Sports Cardiology Presentation · Sports Cardiology Case Presentation Dr. Sabiha Gati @s_gati St....
Transcript of Sports Cardiology Presentation · Sports Cardiology Case Presentation Dr. Sabiha Gati @s_gati St....
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Sports Cardiology Case Presentation
Dr. Sabiha Gati@s_gati
St. George’s University of London United Kingdom
Disclosures: None
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52 year old Caucasian male
• Recreational runner
• Runs 1-2h per week, completed several 5K, 10K runs prior
• No cardiac symptoms
• No medical history, no medications
• Never smoker
• Silverstone Half Marathon
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Silverstone – The race
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Witness report
• No signs of difficulty prior to collapse.
• Fell forward without clear mechanical cause with fascial injury.
• First responders.
• No convincing pulse and CPR commenced/tolerated.
• By the time difibrillator arrived and applied there was rhythm.
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Post “ictal”/event period
• Immediate GCS 3/15• within 3 mins GCS 7/15 (E2,V1,M4) with head
turning to the left, jaw clenching and eye diviation to the left, tonic posture, remained unresponsive
• Airway patent• Pupils equal and reactive to light
• Within 10mins GCS 14/15 • Disorientation in time• Repeated questioning “ did i finish?”
“Where is my family”• Blood glucose normal• Normal intial observations• No focal motor or sensory deficit
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Initial tests?
• A) Temperature, Sodium, Glucose
• B) ECG & Cardiac monitoring
• C) None of the above, CT head
• D) All of the above
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Initial tests?
• Temperature
• Sodium
• Glucose
• ECG
• Cardiac monitoring
• CT head
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12-lead ECG
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Admitted under cardiology
• ECGs and 24h rhythm monitoring: No dynamic changes, single episode NSVT, 7 beats
• Cardiac troponins – 338ng/L (initial), 334 ng/L (12h) [normal <100ng/L]
• Echocardiogram unremarkable
• CT Head: right maxillary fracture, soft tissue injury
• …What next?
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What next?
• A) Discharge, do nothing?
• B) ICD?
• C) Home with Life vest?
• D) Anything else ?
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Diagnosis
• Head injury with concussion, secondary brady-asystole and spontaneous recovery
• Profound vasovagal syncope with prolonged cerebral hypoperfusion in context of acidosis/dehydration
• Cardiac rhythm disturbance, secondary to…
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Cerebral Hypoperfusion
Volume
depletion
Vasodilation
Heat ADP Acidosis
Reduced Activity from
Muscle Pump
Empty
LV
Increased
Mechano-
receptor
activity
Altered
Neuro-cardiogenic
reflexes
? Potentiated
by sudden
withdrawal of
sympathetic
tone
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Referred to London Sports Cardiology Centre
• ECG
• Echo
• 24h tape
• ETT (supervised)
• Bloods: Total cholesterol 4.0, TG 0.59, HDL 1.8, LDL 1.9
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Results
• 24h tape:– 8x VEs – variable morphologies, occasional AEs,
short episodes atrial bigeminy
• ETT:– 15min34 Bruce protocol on treadmill, achieved
98% max HR at a workload of 18 METS. Test terminated due to fatigue and lightheadedness. Isolated PVCs with one couplet. No significant ST changes. Marked drop in BP in initial recovery.
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ETT
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ETT
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ETT
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ETT
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ETT
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ETT
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ETT
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ETT
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What next?....
• A) Do nothing, discharge
• B) CT coronary angiogram
• C) Coronary angiogram
• D) Cardiac MRI
• E) B±C & D
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CMR
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CMR
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Diagnosis
• Primary myocardial pathology resulting in compromising ventricular arrhythmia (e.g. cardiac sacoidosis) and IHD incidental
• Ischaemia-perfusion demand mismatch driving compromising ventricular arrhythmia and resultant hypoperfusion myocardial infarction
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Findings
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Learning points
• 1
• 2
• 3
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1. Red Flags in Athletes with Syncope
• Age > 45 years old
• Syncope whilst lying supine or syncope without warning
• Chest pain, palpitation, headache, transient seizure like activity.
• New or unexplained breathlessness
• Known history of cardiovascular disease
• Family history of premature SCD
• Cardiac murmur/ focal neurology
• Abnormal ECG
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2. SCD/SCA and endurance running
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2. SCD/SCA and endurance running
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3. Pitfalls of the ETT
• If asymptomatic, ETT drops to Sens 46% Spec 16%
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3. Pitfalls of the ETT - Ischaemia Cascade
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Thank you