La Fibrillazione atriale nello sportivo: è sempre un problema? - 24 Febbraio 2018 CardioLucca Dott. Paolo Pieragnoli SOD Aritmologia AOU Careggi ...
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La Fibrillazione atriale nello
sportivo: è sempre un problema?
24 Febbraio 2018
CardioLucca
Dott. Paolo Pieragnoli
SOD Aritmologia
AOU Careggi
1
Athlete and atrial fibrillation
Athletes with atrial fibrillation are
probably unlikely to have comorbidities.
The population subset with these findings is
generally men who are younger than age 60
with normal findings on physical
examinations, chest x-ray scans,
electrocardiograms, and echocardiographic
investigations—criteria for the condition
previously termed lone atrial fibrillation.
Clinical characteristics of sport-related atrial fibrillation
The typical clinical profile of sport-related AF or atrial flutter is a middle-aged
man (in his forties or fifties) who has been involved in regular endurance sport
practice since his youth (soccer, cycling, jogging, and swimming), and is still
active. This physical activity is his favourite leisure time activity and he is
psychologically very dependent on it.
The AF is usually paroxysmal with crisis, initially very occasional and self
limited, and progressively increasing in duration. Characteristically, AF episodes
occur at night or after meals. As many as 70% of patients may suffer
predominantly vagal AF. They almost never occur during exercise. This makes
the patient reluctant to accept a relationship between the arrhythmia and sport
practice, particularly since his physical condition is usually very good. The crises
typically become more frequent and prolonged over the years and AF becomes
persistent. Progression to permanent AF has been described in 17% of individuals
in an observational series. In the GIRAFA study, 43% presented persistent AF. The
AF crisis frequently coexists with common atrial flutter in many patients.
Mont L et al. Europace 2009;11:11-17
Myrstad M et al. Clin Res Cardiol 2016;105:154-161
✓Incidenza di fibrillazione atriale
nell’atleta
✓Cause di fibrillazione atriale nello
sportivo
✓Approccio terapeutico all’atleta con
fibrillazione atriale
✓Attività sportiva idonea nel paziente con
fibrillazione atriale
4
Born to run? Yes!
Advanced Cognitive
Mouth Breathing Capabilities
Swivel Shoulders CNS Coordination of
metabolic and
Sweat Glands cardiovascular
responses to sustained
Sparse Body Hair running
Large Body Surface Swivel Hips
Area
Slow Twitch Muscles
Vascular Reactivity
to temperature Long Legs
Elastic Tendons
Plantar Arch
Short Toes
5
Mattson MP, Ageing Res Rev. 2012
Endurance exercise and
Heart
Eijsvogels T, Physiol Rev 2016 6
Can lifelong exercise hurt the
heart?
7
Eijsvogels T, Physiol Rev 2016
✓Incidenza di fibrillazione atriale
nell’atleta
✓Cause di fibrillazione atriale nello
sportivo
✓Approccio terapeutico all’atleta con
fibrillazione atriale
✓Attività sportiva idonea nel paziente con
fibrillazione atriale
8
Is the risk of atrial
fibrillation higher in
athletes than in general
population?
9
AF is more prevalent in athletes
10
Abdulla J, Europace 2009The Vasaloppet
• 90 km cross-country ski
race
• 52755 health
competitors
• Long term follow-up
12
Andersen K, Eur Heart J 2013The Vasaloppet
Risk by number of completed races Risk by finishing time
Repeated partecipation and faster finishing
time were associated with increased risk of AF
Andersen K, Eur Heart J 2013 13The Birkebeiner • 54 km cross-country ski race • 3.545 men ≥ 53 years Myrstad M, Am J Cardiol 2014 14
The Birkebeiner
Cumulative years of regular endurance exercise were associated with a
gradually increased risk for AF and atrial flutter
15
Myrstad M, Am J Cardiol 2014The Birkebeiner
Myrstad M, Scand J Med Sci Sports 2014 17AF incidence
Incidence rate of AF among man aged 55-64
Rotterdam Study (general
22/10.000 persons - years
population)
Framingham Study (general
31/10.000 persons - years
population)
Vasaloppet Study (endurance
49/10.000 persons - years
athletes)
19AF/AFl
Persistent Athletic
Age Activity
20✓Incidenza di fibrillazione atriale
nell’atleta
✓Cause di fibrillazione atriale nello
sportivo
✓Approccio terapeutico all’atleta con
fibrillazione atriale
✓Attività sportiva idonea nel paziente con
fibrillazione atriale
24Mechanisms involved in the
genesis of AF in athletes
Inflammation Autonomic imbalance
Anatomic remodeling
Neurohormonal activation
Electrophysiological changes
25
Padeletti L, Int J Sports Med 2013Physiopathology
26
Turagam KM. JAFIB 2014Arrhythmias and sport
practice
27
Mont L, Heart 2010Physiopathology
28
Wilhelm M. European Journal of Preventive Cardiology 2014, Vol. 21(8) 1040–1048Atrial Fibrillation Promotion by Endurance
Exercise
Demonstration and Mechanistic Exploration in an
Animal Model
J Am Coll Cardiol 2013;62:68-77Atrial Fibrillation Promotion by Endurance
Exercise
Demonstration and Mechanistic Exploration in an
Animal Model
J Am Coll Cardiol 2013;62:68-77Atrial Fibrillation Promotion by Endurance
Exercise
Demonstration and Mechanistic Exploration in an
Animal Model
J Am Coll Cardiol 2013;62:68-77Inflammation as a risk factor
for atrial fibrillation
33
Aviles et al Circulation 2003C-reactive protein and AF
Psychari et al Am J Cardiol 2005 34IL-6 and strenuous exercise
35
Kasapis et al. JACC 2005AF, LA size and
inflammation in sport
practitioner
3640 Nature Reviews Cardiology 14, 88–101 (2017)
41 Nature Reviews Cardiology 14, 88–101 (2017)
New Study Shows Save Levels of Exercise Differ For
Men and Women With Atrial Fibrillation
Heart Rhythm Society May 15, 2015
The study involved a meta-analysis of 14 prospective
observational studies including approximately 379,884 patients.
Studies were included if they evaluated trials that reported a
relation between incident AF and the level of intensity of
exercise.
Among men, vigorous exercise was associated with a 90 percent
(1.9 times) increased risk of AF, while moderate exercise
lowered the incidence of AF by 19 percent. In women, both
moderate and high intensity levels of exercise were found to be
beneficial. Moderate exercise reduced the risk of AF in women
by 24 percent and by 15 percent when they participated in
vigorous exercises.New Study Shows Save Levels of Exercise Differ For Men and
Women With Atrial Fibrillation
Heart Rhythm Society May 15, 2015
+ moderate exercise vigorous exercise
+ 90 %
Risk
atrial men
fibrillation
women
men women
- 15 %
- - 19 %
- 24 %Paroxysmal at rial fi brillat ion in male endurance
at hlet es. A 9-year follow up
Jan Hoogst een a,) , Goof Schep b, Norbert M. van Hemel c,
Ernst E. van der Wall d
a
Depar t ment of Cardiology, Maxima Medical Cent re, Dommelst raat Zuid 5,
5500 MB Veldhoven, Net herlands
b
Depar t ment of Sport Medicine, Maxima Medical Cent re, Vel dhoven, Net herlands
c
Depart ment of Cardiology, Heart Lung Cent re, Ut recht , Net herlands
d
Depar t ment of Cardiology, Leiden Universit y Medical Cent r e, Leiden, Net herlands
Submit t ed 13 May 2003, and accept ed aft er revision 18 January 2004
KEYWORDS Abst ract Aims To st udy t he course and circumst ances of at rial fibrillat ion
at rial fibrillat ion; endurance sport s.
endurance at hlet es Background At rial fibrillat ion is t he main cause of sympt oms in at hlet es and f
quent ly dist urbs t he performance during t he pract ising of sport . The course of t
arrhyt hmia is seldom report ed in t his populat ion.
Met hods In 1993 and 2002 sympt oms and clinical present at ion of at rial fibrillat i
were evaluat ed in 30 well-t rained at hlet es wit h a specially designed quest ionnair
44
Result
2004s In 1993 paroxysmal at rial fibrillat ion was present in 30 male at hlet es✓Incidenza di fibrillazione atriale
nell’atleta
✓Cause di fibrillazione atriale nello
sportivo
✓Approccio terapeutico all’atleta con
fibrillazione atriale
✓Attività sportiva idonea nel paziente con
fibrillazione atriale
45Work-Up
46
Nature Reviews Cardiology 14, 88–101 (2017)Efficacy of antiarrhythmic drugs
Low
efficacy
M. Gulizia et al “Diagnosi e terapia del Flutter e della Fibrillazione atriale” 2009AF after flutter ablation in
Endurance Sport Practitioners
48
Heidbuchel H, Int J Cardiol 2006Effects of AF ablation in
Athletes
Single Ablation Repeated Ablation
Kaplan–Meier curves for long-term freedom from recurrent arrhythmias
in the lone AF sport group (dashed line) and the control group (solid line).
49
Calvo et al., Europace 2010Effects of AF ablation in
Athletes
50
Heidbuchel H, Europace 2011Pulmonary veins isolation:
pathophysiology
M. Gulizia et al “Diagnosi e terapia del Flutter e della Fibrillazione atriale” 2009Catheter Ablation Pulmonary Veins Isolation
Cryoablation
Cryoballoon
Lasso Catheter
Coronary SinusLaser Ablation
Catheter Ablation Pulmonary Veins Isolation The recordings from the circular multipolar mapping catheter placed in a pulmonary vein are shown during ablation. On Lasso 1–2 prolongation of conduction delay from the atrium into the pulmonary vein is seen on the first four beats before the sharp local pulmonary vein potential finally disappears on beat 5 and 6 as a result of successful pulmonary vein isolation.
✓Incidenza di fibrillazione atriale
nell’atleta
✓Cause di fibrillazione atriale nello
sportivo
✓Approccio terapeutico all’atleta con
fibrillazione atriale
✓Attività sportiva idonea nel paziente con
fibrillazione atriale
63ESC Guidelines 2016
64Atrial Fibrillation Atrial Flutter
6566
Conclusioni
• Atrial fibrillation is more common in
endurance sport athletes in comparison with
general population
• Same evolution than other persons
• Firstly we have to rule out secondary atrial
fibrillation
• Drugs prove the same efficacy than in
general population (≅ 50%)
• Ablation shows the same efficacy than in
general population
68Exercise should be regarded as
a tribute to the heart
69But someone may
disagree…
70Thank you for your attention! 71
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