy GA. Circulation. 2007; 116: e566-e568 www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/CPRFactsandStats/CPR-

Statistics_UCM_307542_Article.jsp Kim JH et al. N Engl J Med 2012; 366:130-140

Meyer L et al. Circulation 2012;126:1363-1372

MLS: Heart screenings more

personal for Crew

Sunday February 24, 2013

MLS: Heart screenings more personal for Crew

Sunday February 24, 2013

Challenges for SCD prevention in athletes

Rare incidence (1 per 200K per year), but highly visible and emotional events

Wide spectrum of etiologies (or spontaneous)

Basic screening (history and exam) applied inconsistently and incompletely

Advanced screening (EKG and Echo) expensive, associated with false + and false -

Inconsistent data from observational studies

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57 year old referred for murmur

Active cyclist for years, has completed TOSRV tours multiple times, rides in hilly southeastern Ohio

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57 year old referred for murmur

Asymptomatic

Physical exam ~ tall thin habitus, regular S1 S2, diminished A2, +systolic click, harsh systolic ejection murmur III/VI, radiates to neck, vascular exam symmetric pulses, carotids parvus et tardus

ECG Sinus bradycardia, voltage criteria LVH

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3

57 year old cyclist

Echocardiogram ~ LVH, Normal LV ejection fraction; bicuspid aortic valve with severe stenosis, normal aorta

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Bicuspid Aortic Valve (BAV)

DaVinci described > 500 years ago

Estimated prevalence 0.5-2%

Varied phenotypes ~ stenosis, insufficiency

Bacterial endocarditis risk

Aortic dissection risk

Familial presentation 9% prevalence BAV in 1st degree relatives

Most common congenital heart condition ~ Valvuloaortopathy

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Michelena H I et al. Circulation. 2014;129:2691-2704

J Am Coll Cardiol. 2010;55(25):2789-2800

Normal and Bicuspid Aortic Valve Schematics

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Figure illustration by Rob Flewell

Copyright © The American College of Cardiology.

All rights reserved.

J Am Coll Cardiol. 2010;55(25):2789-2800

Bicuspid Aortic Valve Imaging

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A. Transesophageal echo (TEE) short-axis view bicuspid aortic valve

B. TEE 3D view fish mouth appearance

C. Transthoracic echo parasternal long axis view bicuspid valve doming

D. MRI saggital oblique view showing dilated ascending aorta

J Am Coll Cardiol. 2010;55(25):2789-2800

Risk Factors for CAD

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Not controllable or modifiable risk factors

Heredity

Gender

Age

Controllable or modifiable risk factors

Smoking

High Blood Cholesterol

High Blood Pressure

Obesity

Physical Inactivity

Stress and Behavior

Your Heart May Be Older Than You Are

Chronologic age: As people get older, the heart muscle can stiffen, reducing pumping efficiency. Valves also might deteriorate.

Blood pressure: Hypertension puts more strain on the heart, making it pump harder.

Cholesterol: A buildup of plaque narrows the blood vessels, forcing the heart to work harder to circulate blood around the body.

Waist circumference: A large waist can indicate high levels of visceral, or organ, fat, which represents a greater risk for cardiovascular conditions than fat found under the skin or around muscles.

Gender: Because of hormonal differences, women tend to develop heart disease roughly 10 years later than men.

American Heart Association; Heart Age

Take to Heart ~ Heart-risk-assessment tools gauge a person's risk for an adverse cardiovascular event:

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4

Why Runners Can't Eat Whatever They Want

Studies Show There Are Heart Risks to Devil-May-Care Diets—No Matter How Much You Run

By KEVIN HELLIKER

Updated March 26, 2014 11:25 a.m. ET

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I do not give patients … green or red lights. We engage in

an open discussion about known and uncertain risks and

benefits and come up with a collective and very

individualized plan about what is reasonable. Dr. Aaron Baggish

57 year old cyclist

Coronary angiography – no significant CAD

Aortic valve replacement with bioprosthetic aortic valve; patient goal to avoid systemic anticoagulation

Cardiac rehabilitation post AVR

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Cardiovascular Care of the Athlete- Athlete’s Heart

♥ Cardiac Enlargement: Physiological Adaptation to exercise vs Pathology

Ventricular enlargement/thickness

Atrial

Aorta – Aortic root dimension 40 mm in highly conditioned male athletes (and 34 mm in female athletes) is uncommon, is unlikely to represent the physiological consequence of exercise training, and is most likely an expression of a pathological condition, mandating close clinical surveillance*

Baggish AL, Wood MJ. Circulation 2011;123:2723-2735

*Pelliccia A. et al. Circulation 2010;122:698-706

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Athlete’s Heart ~ Gray Area

Maron BJ. N Engl J Med 2003;349:1064-1075.

Relative impact of different sports disciplines on aortic dimension

23 Pelliccia A et al. Circulation 2010;122:698-706 Copyright © American Heart Association

27 year old professional cyclist referred for palpitations

Occur when off season, sustained throughout evening with associated feeling of not able to catch breath

No lightheadedness or syncope

Physical exam; BP 138/85mmHg left arm, 135/90mmHg right arm, HR 58bpm, unremarkable cardiovascular exam

ECG Sinus bradycardia

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Cardiovascular Care of the Athlete-Issues

Arrhythmia & Conduction Abnormalities

♥ Premature Beats (atrial and/or ventricular)

♥ Nonsustained ventricular tachycardia

♥ Tachyarrhythmias

♥Supraventricular tachycardia (SVT)

♥Atrial fibrillation ~ Most common cardiac arrhythmia

Baggish AL, Wood MJ. Circulation 2011;123:2723-2735 25

Atrial Flutter (Afl) Atrial Fibrillation (AF)

Regular long-term endurance sports training may increase the risk for AFl and AF

AF in athletes is initially paroxysmal, and most episodes have a vagal origin

Proposed mechanisms in endurance athletes

Atrial ectopic beats

Inflammatory changes

Atrial enlargement with dilatation and fibrosis

Increased vagal tone

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Calvo et al. Br J Sports Med 2012;46:i37-i43

Atrial Fibrillation, Atrial Flutter Management in Athletes

Sports Activity Reduction

Task Force 7, 36th Bethesda Conference Recommendations

Circumferential Pulmonary Vein Isolation (CPVI)

Cavotricuspid isthmus ablation

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Zipes et al. J Am Coll Cardiol 2005;45:1354-63

Calvo et al. Br J Sports Med 2012;46:i37-i43

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Cardiovascular Care of the Athlete-Issues

♥ Arrhythmia & Conduction Abnormalities ♥ Common in trained athletes

♥ Bradyarrhythmias ♥ Sinus bradycardia

♥ Junctional bradycardia

♥ First-degree atrioventricular block

♥ Mobitz type I atrioventricular block

Assess symptoms

Document appropriate chronotropic response to exercise

Baggish AL, Wood MJ. Circulation 2011;123:2723-2735

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Incident AF during 12 years of follow-up among

5446 older adults

Mozaffarian D et al. Circulation. 2008;118:800-807

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27 year old professional cyclist referred for palpitations

Echocardiogram

Bicycle maximal exercise stress test

24 hour Holter Monitor electrocardiogram

~ No restrictions, continued dialogue with cardiovascular specialist, athlete monitoring symptoms, monitoring blood pressure (monitor for hypertension if > 130/80 mmHg)

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Cardiovascular Care of the Athlete-Issues

♥ Syncope = Transient loss of consciousness accompanied by loss of postural tone

♥Common in trained athletes

♥Majority attributed to neurocardiogenic mechanisms (post exertion)

Syncope during intense exercise relates to possible malignant arrhythmia, structural/valvular heart disease, or myocardial ischemia

Baggish AL, Wood MJ. Circulation 2011;123:2723-2735

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Miracle at the Barry Roubaix: Survival of the Fittest

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38 year old cyclist collapsed-

A heart attack mid-race, right

alongside a cemetery, but in

view of several trained medics,

who kept up CPR until an

ambulance arrived. Miracle?

Maybe. Lucky? Absolutely.

Brush Ridge Cemetery, where G collapsed. © Geoffrey Bernard

www.cxmagazine.com/barry-roubaix-heart-attack-story

Diagnosis: Myocardial bridge – Heart artery problem

Cardiovascular Conditions Associated with SCD in Athletes

+ Hypertrophic cardiomyopathy

+ Sarcoidosis

+ Myocarditis

+ Arrhythmogenic Right Ventricular

+ Cardiomyopathy

+ Dilated Cardiomyopathy

+ Long – QT syndrome

+ Short-QT syndrome

+ Wolff-Parkinson-White syndrome

+ Brugada syndrome

+ Catecholaminergic polymorphic VT

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+ Congenital coronary anomalies

+ Acquired atherosclerotic disease

+ Bicuspid aortic valve

+ Aortic root dilation

+ Marfan syndrome

+ Valvular stenosis or regurgitation

+ Mitral valve prolapse

+ Pulmonic stenosis

Baggish AL, Wood MJ. Circulation 2011;123:2723-2735

Eckart RE et al. Ann Intern Med. 7 December 2004;141(11):829-834

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“Red Flags” from History/Interview

+ Sudden Infant Death Syndrome (SIDS) Genetic overlap

+ Unexplained sudden death age < 50y

+ Syncope/pre-syncope (fainting)

+ Exercise intolerance (short of breath, chest pain)

+ “Heart attack”

+ Seizures

+ Heart transplant 36

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Echocardiogram Electrocardiogram

+ Enhance screening questionnaire, history and physical elements

+ Combined have been shown to detect cardiac abnormalities

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Grenier MA et al. An Echo Screening Tool for SCD in

Young Athletes. JASE Abstracts 2013 P1-105

Corrado D et al. JACC 2008;52:1981-9

Jureidini SB et al. Aberrant coronary arteries: a reliable

echocardiographic screening method. JASE 2003;16:756-763

Cardiovascular Conditions Associated with Sudden Death in Athletes

+ Hypertrophic cardiomyopathy

+ Sarcoidosis

+ Myocarditis

+ Arrhythmogenic Right Ventricular

+ Cardiomyopathy

+ Dilated Cardiomyopathy

+ Long – QT syndrome

+ Short-QT syndrome

+ Wolff-Parkinson-White syndrome

+ Brugada syndrome

+ Catecholaminergic polymorphic VT

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+ Congenital coronary anomalies

+ Acquired atherosclerotic disease

+ Bicuspid aortic valve

+ Aortic root dilation

+ Marfan syndrome

+ Valvular stenosis or regurgitation

+ Mitral valve prolapse

+ Pulmonic stenosis

Baggish AL, Wood MJ. Circulation 2011;123:2723-2735

Eckart RE et al. Ann Intern Med. 7 December 2004;141 (11):829-834

( Echo ) ( EKG )

A 46-year-old male triathlete who presented after long-standing

palpitations and a recent episode of syncope

Baggish AL, Wood MJ. Circulation 2011;123:2723-2735 ,

Wood M J Circulation 2011;123:2723-2735 Copyright © American Heart Association

B. Echo-

Normal LV

Dimension

C. CMR-

Fibrosis,

↑ Apical

thickening

A.

Electrocardiogram-

Abnormal T waves

Goals for Screening-All Ages

Normal Ok to participate

Abnormal Further evaluation, assessment, consideration-

Maron BJ, Zipes DP. 36th Bethesda Conference: eligibility recommendations for competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol. 2005; 45: 1312–1375.

Risk Stratification + Risk Management

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*No defined perfect “screening” evaluation exists

ECG: Drezner J A Br J Sports Med 2012;46:i6-i8

Echo: ? MRI: ?

Performance Enhancement Agents

+ World Anti-Doping banned medication list Cardiovascular medications including beta blockers,

adrenergic agonists, diuretics, stimulants

+ Injectable insulin, human growth hormone, creatine Unknown cardiovascular effects

+ Caffeine/stimulants Exacerbate palpitations

+ Erythropoietic stimulants Microvascular infarction

+ Androgenic anabolic steroids Dyslipidemia, exaggerated exercise BP response,

myocardial dysfunction

41 Baggish AL, Wood MJ. Circulation 2011;123:2723-2735

Northeastern (Veneto) region of Italy

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Sample ECGs –

Arrhythmogenic Right

Ventricular

Cardiomyopathy

(ARVC)

Nasir K et al. Circulation 2004;110:1527-1534

Copyright © American Heart Association

A. Diffuse ARVC

B. Localized ARVC

C. ARVC with RBBB pattern

TWI indicates T-wave inversion

18 year old cyclist referred for evaluation of leg pain

Started cycling age 14, 10,000 K / year

18 month history of symptom

No response to physiotherapies

Unexplained left leg symptom - painful & swollen thigh at maximal effort

44 P Abraham et al. Circulation.1999; 100: e38

Differential Diagnosis – Intermittent Claudication Vascular

Atherosclerosis

Popliteal artery entrapment syndrome

Cystic adventitial disease of the popliteal artery

Iliac artery endofibrosis

Fibromuscular dysplasia

Venous claudication

Large- and medium-vessel vasculitis

Nonvascular

Chronic exertional compartment syndrome

Arthritis (lumbosacral spine, hip or knee)

Peripheral neuropathy

Hamstring muscle tightness

Symptomatic popliteal (Baker) cyst

Plantar fasciitis

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I Weinberg; M Jaff .Circulation.2012; 126: 213-222

18 year old cyclist referred for leg pain

Ankle Brachial Index (ABI) normal at rest

ABI on left drop to 0.5 at symptoms & bicycle effort 330 W (50W/3min)

Unexplained left leg symptom - painful & swollen thigh at maximal effort

46 P Abraham et al. Circulation.1999; 100: e38

Arterial Duplex Assessment

Abraham P et al. Circulation. 1999;100:e38

Copyright © American Heart Association, Inc. All rights reserved.

Abraham P et al. Circulation. 1999;100:e38

Copyright © American Heart Association, Inc. All rights reserved.

Iliac Artery Endofibrosis - Histology

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18 year old cyclist with leg pain

Cyclists > runners > x-country skiers > triathletes

Average age of presentation 25 years

1986 series of 23 cyclists with condition

15% with bilateral presentation

Surgery with artery shortening/resection of endofibrotic segment + saphenous vein patch or interpositional graft

Endovascular approach with angioplasty

Stop particular activity

Perlowski A; Jaff M. Vasc Med 2010 15: 469

External iliac artery endofibrosis

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Sudden Death Unrelated to Cardiovascular Disease

Predilection for younger age groups; children and adolescents

Minnesota registry documents 224 cases/15 years

Maron BJ, Estes N III. N Engl J Med 2010;362:917-927

Commotio Cordis Latin Agitation of the heart

Chinese martial art of Dim Mak (or touch of death)

Stop-Frame Images of a Fatal Commotio Cordis Event in a 14-Year-Old-Boy

Maron BJ. N Engl J Med 2003;349:1064-1075.

Pathophysiology of Commotio Cordis.

Maron BJ, Estes N III. N Engl J Med 2010;362:917-927.

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www.heart.org/HEARTORG/CPRAndECC/HandsOnlyCPR/Hands-Only-CPR_UCM_440559_SubHomePage.jsp

handsonlycpr.org/handson/

Early bystander-

administered CPR and use

of Automated External

Defibrillators (AED) at

the scene of the arrest were

common for survivors of

cardiac arrest.

Kim JH et al. N Engl J Med 2012;

366:130-140

OhioHealth Sports Cardiology Partnership with OhioHealth Sports Medicine

1. Maximize Basic Screening (AHA guideline)

2. Expedite referral process for athletes with symptoms or abnormal screen

3. Education for parents/coaches/school systems on early recognition/therapy (hands only CPR, AED placement)

4. Advanced Screening: Echo and EKG

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www.ohiohealth.com/sportsmed-screenings/

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Heart and Vascular Health for Cyclists ~ Conclusions

Know your athletes / prepare for events

Respect – Viral illness/fever

– Changes in the athlete’s body

– Day of the competition

Referral

Learn Hands Only CPR

Identify AED at sports sites/events, understand and get trained to use

Evidence supports athletics and sport as overall cardioprotective

Mortality of French participants in the Tour de France (1947–2012)

The cyclists had a 41% lower mortality rate than men in France

European Society of Cardiology Congress Amsterdam, September 2013

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Marijon E et al. Eur Heart J 2013;34:3145-3150

Standardized Mortality Ratio over time.

Marijon E et al. Eur Heart J 2013;34:3145-3150

“The bottom line here is: Intense activity on a bike is not associated with increased risk.”

-Donna Arnett, PhD, immediate past president of the

American Heart Association, chair of epidemiology at the University of Alabama at Birmingham, commenting to Ed Susman , Contributing Writer, MedPage Today

European Society of Cardiology Congress Amsterdam, September 2013

58 www.medpagetoday.com/MeetingCoverage/ESC

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Thank you

Questions: Anne.Albers@OhioHealth.com

Resources: www.hearthealthdocs.com

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