Transcript 2.) Do endurance sports cause cardiomyopathy?

Prevention of Medical Illness
Cardiovascular Disease
Aaron L. Baggish MD, FACC, FACSM
Director, Cardiovascular Performance Program
Division of Cardiology
Massachusetts General Hospital
Boston, MA
Conflicts: None
Athletic Affiliations:
Funding Sources:
–
–
–
–
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National Institutes of Health
American Heart Association
American Society of Echocardiography
Department of Defense
National Football League Player’s Association
Athlete’s Heart: The Beginnings…
We
a great
increase
in size
and strength
Thehave
left seen
hemithat
thorax
was
mostly
consumed
by is
demanded
theestimation,
heart and it these ski-men had
the heart.ofBy
may easily happen that it is called upon for more
hearts
that
than
size of thata
work than
it iswere
able tomore
do and
thattwice
insteadthe
of establishing
found
in ordinary
man. itI becomes
hesitate diluted
to speculate
compensatory
hypertrophy
and
about
the Along
term significance
such an
weakened.
"broken-winded
" athlete isofprobably
one with
a
dilated, flabby heart.
observation.”
-Eugene
Darling 1899
-Henschen
1899
Athlete’s Heart: The Beginnings…
Henschen / Darling (1899)
•Cardiac Enlargement by Percussion (Nordic Skiers / Rowers)
100+ years of scientific study:
Radiography
Electrocardiography
Non-invasive Imaging
Athlete’s Heart: Historical Overview
JAMA 1918;71:1047
Athlete’s Heart: Historical Overview
Chest 1970;57:102
Cardiac Remodeling: Physiology
Classic concept of LV remodeling……
Aortic
Regurgitation
Volume Challenge
Aortic
Stenosis
Pressure Challenge
Cardiac Remodeling: Physiology
Endurance Activities
Sustained ↑ CO
• 4 to 5 times rest
• ↑ ↑ ↑ HR & ↑ SV
• Vasodilation
Volume Challenge
Strength Activities
Repetitive↑ SBP
• Systolic BP > 200 mmHg
• Skeletal Mus. Contraction
• Vasoconstriction
Pressure Challenge
Cardiac Remodeling: Physiology
Levine, Baggish, et al. In Press
Athlete’s Heart: Historical Overview
Annals of Int Med 1975;82:521
The Harvard Athlete Initiative (HAI)
ECG
Blood
Echo
IHGT
Tono.
CPET
MRI
PET
Baseline
Conditioning
Pre-Study
Period
(48 days)
June
July
August
ECG
Blood
Echo
IHGT
Tono.
CPET
MRI
PET
#1
Study Exercise
Exposure
Study Period
(90 days)
September
October
November
#2
HAI: Sport Specific Structure
∆ Left Ventricular Mass
*
150
(g/m22)
g/m
140
∆= 16±5 g/m2
∆LVEDV (ml/m2)
∆= 14±4 g/m2
Correlation: ∆ LV Mass vs. ∆ Chamber Size
*
130
Endurance
Strength
Correlation: ∆ LV Mass vs. ∆ Wall Thickness
∆IVS + PWT (mm/m2)
120
110
100
pre
post
Endurance
pre
post
Strength
Endurance
J Appl Physiol 2008;104:1121
Strength
HAI: Sport Specific Function
Correlation between LV Hypertrophy & Diastolic Function
r2=0.90
∆ Lateral E’
(cm/s)
=Endurance
r2=0.79
=Strength
∆ LV Mass (g/m2)
J Appl Physiol 2008;104:1121
Beneficial Cardiac Remodeling
Endurance Training
Beneficial Cardiac Remodeling
Beneficial Cardiac Remodeling
Endurance Variants
HAI: Sport Specific Function
Correlation between LV Hypertrophy & Diastolic Function
r2=0.90
∆ Lateral E’
(cm/s)
=Endurance
r2=0.79
=Strength
∆ LV Mass (g/m2)
J Appl Physiol 2008;104:1121
HTN: Sport as a cause?
Linemen
Systolic BP Footballers
Skilled
Weiner, Circulation 2013
HTN: Sport as a cause?
Predictors of Concentric LVH
among Lineman
Characteristic
OR (95% CI)
Systolic HTN
10.4 (7.3,12.5)
Weight Gain / 5 lbs
6.3 (4.2,8.3)
Family Hx of HTN
4.2 (1.8,6.3)
Black Ethnicity
3.2 (1.4,5.3)
Concentric LVH in Athletes
Is hypertensive remodeling….
Weiner, Circulation 2013
Lineman get HTN and LVH even
after adjustment for all known
covariates.
Prescribed Detraining
Alumni Study
Weiner JACC 2012
NHLBI RO1-HL125869
Remodeling Summary
Adaptation or Maladaptation??
Running can take a toll on the heart that essentially
eliminates the benefits of exercise. “Running too far,
too fast and for too many years may speed one’s
progress toward the finish line of life,” concludes an
editorial to be published next month in the British
journal Heart.
The central controversy
Does too much exercise over too much time hurt
your heart (and affect morbidity and mortality)
and if so, what does this pathology look like?
The central uncertainty
Why are we talking about this topic now?
Reassessment of
Epidemiologic Data with
a focus on the high ends
of fitness
Anecdotal Observations
of Physically Fit Athletes
Dying, Perhaps due to
Sport-induced CV
Disease
Observational data
describing CV pathology
among athletes and
athletic patients
A syndrome of cardiovascular
abnormalities (perhaps caused by)
chronic exposure to high volume
exercise
Observational Data
Fiber Damage / Scarring
Myocardium
Brady / Tachy
Arrhythmias
Conduction
System
Normal
Chronic
Cardiac
“Stress”
Function
Coronary
Arteries
Atherosclerosis
Valves
Leaking or
Tightening
Key CV Controversies
1.) Do endurance sports cause arrhythmia?
2.) Do endurance sports cause cardiomyopathy?
3.) Do endurance sports cause coronary disease?
52 y.o. cyclocross rider with decreased ex tolerance
Arrhythmia: AFib
1st
Author
Reference
Subjects
Primary Finding
Karjalainen
BMJ 1998
Runners (n=100)
5.5 (1.3–24.4)
Mont
EHJ 2002
Endurance (n=70)
71% with lone AF
Elosua
Int J Card 2006
Endurance (n=51)
2.87 (1.39–7.05)
Heidbuchel
Int J Card 2006
Endurance (n=53)
1.81 (1.10-2.98)
Molina
Europace 2008
Runnners (n=39)
8.8 (1.26-61.3)
EHJ 2008
Cyclist (n=67)
10% AF in athletes
Mont
Europace 2008
Endurance (n=48)
7.31 (2.33-22.9)
Aizer
Am J Card 2009
PHS Database (n=16,921)
1.20 with ≥ 7 days/week ex.*
Claessen
Heart 2011
Non-sel. Flutter RFA (n=58)
“Sportsmen” 50% of Lone Afl pop.
Andersen
EHJ 2013
Nordic Skiers (n=52,755)
1.29 (1.04-1.61)*
Baldesberger
Arrhythmia: AFib
• Retrospective design
• Sweden -- Vasaloppet (90K)
• >50,000 participants
• 1989-99 >> Dec. 2005
• Incidence of arrhythmia events
• Race time / # of races > Arrhyth.
• AF the dominant rhythm issue
Arrhythmia: Afib
MECHANISMs of ATHLETIC AF
- LA Dilation / Remodeling
- Persistent vagotonia
The strongest association between endurance
- Sympathetic Surges
sport and pathology lies with atrial
- Intermit.
LA Hypertension
fibrillation….the data are clear
that our
aging
patients who engage in these
sports
are at
- Chronic
Inflammation
increased risk….sport or lifestyle
- Geneschoices?
-
ETOH
-
Caffeine
-
Psychological Stress
Key CV Controversies
1.) Do endurance sports cause arrhythmia?
2.) Do endurance sports cause cardiomyopathy?
3.) Do endurance sports cause coronary disease?
Cardiomyopathy
Harvard Athlete Initiative
Cardiomyopathy
LV Systolic Strain Changes with Rowing Training (n=20)
AS
*
4.4 3.2†
*
3.9 2.4†
AL
*
AL
AS
*
MS
MS
BS
3.5 1.8†
0.6 0.8*
2.5 1.7†
1.0 0.8*
ML
ML
BL
BS
BL
(< -2)
(-2 to 2)
(2 to 4)
(4 to 6)
(> 6)
Consistent / Regionally Distinct Increase in Longitudinal Shortening
* = p <0.05 for ∆ from baseline
Am J Physiol Heart Circ Physiol 2008;295:1109
Cardiomyopathy
LV Systolic Strain Changes with Rowing Training (n=20)
A
AS
8.3
9.4*
9.1
10.7*
A
AS
S
S
7.3
8.4*
8.4
L
10.1* L
I
(< -2)
8.8
I
10.2*
9.8
(-2 to 2)
P
(2 to 4)
(4 to 6)
9.3*
P
Consistent / Homogenous Increase in Radial Thickening
Am J Physiol Heart Circ Physiol 2008;295:1109
(> 6)
Cardiomyopathy
LV Systolic Strain Changes with Rowing Training (n=20)
A
AS
-3.3
2.7*
3.4
2.2†
A
AS
S
3.3
S -3.6 1.7†
L
2.4† L
I
3.0
I
3.6*
3.2
2.5†
(< -2)
(-2 to 2)
P
(2 to 4)
(4 to 6)
P
Regional Heterogeneous ∆ in Circumferential Shortening
Am J Physiol Heart Circ Physiol 2008;295:1109
(> 6)
Cardiomyopathy
The Ventricular Interdependence of Physiologic Remodeling
Am J Physiol Heart Circ Physiol 2008;295:1109
Cardiomyopathy
Whyte et al. JAP 2011
LaGerche et al. EHJ 2011
Cardiomyopathy
• 40 trained (>10 h of intense training / week) athletes
• Competitive, top 25% finish recent endurance event
• No cardiac symptoms or traditional risk factors
• No inducible ischemia on stress echo
• MRI/echo/biochem. At 3 time points (pre-finish-6 to 11 d)
Cardiomyopathy
Preliminary data suggests that a small minority of
chronic endurance athletes may develop a fibrotic
cardiomyopathy…a phenotype of uncertain clinical
relevance that deserves our attention and further
outcomes-based study
Exercise Cardiomyopathy ?
Chronic Extreme
Volume & Intensity
+
Training / Recovery
Mismatch
+
Host Susceptibility
(Genetics)
+
Secondary Process
(Drugs, Infection, Disease)
A Theoretical
Pathogenic
Cascade
“The Perfect
Storm”
Key CV Controversies
1.) Do endurance sports cause arrhythmia?
2.) Do endurance sports cause cardiomyopathy?
3.) Do endurance sports cause coronary disease?
CV Risk Factors with Exercise
NEJM 2002
JAMA 1985
Circulation 2007
JAMA 2003
CAD: Observational Data
108 M (>50 y.)
At least 5 marathons
CAD: Observational Data
• Middle-aged runners (59 y.)
• (n=50) >25 Consecutive TCM’s
• No training history
• No race history
• No physiology
CAD: Observational Data
Interpretation Options:
1.) Exercise (rec. marathon training) drives athero.
2.) CAD findings driven by established and studied risk
factors….underappreciated in these studies
3.) CAD findings driven by overlooked, non-running risk
factors
CAD: Observational Data
✓
✓
✓
✓
✓
✓
✓
Do you really think it was the running that caused
these men’s coronary disease??
CAD: Observational Data
Missing Risk Issues:
1.) Diet (Fit vs. Healthy)
2.) “Care-free” 20’s-30’s
3.) Family Genes
✓
Without controlling for
these, can we say anything
about causality?
ASHD
“Man, not so sure that second plate
of chili nachos and the extra couple of
beers last night were such a good
idea….Oh well, they always say don’t
change your routine prior to races.”
“Just wish my old man could see
me now. He died at age 45 from a
massive heart attack. Glad I got
my wake up call. Bad stuff runs in
my family”
Genes
Diet
“Well, regardless of what happens,
I’ve got to be better off than I was
20 years ago when I was smoking
a pack-a-day and got short of
breath just driving up this damn
hill.”
Early Life
Is running really the issue??
“Cough, cough, cough….If this
race wasn’t only once a year I’d be
home in bed. I feel like shit. Oh
well, this little climb will help me
clear out the junk.”
Viral Influence
My Synthesis of the Controversy
A. Fib
CAD
Toxic Exposure
CMP
Too much exercise….Huh???
7 - Rules of “Common Sense”
1. Address CV Risk Factors
2. Discuss health vs. performance
3. Plan for Annual Periodicity
4. Prioritize Warm-ups & Cool Downs
5. Practice Careful Event Preparation
6. Respect a Virus
7. Listen to Warning Signs
Thank You !