Sudden Cardiac Death in Young Athletes

1. Sudden Cardiac Death in Young Athletes Yann Ping Pan, MD Ruey-Kang Chang, MD, MPH

2. What do they have in common? • Hank Gathers (1967-1990) • Reggie Lewis (1965-1993) • Flo Hyman (1954-1986) • Sergei Grinkov (1967-1995) • Pete Maravich (1947-1988)

7. Athlete SCD– why is it important • Family physicians see a lot of athletes for sports related issues • Family physicians are involved in school health and pre-participation examinations • It is important to know the clinical characteristics of SCD and identify athletes who are at risk • It is important to know the current recommendations for pre-participation examinations

8. What do we know about SCD in Athletes? • 12-15 million young (<30 years) competitive athletes in the US • Estimated incidence of sudden cardiac death at 2.1 per 100 000 athletes per year • Estimated 200 athletes in the US die per year of sudden cardiac death • Sudden death of the young athletes is mostly unexpected, dramatic, tragic and carries huge emotional impact on the society

9. Sudden Cardiac Death of Athletes Epidemiology Based on Autopsy Series • Age-- • 9% in middle school • 62% in high school • 22% in college • 7% in professional • Sex—90% male, 10% female • Caucasians at highest risk Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

10. Sudden Cardiac Death of Athletes Sports engaged in at the time of sudden death Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

11. Sudden Cardiac Death of Athletes Causes of Sudden Cardiac Deaths in Young Athletes Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

12. Research Questions • What are the epidemiologic characteristics of athlete SCD from the an active surveillance, population-based sample? • What are the major causes for athlete SCD from the an active surveillance, population-based sample?

13. Objectives • To evaluate an active surveillance system of athlete SCD from a population-based sample using Google Internet search engine • To compare the active surveillance of athlete SCD by Google with reported athlete SCD data using autopsy or passive report systems

14. Methods • Advanced Google Internet search was conducted once a week (every Friday) from April 2007 to March 2008 • Combinations of keywords were used– athlete, player, practice, game, collapse, pass out, die, gym class, etc. • Only US athletes died in a game or practice or immediately after, occurred in the US • Age 11 to 30 years, death between 4/07 to 3/08 • Exclusions– known cardiac history, trauma, non-US athletes, died in sleep or at home, possible drugs or alcohol,

17. Methods • First 200 Google search results are carefully examined • For cases that fulfill inclusion criteria, the web pages are printed/saved • All demographic data, history and circumstances (CPR, use of AED), are recorded and compiled for analysis • Autopsy results are searched 1 month to 12 months later to determine the cause of death

18. Results • Total of 74 athletes died in April 2007 to March 2008 in a game or during or after practice (comotio cordis are excluded) • 25 athletes died in a game (34%), and 49 died in or after practice (66%)– consistent with the literature or 1:2 • Most common sports are basketball and football– consistent with the literature

19. Results

20. Sudden Cardiac Death of Athletes F:M= 1:3 Female Male

21. Race and Ethnicity

22. Sports Associated with SCD

23. Sudden Cardiac Death of Athletes Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

24. Causes of SCD

25. Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

26. Conclusion • Excluding comotio cordis, there are 74 SCD of young athletes in the US in 2007-2008 • 1/3 SCD occurs in a game, 2/3 in practice • Including gym class death, there are more females than previously described • Blacks may be at higher risk, ore studies needed • Basketball and football are common sports associated with SCD • HOCM/LVH accounts for almost 50%, coronary anomaly and arrhythmia are next common causes

28. Sudden Cardiac Death of Athletes Circulation 2007;115;1643-1655

29. Endorsement of AHA Guidelines • American Academy of Family Physicians • American Academy of Pediatrics • American College of Cardiology • American College of Sports Medicine • American Medical Society for Sports Medicine • American Orthopaedic Society for Sports Medicine • American Osteopathic Academy of Sports Medicine

30. European Guidelines for PPE • In 2005, The European Society of Cardiology issued official recommendation for PPE, including 12-lead ECG

31. Sudden Cardiac Death of Athletes Coronary Artery Anomaly

32. Sudden Cardiac Death of Athletes Coronary Artery Anomaly • With increased stroke volume during exercise ascending aorta expands and the take-off angle is further exaggerated • LMCA may also be compressed against root of pulmonary trunk during exercise • ECG is likely normal • Very difficult to screen or diagnose even with echocardiogram • Treatment: Surgery for coronary reimplantation

33. Sudden Cardiac Death of Athletes Commotio Cordis • Sudden disturbance of heart rhythm as the result of a blunt, non-penetrating impact to the precordial region • Impact occurring within a specific 10-20 millisecond portion of the cardiac cycle in the ascending phase of the T wave, when the ventricular myocardium is repolarizing, moving from systole to diastole • Most effective preventions are: • Chest shield • Automatic External Defibrillator (AED)

34. Sudden Cardiac Death of Athletes J Am Coll Cardiol 2008;52:1990–6

35. Sudden Cardiac Death of Athletes