Saturday, 12 March 2016

2016 - War veterans:Olympic games and cardiac risks



WAR VETERANS: OLYMPIC GAMES
and CARDIAC RISK

EDUARDO C. GERDING



The importance of physical activity

The message from the nation’s scientists is clear, unequivocal, and unified: physical inactivity is a risk factor for cardiovascular disease and its prevalence is an important public health issue. 2

46.2 percent of Argentine adults are not physically active. Seven in 10 Britons are not physically active.
9

In Argentina 39,000 deaths occur each year from causes related to physical inactivity in people between 40 and 79 years old.
18

To promote and maintain health, all healthy adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week.
11
In this article when it comes to participants who are not athletes we refer to individuals who do not regularly participate in competitive activities, including a sedentary people or those who play sports only recreationally.
6 



The Olympic and Paralympic Games for war Veterans
 
Our veterans who average age 52 years, annually organize in different provinces since 1999 an event called the Olympic and Paralympic Games for War Veterans to stimulate sports, socialize, share experiences and reconnect with their peers.

The National Sports Association for War Veterans has a policy that specifies that the veteran wishing to register must do so through a Veterans Center, since no individual registrations are accepted.

In these games more than 1,000 veterans of the 23 Argentine provinces gather. The disciplines are: football, swimming, tennis, table tennis, cycling, volleyball, basketball, shooting, athletics, bowls, weights, cards, chess and checkers among others.
17

In U.S.A. gyms inscriptions reveal a significant increase in the segment of the population that ranges from 35 to 55 years and more ( 1997 IHRSA/American Sports Data Health Club Trend Report. Hartsdale, NY: American Sports Data; 1997.)


Note:

The Paralympic Games are an official Olympic competition founded by Ludwig Guttmann in 1960 for athletes with certain types of physical, mental and / or sensory disabilities, including motor disabilities, amputations, blindness, cerebral palsy and intellectual disabilities.


In 2014 a 26 years old man died in a gym in Recoleta while performing crossfit. This high-performance activity was born in the US in 2001 and was initially used to train police forces in California and later by firefighters and soldiers.
3

 


Risks of physical activity

En EEUU. las inscripciones en gimnasios revelan un importante incremento del segmento de la población que va de los 35 a 55 años y más aún

Dr. Paul D. Thompson, chief of cardiology at Hartford Hospital in Connecticut (USA) says: Exercise increases the chances of sudden death if there is a heart abnormality whether you are an athlete or not. 1

 
While the possibility of sudden death doing physically activity occurring before the age of forty is very small-about 13 cases per 2,700,000 people it is nevertheless tragic when it happens.

According to international statistics, in marathons there´s one death every 50,000 to 100,000 participants . "A British study found that in 19 editions of the London Marathon, with more than 440,000 runners, there were 10 cardiac arrests, 5 of which could be revived."
3

According to data released by the Cardiovascular Institute of Buenos Aires, based on statistics from the Ministry of Health in our country one of ten Argentines die of sudden death, and 20 percent of healthy people are unaware they may die for such cause.



Note:
Sudden death is a nontraumatic death that occurs abruptly within the first hour of the symptoms onset.


Argentina leads Latin American ranking in cardiovascular mortality: 1 in 3 deaths in women are caused by cardiovascular causes, according to the Ministry of Health of the Nation. Furthermore, in recent years it has increased the number of acute myocardial infarction among women.



Particularities of war veterans

A study by Cohen et al found that war veterans from Iraq and Afghanistan with mental disorders suffered from a higher prevalence of cardiovascular risk factors. 4

Turner et al showed that PTSD was associated with myocardial ischemic changes. 20

By the time our veterans met 66 years it is expected that 7 out of 10 deaths will be due to noncommunicable diseases including heart disease; stroke being the fourth leading cause. 9

A 1995 study revealed that 58 percent of Argentine war veterans experienced bouts of depression related to the conflict and 28 percent had suicidal thoughts. Between 1990 and 1998, 150 members of the British forces were discharged for suffering from Post Traumatic Stress. 10,13


We know that a percentage of patients with no history of depression are depressed after a heart attack and, in turn, depressed patients without previous heart disease develop heart disease more frequently than the general population. 22

Depressed individuals experience changes in their nervous system and hormonal balance that makes them more likely to suffer from cardiac arrhythmias. The combination of depression and disease makes them more susceptible to fatal arrhythmia. Depressed patients have extremely sticky platelets which accelerates the process of atherosclerosis. 19.22


Anxiety and anger are unpleasant feelings linked to disturbing situations .If they remain in time with no possibility of obtaning a satisfactory answer they´ll involving a number of mechanisms which end up in distress This in turn can lead to illness or aggravate the course of it. As a result of unpleasant emotions, metabolic diseases such as diabetes, dyslipidemia and autoimmune diseases may be triggered. All these have in turn an effect on the cardiovascular system.


Mian Li et al have identified alterations of the autonomic nervous system which cause the post effort dyspnea among Gulf War Veterans. 14

Currently, the US Veterans Administration is aiming to prevent heart disease particularly in female war veterans as 1 in 30 women die from breast cancer while 1 in 3 die from cardiovascular disease. 21

 

(Kindly submitted by War Veteran Carlos Sánchez)

Risk factors for sudden death to be taken into account are: history of sudden death in the family, previous heart attacks, heart failure, diabetes, high cholesterol, hypertension, obesity and smoking.



The cardiologic screening


The American Heart Association and the American College of Cardiology (in a controversial position) oppose mandatory ECG screening for young athletes or not athletes. 1

However, the state of New Jersey´s legislation demands doctors to perform a cardiac medical history and physical exam during wellness checks for youths under 20, regardless of whether they participate in competitive sports. 1


It is said that to date there is no method of screening, whether an ECG or other method that has been proven to save lives. However, if an ECG detects a condition that can cause sudden death then we may well say that the ECG saved his life.

An abnormal ECG in a healthy young athlete may be the expression of a cardiomyopathy and warrant follow up. 16


Likewise, people suffering from long QT syndrome should not participate in competitive sports. 15

When the ECG is performed by an experienced doctor the possibility of a false positive is around 2 to 6% depending on the age, type of sport, sex and race of the athletes. 1,5





According to Dr. Héctor Kunik, president of the Metropolitan Association of Sports Medicine assessments are different depending on age.

Under 35, a clinical examination, personal and family medical history and a resting electrocardiogram is required. "This is very important in young people with a history of close relatives. When this happens, it is generally due to congenital diseases," says Kunik.


In those over 35, the same studies are required plus a stress test, which measures the heart function under stress conditions. 3




 
Treadmill test with maximum consumption

The treadmill or stress test is an essential diagnostic technique which is mainly used for the diagnosis of angina in patients with chest pain and to assess the heart's response to exercise. Its use in coronary heart disease is based on the ability to highlight cardiovascular abnormalities not present while the patient is at rest which may occur during exercise.


The PAR-Q (Revised Physical Activity Readiness Questionnaire): 2


Yes           No

1. Has a doctor ever said that you have a heart condition and recommended only medically supervised activity?

2. Do you have chest pain brought on by physical activity?

3. Have you developed chest pain in the past month?

4. Have you on 1 or more occasions lost consciousness or fallen over as a result of dizziness?

5. Do you have a bone or joint problem that could be aggravated by the proposed physical activity?

6. Has a doctor ever recommended medication for your blood pressure or a heart condition?

7. Are you aware, through your own experience or a doctor’s advice, of any other physical reason that would prohibit you from exercising without medical supervision? 



If you answered “yes” to any of these questions, call your personal physician or healthcare provider before increasing your physical activity.


Marathon in Buenos Aires


Rated applicants for physical activity 2


There are nine factors that allow us to predict coronary heart disease: heredity, being male, older age, smoking, hypertension, diabetes, obesity, physical inactivity and high blood cholesterol. The three most serious are smoking, hypertension and high cholesterol levels. 9



(Kindly submitted by War Veteran Carlos Sánchez)


60 percent of cardiovascular disease are linked to values of serum cholesterol above 200 mg / dl which increases by 49 percent the likelihood of acute myocardial infarction. The prevalence of hypertension between 50 and 59 years is 49.7 percent but increases to 65 percent over 60 years. 9


  • Class A: Apparently healthy. There is no evidence of increased cardiovascular risk for exercise.2
  • Class B: Presence of known, stable cardiovascular disease with low risk for vigorous exercise but slightly greater than for apparently healthy persons. (e.g: coronary artery bypass surgery, percutaneous transluminal coronary angioplasty, valvular heart disease)
  • Class C: Those at moderate to high risk for cardiac complications during exercise and/or who are unable to self-regulate activity or understand the recommended activity level. (e.g: complex ventricular arrhythmias, heart failure)
  • Class D: Unstable conditions with activity restriction.(e.g: unstable ischemia; heart failure that is not compensated and severe and symptomatic aortic stenosis)


    Note:
    It should be recalled the Municipal Ordinance 39,884 / 84 from the City of Buenos Aires -.. Comprehensive health plan for veterans residing throughout the national territory, Law 1,636 / 05 from the City of Buenos Aires - Permanent Health Program for Malvinas war veterans , Resolution 142/84 of the Ministry of Public Health and Environment of the City of Buenos Aires -Sector advisory and medical, social, economic and cultural attention to Malvinas war veterans.



Bibliography

  1. Heart screening: What about young non-athletes?- American Heart Association News. http://blog.heart.org/heart-screening-what-about-young-non-athletes/
  2. Balady, Gary e tal-AHA/ACSM Scientific Statement-Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities.
  3. Bär, Nora-Muerte súbita un cuadro entre la tragedia y la falta de prevención-La Nación-Abril 22, 2014.
  4. Cohen, Beth E. et al- Association of Cardiovascular Risk Factors With Mental Health Diagnoses in Iraq and Afghanistan War Veterans Using VA Health Care. JAMA. 2009;302(5):489-492. doi:10.1001/jama.2009.1084.
  5. Corrado, Domenico-Cardiac Screening for Young Athletes before Participation in Sports Should Include a History, Physical Examination, and ECG. Clinical Decisions-The New England Journal of Medicine –November 21, 2013
  6. Curtis Anne et al- ECG Screening Is Not Warranted for the Recreational Athlete-JACC- Volume 63, Issue 19, May 20, 2014
  7. Drezner, Jonathan- Is cardiovascular screening in athletes justified? Inconsistent messages from the American Heart Association- Br J Sports Med doi:10.1136/bjsports-2015-095554
  8. En Argentina un 10% de la población fallece a causa de muerte súbita- http://entremujeres.clarin.com/vida-sana/salud/muerte_subita-infarto-corazon-cardiovascular-miocardio_0_1334870069.html
  9. Gerding, Eduardo. The War Veteran´s silent killers- The International Review of the Armed Forces Medical Services-September 2010-Vol 83/3
  10. Gerding, Eduardo-The 1982 conflict´s aftermath- The International Review of the Armed Forces Medical Services,Vol. 75/2, 2002, p 84-94
  11. Haskell, William et al-Physical activity and public health: Updated. Recommendation for Adults from the American College of Sports Medicine and the American Heart Association-University of South Carolina-Scholar Commons. Circulation (116)9 , 1081-1093.
  12. Heart-mind mistery-Unraveling the link between PTSD and heart disease-US Department of Veterans Affair. http://www.research.va.gov/currents/spring2014/spring2014-1.cfm
  13. Las emociones y el corazón- http://entremujeres.clarin.com/vida-sana/salud/corazon-salud_cardiovascular_0_1334271308.html
  14. Li, Mian et al- Self-reported post-exertional fatigue in Gulf War veterans: roles of autonomic testing- Neurosci., 07 January 2014
  15. Marijon,Eloi –Long QT Syndrome-The New England Journal of Medicine, May 1, 2008.
  16. Pelliccia, Antonio-Outcomes in Athletes with Marked ECG Repolarization Abnormalities- The New England Journal of Medicine –January 10, 2008.
  17. Sánchez, Carlos VGM (Comunicación Personal).
  18. Telam- En Argentina se producen anualmente 39.000 muertes por causas asociadas a la falta de actividad física en personas entre 40 y 79 años. http://www.telam.com.ar/nota/32241/
  19. Tristeza y salud cardiovascular-¿El corazón duele? http://entremujeres.clarin.com/vida-sana/salud/tristeza-corazon-cardiovascular-depresion_0_1334272457.html
  20. Turner, JH et al-Objective evidence of myocardial ischemia in patients with posttraumatic stress disorder. Biol Psychiatry. 2013 Dec 1;74(11):861-6. doi: 10.1016/j.biopsych.2013.07.012. Epub 2013 Aug 23.
  21. VA Fights to Prevent Heart Disease in Women Vets-US Department of Veterans affair-http://www.va.gov/health/newsfeatures/20121210a.asp
  22. Ziegelstein, Roy-Depression and heart disease-John Hopkins Medicine-http://www.hopkinsmedicine.org/heart_vascular_institute/clinical_services/centers_excellence/womens_cardiovascular_health_center/patient_information/health_topics/depression_heart_disease.html