21 vcc park 12h30 Warburton

Cardiovascular Disease and High Level Athletes: 

Cardiovascular Disease and High Level Athletes Darren E.R. Warburton, PhD Canadian Institutes of Health Research New Investigator Michael Smith Foundation for Health Research Career Scholar University of British Columbia Canadian Association of Cardiac Rehabilitation Vancouver 2006

Welcome and Open Discussion: 

Welcome and Open Discussion Controversial Points to Consider Exercise is associated with an increased risk for sudden cardiac death (SCD) in untrained individuals and highly trained athletes? Yes No Individuals who train at the elite level will be predisposed to the development of cardiovascular disease (CVD)? Yes No Dose Response: Too much exercise is bad for the heart? Yes No

The Paradox of Physical Activity: 

The Paradox of Physical Activity Habitual physical activity is an effective primary and secondary preventive measure for multiple chronic diseases (including CVD). Warburton et al. CMAJ 2006 Cases of SCD or advanced CVD in athletes or former athletes create great public debate. Increase the short-term risk of SCD while decreasing the long-term risk for CVD and SCD.

Cases of SCD: 

Cases of SCD 490 BC, Pheidippides, collapsed and died after running from Marathon to Athens 42.2 km (26.2 miles) Legend holds that he ran 150 miles in 2 days. Jim Fixx (1984) Marathon Runner Pete Maravich (1988) Former Basketball Player Hank Gathers (1990) College Basketball Player Reggie Lewis (1993) Basketball Player Sergei Grinkov (1995) Olympic Figure Skater Sy Mah (1988) World Record Marathoner 524 marathons and ultra events

Purpose: 

Purpose To evaluate the current literature regarding the relative risk for SCD and CVD in current and former highly trained athletes.

Physical Activity/Fitness and Chronic Disease: 

Physical Activity/Fitness and Chronic Disease All-cause and Cardiovascular-related Mortality Active adults have 20-35% reduced risk of premature mortality. Warburton et al. CMAJ 2006;174:801-9. Recent evidence indicates up to 50% reduction in the risk for premature mortality. Myers et al. Am J Med. 2004;117:912-8. Williams PT. Med Sci Sports Exerc. 2001;33: 754-61.

Physical Activity and SCD in the General Population: 

Physical Activity and SCD in the General Population 6 - 17% of all SCD in men are associated with acute physical exertion. 4-10% of myocardial infarction (MI) cases occur within 1 hr of vigorous exercise. Corrado et al. J Cardiovasc Med 2006;7:228-33. There appears to be a 9-19-fold higher risk of exertion-related SCD among men. Whang et al. JAMA 2006;295:1399-1403. The risk of exercise-related MI decreases with increasing levels of physical activity. Mittleman et al. New Eng J Med 1993;329:1677-1683. The absolute risk is relatively low (1 sudden death per 19 million hours of exertion) Equates to 1 excess SCD per 1.51 million episodes of vigorous exertion. Albert et al. New Eng J Med 2000;343:1355-61.

SCD and Women: 

SCD and Women In women, the acute risk for SCD is transiently increased during moderate-vigorous activity vs. lesser or no activity. The risk is not significantly elevated in those who exercise 2 or more hours per week. Whang et al. JAMA 2006;295:1399-1403. The risk of SCD related to moderate to vigorous exertion is extremely low in women. 1 per 36.5 million hours of exertion. Whang et al. JAMA 2006;295:1399-1403. Women who exercise 4 or more hours per week have a significant reduction (59%) in the long-term risk for SCD. Whang et al. JAMA 2006;295:1399-1403.

The effects of habitual vigorous exercise on the risk for CVD during vigorous exertion in men.: 

The effects of habitual vigorous exercise on the risk for CVD during vigorous exertion in men. Source: Albert et al. New Eng J Med 2000;343:1355-61.

Long-term SCD Mortality Risk and Exercise in Women: 

Long-term SCD Mortality Risk and Exercise in Women Source: Whang et al. JAMA 2006;295:1399-1403.

Most Common Activities: 

Most Common Activities Youth and Young Adults Basketball, football, track, and soccer. Maron et al. JAMA 1996;276:199-204. Adults Distance running, racquet sports, isometric lifting.

Risk for SCD: 

Risk for SCD The risk for SCD is “exceedingly small” 1 in 50,000 (0.002%) Maron et al. JACC 1996;28:428-31. In apparently healthy adolescents, the chances of a SCD is 1 in 250,000. Weekend Warriors Prevalence is higher amongst individuals who are unaccustomed to regular exercise. Maron New Eng J Med 2000;343:1409-11.

Causes of sudden cardiac death in competitive athletes.: 

Causes of sudden cardiac death in competitive athletes. Source: Maron et al. JACC 1986;7:204-14. <35 yr Hypertrophic Cardiomyopathy ≥35 yr Coronary Artery Disease

SCD and Young Athletes: 

SCD and Young Athletes Risk is low. Competitive sport activity increases 2.5-fold the risk of SCD in young Italian individuals. North American rates are lower (0.35/100,000 person-years). Sports are not the cause, but the trigger. Corrado et al. J Cardiovasc Med 2006;7:228-33.

SCD and Adolescents: 

SCD and Adolescents “Sport is not per se the cause of the enhanced mortality in this age group; rather, it acts as a trigger of cardiac arrest in those athletes who are affected by silent cardiovascular conditions, mainly cardiomyopathy, premature coronary artery disease, and congenital coronary anomalies, which predispose to life-threatening ventricular arrhythmias during physical exercise.” Corrado et al. J Cardiovasc Med 2006;7:228-33.

Pre-participation Screening: 

Pre-participation Screening American Heart Association Recommends screening of high school and college athletes before participation. “Athletic screening should be performed by a healthcare worker with the requisite training, medical skills, and background to reliably obtain a detailed cardiovascular history, perform a physical examination, and recognize heart disease. Screening evaluations should include a complete medical history, and physical examination, including brachial artery blood pressure.” Pre-screening is somewhat controversial Recent study revealed a 89% reduction in SCD over a 26 year period with the implementation of pre-participation screening in Italy. Greater identification of cardiomyopathies. Corrado et al. JAMA 2006;296:1593-1601.

Slide17: 

Corrado, D. et al. JAMA 2006;296:1593-1601. Annual Incidence Rates of Sudden Cardiovascular Death in Screened Competitive Athletes and Unscreened Nonathletes Aged 12 to 35 Years in the Veneto Region of Italy (1979-2004)

Risk for CVD in Former Athletes: 

Risk for CVD in Former Athletes Former athletes have decreased mortality rates and prevalence of chronic disease (including diabetes, CVD, cancer, hypertension). Hernelahti et al. Int J Sports Med 2001;23:178-182. Kujala et al. Metab Clin Exp 1994;43:1255-60. Former athletes who remain active have a significantly reduced risk for CVD across their lifespan.  total cholesterol (TC),  ratio of TC to HDL cholesterol,  LDL cholesterol,  triglycerides Dey et al. J Cardiovas Risk 2002;9:383-392. Seals et al. JAP 1984;57:1024-29. Pihl et al. Atherosc 2003;171:321-326.  C-reactive protein Pihl et al. Atherosc 2003;171:321-326.  resting blood pressure Dey et al. J Cardiovas Risk 2002;9:383-392.

Risk for CVD in Former Athletes: 

Risk for CVD in Former Athletes Former athletes (who become sedentary) may have similar risks for CVD as sedentary non-athletes. Dey et al. J Cardiovas Risk 2002;9:383-392. Current levels of activity appear to be more protective. Pihl et al. Scand J Med Sci Sports 1998;8:229-35.

Dose Response: 

Dose Response Caution Possible Reductions in Health Benefits Source: Gledhill and Jamnik. Canadian Physical Activity, Fitness and Lifestyle Approach.

Special Considerations during Prolonged Exercise: 

Special Considerations during Prolonged Exercise Electrophysiological Abnormalities Cardiac Fatigue Hyponatremia

Benefit to Risk Ratio: 

Benefit to Risk Ratio Benefits of physical activity clearly outweigh the transient risks. Warburton et al. CMAJ 2006;174:801-9. Clinicians should not assume that highly trained individuals do not have underlying cardiovascular disease. “Weekend Warriors” may be at an increased risk.

Recap: 

Recap Controversial Points to Re-Consider Exercise is associated with an increased risk for sudden cardiac death (SCD) in untrained individuals and highly trained athletes? Yes No Individuals who train at the elite level will be predisposed to the development of cardiovascular disease (CVD)? Yes No Dose Response: Too much exercise is bad for the heart? Yes No

Vancouver 2010: 

Vancouver 2010

Acknowledgements: 

Acknowledgements Graduate Students Ben Esch PhD Jessica Scott PhD Lindsay Nettlefold PhD Crystal Whitney Nicol PhD Anita Cote PhD Arlana Taylor MSc Dominik Zbogar MSc Ashlee McGuire MSc Shirley Wong MSc Funding Canadian Institutes of Health Research CIHR New Investigator Award Canada Foundation for Innovation Michael Smith Foundation for Health Research MSFHR Scholar Award Own the Podium, Vancouver 2010 Natural Sciences and Engineering Research Council BC Knowledge Development Fund BC Neurotrauma Fund Peter Wall Institute for Advanced Studies BC Ministry of Health Worker’s Compensation Board of BC

Thank you!: 

Thank you!