Exercise and Your Heart Erik Carlson, M.D.

70 yo AAM no previous C/V disease history and really no medical issues presents given an abnormal ECG.

Plays singles tennis most days of the week for about 60-90 minutes per session.

Also cycles several days per week and has been doing this for decades.

No family Hx of C/V disease and never smoked.

He feels well with no symptoms. PE is normal. BP 131/79mmHg.

50 yo endurance athlete, no PMHx, referred for echocardiogram following finding of a “murmur” by internist. ECHO:LVEF of 45-50% - Normal LVEF >51%LV size 5.8 cm – Normal 5.8 cmLV wall thickness 1.2 cm – Normal being 1.0 cm of less.Diastolic function normalLV mass 128g/m2 – Upper limits of normal 115g/m2Right ventricle is mild to moderately dilated but normal systolic functionRight atrium - severely dilatedLeft atrium - mildly dilated

J Am Coll Cardiol. 2015;65(5):493-502. doi:10.1016/j.jacc.2014.10.064

Between 1990 and 2013, the number of participating athletes who completed running races in the United States increased significantly to 20 million per year; 54% were ∼

older than 35 years of age.

Physiologic Response to Exercise

• HR and Stroke Volume (21 L/min; 35L/min)

• SBP

• DBP

Physiologic Response to Exercise

Rev Esp Cardiol. 2012;65:14-21 - Vol. 65 Num.01

Weightlifting

X-skiing

Soccer

Cycling

Rowing

Average

0 1 2 3 4 5 6

Physiologic Cardiac Hypertrophy among 947 Elite Level Athletes.

Pellicchia, et al. NEJM 1991 325:295-301.

Thickness (cm)LV-size (cm)

Findings That Suggest Pathologic LVH

1. Pathologic Q-waves

2. LVH greater than 15 mm

3. Presence of diastolic dysfunction - Reduced longitudinal motion (Septal E prime velocity less than 8 cm/s)- E/e' > 15

4. Smaller left ventricular cavity diameter in end-diastole <45 mm

5. Presence of late gadolinium enhancement (LGE) by CMR

Exercise is a Good Thing…right?In 1953, Morris et al published the findings from a study showing that bus conductors in London, who spent their working hours walking the length of the buses as well as climbing up and down the stairs of the English double-decker buses to collect fares, experienced half the coronary heart disease (CHD) mortality rates of their driver counterparts, who spent their day sitting behind the wheel.

Coronary heart-disease and physical activity of work. Lancet. 1953; 265: 1053–1057.

Cardiac Biomarkers with Prolonged Exercise

Ironman Australia – 2001

Am Heart J. 150 2005:1128-1134Br J Sports Med. 40 2006:605-609

• 86% had cTnT>0.01mcg/dL• 16% had cTnT >0.10mcg/dL• Decrease in RV ejection

fraction• Elevations in BNP

Distribution by age of sports-related sudden deaths (SDs) in the overall population (blue) and among young competitive athletes (red) in a nationwide, 5-year study in France, showing that the vast majority occurred in those 35 years of age and older.

J Am Coll Cardiol. 2015;65(5):493-502. doi:10.1016/j.jacc.2014.10.064

The Greater the Frequency of Weekly Exertion, the Greater the Reduction in Relative Risk of MI

A clear dose-response effect of exertion on the relative risk of MI was demonstrated. MI = myocardial infarction

J Am Coll Cardiol. 2015;65(5):493-502.

Date of download: 1/29/2016 Copyright © The American College of Cardiology. All rights reserved.

From: Sudden Cardiac Death in the Older AthleteJ Am Coll Cardiol. 2015;65(5):493-502. doi:10.1016/j.jacc.2014.10.064

Outside Magazine December 2013

50 yo endurance athlete, no PMHx, referred for echocardiogram following finding of a “murmur” by internist. ECHO:LVEF of 45-50% - Normal LVEF >51%LV size 5.8 cm – Normal 5.8 cmLV wall thickness 1.2 cm – Normal being 1.0 cm of less.Diastolic function normalLV mass 128g/m2 – Upper limits of normal 115g/m2Right ventricle is mild to moderately dilated but normal systolic functionRight atrium - severely dilatedLeft atrium - mildly dilated

70 yo AAM no previous C/V disease history and really no medical issues present for an abnormal ECG.

Plays singles tennis most days of the week for about 60-90 minutes per session.

Also cycles several days per week and has been doing this for decades.

No family Hx of C/V disease and never smoked.

He feels well with no symptoms. PE is normal. BP 131/79mmHg.

Take Home Messages 1. Cardiac physiologic changes start to occur with 5-7 hours of moderate to high intensity activity per week and can occur within 90 days of training.

2. Long-standing, high intensity exercise (yearly marathons, ironman distance triathlons) are associated with temporary increases in biomarker production (i.e. troponin, BNP) as well as right ventricle dilation and dysfunction.

3. Leisure running, even 5 to 10 min per day at slow speeds (<6 miles/h), is associated with substantial mortality benefits.

4. There is likely a “sweet spot” with exercise in which additional duration, intensity likely provides no additional health benefits.

5. The benefits of exercise (40-60% reduction in mortality) far outweighs the very, very small risks of sudden cardiac death.