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The Danger’s of Being a Weekend Warrior Hockey Player

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.

Muscle Pain with Statins Likely the Result of Expectations

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.]

Is there an association between tendinopathy and diabetes mellitus? A systemic review and analysis

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

Cognitive Decline Not Impacted by Cholesterol or Blood Pressure Drugs

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.brain

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.]

Falls Prevention Planning in Champlain: Article 5

Exercise Class Navigation Flow Chartexercise-class-in-action-1

Encouraging seniors to exercise and to be physically active is an important part of a fall prevention strategy. Exercise programs that promote balance training combined with strength and flexibility have been shown to be effective in significantly reducing falls and the injuries resulting from a fall.  LHIN funded exercise and Fall Prevention programs are available across the Champlain region, and different levels of programs for people of different abilities are provided.  However, determining which class is the right one is key to ensuring that participants gain maximum benefit from the class. Choosing the wrong level of class can be a lost opportunity to promote increased activity.

To simplify the choices and decisions for older adults, their families and health care providers, the Navigation Working Group of Champlain Fall Prevention Steering Committee has developed a flow chart. Each region has its own flow chart with local class details and contact information, but the descriptions for each level have been standardized across Champlain with consistent wording for each level of class.

 

Ottawa
Eastern Counties (Prescott Russell and Stormont, Dundas and Glengarry)
Renfrew County

List of locations (Renfrew County and District)

On the reverse of the chart is the Staying Independent Checklist and seniors are urged to complete this fall-risk screening tool, although it is not a determinant of exercise and activity levels. This screen is a key first step in the Champlain Fall Prevention Algorithm of Detection, Diagnosis and Intervention.  Primary care providers should encourage their older patients to complete the Staying Independent Checklist annually and to bring issues and concerns to the primary care team.

The exercise class flow chart will be launched in November 2016 (Fall Prevention month) and will be distributed to public health units, community support services, primary care providers and other agencies, to encourage seniors to choose an active lifestyle. The flow charts can be found on the www.stopfalls.ca website under the community resources tab, and also on the Champlainhealthline website , under the Exercise Classes for Seniors button, “Which Exercise Class for me?”

For more information contact:

Christine Bidmead 

Project Manager

Champlain Falls Prevention Strategy

Regional Geriatric Program of Eastern Ontario

email: cbidmead@toh.ca

Cell Phone 519 639 3000

The Importance of Best Practices for Successful Smoking Cessation

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.smoking-cessation

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.]

Aortic Valve Replacement: What’s Next for TAVI?

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.TAVI

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.

Improved Technology

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.

Looking Ahead

“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.”

Major Statement on Heart Attack in Women

Every year for more than three decades, cardiovascular disease has killed more women than men in North America. While that gap has been narrowing, it still remains. On January 26, the American Heart Association (AHA) issued its first scientific statement on heart attack in women in the journal Circulation.

The AHA released the statement as a comprehensive summary of what the cardiovascular community knows about heart attack in women: its causes, presentation, treatment and outcomes. No matter their age, more women than men die within a year of their first heart attack (26 per cent of women compared with 19 per cent of men). However, women are on average older at the time of first heart attack: 71.8 years compared with 65 for men. This difference explains, in part, the higher mortality that continues to be seen in women five to 10 years after a heart attack.

Although risk factors for heart disease are shared between men and women, some factors—such as high blood pressure, and diabetes in younger women—seem to confer greater risk to women than men. Symptoms of a heart attack can also differ between women and men, a fact that many Canadian women are unaware of.

Women in general seek treatment later for a heart attack than men, which may contribute to poorer outcomes. Women are less frequently referred for appropriate treatment during a heart attack compared with men and, following a heart attack, are less likely to use guideline-recommended medical therapies. Less than 20 per cent of women eligible for cardiac rehabilitation have participated over the last three decades, and even with a referral to rehabilitation, women participate and complete it less frequently than men.

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