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COMO IDENTIFICAR O ATLETA COM RISCO CARDIOLÓGICO

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COMO IDENTIFICAR O ATLETA COM RISCO CARDIOLÓGICO
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
fisiológicas e
por
várias
alterações
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 DM1,3, Dias MP1, DerTorossian SP1, Mastrorosa JD1, Faria PA2, Portella DL2, Shiraiwa R3, Grava J2.
1SantanaCor
Cardiology Clinic- São Paulo, Brazil; 2Sport Club Corinthians Paulista- São Paulo, Brazil; 3University of São Paulo (HCFMUSP), Medical School.
INTRODUCTIO
N
MF
LVMI
A
125
LVEDDI
B
*†
mm/m2
120
g/m2
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.
RESULTS
115
110
105
100
95
DE
*†
30
29
28
27
26
25
24
23
22
F
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.
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.
MF
A
O2 pulse
B
DE
F
*†
30
ml/bat
ml/kg/min
60
Peak VO2
55
50
25
*†
*†
*†
20
15
45
10
MF
DE
F
VAT
RCP
PEAK
Figure 2. Aerobic fitness and cardiovascular responses in professional elite soccer
players according to playing position. A) Peak VO2= peak oxygen consumption; B) O2
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.
CONCLUSION
- All data are presented as mean + SE. One-way analysis of variance was performed to
compare echocardiographic parameters and Peak VO2 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.
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
Septo 12mm
HIPERTROFIA
CONCÊNTRICA
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 PA2, Dias MP1, DerTorossian SP1, Mastrorosa JD1, Prado DM1,3, Dias RG4, Oliveira CB1, Grava J2, Stancati J2,
Galotti R2.
1SantanaCor
Cardiology Clinic- São Paulo, Brazil; 2Sport Club Corinthians Paulista- São Paulo, Brazil; 3University of São Paulo (HCFMUSP),
Medical School; 4Heart 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.
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).
RESULTS
Table 1. Echocardiographic parameters in 236 brazilian professional
soccer players according to the type of left ventricular hypertrophy .
CLVH
VMI (g/m2)
143.6 ± 3.0 143.5 ± 1.6
100
RWT
90
80
ELVH
0.45 ±
0.0ą†
NLVH
109.1 ±
1.1 *†
87.9%
0.36 ± 0.0 0.35 ± 0.0
P
0.001
0.001
70
60
%
LVEF (%)
50
68.2 ± 0.3
67.0 ± 1.2
66.7 ± 0.3
NS
40
30
10.4%
VMI= ventricular 20
mass index;
1.7% RWT= relative wall thickness; LVEF=
left ventricular ejection
fraction; NS= not significant. *P <0.05
10
different from CLVH; †P <0.05 different from ELVH; ą P <0.05
0
different from NLVH.
Values are expressed as mean ± SEM.
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
CAUSAS DE MORTE SÚBITA
Morte súbita em atletas jovens
Mecanismos e causas:
Maron e Pelliccia, 2006
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!
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