Talking Tall Rounds®: Sports Cardiology

Podcast Transcript

Announcer:

Welcome to the Talking Tall Rounds Series brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Tamanna Singh, MD:

I'm Dr. Tamanna Singh. I'm one of the Co-Directors for our Sports Cardiology Center. And I'm excited to provide an introduction to our center, as well as introduce you to an exciting case and our multidisciplinary approach to that case management. I'm also thrilled to be here with my new co-director, Dr. Michael Emery, who just recently joined us, and who you will meet later this morning. So let's go ahead and quickly get started. I'd like to introduce Dr. Travis Howard, who is our cardiology fellow, and he will introduce our case for this morning.

Travis Howard, MD:

Good morning. Thank you all for tuning in. As Dr. Singh mentioned, my name's Travis Howard. I'm one of the general cardiology fellows here. I'll be giving a brief case presentation to provide somewhat of a background and foundation for this week's Tall Rounds. So let's jump right in.

Travis Howard, MD:

We have a 37-year-old male, with no prior cardiac history. Developed chest tightness, jaw pain, and nausea one hour into his routine Saturday morning run. Symptoms progressed so he presented to his local urgent care. Past medical history, notable for depression, no past surgical history, no family history of CAD or sudden cardiac death. As mentioned in the title, he's a marathon runner. Runs 50 miles per week. No drugs, alcohol or tobacco. Only home medication is venlafaxine.

Travis Howard, MD:

Upon presentation to urgent care, EKG demonstrated ST depressions in multiple leads. So he was triaged in the emergency department. In the ED, he had a cardiac arrest due to pulseless VT with ROSC after defibrillation and he was sent for an urgent left heart cath.

Travis Howard, MD:

I don't have the cine films, but his pathology is apparent even on these still frames. You can see in the top right, that this is diastole. He has a severe lesion in his distal LAD. They performed IVUS and demonstrated stable plaque. iFR was 0.86 and so a drug-loading stent was placed. On the bottom right you can see systole. He has a dynamic cornea obstruction consistent with myocardial bridging, and that was not intervened upon that day.

Travis Howard, MD:

Unfortunately, he continued to have chest pain. So he was referred to Cleveland Clinic for further management. Initial study performed here as a dobutamine PET. You can see the non gated imaging on top and the right arrow is marked or I should say, highlight an area of mild LAD territory ischemia. Next at according to CTA, you can see on the left, sagittal plain a long segment of intramyocardial LAD, with a distal stent there, and then on the right, there's just a 3D representation to further highlight this.

Travis Howard, MD:

And then lastly, he had a coronary angiogram. This is our myocardial bridging protocol, which Dr. Ghobrial will touch on a little bit later, but on the left is his resting images. You can see evidence of the myocardial bridging. iFR rest was 0.94. And the right is peak stress with dobutamine-atropine. iFR is around 0.75 with normalization, pull back across the proximal edge of the myocardial bridging. So clearly a hemodynamically significant lesion given that his ongoing symptoms and his desire to continue exercising, he underwent LAD and roofing with placement of a distal vein graft with an uncomplicated post-op course.

Travis Howard, MD:

And he just had his followed coronary angiogram a few weeks ago. On the left, you'll see native coronary artery injection. The LAD is not fully apparent because of the competitive flow. And you can see on the right here with injection of the vein graft, he has back filling LAD and no apparent myocardial bridging. And this was confirmed on hemodynamic assessment with an iFR of 0.94 at rest and peak stress. And so he was actually counseled that he could return to exercise. He actually completed a half marathon last week was asymptomatic and did quite well.

Tamanna Singh, MD:

Next. What we'll do is we're going to shift the focus a little bit more towards the management of athletes. Now that we've already discussed the diagnosis, the surgical management, the role of intervention and how we as sports cardiologists can really contribute to helping our athletes and advocating for them to get back into their sport of choice. And so we've already reviewed what we do with respect to surgical repair for myocardial bridging. But I did want to bring up our 2015 guidelines that we have from the AHA/ACC. So typically when we do see an athlete asymptomatic or symptomatic with bridging as has already been mentioned, if they're asymptomatic, we do still want to see whether or not we can provoke myocardial ischemia and stress testing, because these are high-stakes individuals. And if we don't see any ischemia, then typically we recommend that they have no restriction to competitive sports participation.

Tamanna Singh, MD:

If there is any evidence of myocardial ischemia, or if they have had a prior MI as in the patient that we've presented today, there's two mainstay categories that we can utilize with respect to how we treat them. First line recommendation is beta-blockers. However, as sports cardiologists, we are quite aware of the limitations that beta-blockers can pose on actual exercise intensity, how athletes field, and also with respect to competition with regards to whether or not they're even allowed to be on them. And so if we do choose medical management and athletes' goals are modified in this regard, then our recommendation is that they proceed with low, moderate dynamic and static intensity sports. If they do go forward with surgical resection or stenting, and we've discussed the difference in the value of resection over stenting, then for that initial six-month window post-repair, we do recommend that they specifically stay in line with proceeding with low-intensity sports.

Tamanna Singh, MD:

Now, these guidelines essentially mirror those that were recently put out by the European Society of Cardiology that we also look at from just last year, where again, in individuals that are asymptomatic with no evidence of myocardial ischemia, no provocation of exertional ventricular arrhythmias, we do not restrict them because there's little evidence of any actual exercise-induced harm. And then again, from a medication standpoint, should we choose to go that route beta-blockers are the typical mainstay for which we then also put that in line with low-intensity sports participation. If they do fail medications, or again, if they choose to go through surgery, the same recommendation holds with respect to low-intensity participation for six months. So when I talk about low intensity, I've brought up the word static and dynamic, and basically, these two terms correlate to both the pressure and the volume challenges, respectively that are seen with exercise.

Tamanna Singh, MD:

And this three-by-three plot that you can see on the right shows, our attempt to put specific sport types within categories. And that shade of red to this purplish-blue hue is meant to show that there is some overlap with respect to sports, having both a pressure challenge component, as well as a volume challenge component. So when I was alluding to low-intensity static and dynamic sports participation, if you take a look at that highlighted bottom left quadrant there that typically relates to sports such as yoga or golf things that really don't require much pressure and volume challenge on the heart. Once these athletes have gone through that six-month period of low-intensity sports participation, we can then move forward with these functional assessments, albeit whether or noninvasive or invasive strategies to see whether or not they are truly having absolutely no myocardial ischemia and therefore can participate in a competitive sports.

Tamanna Singh, MD:

And so we've discussed the roles of PET stress we've discussed the role of, iFR with both Dr. Cremer and Dr. Ghobrial, respectively. So I just wanted to highlight those with respect to those being two very important components with respect to individuals returning to sport. So from a structural standpoint, echocardiography is one modality that we nearly use on all athletes when we're evaluating them for return. And then the other thing I wanted to bring up was rhythm monitoring. You know, I had alluded to the fact that one of our roles of sports cardiologists is making sure that our athletes are not at risk for sudden death. There is that association with bridging. And so we want to make sure that there's no provocation of ventricular arrhythmias, even after the ischemia has been addressed. One modality of stress testing that we have not discussed today, that as sports cardiologist, we really highlight is the cardiopulmonary exercise test referred to as metabolic here at the Clinic.

Tamanna Singh, MD:

And it's a fantastic tool, not only to allow for us to assess myocardial ischemia but to use as a modality, to provide training guidelines for our athletes that are very sport-specific. So CPET's are basically an assessment of inhaled oxygen and eliminated carbon dioxide during physical stress. We are able to see how well the cardiopulmonary system works, whether there's any neuromuscular deficits, it's very useful for discriminating some non-specific symptoms such as exertional dyspnea. And I had mentioned that we can use various modalities as sports cardiologists. We always want to exercise athletes to their ultimate max intensity in a form or a sport that they are used to, where they can actually truly put out their best effort. And so we use treadmills, we've used bikes, we've used indoor rowers, and there's even a location internationally where they have a swimming pool for swimmers.

Tamanna Singh, MD:

And so in our mindset, we want to create the ideal environment to put that competitive athlete really in a mindset of going all out. So we can truly prove that there's no ischemia. And so here's a schematic of what a cardiopulmonary exercise test looks like with a mask that is worn in metric gas exchange. And one other point about cardiopulmonary testing that I wanted to bring up was the importance of the type of protocol. Obviously, the modality is important, but we specifically prefer a Ramp protocol over the Bruce protocol, because it doesn't allow for this equilibration that you can see when you have that stepwise approach increase and increase in intensity and incline that you see with the Bruce versus the Ramp. And what does this mean? It means that we have a closer estimated oxygen consumption or VO2 to a measured one versus the Bruce protocol, which typically overestimates oxygen consumption.

Tamanna Singh, MD:

And so this is just a schematic of four of the nine plots that we typically obtain from metabolic testing. We're able to see aerobic efficiency, which is the amount of oxygen required to perform work. We're able to get a measure of ventilatory efficiency, which is the amount of minute ventilation required to eliminate CO2 and the better your ventilatory efficiency, really the better your functional capacity. And the bottom left plot allows for us to really see that nice chronotropic response to exercise as well as the increase in oxygen consumption and how they fare based on age and gender predictions. And then finally, we're able to see kind of the whole picture with respect to oxygen consumption increasing, the increase in carbon dioxide elimination and the point where they cross, which is the point that we call our anaerobic threshold. Now, these plots and these parameters really do help us, not only in evaluating ischemia, we can look at things like an oxygen pulse, which is a surrogate for a stroke volume to see that.

Tamanna Singh, MD:

But as I had alluded to, as a sports cardiologist, we can use this information to provide heart rate training parameters, to provide guides for when they're trying to do work within their aerobic metabolic state versus their anaerobic state, if they're doing lactate threshold work. So there's a lot more information from this stress modality than we could get from other non-invasive tests. We've discussed invasive functional assessment with Dr. Ghobrial already, but I really wanted to highlight this because we do not talk about the utility of iFR in our current guidelines, most recent being obviously 2015. And so, as she had alluded to this is a great modality to interrogate dynamic stenosis, where we utilized dobutamine and atropine for both inotropic and chronotropic augmentation. And in my personal opinion, I think despite that procedural risk, particularly with the protocol that Dr. Ghobrial is using, I think it might actually become a favorable modality for high-stakes individuals, because there are times when, even though we think we're pushing our athletes to their max effort, which is measurable on a metabolic stress, we may not, we may still miss that mark of actually provoking myocardial ischemia.

Tamanna Singh, MD:

And I think iFR is a very exciting modality to investigate for these specific athlete patients and so ongoing utilization and demonstration of the effectiveness of iFR stress protocols, I think may contribute to the changes in our current guidelines. And as Dr. Cremer had mentioned, I think there's still an incredible role for using PET stress as well. With respect to the approach, to training at sports cardiologists, we really try to personalize our exercise, “prescriptions and training plans” which again are going to be very sport dependent, age-dependent, dependent upon their level of competition, as well as any comorbidities that exist. And one area for exploration that I think is quite novel is the role of precision medicine as a guide for athletic training and this is a very new field. I think precision medicine itself is quite novel, but really investigating how it can correlate to training is exciting.

Tamanna Singh, MD:

And then finally shared decision-making is a huge component of our counseling. And we utilize this model, which is a very specific approach for counseling athletes because we really want to avoid that traditional binary and paternalistic approach. It's very important for us to align with our athlete patients help them manage any grief that they may have when they are going through a period where they cannot participate in a sport that's really their livelihood, or that really adds to their quality of life. And so we do our due diligence to review all of our clinical outcomes data to acknowledge our areas of uncertainty so that they really have all the tools to make the best decision for themselves. And then we also want to make sure we understand their belief system and how much they comprehend. And we also want to acknowledge the role of sports participation in just promoting healthy living, emotional and cognitive development.

Announcer:

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