Competitive sports in cvs diseases

COMPETITIVE SPORTS IN
CARDIOVASCULAR DISEASES
-Rohit S Walse
Senior Resident
DM Cardiology
SCTIMST

Scope of discussion
• INTRODUCTION
• EPIDEMIOLOGY OF SCDs
• CAUSES
• MECHANISM
• GUIDELINES FOR CVS DISEASES
• CASES

INTRODUCTION
• Siscovick et al - Significant increase in relative
risk with exercise, but this effect strongly
dependent on the habitual exercise level.

Chugh SS, Weiss JB. Sudden cardiac death in the older athlete. J Am Coll Cardiol.
2015;65:493–502

EPIDEMIOLOGY
• Annual incidence of SCDs- 50–100 per million
in the general population
• Sports-related SCDs- 4.6 per 1 million
population

SUDDEN DEATH IN ATHLETES
• M:F= 10:1
• Higher participation rate of male
• More intensive training load and level of
athletic achievement

E. Marijon, M. Tafflet, D.S. Celermajer, et al.Sports-related sudden death in the
general population
Circulation, 124 (2011), pp. 672-681
Overall population (blue) and among young competitive athletes (red)

A Competitive Athlete
• Who participates in an organized team or
individual sport
• Who engages in regular competition against
others
• Who places a high priority or premium on
athletic excellence and achievement
• Who engages in vigorous training in a
systematic fashion to achieve all the above
goals

YOUNGER ATHLETE
• HCM
• Idiopathic left ventricular
hypertrophy (LVH)
• Coronary anomalies
• Myocarditis
• ARVC
• Marfan’s syndrome
• Valvular heart disease
• Ion channelopathies
OLDER ATHLETE [>35 yrs]
• CAD
• HCM
• ARVD
• Myocarditis
• Valvular heart disease
• Unexplained

MECHANISM OF SCD
• Sympathetic activation
• Electrolyte and
metabolic factors
• Activation of the
hemostatic system
• Hemodynamic effects
on vulnerable coronary
plaque
• Sensitization of
vulnerable myocardium
to ischemia and
arrhythmia due to
exercise related
sympathetic activity
• heat stroke (long-
distance races)
ISCHEMIC VENTRICULAR ARRHYTHMIA

MECHANISM IN PATIENTS WITH CAD
• 68% Acute Plaque Rupture 23%
• (p < 0.001)
• 71% Hemorrhage into the Plaque 41%
• (p= 0.007)
• STRESS RELATED SCDs • SCDs AT REST

CLASSIFICATION OF SPORTS
1) STATIC 2) DYNAMIC

PROBABILITY FOR EXERCISE INDUCED EVENTS
LOW
• Absence of critical coronary
stenoses (i.e. <70%) of major
coronary arteries or <50% of left
main stem on coronary
angiography
• EF > 50% on echocardiography,
CMR or angiography (and no wall
motion abnormalities)
• TMT-
Normal exercise capacity,
No inducible ischemia,
No arrhythmia (i.e.NSVT,
polymorphic or very frequent
ventricular extra beats (VEBs), at
rest and during maximal stress
testing)
HIGH
• Presence of at least one critical
coronary stenosis of a major coronary
artery (>70%) or left main stem (>50%)
on coronary angiography
• EF <50% on echo (or other tests)
• Exercise-induced ischaemia,
• Dyspnoea at low exercise intensity
(angina equivalent)
• Relevant ventricular tachyarrhythmias
(i.e. NSVT, polymorphic or very frequent
VEBs, at any time)
• Dizziness or syncope on exertion
• High degree of myocardial scarring on
CMR imaging

CAD RECOMMENDATIONS
• Clinically proven CAD, with a low probability for events
(anatomically as well as functionally),  eligible for most sports.
• Exceptions -for high-intensity sports (intensive power and
endurance sport) and -athletes-patients of older age (>60 years)
[Level of recommendation: Class IIa, level of evidence C]
• Clinically proven CAD, with a high risk should be temporarily
restricted from competitive sport and receive appropriate
management. [Level of recommendation: Class IIa, level of evidence
C]
• For a patient-athlete with a “low-probability” for cardiac events, a
period of minimum three months after- (PCI), is recommeded
before participation in competitive sports can be resumed

CAD RECOMMENDATIONS
• It is reasonable for athletes with clinically concealed
ASCAD to participate in all competitive activities if their
resting LVEF is >50% and they have no inducible
ischemia or electrical instability (Class IIb; Level of
Evidence C).
• It is reasonable for patients with clinically manifest
ASCAD to participate in all competitive activities if
their resting LVEF >50%, are asymptomatic, and have
no inducible ischemia or electrical instability (Class
IIb; Level of Evidence C).

• It is reasonable to restrict patients with clinically manifest
ASCAD that does not fulfil the criteria in the above
mentioned recommendation to sports with low dynamic
and low to moderate static demands (Class IIb; Level of
Evidence C).
• It is reasonable to prohibit patients with clinically manifest
ASCAD from competitive sport participation:
a. For at least 3 months after an AMI or coronary
revascularization procedure (Class IIb; Level of Evidence C);
b. If they have increasing frequency or worsening
symptoms of myocardial ischemia (Class IIb; Level of Evidence
C).

HYPERTENSION
• Before people begin training for competitive athletics, it is reasonable that they
undergo careful assessment of BP, and those with initially high levels (>140 mm
Hg systolic or >90 mm Hg diastolic) should have comprehensive out-of-office
measurements to exclude errors in diagnosis. AMBULATORY BP MONITORING
with proper cuff and bladder size would be the most precise means of
measurement (Class I; Level of Evidence B).
• It is reasonable that the presence of stage 1 hypertension in the absence of
target-organ damage should not limit the eligibility for any competitive sport.
Once having begun a training program, the hypertensive athlete should have BP
measured every 2 to 4 months (or more frequently, if indicated) to monitor the
impact of exercise (Class I; Level of Evidence B).
• Those with prehypertension (BP of 120/80 mm Hg– 139/89 mm Hg) should be
encouraged to modify their lifestyles but should not be restricted from physical
activity. Those with sustained hypertension should have screening
echocardiography performed. Athletes with LVH beyond that seen with “athlete’s
heart” should limit participation until BP is normalized by appropriate
antihypertensive drug therapy (Class IIa; Level of Evidence B).

HCM
• Genetically transmitted primary myocardial
disease
• Prevalence -1 in 500
• MC cause of SCD in young people, including
competitive athletes
• Problem- inability to augment stroke volumes
due to a small LV cavity size, impaired diastolic
function, dynamic LVOTO, microvascular
ischaemia

Mechanism
• Myocardial disarray
• Interstitial fibrosis
• Microvascular ischemia
• Ventricular tachycardia
(VT) or fibrillation (VF).

ACC
• Asymptomatic, genotype-positive, phenotype negative HCM  All
sports (Class IIa; Level of Evidence C)
• Athletes with a probable or unequivocal clinical expression and
diagnosis of HCM (ie, with the disease phenotype of LV
hypertrophy) should not participate in most competitive sports,
with the exception of those of low intensity (class IA sports)
• [This recommendation is independent of age, sex, magnitude of
LV hypertrophy, particular sarcomere mutation, presence or
absence of LV outflow obstruction (at rest or with physiological
exercise), absence of prior cardiac symptoms, presence or absence
of late gadolinium enhancement (fibrosis) on CMR, and whether
major interventions such as surgical myectomy or alcohol ablation
have been performed previously] (Class III; Level of Evidence C)

ACC
• Pharmacological agents (eg, β-blockers) to
control cardiac-related symptoms or ventricular
tachyarrhythmias should not be administered
for the sole purpose of permitting participation
in high-intensity sports. (Class III; Level of
Evidence C)
• Prophylactic ICDs should not be placed for the
sole or primary purpose of permitting
participation in high-intensity sports
competition (Class III; Level of Evidence B)

ARVD
• Progressive fibrofatty
replacement of the
right ventricular (RV)
myocardium
• Arrhythmia

ARVC
• Definite ARVC - should not participate in most competitive
sports, with the possible exception of low-intensity class
1A sports (Class III; Level of Evidence C).
• Borderline ARVC - should not participate in most
competitive sports, with the possible exception of low-
intensity class 1A sports (Class III; Level of Evidence C).
• Possible ARVC - should not participate in most
competitive sports, with the possible exception of low-
intensity class 1A sports (Class III; Level of Evidence C).
• Prophylactic ICD  not recommended (Class III; Level of
Evidence C)

CORONARY ARTERY ANOMOLIES
• In CAA originating from the wrong sinus, with
acute angled take-off from the aorta and
anomalous coursing between the aorta and
the pulmonary artery,  Prior to successful
correction, participation in high-intensity
sport is discouraged. [Level of
recommendation: Class II, level of evidence C]

• CAAs without inter-arterial course have been
considered having a low risk of SCA/SCD.
• At present, because of a lack of adequate
data, an individualized approach for
competitive sports participation is
recommended, based on comprehensive
evaluation. [Level of recommendation: Class
III, level of evidence C]

• In case of previous surgical correction and lack of
persistent, inducible ischemia all competitive
sports are allowed. [Level of recommendation:
Class III, level of evidence C]
• In other types of CAA, such as anomalous origin
of the circumflex artery from the right sinus, it is
relevant to confirm the absence of inducible
ischemia and, in this case, no restriction exist
regarding competitive sport participation. Level
of recommendation: Class IIa, level of evidence C

• After successful surgical repair of an
anomalous origin from the wrong sinus,  all
sports 3 months after surgery if the patient
remains free of symptoms and an exercise
stress test shows no evidence of ischemia or
cardiac arrhythmias (Class IIb; Level of
Evidence C).
CORONARY ARTERY ANOMALIES

CORONARY DISSECTION
• Individuals with SCAD, at present, should be
discouraged from competitive sport
participation, leisure time activity is advised,
and should be recommended individually (i.e.
exercise prescription). Level of
recommendation: Class III, level of evidence C.

CORONARY DISSECTION
• There are insufficient data to provide
definitive recommendations for sports
participation, but because spontaneous
dissection can occur with exertion, it is
reasonable that patients with prior
spontaneous coronary artery dissection be
restricted to participation in sports with low to
moderate dynamic and low to moderate static
demands (Class IIa; Level of Evidence C).

MYOCARDIAL BRIDGING
• In the absence of inducible effort-related ischemia or complex
ventricular tachyarrhythmias (i.e. NSVT, polymorphic or very
frequent VEBs, induced by exercise), there is little evidence for
exercise-induced harm. Therefore, asymptomatic athletes-patients
with myocardial bridging can participate in all competitive sports.
Level of recommendation: Class IIa, level of evidence C.
• Conversely, in those with evidence of ischemia or symptoms, beta-
blockers are the first line therapy. If this therapy fails, then surgical
repair may be considered, whereas stenting is discouraged. These
individuals should be restricted from participation in competitive
sports, and should be properly advised regarding leisure-time
activities. Level of recommendation: Class IIa, level of evidence C.

MYOCARDIAL BRIDGING
• It is reasonable for athletes with myocardial bridging and no
evidence of myocardial ischemia during adequate stress testing to
participate in all competitive sports (Class IIa; Level of Evidence C).
• It is reasonable to restrict athletes with myocardial bridging of an
epicardial coronary artery and objective evidence of myocardial
ischemia or prior myocardial infarction to sports with low to
moderate dynamic and low to moderate static demands (Class IIa;
Level of Evidence C).
• It is reasonable to restrict athletes who have undergone surgical
resection of the myocardial bridge or stenting of the bridge to low-
intensity sports for 6 months after the procedure. If such athletes
have no subsequent evidence of ischemia, they may participate in
all competitive sports (Class IIa; Level of Evidence C).

AORTIC VALVE DISEASES
AS
• Mild AS - all sports
• Moderate AS - Low and
moderate static or low and
moderate dynamic
competitive sports.
• Asymptomatic severe AS-
(class IA) sports.
• Symptomatic AS- NO
SPORTS.
AR
• Mild to moderate AR -all sports
• Mild to moderate AR with moderate LV
dilatation - all competitive sports
• Severe AR, LV ejection fraction ≥50% and LVESD
<50 mm (men), <40 mm (women), or <25
mm/m2 (either sex) - all competitive sports if
they have normal exercise tolerance,
• AR and aortic dimensions of 41 to 45 mm to
participate in sports with low risk of bodily
contact
• Severe AR and symptoms, LV systolic
dysfunction, LVESD >50 mm or >25 mm/m2, or
severe increase in LVEDD (>70 mm or ≥35.3
mm/ m2 [men], >65 mm or ≥40.8 mm/m2
[women])-No sports

MITRAL VALVE DISEASES
MS
• Mild MS (mitral valve area >2.0
cm2, mean gradient <10 mm Hg
at rest) - all sports.
• Athletes with severe MS (mitral
valve area <1.5 cm2) in either
sinus rhythm or atrial fibrillation
- low-intensity (class IA) sports
• MS of any severity who are in
atrial fibrillation or have a
history of atrial fibrillation, who
must receive anticoagulation
therapy, should not engage in
any competitive sports involving
the risk of bodily contact
MR
• Mild to moderate MR who are in
SR- all sports
• Moderate MR, mild LV
enlargement- all sports
• Severe MR, mild LV enlargement-
low-intensity and some
moderate-intensity sports
• MR and definite LV enlargement,
pulmonary hypertension, or any
degree of LV systolic dysfunction
at rest- low-intensity class IA
sports
• AF on OAC- no sports involving
bodily contact

POST VALVE REPLACEMENT SURGERY

CASE I
• 36 YR OLD –FOOTBALL PLAYER
• ACS-AWSTEMI, LAD-99%, RCA-70%
• P/10 PCI TO LAD[3 MONTHS BACK],
ASYMPTOMATIC
• WANTS TO RESUME PLAYING…

CASE II
• HCM, MYH7+
• ASYMPTOMATIC
• NO LVH
• WANTS TO START MARATHON RUNNING…

TAKE HOME MESSAGE
• The ultimate goal is prevention of sudden
death, although it is also important not to
unfairly or unnecessarily remove people from
a healthy athletic lifestyle or competitive
sports because of fear of litigation.

Competitive sports in cvs diseases

In this document