sports and physical exercise in special clinical settings ...€¦ · sports and physical exercise...

Myocarditis

Brian Olshansky MD Professor Emeritus, University of Iowa

Electrophysiologist, Mason City, Iowa USA

SPORT AND ARRHYTHMIA Sports and Physical Exercise in Special Clinical Settings

Chairmen: P. Delise, F. Giada

MY CONFLICTS OF INTEREST ARE Medtronic – consultant Boston Scientific – DSMB, consultant, research Amarin – DSMB, consultant Biocontrol – consultant, research Sanofi-Aventis - DSMB Boehringer Ingelheim – consultant, research On-X - consultant Biotronik - consultant Lundbeck – consultant Daiichi Sankyo – consultant, speaker

A Case of Intractable VF

300 µgm/min)


Bharati S. J Cardiovasc Electrophysiol 1992;3:437-441


Bharati S. J Cardiovasc Electrophysiol 1992;3:437-441

Myocarditis of the AV node

Fibrosis of the septum Diagnosis: Chronic myocarditis of the septum

Sudden Cardiac Death Young People Apparently Normal Heart

Corrado D. Cardiovasc Res 2001;50:399–408

Myocarditis

Schultz JC. Mayo Clin Proc 2009;84:1001-1009

Toxins

  Amphetamines, anthracyclines, cocaine, ethanol, cyclophosphamide, fluorouracil, lithium, hemetine, catecholamines, interleukin-2, trastuzumab, clozapine   Chemicals - copper, iron, lead, carbon monoxide, arsenic, phosphorus, sodium azide   Radiation, electric shock   Other - scorpion sting, snake/spider bites, bee and wasp stings, pheochromocytoma, beri–beri

Position Statement - ESC Working Group

Caforio ALP. Eur Heart J 2013;34:2636–2648

Infectious Etiologies

  Bacterial, mycobacterial, spirochete, fungal, protozoal, parasitic, rickettsial   RNA virus: Coxsackie A and B, echo, polio, influenza A/B , respiratory syncytial, mumps, measles, rubella, hepatitis C, dengu, yellow fever, Chikungunya, Junin, Lassa fever, rabies, HIV-1   DNA virus: adeno, parvo, B19, cytomegalovirus, herpes-6, Epstein-Barr, varicella-zoster, herpes simplex, variola, vaccinia



Immune-Mediated

  Tetanus toxoid, vaccines, serum sickness   Drugs: penicillin, cefaclor, colchicine, etc.   Heart transplant rejection   Autoantigens: lymphocytic or giant cell   Autoimmune: lupus, rheumatoid arthritis, Churg-Strauss, Kawasaki’s disease, inflammatory bowel, scleroderma, polymyositis, myasthenia, diabetes, thyrotoxicosis, sarcoidosis, Wegener’s, rheumatic fever



Time Course of Myocarditis

Kindermann J. Am Coll Cardiol 2012;59:779–92

Edema

Gadolinium enhancement

Causes of Sudden Death Young Competitive Athletes

Maron BJ. Circulation 2007;115:1643-1455

Hypertrophic cardiomyopathy

Sudden Death in NCAA and Other Populations

Harmon KG. Circ Arrhythm Electrophysiol 2014;7:198-204

European Prospective Registry

Bohm P. Eur J Preventive Cardiol 2015 in press

Sports-related sudden cardiac death

Age ≤35 Total population

Mean age: 46.8±16.2 years

Assessment of the Athlete

 History – upper respiratory/GI symptoms, palpitations, fatigability, exertional dyspnea, syncope. Flu-like illness or epidemiological circumstances supporting viral infection  ECG – Frequent, complex ventricular and/or supraventricular arrhythmias, ST-T changes, bundle branch block, AV block

Pelliccia A. Eur Heart J 2005;26:1422–1445

Recommendations for competitive sports participation in athletes


Diagnostic Criteria

 ECG abnormalities  Elevated troponin (T/I)  Functional/structural abnormalities on imaging (echo/angiography/MRI)  Tissue characterization – MRI -> edema and/or classical myocarditis  Angiography, myocardial biopsy



Echocardiography

 Global LV enlargement and dysfunction  Mildly enlarged LV, borderline dysfunction  Localized wall motion abnormality (apex)  Pericardial effusion



Lesion Reversibility by MRI

Zagrosek A. J Am Coll Cardiol Img 2009;2:131–8

Partial reversibility

Complete reversibility

Proposed MRI Criteria

  Regional/global myocardial increase in T2-weighted image signal intensity   Increased global early enhancement ratio between myocardium and skeletal muscle in gadolinium-enhanced T1-weighted images   Focal lesion(s) with nonischemic distribution in inversion recovery-prepared gadolinium-enhanced T1-weighted images (c/w injury or scar)   Left ventricular dysfunction or pericardial effusion

Friedrich MG. White Paper. J Am Coll Cardiol 2009;53:1475-1487

Recommendations

 Active myocarditis !  History, PE, ECG, Echo !  No competitive sports

 After resolution (6-months post-onset) !  History, PE, ECG, Echo, exercise test, Holter !  No symptoms or arrhythmias, normal LV function !  All competitive sports

Pellicia A. Eur J Cardiovasc Prev Rehabil 2006;13:876–885

Competitive Sports Participation

Exercise in Myocarditis?

 Mice-> Coxsackie B3 inoculation, exercised to exhaustion  Exercise nearly doubled lesion size and tripled T cytotoxic, T suppressor cells and doubled T cytotoxic, suppressor/T helper cell ratio  Thus, exercise during acute infection may contribute to disease progression

Avoidance prudent based on animal data

Ilback N-G. Am Heart J 1989;117:1298 Gatmaitan BG J Exp Med 1970;131:1121–36

Coxsackie B3 Myocarditis Worsened by Exercise

 Coxsackie B-3 myocarditis induced in mice had an acute mortality of 5.5%  Acutely, when mice were forced to swim, half died most while swimming but, after the acute phase, swimming led to a 13.8% mortality  Myocardial Coxsackie replication increased 530X with swimming during the acute phase

Gatmaitan BG. J Exp Med 1970;131:1121–36

Exercise - Not a Good Thing

Cabinian AE. J Lab Clin Med 1990;115:454-62

Mortality in Coxsackie B3 infected Mice

Exercise and Myocarditis A Bad Combination

INF – infected with coxsackie B3 EX - exercise AB – anti-thymocyte antibodies CYA – cyclosporine A

Cabinian AE. J Lab Clin Med 1990;115:454-62

Asymptomatic Athletes

Schnell F. Br J Sports Med 2015;0:1–8

Asymptomatic Arrhythmias


T-Wave Changes


Delayed Hyperenhancement MRI – Asymptomatic Athletes


Asymptomatic Myocarditis

  “Isolated large areas of subepicardial delayed enhancement in an asymptomatic athlete is not benign and requires careful evaluation at exercise and strict follow-up”   “These findings question whether extreme exercise during silent myocarditis may facilitate fibrosis generation and adverse remodeling”


Conclusion

 Myocarditis, a cause for death among athletes, may be more common than thought  Diagnosis is clinical but may be missed  Restriction from sports for at least 6 months until complete resolution is present

sports and physical exercise in special clinical settings ...€¦ · sports and physical exercise...

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