docPhidippides Cardiomyopathy and Beyond Feb 06, 2016
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Phidippides Cardiomyopathy and Beyond Feb 06, 2016
ExerciseBenefitsandRisks DeniseSorrentinoMD Cardiologist/Electrophysiologist IowaHeartCenter ¡ Analyze ¡ Medtronic ¡ MedtronicTYRX ¡ St.JudeMedical ¡ Employer-Mercy/DesMoines A. Theyallarefamousscientists B. Theyareallrunninglatefordinner C. Theyareallfamousenduranceathleteswho diedyounginthemidstofrunning D. Notenoughinformationgiventoanswer . ¡ 1976--25,000finishers ofmarathonsinUS ¡ 2014--marathonsinUS werecompletedby 550,637! ¡ In2014thereweremorethan1,200 “ultramarathon”races–morethantriplethat in2004 Inthe1970s,ThomasBasslerputforththe “BasslerHypothesis” Ifyoucouldrunamarathoninunder4hours itgaveyouimmunityagainsthavinga heartattackforthenext6years ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ Conditionscausingmyocardialischemia Atheroscleroticcoronaryarterydisease Coronaryarteryspasm Denovocoronaryarterythrombus Intramyocardialbridging Hypoplasticcoronaryartery Anomalouscoronaryarteries Coronaryarterydissection StructuralAbnormalities Hypertrophiccardiomyopathy Mitralvalveprolapse Valvularheartdisease Lipomatousinfiltrationoftherightventricle Marfan'ssyndrome Rightventriculardysplasia Aorticstenosis Sicklecelltrait Arrythmias Wolfe-Parkinson-White Lown-Ganong-Levine LongQTsyndrome Ventriculararrhythmias Medialhyperplasiaandintimalproliferationofthemainsinusnodeartery Miscellaneous Myocarditis Anabolicsteroiduse Cocaineabuse Sarcoidosis ¡ Hypertrophiccardiomyopathy—VT/VF ¡ Coronaryarterydisease—ischemia ¡ Anomalouscoronaryartery ¡ Primaryarrhythmia(longQTc, catecholaminergicVT,primaryVF) ¡ ArrhythmogenicRightVentricular Cardiomyopathy ¡ PhidippidesCardiomyopathy ¡ Cardiacremodelingasaresultofprolonged strenousexercise ¡ Pressureandvolumeoverloadtransientlyof RA/RV ¡ Elevatedcardiacmarkers ¡ Volumedepletionandreducedrenalfiltration ¡ Withrepetitivecyclesoftraining,recovery, repeattraining,chronicstructuralchanges mayoccur ¡ Longtermchangeshavebeenfoundto includepatchesofcardiacfibrosis ¡ Thesepatchesoffibrosisthencanallowfor zonesof“reentry”forpotentialarrhythmias ¡ Duringlongdistancerunningandcycling,the heartisputintoastateofincreasedcardiac output ¡ RA/RVdilateinapproximately1/3ofall marathoners ¡ TroponinandBNPareoftenfoundtobe elevatedpostrace ¡ Ittakesseveraldaystoweeksforrightheart toreturntobaselinestatepostrace ¡ Exercise—likeapharmacologicagent,may haveanupperdoselimit ¡ Abovethis,adverseeffects(muscletrauma, metabolicderangements,cardiovascular stress)mayexist. ¡ Largerecenttrialshowedbenefitsofexercise beginningat15minutesperdayandthe benefitscontinueupto1hourperdayand thenplateau ¡ Chronicendurancetrainingincreases demandsontheheart—espinendurance athletes. ¡ Distancerunners,rowing,swimmingand cyclistshaveadaptationsincludingenlarged LVandRVvolumes,increasedLVwall thicknessandincreasedLAsize ¡ Intheseenduranceathletes,cardiacsizedoes notalwaysregressbacktonormalafter competition ¡ Cardiacoutputatrestis5L/minbutincreases upto25L/minwithvigorousendurance training ¡ Longtermdailytrainingmaycausedilation ofRAandRV ¡ Postexercisethedimensionsmaynotalways berestored ¡ Cohortof40highlytrainedathletes (marathon,halfandfulltriathalon,alpine cyclists) ¡ TroponinandBNPelevatedpostevent ¡ ReducedRVEF ¡ Inthiscohort,12.5%hadscarringon gadoliniumenhancedMRI ¡ ScarringandRVremodelingmostcommonin athleteswithlargestaccumulatedexperience ¡ Studyshowedthatenduranceathleteswith symptomsofarrythmias(palpitations)had 50%incidenceofRVstructuralabnormalities onMRIimaging ¡ Theseauthorsspeculatedasyndromeof “exercise-inducedarrhythmogenicRV cardiomyopathy” ¡ Delayedgadolidium enhancementin5 athletesrevealpatchy myocardialfibrosisthat maydevelopand becomesubstratefor arrhythmia ¡ 108middle–agedGermanmarathoners comparedtoagematchedcontrols ¡ Greateratheroscleroticburdeninthe marathonsusingCalciumScoreCT ¡ Adversecardiovasculareventratewas equivalenttoapopulationwithestablished coronarydisease ¡ CohortofUSlongtermmarathoners(>25 marathonsin25years) ¡ Foundmorecalcifiedplaquevolumeinthe marathonerswhencomparedtosedentary age-matchedcontrols(274mmcubedvs. 169mmcubed)onCTcoronaryangiography ¡ Rhythmdisturbancesmaybethemost commonproblemforveteranendurance athletes ¡ Longtermendurancetraininghasbeen associatedwithasmuchasa5-foldincrease intheprevalenceofatrialfibrillation ¡ Increasedvagalandsympathetictone ¡ Longtermbradycardia ¡ Atrialwallfibrosis ¡ Increasedatrialsize—leftatriummaybe enlargedinupto20%competitiveathletes ¡ Recentresearchshowsenduranceathletes mayhaveareducedlevelsofHCN4proteinin theSAnodeleadingtomorebradycardia ¡ Generallyoriginatefrommildlydysfunctional rightventricle OR ¡ Interventricularseptum Thepatchymyocardialfibrosismaydevelopas areparativeresponsetodamaged myocardiumwhichallowsreentry ¡ Heavyandsustainingtraininggeneratesfree radicalsthatmaynotbefullybuffered ¡ Oxidativestress—transientcardiomyocite dysfunction ¡ Thismaystimulate—lymphocytes, macrophages,mastcells,myofibroblasts, procollagenandfibrosisdeposition FIGURE7 MayoClinicProceedings201287,587-595DOI:(10.1016/j.mayocp.2012.04.005) Copyright©2012MayoFoundationforMedicalEducationandResearchTermsandConditions ¡ Dailyactivityishighlyeffectivefor preventionandtreatmentofourmost commondiseases:HTN,diabetes,obesity, heartfailureanddepression ¡ Peoplewhoexerciseregularlyhavemarkedly lowerratesofdisabilityandmeanlife expectancy7yearslongerthanthatof physicallyactivecounterparts ¡ Thebenefitsofregulardailyexerciseare indisputable!Inordertoreversethecrippling epidemicoftypeIIdiabetes,obesityand associatedheartdisease—allchildrenand adultsmustexercise ¡ …Highintensity,highendurancetraining althoughmayleadtoRVchamber enlargementandfibrosis,coronary calcification,andlargearterystiffening ¡ Smallstudiesareavailable,butduetothe massivecontinuedandgrowingparticipation inendurancesports,thereisagreat opportunitytostudyeffects ¡ Echocardiography,Calciumscoring,CT angiographyandserumbiomarkerscanbe evaluatedpreanpostevent ¡ PostraceRVEFovertimemayhelp determine“safe”timingtoreturntotraining
