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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 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 /year Paris > 40 000 runners, , , 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 , 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