Cardiac Cases

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Cardiac Cases

• Karl B. Fields, MD
• Chief of Family Medicine Program
• Director of Sports Medicine Fellowship
• Moses Cone Hospital, Greensboro, NC
• 2007 Ironman

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GR 46 yo Marathon Runner

• Hx of awakening to go to bathroom at 4 AM before
  twin cities marathon, blacked out and bumped
  his head on floor
• Felt fine as soon as he awakened
• Ran marathon without problems
• History of feeling light-headed when swallowing
  bagel

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GR- Resting
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GR - Holter
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GR - Holter
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GR - Holter
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GR - ETT
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GR- ETT Stage 7 Bruce
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Marathoners are Different!!

• 8 year follow-up shows no syncope or heart
  related problems
• Avoids foods difficult to swallow
• Trains 150 miles per week on bike and runs 20 to
  30 miles per week
• ETT still reaches 7 Stages on Bruce protocol
• ECHO normal with high EF

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V Tach in Marathon Runners

• 355 competitive athletes with PVCs on holter
• (gt or 3 PVCs)
• Group A gt 2000 PVCs per 24 hrs
• 21 of 71 athletes had cardiac abnormalities
• Group B gt 100 but lt 2000 PVCs per 24 hrs
• 5 of 153 had cardiac abnormalities
• Group C lt 100 PVCs in 24 hrs
• 0 of 131 had cardiac abnormalities
• 1 athlete in Group A ultimately had a cardiac
  event
• Biffi, et al., JACC 2002

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Sinus Node Dysfunction in Athletes

• Bradycardia well known and vagotonia but
  increasing evidence of intrinsic SA and AV node
  changes
• Sinus arrhymia and wandering atrial pacemaker
  should be seen as normal response to vagal
  stimulation
• Wenckebach with pauses as long as 2.4 secs common
  in athletes
• SA block with longest pauses of 3.1 secs
• No cases of 3rd degree block
• Bjornstad H Storstein L Meen HD Hals O
  Cardiology 199484(1)42-50.

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Congenital or Narrow Complex 3rd Degree Heart
Block

• May represent an interruption of conduction
  between atrium and AV node in absence of other
  structural disease
• Narrow complex 3rd degree block even if acquired
  may be less serious
• Evaluation with ETT, 24 hour monitor and ECHO
• Close follow-up rather than pacemaker

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36th Bethesda Conference 2005

• Athletes with a structurally normal heart and
  normal cardiac function, with no history of
  syncope or near syncope, a narrow QRS complex,
  ventricular rates at rest gt40 to 50 beats/min
  increasing appropriately with exertion, no or
  only occasional premature ventricular complexes,
  and no VT during exertion can participate in all
  competitive sports.
• Zipes, DP, Ackerman, MJ, Estes NA, 3rd, et al.
  Task Force 7 arrhythmias. J Am Coll Cardiol
  2005 451354.

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Is Endurance Training a Risk Factor for Atrial
Fibrillation

• Observation of increased number of cases in
  middle-aged endurance athletes
• Case Control study of men age 35 to 59
• Vigorous orienteers had increase risk of atrial
  fibrillation RR of 5.5
• However, much lower risk of mortality 1.7 vs
  8.5 and of CAD 2.7 vs 7.5
• Karjalainen, et al. BMJ 19983161784-1785
  (13 June) 

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Is This a Serious Complication of Training?

• Study of 30 athletes with atrial fibrillation
  followed 9 years
• 15 stable, 7 resolved, 5 chronic atrial
  fibrillation, 3 died
• Hoogsteen,Europace 2004 6(3)222-228
• Case series of lone atrial fibrillation showed
  athletes represented 63 vs. 15 of population
• Mont, European Heart Journal (2002) 23, 477482
• Onset in athletes is younger mean 52
• Risk is not present in physically active workers

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KL 53 Year Old Physician and Former Elite
Marathoner

• Saturday night you return from a play and the
  message on your answering machine from your
  running partner says, Come over as quick as you
  can, I feel dizzy, nauseated and my pulse is only
  23.
• Runner for 40 years with marathon best of 218
• Syncope with micturition on and off for years
  with resting HR often about 32
• Symptoms of palpitations evaluated with normal
  ETT and EF gt 60 in prior years

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Follow-up KL 2004

• Carotid massage leads to HR of 14
• Cath shows large CA with no obstruction
• Mild LVH with high EF
• Pacemaker installed and felt better once rate
  adjusted to 50
• All symptoms absent at 2 weeks and starting to
  run again

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RD 48 Year Old Runner

• C/O SOB with running primarily noted after eating
  too soon before a run
• Extreme fatigue at 14 miles into his 18 mile run
  during marathon preparation
• Runs 2000 miles per year/ 20 years of running
• History of severe reflux and allergic rhinitis
• No risk factors except marital stress

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Cardiac Referral RD

• Cath shows severe right CAD
• Stented June 2000
• Focal lesions in proximal diagonal and distal LAD
  undergo PTCA in July 2000
• January 2001 exercised to Bruce stage 5 with EF
  59 and mild inferior ischemic change on thallium
• Normal stress cardiolyte in November 2001 before
  marathon in December 2001

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Cardiac Referral 2 RD

• Normal Stress cardiolyte March 2002
• Epigastric pain August 2002 feels different GI
  referral Reflux
• September 2002 felt bad for 3 weeks and chest
  pain with running/ fast walking
• Cholesterol, BP all risk factors well controlled
• Cath shows severe triple vessel disease

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Follow-up - RD

• Sept. 18, 2002 undergoes quadruple bypass with
  atrial fibrillation in post-op phase
• Nov. 29, 2002 now about 10 weeks post op
  exercises to stage 5 Bruce protocol
• April 27, 2004 seen for tibial stress fracture
  while training for marathon

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Which Athletes Do You Stress Test?

• Young symptomatic athletes particularly those
  with symptoms during exercise.
• Previously sedentary adults who want to begin a
  fitness program, particularly if risk factors are
  present
• Periodic testing for adult athletes engaged in
  vigorous sport men age 40 and women age 50
• All adult athletes over 40 with symptoms that may
  be a CV equivalent
• All adults athletes over 40 with a know CVD
  or equivalent

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Pearls Regarding Athletes and ETT

• Fitness assessment relative to age and activity
  is best predictor of cardiac outcomes for men and
  women
• Failure to obtain high fitness levels in an
  endurance athlete is worrisome
• HR recovery after exercise is better predictor of
  CAD than the EKG or imaging tests we use
• Stress imaging offers minimal advantages vs.
  standard ETT except in special populations

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Pearls Regarding Exercising Adults and ETT

• Each 1 MET increase confers a 12 increase in
  survival
• No interaction from use of beta blockers and
  predictability of exercise capacity
• Absolute peak exercise capacity is a better
  predictor than age-adjusted

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7 Year Survival Norm vs. CVD

• Support low risk status for individuals with
  
• gt 8 METS and High risk in those lt 5 METS

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Women, Fitness, HRR and Cardiac Risk

• 2994 women with Max ETT tested between 1972 and
  1976 in LRCC.
• 20 yr follow-up in 1995
• Women below median for exercise capacity
  (fitness) and HRR had a 3.5x increased risk of
  cardiac death
• ST segment depression did not predict CV death
  risk
• Mora, et al. Jama, 2003.

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Clinical vs. Technical Assessment of CVD risk

• EKG changes of ST segment depression and
  perfusion defects on scans are only moderately
  strong predictors of disease
• Technology while useful is often misleading
• Fitness level and HR recovery are strong
  predictors of cardiac outcomes and disease
• Clinical variables such as resting HR, Max HR,
  Max systolic BP also help predict CAD