John J. Ryan MD FACC FAHAUniversity of Utah, Division of Cardiovascular Medicine.

3rd Annual Sports Medicine SymposiumFebruary 22nd, 2019

Pre-exercise medical clearance and cardiovascular screening

@drjohnjryan@JJRyanMD @UofUHealth

Objectives

• Identify individuals who may be at risk for cardiovascular disease and implement appropriate pre-exercise screening tools and testing if necessary.

“Always consult your physician before performing any kind of physical activity”

N Engl J Med. 1993

of dynamic exercise are primarily related to increases inheart rate, whereas the CV demands of static exerciseprimarily involve increases in systolic BP. This may beimportant in deciding whether or not athletes with variousCV conditions can participate, but clinicians should alsoappreciate that virtually all sports require a combinationof both dynamic and static exercise especially during ET.Therefore, the exercise prescription and proscription forindividuals with CVD should be individualized not only bysport, but also by training requirements.

Clinicians evaluating athletes for competition should alsobase their recommendations on the greatest cardiac demandrequired during competition and training even if this level isachieved relatively infrequently. Environmental conditionsalter the CV demand of any given sport. Exercising in the heatand at altitude increases the heart rate and cardiac outputrequired for any given absolute work rate. Other issues such asthe risk of bodily collision, between competitors or between thecompetitor and an object, as well as the risk to the athlete andothers if syncope occurs, should also be considered.

Specific management considerations and ourapproach in patients with coronary arterydisease (CAD)

The risk of an acute exertion-related cardiac event is greaterin individuals with diagnosed ASCAD than in those withoccult ASCVD. The risk of an acute, exertion-related cardiacevent increases with the extent of CAD, the degree of LVdysfunction, the presence and extent of ischemia, and thepresence of electrical instability. Unstable or vulnerableatherosclerotic plaques are lipid rich so it is possible to reducethe risk of plaque instability and an acute coronary syndromeby aggressive lipid-lowering treatment, which has beenshown to reduce plaque burden.41

Patients with a history of a recent acute coronary syndrome(ACS), stable angina or coronary artery bypass graft (CABG)surgery (with or without LV dysfunction) should undergo amedically supervised, exercise-based cardiac rehabilitation (CR)program. This will help achieve and maintain the patient's

Fig 2 – Classification of sports. The increasing dynamic component is defined in terms of the estimated percentage of maximaloxygen uptake (V[Combining Dot Above]O2max) achieved and results in an increasing cardiac output. The increasing staticcomponent is related to the estimated percentage of maximal voluntary contraction reached and results in an increasing bloodpressure load. The lowest total cardiovascular demands (cardiac output and blood pressure) are shown in the palest color, withincreasing dynamic load depicted by increasing blue intensity and increasing static load by increasing red intensity. Note thegraded transition between categories, which should be individualized on the basis of player position and style of play. *Dangerof bodily collision. +Increased risk if syncope occurs. Reproduced from Levine et al.71 [from an Elsevier journal].

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How much exercise?

Exercise Training In Athletes With Heart Disease. Fernandez AB, Thompson PD. Prog Cardiovasc Dis. 2017

• Light-intensity exercise- 30% to 40% HRR or 2 to 3 METs.

• Moderate-intensity exercise- 40% to 60% HRR or 3 to 6 METs.

• Vigorous-intensity exercise- > 60% HRR or > 6 METs.

ACSM:Who needs to be screened?

• No known cardiovascular, renal, or metabolic disease.

• No Symptoms.

–No Screening

• Known cardiovascular, renal, or metabolic disease.

• Symptoms.

–Screening

Physical Activity Readiness Questionnaire (PAR-Q)

• Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

• Do you feel pain in your chest when you do physical activity?

• In the past month, have you had chest pain when you were not doing physical activity?

• Do you lose your balance because of dizziness or do you ever lose consciousness?

• Do you have a bone or joint problem that could be made worse by a change in your physical activity?

• Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

• Do you know of any other reason why you should not do physical activity?

Answer yes or no to the following questions:

If you answered yes:

• If you answered yes to one or more questions, are older than age 40 and have been inactive or are concerned about your health, consult a physician before taking a fitness test or substantially increasing your physical activity. You should ask for a medical clearance along with information about specific exercise limitations you may have.

If you answered no:

• If you answered no to all the PAR-Q questions, you can be reasonably sure that you can exercise safely and have a low risk of having any medical complications from exercise.

If answered yes

• Exercise Stress Test (max effort):– ECG only (more useful in arrhythmia cases; less

useful in women for CAD evaluation).– Echocardiogram, nuclear scan, MRI.

• Coronary Artery Calcium (CAC).

• Coronary CT scan.

Interpretation

• Requires evaluation for decision making.

• If positive, treatments recommended:–Medications.

– Interventions.

– Exercise.

Coronary Artery Calcium (CAC)• CAC score of 0: – Asymptomatic patients: • 0.5 % risk of event vs. 4 % over 50 months.

– Symptomatic patients: • 2 % risk of event vs. 9% over 42 months.

• Positive CAC score increases rate of statin adherence.• CAC is likely cost effective in patients with intermediate

risk for CAD (ASCVD risk of 5%-20%).• Of note, male endurance athletes appear more likely to

have a CAC score >300 than sedentary counterparts.

Slide courtesy of Jason Lippman MD

Recommend restrictions in patients with:

• Symptomatic CAD plus– LVEF <50%.– Inducible ischemia.– Electrical instability.

• Ischemic symptoms that are worsening or becoming more frequent.

• MI, PCI, CABG or ventricular arrhythmia for 3 months from competitive activity.

2015 JACC Guidelines for Competitive Athletes

Cardiac Rehab

Cases

Case 1

• 53 year old gentleman with hyperlipidemia keen to start exercising again. Feels chest pain on exertion, but thinks it is indigestion.

Case 1: Referred for Stress test:

Rest ECG

Exercise ECG

Case 1: Referred for Coronary Angiogram: Multivessel Disease.

• Underwent Coronary Artery Bypass

Case 2

• 64 year old gentleman started to notice chest pain during half marathon.

Case 2: Referred for Stress test:

Rest ECG

Exercise ECG

Case 2: Referred for Coronary Angiogram: No significant Disease

• Recommended continued running.

Case 3

• 58 year old lady answered yes to “chest pain while you were not doing physical activity”.

Case 3: Referred for Stress test:

Rest ECG

Exercise ECG

Case 3: Negative Stress: Presented with STEMI and LAD occlusion.

• Developed chest pain during CrossFit.

Case 4

• 44 year old lady being treated for hypertension.

Case 4: Referred for Stress test:

Rest ECG

Exercise ECG

Case 4: Chest pain after skiingTakotsubo (Stress-induced) Cardiomyopathy

Case 5

• 41 year old gentleman answered yes to “do you lose your balance because of dizziness”.

Case 5: Referred for Stress test:

Summary• PAR-Q is central to

evaluation.

• If positive, recommend further evaluation.

• Work-up frequently involves imaging.

• Most cardiac diagnoses require exercise as treatment.

Nathan HattonJennalyn MayeuxChristy MaBrent WilsonJess HustonTeshia SorensenJess CareyJosh SessionsJohn DechandIrene PanJosh JacobsCourtney SheetsDom Ingram

Acknowledgements

john.ryan@hsc.utah.edu@JJRyanMD

University of Utah Dyspnea Center

John KirkAshlee RooksMeghan CirulisLeif JensenLyska EmersonJosh ZimmermanStephen McKellarBrandon SullivanStephen IshiharaWalter WrayJennifer SchroffPartha SardarDavid Peritz

617-459-0800