1 / 74

Sudden Cardiac Death in College Athletes: Causes & Screening

Explore the causes and screening methods for sudden cardiac death in college athletes. Learn about the prevalence and common risk factors such as hypertrophic cardiomyopathy.

percyt
Download Presentation

Sudden Cardiac Death in College Athletes: Causes & Screening

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Sudden Cardiac Death causes and screening in college athletics Matthew Pecci, MD Assistant Professor in Family Medicine Director of Sports Medicine Boston University

  2. Objectives • Scope of the problem • Review the most common causes of SCD in the US • Review current consensus on preparticipation(PPE) screening • Review the pros and cons of the addition of ECG screening to the PPE exam

  3. SUDDEN DEATH Sudden death in athletics can occur from direct or indirect causes direct - traumatic indirect - atraumatic

  4. SUDDEN DEATH Most indirect causes are cardiac in origin. A very small number of indirect causes of sudden death are noncardiac heat stroke CVA pulmonary embolus drug abuse

  5. SUDDEN DEATH From 1931 to 1986 direct causes of sudden death outnumbered indirect cause by 2 to 1. From 1982 to the present this has reversed with indirect causes now outnumbering direct causes by 2 to 1.

  6. SUDDEN CARDIAC DEATH Sudden cardiac death (SCD) in athletes: nontraumatic, nonviolent, unexpected death due to cardiac causes within one hour after the onset of symptoms, and occurring within one hour of sports participation

  7. SCD EPIDEMIOLOGY How prevalent a problem is SCD?

  8. SCD Incidence Incidence of SCD in US is unknown Studies to date have relied on surveys, and non-mandatory reporting systems that may underestimate the true incidence There has been some push from the sports medicine community for a national registry National Center for Catastrophic Sports Injury US National Registry of Sudden Death in Athletes

  9. SCD Incidence • Van Camp et al • SCD in HS and college athletes 1983-1993 • Identified by media reports and newspaper clippings • 100 cases of SCD • Estimated number of athletes based on HS and college participation rates • SCD rate 1:300,000 annually • Van Camp SP, Bloor CM, Mueller FO, Cantu RC, Olson HG. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc. 1995;27:641– 647.

  10. SCD Incidence • Maron et al • Minnesota HS athletes • Mandatory insurance for catastrophic death in HS athletes • 12 year period, grades 10-12 • 3 cases of SCD occurred during study period • Rate of SCD was 1:200,000 participants annually • Maron BJ, Gohman TE, Aeppli D. Prevalence of sudden cardiac death during competitive sports activities in Minnesota high school athletes. J Am CollCardiol. 1998;32:1881–1884.

  11. SCD Incidence • Maron et al • SCD over 27 year period in athletes up to age 39 • Identified cases of SCD through various sources – news media, internet, direct reports, etc • 1866 cases identified, in 1353 cause of death determined • Rate of SCD 1:164,000 participants annually • Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980–2006. Circulation. 2009;119:1085–1092.

  12. SCD Incidence • Eckart et al • SCD in military recruits over 25 year period • Ages 18-35 • Mandatory reporting of all deaths • Autopsy confirmation of cause • Rate of SCD 1:9,000 recruit-years • Eckart RE, Scoville SL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med. 2004;141(11):829–834

  13. SCD Incidence • Harmon et al • SCD in NCAA student-athletes over 5 year period • Identified by NCAA database, media reports, and insurance claims • 273 death with 45 SCD • Incidence SCD 1:43,770 participants per year • Breakdown by sport, sex, and race • Div 1 men’s basketball SCD rate 1:3100 per year • Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of Sudden Cardiac Death in National Collegiate Athletic Association Athletes. Circulation. 2011;123:1594-1600.

  14. SCD Incidence Incidence likely somewhere in between Based on available data experts estimate the true incidence of SCD in the US is 1 in 75,000

  15. SCD What is the most common cause of SCD in athletes?

  16. SCD Over age 35 - 90% of SCD are due to coronary artery disease In many cases the athlete has no known history of disease Acute plaque rupture

  17. SCD Cause of SCD in athletes less than 35yrs 36-50% hypertrophic cardiomyopathy 10-19% coronary artery anomalies 6% myocarditis 5% ruptured aorta (Marfans syndrome) <5% aortic stenosis, right ventricular dysplasia, CAD, Ion channel disorders

  18. HCM Hypertrophic cardiomyopathy Clinically recognized in 1 in 500 in the general population (0.2%) Genes mutations on at least 12 genes which code components of the heart muscle fibers Autosomal dominant with variable expression Myocardial disarray, myocardial scarring

  19. HCM Classic findings: LV wall thickness of 16mm or more (nl < 12mm) vast disarray of the walls affected and extent of hypertrophy septum to free wall ratio >1.3 Small LV cavity size < 45mm with impaired diastolic function

  20. HCM Functional findings: impaired filling of the LV during diastole due to small cavity size abnormal flow across the mitral valve pressure gradient to blood flowing into the aorta due to thickened septum

  21. HCM Incidence of SCD in HCM 2-4% / year in adults 4-6% / year in children and adolescents

  22. HCM Causes of SCD in HCM - speculative Arrythmia - ventricular tachyarrythmias hypotension from diastolic dysfunction and outflow tract obstruction myocardial ischemia

  23. Screening for HCM Can we identify HCM in an athlete before it causes SCD? Family history – autosomal dominant symptoms - syncope, CP, fatigue, dyspnea physical exam findings

  24. HCM • Most athletes are asymptomatic and their sentinel event is SCD • Estimated that only 21% of athletes with HCM have signs or symptoms1 1. Maron BJ, Shirani J, et al. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA. 1996;276(3):199–204

  25. HCM Physical exam - murmur from outflow obs. Harsh, mid systolic heard best at right upper sternal border decreases in intensity with increased blood flow to the heart i.e. squatting, lying down increase in intensity with decreased blood flow to the heart i.e. Valsalva, standing Estimated that only 25% of HCM patients have a murmur

  26. Is an ECG helpful? • An ECG will be abnormal in 75-95% of patients with HCM • wide array of abnormalities • prominent Q waves • deep negative T waves • increased QRS voltage associated with ST depression or T-wave inversion.

  27. Is an echocardiogram helpful? • Echocardiography remains the standard to confirm the diagnosis of HCM • identifying pathologic LV wall thickness (>16 mm) • a non-dilated LV with impaired diastolic function • Septum to free wall ratio > 1.3 • Changes may not be apparent until physical maturity

  28. HCM diagnosis uncertainty • In cases where the diagnosis of HCM is uncertain (ie, borderline LV wall thickness) • Cardiac magnetic resonance imaging (MRI) • Genetic testing • Repeat echocardiogram after 4 to 6 weeks deconditioning • deconditioning should resolve the hypertrophy in an athletic heart and may help in distinguishing from HCM.

  29. HCM and participation No single clinical, morphologic, or electrophysiologic feature has been found to be a reliable predictor of SCD in patients with HCM 36th Bethesda Conference: “present recommendations for sports eligibility remain conservative and homogeneous for those athletes within the diverse HCM clinical spectrum” “Broad recommendation to exclude such individuals from competitive sports will, by definition, deny participation to some unnecessarily” Maron BJ, Zipes DP, et al. 36th Bethesda conference. Journal of the American College of Cardiology. 2005;45(8):1317-75.

  30. HCM and participation • 36th Bethesda recommendations: “Athletes with a probable or unequivocal clinical diagnosis of HCM should be excluded from most competitive sports, with the possible exception of those of low intensity (class IA). This recommendation is independent of age, gender, and phenotypic appearance, and does not differ for those athletes with or without symptoms, LV outflow obstruction, or prior treatment with drugs or major interventions with surgery, alcohol septal ablation, pacemaker, or implantable defibrillator.”

  31. Coronary Artery Anomalies The right and left coronary arteries arise from the aortic sinuses and are responsible for blood supply to the heart a small percentage of people have arteries which originate in atypical locations certain of these atypical arterial originations may affect blood flow to the heart

  32. Coronary Artery Anomalies Most common anomaly leading to SCD: left coronary from the right sinus of valsalva - causes a severe angle in the artery which disrupts blood flow Others: hypoplastic coronary arteries tunneled epicardial arteries

  33. Coronary Artery Anomalies Cause of death is from myocardial ischemia Very difficult to detect with screening No genetic component No exam findings Small percentage may have symptoms - review of 78 cases - 62% asymptomatic

  34. Questions?

  35. SCREENING for SCD No outcome based study exists on the effectiveness of the PPE The American Heart Association recommends a detailed history and exam consisting of 12 items1 The 4th edition PPE monograph endorses the AHA recommendations2 Maron BJ, Thompson PD, et al. Recommendations and considerations related to preparticipation examination screening for cardiovascular abnormalities in competitive athletes: a 2007 update. Circulation. 2007;115(12):1643-55. American Academy of Family Physicians , American Academy of Pediatrics , American College of Sports Medicine , et al. Preparticipation Physical Evaluation. In:  Roberts W,  Bernhardt D editor. 4th edition. Elk Grove (IL): American Academy of Pediatrics; 2010;

  36. SCREENING for SCD Personal History: Exertional chest pain Unexplained syncope or near syncope Excessive exertional and unexplained dyspnea/fatigue associated with exercise Prior recognition of a heart murmur Elevated systolic blood pressure

  37. SCREENING for SCD Family History: Premature death(sudden and unexpected, or otherwise) before age 50 years due to heart disease, in 1 or more relatives Disability from heart disease in a close relative <50 years of age Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias

  38. SCREENING for SCD Additional questions in PPE monograph: Does your heart ever race or skip beats? Has your doctor ever ordered tests for your heart? Have you ever had an unexplained seizure? Do you get more tired or short of breath more quickly than your friends during exercise? Family history of unexplained or unexpected death prior to age 50 including drowning, unexplained car accidents, SIDs Family member with a pacemaker or implantable defibrillator Family member with unexplained seizures, fainting or near drowning

  39. SCREENING for SCD Physical exam: Auscultation for a murmur (sitting and standing) Femoral pulses to exclude aortic coarctation Stigmata of Marfans syndrome Brachial artery BP (sitting)

  40. SCREENING for SCD AHA recommendation compliance: In 2000 only 26% of NCAA schools had forms containing at least 9 of the 12 items In 2005 48 states had approved forms for high schools and 39 of these forms had at least 9 items In 2010 a survey to the Washington chapter of AAP, AAFP, and high school ADs only 6% of providers and 0% of schools were compliant. Only 47% of physicians and 6% of ADs reported awareness of the guidelines.1 Madsen NL, Drezner JA, Salerno JC. Sudden death screening in adolescent athletes: an evaluation of compliance with national guidelines. Br J Sports Med 2013; 47:172-77

  41. SCREENING for SCD What should colleges do? Make sure forms contain recommended history and exam items If you are performing your own PPEs make sure you have qualified examiners who are aware of the guidelines If you are not performing your own PPEs make sure forms are adequately reviewed and if there are any questions athletes reexamined

  42. ECG Screening in the USA • 2007 consensus statement by the American Heart Association recommended not to screen athletes with an ECG • “Admirable proposal deserving serious consideration”, “many epidemiologic, social, economic, and other issues” which impact this screening proposal in the US • The 4th edition Pre-participation examination monograph does not recommend for or against ECG screening

  43. ECG and the Italian Data • Mandatory screening of competitive athletes with history, physical and ECG begun in 1982 • Population-based observational study • Incidence of SCD in athletes in prescreening (1979-81), early screening (1982-92), and late screening (1993-2004); causes of SCD • Incidence of SCD in athletes decreased by 89%, 10 fold decrease in deaths from cardiomyopathies Corrado D, Basso C, Pavei A, et al. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006; 296:1593–1601.

  44. ECG and the Italian Data • Based on the Corrado study the European Society of Cardiology and the International Olympic Committee now recommend ECG screening as part of the Pre-participation exam Pelliccia A, Fagard R. Bjørnstad HH, et al. A European Society of Cardiology consensus document: recommendations for competitive sports participation in athletes with cardiovascular disease. Eur Heart J. 2005;26:1422–1445.

  45. No ECG Rationale Italian data Scope of problem in US ECG Specificity Cost Challenge of mass screening Ethical considerations for testing

  46. Italian Data • Not controlled • Mandatory H+P, and ECG all implemented in 1982 • High prescreening annual death rate in athletes of 3.6/100,000 person years somewhat accounts for the large change with screening • Lowest death rate 0.4 death/100,000 person years is similar to reported death rates of HS and college athletes in US without the use of ECG screening

More Related