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Cardiovascular effects of strenuous exercise in adult recreational hockey: the Hockey Heart Study
Sanita Atwal, Jack Porter and Paul MacDonald
CMAJ February 05, 2002 166 (3) 303-307;
There is a well-known trend for adult hockey players of all skills to join recreational hockey leagues as they become too old to play in competitive leagues as they did in their youth. In Canada, there are more than 500 000 men who play in these leagues. The reality of these men’s leagues is that most of the players treat their one or two games a week as their only physical activity for the week. On top of this, they often only get about 2 minutes of light warm up as they get on the ice before the game.
This study recruited 113 male recreational league hockey players to see if this “weekend warrior” behavior had any negative cardiovascular effects on these types of players. In other words, to look at if doing high-intensity activity playing hockey once or twice a week without proper warm-up would cause a dangerous strain on these men’s cardiovascular systems. To do so, they looked at the baseline cardiac risk factors of the 113 volunteers (Table 1 below). As well, each one of the players underwent Holter electrocardiographic monitoring before, during and after at least one hockey game to assess the player’s heart rates, any occurrence of arrhythmias, ST-segment changes and for correlation with symptoms and other predictors of fitness.
When looking at the maximum heart rate the players reached in this study while playing, the mean maximum heart rate was 184 beats/min. General recommendations for healthy and safe physical activity in Canada recommends that the maximum heart rate that should be targeted during exercise to be between 65% to 85% of the age-predicted maximum heart rate (HRmax = heart rate of 220 – age in years). Studies have shown that anything of higher intensity causing the heart rate to go above this range can potentially to lead to an increase in frequency of cardiac events and sudden death. In this study, all of the players had a maximum attained heart rate higher than this suggested range of 65%-85% (Graph 1 below). Furthermore, the mean period for which these player’s heart rates exceeded 85% of the age-predicted maximum heart rate was 30 minutes. For 70.1 % of the player’s heart rates recovery was poor post-exercise. Non-sustained ventricular tachycardia was seen 2 Holter monitoring sessions, atrial fibrillation was seen in one subject and ST-segment depression in data from 15 sessions. However, of these patients with irregular heart rhythms, none had irregular follow-up cardiac stress work-ups.
This study suggests that the recreational hockey player faces an exercise intensity that can be dangerous to their health as seen in all the cases of this study. Even though each of the participants had higher than recommended maximum heart rates and some even had abnormal Holter findings there were no adverse events and no abnormal follow-up cardiac studies. Canadian exercise recommendations suggest at least 150 minutes of moderate to vigorous intensity aerobic physical activity per week, in bouts of 10 minutes or more. Studies have shown that engaging in 4 or more per week resulted in a reduced relative risk of myocardial infarction. Ideally, recreational ice hockey players as well as any high-intensity sports participant should be aware of these risks and should be advised by their primary care health providers to train their cardiovascular system gradually and regularly to be able to do this high-intensity exercise. It is often noted that when we get older playing high-intensity sports is a privilege and not a right; to continue to have the privilege of playing hockey, these “weekend warriors” should be encouraged to integrate regular cardiovascular exercise into their weekly routine. When we are young and in competitive leagues, we practice on a regular basis to prepare for our games. As adult athletes, we must take the same approach of preparation for our games but with the focus on exercise tolerance as oppose to on performance as is the case when we are younger.
Physiotherapist-Led Physical Activity Interventions Are Efficacious at Increasing Physical Activity Levels: A Systematic Review and Meta-analysis
Breanne E. Kunstler, MPhty, Jill L. Cook, PhD, Nicole Freene, PhD, Caroline F. Finch, PhD, Joanne L. Kemp, PhD, Paul D. O’Halloran, PhD, and James E. Gaida, PhD
As per the Canadian Institute for Health Information, in 2017, total health expenditures in Canada are expected to represent 11.5% of Canada’s gross domestic product (GDP). Physicians and health care professionals continue to promote preventative care as one way to tackle the ever-growing cost of health care. Primary prevention is generally low cost and has wide-reaching benefits. Specifically, physical activity has been shown to reduce the burden of disease and decrease the progression of many common non-communicable diseases (NCDs). In 2013, just over 2 in 10 adults and 1 in 10 children and youth in Canada met the Canadian Physical Activity Guidelines, which requires adults to achieve 150 to 300 minutes of moderate intensity of physical activity or 75 to 150 minutes of vigorous intensity physical activity, or an equivalent combination of both each week, as well as muscle-strengthening activities on at least 2 days each week. With so many people in Canada being physically inactive and with the rise in preventable diseases, primary care providers, including allied health professionals, have a critical role to promote physical activity and well-being. Physiotherapists are particularly well trained and positioned to promote physical activity in patients as their treatment plans often involve some type of physical activity.
This article did a systematic review of studies that assessed the efficacy of one-on-one, physiotherapist-led physical activity (PLPA) interventions at increasing physical activity levels among adults in clinic-based private practice, primary care, and outpatient settings. The eight studies that met this articles inclusion criteria looked at adults over the age of 18 who either had MSK injuries, risk factors for NCDs or who were suffering from NCDs. The studies either used subjectively (questionnaire) or objectively (accelerometry) quantified change in physically activity. A meta-analysis was conducted to look at the correlation of PLPA interventions at different follow-up times, as well as looking at success rates of PLPA interventions meeting minimum recommended physical activity levels. It also looked at the effect that the length of the therapy session had on the PLPA interventions success.
Looking at 3 out of the 8 studies included in the review, there was a significant finding that PLPA interventions were efficacious at assisting adults achieve the minimum recommended physical activity levels with an OR of 2.15. The other 5 studies included in the review showed a significant finding that PLPA interventions had only a small effect on patient’s physical activity level in short and medium term follow-up which was not seen past 1 year of follow-up. When comparing the length of intervention seen in the different studies there was no difference in efficacy of PLPA interventions on the improvement physical activity level. Overall, the improvement in PA seen by PLPA interventions ranged from increasing vigorous, moderate and low-intensity PA.
In this article, it was highlighted that there was a lack of analysis on the content as opposed to the length of the interventions. There was also no emphasis on the importance of maintaining the level of physical activity achieved over time. As it was shown, the benefits of the PLPA interventions were not seen in the majority of the studies in long-term follow-up. The one study that did use intervention techniques geared towards maintenance of PA improvements resulted in such maintenance. Even though there was improvement of PA in most patients who received PLPA, the benefits of preventative lifestyle changes such as PA is truly seen when maintained over time and integrated into a person’s weekly routine.
In summary, patients ultimately are responsible for the maintenance of their lifestyles. To help them integrate physical activity into their daily lives primary care providers can play an important role. This article shows that training physiotherapists and primary care health care professionals in behavioral changing counseling can help tackle the growing rate of inactivity and ultimately decrease the risks of NCDs.
- Moroz M.D.C.M. CCFP
Sport and Exercise Medicine Fellow, University of Ottawa
Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (CAC SEM), Dip Sport & Exercise Med
Statins are one of the most commonly prescribed medications. Studies have repeatedly demonstrated that the benefits of statins greatly outweigh any side effects, there is an ongoing concern that some patients may stop taking the drug after experiencing muscle pain or soreness. Interestingly, a new study has found that patients taking statins report no increase in muscle problems – if they are unaware that they are taking the drug.
Published in the The Lancet, the study out of Imperial College London, analyzed data from a large randomized clinical trial which looked at lowering cholesterol in more than 10,000 patients in the UK, Ireland and the Nordic regions over three years. What the researchers found suggests that cases of muscle pain and weakness in patients are unlikely to be directly caused by statins, but rather by the so-called “nocebo” effect, where the very expectation of side effects can make patients more likely to report them.
Quick to acknowledge that patients can experience very real pain because of the nocebo effect, lead author Peter Sever, MD, PhD, said that he hopes the study’s data will help persuade physicians and patients that exaggerated concerns about statins are not supported by the available scientific evidence. “We know there is a significant emergence of heart attacks, strokes and deaths in people who have stopped taking statins, who would benefit from them,” he said. “It’s a huge problem affecting tens if not hundreds of thousands of patients worldwide.”
[This article originally appeared in The Beat.]
Tom A Ranger, Andrea M Y Wong, Jill L Cook, Jamie E Gaida
Ranger TA et al. Br J Sports Med 2016; 50: 982-989
The prevalence of Diabetes in our population is increasing, as is the morbidity and mortality associated with this chronic disease. As a primary care provider, we are well aware of the role ‘lifestyle’ plays in the development and control of Type 2 diabetes mellitus. For this reason, the guidelines recommend exercise and diet as first line treatment for this condition. It has been shown that up to 50% of participants who quit exercise as part of their management do so because of musculoskeletal symptoms. So the question arises: Does tendinopathy, a condition that reduces exercise tolerance, have a role to play in lack of adherence to an exercise program in diabetics?
Earlier studies have shown that hyperglycemia does change the collagen cross-linking of tendons and reduced their proteoglycan content (Reddy, 2003) leading to weakened tendons and predisposing them to tendinopathy. This study investigated the potential association between diabetes and tendinopathy by systematically reviewing and meta-analysing case control, cross sectional, and studies that considered both of these conditions. In total 31 studies were selected for the final analysis with good attention paid to exclusion criteria and reduction of bias. Confounding variables were identified: age, sex, adiposity, statin use and hyperglycemia. There is observational evidence that statins may induce tendinopathy (Marie I, Arthritis Rheum 2008;59:367-72) as well as an association between adiposity and tendinopathy (Gaida, Arthritis Rheum 2009; 61 840-9).
This systematic review showed that “diabetics had greater than three times the odds of tendinopathy compared to controls; and people with tendinopathy had 1.3 times increased odds of diabetes compared to controls. Therefore there is evidence of a strong link between diabetes and tendinopathy however cause and effect cannot be established even though there are plausible biological pathways by which high blood glucose can affect tendon structures.” It was also shown that those diabetics with tendinopathy have had a longer duration of diabetes.
Regardless of the cofounders that may exist, the compelling evidence supports the link between diabetes and tendinopathy. This has important clinical implications such as careful monitoring and structuring of load progression when initiating exercise to prevent the development of tendinopathy. A slower, more graduated approach would be crucial for these patients. As well, those who have tendinopathy and require rehabilitation should ensure tight glycemic control to speed resolution.
“Co-management by medical and allied health practitioners may be indicated for people with tendinopathy and long standing diabetes.”
Keith Morgan BSC, MD, CCFP, Sport Medicine Fellow February 2017
Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Med
With populations aging in much of the world, the decline of mental capacity in later years is of increasing concern. There has been hope in the medical community that effectively treating hypertension and atherosclerosis could slow or delay this decline.
In the HOPE-3 clinical trial, a study of people over the age of 70 taking either blood pressure medication or statins for the prevention of heart disease, neither drug slowed cognitive decline during treatment. These results, presented at the American Heart Association 2016 Scientific Sessions, were disappointing for researchers looking to delay or even prevent the cognitive decline that comes with aging.
However, the findings were encouraging in one respect. There have been persistent concerns among patients and regulators that the use of statins to control cholesterol could negatively impact cognitive function and memory. The trial found that the patients taking statins did not have a larger decline in cognitive ability than other participants.
Patients were randomly assigned to receive either one of three drug regimens (combination blood pressure medication, a statin, or both) or to corresponding placebo groups. At the beginning and end of the study, 1,626 older adults completed several questionnaires and tests of mental processing speed and cognitive function.
While participants in all groups experienced a decline in cognitive function over the time of the study, there was no difference in the amount of this decline between treatment or placebo groups.
Data from the trial seemed to suggest that there might be some prevention of cognitive decline in patients with the highest blood pressure and LDL cholesterol levels at the start of the study, but this would need to be confirmed in other trials, said Jackie Bosch, PhD, of McMaster University, who presented the study results at AHA.
Dr. Bosch indicated that the results of this and other recent studies should put to rest concerns about statins and cognitive decline. “We have the data…that show that there is no adverse effect of statins” on cognition, she concluded.
[This article originally appeared in The Beat.]
Early Screening for Cardiovascular Abnormalities with Preparticipation Echocardiography: Feasibility study
Gleason, Kerkhof, Cilia, Lanya, Finnoff, Sugimoto, Corrado
Clin J Sport Medicine 2016; 0: 1-7
Sudden Cardiac Death (SCD) is estimated to occur between 1/40000 – 1/80000 of our young athletes. Although the incidence is uncommon, it remains a concern because the consequences are so tragic. So how should we screen our young athletes? This article aims to address this.
The traditional H&P often leads to a significant number of false positives and false negatives. The ECG has been mandated by the European Society of Cardiology and the IOC. This has led to a reduction of SCD in Italy by 90% however this effect has not been duplicated in North America. This is likely due to the fact that the etiology of SCD in Europe is arrhythmogenic RV cardiomyopathy whereas in North America the most common cause is structure cardiomyopathy (eg. HOCM). This is not picked up by the standard ECG. There has been an attempt to increase the sensitivity of ECG findings by using the ‘Seattle criteria’, however, there still appears to be some deficits with this method.
The American Heart Association has encouraged the investigation of a feasible and clinically relevant method to meet the shortcomings of the traditional H&P and ECG.
The ESCAPE protocol (Early Screening for Cardiac Abnormality with Pre-participation Echocardiography) attempts to meet this need. Essentially a front-line physician (non-cardiologist) performs an Echo of the heart using a portable ECHO to look for structural abnormalities in their athletes. Three measurements are taken: septal to free wall ratio <1.3; a septal thickness of >15mm, and/or a hypertrophied LV. It has been shown that there is no significant difference between a cardiologist and a non-cardiologist in gathering these measurements with accuracy.
This study chose to compare the time it takes to perform H&P vs ECG vs Echo as the primary outcome regarding feasibility. They found on average the H+P and ECG took approximately 4 min each and the ECHO averaged approximately 2min 17 sec which is statistically significant. The goal of the ECHO screen is to determine who needs a formal CV workup, not to diagnose HOCM. One of the limitations of this study was its small sample size of n=35. Some barriers to successful implementation of ECHO screening would be physician training, and accessibility to portable ECHOs. However, access to improved diagnostic modalities may improve in the future allowing our screens to be more cost effective, as well as more reliable and accurate.
In summary, the writers felt that the portable ECHO is feasible and accurate if used for CV screening in our athletes. Primary outcome of ‘physician time’ needed to screen is significantly less than that required of an H&P and/or ECG. Secondary outcomes are also encouraging. This included a reduction of false positive and false negative rates of ECG’s and H&P’s that led to unnecessary testing and costs. They conclude that a directed physical exam, a rhythm strip, and a portable ECHO screen may be the answer to the question, “How do we as healthcare providers best screen athletes at risk for Sudden Cardiac Death?”
View original research (PDF): Early_screening_for_cardiovascular_abnormalities-99503
Article summarized and presented by:
Keith Morgan BSc, MD, CCFP
Sport and Exercise Medicine Fellow
University of Ottawa.
Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (CAC SEM), Dip Sport & Exercise Medicine
Cigarette smokers face twice the risk of heart disease compared with non-smokers, and most of them—more than 60%—want to quit. Unfortunately, the likelihood of success for those who attempt to quit on their own is dismal: fewer than 5% will remain tobacco-free one year later.
But “with effective treatments, we can quadruple or quintuple or even sextuple the success rate,” explained Robert Reid, PhD, deputy division head of Prevention and Rehabilitation at the Ottawa Heart Institute. “There are opportunities to intervene with smokers and offer treatment that are not being taken advantage of at this point in time.”
With the goal of highlighting recent advances in treatments to aid smoking cessation, as well as pointing out persistent myths about cessation that might be preventing doctors from providing the most effective tools to their patients, Dr. Reid and colleagues at the Heart Institute published the first review of smoking cessation treatment in the Canadian Medical Association Journal in over a decade.
The issues discussed in the review include:
- Effectiveness: Combining smoking cessation aids is more effective than any single treatment alone. For example, combining a nicotine patch with a nicotine gum, lozenge, inhaler or oral spray is more effective than any single nicotine replacement (NRT) aid. Adding a nicotine patch to the oral cessation drug varenicline (Chantix®) works better than varenicline alone.
- Safety: Contrary to earlier concerns, a recent large clinical trial showed that varenicline does not increase the risk of suicide, depression or other mental health issues. And NRT is both safe and effective for patients who already have heart disease.
- Goals: Even though some smokers might not be ready to quit right away, many are interested in reducing their tobacco use, either as a step towards quitting or as a goal in itself, and many of the treatments for cessation can also be used to help people minimize their smoking.
The authors also address the fact that reliable systems are needed at every level of care “to make sure that all smokers are identified and offered assistance when you come into contact with them,” said Dr. Reid. “There’s a gap in that clinicians don’t seem to address this very routinely in their practice.” Many barriers keep this gap open, including competing medical priorities during visits and knowledge of what it is that patients need to help them quit, he explained.
“A cigarette is a finely tuned instrument of addiction,” added Dr. Reid. “People are generally smoking, particularly if they’ve been at it a while, out of compulsion and addiction, not as a choice.”
The practice setting itself must be changed “to make it easy for clinicians to intervene with smokers that they come into contact with. That’s everything from having materials close to hand, to having reminders and cues in the environment and in the electronic medical record, to having easy access to referral for follow-up,” he explained.
“Smoking is really the most preventable cause of why people are being hospitalized, why they’re accessing the healthcare system in the first place,” said Dr. Reid. “So it doesn’t make sense if we don’t address the root the cause of why people are coming to see us.”
[A longer version of this article originally appeared in The Beat.]
Elderly patients who start taking blood pressure medication or change their prescription or dosage have a temporarily increased risk of serious fall-related injury. The findings, published in Circulation: Cardiovascular Quality and Outcomes, included more than 90,000 patients in the United States aged 65 years and older.
Between 2007 and 2012, researchers found that 272 of the patients began taking drugs for high blood pressure, 1,508 added a new drug to their existing blood pressure regimen, and 3,113 had the dose of at least one blood pressure drug increased. The likelihood of a serious fall-related injury went up 36% for patients starting a medication regimen, 16% for patients adding a new drug and 13% for patients increasing a dose.
This increased risk dissipated after two weeks following the medication changes. The authors of the study stressed that, due to its observational nature, the research could only show an association between medication changes and fall risk, not determine cause and effect. However, it identifies a time period during which elderly patients may need closer monitoring for short-term side effects.
Aortic stenosis affects more than 100,000 Canadians over the age of 65. Until recently, surgical replacement was the only treatment option, but over the last several years, TAVI, or transcatheter aortic valve implantation (often referred to as transcatheter aortic valve replacement (TAVR) in the US), has emerged as a viable alternative with advantages over surgery. Because the TAVI valve is inserted through a catheter, the incision is small and recovery times can be much shorter than for the open heart surgical procedure.
First introduced in the early 2000s, TAVI is approved in Canada mostly for use in patients who are inoperable or whose condition makes surgery a high risk. As evidence for TAVI’s safety and durability grows and advanced technology comes on the market, the procedure is poised to become much more common.
Extending TAVI to Lower Risk Patients
“We do patients for whom surgery would be high risk, often higher risk patients than at other centres in the province,” said Interventional cardiologist Marino Labinaz, head of the TAVI heart team at the Ottawa Heart Institute.
The older and sicker high risk patients require hospital stays similar to surgical patients. In Europe, where TAVI is used in a broader range of patients, the time in hospital can be much shorter.
“In low risk patients, we are seeing expedited discharge. There is a trial underway in Vancouver where they are looking at 24-hour discharge,” he said. “Where I see the sweet spot for TAVI in the low-risk patient is in rapid recovery. You’re going to come in, get your TAVI and go home the next day. In our patients, we haven’t reaped the benefit of early discharge yet.”
“The use of TAVI in these patients will be, in part, patient choice. It may also become a societal choice,” he continued, “Because, if you can send a patient home in 24 hours, then TAVI could become very cost effective when compared to a five- to seven-day stay for surgery. This will particularly be true if the cost of the valves comes down.”
TAVI is currently a more expensive option than surgery due to the cost of the valves, but as demand for TAVI grows and as new vendors enter the market and increase competition, costs are expected to decline.
Conscious Sedation Over General Anesthetic
Another emerging benefit of TAVI over surgery is the use of conscious sedation.
“Currently, we give patients a general anesthetic and they are intubated. Conscious sedation means we give them short-acting medication,” he explained. “They are conscious, and they are never intubated. The patient doesn’t have the issue of the anesthetic to recover from, and it saves time so you can do more patients in a day.”
Given the Heart Institute’s emphasis on high-risk patients, conscious sedation is only just getting started in Ottawa.
One of the limitations of TAVI is the size of the catheter. To fit the valve inside, the catheter has to be larger around than those used in angioplasty for delivering stents.
“From a patient perspective, one of the biggest changes is that the valves are becoming smaller in size,” said Dr. Labinaz. “The first generation devices were very large calibre and we would see higher rates of dissections or occlusions in the arteries. Smaller tubes mean fewer vascular complications.”
Another important advancement is retrievability. Until recently, the cardiologist had only one shot to position and deploy the valve. Poor positioning can impact the seal of the valve and cause leaking—known as paravalvular aortic regurgitation—as well as complications that can require a pacemaker. A retrievable valve allows for real-time adjustments to be made.
“They aren’t yet commercially available here, but there are three valves available on special access from Health Canada that have the ability to be retrieved,” he said. “With two of them, you can deploy the valve to 80% to get an idea how it is positioned and functioning, and then retrieve it. The only completely deployable valve that can be retrieved is the new Lotus valve. We will begin using it this spring.”
“Another advance related to leaking is the addition of flexible sleeves on the outside of the valves that provide a better seal with the calcium and nodules and crevices that can create an uneven surface. Preliminary data is positive.”
One complication of aortic valve replacement that’s common to surgery and TAVI is stroke. Material from the calcium deposits in and around the valve can break away during the procedure and travel up the bloodstream to the brain. For both surgery and TAVI, the rate of stroke is 5 to 10%. On the horizon for TAVI is the use of protective filters in the blood vessels to capture that material. Results so far have been mixed.
“TAVI has been a real game changer,” concluded Dr. Labinaz. “We’re getting lots of data now on the durability of the valves in people who have had them for five and 10 years. They have low failure rates and seem to be comparable to the surgical valves.”
“It’s my prediction that TAVI will become a standard way of doing aortic valve replacement in the next five years. In Germany, it already is. Sixty per cent of aortic valve replacements in Germany are now TAVI. That’s the way it’s going. In Canada, cost and funding are the limiting factors.”
Heart Health Infographics
This series of heart health infographics, developed by the Prevention & Wellness Centre at Ottawa Heart Institute, are good tools for reminding patients about the importance of staying healthy.
Download them, share them, and print them to use with your patients. More health information and resources are available at the Prevention & Wellness Centre.
(Click on the images below to enlarge and download.)