Cardiac Clearance for Sports Wayne H. Franklin, MD, MPH Pediatric Electrophysiologist Children’s Memorial Hospital Associate Professor of Pediatrics Feinberg School of Medicine

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Cardiac Clearance for Sports: Sudden Death in the Young Athlete Wayne H. Franklin, MD, MPH Pediatric Electrophysiologist Children’s Memorial Hospital Associate Professor of Pediatrics Feinberg School of Medicine

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Sudden Death: Incidence 1:100,000 - 1:300,000 students/year Approximately 25 high school and college students/year in the United States.

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Deaths per year 16,000

14,700

14,000 12,000

MVA Drowning Firearms Sudden Death

10,000 8,000 6,000 4,000

1500

2,000

500

25

0

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Why does sudden death in a young athlete affect the community and physicians to such a degree? • The death is “sudden” • It is a “rare” event • It is not related to an outside “force” • It is believed that this death is “preventable” • High Profile People (Gathers etc.)

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Categories of Sudden Death • No Predisposing Substrate Commotio Cordis Neck Injury • Predisposing Substrate

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Commotio Cordis Definition: Cardiac Contusion secondary to blunt trauma (Maron et al. NEJM 1995;333:337-42) 25 Children: Age 3-19 Usually involved a projectile: baseball and hockey 16 in organized competitive sports; 9 in recreational activities 12 collapsed instantaneously; 13 remained conscious, but then had sudden cardiac arrest 2 were able to be revived, but had irreversible brain damage 7 were wearing some form of protective chest padding

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Etiology of Sudden Death 5

4

10 36

HOCM Coronary Other Cardiac Mass Marfan Aortic Stenosis

21

24

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Case Presentation A 12 year old girl was playing with her friends. During an especially competitive game of basketball she fell to the ground and passed out. She gained consciousness within 1 minute, but required stitches to the back of her head. Her past medical history was negative except for a history of a heart murmur. Her family history is significant for a maternal uncle who died suddenly at age 23.

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Hypertrophic Obstructive Cardiomyopathy (HOCM) Also Known As (aka): • Hypertrophic Cardiomyopathy (HCM) • Idiopathic Hypertrophic Subaortic Stenosis (IHSS) • Asymmetric Septal Hypertrophy (ASH)

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Hypertrophic Obstructive Cardiomyopathy (HOCM) Incidence:

2.5/100,000 population

Natural History:

Presentation in childhood has worse prognosis Annual mortality: 2-4% Death not related to LVOT obstruction

Risk for Sudden Death:

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Family History of Sudden Death History of Syncope

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Hypertrophic Obstructive Cardiomyopathy (HOCM) Physical Exam: Systolic Ejection Murmur Softer with Hand-grip Louder with release of Hand-grip Standing increases murmur Squatting decreased murmur

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Coronary Abnormalities • Intramural Coronary Artery • Hypoplastic Coronary Artery or Ostium • Anomalous Origin of Coronary from Pulmonary Artery • History of Kawasaki Disease

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Coronary Abnormalities History: Kawasaki Disease Synope DURING high intensity activity Physical Exam: Virtually unhelpful except with anomalous coronary artery from the pulmonary artery (continuous murmur)

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Primary Arrhythmia Substrate • Long QT Syndrome • Wolff-Parkinson-White Syndrome • Arrhythmogenic Right Ventricular Dysplasia • Catecholamine Related Ventricular Tachycardia

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Case Presentation A 5 year old boy is referred to the cardiology offices for evaluation of syncopal episodes. These occur twice monthly for the past 2 years. All episodes occur while the patient is running or playing. The patient’s spells have been diagnosed as seizures and he is being treated with carbamazepine.

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Case Presentation A 12 year old girl was at track practice running sprints when she did a “face plant.” She had no pulse and she was apneic. Cardiopulmonary resuscitation was instituted and when the EMS personnel arrived they noted that her first rhythm was ventricular fibrillation. She was defibrillated with 200 joules and converted to normal sinus rhythm.

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Primary Arrhythmia Substrate History: Tachycardia *Family History of Early Sudden Death* Syncope

Physical Exam: Unhelpful Copyright © 2005 Children's Memorial Hospital. All rights reserved.

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Marfan Syndrome Incidence:

1/10,000

Inheritance: Autosomal Dominant Abnormality: Fibrillin

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Marfan Syndrome History:

Family History History of Pneumothorax

Physical Exam: Key!!!!!!!! Skeletal Ophthalmologic Cardiovascular Skin Copyright © 2005 Children's Memorial Hospital. All rights reserved.

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Aortic Stenosis and Other Congenital Heart Diseases • Usually known prior to death • Recommendations should be made in conjunction with pediatric cardiologist • Recommendations for restriction of exercise must be made with balancing the risks of exercise restriction

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Myocarditis • Recent viral syndrome • May have symptoms of tachycardia or exercise intolerance • Unlikely to occur just prior to the sports physical

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Sudden Death: Screening History • Exertional Chest Pain • Syncope and Pre-syncope (during Exercise) • Past History of murmur • Family History of premature death (sudden)

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Sudden Death: Screening History • Auscultation supine and upright • Physical Stigmata of Marfan’s • Femoral pulses and right arm BP

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Should ROUTINE ECG and/or ECHO be performed prior to participation in competitive organized athletics? 501 College Athletes Screened with ECG, PE, Hx: 90 had further ECHO 1/90 had LV hypertrophy secondary to BP 1424 12-18 year olds with ECG, PE, Hx: 124 had further cardiac evaluation 0/124 had a cardiovascular abnormality

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Should ROUTINE ECG and/or ECHO be performed prior to participation in competitive organized athletics? Estimated Screening 200,000 athletes to detect CHD in 1000 Of these 10 would be at risk for sudden death and 1 would die.

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Sudden Death: Screening Laboratory • NOT RECOMMENDED: ECG ECHO Exercise Test • Tests listed above are indicated in specific situations, most often in consultation with a pediatric cardiologist

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Teachable Moment: Preparticipation Sports Physical • Tobacco/Alcohol/Drugs • Exercise • Diet

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Summary • Some young athletes are at risk for sudden death, however it is a rare individual who is. • Some history and physical exam information may be helpful in identifying individuals at risk, however, most individuals will not be able to be identified in a cost-effective manner • Death from MVA, drowning and firearms are more common and more preventable than sudden cardiac death during athletics

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