[PPT] - Recommenda)ons regarding sports and rehabilita)on in CHD: do they PowerPoint Presentation

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Recommenda)ons regarding sports and rehabilita)on in CHD: do they resist the trials?

Werner Budts Structural and Congenital Cardiology University Hospitals Leuven Department of Cardiovascular Sciences

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CHD: explosive growth

5000 10000 15000 6146 500 10790 < 15 y range 15 - 16 y > 16 y University Hospitals Leuven Alive In continuous follow-up N = 17436

Data on file 2014

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CHD: explosive growth

Data on file 2016

500 1000 1500 2000 2500 3000 3500 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Outpa)ent visits

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First problem: body weight

Pinto et al. Pediatrics 2007

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Second problem: aging

University Hospitals Leuven Alive (in FU - dismissed) Age categories N = 37293

Data on file 2014

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Increase of risk factors

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Third problem: no advice

Daily 30 min moderate physical acitvity

Dua et al. Eur J Cardiovasc Prev Rehabil 2007

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Third problem: no advice

Overprotection

Dua et al. Eur J Cardiovasc Prev Rehabil 2007

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4th problem: beyond limits

Data based on experience

Uncertainty about allowed physical activities

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Are there no guidelines?

Physical activity Competitive sports Elite Recreational sports ESC recommendations (2) ESC consensus (3) ESC consensus (3) „New recommendations“ ESC recommendations (1) (1) Takken et al. Eur J Cardiovasc Prev Rehabil 2011 (2) Pelliccia et al. Eur Heart J 2005 (3) Hirth et al. Eur J Cardiovasc Prev Rehabil 2006

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Are there no guidelines?

Physical activity Competitive sports Elite Recreational sports ESC recommendations (2) ESC consensus (3) ESC consensus (3) „New recommendations“ ESC recommendations (1) (1) Takken et al. Eur J Cardiovasc Prev Rehabil 2011 (2) Pelliccia et al. Eur Heart J 2005 (3) Hirth et al. Eur J Cardiovasc Prev Rehabil 2006

Children

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Are there no guidelines?

Physical activity Competitive sports Elite Recreational sports ESC recommendations (2) ESC consensus (3) ESC consensus (3) „New recommendations“ ESC recommendations (1) (1) Takken et al. Eur J Cardiovasc Prev Rehabil 2011 (2) Pelliccia et al. Eur Heart J 2005 (3) Hirth et al. Eur J Cardiovasc Prev Rehabil 2006

Children Professionals

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Are there no guidelines?

Physical activity Competitive sports Elite Recreational sports ESC recommendations (2) ESC consensus (3) ESC consensus (3) „New recommendations“ ESC recommendations (1) (1) Takken et al. Eur J Cardiovasc Prev Rehabil 2011 (2) Pelliccia et al. Eur Heart J 2005 (3) Hirth et al. Eur J Cardiovasc Prev Rehabil 2006

Children Professionals Specified by anatomy

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Are there no guidelines?

Physical activity Competitive sports Elite Recreational sports ESC recommendations (2) ESC consensus (3) ESC consensus (3) „New recommendations“ ESC recommendations (1) (1) Takken et al. Eur J Cardiovasc Prev Rehabil 2011 (2) Pellicia et al. Eur Heart J 2005 (3) Hirth et al. Eur J Cardiovasc Prev Rehabil 2006

Children Professionals Specified by anatomy

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Daily practice

Eisenmenger patient
Yes: low dynamic sports ex. rock climbing
No: high dynamic sports ex. cycling
ASD patient with pulmonary hypertension
Yes: no restrictions
TOF repair with severe PI but normal RV function
Yes: low to moderate dynamic and static sports ex. running
No: high dynamic sports ex. badminton

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Eisenmenger patient
Yes: low dynamic sports ex. rock climbing
No: high dynamic sports ex. cycling
ASD patient with pulmonary hypertension
Yes: no restrictions
TOF repair with severe PI but normal RV function
Yes: low to moderate dynamic and static sports ex. running
No: high dynamic sports ex. badminton

Daily practice

ASD with PH TOF with optimal repair

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Daily practice

Eisenmenger patient
Yes: low dynamic sports ex. rock climbing
No: high dynamic sports ex. Cycling
ASD patient (with pulmonary hypertension)
Yes: no restrictions
TOF repair with severe PI but normal RV function
Yes: low to moderate dynamic and static sports ex running
No: high dynamic sports ex badmington

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The council

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Position paper

Physical activity in adolescents and adults with congenital heart defects; individualized exercise prescription (to maximize benefit and minimize risk)

Working Group of Grown Up Congenital Heart Disease Section of Sports Cardiology of the EACPR

Werner Budts Leuven, Belgium Massimo Chessa Milan, Italy Pedro Trigo Trindade Petit-Lancy, Swi`erland Gary Webb Ohio, United States Johan Holm Lund, Sweden Mats Börjesson Stockholm, Sweden Frank van Buuren Bad Oeynhausen, Germany Domenico Corrado Padova, Italy Hein Heidbuchel Leuven, Belgium Michael Papadakis London, UK

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Aim and innovation

To produce clear, concise and practical

recommendations, pertinent to the majority of adolescents and adults with ACHD, which can be used as an everyday clinical tool

Recommendations are aimed at congenital

heart disease specialists

ACHD patients with mild disease are frequently

managed by non-specialists

Budts et al. Eur Heart J 2013

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Aim and innovation

The hemodynamic and electrophysiological

status determines the degree of the static component of the physical activity

The intensity of each type of physical activity is

determined by the degree of individual cardiovascular fitness

Budts et al. Eur Heart J 2013

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Aim and innovation

The hemodynamic and electrophysiological

status determines the degree of the static component of the physical activity

The intensity of each type of physical activity is

determined by the degree of individual cardiovascular fitness

Static component of exercise ≈ pressure load Protect myocardium and great vessels in pressure loading defects

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Pressure load

Mitchell et al. J Am Coll Cardiol 2005

Concentric hypertrophy

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Aim and innovation

The hemodynamic and electrophysiological

status determines the degree of the static component of the physical activity

The intensity of each type of physical activity is

determined by the degree of individual cardiovascular fitness

Dynamic component ≈ intensity of the activity Relative intensity

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Relative intensity

Kempny et al. Eur Heart J 2012

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Aim and innovation

The hemodynamic and electrophysiological

status determines the degree of the static component of the physical activity

The intensity of each type of physical activity is

determined by the degree of individual cardiovascular fitness

Dynamic component ≈ intensity of the activity Relative intensity Intensive golf versus Moderate cycling

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Six steps plan

Step 1: History, anamnesis and physical examina)on Step 2: Assessment of five baseline parameters Step 3: Recommenda)on: type of exercise Step 4: (CP)ET Step 5: Recommenda)on: rela)ve intensity Step 6: Follow-up Budts et al. Eur Heart J 2013

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Step 1

History, anamnesis and physical examination

Complete medical history Knowledge about the defect and its (late) complications Syncope, presyncope Dyspnea Palpitations Chest pain … Physical examination ≈ underlying defect

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Step 1

History, anamnesis and physical examination

Complete medical history Knowledge about the defect and its (late) complications Syncope, presyncope Dyspea Palpitations Chest pain … Physical examination ≈ underlying defect Symptoms do not per se exclude physical activity!!

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Step 2

Assessment of five baseline parameters

1. Ventricular function 2. Pulmonary artery pressure 3. Aorta 4. Arrhythmia 5. Saturation

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Step 2

Assessment of five baseline parameters

1. Ventricular function 2. Pulmonary artery pressure 3. Aorta 4. Arrhythmia 5. Saturation

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Step 2

Assessment of five baseline parameters

1. Ventricular function 2. Pulmonary artery pressure 3. Aorta 4. Arrhythmia 5. Saturation

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1. Ventricles

No systolic dysfunc)on No hypertrophy No pressure load No volume load No systolic dysfunc)on No hypertrophy Mild pressure load Mild volume load Mild systolic dysfunc)on Mild hypertrophy Single ventricle physiology Systemic right ventricle Moderate systolic dysfunc)on Moderate hypertrophy Moderate pressure load Severe systolic dysfunc)on Severe hypertrophy Severe pressure load Moderate/severe volume load

2. Pulmonary

artery pressure Low pulmonary artery pressure Low pulmonary artery pressure Mildly elevated pulmonary artery pressure Moderately/severely elevated pulmonary artery pressure

3. Aorta

No/mild dilata)on Moderate dilata)on Severe dilata)on Dilata)on approaching indica)on for repair

4. Arrhythmia

No arrhythmia No arrhythmia Mild arrhythmic burden Non-malignant arrhythmia Significant arrhythmic burden Malignant arrhythmia

5. Satura)on at

rest/during exercise No central cyanosis No central cyanosis No central cyanosis Central cyanosis

Budts et al. Eur Heart J 2013

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Step 3

Type of exercise
Low static
Moderate

static

High static

Mitchell et al. JACC 205

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1. Ventricles

No systolic dysfunc)on No hypertrophy No pressure load No volume load No systolic dysfunc)on No hypertrophy Mild pressure load Mild volume load Mild systolic dysfunc)on Mild hypertrophy Single ventricle physiology Systemic right ventricle Moderate systolic dysfunc)on Moderate hypertrophy Moderate pressure load Severe systolic dysfunc)on Severe hypertrophy Severe pressure load Moderate/severe volume load

2. Pulmonary

artery pressure Low pulmonary artery pressure Low pulmonary artery pressure Mildly elevated pulmonary artery pressure Moderately/severely elevated pulmonary artery pressure

3. Aorta

No/mild dilata)on Moderate dilata)on Severe dilata)on Dilata)on approaching indica)on for repair

4. Arrhythmia

No arrhythmia No arrhythmia Mild arrhythmic burden Non-malignant arrhythmia Significant arrhythmic burden Malignant arrhythmia

5. Satura)on at

rest/during exercise No central cyanosis No central cyanosis No central cyanosis Central cyanosis When all applicable When at least one applicable When at least one applicable Sta)c component

f sport

Up to high sta)c Up to moderate sta)c Low sta)c

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1. Ventricles

No systolic dysfunc)on No hypertrophy No pressure load No volume load No systolic dysfunc)on No hypertrophy Mild pressure load Mild volume load Mild systolic dysfunc)on Mild hypertrophy Single ventricle physiology Systemic right ventricle Moderate systolic dysfunc)on Moderate hypertrophy Moderate pressure load Severe systolic dysfunc)on Severe hypertrophy Severe pressure load Moderate/severe volume load

2. Pulmonary

artery pressure Low pulmonary artery pressure Low pulmonary artery pressure Mildly elevated pulmonary artery pressure Moderately/severely elevated pulmonary artery pressure

3. Aorta

No/mild dilata)on Moderate dilata)on Severe dilata)on Dilata)on approaching indica)on for repair

4. Arrhythmia

No arrhythmia No arrhythmia Mild arrhythmic burden Non-malignant arrhythmia Significant arrhythmic burden Malignant arrhythmia

5. Satura)on at

rest/during exercise No central cyanosis No central cyanosis No central cyanosis Central cyanosis When all applicable When at least one applicable When at least one applicable Sta)c component

f sport

Up to high sta)c Up to moderate sta)c Low sta)c

A B C D E

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Step 4

(Cardiopulmonary) exercise test
Peak oxygen consumption
Parameter of physical fitness (1) and outcome (2)
Maximal heart rate
Borg scale

(1) Frederiksen et al. Eur J Appl Physiol 1999 (2) Fernandes et al. Congenital Heart Dis 2011

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Step 4

(Cardiopulmonary) exercise test
Transcutaneous oxygen saturation
If present, reenter the algorithm
Rhythm and conduction disorders
Induced arrhythmia increases risk of sudden death 6.6

fold (1)

When treatment is established, reenter the algorithm
Blood pressure evolution
Normal rise in systolic blood pressure (≥ 25 mmHg)
Blood pressure drop

(1) Koyak et al. Circulation 2012

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Step 5

Determine relative intensity

Oxygen consumption Heart rate Borg scale High intensity Moderate intensity Low intensity

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1. Ventricles

No systolic dysfunc)on No hypertrophy No pressure load No volume load No systolic dysfunc)on No hypertrophy Mild pressure load Mild volume load Mild systolic dysfunc)on Mild hypertrophy Single ventricle physiology Systemic right ventricle Moderate systolic dysfunc)on Moderate hypertrophy Moderate pressure load Severe systolic dysfunc)on Severe hypertrophy Severe pressure load Moderate/severe volume load

2. Pulmonary

artery pressure Low pulmonary artery pressure Low pulmonary artery pressure Mildly elevated pulmonary artery pressure Moderately/severely elevated pulmonary artery pressure

3. Aorta

No/mild dilata)on Moderate dilata)on Severe dilata)on Dilata)on approaching indica)on for repair

4. Arrhythmia

No arrhythmia No arrhythmia Mild arrhythmic burden Non-malignant arrhythmia Significant arrhythmic burden Malignant arrhythmia

5. Satura)on at

rest/during exercise No central cyanosis No central cyanosis No central cyanosis Central cyanosis When all applicable When at least one applicable When at least one applicable Sta)c component

f sport

Up to high sta)c Up to moderate sta)c Low sta)c

A B C D E

Rela)ve intensity

f sport

HIGH INTENSITY RPE Borg scale: 15-17 Training HR: 75%-90% of achieved MHR during CPET MODERATE INTENSITY RPE Borg scale: 13-14 Training HR: 60%-75% of achieved MHR during CPET LOW INTENSITY RPE Borg scale: 11-12 Training HR: <60% of achieved MHR during CPET

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1. Ventricles

No systolic dysfunc)on No hypertrophy No pressure load No volume load No systolic dysfunc)on No hypertrophy Mild pressure load Mild volume load Mild systolic dysfunc)on Mild hypertrophy Single ventricle physiology Systemic right ventricle Moderate systolic dysfunc)on Moderate hypertrophy Moderate pressure load Severe systolic dysfunc)on Severe hypertrophy Severe pressure load Moderate/severe volume load

2. Pulmonary

artery pressure Low pulmonary artery pressure Low pulmonary artery pressure Mildly elevated pulmonary artery pressure Moderately/severely elevated pulmonary artery pressure

3. Aorta

No/mild dilata)on Moderate dilata)on Severe dilata)on Dilata)on approaching indica)on for repair

4. Arrhythmia

No arrhythmia No arrhythmia Mild arrhythmic burden Non-malignant arrhythmia Significant arrhythmic burden Malignant arrhythmia

5. Satura)on at

rest/during exercise No central cyanosis No central cyanosis No central cyanosis Central cyanosis Rela)ve intensity

f sport

HIGH INTENSITY RPE Borg scale: 15-17 Training HR: 75%-90% of achieved MHR during CPET MODERATE INTENSITY RPE Borg scale: 13-14 Training HR: 60%-75% of achieved MHR during CPET LOW INTENSITY RPE Borg scale: 11-12 Training HR: <60% of achieved MHR during CPET When all applicable When at least one applicable When at least one applicable Sta)c component

f sport

Up to high sta)c Up to moderate sta)c Low sta)c Solid lines indicate recommenda)on ; if op)on for sports with high sta)c component, reduce intensity (do_ed lines)

A B C D E

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Step 5

Relative intensity
Frequency and duration
Combined minimum of 3 to 4.5 hours of physical activities
Minimum minutes per session shunt be 30 minutes
Habitual training will be necessary to achieve long-term

clinical benefit

Team sports
Participate in teams with similar physical fitness

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Step 6

New symptoms: discontinue physical activities

and reassess

Physical activities with medium or low intensity:

follow-up frequency as stated by the ESC GUCH guidelines (1)

Physical activities with regular high intensity:

follow-up frequency as recommended by the ESC guidelines for competitive and elite sports (2)

(1) Baumgartner et al. Eur Heart J 2010 (2) Pelliccia et al. Eur Heart J 2005

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1. Ventricles

No systolic dysfunc)on No hypertrophy No pressure load No volume load No systolic dysfunc)on No hypertrophy Mild pressure load Mild volume load Mild systolic dysfunc)on Mild hypertrophy Single ventricle physiology Systemic right ventricle Moderate systolic dysfunc)on Moderate hypertrophy Moderate pressure load Severe systolic dysfunc)on Severe hypertrophy Severe pressure load Moderate/severe volume load

2. Pulmonary

artery pressure Low pulmonary artery pressure Low pulmonary artery pressure Mildly elevated pulmonary artery pressure Moderately/severely elevated pulmonary artery pressure

3. Aorta

No/mild dilata)on Moderate dilata)on Severe dilata)on Dilata)on approaching indica)on for repair

4. Arrhythmia

No arrhythmia No arrhythmia Mild arrhythmic burden Non-malignant arrhythmia Significant arrhythmic burden Malignant arrhythmia

5. Satura)on at

rest/during exercise No central cyanosis No central cyanosis No central cyanosis Central cyanosis Rela)ve intensity

f sport

HIGH INTENSITY RPE Borg scale: 15-17 Training HR: 75%-90% of achieved MHR during CPET MODERATE INTENSITY RPE Borg scale: 13-14 Training HR: 60%-75% of achieved MHR during CPET LOW INTENSITY RPE Borg scale: 11-12 Training HR: <60% of achieved MHR during CPET When all applicable When at least one applicable When at least one applicable Sta)c component

f sport

Up to high sta)c Up to moderate sta)c Low sta)c Solid lines indicate recommenda)on ; if op)on for sports with high sta)c component, reduce intensity (do_ed lines)

A B C D E

Eisenmenger patient

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1. Ventricles

No systolic dysfunc)on No hypertrophy No pressure load No volume load No systolic dysfunc)on No hypertrophy Mild pressure load Mild volume load Mild systolic dysfunc)on Mild hypertrophy Single ventricle physiology Systemic right ventricle Moderate systolic dysfunc)on Moderate hypertrophy Moderate pressure load Severe systolic dysfunc)on Severe hypertrophy Severe pressure load Moderate/severe volume load

2. Pulmonary

artery pressure Low pulmonary artery pressure Low pulmonary artery pressure Mildly elevated pulmonary artery pressure Moderately/severely elevated pulmonary artery pressure

3. Aorta

No/mild dilata)on Moderate dilata)on Severe dilata)on Dilata)on approaching indica)on for repair

4. Arrhythmia

No arrhythmia No arrhythmia Mild arrhythmic burden Non-malignant arrhythmia Significant arrhythmic burden Malignant arrhythmia

5. Satura)on at

rest/during exercise No central cyanosis No central cyanosis No central cyanosis Central cyanosis Rela)ve intensity

f sport

HIGH INTENSITY RPE Borg scale: 15-17 Training HR: 75%-90% of achieved MHR during CPET MODERATE INTENSITY RPE Borg scale: 13-14 Training HR: 60%-75% of achieved MHR during CPET LOW INTENSITY RPE Borg scale: 11-12 Training HR: <60% of achieved MHR during CPET When all applicable When at least one applicable When at least one applicable Sta)c component

f sport

Up to high sta)c Up to moderate sta)c Low sta)c Solid lines indicate recommenda)on ; if op)on for sports with high sta)c component, reduce intensity (do_ed lines)

A B C D E

ASD with mildly elevated PAP

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1. Ventricles

No systolic dysfunc)on No hypertrophy No pressure load No volume load No systolic dysfunc)on No hypertrophy Mild pressure load Mild volume load Mild systolic dysfunc)on Mild hypertrophy Single ventricle physiology Systemic right ventricle Moderate systolic dysfunc)on Moderate hypertrophy Moderate pressure load Severe systolic dysfunc)on Severe hypertrophy Severe pressure load Moderate/severe volume load

2. Pulmonary

artery pressure Low pulmonary artery pressure Low pulmonary artery pressure Mildly elevated pulmonary artery pressure Moderately/severely elevated pulmonary artery pressure

3. Aorta

No/mild dilata)on Moderate dilata)on Severe dilata)on Dilata)on approaching indica)on for repair

4. Arrhythmia

No arrhythmia No arrhythmia Mild arrhythmic burden Non-malignant arrhythmia Significant arrhythmic burden Malignant arrhythmia

5. Satura)on at

rest/during exercise No central cyanosis No central cyanosis No central cyanosis Central cyanosis Rela)ve intensity

f sport

HIGH INTENSITY RPE Borg scale: 15-17 Training HR: 75%-90% of achieved MHR during CPET MODERATE INTENSITY RPE Borg scale: 13-14 Training HR: 60%-75% of achieved MHR during CPET LOW INTENSITY RPE Borg scale: 11-12 Training HR: <60% of achieved MHR during CPET When all applicable When at least one applicable When at least one applicable Sta)c component

f sport

Up to high sta)c Up to moderate sta)c Low sta)c Solid lines indicate recommenda)on ; if op)on for sports with high sta)c component, reduce intensity (do_ed lines)

A B C D E

TOF repair with severe PI but normal RV function, no significant dilatation

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Limitations

Consensus paper – level C of evidence
No scientific data to rely on
Diversity of ACHD patients does create a gray

zone

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Conclusions

Consensus document offers a platform for

uniformed advice for physical activity in CHD patients

This document will require fine tuning in the

future, but starting with a first draft sounds useful

The document might offer a frame for

prospective randomized trials to achieve increasing levels of evidence

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