Benefits of Exercise Recognizing and Treating • Cardiovascular health Heart Problems in • Musculoskeletal health • Weight maintenance/reduced risk of diabetes and high Athletes blood pressure/improved cholesterol profile • Decreased inflammation Sam Aznaurov, MD • Reduced risk of cancer Molly Ware, MD • Psychological benefits Boulder Heart • Longevity • One study of >250,000 middle aged people demonstrated 303-720-7918 50% decreased mortality in those who engaged in combination vigorous and moderate exercise

Benefits of Exercise Heart Rate Recovery

N Engl J Med 1999; 341:1351-1357 Physiological Changes with Physiological Changes with Exercise Exercise

• Increased lung ventilation • Nervous system: the control center • Increased oxygen uptake by muscles (VO2 • Increased cardiac output (heart rate and stroke mL/kg/min) volume) • Good warm up is important to activate metabolic • 5-6 L/minute at rest • Up to 35 L/minute in well trained athletes! pathways (eg, anaerobic and aerobic glycolysis) • A definite stress test . . . • Increased blood pressure • Complex, efficient system

Different Types of Athletes

• Endurance (volume loading) • Weight lifters (pressure loading) • Mixed • Different adaptations to training

Front.Physiol.29 May 2017 The Fittest Community in the The Fittest Community in the Nation Nation • Impressive number of professional athletes from all fields • High school athletes: many students participate, often at the national/international level • University of • 28 National Championships • Huge number of recreational athletes, many train • Two former CU runners won medals at the 2016 Rio and compete at an elite level Olympics — in the 1,500 meters and Emma Coburn in the • GO BUFFS!

The Fittest Community in the Community Partnerships Nation • Active in general • 93, 000 bikes around town • Boulder Community Health and CU Sports Medicine and Performance Center • Countless youth programs • https://cusportsmedcenter.com • The annual Bolder Boulder 10 k has been run for 41 years and is the 3rd largest running race in the and the 7th largest in the world. Athletes Are Not Immune Coronary Artery Disease in the Masters Athlete https://www.youtube.com/watch?v=6vxs9U9wjeI

Coronary Artery Disease Coronary Artery Disease Coronary Artery Disease in the Coronary Artery Disease Masters Athlete • Increased risk of heart attack during exercise • https://www.webmd.com/heart/video/inside-look- compared with rest heart-attack • 1-2/100,000 person years; majority 45-55 years old • Habitual exercise decreases the risk of exercised induced heart attack

• Underlying risk factors for heart disease • Age, genetics, cholesterol, high blood pressure, past smoking, diabetes, overweight

Coronary Artery Disease in the Heart Valve Problems Masters Athlete • The benefits of exercise may plateau above 100 minutes/day • Sweet spot for mortality benefit seems to be 22-40 MET hours/week • Examples: • Brisk walking is 3 METS/hr . . . 8 hours of walking per week • Running at 8 mph is 13 METS/hr . . . 3 hours of fast running per week • Cycling at 10-16 mph is 6-10 METS/hr . . . 4 hours of moderate cycling per week • Masters endurance athletes have higher prevalence and burden of coronary plaque than controls • Men more affected than women

Dr. Sanjay Sharma, lecture Heart Valve Problems Heart Valve Problems

• Can lead to heart failure . . .

• Shortness of breath • Leg swelling • Decreased performance • Fainting

BAV 1% of the population

Aortic Problems Aortic Problems

• High blood pressure • Other causes of aortic enlargement • Genetic syndrome/connective tissue disease • Marfan’s disease • 1/3000-5000 people • Bicuspid aortic valve • Can lead to . . . • Rupture/dissection which is generally a very bad thing • Burst type exercise/heavy weight lifting can worsen dilation and increase risk of dissection Performance Enhancers Are Not Other Conditions Worth the Risk • Underlying medical issues can worsen cardiac • Anabolic steroids symptoms • High blood pressure; cholesterol and glucose abnormalities; skin/muscle/joint damage; psychiatric and sexual side effects • Or underlying medical issues can present as cardiac • Erythropoetin symptoms • Stroke, heart attack, blood clots in the lungs • Anemia • Thyroid disease • Stimulants (high dose caffeine, amphetamines, • Kidney disease ephedrine) • Stroke, heart attack, high blood pressure, arrhythmia, insomnia

Other Conditions Arrhythmias and Syncope in • Electrolyte derangements during prolonged exercise Athletes

• Body temperature extremes (heat Sam Aznaurov, MD, FACC, FHRS stroke/hypothermia) Cardiac Electrophysiologist Boulder Heart • High altitude • 1% decrease in MV02 for every 100 m above 1500 m • An MVO2 of 50 mL/mg/min at sea level equates to an MVO2 of 14 mL/kg/m2 at Everest base camp! Syncope - definitions Syncope – natural history

• Sudden, temporary loss of • Most syncope has a consciousness defined cause (50-70%)

• Traumatic • 500,000 first-time cases of syncope every year • Nontraumatic • 2/3 never recur • Loss of cerebral perfusion (blood • 1/3 recurrent but benign supply to the brain) – 80% • Very small percentage • Preserved cerebral perfusion – malignant 20% • Seizure • Non-seizure

Syncope – benign vs malignant Orthostasis and vasovagal syncope

• Benign syncope • Inadequate blood return to the heart • Vasovagal / • Sudden change in posture Neurocardiogenic / • Prolonged standing Orthostatic / Situational • Inappropriate feedback loop • Slowed heart rate • Malignant syncope • Decreased pump action • Cardiac • Dilation of blood vessels • Arrhythmias • Exacerbated by: • Neurologic • Dehydration • Seizure • Medications • Heat • Situational factors (blood, urination/defecation, abdominal/thoracic strain) Syncope – features of malignant Cardiac rhythm syncope • Resulting in injury • Generates coordinated • Facial trauma pump action of the heart • Laceration / fracture Was there a • Exercise-mediated cessation in • Responsive to physiologic • At rest, especially seated/reclined heartbeat?? changes in the body • Pulseless/apneic Requiring CPR or defibrillation • • Made possible by • Not immediately resolved specialized electrical • No latent neurologic symptoms pathways in the heart

Congenital arrhythmic syndromes Hypertrophic cardiomyopathy • Associated with a family HCM • Abnormally thickened heart muscle history of syncope or ACA • Multifactorial genetic disease sudden death • 1:500-5000 (0.02-0.2%) in general adult population • May present with • 30-40% of sudden death in young syncope (+/- recurrent), athletes! or with sudden cardiac arrest • Ventricular fibrillation / sudden cardiac arrest • Outflow tract obstruction • Can cause arrest in an otherwise normal heart! • Requires exercise restriction Arrhythmogenic (right) ventricular Anomalous coronary artery cardiomyopathy • Structurally abnormal heart muscle • Abnormal origin of coronary artery • Cell-cell binding elements • Variety of defects • Accelerated “wear and tear” • Origin from pulmonary artery • Multifactorial genetic disease • Origin from incorrect aspect of aorta • Inter-arterial course • LARGE lifestyle modifier – • 1-2% prevalence in general endurance exercise population! • 1:5000 (0.02%) in general • ½ are benign population • 10-15% of sudden death in young athletes • 3:1 male predominance • 20% of sudden death in young athletes! • May be treated with bypass surgery • May require exercise restriction • Requires exercise restriction

Ion channel disorders in structurally Atrial fibrillation normal heart • Disorganized rhythm in the atria • Defect in regulation of cardiac activation (non-pumping chambers) • (mostly) single-gene disorders • NOT immediately unstable • Short-term effects • Long QT syndrome • Elevated heart rate • 1:2000 (0.05%) in general population • Palpitations / fatigue / lightheadedness • Exacerbation of underlying heart/lung conditions • Catecholaminergic polymorphic ventricular tachycardia Long-term consequences • 1:10000 (0.01%) in general population • • Stroke • Heart failure • Brugada syndrome • 1:5000 (0.02%) in general population • 1:600 (0.15%) in Asian population • Require exercise restriction Atrial fibrillation causes Atrial fibrillation timeline • “Wear and tear” disease of the heart • Progressive disease • Age • Risk factors accumulate over time • Cardiac disease – hypertension, diabetes, heart failure, Burden of disease accelerates valvular disease • • “AFib begets AFib” • Non-cardiac disease – lung disease/sleep apnea, thyroid, anemia, alcohol/drug use, many many others • Later-stage disease more difficult to treat • Athletes are at 3-8x increased risk • AF present in 15% of veteran athletes • AFib is a very individual disease, • In young patients with no other AF risk factors, intense and treatment decisions need to exercise history in 60% be made on an individual basis • Middle-aged men with >10year strenuous exercise history are highest risk group

Conclusions – symptoms of concern Conclusions – getting help

• Fainting/syncope • TALK to your doctor! • Chest pain or pressure • Primary care • Unusual shortness of breath • Cardiologist • Unusual heart racing/skipping • Other • Unexplained decline in exercise tolerance • Workup (investigation) • ECG • Spot • Continuous • Wearable data • Pulse oxymetry vs electrocardiographic Conclusions – getting help Conclusions – getting help • Treatments • Workup (investigation) • Exercise prescription • Imaging • Medications • Echo/ultrasound • Procedures • Cardiac CT • Cath / stent / bypass surgery • Cardiac MRI • EP study / ablation • Nuclear imaging • Implantation of cardiac monitor / pacemaker / ICD • Stress testing • All treatment decisions have to be made on an individual basis!

Thank you!

Sam Aznaurov, MD Molly Ware, MD Boulder Heart 303-720-7918