Fibrillazione atriale negli atleti - ASIAM · Fibrillazione atriale negli atleti 10 Giugno 2017 Stadio Artemio Franchi Dott. Paolo Pieragnoli SOD Aritmologia AOU Careggi 1

Fibrillazione atriale negli atleti

10 Giugno 2017

Stadio Artemio Franchi

Dott. Paolo Pieragnoli

SOD Aritmologia

AOU Careggi1

Athlete and atrial fibrillation

Athletes with atrial fibrillation areprobably unlikely to have comorbidities.The population subset with these findings isgenerally men who are younger than age 60with normal findings on physicalexaminations, chest x-ray scans,electrocardiograms, and echocardiographicinvestigations—criteria for the conditionpreviously 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-agedman (in his forties or fifties) who has been involved in regular endurance sportpractice since his youth (soccer, cycling, jogging, and swimming), and is stillactive. This physical activity is his favourite leisure time activity and he ispsychologically very dependent on it.

The AF is usually paroxysmal with crisis, initially very occasional and selflimited, and progressively increasing in duration. Characteristically, AF episodesoccur at night or after meals. As many as 70% of patients may sufferpredominantly vagal AF. They almost never occur during exercise. This makesthe patient reluctant to accept a relationship between the arrhythmia and sportpractice, particularly since his physical condition is usually very good. The crisestypically become more frequent and prolonged over the years and AF becomespersistent. Progression to permanent AF has been described in 17% of individualsin an observational series. In the GIRAFA study, 43% presented persistent AF. TheAF crisis frequently coexists with common atrial flutter in many patients.

Mont L et al. Europace 2009;11:11-17Myrstad M et al. Clin Res Cardiol 2016;105:154-161

4

✓Incidenza di fibrillazione atrialenell’atleta

✓Cause di fibrillazione atriale nellosportivo

✓Approccio terapeutico all’atleta confibrillazione atriale

✓Attività sportiva idonea nel paziente confibrillazione atriale

Born to run? Yes!Mouth Breathing

Swivel Shoulders

Sweat Glands

Sparse Body Hair

Large Body Surface Area

Vascular Reactivity to temperature

Advanced Cognitive Capabilities

CNS Coordination of metabolic and cardiovascular responses to sustained running

Swivel Hips

Slow Twitch Muscles

Long LegsElastic Tendons

Plantar ArchShort Toes

Mattson MP, Ageing Res Rev. 20125

Endurance exercise and Heart

Eijsvogels T, Physiol Rev 2016 6

Can lifelong exercise hurt the

heart?

Eijsvogels T, Physiol Rev 20167

8





Is the risk of atrial fibrillation higher in

athletes than in general population?

9

AF is more prevalent in athletes

Abdulla J, Europace 200910

The Vasaloppet

• 90 km cross-country ski

race

• 52755 health

competitors

• Long term follow-up

Andersen K, Eur Heart J 2013 12

The Vasaloppet

Andersen K, Eur Heart J 2013

Risk by number of completed races Risk by finishing time

Repeated partecipation and faster finishingtime were associated with increased risk of AF

13

The Birkebeiner

• 54 km cross-country ski

race

• 3.545 men ≥ 53 years

14Myrstad M, Am J Cardiol 2014

The Birkebeiner

Myrstad M, Am J Cardiol 201415

Cumulative years of regular endurance exercise were associated with a gradually increased risk for AF and atrial flutter

The Birkebeiner

Myrstad M, Scand J Med Sci Sports 2014 17

18

AF incidenceIncidence rate of AF among man aged 55-64

Rotterdam Study (generalpopulation)

22/10.000 persons - years

Framingham Study (general population)


Vasaloppet Study (endurance athletes)


19

20

AF/AFl

AgePersistent Athletic

Activity

24





25

Mechanisms involved in the genesis of AF in athletes

Padeletti L, Int J Sports Med 2013

Autonomic imbalance

Neurohormonal activation

Electrophysiological changes

Anatomic remodeling

Inflammation

Physiopathology

Turagam KM. JAFIB 201426

Physiopathology

Wilhelm M. European Journal of Preventive Cardiology 2014, Vol. 21(8) 1040–104827

Atrial Fibrillation Promotion by Endurance Exercise

Demonstration and Mechanistic Exploration in an Animal Model

J Am Coll Cardiol 2013;62:68-77







32

Inflammation as a risk factor for atrial fibrillation

Aviles et al Circulation 2003

33

C-reactive protein and AF

Psychari et al Am J Cardiol 2005

34

IL-6 and strenuous exercise

Kasapis et al. JACC 2005

35

AF, LA size and inflammation in sport

practitioner

36

Arrhythmias and sport practice

Mont L, Heart 2010

Nature Reviews Cardiology 14, 88–101 (2017)40


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 prospectiveobservational studies including approximately 379,884 patients.

Studies were included if they evaluated trials that reported arelation between incident AF and the level of intensity ofexercise.

Among men, vigorous exercise was associated with a 90 percent(1.9 times) increased risk of AF, while moderate exerciselowered the incidence of AF by 19 percent. In women, bothmoderate and high intensity levels of exercise were found to bebeneficial. Moderate exercise reduced the risk of AF in womenby 24 percent and by 15 percent when they participated invigorous exercises.

New Study Shows Save Levels of Exercise Differ For Men and Women With Atrial Fibrillation

Heart Rhythm Society May 15, 2015

men

+ 90 %+

-

women

- 15 %

women

- 24 %

men

- 19 %

Risk

atrial

fibrillation

moderate exercise vigorous exercise

Paroxysmal at r ial fibrillat ion in male endurance

athletes. A 9-year follow up

Jan Hoogsteena,) , Goof Schepb, Norbert M. van Hemelc,Ernst E. van der Walld

aDepar tment of Cardiology, Maxima Medical Cent re, Dommelst raat Zuid 5,

5500 MB Veldhoven, NetherlandsbDepar tment of Sport Medicine, Maxima Medical Cent re, Veldhoven, NetherlandscDepart ment of Cardiology, Heart Lung Cent re, Ut recht , NetherlandsdDepar tment of Cardiology, Leiden Universit y Medical Cent re, Leiden, Netherlands

Submit ted 13 May 2003, and accepted after revision 18 January 2004

Abst ract Aims To study the course and circumstances of at rial fibrillat ion in

endurance sports.

Background Atrial fibrillat ion is the main cause of symptoms in athletes and fre-

quent ly disturbs the performance during the pract ising of sport . The course of the

arrhythmia is seldom reported in this populat ion.

Methods In 1993 and 2002 symptoms and clinical presentat ion of at rial fibrillat ion

were evaluated in 30 well-t rained athletes with a specially designed quest ionnaire.

Results In 1993 paroxysmal at rial fibrillat ion was present in 30 male athletes at

the mean age of 48:1G 7:8, 3 (10%) of them also had paroxysmal at rial flut ter. Three

(10%) of the athletes died before 2002. In 2002 paroxysmal at rial fibrillat ion cont in-

ued in 15 (50%) athletes, permanent at rial fibrillat ion emerged in 5 (17%) athletes

and 7 (23%) of them showed no further at rial fibrillat ion. In 1993 paroxysms of at rial

fibrillat ion started at a relat ively low level of t raining intensity compared with the

mean maximal t raining intensity of 11G 7 versus 8G 4 h=week (p ! 0:05). The first

at tack of adrenergically induced paroxysmal at rial fibrillat ion was more often pres-

ent in younger athletes (p ! 0:005) and vagally induced paroxysmal at rial fibrillat ion

was more apparent in older athletes (p ! 0:05). In 10 (38%) of the athletes a familiar

form of paroxysmal at rial fibrillat ion was present .

Conclusion A small proport ion of the athletes (26%) was asymptomat ic. Paroxys-

mal at rial fibrillat ion remained stable in half of the athletes whereas the arrhythmia

changed into permanent at rial fibrillat ion in a minority of this populat ion.

ª 2004TheEuropeanSocietyof Cardiology. PublishedbyElsevier Ltd. All rightsreserved.

KEYWORDSat rial fibrillat ion;

endurance athletes

) Corresponding author. Tel.: D 31-40-8888210; fax: D 31-40-8888216.

E-mail address: j [email protected] (J. Hoogsteen).

Europace (2004) 6, 222e 228

1099-5129/ $30 ª 2004 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/ j .eupc.2004. 01.004

200444

45





Work-Up


Efficacy of antiarrhythmic drugs

Low efficacy

M. Gulizia et al “Diagnosi e terapia del Flutter e della Fibrillazione atriale” 2009

48

AF after flutter ablation in

Endurance Sport Practitioners

Heidbuchel H, Int J Cardiol 2006

49

Effects of AF ablation in

Athletes

Calvo et al., Europace 2010

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).

50

Effects of AF ablation in

Athletes

Heidbuchel H, Europace 2011

Pulmonary veins isolation: pathophysiology

M. Gulizia et al “Diagnosi e terapia del Flutter e della Fibrillazione atriale” 2009

Catheter Ablation Pulmonary Veins Isolation

Cryoablation

Cryoballoon

Lasso Catheter

Coronary Sinus

Laser Ablation

The recordings from the circular multipolar mapping catheter placed in a pulmonaryvein are shown during ablation. On Lasso 1–2 prolongation of conduction delay fromthe atrium into the pulmonary vein is seen on the first four beats before the sharp localpulmonary vein potential finally disappears on beat 5 and 6 as a result of successfulpulmonary vein isolation.

Catheter Ablation Pulmonary Veins Isolation

63





64

ESC Guidelines 2016

65

Atrial Fibrillation Atrial Flutter

66

67

Position Paper

Recommendations for participation in leisure-time physicalactivity and competitive sports in patients with arrhythmiasand potentially arrhythmogenic conditionsPart I: Supraventricular arrhythmias and pacemakersHein Heidbuchela, Nicole Panhuyzen-Goedkoopb,c, Domenico Corradod, Ellen

Hoffmanne, Allessandro Biffif, Pietro Deliseg, Carina Blomstrom-Lundqvisth,

Luc Vanheesi, Per IvarHoffj, Uwe Dorwarthe and Antonio Pellicciaf on behalf

of the Study Group on Sports Cardiology of the European Association for

Cardiovascular Prevention and Rehabilitation

aDepartment of Cardiology-Electrophysiology, University Hospital Gasthuisberg, Leuven, Belgium,bDepartment of Cardiology, Radboud University Hospital, Nijmegen, cDepartment of Sports Cardiology andCardiac Rehabilitation, St Maartenskliniek, Nijmegen, The Netherlands, dDepartments of Cardiology andPathology, University of Padova, Padua, Italy, eDepartments of Cardiology and Pneumology, HospitalMunchen-Bogenhausen, Munich, Germany, fNational Institute of Sports Medicine, Italian National OlympicCommittee, Rome, gDepartment of Cardiology, Civil Hospital, Conegliano, Italy, hDepartment of Cardiology,University Hospital Uppsala, Uppsala, Sweden, iDepartment of Rehabilitation Sciences, University of Leuven,Leuven, Belgium and jDepartment of Heart Disease, Haukeland University Hospital, Bergen, Norway.

Received 26 October 2005 Accepted 4 January 2006

This document by the Study Group on Sports Cardiology of the European Society of Cardiology extends on previous

recommendations for sports participation for competitive athletes by also incorporating guidelines for those who want to

perform recreational physical activity. For different supraventricular arrhythmias and arrhythmogenic conditions, a

description of the relationship between the condition and physical activity is given, stressing how arrhythmias can be

influenced by exertion or can be a reflection of the (patho)physiological cardiac adaptation to sports participation itself. The

following topics are covered in this text: sinus bradycardia; atrioventricular nodal conduction disturbances; pacemakers;

atrial premature beats; paroxysmal supraventricular tachycardia without pre-excitation; pre-excitation, asymptomatic or

with associated arrhythmias (i.e. Wolff–Parkinson–White syndrome); atrial fibrillation; and atrial flutter. A related document

discusses ventricular arrhythmias, channelopathies and implantable cardioverter defibrillators. Eur J Cardiovasc Prev

Rehabil 13:475–484 c 2006 The European Society of Cardiology

European Journal of Cardiovascular Prevention and Rehabilitation 2006, 13:475–484

Keywords: athlete’s heart, guidelines, atrial fibrillation, atrial flutter, pacemakers, recommendations, sports cardiology, supraventricular tachycardia,Wolff–Parkinson–White

IntroductionPatients with cardiac arrhythmias form an important

proportion of those presenting for eligibility assessment

to part icipate in competit ive or leisure sports act ivity [1] .

Although recommendations for competit ive athletes have

been published before [1,2] , guidelines concerning

recreational physical act ivity are scarce and have only so

far addressed inherited arrhythmogenic condit ions [3] . By

including recommendations for leisure-time activit ies,

this paper (and an accompanying article on ventricular

arrhythmias in an upcoming issue of the journal) extends

Correspondence and requests for reprints to Hein Heidbuchel, MD, PhD,Department of Cardiology, University Hospital Gasthuisberg, Herestraat 49,B-3000 Leuven, Belgium.Tel: + 32 16 34 42 48; fax: + 32 16 34 42 40;e-mail: [email protected]

1741-8267 c 2006 The European Society of Cardiology

Copyright © European Society of Cardiology. Unauthorized reproduction of this article is prohibited. at University of Texas Libraries on December 5, 2014cpr.sagepub.comDownloaded from

Conclusioni

68

• 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

69

Exercise should be regarded as

a tribute to the heart

But someone may disagree…

70

71Thank you for your attention!

Documents

Fibrillazione atriale negli atleti - ASIAM · Fibrillazione atriale negli atleti 10 Giugno 2017 Stadio Artemio Franchi Dott. Paolo Pieragnoli SOD Aritmologia AOU Careggi 1