SEMS-journal

Sports Cardiology: Common Issues in the Masters Athlete

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Oestreicher Simon MD1, Besson Cyril MS1, Daucourt Chantal RN1, Desgraz Benoit1, Gabus Vincent1,2, Baggish Aaron MD1,3

1 Departments of Cardiology and Sports Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
2 Departments of Cardiology, l’Hôpital Riviera Chablais, Rennaz, Switzerland
3 Institute for Sport Science, University of Lausanne (ISSUL), Lausanne, Switzerland

Abstract

Masters athletes (MA), people 35 years of age or older who participate in high levels of exercise training and competition, are commonly encountered in clinical practice. Although the MA are typically healthy and high functioning, they are not immune to cardiovascular disease. MA may develop cardiovascular disease due to underlying traditional risk factors or in some cases, as a function of exposure to chronic high levels of exercise. This review was written to highlight common cardiovascular issues among MA with an emphasis on risk factor / disease recognition and clinical management.

Zusammenfassung

Masters-Athleten (MA), Menschen im Alter von 35 Jahren oder älter, die ein hohes Maß an körperlichem Training und Wettkämpfen absolvieren, sind in der klinischen Praxis häufig anzutreffen. Obwohl die MA in der Regel gesund und leistungsfähig sind, sind sie nicht immun gegen Herz-Kreislauf-Erkrankungen. MA können aufgrund traditioneller Risikofaktoren oder in einigen Fällen als Folge einer chronisch hohen sportlichen Belastung Herz-Kreislauf-Erkrankungen entwickeln. Diese Übersicht wurde verfasst, um häufige kardiovaskuläre Probleme bei MA hervorzuheben, wobei der Schwerpunkt auf der Erkennung von Risikofaktoren/Krankheiten und dem klinischen Management liegt.

Schlüsselwörter: Masters-Sportler, Herz-Kreislauf-Erkrankungen, Extrembelastung

Introduction

Medical care for competitive athletes was historically provided almost exclusively by sports medicine doctors and orthopedic surgeons. The last several decades have seen this paradigm evolve into a more comprehensive team-based approach to this population. Sports cardiology is the sub-specialty of general cardiology designed to provide comprehensive cardiovascular care to competitive athletes across the complete lifespan. Comprehensive clinical recommendations for the practice of sports cardiology have been produced both by American,[1] and European medical organizations.[2,3] Clinical sports cardiologists must possess a knowledge base in applied exercise physiology, an understanding of how the cardiovascular system responds to acute bouts of exercise and long-term training, and a familiarity with how to diagnose and manage cardiovascular disease processes that impact competitive athletes. The role of the sports cardiologist can be broadly divided into 4 categories: 1) Oversight of pre-participation cardiovascular screening, 2) Differentiation of exercise-induced cardiac remodeling from cardiovascular pathology, 3) Clinical evaluation of high-risk asymptomatic or symptomatic athletes with potential cardiovascular disease, and 4) Treatment and longitudinal management of athletes with established cardiovascular disease.[1]
Prevention of sudden cardiac death during exercise is a fundamental goal of the sports cardiologist. Sudden cardiac death occurs among athletes of all ages but causes of death vary as a function of age.[4,5] Young athletes, defined by an age of < 35 years, most commonly experience adverse cardiovascular events during exercise due to underlying genetic or congenital heart disease.[6] In contrast, older athletes are primarily at risk for adverse outcomes due to atherosclerotic coronary artery disease.[7] Acquired causes of cardiovascular disease, including but not limited to post viral myocarditis, can and do affect athletes of all ages. Although exceptions do occur, this age-based framework informs differential diagnosis of athletes undergoing a pre participation screening or individual clinical evaluation for concerning symptoms. This review was written to provide an overview of common sports cardiology issues pertaining to the “Masters Athlete” (MA).

Defining the Masters Athlete (MA)

The term MA is commonly used to refer to people 35 years of age or older who participate in high levels of exercise training.[8] While some MA engage in team sport training and competition, the majority of MA pursue endurance sport disciplines including long distance running, cycling, swimming, rowing, and triathlon. Although a uniformly recognized exercise profile of the MA has not been developed, most masters athletes engage in at least five hours of exercise training per week and participate in organized competitions. In addition to competitive aspirations, MA pursue sport in order to maintain lean body mass, to avoid weight gain, to enjoy the social benefits of group-based exercise, and to reap the many health benefits associated with habitual exercise. In addition, a sizeable number of MA recognize a family history of heart disease and seek to reduce their personal risk through exercise. It has been well established that habitual exercise has beneficial impact on traditional determinants of cardiovascular risk including hypertension, dyslipidemia, and diabetes.[9] However, no amount of exercise can fully eliminate risk factors among people with genetic predisposition nor confer complete immunity form atherosclerotic cardiovascular disease. Risk factor recognition and subsequent management through lifestyle intervention and medical therapy is a fundamental goal of the clinical sports cardiologist.[10]

Health Benefits of Exercise

A broad-based epidemiologic literature demonstrates an inverse dose-response relationship between the amount of habitual physical activity and both all cause and cardiovascular mortality.[11–14] Mortality data underlie contemporaries public health physical activity guidelines which suggest at least 150 minutes of moderate intensity and or 75 minutes of vigorous physical activity on a weekly basis.[15] These values were chosen as they represent the location on the physical activity / mortality curve where the curve begins to flatten with additional exercise producing diminishing reductions in mortality.[16] However, mortality benefits continue to accrue past the level suggested by physical activity guidelines with no well-established exercise dose at which the curve flattens. While suggested by some authors,[17] there are no definitive data demonstrating a dose of exercise at which harm exceeds benefit.
Health benefits of physical activity extend beyond mortality to include reductions in age-related sarcopenia,[18] cancer prevention,[19] mental illness,[20] psychosocial social stress reduction,[21] and attenuation of traditional cardiovascular risk factors.[9] Glucose intolerance, the pathophysiology underlying adult-onset diabetes, is particularly responsive to both aerobic and resistance exercise.[22,23] Systemic blood pressure and circulating levels low density lipoprotein also respond favorably to exercise.[24]

The Exercise Paradox

Acute bouts of exercise increase the risk of sudden death among people with underlying cardiovascular disease.[25] However, people that exercise routinely are at an overall lower risk of sudden cardiac death.[26] The notion that exercise both acutely increases the risk of sudden death while simultaneously chronically reducing the overall risk of sudden death is commonly referred to as the “exercise paradox.” Observations of people dying during physical activity and organized sport are often used by both clinicians and the general population to dissuade people from engaging in intense physical activity. This tendency should be avoided as it only accounts for the first half of the exercise paradox. Instead, it should be recognized that routine exercise and corollary high levels of cardiorespiratory fitness provide an important protective effect. In clinical practice, it may be prudent to advise sedentary people to avoid undertaking particularly strenuous activity to which they are not accustomed and to advise MA to avoid mark surges in exercise intensity that exceed their typical training regimens. This line of counseling is particularly important among patients with established forms of cardiovascular disease that have been associated with sudden death.

Cardiovascular Disease in MA

While exercise habits of MA confer health benefits, MA may be at risk for cardiovascular disease. Cardiovascular disease among MA develops due to traditional underlying risk factors that are incompletely attenuated by exercise or in some cases due to high levels of exercise as a primary pathophysiologic mechanism. Four of the most common clinical cardiovascular issues among MA are now discussed in more detail.

Atrial Fibrillation

Routine physical activity approximating contemporary physical activity guidelines reduces incident atrial fibrillation.[27]However, levels of exercise that far exceed current recommendations are associated with an increase in the prevalence of atrial fibrillation. Numerous case control studies have shown that the exercise levels typical of MA are associated with increased risk of atrial fibrillation.[28] This arrhythmia, which is observed more commonly among male MA than female MA, appears to represent a form of “overuse pathology”. Mechanisms underlying atrial fibrillation in MA remain incompletely understood.[29,30] Structural remodeling of the left atrium caused by the sustained increases in cardiac output during endurance exercise have been proposed as an important pathogenic factor. Exercise-induced left atrial dilation and fibrosis likely represent an important aspect of the pathophysiology of atrial fibrillation among MA. Concomitant changes in the autonomic nervous system including heightened parasympathetic tone at rest coupled with sympathetic surges during exercise may also be contributory. On an individual patient basis, additional factors including family genetics, caffeine consumption, alcohol consumption, and inadequate rest or recovery following periods of increased training load and/or intensive acute bouts of exercise are additional considerations.
Clinicians caring for MA should have a high index of suspicion for atrial fibrillation as its presentation is highly variable. Atrial fibrillation among MA may manifest as palpitations or sustained subjective tachyarrhythmia at rest and during exercise or simply as a sudden loss of power during exercise. The majority of MA wear some form of a commercial heart rate monitor which, if carefully reviewed, may hold data supporting the presence or absence of an underlying arrhythmia.[31] A general approach to the clinical management of MA with atrial fibrillation is provided in Figure 1. Therapeutic options among MA with confirmed atrial fibrillation include conservative observation when arrhythmias are infrequent and/or minimally symptomatic, sinus maintenance with antiarrhythmic medical therapy, and catheter-based ablation. These options should be discussed with each individual patient using a shared decision-making format. Stroke risk should be assessed for all MA and anticoagulant use should be determined based on contemporary clinical guidelines.[32] The risk of bleeding complications during oral anticoagulant use, in part determined by the likelihood of trauma or collision during training and competition, should be discussed with all MA requiring this form of therapy.

Figure 1: A proposed clinical approach to the Masters athlete with newly diagnosed paroxysmal atrial fibrillation.

Myocardial Fibrosis

Cardiac MRI has emerged as a valuable tool for characterization of myocardial tissue and is mainstay in the assessment of MA with suspected diseases of the heart muscle.[33] In addition to accurate determination of cardiac wall thicknesses and chamber volumes, cardiac MRI provides information about the presence and magnitude of myocardial scar. Significant myocardial scar is typically caused by pathologic injuries stemming from myocardial ischemia, inflammation, or abnormal tissue architecture. The finding of scar should prompt a thorough diagnostic evaluation for the underlying casual pathology and risk stratification for secondary ventricular arrhythmia with maximal effort limited exercise testing and ambulatory rhythm monitoring. However, scar has been documented in several studies among ostensibly healthy MA.[34–36] It is increasingly recognized that one specific type of myocardial scar, patchy fibrosis confined to the right ventricular insertion portions of the left ventricle (i.e. “hinge point” fibrosis), may be caused by long term exposure to high levels of exercise. To date, there are no definitive outcome data to suggest that this finding is associated with any risk of adverse events during future exercise. Accordingly, the incidental finding of “hinge point” fibrosis does not mandate a recommendation for exercise reduction or abstinence.

Ascending Aortic Dilation

Several large studies examining aortic dimensions in competitive athletes have documented little or no dilation.[37–39] Accordingly, the aorta has traditionally been considered minimally responsive to exercise training and findings of aortic dilation exceeding general population upper limits of normal have been considered pathologic. However, the vast majority of data underlying this assumption have been derived from cohorts of young competitive athletes. Recent data focusing on MA suggest that a significant minority harbor mild to moderate dilation of the aortic root and ascending tubular segment.[40] In clinical practice, aortic dimensions ranging from 40 to 45 millimeters are commonly observed among otherwise healthy MA. Long term outcomes data among MA with mild to moderate aortic dilation are lacking. However, the observed prevalence of this phenotype far exceed prevalence estimates of acute aortic syndromes including aortic dissection. Clinically, the finding of mild to moderate aortic dilation should prompt a detailed family history for genetic forms of aortopathy and careful assessment of blood pressure both at rest and during exercise. Among normotensive MA with no familial pedigree for aortic disease, mild to moderate dilation may reflect benign adaptation to long term exercise rather than pathology. Continued unrestricted participation in endurance sport coupled with longitudinal clinical surveillance with some combination of echocardiographic and tomographic imaging is recommended in this clinical scenario.

Coronary Artery Disease

Obstructive atherosclerotic coronary disease is the most common cause of sudden death during exercise in MA.[7]Proximal atherosclerotic plaques may trigger sudden death due to demand mediated ischemia from a focal chronic high-grade obstruction or acute plaque rupture resulting in arterial thrombosis. The final common outcome of both pathophysiologic process is unstable ventricular arrhythmia. As discussed above, most MA with clinically appreciable coronary artery disease harbor explanatory risk factors including undiagnosed or inadequately treated hypertension and dyslipidemia. Genetic predisposition to atherosclerosis and prior tobacco consumption also commonly underlie the development of coronary artery disease in MA.
CT coronary artery calcium scoring has emerged a valuable determinant of risk in the general population.[41] However, the utility of CT calcium scoring in MA has not been well-established and remains controversial.[42] Early studies examining MA reported surprisingly high levels of coronary artery calcium.[43,44] These data emerged from cohorts of MA with explanatory traditional risk factors thereby emphasizing the notion that no level of exercise negates will completely offset the impact of cardiovascular risk factors. Several more recent studies deliberately recruited MA without cardiac risk factors and demonstrated higher coronary calcium levels compared to sedentary age matched controls.[45–48] These data suggest that some element of the MA lifestyle may precipitate coronary calcification. One intriguing hypothesis is that high levels of exercise, possibly due to mechanical stress imparted by high blood flow through the coronary system during endurance exercise, may be response. An addition possible explanation is that MA may tend to consume an atherogenic diet.
At present, the clinical implications of coronary artery calcium among MA remain incompletely understood. Emerging data from one US-based cohort suggest that high levels of fitness markedly attenuate the risk of adverse outcomes associated with calcification in sedentary populations,[49] and that exercise during longitudinal follow-up is not associated with progressive coronary calcification.[50] The uncertainties regarding the pathogenesis and clinical significance of coronary calcification among MA suggest a limited role for coronary artery calcium scoring, as a means to determine risk of adverse events, in this population. Nonetheless, many MA present with previously measured coronary artery calcium scores seeking advice. A clinical approach this common presentation is presented in Figure 2.

Figure 2: A proposed clinical approach to the Masters athlete with coronary artery calcification.

Conclusion

MA experience the myriad health benefits of routine exercise and represent a healthy and vibrant segment of the population. Nonetheless, MA are not immune to common forms of cardiovascular disease. This review was generated to provide practitioners with an overview of the MA with an emphasis on the recognition and management of the most common clinical cardiovascular presentations among MA.

Corresponding author

Aaron L. Baggish, MD, FACC, FACSM
Department of Cardiology Lausanne University Hospital (CHUV)
Rue du Bugnon 21, CH-1011 Lausanne, Switzerland
Phone: +41 79 918 05 63
Email: aaron.baggish@chuv.ch

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