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Alterações de repolarização no atleta

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Mafalda de Noronha Lopes

on 21 June 2013

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Transcript of Alterações de repolarização no atleta


Mafalda de Noronha Lopes
Miguel Pádua Figueiredo
Rita Rocha

Alterações da repolarização ventricular em desportistas -
Correlação com idade, sexo, raça, modalidade e volume de treino

Objectivo
Objectivo
Introdução
Condicionantes do ECG no atleta
Idade
Sexo
Raça
Modalidade
Outros ?
Conclusão
Bibliografia
Introdução
A morte súbita (de origem cardiovascular) em atletas e a principal causa de morte durante a actividade desportiva

A interpretaçao do ECG nos atletas requer uma avaliaçao cuidadosa e discernimento entre alteraçoes FISIOLOGICAS relacionadas com a actividade fisica e alteraçoes PATOLOGICAS que sugerem patologia subjacente
Fisiológico vs Patológico
9 curso Pós-Graduação em Medicina Desportiva da SPMD
Revisão da bibliografia
Sistematização de conceitos


Alterações estruturais e de remodelação
Adaptação SNA

Adaptação Fisiológica
Regular and long-term participation in intensive exercise (minimum of 4 h/week) is associated with unique electrical manifestations that reflect increased vagal tone and enlarged cardiac chamber size. These ECG findings in athletes are considered normal, physiological adaptations to regular exer- cise and do not require further evaluation (box 1).
Repolarização Ventricular
Early repolarisation consists of concave ST segment elevation most commonly observed in the precordial leads and present in up to 45% of Caucasian athletes and 63–91% of black athletes of African-Caribbean descent (hereto referred to as ‘black/ African’ athletes).11–13 Black/African athletes also commonly demonstrate a repolarisation variant consisting of convex ST

segment elevation in the anterior leads (V1–V4) followed by T wave inversion. On the basis of current data, T wave inversions preceded by ST segment elevation are present in leads V1–V4 in up to 13% of black/African athletes and do not require further assessment in the absence of symptoms, positive family history or abnormal physical examination.12 13
A junctional (nodal) rhythm or wandering atrial pacemaker may be observed in up to 8% of all athletes under resting condi- tions.11 First-degree AV block (4.5–7.5%) and less commonly Mobitz type I second-degree AV block are also seen in athletes and a result of increased vagal tone.6 11 14
Growing attention has been paid to ethnic-related differences in morphological and ECG features of the athlete’s heart. Notably, there are specific repolarisation patterns in black/ African athletes that are normal variants and should be distin- guished from abnormal findings suggestive of a pathological cardiac disorder.
As aforementioned, early repolarisation is common in athletes and usually characterised by an elevated ST segment with upward concavity, ending in a positive (upright ‘peaked’) T wave (figure 11). There is also a normal variant early repolarisation pattern found in some black/African athletes, characterised by an elevated ST segment with upward convexity (‘dome’ shaped), fol- lowed by a negative T wave confined to leads V1–V4 ( figure 15). The presence of either repolarisation pattern in an asymptomatic black/African athlete does not require additional testing.
Differentiating normal repolarisation variants from pathological findings
The presence of early repolarisation and T wave inversion in the anterior leads in black/African athletes probably represents a specific, ethnically dependent adaption to regular exercise. More than two-thirds of black athletes exhibit ST segment eleva- tion and up to 25% show T wave inversions.12 13 However, normal repolarisation changes in black/African athletes do not extend beyond V4. Thus, T wave inversion in the lateral leads (V5–V6) is always considered as an abnormal finding and requires additional testing to rule out HCM or other cardiomy- opathies (figure 16).
Junho 2013
Idade, sexo, raça, modalidade e volume de treino como preditores de alterações de repolarização em atletas
Pre-participation screening has been recommended to identify athletes at risk [29]. However, exercise-in- duced cardiac remodelling may mimic several cardiac pathologies. Black athletes in particular exhibit strik- ing repolarisation abnormalities and left ventricular (LV) hypertrophy [5, 6]. Over-diagnosis of cardiac dis- ease may lead to unnecessary disqualification of ath- letics with psychosocial and economic consequences for the athlete. On the other hand, restriction from com- petitive sports may protect athletes with cardiovascu- lar diseases from the devastating consequences of ex- ercise-induced ventricular arrhythmias




he ECG findings presented as normal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine. - reunião em fev 2012 da American medical society for sports medicine (AAMSSM) e pela FIFA medical assessment and research center (F-MARC) - ver artigo
in Electrocardiographic interpretation in athletes: the "Seattle Criteria"
Género como condicionante de adaptação cardíaca

Between 1996 and 2010, 2745 male athletes aged 14–35 years were evaluated in the UK and France. Athletes competed at regional, national, or international level. All athletes underwent at least one pre- participation evaluation comprising of a health questionnaire relating to training activity, presence of cardiac symptoms, family history of cardi- omyopathy or premature (≤40 years) SCD and drug history, cardio- vascular examination, 12-lead ECG, and 2D echocardiography. Black ethnicity was determined through self-reported questionnaires.
Twenty-two athletes were excluded based on blood pressure readings .140 mmHg systolic and/or .90 mmHg diastolic. The final cohort comprised of 904 BAs and 1819 WAs.
O médico responsável pela avaliação dos doentes tem de ter conhecimento sobre as adaptações cardíacas fisiológicas ao exercício regular/competição que se manifestam no ECG
Faca de dois gumes
"Over diagnosis"
Desqualificação "desnecessária" do atleta
Consequências psicossociais e económicas
O coração do Atleta
Screening dos doentes
Restrição da actividade em atletas com patologia subjacente
Prevenção de eventos cardiovasculares catastróficos

ECG changes in athletes are common and usually reflect the electrical and structural remodel- ling or autonomic nervous system adaptations that occur as a consequence of regular and sustained physical activity (ie, athlete’s heart). In fact, up to 60% of athletes demonstrate ECG changes (in iso- lation or in combination) such as sinus bradycardia, sinus arrhythmia, first-degree atrioventricular (AV) block, early repolarisation, incomplete right bundle branch block (IRBBB) and voltage criteria for left ventricular hypertrophy (LVH).4 The extent of these changes is also dependent on the athlete’s ethnicity, age, gender, sporting discipline and level of training and competition.5–7 Accordingly, the ability to identify an abnormal ECG suggestive of underlying cardiac disease is based on a sound understanding of ECG normality within a broad spectrum of athletic populations.
Maioria dos estudos - Atletas sexo masculino [18-35]

Pellicia et al , 1996 - "Athlete's heart in women"


635 atletas sexo fem. vs 735 atletas sexo masc vs. 65 não atletas sexo fem.
Intensidade de treino equivalente
Modalidade de treino equivalente

Prevalence and distribution of repolarization changes
Black athletes vs. white athletes
Both ST-segment elevation and T-wave inversions (including deep T-wave inversions) were commoner in BAs compared with WAs (Table 3). T-wave inversions in BAs were predominantly observed in the anterior leads (12.7%) (Figure 2A and 2B) with only 4.1% of BAs exhibiting T-wave inversions in the lateral leads. ST-segment depression was rare in both ethnic groups.
Sexo feminino - Atletas vs não atletas
Espessura da parede VE - LVWT
Tamanho da cavidade VE - CVE
IDADE
O treino físico regular está associado a variadas adaptações fisiológicas e bioquímicas que condicionam a um aumento do débito cardíaco e do gradiente de oxigénio arteio-venoso sistémico (diminuição da resistência periférica).
A dilatação das cavidades cardíacas é fundamental para um aumento sustentável de débito cardíaco por longos períodos. A adaptação fisiológica do coração compreende uma hipertrofia ventricular que conduz a um aumento do volume ventricular diastólico que conduz a um aumento do volume de ejecção.
O coração do atleta se caracteriza por um coração "grande" e um baixo ritmo cardíaco. Manifesta-se por complexos QRS alargados, bradicárdia sinusal, bloqueios do 1° e 2° nas 12 derivações do ECG e um aumento da proporção cárdio-torácica no Rx simples do tórax.
Esta adaptação é diferente consoante a idade do atleta. Na pré-puberdade, a hipertrofia cardíaca é pouco evidente, provàvelmente devido à menor carga horária e intensidade do treino, e à imaturidade hormonal. Também a massa muscular pode não ser volumoso suficiente para desencadear sobrecarga para o coração. Assim como nos atletas mais maduros e veteranos, as alterações não são significativas. Isto sugere que a resposta cardíaca face ao treino diminui com a idade.


Altetas: 8.2 +/- 0,9mm - LVWT
46 +/- 3.0mm - CVE
Atletas - aumento de 6% LVWT e 14 % CVE
in Pellicia et al , 1996 - "Athlete's heart in women"
Atletas sexo fem. vs Atletas sexo masc.
Pellicia et al , 1996 - "Athlete's heart in women"
LVWT; CVE significativamente menor ( 23%; 11%)
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