Marathon: Prohibited for Cardiac Patients?
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Déclaration de Relations Professionnelles - J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : Affiliation/Financial Relationship Company Grant/Research Support no Consulting Fees/Honoraria Bayer Health, Sanofi, Menarini Major Stock Shareholder/Equity no Royalty Income no Ownership/Founder no Intellectual Property Rights no Other Financial Benefit no Marathon: prohibited for cardiac patients? Dr Jean-Michel Chevalier. Bordeaux Armées. XXIIIrd ED of FSC Paris 18 01 2013. (Ischemic Heart Disease) Study Group of Sports Cardiology. Eur J CV Prev Rehabil 2006; 13:137-49. Is marathon really dangerous? For all runners? or a particular population? What is a “cardiac patient”? Same rules for everybody? What are the limits of “normality”? Enthusiasm + Popularity ++ USA + Europe > 2 millions runners/year; > 50 marathons/year Paris > 40 000 runners, London, Berlin, NY, ….. 2/3 = men; 39 years (F = 1/3; 34 years) Ultra marathons! Trails! UTMB … Norseman Xtreme Triathlon …… Although inequitable and always spectacular, deaths are rare. Namibia's Beata Naigambo collapses during the Commonwealth Games women's marathon, March 19, 2006, in Melbourne, Australia. Regularly, among thousand runners, one succumb (male x 6, young or not). USA : marathons or half marathons from 2000 to 2010 = 11 million runners: 59 cardiac arrests: 51 men, 8 women; 43 ± 13 years 42 deaths = 1 death / 260.000 runners. Kim JH, et al. Cardiac arrest during long-distance running races. N Engl J Med. 2012; 366: 130-40. London: from 1981 to 2012: > 750 000 marathon runners: 11 deaths (10 men, 1 woman) = 1/67.000 marathon runners For the overwhelming majority of runners, health benefits of exercising outweigh risks: life expectancy of 7 years longer / sedentary counterparts. Sharma S, Aaïdi A. Eur Heart J. 2012; 33 (8): 938-40. Registre des Accidents Cardiaques lors des courses d'Endurance Dr B Gérardin, 5ème Forum Européen Cœur, Exercice et Prévention 2012, Paris 15 03 2012. 5 big races « franciliennes » (Paris-Versailles, 20 km of Paris, Marathon of Paris, Half-Marathon of Paris, Half-Marathon of Boulogne-Billancourt) = 512 000 runners since 2006. 13 serious accidents . 13 men. 2 deaths (1/250 000 runners) - 9 CRA: 6 coronaropathy (1 death) + 3 rhythmic (1 DAVD, 1 Brugada, 1 unknow) - 4 hyperthermias (1 malign). < 35 years: never ischemic > 35 years: 8 /10 = coronaropathy. Experienced: only one novice + unprepared Low risk factors: only 1 = overweight + smoking Occurrence : - at any time (on departure, in the midst, on arrival or 1h30 after) - 3 during marathon (1/50 000) or 10 during other race (1/36 000) 2 previous angor, 1 fever: «distrust functional signs which appear at a sportsman's » Running a marathon puts immense strain on the body. What are the main health risks? Main events = minor injuries: tendinous or muscular pains, muscular and digestive cramps, … Deshydration (with hyperthermia) is the biggest problem, Hyponatremia, Hypoglycemia, Vaso-vagal faintness. CV accident(during training or race) : UNCOMMON … for the healthy subject! But: short or bad training, « fight spirit », race in hostil environment (warm, cold, wind, rain, …), CAN BE FATAL especially if exists a CARDIAC « ABNORMALITY », KNOWN or REVEALED by race. Maron B, et al. Circulation. 2009; 119: 1085-92. Markers of myocardial injury .. Symptoms! ECG changes. Elevation of serum biomarkers (plethora of studies): - NT pro-BNP / LV dysfunction - troponin T / LV or RV dysfunction. Echocardiographic assessment of ventricular dysfunction: - modification LV diastolic function by mitral doppler + annular DTI - study by speckle tracking of LV Strain + LV distortion - PAPS elevation, RV enlargement + RV systolic dysfunction, also visible with tissular Doppler and RV strain. Cardiovascular Magnetic Resonance: size, structure , kinetics (RV ++) Reversal perturbations? « Healthy » runners? Symptoms? 4037 (3209 M; 828 F) racers of « the Medoc » 2000. S Epiphanie S. Chevalier JM. 43 runners (1,1%) had already felt thoracic pain! 35 M / 8 F; mean age = 43,5 years Risk factors: familial history = 25 % hypercholesterolemia = 14 % HTA = 7 %; smoking = 7 % 1 coronary angioplasty with chronic treatment ! Exploration: 9 ECG; 13 treadmill tests 21/43 NO investigation before the race !!! Marathon: ECG abnormality? 950 ECG runners non elite. Medoc 2002. Fayard JD, Chevalier JM. 109 Females: 45 years; trained = 4h20 1h; 5,8 marathons RIB = 14 % + AVB 1 = 1 no auricular or ventricular abnormality 841 Males: 44 years; trained = 3h50 0h54; 7,2 marathons RIB = 15% + AVB 1 = 2,5% no ventricular hypertrophy RAE = 11% + LAE = 7,7 % CNCF Strasbourg 18 09 03 Left atrial volume index in 615 athletes. Calabrò R et al. Am Heart J. 2010 ; 159:1155-61. Cardiac troponins increases among 482 runners in the Boston marathon. Fortescue EB. Ann Emerg Med. 2007; 49: 137-43. 20% < 30 years; 34% = F ; 8 % = first marathon. 68 % : moderate troponine T ≥ 0,001 or I ≥ 0,01 ng/ml 12 % : significant increase > threshold of necrosis! - correlation with young age and inexperience - but not / duration of race or classical CV risk factor. Cardiac injuries in WOMEN? Bascou M, Chevalier JM. Medoc 2008. Nt-proBNP 67 volunteers, without any pathology, 500 450 400 47 7 years; 350 300 6,6 marathons ran (7 novices); 250 µg/L 200 regular training ; mean race = 4h10. 150 100 50 0 Veille (Moyenne=31,1) Arrivée (Moyenne=117,2) Après 4h (Moyenne=126,75) 60 runners = normal 1h and 4h after (Nt-proBNP, troponin, kydney, liver) 3 moderate elevations of troponin: release? 4 significant increases (x 4 to 10) of troponin: * 56 y. poorly trained, little hydrated, 6h15! * 44 y. ran too fast: cramps + asthenia + liver cytolysis + reversible LV dysfunction * 35 y. fatigue fracture 3 months before, stop training, pain ++ during race * 52 y. fever 10 days before, white blood cells: myocarditis? EDUCATION +++ What after an intensive life with running practice? Bones and articular problems!! Conduction abnormality: sino-atrial disease, heart block , .. Bi-auricular dilatation (20%) Atrial Fibrillation x 5. Abdulla J, Nielsen JR. Europace, Vol. 11, No. 9, 2009, pp. 1156-9. Bi-ventricular dilatation: not always reversible after discontinuation endurance practice! Veteran heart’s athlete. Waterhouse D et al. Br J Sports Med. 2012; 46: i69-i77. “Exercise-induced arrhythmogenic right ventricular cardiomyopathy” Sharma S, Zaidi A. Eur Heart J. 2012; 33(8): 938-40. Heidbuchel H, Prior D, La Gerche A. Br J Sports. Med. 2012; 46 Suppl1: i44-i50. Regular myocardial injury due to repeated marathon running : fibrosis? Karlstedt E et al. J Cardiovasc Magn Reson. 2012; 14(1): 58. 16 921 apparently healthy men in the Physicians' Health Study. Follow-up 12 years, 1661 men (10%) developing AF. Aizer A. Am J Cardiol 2009; 103 (11): 1572-7. FA relative risk (p<0,01) = jogging++ /racquet sports /cycling /swimming training > 1 h; 5 - 7 days/week (RR 2,08)! Potential adverse cardiovascular effects from excessive endurance exercise. O'Keefe JH, et al. Mayo Clinic Proceedings. 2012; 87: 587-95. Potential impact of repeated bouts of ultra-endurance exercise on Right Ventricular structure and function. Sharma S. Eur Heart J. 2011. Exercise-induced Right Ventricular dysfunction and structural remodeling in 40 endurance men athletes. La Gerche A. Eur Heart J. 2012; 33 (8): 998-1006. ETT RV volumes increased and all functional measures decreased post-race, LV volumes reduced and function was preserved. BNP increase post-race (13 vs. 25, P = 0.003) cTnI increase (0.01 vs. 0.14 μg/L, P < 0.0001) correlated with reductions in RVEF (P = 0.001) RV function decreases when race duration increases, but mostly recovered by 1 week. On CMR, delayed gadolinium enhancement localized to the inter ventricular septum was identified in 5 of 39 athletes who had greater cumulative exercise exposure and lower RVEF (47 vs. 51 %, P = 0.042). Long-term clinical significance: fibrosis? Aptitude for marathon : search a «cardiac abnormality » and use reason! Interrogation (information sheet signed by the sportman?) - palpitations, dyspnoea, «faintness», precordialgia? it is not « normal » to feel symptoms by running - reduction of the performances? - family sudden death? coronaropathy? HTA? .. - recent infection? - dopage? Clinical exam: heart murmur? HTA? ECG? ETT? VO2max > 30 ml/kg/min ? The endurance athletes heart: acute stress and chronic adaptation. George K et al. Br J Sports Med. 2012;46:i29-i36. Acute endurance exercise bouts = a significant stress to the heart with evident ‘cardiac fatigue’ (biomarker release + ventricular dilatation) and adequate recovery. Vast majority of endurance athletes (training + competition) will lead heart healthy. Small minority: emerging evidence that endurance exercise = patho-physiological cascade. “Patients with cardiac pathology, even minimal, are exposed to accident.” Run for your life ... at a comfortable speed and not too far ! O’Keefe J, Lavie C. Heart. December 2012. Don’t run if symptoms …. Education ++ Marathon is dangerous with « cardiac patient » MERCI .