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

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

CHD: explosive growth University Hospitals Leuven 10790 Alive 500 In continuous follow-up 6146 N = 17436 0 5000 10000 15000 < 15 y range 15 - 16 y > 16 y Data on file 2014

CHD: explosive growth 3500 Outpa)ent visits 3000 2500 2000 1500 1000 500 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Data on file 2016

First problem: body weight Pinto et al. Pediatrics 2007

Second problem: aging University Hospitals Leuven Alive (in FU - dismissed) Age categories N = 37293 Data on file 2014

Increase of risk factors

Third problem: no advice Daily 30 min moderate physical acitvity Dua et al. Eur J Cardiovasc Prev Rehabil 2007

Third problem: no advice Overprotection Dua et al. Eur J Cardiovasc Prev Rehabil 2007

4th problem: beyond limits Uncertainty about allowed physical activities Data based on experience

Are there no guidelines? ESC recommendations (1) ESC recommendations (2) Physical activity Recreational sports Competitive sports Elite ESC consensus (3) ESC consensus (3) „New recommendations“ (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

Are there no guidelines? Children ESC recommendations (1) ESC recommendations (2) Physical activity Recreational sports Competitive sports Elite ESC consensus (3) ESC consensus (3) „New recommendations“ (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

Are there no guidelines? Professionals Children ESC recommendations (1) ESC recommendations (2) Physical activity Recreational sports Competitive sports Elite ESC consensus (3) ESC consensus (3) „New recommendations“ (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

Are there no guidelines? Professionals Children ESC recommendations (1) ESC recommendations (2) Physical activity Recreational sports Competitive sports Elite ESC consensus (3) ESC consensus (3) „New recommendations“ Specified by anatomy (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

Are there no guidelines? Professionals Children ESC recommendations (1) ESC recommendations (2) Physical activity Recreational sports Competitive sports Elite ESC consensus (3) ESC consensus (3) „New recommendations“ Specified by anatomy (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

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

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

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

The council

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

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

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

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

Pressure load Concentric hypertrophy Mitchell et al. J Am Coll Cardiol 2005

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

Relative intensity Kempny et al. Eur Heart J 2012

Aim and innovation • The hemodynamic and electrophysiological status determines the degree of the static component of the physical activity Intensive golf versus • The intensity of each type of physical activity is Moderate cycling determined by the degree of individual cardiovascular fitness Dynamic component ≈ intensity of the activity Relative intensity

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

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

Step 1 • History, anamnesis and physical examination Complete medical history Knowledge about the defect and its (late) complications Syncope, presyncope Dyspea Palpitations Chest pain … Symptoms do not Physical examination per se exclude ≈ underlying defect physical activity!!

Step 2 • Assessment of five baseline parameters 1. Ventricular function 2. Pulmonary artery pressure 3. Aorta 4. Arrhythmia 5. Saturation

Step 2 • Assessment of five baseline parameters 1. Ventricular function 2. Pulmonary artery pressure 3. Aorta 4. Arrhythmia 5. Saturation

Step 2 • Assessment of five baseline parameters 1. Ventricular function 2. Pulmonary artery pressure 3. Aorta 4. Arrhythmia 5. Saturation

1. Ventricles No systolic dysfunc)on No systolic dysfunc)on Mild systolic dysfunc)on Moderate systolic Severe systolic dysfunc)on dysfunc)on No hypertrophy No hypertrophy Mild hypertrophy Moderate hypertrophy Severe hypertrophy No pressure load Mild pressure load Moderate pressure load Severe pressure load No volume load Mild volume load Moderate/severe volume load Single ventricle physiology Systemic right ventricle 2. Pulmonary Low pulmonary artery Low pulmonary artery Mildly elevated Moderately/severely elevated artery pressure pressure pressure pulmonary artery pressure 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 Significant arrhythmic burden Non-malignant arrhythmia Malignant arrhythmia 5. Satura)on at No central cyanosis No central cyanosis No central cyanosis Central cyanosis rest/during exercise Budts et al. Eur Heart J 2013

Step 3 • Type of exercise o Low static o Moderate static o High static Mitchell et al. JACC 205