Cardiovascular Conditions in Sport & Exercise
Chest Pain
Dr. Anita Green
Cardiovascular Symptoms
• Chest pain• Palpitations• Syncope
• Sudden Cardiac Death
Chest Pain – Non Traumatic• Musculoskeletal
o Costochondritis / Sternoclavicular jointo Thoracic spine – referredo Intercostal muscle
• Gastrointestinalo Refluxo Peptic ulceration
• Cardiaco Ischaemic
• Respiratoryo Pulmonary embolism
Ischaemic Chest Pain - History• Age – increased risk with age• Site – retrosternal/jaw/neck/arm/epigastric• Type – pressure/constricting/burning• Aggravation – activity/meal/cold/’stress’
- not mechanical• Relieving – rest/GTN – not with postural
change• Associations – nausea/vomiting/sweating
Stratification of Risk• Typical vs atypical pain• Risk factors
o Ageo Sexo Family history
Lipid profile Smoking Blood pressure Diabetes Obesity Physical inactivity Cerebro- /Reno- / Peripheral- vascular disease
Non Modifiable
Modifiable
Examination
• Often unremarkable• PR / rhythm• BP• Carotid & peripheral pulses• Murmurs• Failure
Investigation
• ECG• Serial troponins• [Ventilation / perfusion (VQ scan)
– exclude PE]• Maximal exercise stress test (MEST)• Myocardial perfusion stress test (MPS)• Stress echocardiogram• CT coronary angiogram (CTCA)• Cardiac MRI
Exercise Stress Testing
• Assess potential CAD as causefor chest pain
• Extension of clinical and riskfactor assessment
“Stratification of risk”• Intermediate risk patients
25 to 75% of CAD• Sensitivity = 68%• Specificity = 77%
Exercise Stress Testing - Limitations
• Not useful as a screening test – high false positive• Divided opinion on stress test those commencing
vigorous exercise program – tests static narrowing
• Chest pain + Low pre test probability CAD <25% -high false positive
• Chest pain + High pre test probability CAD >75% -coronary angiogram
Maximal Exercise Stress Testing
• Treadmill vs bike• Bruce protocol
ramped 3 min stages• Modified Bruce / Naughton
6 to 12 mins• CSANZ• Aim 100% predicted max HR
(need min 90%)
Exercise Testing Indications• Screening of higher risk individuals
risk factor profile,age / family history
• Diagnosis of chest pain / dyspnoea• Assess severity of CAD, arrhythmias• Assess adequacy of medication• Assess Post Infarction
- Sub-max at Day 5+- Maximal at ~ 6wks
Contraindications
• Recent Infarction < 5days• Unstable Angina• Severe Aortic Stenosis / HOCM• Severe Hypertension• Uncontrolled Arrhythmias• Conduction Defects• Significant Cardiac Failure
Indications for Terminating
• Max heart rate achieved• Severe angina• Severe dyspnoea• Dizziness• ST depression >2mm• ST elevation• Significant arrhythmia• BP > or = 250mm Hg• Significant fall in BP
Resting ECG
ECG Study - 4 minutes
ECG Study - 11 minutes
Exercise ECG
Risks of Maximal Stress Testing
Risks per 10,000 tests• Myocardial infarction = 3.5• Serious arrythmia = 4.5• Death = 0.5
Diagnostic Stress Testing• Sub-maximal - post infarct pre discharge - 85% max heart rate - or 6 mins on Bruce - symptom limited - significant ECG changes• Maximal - ~ 6 weeks post infarct - diagnosis in chest pain - assessment of therapy
Myocardial Perfusion Scan
Nuclear Medicine -Technetium Isotope (Sestamibi / Tetrafosmin)
• Perfusion scano Maximal exercise stress testo Adenosine / Persantin stress testo Dobutamine stress test
• Gated heart pool scano Regional wall motion abnormalitieso Ejection fraction
Myocardial Perfusion Scan• Unable to exercise to maximal heart rate
o Orthopaedic problemso Deconditioningo Pulmonary diseaseo Peripheral arterial disease
• Resting ECG abnormalities – unable to interpreto Paced rhythmo Left bundle branch blocko ST depression > 1mm
Normal Nuclear Medicine ImagesCross-Section
Stress
Rest
Sagittal View
Stress
Rest
Nuclear Medicine Images of DefectsFixed Defect
Stress
Rest
Stress
Rest
Reversible Defect
Stress Echocardiogram
• Contractility of myocardium• Regional wall motion abnormalities• Ejection fraction – increase with exercise• Valve
o opening / closing / velocitieso exclude significant Aortic Stenosis and
Pulmonary Hypertension
Stress Echocardiogram - Indications• Non pharmacologic
o Still need to be able to exerciseo ECG changes at resto Positive maximal exercise test in lower risk
patiento Advantage over MPS - no radiation
• Pharmacologic – Dobutamineo Cannot exercise – low ejection fractiono Add contrast bubbles – if echo quality limited
Cardiac Catheterisation
• High risk patient with chest pain• Positive stress test
• If significant lesions – treatment optionso Angioplastyo Stento Coronary bypass grafting
Chest Pain - Summary
Young athletes majority chest wall•History - including family history
Assessing chest pain - risk stratification•Low risk - high false positive rate testing•Intermediate risk - stress test•High risk - consider angiogram
