September 26, 2023 • 27 mins
Welcome to "In the Thick of It," a podcast by the HCM Society, dedicated to shedding light on the latest developments in Hypertrophic Cardiomyopathy. In this episode, Cardiologist Dr. Robyn Bryde engages in an insightful conversation with Dr. Michael Emery. They delve into the crucial topic of exercise restrictions in HCM, exploring the art of crafting exercise prescriptions, counseling athletes and enthusiasts with HCM, and ensuring their safe participation in sports. Tune in for expert insights into this vital aspect of HCM management.
About our Guest:
Dr. Emery is an associate professor of medicine at the Cleveland Clinic Learner College of Medicine. He’s also the Co-Director of the sports cardiology center at Cleveland Clinic and has a background in exercise physiology.
In the Thick of It is brought to you by the HCM Society, and is produced by Earfluence.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
ANNOUNCER (00:05):
You are listening to End the Thick
of It, a podcast from the HCM Society, where we
interview experts in the hypertrophic cardiomyopathy
field to broaden the awareness of new HCM studies
and advancements. In this episode, cardiologist
Dr. Robin Bride has the pleasure of speaking with
Dr. Michael Emory. Dr. Emory is an associate professor
of medicine at the Cleveland Clinic Lerner College
(00:27):
of Medicine. He's also the co-director for the
Sports Cardiology Center at the Cleveland Clinic,
and he has a background in exercise physiology.
In this episode, they'll be discussing exercise
restrictions, how to develop an exercise prescription,
how to safely counsel an athlete or exercise enthusiast
who has hypertrophic cardiomyopathy, and how to
(00:47):
help them safely participate in sports. Let's
get in the thick of it. Here's Dr. Emory.
DR. EMERY (00:53):
Thanks for having me on, Robin.
DR. BRYDE (00:55):
Absolutely. So again, kind of the continuation,
we're shifting from exercise restriction in this
patient population, now we're moving more towards
how can we get our patients with HCM to safely
participate in exercise. And I'd like to start
this talk off by understanding how these patients
(01:15):
show up in your clinic. What is the general perception?
Are they coming to you having been told that they
need to restrict their participation?
DR. EMERY (01:25):
Or...
DR. BRYDE (01:27):
Cardiology colleagues. Now adopting
exercise participation. Just like to get a feel
of that from you.
DR. EMERY (01:37):
So they come with a wide. Variety of
opinions and counseling. For good and for bad
in a lot of cases. And we have to divide our cases
up in a sort of that person that wants to be athletic.
And or compete in sports and those who just want
to be active in day to day life. And you know
the classical historical is that everything should
(01:59):
be restricted you know decades ago they were afraid
to let you walk across the parking lot And that
still persists in a lot of physicians. You know,
in fact, just a couple weeks ago, sports medicine
physician was relaying to me that he goes I thought
HCM was a death sentence to exercise with. So
that's perception is still out there. So we have
(02:21):
to continue to break that perception. That exercise
is good. For people. And then when we talk about
patients that come into our clinics and we're
talking about exercise, we have to make that distinction
of what they mean by exercise and what they want
to do. Whether that's the low to moderate intensity
sort of. General exercise. That we recommend for
(02:43):
anyone, including now HCM patients. Or if they
want to be very athletic and very competitive
and they want to go run 5Ks, 10Ks, marathons,
triathlons, do crossfit. So we have to come to
them and understand what they really want to do
and what we can help guide them to do safely.
In either of those realms.
DR. BRYDE (03:02):
I think that with your background in
particular, I know you're a CrossFit enthusiast,
but particularly the exercise physiology component
that you know so well, I think that that really
helps you probably relate to these patients to
understand the exercise intensity that they desire
to perform and to understand their specific sport
(03:22):
of choice. So yeah, I agree. I think that that's
incredibly important to really understand what
their goals are and how we can safely help them
achieve those goals.
DR. EMERY (03:34):
Yeah, it certainly helps to create
a bond with them when I can, you know, walk the
walk and talk the talk at the same time. Doesn't
mean you have to be walk the walk, but certainly
it creates a bond with a lot of patients.
DR. BRYDE (03:47):
Right. They understand the passion.
It does help to understand that I'm here with
you. I'm trying to help you continue to do what
you love to do. So how much does the obstructive
versus non-obstructive nature of each patient's
disease come into play in this evaluation?
DR. EMERY (04:10):
So the first step in the evaluation
is like we would do with any HCM patient. We're
trying to elicit whether they're obstructive or
non-obstructive, and often it takes some provocative
maneuvers to do that beyond resting. So before
we talk exercise prescription, we have to make
sure they're. Very adequately. Phenotypes. Do
(04:30):
we? Understand their obstructing and their obstructed
physiology, their concomitant value, their disease
that they may have. Scar burden that they may
have. And that's part of a standard evaluation,
right? We haven't even gotten to exercise yet.
Because that's gonna sort of guide us into therapies.
Are you symptomatic? With obstruction. Then we
(04:52):
need to work on being symptomatic with that obstruction
and how we can improve that obstruction and those
symptoms based to that. And then after that sort
of standard. You know. Subjective evaluation,
objective evaluation, risk stratification. Then
we can talk about exercise prescription. Being.
(05:14):
What do you want and what do you intend to do?
So. In the setting of, you know, I just want to
go walk the dog and go for a brisk walk. That's
going to be a lower risk. Even if you have obstruction,
then it's... You have obstruction and you want
to do crossfit or you want to do marathons. Um,
(05:34):
Those are different discussions. So we want to
make sure they're very well phenotypes before
we start talking about those kinds of things.
Prescriptions.
DR. BRYDE (05:45):
So I imagine sometimes patients come
to you and perhaps they have great images and
you can clearly see based on their history whether
they're obstructive or not. Sometimes I imagine
too, you're repeating the stress echo to really
clearly phenotype their condition. How do you
get into and where do you really cross the line
(06:05):
of performing the cardiopulmonary exercise test?
I think... You know, most of our listeners who
are seeing patients with HCM are very familiar
with the stress echocardiogram and the utility
of the stress echo to clearly define the gradient.
But at what point are you transitioning over into
getting the CPAT? And how do you use each of those,
(06:26):
the variables for each one of those tests differently?
DR. EMERY (06:30):
So I'm a little biased because of my
background and interest in cardio pulmonary exercise
testing. So I tried to do. A CPET stress echo.
So really combining a CPET with the Echo at the
same time. So then I get the information all at
once without having to double up on the tests.
You don't need to do that and you need the resources
to be able to do both. If you're looking predominantly
(06:51):
for. A very basic exercise prescription, meaning
percent of heart rate reserves. You could probably
do that with a stress echo without the cardiopulmonary
piece. To define those percentages of heart rate
reserves. Which is a reasonable starting place
for someone who's been very inactive. And then.
(07:12):
You also get the degree of their obstruction post-error.
Exercise. If we want more details, meaning someone's
really wanting to dive deeper into the physiology
and very specific exercise prescription to...
Their level of fitness currently as well as their
maximal capabilities. Then we can use those parameters
(07:34):
from a cardiopulmonary exercise test. I.e. The
anaerobic or ventilatory thresholds or respiratory
compensation points, which are these turn points
in an exercise prescription that we're trying
to estimate on heart rate reserves. We can be
much more specific about it. Whether you need
one versus the other for a prescription, sort
(07:54):
of depends upon what you're going to do with that
data and how specific you need to be for an individual.
In other words, if you're just talking low to
moderate intensity exercise to keep someone moving
and generally healthy. You may not need that very
detailed exercise prescription from a CPET, but
if you're having a runner who really wants to
dial things in to try to be... Safe and effective,
(08:17):
then a CPET may be an advantageous test to add
on to them. Beyond the standard I'm trying to
elicit a gradient
DR. BRYDE (08:26):
Okay. That's all fantastic information.
So it sounds like the higher performing athlete.
Little more utility with the CPET, or actually
a lot more utility with the CPET in the higher
performing athlete. And then low to moderate intensity
exercise, maybe we can just get away with a stress
(08:47):
echocardiogram, but still there are some variables
that are pretty helpful with the cardiopulmonary.
DR. EMERY (08:54):
It depends upon what you want out of
it and what you plan to do with that information.
From an exercise prescription standpoint. I'm
from a diagnostic standpoint of. What's their
true exercise capacity to know whether they're
truly symptomatic or asymptomatic? What's their
hemodynamic responses? Do they have concomitant
pulmonary disease or other problems contributing
(09:16):
to their exercise and tolerance? The CPET will
give you Just a wealth of additional information
that can help you better characterize those patients.
From a exercise prescription standpoint, it really
depends upon then what you want to do with that
information.
DR. BRYDE (09:31):
And kind of as a side point, I want
our listeners to know you, you actually are a
little creative in the CPAT lab. And I, in some
of our conversations in the past, you've told
me that you can actually do this on the bike or
you could do it on the treadmill. And I think
for certain athletes, you know, some of our triathletes
or cyclists, they're really interested in this
(09:51):
information as it pertains to the bike. And then
some of our big time runners, marathoners, of
course, they're going to be limited or going to
want the information for the treadmill. So so
I think that I like how you're able to offer both
of these aspects in your lab. I think that that's
very interesting.
DR. EMERY (10:11):
Yeah, we have to remember that the
numbers are different bike to treadmill. Um So.
If you develop an exercise prescription and heart
rate training zones based upon a treadmill. They're
not going to quite translate to the bike appropriately.
And if you're a very high end athlete, then. Um
that's going to affect what zones and what training
(10:33):
parameters they want. Triathletes may be a little
bit similar, at least in terms of the very high
max numbers, but maybe not. Um, the training number.
So you need to be very specific. When I'm evaluating
a patient up front and we're doing a CPED, I really
like to do it on a bike. I get additional gas
exchange information out of it that can help me.
(10:53):
And you know, with our very talented sonographers,
we can do simultaneous echo Doppler while they're
still peddling on the bike and now I can look
for the gradients. As we increase those intensities
to see where we're seeing the most. Profound gradients
at what I can't really do on a treadmill, obviously,
because you're not getting the gradients until
after they get off the treadmill.
DR. BRYDE (11:16):
So discussing the CPET variables a
little bit more, at Care of the Athletic Heart
this year, you had a great presentation on using
the anaerobic threshold to help predict catecholamine
release. And how this is important to understand
in patients with HCM. Can you explain that in
(11:37):
a little more detail for our listeners to better
understand this relationship between anaerobic
threshold and the importance of this catecholamine
surge after that?
DR. EMERY (11:47):
Sure. You know, one of the. Concerns
with regards to anybody with you know, significant
heart disease is it's that. Catecholamine surge
of higher intensity exercise that puts them at
risk of ventricular arrhythmias and sudden cardiac
arrest. And that certainly holds true in our concern
for hypertrophy cardiomyopathy as well. This goes
(12:09):
beyond any obstruction questions. And more about
the unstable substrate. So is there a way that
we can predict that catecholamine surge. We can't
measure readily catecholamines, but it turns out
that from studies that have already been done
and in hypertrophic cardiomyopathy patients that
that catecholamine surge starts to happen just
(12:32):
after your ventilatory threshold one or your anaerobic
threshold, depending upon the terminology you
like to use. So if we can identify that first
ventilatory threshold by gas exchange data, also
called the anaerobic threshold. Then we can write
an exercise prescription to sort of keep you in
that zone, that sort of moderate intensity, or
(12:54):
zone two, it's affectionately referred to in the
five zone model. Um, that can in theory keep you
below that threshold to keep you safe while still
gaining the benefits of the exercise, particularly
if you have a more unstable threshold. So... Being
able to do a cardiopulmonary exercise test, collect
(13:14):
those gas exchange parameters, really know how
to identify those numbers and generate an exercise
prescription. Is okay. Potentially a good way
to. Gain the benefits of Exercise. While still
keeping you as safe as we can keep you. Because
it turns out that that zone right around that
anaerobic threshold. Is where you gain probably
(13:35):
the biggest chunk of your aerobic base and your
aerobic benefit from exercise.
DR. BRYDE (13:42):
And it is that zone where I do think
most of our patients, they're trying to stay within
that zone. We don't have many people that are
going out there trying to train in zone five for
a long period of time or depending on how many
zones you train with. But I do just, I love this
objective data. That we're able to gather from
cardiopulmonary exercise testing. I think that.
(14:04):
When done correctly and when analyzed properly,
that this objective data can provide a wealth
of knowledge and help in developing this exercise
prescription. So again, kind of one of the benefits
of what are we getting from a cardiopulmonary
exercise test compared to what we're getting from
our Stress Echo cardiogram.
DR. EMERY (14:26):
And I think it's important for a lot
of patients to sort of see we have some objective
data. And we're not just sort of picking numbers
out of the air. That this is tailored specifically
for them and where they're at in their fitness
journey right now. It helps, I think, them understand
that exercise is important. It can be safe. And
(14:46):
we're being very specific for them. You know,
oftentimes, you know, you and I have probably
both heard this. Patients are given a heart rate
number to stay below and you try to figure out
where that heart rate number came from. They're
just picking numbers out of the air that may or
may not be important to them. Or specific to them.
Obviously these numbers are gonna be different
(15:07):
if you are 60 versus you're 20. Those numbers
should be different. They shouldn't be the same
empiric number. They should be different based
upon your current level of fitness and your desired
fitness level as well. So I think patients really
appreciate those. Now you don't. Always need this.
Some people can get by with the talk test and
(15:28):
the heart rate reserve percentage wise. Um, But
some people enjoy this discussion and this practice
a little bit more. So it's how I've developed
my practice. It's not, uh, you know. Only way
it can be done but it certainly is fun. It's fun
for me. And I think it's valuable for my patients.
DR. BRYDE (15:46):
Sure, I agree completely. So shifting
gears a little bit more back to Stress Echo. How
are you tailoring? Treatment therapies, so in
your obstructive patients. When they're doing
the stress echocardiogram and you're assessing
gradients with varying degrees of exercise intensity.
(16:09):
How are you tailoring the exercise prescription
and how do you tailor medical therapy for this
specific obstructive population with significantly
elevated gradients on the stress psychopardiogram?
DR. EMERY (16:25):
So those are longer discussions with
the patient. Um, you know. It depends upon what
their overall capacity is. It depends upon. At
what? Degree their obstruction is and by that
I mean at what. Exercise intensity if I'm for
(16:46):
instance doing a bike and can able to see different
degrees of intensity in the level of obstruction.
Versus significant resting or valsalva. Obstructions.
The concern is that if you're spending even long
periods of time Um. At a level of which you're
obstructed, that left ventricular pressure is
(17:08):
quite elevated. Potentially producing some subendocardial
ischemia putting you at risk, even if though you
may not be at a high intensity. Where your catecholamine
surge that may compound. The concern and the risk.
So then we're trying to being more. Aggressive
with our medical therapy if we can, whether that's
(17:31):
beta blockers or calcium channel blockers. To
try to knock those gradients down some. So that
we can improve symptoms and potentially improve
risk. Now, a lot of this is theoretical. But I
think it's sound theory that we can use to sort
of guide our patients with. Um, whether we're
talking. You know. More advanced therapies. I
(17:54):
think the jury's still out on that because now
we're talking a very small subset of population
who may have no symptoms but have significant
gradients and that's a little harder to justify
things like septal reduction therapies or cardiac
myosin inhibitors if they're truly asymptomatic
despite those therapies. Although it's certainly
worth discussing and looking at observational
(18:14):
data as we collect more data in this population
that we now no longer... Blanket statement restrict.
DR. BRYDE (18:22):
And for the patients with the obstruction,
if you're seeing a gradient, for example, of 100,
and they're in that, let's say, zone two, zone
three. This is maybe not on therapy. We're gonna
up-titrate, let's say, a beta blocker therapy.
Heart rates may come down a little bit, gradients
(18:42):
may come down a little as well. Do you see that
this population and the athletes and the exercise
enthusiasts generally tolerate that?
DR. EMERY (18:55):
They tolerate it, that's for sure.
We've seen people with pretty significant gradients
have pretty. Great exercise capacity. Part of
that may be when you look at the literature of
the degree of outflow tract gradients. And CPET
variables, there's not very good correlation.
Because it's a very dynamic variable. And can
(19:15):
be affected by how much they had to drink before
they worked out, before they exercised, or they
NPO before your CPET. Stress echo or your stress
echo and they're not. That dehydrated. Or they're
not that far depleted not even overtly void dehydrated.
Those all can affect your gradients. So it's part
of the counseling process and part of the thought
(19:37):
process of how we may strategize with them for
a hydration. Standpoint and a fueling standpoint.
DR. BRYDE (19:48):
And that's about the perfect lead in
into my next question is. How else do you counsel
these patients? So we. We get great objective
data from both of these tests, the Stress Echo
and the CPAT. And then. What other things do you
counsel these patients on like hydration and?
Exercising in hot weather.
DR. EMERY (20:08):
We talk about hydration a lot, right?
We tell our patients. Drink plenty of fluids and
don't get dehydrated. Unfortunately, a lot of
patients don't know what that means. Right. So
you may have to be more specific and work with
your sports nutritionists. Help them get a high.
True hydration plan and if we have to get more
specific, we can do that in the sports world,
(20:29):
right? We can get. Sweat tests. Done with experts
to sort of know what their. Sweat losses and their
sodium losses and how do we adequately replace
that? That may be more impactful and A marathon
than it is. In a 5K. But we also have to be careful
that we don't tell them to drink so much water
(20:49):
because we're so worried about them. Being dehydrated
increasing their gradients that now they overdo
the hydration and they become hyponatremic and
they have. Problems from. Hyponatremia. So we
have to know what we're talking about and who
we're talking to. And what resources we can get
them. I do worry about the longer distance, the
(21:11):
longer runs, and about maintaining hydration and
maintaining some degree of sodium intake. And
in maintaining the heats or exercising in the
heat Exercising in the cold is probably not as...
Big of a deal as long as they're trained for it.
Um, because they, you know, basal constrict in
their periphery and. Load their ventricle a little
(21:33):
bit. To reduce those gradients, but we have to
be careful they don't have subendocardial ischemia
either. So it's always about being cautious and
being careful. And staying away from blanket statements
that are too vague for patients, especially too
vague for athletes who want specifics. Staying
(21:53):
away from the vague statements.
DR. BRYDE (21:55):
We oftentimes do the same thing. It's,
hydration's great, hydration's super important,
but so are the electrolytes that go along with
it. So making sure that you're replacing those
electrolytes, you hold onto that extra water and
it stays in your vasculature. So yeah, we agree
there completely. Any other general considerations
(22:16):
for maybe your collegiate level athletes or people
participating in team sports with emergency action
plans or access to AEDs?
DR. EMERY (22:26):
Emergency action plans, you can't overemphasize
those enough. Right? There's all kinds of controversy,
even though there's better data about participation
with hypertrophic cardiomyopathy and other genetic
diseases because there's still a lot of consternation
and hand ringing. But one way that we know works
is emergency action plans. AEDs, well rehearsed
(22:49):
emergency action plans, AEDs that are functional
and not locked up in some place because you're
afraid to get them stolen. I think a lot of us
now when we counsel patients, because there's
a lot of counseling that goes on in these patients
that an AED ought to be part of their own personal
year. They have the whatever they have in their
bag for a ball bat a minute. They also have their
(23:12):
own AED that people around them that they would
be participating with know that there's they have
this condition and. Then know there's an AED available
and they know how to use it. It's probably worthwhile.
Making sure coaches know it. This may be an ample
opportunity to continue to spread the value of.
Hands only CPR and AED use in the public. Think
(23:32):
these are all important discussions that need
to be had not only with that athlete but the family.
Any team they may be participating with. I often
encourage athletes who are more... Um, solo based
athletes. Cyclists and not exercise alone. They
should go out with someone Hopefully they never
need that someone, but it's certainly a part of
(23:54):
an emergency action plan that can be put into
place to be very effective because we know the
AEDs. Work. If they're used.
DR. BRYDE (24:03):
As I think that the sports cardiology
world has certainly done a great job at bringing
this into front and center, especially in light
of recent highly publicized sudden cardiac death
events in professional athletes. And so, our colleague
Eli Freeman, he's been great about this and he's
always said, who's the closest person to the athlete
(24:26):
when they go down, it's the other athletes. And
that's why we've just really geared up in training.
Other athletes on what they can do because they're
usually the first one at the scene. So yes, definitely
important, important for the team to be aware
of physical condition like HCM that one of their
players may have so we can all be there and help
(24:48):
out as soon as we need to. So I think that this
has been a great talk, Dr. Emory. Really appreciate
you spending your time talking with us today on
this. Certainly for me, the fantastic takeaways
from all of our discussions with you have been
the importance of this objective data. And truly,
(25:11):
I agree with you. I think that our athletes really
like to walk away with this personalized exercise
prescription. It's not just 220 minus age and
here's your zones. It does have to tailored and
it changes over time. And so a patient like this
who can, a patient with HCM, who can develop a
(25:31):
relationship with somebody like you for repeat
evaluations if that's what they desire to participate
in sports over a long period of time, they can
come back, you can reevaluate the subjective data,
change the markers, change the zones. But you
know, of course, these people need to continue
to be evaluated on an annual basis. So that we
(25:53):
can be sure that nothing has changed within their
disease of HCM and that we're able to continue
to see them through safely and continue to participate
in exercise. Any last remarks from you that you
would like our listeners to walk away with?
DR. EMERY (26:11):
Yeah, thanks for having me on today.
You know, it's been a great discussion. I do like
using these parameters. As you said, it really
helps you engage with that athletic individual
who may have HCM. When they're engaged, they're
more likely to pay attention to the peripheral
stuff that can also help. Um. Their risk rather
(26:32):
than. Not feeling like. You as the caregiver is.
Taking them seriously in their athletic endeavor.
So they start ignoring all the stuff that we would
not want them to ignore. So that engagement process.
With stuff that's very close and personal to them
helps to create that bond and I think keep them
safe just by engaging them in their own athletic
(26:53):
endeavors and their own healthcare.
ANNOUNCER (27:00):
That was Dr. Bride and Dr. Emory. For
more information on HCMA, visit 4HCM.org. This
episode was edited and produced by Ear Fluence.
Thanks for listening and we'll talk to you soon
on In the Thick of It.
You are listening to End the Thick
of It, a podcast from the HCM Society, where we
interview experts in the hypertrophic cardiomyopathy
field to broaden the awareness of new HCM studies
and advancements. In this episode, cardiologist
Dr. Robin Bride has the pleasure of speaking with
Dr. Michael Emory. Dr. Emory is an associate professor
of medicine at the Cleveland Clinic Lerner College
(00:27):
of Medicine. He's also the co-director for the
Sports Cardiology Center at the Cleveland Clinic,
and he has a background in exercise physiology.
In this episode, they'll be discussing exercise
restrictions, how to develop an exercise prescription,
how to safely counsel an athlete or exercise enthusiast
who has hypertrophic cardiomyopathy, and how to
(00:47):
help them safely participate in sports. Let's
get in the thick of it. Here's Dr. Emory.
DR. EMERY (00:53):
Thanks for having me on, Robin.
DR. BRYDE (00:55):
Absolutely. So again, kind of the continuation,
we're shifting from exercise restriction in this
patient population, now we're moving more towards
how can we get our patients with HCM to safely
participate in exercise. And I'd like to start
this talk off by understanding how these patients
(01:15):
show up in your clinic. What is the general perception?
Are they coming to you having been told that they
need to restrict their participation?
DR. EMERY (01:25):
Or...
DR. BRYDE (01:27):
Cardiology colleagues. Now adopting
exercise participation. Just like to get a feel
of that from you.
DR. EMERY (01:37):
So they come with a wide. Variety of
opinions and counseling. For good and for bad
in a lot of cases. And we have to divide our cases
up in a sort of that person that wants to be athletic.
And or compete in sports and those who just want
to be active in day to day life. And you know
the classical historical is that everything should
(01:59):
be restricted you know decades ago they were afraid
to let you walk across the parking lot And that
still persists in a lot of physicians. You know,
in fact, just a couple weeks ago, sports medicine
physician was relaying to me that he goes I thought
HCM was a death sentence to exercise with. So
that's perception is still out there. So we have
(02:21):
to continue to break that perception. That exercise
is good. For people. And then when we talk about
patients that come into our clinics and we're
talking about exercise, we have to make that distinction
of what they mean by exercise and what they want
to do. Whether that's the low to moderate intensity
sort of. General exercise. That we recommend for
(02:43):
anyone, including now HCM patients. Or if they
want to be very athletic and very competitive
and they want to go run 5Ks, 10Ks, marathons,
triathlons, do crossfit. So we have to come to
them and understand what they really want to do
and what we can help guide them to do safely.
In either of those realms.
DR. BRYDE (03:02):
I think that with your background in
particular, I know you're a CrossFit enthusiast,
but particularly the exercise physiology component
that you know so well, I think that that really
helps you probably relate to these patients to
understand the exercise intensity that they desire
to perform and to understand their specific sport
(03:22):
of choice. So yeah, I agree. I think that that's
incredibly important to really understand what
their goals are and how we can safely help them
achieve those goals.
DR. EMERY (03:34):
Yeah, it certainly helps to create
a bond with them when I can, you know, walk the
walk and talk the talk at the same time. Doesn't
mean you have to be walk the walk, but certainly
it creates a bond with a lot of patients.
DR. BRYDE (03:47):
Right. They understand the passion.
It does help to understand that I'm here with
you. I'm trying to help you continue to do what
you love to do. So how much does the obstructive
versus non-obstructive nature of each patient's
disease come into play in this evaluation?
DR. EMERY (04:10):
So the first step in the evaluation
is like we would do with any HCM patient. We're
trying to elicit whether they're obstructive or
non-obstructive, and often it takes some provocative
maneuvers to do that beyond resting. So before
we talk exercise prescription, we have to make
sure they're. Very adequately. Phenotypes. Do
(04:30):
we? Understand their obstructing and their obstructed
physiology, their concomitant value, their disease
that they may have. Scar burden that they may
have. And that's part of a standard evaluation,
right? We haven't even gotten to exercise yet.
Because that's gonna sort of guide us into therapies.
Are you symptomatic? With obstruction. Then we
(04:52):
need to work on being symptomatic with that obstruction
and how we can improve that obstruction and those
symptoms based to that. And then after that sort
of standard. You know. Subjective evaluation,
objective evaluation, risk stratification. Then
we can talk about exercise prescription. Being.
(05:14):
What do you want and what do you intend to do?
So. In the setting of, you know, I just want to
go walk the dog and go for a brisk walk. That's
going to be a lower risk. Even if you have obstruction,
then it's... You have obstruction and you want
to do crossfit or you want to do marathons. Um,
(05:34):
Those are different discussions. So we want to
make sure they're very well phenotypes before
we start talking about those kinds of things.
Prescriptions.
DR. BRYDE (05:45):
So I imagine sometimes patients come
to you and perhaps they have great images and
you can clearly see based on their history whether
they're obstructive or not. Sometimes I imagine
too, you're repeating the stress echo to really
clearly phenotype their condition. How do you
get into and where do you really cross the line
(06:05):
of performing the cardiopulmonary exercise test?
I think... You know, most of our listeners who
are seeing patients with HCM are very familiar
with the stress echocardiogram and the utility
of the stress echo to clearly define the gradient.
But at what point are you transitioning over into
getting the CPAT? And how do you use each of those,
(06:26):
the variables for each one of those tests differently?
DR. EMERY (06:30):
So I'm a little biased because of my
background and interest in cardio pulmonary exercise
testing. So I tried to do. A CPET stress echo.
So really combining a CPET with the Echo at the
same time. So then I get the information all at
once without having to double up on the tests.
You don't need to do that and you need the resources
to be able to do both. If you're looking predominantly
(06:51):
for. A very basic exercise prescription, meaning
percent of heart rate reserves. You could probably
do that with a stress echo without the cardiopulmonary
piece. To define those percentages of heart rate
reserves. Which is a reasonable starting place
for someone who's been very inactive. And then.
(07:12):
You also get the degree of their obstruction post-error.
Exercise. If we want more details, meaning someone's
really wanting to dive deeper into the physiology
and very specific exercise prescription to...
Their level of fitness currently as well as their
maximal capabilities. Then we can use those parameters
(07:34):
from a cardiopulmonary exercise test. I.e. The
anaerobic or ventilatory thresholds or respiratory
compensation points, which are these turn points
in an exercise prescription that we're trying
to estimate on heart rate reserves. We can be
much more specific about it. Whether you need
one versus the other for a prescription, sort
(07:54):
of depends upon what you're going to do with that
data and how specific you need to be for an individual.
In other words, if you're just talking low to
moderate intensity exercise to keep someone moving
and generally healthy. You may not need that very
detailed exercise prescription from a CPET, but
if you're having a runner who really wants to
dial things in to try to be... Safe and effective,
(08:17):
then a CPET may be an advantageous test to add
on to them. Beyond the standard I'm trying to
elicit a gradient
DR. BRYDE (08:26):
Okay. That's all fantastic information.
So it sounds like the higher performing athlete.
Little more utility with the CPET, or actually
a lot more utility with the CPET in the higher
performing athlete. And then low to moderate intensity
exercise, maybe we can just get away with a stress
(08:47):
echocardiogram, but still there are some variables
that are pretty helpful with the cardiopulmonary.
DR. EMERY (08:54):
It depends upon what you want out of
it and what you plan to do with that information.
From an exercise prescription standpoint. I'm
from a diagnostic standpoint of. What's their
true exercise capacity to know whether they're
truly symptomatic or asymptomatic? What's their
hemodynamic responses? Do they have concomitant
pulmonary disease or other problems contributing
(09:16):
to their exercise and tolerance? The CPET will
give you Just a wealth of additional information
that can help you better characterize those patients.
From a exercise prescription standpoint, it really
depends upon then what you want to do with that
information.
DR. BRYDE (09:31):
And kind of as a side point, I want
our listeners to know you, you actually are a
little creative in the CPAT lab. And I, in some
of our conversations in the past, you've told
me that you can actually do this on the bike or
you could do it on the treadmill. And I think
for certain athletes, you know, some of our triathletes
or cyclists, they're really interested in this
(09:51):
information as it pertains to the bike. And then
some of our big time runners, marathoners, of
course, they're going to be limited or going to
want the information for the treadmill. So so
I think that I like how you're able to offer both
of these aspects in your lab. I think that that's
very interesting.
DR. EMERY (10:11):
Yeah, we have to remember that the
numbers are different bike to treadmill. Um So.
If you develop an exercise prescription and heart
rate training zones based upon a treadmill. They're
not going to quite translate to the bike appropriately.
And if you're a very high end athlete, then. Um
that's going to affect what zones and what training
(10:33):
parameters they want. Triathletes may be a little
bit similar, at least in terms of the very high
max numbers, but maybe not. Um, the training number.
So you need to be very specific. When I'm evaluating
a patient up front and we're doing a CPED, I really
like to do it on a bike. I get additional gas
exchange information out of it that can help me.
(10:53):
And you know, with our very talented sonographers,
we can do simultaneous echo Doppler while they're
still peddling on the bike and now I can look
for the gradients. As we increase those intensities
to see where we're seeing the most. Profound gradients
at what I can't really do on a treadmill, obviously,
because you're not getting the gradients until
after they get off the treadmill.
DR. BRYDE (11:16):
So discussing the CPET variables a
little bit more, at Care of the Athletic Heart
this year, you had a great presentation on using
the anaerobic threshold to help predict catecholamine
release. And how this is important to understand
in patients with HCM. Can you explain that in
(11:37):
a little more detail for our listeners to better
understand this relationship between anaerobic
threshold and the importance of this catecholamine
surge after that?
DR. EMERY (11:47):
Sure. You know, one of the. Concerns
with regards to anybody with you know, significant
heart disease is it's that. Catecholamine surge
of higher intensity exercise that puts them at
risk of ventricular arrhythmias and sudden cardiac
arrest. And that certainly holds true in our concern
for hypertrophy cardiomyopathy as well. This goes
(12:09):
beyond any obstruction questions. And more about
the unstable substrate. So is there a way that
we can predict that catecholamine surge. We can't
measure readily catecholamines, but it turns out
that from studies that have already been done
and in hypertrophic cardiomyopathy patients that
that catecholamine surge starts to happen just
(12:32):
after your ventilatory threshold one or your anaerobic
threshold, depending upon the terminology you
like to use. So if we can identify that first
ventilatory threshold by gas exchange data, also
called the anaerobic threshold. Then we can write
an exercise prescription to sort of keep you in
that zone, that sort of moderate intensity, or
(12:54):
zone two, it's affectionately referred to in the
five zone model. Um, that can in theory keep you
below that threshold to keep you safe while still
gaining the benefits of the exercise, particularly
if you have a more unstable threshold. So... Being
able to do a cardiopulmonary exercise test, collect
(13:14):
those gas exchange parameters, really know how
to identify those numbers and generate an exercise
prescription. Is okay. Potentially a good way
to. Gain the benefits of Exercise. While still
keeping you as safe as we can keep you. Because
it turns out that that zone right around that
anaerobic threshold. Is where you gain probably
(13:35):
the biggest chunk of your aerobic base and your
aerobic benefit from exercise.
DR. BRYDE (13:42):
And it is that zone where I do think
most of our patients, they're trying to stay within
that zone. We don't have many people that are
going out there trying to train in zone five for
a long period of time or depending on how many
zones you train with. But I do just, I love this
objective data. That we're able to gather from
cardiopulmonary exercise testing. I think that.
(14:04):
When done correctly and when analyzed properly,
that this objective data can provide a wealth
of knowledge and help in developing this exercise
prescription. So again, kind of one of the benefits
of what are we getting from a cardiopulmonary
exercise test compared to what we're getting from
our Stress Echo cardiogram.
DR. EMERY (14:26):
And I think it's important for a lot
of patients to sort of see we have some objective
data. And we're not just sort of picking numbers
out of the air. That this is tailored specifically
for them and where they're at in their fitness
journey right now. It helps, I think, them understand
that exercise is important. It can be safe. And
(14:46):
we're being very specific for them. You know,
oftentimes, you know, you and I have probably
both heard this. Patients are given a heart rate
number to stay below and you try to figure out
where that heart rate number came from. They're
just picking numbers out of the air that may or
may not be important to them. Or specific to them.
Obviously these numbers are gonna be different
(15:07):
if you are 60 versus you're 20. Those numbers
should be different. They shouldn't be the same
empiric number. They should be different based
upon your current level of fitness and your desired
fitness level as well. So I think patients really
appreciate those. Now you don't. Always need this.
Some people can get by with the talk test and
(15:28):
the heart rate reserve percentage wise. Um, But
some people enjoy this discussion and this practice
a little bit more. So it's how I've developed
my practice. It's not, uh, you know. Only way
it can be done but it certainly is fun. It's fun
for me. And I think it's valuable for my patients.
DR. BRYDE (15:46):
Sure, I agree completely. So shifting
gears a little bit more back to Stress Echo. How
are you tailoring? Treatment therapies, so in
your obstructive patients. When they're doing
the stress echocardiogram and you're assessing
gradients with varying degrees of exercise intensity.
(16:09):
How are you tailoring the exercise prescription
and how do you tailor medical therapy for this
specific obstructive population with significantly
elevated gradients on the stress psychopardiogram?
DR. EMERY (16:25):
So those are longer discussions with
the patient. Um, you know. It depends upon what
their overall capacity is. It depends upon. At
what? Degree their obstruction is and by that
I mean at what. Exercise intensity if I'm for
(16:46):
instance doing a bike and can able to see different
degrees of intensity in the level of obstruction.
Versus significant resting or valsalva. Obstructions.
The concern is that if you're spending even long
periods of time Um. At a level of which you're
obstructed, that left ventricular pressure is
(17:08):
quite elevated. Potentially producing some subendocardial
ischemia putting you at risk, even if though you
may not be at a high intensity. Where your catecholamine
surge that may compound. The concern and the risk.
So then we're trying to being more. Aggressive
with our medical therapy if we can, whether that's
(17:31):
beta blockers or calcium channel blockers. To
try to knock those gradients down some. So that
we can improve symptoms and potentially improve
risk. Now, a lot of this is theoretical. But I
think it's sound theory that we can use to sort
of guide our patients with. Um, whether we're
talking. You know. More advanced therapies. I
(17:54):
think the jury's still out on that because now
we're talking a very small subset of population
who may have no symptoms but have significant
gradients and that's a little harder to justify
things like septal reduction therapies or cardiac
myosin inhibitors if they're truly asymptomatic
despite those therapies. Although it's certainly
worth discussing and looking at observational
(18:14):
data as we collect more data in this population
that we now no longer... Blanket statement restrict.
DR. BRYDE (18:22):
And for the patients with the obstruction,
if you're seeing a gradient, for example, of 100,
and they're in that, let's say, zone two, zone
three. This is maybe not on therapy. We're gonna
up-titrate, let's say, a beta blocker therapy.
Heart rates may come down a little bit, gradients
(18:42):
may come down a little as well. Do you see that
this population and the athletes and the exercise
enthusiasts generally tolerate that?
DR. EMERY (18:55):
They tolerate it, that's for sure.
We've seen people with pretty significant gradients
have pretty. Great exercise capacity. Part of
that may be when you look at the literature of
the degree of outflow tract gradients. And CPET
variables, there's not very good correlation.
Because it's a very dynamic variable. And can
(19:15):
be affected by how much they had to drink before
they worked out, before they exercised, or they
NPO before your CPET. Stress echo or your stress
echo and they're not. That dehydrated. Or they're
not that far depleted not even overtly void dehydrated.
Those all can affect your gradients. So it's part
of the counseling process and part of the thought
(19:37):
process of how we may strategize with them for
a hydration. Standpoint and a fueling standpoint.
DR. BRYDE (19:48):
And that's about the perfect lead in
into my next question is. How else do you counsel
these patients? So we. We get great objective
data from both of these tests, the Stress Echo
and the CPAT. And then. What other things do you
counsel these patients on like hydration and?
Exercising in hot weather.
DR. EMERY (20:08):
We talk about hydration a lot, right?
We tell our patients. Drink plenty of fluids and
don't get dehydrated. Unfortunately, a lot of
patients don't know what that means. Right. So
you may have to be more specific and work with
your sports nutritionists. Help them get a high.
True hydration plan and if we have to get more
specific, we can do that in the sports world,
(20:29):
right? We can get. Sweat tests. Done with experts
to sort of know what their. Sweat losses and their
sodium losses and how do we adequately replace
that? That may be more impactful and A marathon
than it is. In a 5K. But we also have to be careful
that we don't tell them to drink so much water
(20:49):
because we're so worried about them. Being dehydrated
increasing their gradients that now they overdo
the hydration and they become hyponatremic and
they have. Problems from. Hyponatremia. So we
have to know what we're talking about and who
we're talking to. And what resources we can get
them. I do worry about the longer distance, the
(21:11):
longer runs, and about maintaining hydration and
maintaining some degree of sodium intake. And
in maintaining the heats or exercising in the
heat Exercising in the cold is probably not as...
Big of a deal as long as they're trained for it.
Um, because they, you know, basal constrict in
their periphery and. Load their ventricle a little
(21:33):
bit. To reduce those gradients, but we have to
be careful they don't have subendocardial ischemia
either. So it's always about being cautious and
being careful. And staying away from blanket statements
that are too vague for patients, especially too
vague for athletes who want specifics. Staying
(21:53):
away from the vague statements.
DR. BRYDE (21:55):
We oftentimes do the same thing. It's,
hydration's great, hydration's super important,
but so are the electrolytes that go along with
it. So making sure that you're replacing those
electrolytes, you hold onto that extra water and
it stays in your vasculature. So yeah, we agree
there completely. Any other general considerations
(22:16):
for maybe your collegiate level athletes or people
participating in team sports with emergency action
plans or access to AEDs?
DR. EMERY (22:26):
Emergency action plans, you can't overemphasize
those enough. Right? There's all kinds of controversy,
even though there's better data about participation
with hypertrophic cardiomyopathy and other genetic
diseases because there's still a lot of consternation
and hand ringing. But one way that we know works
is emergency action plans. AEDs, well rehearsed
(22:49):
emergency action plans, AEDs that are functional
and not locked up in some place because you're
afraid to get them stolen. I think a lot of us
now when we counsel patients, because there's
a lot of counseling that goes on in these patients
that an AED ought to be part of their own personal
year. They have the whatever they have in their
bag for a ball bat a minute. They also have their
(23:12):
own AED that people around them that they would
be participating with know that there's they have
this condition and. Then know there's an AED available
and they know how to use it. It's probably worthwhile.
Making sure coaches know it. This may be an ample
opportunity to continue to spread the value of.
Hands only CPR and AED use in the public. Think
(23:32):
these are all important discussions that need
to be had not only with that athlete but the family.
Any team they may be participating with. I often
encourage athletes who are more... Um, solo based
athletes. Cyclists and not exercise alone. They
should go out with someone Hopefully they never
need that someone, but it's certainly a part of
(23:54):
an emergency action plan that can be put into
place to be very effective because we know the
AEDs. Work. If they're used.
DR. BRYDE (24:03):
As I think that the sports cardiology
world has certainly done a great job at bringing
this into front and center, especially in light
of recent highly publicized sudden cardiac death
events in professional athletes. And so, our colleague
Eli Freeman, he's been great about this and he's
always said, who's the closest person to the athlete
(24:26):
when they go down, it's the other athletes. And
that's why we've just really geared up in training.
Other athletes on what they can do because they're
usually the first one at the scene. So yes, definitely
important, important for the team to be aware
of physical condition like HCM that one of their
players may have so we can all be there and help
(24:48):
out as soon as we need to. So I think that this
has been a great talk, Dr. Emory. Really appreciate
you spending your time talking with us today on
this. Certainly for me, the fantastic takeaways
from all of our discussions with you have been
the importance of this objective data. And truly,
(25:11):
I agree with you. I think that our athletes really
like to walk away with this personalized exercise
prescription. It's not just 220 minus age and
here's your zones. It does have to tailored and
it changes over time. And so a patient like this
who can, a patient with HCM, who can develop a
(25:31):
relationship with somebody like you for repeat
evaluations if that's what they desire to participate
in sports over a long period of time, they can
come back, you can reevaluate the subjective data,
change the markers, change the zones. But you
know, of course, these people need to continue
to be evaluated on an annual basis. So that we
(25:53):
can be sure that nothing has changed within their
disease of HCM and that we're able to continue
to see them through safely and continue to participate
in exercise. Any last remarks from you that you
would like our listeners to walk away with?
DR. EMERY (26:11):
Yeah, thanks for having me on today.
You know, it's been a great discussion. I do like
using these parameters. As you said, it really
helps you engage with that athletic individual
who may have HCM. When they're engaged, they're
more likely to pay attention to the peripheral
stuff that can also help. Um. Their risk rather
(26:32):
than. Not feeling like. You as the caregiver is.
Taking them seriously in their athletic endeavor.
So they start ignoring all the stuff that we would
not want them to ignore. So that engagement process.
With stuff that's very close and personal to them
helps to create that bond and I think keep them
safe just by engaging them in their own athletic
(26:53):
endeavors and their own healthcare.
ANNOUNCER (27:00):
That was Dr. Bride and Dr. Emory. For
more information on HCMA, visit 4HCM.org. This
episode was edited and produced by Ear Fluence.
Thanks for listening and we'll talk to you soon
on In the Thick of It.
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