Prof. Dato’ Seri Dr Jeffrey Jeswant Dillon, Director of Cardiovascular Sports & Fitness
Sports cardiology is one of the rapidly growing subspecialties of cardiology that is now advancing for the care of athletes and active individuals who are known to have diagnosed heart ailments and also for those with undiagnosed cardiovascular conditions. The target population include competitive athletes, active sports enthusiasts and also those sedentary individuals who endeavour to start sports and exercise for the first time. The sports cardiology team includes those with expertise in cardiology, cardiothoracic surgery, paediatric cardiology, especially congenital heart disease and genetic diseases, cardiovascular imagers, electrophysiologists, heart failure specialists and exercise physiologists.
The effects of working out your heart can be categorised into three categories. The good, the bad and the ugly. The good characterises include the benefits of exercising and staying active for the heart. The bad could indicate the development of the athlete’s heart syndrome, that may confuse accurate diagnosis if unrecognised and may lead to unnecessary concern and treatment strategies. Finally, the ugly comprises the sudden death syndrome while exercising.
It is important to know the mechanism behind these classifications. The positive benefits of regular exercise and sports include good control of body weight, blood sugar, cholesterol and blood pressure, all of which collectively reduces the risks of heart attack and stroke to the individual. Exercise also reduces anxiety and depression leading to beneficial mental health wellbeing. The term the athlete’s heart refers to the normal physiological changes the heart undergoes in a person who regularly does strenuous aerobic/endurance exercise such as high intensity running, cycling or swimming and also in those who do high intensity power/resistant training exercises such as weight lifting. For the endurance athletes the heart chambers may adapt to be larger (dilatation) in response to the prolonged exercise stimulus, while for the power athletes their heart muscles may get thicker (hypertrophy). It is important to recognise that these changes within the heart chambers and muscles are largely normal responses to exercise and not to be confused as being a pathological feature of organic heart disease that may cause anxiety to the athletes and worse still to physicians who might send them for further unnecessary investigations and treatment.
A not uncommon scenario that has been in the spotlight nowadays is endurance athletes, power athletes like bodybuilders and even amateur exercise enthusiasts collapsing with sudden death during exercise. The causes of sudden cardiac death in athletes can be broadly categorize according to their age groups; the senior (master) athletes above the age of 35 years and the young athletes have different aetiology for sudden cardiac arrest. In the master athletes’ group, atherosclerotic disease caused by deposit of cholesterol plaques in the coronary arteries is the most common risk factor for acute myocardial infarct (heart attack) leading to sudden cardiac death (SCD). The common risk factors to develop atherosclerosis and heart attack include hypercholesterolaemia, obesity, hypertension, diabetes mellitus, smoking, a strong family history and sedentary lifestyle.
Hypercholesterolaemia is identified by having a high level of total and LDL cholesterol in the blood leading to cholesterol plaque build-up in arteries in the body including the coronary arteries of the heart and when present, is typically treated by statin group of medications. Statin related muscle fatigue may be more common amongst athletes. Hence treatment with lipid lowering agents should be stratified according to the coronary disease risk profile and balanced against side effects and exercise/sporting targets. Athletes who have undergone acute coronary events should be encouraged to continue to participate in a cardiac rehabilitation program and return to active exercise and sports under the supervised care of a sports cardiologist.
Hypertension is a common cardiovascular condition, even amongst the healthy athletic population. A thorough evaluation of an athlete should involve a detailed history and measurement of their blood pressure during each visit. Measurements of blood pressure during exercise may be useful in diagnosing those with concealed hypertension or to help evaluate effectiveness of ongoing treatment. Depending on the extent of the elevated blood pressure, some athletes would be restricted from sports with particularly high static strain, for example, weightlifting or martial arts, until hypertension is controlled.
In the young athletes, the causes of sudden cardiac death differ from their more senior counterparts. The common causes in the apparently young fit individuals include hypertrophic cardiomyopathy (HCM), anomalous coronary arteries, long QT syndrome, heart valve diseases, diseases of the aorta and myocarditis. Hypertrophic cardiomyopathy (HCM) is a genetic condition that causes the heart muscle to enlarge and may obstruct blood flow out of the heart, leading to abnormal heart rhythm (arrhythmia), heart failure and sudden death. Long QT syndrome is another genetic disorder where abnormality of the electrical system of the heart may trigger arrhythmia during exercise and stress which may be fatal. Anomalous origins of coronary arteries from the aorta is a congenital condition that may cause chest pain or sudden cardiac arrest during exercise. These group of young athletes may be suspected to have these dangerous but treatable conditions if they present with symptoms of chest pain, breathlessness or fainting. Those that are symptomatic or have an episode or resuscitated cardiac arrest or a family history of sudden death are recommended to be fully evaluated and monitored by a sports cardiologist team for diagnosis, treatment and rehabilitation for safe return to play.
When an athlete presents with symptoms of chest pain, breathlessness or syncope (fainting), it could be due to benign and malignant causes. Chest pain and syncope or near syncope during exercise or sports events typically warrant immediate restriction from sport and evaluation. Syncope and presyncope can be physiologic responses to exercise such as vasodilation and blood pooling that can lead to excessive fall in blood pressure (BP) when an upright position is assumed. Athletes over the age of 35 are more likely to present with atherosclerosis as the underlying cause. Evaluation should highlight whether symptoms occurred during or after exercise with the latter more likely to be benign. A detailed physical examination and other tests should include the ECG, echocardiography, ambulatory rhythm monitoring and maximal exercise tolerance test. Basic laboratory evaluations should be performed to rule out anaemia, thyroid disorder and other metabolic abnormalities. In addition, ECG, echocardiogram and maximal effort exercise stress test are recommended as part of a complete work-up.
We must be mindful that active individuals are not immune to heart conditions that may endanger lives during physical activities. Hence, before embarking on strenuous exercise, it is vital to get your heart health checked. At IJN we offer Active Fitness Screening program. This package encompasses general assessment, cardiac service investigation, physiotherapy, laboratory tests, consultation by cardiology clinical specialist, refreshment and finally with the report summary.
In the sports world, a healthy heart equals optimum performance. Whether an individual is a professional or an amateur, IJN also offers Active Plus Endurance Screening programme which helps to determine the risk of heart problems, and helps to measure fitness levels and offers a sport prescription to keep you at the top of your game. This screening plan encompasses general assessment, cardiac service investigation that includes electrocardiogram, VO2 Max and 2D echocardiogram, imaging investigation, physiotherapy, laboratory tests, consultation by cardiology clinical specialist, consultation by sports medicine specialist, refreshments and finally with the report summary.
At IJN sports cardiology clinic, we offer evaluation by a cardiologist and an exercise physiologist. They will carry out a full clinical evaluation, including assessment of symptoms, medical and athletic history, and a comprehensive physical examination. A cardiopulmonary exercise test (PET/CDP/Vo2max) is an exercise test in which your lung and heart’ response to various levels of exercise will be tested. This test is the best test to measure how our heart and lungs cope with daily activity and exercise. This may help identify the reasons why exercise is difficult and may be causing breathlessness, disease progression and fitness levels.
In this test, you will be asked to run on a treadmill or pedal on a bicycle ergometer, while your heart beat rhythm and as well as breathing is measured. The intensity of this exercise will increase gradually and the total duration can vary from about 10 minutes to about 40 minutes. During this test, patients will be using a mask that measures oxygen use during exercise on a treadmill, bicycle or other device. This test provides comprehensive information on maximal heart rates, peak oxygen consumption (VO-2 max) and your anaerobic threshold.
In summary sports cardiology advocates for individuals how to be safe from cardiovascular events while they exercise and to prevent sudden cardiac arrest and death. We would encourage any individual above the age of 35 years to have at least one screening medical check-up before embarking on or chasing your sporting ambitions. Younger athletes who are symptomatic or have a family history of sudden death are also advised to be evaluated to exclude cardiac abnormalities that may be dangerous if left unrecognized.
