COMO IDENTIFICAR O ATLETA COM RISCO CARDIOLÓGICO I Fórum de Medicina Esportiva do S C Corinthians Paulista Apresentação: Dr. Sergio Paulo Der Torossian
OBJETIVOS Diagnosticar cardiopatia incipiente que possa causar risco ao atleta Avaliar o impacto dos treinos intensivos ao aparelho CV ( coração do atleta ) Avaliar a regressão das alterações cardiovasculares existentes nos casos de afastamento temporário ou definitivo Determinar capacidade funcional
Coração do Atleta Henschen 1896 Síndrome caracterizada por várias alterações fisiológicas e anatômicas, de caráter benigno e reversível, correspondendo a adaptações do aumento da demanda energética durante o esforço repetitivo. > DDVE, > espessura miocárdica, >tônus vagal, função sistólica nl e melhora do enchimento VE (função diastólica) Aumento da força de contração, com melhor reserva cardíaca e aproveitamento do oxigênio, mesmo em níveis máximos de trabalho.
Diagnóstico Diferencial Coração de Atleta X Cardiomiopatia Hipertrófica (CMH) ou Dilatada CMH é uma das principais causas de morte súbita em jovens atletas assintomáticos.
Morte súbita em atletas Grande impacto na mídia
Morte súbita em atletas Metanálise do Comitê Olímpico Internacional (sede Lauzane; Suiça): De 1966 a 2004: 1.101 mortes súbitas de jovens atletas com < 35 a Aproximadamente 29/ ano De 130 mortes súbitas em atletas americanos de 1985-95, apenas 8 (6%) tiveram diagnóstico pela avaliação clínica ainda em vida
PROTOCOLO DE ACOMPANHAMENTO MÉDICO ANAMNESE GERAL E ESPORTIVA EXAME CLÍNICO ECG repouso, Rx tórax, Perfil Laboratorial, teste Ergométrico, HOLTER 24 H, Ecodopplercardiograma com ou sem esforço Teste cardiopulmonar e OUTROS (RNM, CINTILOGRAFIA, ANGIOTC, CINECORON, EEF...)
ELETROCARDIOGRAMA ECGrepouso, esforço e Holter Arritmias: 40 % Aumento do tônus vagal: bradi sinusal, BAV 1 e 2 G (Mobitz I)
Holter: ES frequentes, taquiarritmias complexas (ex.: TVNS),WPW, OUTRAS Maron e Pelliccia, 2006
6 meses após descondicionamento AVALIAÇÃO PRÉVIA: HOLTER 24 H (07/08/2006): 55 pausas de 3,8 seg, 4 ESV isoladas e polimorf., 1 ESV pareada e 2 episódios de TVNS (4 bat.)
TESTE ERGOMÉTRICO E CARDIOPULMONAR
CARDIAC ADAPTATIONS AND CARDIOVASCULAR RESPONSE DURING GRADED EXERCISE IN SOCCER PLAYERS ACCORDING TO PLAYING POSITON Prado DM 1,3, Dias MP 1, DerTorossian SP 1, Mastrorosa JD 1, Faria PA 2, Portella DL 2, Shiraiwa R 3, Grava J 2. 1 SantanaCor Cardiology Clinic- São Paulo, Brazil; 2 Sport Club Corinthians Paulista- São Paulo, Brazil; 3 University of São Paulo (HCFMUSP), Medical School. INTRODUCTIO N Data available on aerobic soccer demands seem to confirm that the cardiovascular system is heavily taxed during the matches. Previous studies have demonstrated differences in aerobic power during soccer match among different playing positions. Until the moment, little is known about both cardiac adaptations (CA) and cardiovascular responses during graded exercise (CRGE) in elite soccer players according to their playing position. PURPOSE: To investigate differences in: 1) CA and 2) CRGE among defenders (DE), midfield (MF) and forward (F) elite professional soccer players. g/m 2 A 125 120 115 110 105 100 95 * LVMI RESULTS mm/m 2 30 29 28 27 26 25 24 23 22 B * LVEDDI MF DE F METHODS Forty five elite professional elite soccer players (age= 23.7 ± 0.6) were divided into three groups: (DE, n= 12); (MF, n= 20); (F, n=13). Cardiac morphology was evaluated by echocardiography and cardiovascular response by a maximal cardiopulmonary exercise test (Cortex Metalyzer IIIB- ErgoPC Elite) with individualized ramp protocols on treadmill. ml/kg/min Figure 1. Left- ventricular parameters in professional elite soccer players according to playing position. A) LVMI= left-ventricular mass index; B) LVEDDI= left- ventricular end- diastolic diameter index. *P <0.05 different from DE; p<0.05 different from F. 60 55 50 A * Peak VO 2 ml/bat 30 25 20 15 B * O 2 pulse * * MF DE F 45 MF DE F 10 VAT RCP PEAK Figure 2. Aerobic fitness and cardiovascular responses in professional elite soccer players according to playing position. A) Peak VO 2 = peak oxygen consumption; B) O 2 pulse= oxygen pulse during graded exercise. VAT= ventilatory anaerobic threshold; RCP= respiratory compensation point. *P <0.05 different from DE; p<0.05 different from F. - All data are presented as mean + SE. One-way analysis of variance was performed to compare echocardiographic parameters and Peak VO 2 among groups. - The cardiovascular responses during graded exercise test were analyzed among groups at VAT, RCP and Peak of exercise using two-way analysis of variance (ANOVA) with repeated measures. P<0.05 was considered statistically significant. If significance was obtained, Scheffés post hoc was performed. CONCLUSION We showed that MF soccer players had an increased left ventricular chamber size when compared to D and F. Furthermore, MF players performed greater cardiovascular responses during graded exercise than those in a different playing position. These findings suggest that higher aerobic demands during soccer match in midfield players may be associated with an increased cardiac volume overload and consequently, positive cardiovascular adaptations.
ECODOPPLERCARDIOGRAMA AVALIAÇÃO DO REMODELAMENTO VENTRICULAR FUNÇÃO VENTRICULAR PATOLOGIAS CONGÊNITAS E ADQUIRIDAS
21 A IMVE= 152 gr/m2 Rel esp/ve= 0,33 DDVE/SC = 29,5 HVE EXCÊNTRICA septo10mm 59mm
46 A. IMVE = 176 gr/m2 REL esp/ve = 0,44 DDVE/SC = 28 HIPERTROFIA CONCÊNTRICA Septo 12mm
CIA F OVAL PATENTE
ESTENOSE SUPRA VALVAR PULMONAR
HIP. MUSC. PAPILAR/ PVM
MASSA: HAMARTOMA
DIFFERENCES IN CARDIAC STRUCTURE INDUCED BY LONG-TERM INTERMITTENT EXERCISE IN ELITE PROFESSIONAL SOCCER PLAYERS Faria PA 2, Dias MP 1, DerTorossian SP 1, Mastrorosa JD 1, Prado DM 1,3, Dias RG 4, Oliveira CB 1, Grava J 2, Stancati J 2, Galotti R 2. 1 SantanaCor Cardiology Clinic- São Paulo, Brazil; 2 Sport Club Corinthians Paulista- São Paulo, Brazil; 3 University of São Paulo (HCFMUSP), Medical School; 4 Heart Institute- University of São Paulo (HCFMUSP), Medical School. INTRODUCTIO N Left ventricular hypertrophy (LVH) in athlete's heart is intermediate between concentric and eccentric, a fact partially determined by the specificity of the sport modality. Soccer matches is characterized by periods of high- and low- intensity activity and the effect of this long- term intermittent exercise in athlete's cardiac structure is highly variable. PURPOSE: To investigate the prevalence of long-term intermittent exercise- induced eccentric or concentric left ventricular hypertrophy in Brazilian professional soccer players. RESULTS Table 1. Echocardiographic parameters in 236 brazilian professional soccer players according to the type of left ventricular hypertrophy. CLVH ELVH NLVH P METHODS In the course of 36 months, 231 soccer players (age= 21.8 ± 0.2 years; body weight= 75.0 ± 0.5 kg) representing the Corinthians team were included in this study. Dopplerechocardiography was used to assess athlete s heart at rest and also for the differentiation of concentric LVH (ventricular mass index (VMI) > 134 g/m 2 and relative wall thickness (RWT) > 0.45) and eccentric LVH (VMI > 134 g/m 2 and RWT < 0.45). VMI (g/m 2 ) 143.6 ± 3.0 143.5 ± 1.6 109.1 ± 1.1 * RWT 90 0.45 ± 80 0.0ą 60 LVEF (%) 68.2 ± 0.3 67.0 ± 1.2 66.7 ± 0.3 NS 50 % 100 70 40 0.001 87.9% 0.36 ± 0.0 0.35 ± 0.0 0.001 30 VMI= ventricular 20 mass index; 1.7% RWT= relative wall thickness; LVEF= left ventricular ejection 10 fraction; NS= not significant. *P <0.05 different from CLVH; P <0.05 different from ELVH; ą P <0.05 0 different from NLVH. Values are expressed as mean ± SEM. 10.4% CLVH ELVH NLVH Figure 1. Prevalence of left- ventricular hypertrophy in professional elite soccer players. CLVH= concentric left-ventricular hypertrophy; ELVH= eccentric left- ventricular hypertrophy; NLVH= no left- ventricular hypertrophy. CONCLUSION - All data are presented as mean + SE. One-way analysis of variance was performed to compare echocardiographic parameters among groups. P<0.05 was considered statistically significant. If significance was obtained, Scheffés post hoc was performed. Our findings showed lower prevalence to both concentric and eccentric LVH and preserved cardiac contractility and function with the predominance of eccentric LVH. LV quantitative analysis did not exceed normal limits or extend into the borderline gray zone in any brazilian professional soccer players, which characterized physiological adaptation.
Diagnóstico Diferencial Pelliccia A et col. CMH e MCPd ZONA CINZA? CORAÇÃO ATLETA 13-15 mm 60-70 mm + modelo não usual HVE - + cavidade vent < 45 mm - - cavidade ventricular > 45 mm + + AE>45mm - + modelo bizarro ECG - + enchimento VE anormal - + sexo feminino - - espessura c/ descondic. + + H FAM+ CMH - + SAM valva mitral ( CMHO ) - VO 2 max > 45 ml/kg/min +
MORTE SÚBITA
FOE - seleção de Camarões 2003 Feher - Benfica jan 2004
Athlete s Heart and Risk of Sports Morte súbita em atletas jovens Maior ocorrência em esportes de maior intensidade (futebol americano, basquete e futebol de campo) Mais frequente no sexo maculino (9:1) Prevalência desproporcional em negros relacionada a MCH não diagnosticada Outros riscos Maron e Pelliccia, 2006
Maron e Pelliccia, 2006 CAUSAS DE MORTE SÚBITA Morte súbita em atletas jovens Mecanismos e causas:
MIOCARDIOPATIA HIPERTRÓFICA
DISPLASIA ARRITMOGÊNICA DE VD
ORIGEM ANÔMALA DE CORONÁRIAS
CONCLUSÃO Como minimizar risco de morte súbita? Periódica e adequada avaliação CV Medidas emergenciais: TREINAMENTO DOS PROFISSIONAIS EQUIPAMENTOS TRABALHO EM EQUIPE
Periódica e adequada avaliação cardiovascular
MEDIDAS EMERGENCIAIS
TREINAMENTO DE PROFISSIONAIS - BLS
DEA DEA (desfibrilador automático externo) AUTO PULSE
TRABALHO EM EQUIPE OBRIGADO!