1. ΑΣΘΕΝΗΣ ΜΕ ΚΟΙΛΙΑΚΕΣ ΑΡΡΥΘΜΙΕΣ
Διαγνωστικη προσπελαση και διαχειριση ασθενων με μυοκαρδιοπαθεια στην πραξη
ΑΣΘΕΝΗΣ ΜΕ ΚΟΙΛΙΑΚΕΣ ΑΡΡΥΘΜΙΕΣ
Κυριακός Γιάγκου MD, MSc (sports cardio), FESC, FACC
Καρδιολόγος
Γραμματέας, Καρδιολογική Εταιρεία Κύπρου

2. Δεν υπαρχει συγκρουση συμφεροντων

3. Case presentation Male, 24 yo, caucasian Track athlete - runner
Palpitation

4. INTERNATIONAL RECOMMENDATIONS 2017
Sharma S et al JACC 2017;69:

6. RWT = ( )/56.3
= 0.43
RWT = ( )/40
= 0.68
Relative Wall Thickness (IVSD + PWD / LVEDD) > 0.45 suggests pathology
Eur J Echocardiography 2009;10:

8. Ventricular ectopy and Ventricular Tachycardia
Common in athletes
Strategy
Normal or abnormal cardiac structure
Determine location
Multiple foci
Burden
Effect of exercise
Sustained arrhythmia
Low burden VE’s are relatively common in athletes across the age groups
Of importance as it may be associated with underlying structural disease
A comprehensive strategy is to determine the presence of either myocardial disease or coronary abnormalities, the precise location of the the ve’s, whether multiple foci exists, overall burden the effect of exercise and whether sustained arrhythmias can be identified either on resting holter or with exercise testing***
Long term studies have shown that In the absence of structural disease the risk of sustained ventricular arrhythmias and this SCD is very low

9. Ventricular ectopy and Ventricular Tachycardia
Cardiac MRI, exercise testing, electrophysiological studies, coronary evaluation
“Normal heart VT” – 10% of all VT
Single focus – RVOT is a common site (70%) – LBBB & Inferior or RAD
Amenable to ablation – can compete 2-4 weeks post procedure
Medical therapy – 2 -3 month restriction
The full battery of tests are required to identify structural anomalies
In the absence of any structural or channel disorder this may considered Normal heart VT or idiopathic VT
The rvot is a common site for idiopathic VT and is thus amenable to ablation which can be potentially curative
If the athlete choose a conservative approach – a 2-3 month restriction on any sport is in place with exercise testing before they can compete

10. Ventricular Arrhythmias and Athlete’s Heart
50 out of 70 athletes (71%) with full or partial reversibility after 3 months
(< 500 PVD’s – no NSVT)
Biffi A et al. J Am Coll Cardiol 2004;44:

11. Ventricular Arrhythmias and LV Mass
Biffi A et al. Am J Cardiol 2008;101:

12. Elliott PM et al. Lancet 2001;357:420-424
HCM: LVH and Risk of Malignant Arrhythmias
Spirito P et al. N Engl J Med 2000;342:
Elliott PM et al. Lancet 2001;357:

13. LVWT in male black and white athletes
LVWT in female black and white athletes
12.4%
1.6%
Papadakis M et al. Eur Heart J 2011;32:
Rawlins J et al. Circulation 2010;121: )

14. HCM

15. Elliott P, Anastasakis A et al EHJ 2014;35:2733-2779

16. Is Exercised Induced Cardiac Hypertrophy Always Beneficial and Benign ?
A Potential Substrate for Arrhythmias
LVH alters ion channel expression and function
Reduction in the transient outward K+ currents (Ito)
Reduced density L-type calcium channel (ICa)
Prolongation of the action potential duration
McIntosh MA et al. J Mol Cell Cardiol. 1998;8:
Heterogeneous process throughout the myocardium
Marked dispersion of repolarisation
Re-entry arrhythmias  Ventricular fibrillation
Bacharova L et al J Electrocardiol 2016;49:
Kim N et al Cir Res 2008;93:
Lin X et al J Cardiovasc Trans Res 2013;4:
Huenecke R et al J Mol Cell Cardiol 2017;103:93-101

17. Cardiac adaptation to exercise
Electrical
Functional
Sinus bradycardia
Voltage for chamber enlargement
Repolarisation anomalies
Structural
Increased cavity size
Increased wall thickness

18. Ventricular arrhythmia
Adverse atrial remodelling
Atrial fibrillation
High degree AV block
Intense Training
Myocyte necrosis
(cTn rise)
LVH (patho or physio)
Ventricular arrhythmia
Myocardial scars / fibrosis
Dilated Cardiomyopathy
Acquired ARVC

19. La Gerche A et al 2015;130:

20. La Gerche A et al 2015;130:

21. conclusions Athletes often have ventricular arrhythmias Mostly benign
Normally warrant further investigation
Differentiate physiology from pathology may be difficult and challenging / athletic cardiomyopathy?

22. ευχαριστω πολυ