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Preparticipation Physical Evaluation PPE and Prevention of Sudden Cardiac Death

Sudden Cardiac Death (SCD) Overview. Infrequent occurrence?600 -1,000 children and adolescents No accurate or mandatory reportingCaused by rare cardiac defects, trauma, or stimulants Warning signs/symptomsWhen SCD occurs, stories are bigEmotional responses from parents, coaches, friends, and

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Preparticipation Physical Evaluation PPE and Prevention of Sudden Cardiac Death

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    1. Preparticipation Physical Evaluation (PPE) and Prevention of Sudden Cardiac Death Jack Stevens, MD, FACC Director of Preventive Cardiology and Exercise Physiology, Sibley Heart Center Section Chief of Cardiology, Children’s Healthcare of Atlanta at Scottish Rite Assistant Professor of Pediatrics, Emory University School of Medicine

    2. Sudden Cardiac Death (SCD) Overview Infrequent occurrence? 600 -1,000 children and adolescents No accurate or mandatory reporting Caused by rare cardiac defects, trauma, or stimulants + Warning signs/symptoms When SCD occurs, stories are big Emotional responses from parents, coaches, friends, and the community SCD episodes may not be predictable or preventable

    3. Introduction

    4. “Advanced Screening” with EKG or Echocardiography: Pros and Cons PRO: Echo identifies HCM better than exam; EKG may be superior echocardiography for HCM. EKG can identify asymptomatic cardiac conduction problems. Tests make everyone feel like they have done a better screening. CON: EKG and echocardiographic screening have not been shown to reduce sudden cardiac deaths. False positives are high for both?leading to further testing (increased costs) and often inappropriate disqualification. “Athletic heart” Echocardiographic screening misses many potential causes of SCD, including some HCM. If athletes deserve advanced screening so do other students. Echo. screening needs to be repeated every 1-2 years for HCM in the HS age group. Cost vs. benefit; fairness for lower income groups?

    5. Has PPE Worked?

    6. Sudden Cardiac Death (SCD): What Are We Screening For? Structural/Functional Hypertrophic Cardiomyopathy (HCM) Coronary Artery Anomalies Aortic Rupture/Marfan Dilated Cardiomyopathy (DCM) Myocarditis Left Ventricular Outflow Tract Obstruction Mitral Valve Prolapse (MVP) Coronary Artery Atherosclerotic Disease Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) Post-operative Congenital Heart Disease Electrical Long QT Syndrome (LQTS) Wolff-Parkinson-White Syndrome (WPW) Brugada Syndrome Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) Short QT Syndrome

    7. Sudden Cardiac Death (SCD): Differential Diagnosis Structural/Functional Hypertrophic Cardiomyopathy (HCM)* Coronary Artery Anomalies Aortic Rupture/Marfan* Dilated Cardiomyopathy (DCM)* Myocarditis Left Ventricular Outflow Tract Obstruction Mitral Valve Prolapse (MVP) Coronary Artery Atherosclerotic Disease* Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)* Post-operative Congenital Heart Disease Electrical Long QT Syndrome (LQTS) Wolff-Parkinson-White Syndrome (WPW) Brugada Syndrome* Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)* Short QT Syndrome

    9. SCD Differential Diagnosis: Structural/Functional 1) Hypertrophic Cardiomyopathy: Thickening of the heart muscle

    10. PPE Findings HCM Exertional chest pain and/or dyspnea, arrhythmia symptoms, fatigue, syncope/near syncope/SCD EIB symptoms Post exertional syncope/SCD Cardiac murmur Family history of HCM, non-specific cardiomyopathy Family history of heart disease

    11. PPE Findings ARVC Exercise-induced syncope/near syncope/SCD Exercise palpitations Family history of ARVC, SCD

    12. SCD Differential Diagnosis: Primary Electrical

    14. EKG Patterns: T-Waves

    15. PPE Findings Long QT Syndrome Exercise/emotion/startle syncope or seizure (occasionally misdiagnosed as neurologic or vasovagal) Drowning/near drowning SIDS Congenital deafness Family history of SCD, seizure, syncope, LQTS

    16. SCD Differential Diagnosis: Structural/Functional Coronary Artery Anomalies: Congenital or Acquired

    17. Congenital Coronary Artery Anomalies Left From The Right

    18. PPE Findings Congenital Coronary Artery Abnormalities Exercise syncope, chest pain, dyspnea, palpitations, SCD No family history

    19. PPE Findings - CPVT (Catecholaminergic Polymorphic Ventricular Tachycardia) Young patient age Exercise/emotion induced seizure/syncope (occasionally misdiagnosed as epilepsy) Drowning / near drowning Family history of CPVT, seizure/syncope/SCD

    20. Older patient age (3rd – 4th decade) Syncope Family history of Brugada Syndrome, syncope, SCD

    21. Other Causes of Athletic “Collapse” Heat Stress/Stroke: Importance of conditioning, attention to environmental temperature and humidity, continuous access to water. Always take the opportunity to remind coaches in your community when summer and early fall practices start. Vasovagal Faint (Neurocardiogenic Syncope)

    22. Neurocardiogenic Syncope (NCS) Prodrome (warning signs) Syncope (loss of consciousness) short duration Occurs at the end of exercise, after exercising has stopped

    23. Primary Prevention: Pre-participation Physical Exam Goal: Appropriately restrict; appropriately clear Be thorough and conscientious Are there any warning signs or family history?

    24. AHA Statement 2007

    25. AHA Statement 2007 Seizure Family history of seizure, syncope, accidental death or near drowning Pacemaker / AICD Congenital deafness

    26. American Academy of Pediatrics PPE 2005

    27. American Academy of Pediatrics PPE 2005 Exercise SCD, dyspnea, fatigue Family history of seizure, syncope, accidental death or near drowning SIDS Specific arrhythmic disorders

    28. Cardiovascular Risk Assessment Form

    29. Is This A Sports Clearance Form?

    30. Cardiovascular Risk Assessment Form Any patient Any age Any time Any MD

    31. Summary Warning signs frequently exist in patients/families at risk for SCD These symptoms may be subtle and nonspecific, but also misinterpreted or disregarded Diligent attention to the details of a PPE (or CV risk assessment questionnaire) is critical

    32. Automated External Defibrillator (AED) What is an AED? A device that looks for shockable heart rhythms and delivers a defibrillator shock, if needed. It is small, portable, automatic, and simple to operate. An AED is a prescription device that analyzes the heart’s rhythm and tells the user to deliver a shock if it detects one is needed. An AED is small, about the size of a laptop computer. It is portable and can be carried to the victim. An AED is designed to be very easy to use. This is how it works (demonstrate with AED if available): • Once the AED is turned on, it begins giving audible instructions • The AED will tell the user to deliver a shock if it detects one is needed • The AED is designed to prevent a shock from being delivered if it is not neededAn AED is a prescription device that analyzes the heart’s rhythm and tells the user to deliver a shock if it detects one is needed. An AED is small, about the size of a laptop computer. It is portable and can be carried to the victim. An AED is designed to be very easy to use. This is how it works (demonstrate with AED if available): • Once the AED is turned on, it begins giving audible instructions • The AED will tell the user to deliver a shock if it detects one is needed • The AED is designed to prevent a shock from being delivered if it is not needed

    35. Are School AED’s the “Right Thing To Do”?

    36. Project S.A.V.E. Summary Project S.A.VE.: Program at Children’s Healthcare of Atlanta available to any Georgia school to assist with SCD prevention S: Sudden Cardiac Death A: Awareness Warning signs, recognition, need for timely response Resources V: Vision for Prevention ? SCD ? Collaboration E: Education for the School Community Pre-Participation Evaluation process CPR training for staff and students AED program implementation

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