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Sports cardiology talk slideshare export

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Sports Cardiology Grand Rounds at Lions Gate Hospital. EKG screening and other services available through Dr. John Vyselaar, cardiologist, at the North Shore Heart Centre.

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Sports cardiology talk slideshare export

  1. 1. SPORTS CARDIOLOGY John Vyselaar, MD, FRCPC Consultant Cardiologist: • Vancouver Whitecaps FC • BC Lions Football Club • Vancouver Canucks • Tennis Canada • Canadian Olympic Team • Other high level athletes and more American College of Cardiology Sports and Exercise Section
  2. 2. Disclosures • Speaker honoraria: Bayer, Servier, Novartis, Boehrigher-Ingleheim, Amgen, BMS/Pfizer, more… • Advisory board: Amgen, Bayer, Boehrigher-Ingleheim, Astra Zeneca, more… • Grants: Servier, Mylan, Boehrigher-Ingleheim • Clinical trials: Amgen, Astra Zeneca • NOTHING relevant to this presentation! • THANKS to Dr. Jim Bovard who gave me my start in sports cardiology!
  3. 3. Objectives • Define sports cardiology • Review screening of athletes for cardiovascular illness • Review common sports cardiology problems • Detail our sports cardiology program
  4. 4. What is sports cardiology? Aren’t athletes healthy?
  5. 5. Sports Cardiology • A discipline within cardiology that deals with the interaction between the heart and cardiovascular system, performance during sports or athletic activities, and ensuring sports participation is safe from a cardiovascular standpoint.
  6. 6. Sports Cardiology • Who doesn’t like sports – at least somehow? • Childhood memories • Recreational sports – team building • Solo athletic activities • Spectator sports • What is an athlete? • We are all athletes in some form
  7. 7. Sports Cardiology • Two main goals • Ensuring safety during exercise by screening for conditions that predispose to sudden cardiac death • Optimizing the performance of the cardiovascular system during exercise (i.e. investigating symptoms during exercise)
  8. 8. Screening Athletes to Prevent Sudden Cardiac Death What can we do? Does it work?
  9. 9. Who is an athlete? • Pros • Joes • Youth • Collegiate • Masters athlete • Weekend warriors • Team play or solo • Hiking? Dog walking? • Occupational athlete • Anyone CAN be an athlete
  10. 10. Occupational Athlete • Physical skills / fitness are an important component of their job / occupation • Military • Firefighters • Police • EMS • Farmers • Skilled labourers
  11. 11. Who do you screen? • Everyone who is active? • Beyond a set limit of activity? • Certain ages? Certain activities? • No right answer
  12. 12. What are you screening for? • Athletes under age 35 • Variety of weird and unusual disorders • Athletes over age 35 • Coronary artery disease
  13. 13. Navin Chandra et al. JACC 2013;61:1027-1040 American College of Cardiology Foundation
  14. 14. Harmon et al, Circulation. 2015 Jul 7; 132(1): 10–19. Causes of Death in NCAA Athletes 2003 – 2013
  15. 15. Harmon et al, Circulation. 2015 Jul 7; 132(1): 10–19. Causes of Sudden Cardiac Death in NCAA Athletes 2003 – 2013
  16. 16. Sumeet S. Chugh, and Joseph B. Weiss JACC 2015;65:493- 502 American College of Cardiology Foundation
  17. 17. Sumeet S. Chugh, and Joseph B. Weiss JACC 2015;65:493-502 American College of Cardiology Foundation
  18. 18. Scope of the problem • SCA during exercise is relatively rare but devastating when it occurs • Patient • Family • Community • 1 in 300 children has a condition that predisposes to sudden cardiac death • 1 in 500 have HCM • Regional variation; e.g. ARVC more common in Italy and Denmark (25% of all SCD in athletes) • More recent data suggest autopsy-negative SCD is more common, up to 25% of all SCD (presumably, therefore, arrhythmia)
  19. 19. Rates of sudden cardiac arrest • Studies consistently yield an incidence of SCD of: • 1:50,000 per athlete year in college athletes • 1:50,000 to 1:80,000 per athlete year in high school athletes • Certain subgroups are at particularly high risk • Men (1:37,000 vs 1:121,000) • Basketball players (1:9,000) • People of African descent (1:21,000 vs 1:68,000) • Black male basketball players: incidence of SCD 1:3,000 Asif and Harmon, Sports Health, 2017 May/June;9(3):268-279.
  20. 20. Screening for Causes of SCD? • These are devastating events, but relatively uncommon • Therefore, any screening tests have a high potential for false positives, given the low event rate • What tests should we do? • Who should we screen? • Resource allocation • Cost effectiveness • Is screening effective at reducing the incidence of SCD?
  21. 21. Adaptation to Exercise • Confounds the screening assessment • Many EKG (or imaging) findings that are abnormal in untrained people, may be normal in athletes • Even a low false positive rate (<5%) will generate a lot of false positive results, cost in downstream testing, and anxiety for the athlete and their family (and possibly even restriction from athletics) • Consultation with a cardiologist experienced in adaptations to exercise is essential • Not part of regular cardiology training • Requires on the job training afterwards (extensive CME and mentoring)
  22. 22. What is Normal? • Requires ongoing study, registries and data collection to determine normal variants vs pathology • Big topic of debate • We are beginning a registry in sports cardiology for this reason, and will contribute to the American College of Cardiology data set and publications wherever feasible
  23. 23. EKG Standards • Have been refined multiple times, in an attempt to reduce false positives • Currently we use the International Criteria for Electrocardiographic Interpretation in Athletes • False positive rates in high school or collegiate athletes <1.5% • Need a cardiologist with experience in sports cardiology
  24. 24. International consensus standards for ECG interpretation in athletes. Jonathan A Drezner et al. Br J Sports Med doi:10.1136/bjsports-2016-097331 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  25. 25. ECG of a 29-year-old male asymptomatic soccer player showing sinus bradycardia (44 bpm), early repolarisation in I, II, aVF, V4-V6 (arrows), voltage criteria for left ventricular hypertrophy (S-V1 + R-V5 >35 mm) and tall, peaked T waves (circles). Jonathan A Drezner et al. Br J Sports Med doi:10.1136/bjsports-2016-097331 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  26. 26. ECG from a patient with HCM demonstrating QRS voltage criteria for LVH in association with deep TWI and ST segment depression predominantly in the lateral leads (I, aVL, V4–V6), voltage criteria for left atrial and right atrial enlargement and left axis deviation. HCM, hypertrophic cardiomyopathy; LVH, left ventricular hypertrophy; TWI, T wave inversion. Jonathan A Drezner et al. Br J Sports Med doi:10.1136/bjsports-2016-097331 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  27. 27. ECG from a black athlete demonstrating voltage criteria for LVH, J-point elevation and convex (‘domed’) ST segment elevation followed by TWI in V1-V4 (circles). Jonathan A Drezner et al. Br J Sports Med doi:10.1136/bjsports-2016-097331 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  28. 28. (A) ECG from an 18-year-old black basketball player demonstrating abnormal TWI extending into V5. Jonathan A Drezner et al. Br J Sports Med doi:10.1136/bjsports-2016-097331 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  29. 29. Presence of Abnormalities on Resting EKG Disease Frequency of Abnormalities HCM High ARVC Moderate Dilated CM Moderate (LBBB) Myocarditis Moderate Long QT Low Brugada Low Pre-excitiation (WPW) High Coronary artery anomalies Low / almost never Coronary artery disease Low (if no history)
  30. 30. Examples of Adaptations to Exercise • Structural • Increased left ventricular wall thickness (12-15 mm); overlaps with mild HCM • Dilated left ventricle with low normal LV function; overlaps with dilated CM • Dilated right ventricle with reduced systolic function; overlaps with ARVC • Ventricular trabeculation; overlaps with noncompaction cardiomyopathy • Aortic size; overlaps with aortic aneurysm • Question in tall people like myself – so a big problem in the NBA
  31. 31. Coronary Artery Anomalies: a Pictorial Review (PDF Download Available). Available from: https://www.researchgate.net /publication/276467963_Cor onary_Artery_Anomalies_a_Pi ctorial_Review [accessed Sep 9, 2017]
  32. 32. Coronary Artery Anomalies: a Pictorial Review (PDF Download Available). Available from: https://www.researchgate.net/publication/276467963_Coronary_Artery_Anomalies_a_Pictorial_Review [accessed Sep 9, 2017]
  33. 33. Does screening work? • Hard to show a reduction in rare events
  34. 34. Domenico Corrado et al. JACC 2008;52:1981-1989 American College of Cardiology Foundation
  35. 35. Domenico Corrado et al. JACC 2008;52:1981-1989 American College of Cardiology Foundation
  36. 36. Carl J. Lavie, and Kimberly G. Harmon JACC 2016;68:712-714 American College of Cardiology Foundation
  37. 37. Screening in older athletes >35 years old • No good data • Basically, screening for coronary artery disease • How to do that? • Most protocols involve self-referral from interested patients, history, physical, EKG, +/- stress test • Stress testing – poor PPV in asymptomatic patients • Role of calcium score or coronary CT? Still undefined • Little data in older athletes specifically
  38. 38. Screening – Conclusions • Most protocols involve history and physical exam, +/- an EKG • Some argue, just do the EKG – better predictive value, with lower false positive rates than history, and less downstream testing required • No screening approach is perfect and some conditions will be missed regardless • Anomalous coronary arteries and some channelopathies • Data that it works to reduce SCD are very limited, although some encouraging trends are seen • Who to screen and how much to spend remain uncertain • When to restrict / allow play and what precautions, is a whole other talk
  39. 39. Investigating Symptoms During Exercise
  40. 40. Symptoms • The OTHER part of sports cardiology • Anything from decreased performance, to palpitations or chest pain or other specific cardiac symptoms • Symptoms at rest also can provoke anxiety and make athletes afraid to compete • PVCs at rest in a high level Olympian runner – totally benign, but the athlete lost his confidence and held back • I did the usual workup, ensured all was OK, then remained available to him to talk through his symptoms and concerns. Not onerous, but did take a bit of effort • Patient / athlete went on to place on the podium
  41. 41. Answer • FALSE • Sporting activities vary tremendously in terms of aerobic intensity, isometric activity, and continuous action vs intervals and rest, and duration • E.g. Soccer vs Football vs Hockey • Specific physiologic conditions, or changes in conditions, can trigger symptoms • Can be completely missed on the standard stress test with its three minute stages • And some athletes can complete the whole protocol
  42. 42. Jere H. Mitchell et al. JACC 2005;45:1364-1367 American College of Cardiology Foundation
  43. 43. What to do? • “Go to where the athlete is” • Be creative • Adjust stress protocols to reproduce activity • Ramp – continuous increase • Intervals – often better, but no widely recognized, reproducible protocols • Other stress protocols • NCAA div 1 “Diving stress test” • Monitor during exercise and try to reproduce symptoms • Holters can be awkward or socially embarrassing – or get trashed in contact sports • And is this really how you want to investigate syncope? • Event monitors • Implantable loop recorders – but these are invasive • Remember first step is ALWAYS a careful history!
  44. 44. Common Symptoms in Athletes • “Getting winded too early” • Broad differential: deconditioning, exercise-induced asthma, anemia, poor sleep / nutrition / hydration, performance anxiety, and cardiovascular disease • Fainting or near-fainting • Exertional: usually bad – red flag • After exercise: usually benign (vagal, dehydration) • Palpitations • Sinus tachycardia, PVCs, AF, other…
  45. 45. North Shore Sports Cardiology • Expanding further this fall • Team of • Myself • Sam Doe • Lana Galac • Nancy Lord • Jen Philips and Megan Human • Chris and Lindsay • And others
  46. 46. North Shore Sports Cardiology • Goal is to improve and augment existing sports cardiology interest and make it more accessible • Always looking for enthusiastic partners • Speak with me, email, or send me a message through jvcardio.com
  47. 47. North Shore Sports Cardiology • Other groups we work with • American College of Cardiology, Sports and Exercise Section • Ironheart Foundation • Nick of Time Foundation • Stryker
  48. 48. Five Pillars • Consultation services • EKG screening programs • High school, collegiate, masters athletes • Incorporating technology • Unique and more advanced stress testing protocols • Novel Holter-like monitors that work better on athletes • Attempts to make use of consumer electronics (e.g. Fitbit) • More accurate VO2 Max determination • Public advocacy and education • Education and awareness • Defibrillator accessibility and site response plans • Partnering with Stryker and other companies to help make AEDs available even for low budget/income schools and organizations • Research and registries • New EMR (iClinic) • Collaborate with ACC and others
  49. 49. SITE DEFIBRILLATOR? STAFF TRAINING WITH DEFIBRILLATOR STAFF TRAINING WITH CPR? All North Vancouver Recreation Centres – 13 Sites (Harry Jerome Community Recreation Centre, John Braithwaite Community Centre, Karen Magnussen Community Centre, Lynn Valley Recreation Community Centre, Lynn Valley Village Community Complex, Memorial Community Recreation Centre, Mickey McDougall Community Centre, New Delbrook Community Recreation Centre, North Vancouver Tennis Centre, Old Delbrook Community Centre, Parkgate Community Recreation Centre, Ron Andrews Community Recreation Centre, Seylynn Community Recreation Centre YES ALL OF THE POOL, WEIGHT ROOM, AND ICE SKATE SHOP STAFF HAVE BEEN TRAINED ALL OF THE POOL, WEIGHT ROOM, AND ICE SKATE SHOP STAFF HAVE BEEN TRAINED Capilano Mall YES YES YES North Vancouver City Library YES SOME STAFF HAVE BEEN TRAINED 10 STAFF MEMBERS HAVE ST. JOHN’S AMBULANCE TRAINING (WHICH INCLUDES CPR) West Vancouver Memorial Library Yes Yes 20% of staff have first aid training (CPR not specified) Glen Eagles Community Centre Yes Yes Yes – all staff are trained in CPR Seniors Activity Centre – 695 21st Street, West Vancouver Yes Yes All staff trained in CPR West Vancouver Community Centre Yes Yes All staff trained in CPR West Vancouver Aquatic Centre Yes Yes All staff trained in CPR West Vancouver Ice Arena Yes Yes All staff trained in CPR
  50. 50. North Shore Sports Cardiology • Part of our goal to be a centre of excellence at NSHC • Cardiologists, nurse practitioner, dietician, technologists, MOAs • Multiple clinical interests and services • We tell everyone to exercise • We should make it as safe as possible for them to do so!

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