Preventing Sudden Cardiac Death in Youth Sports Victoria L. Vetter, M.D., MPH Professor of Pediatrics Perelman School of Medicine at the University of Pennsylvania Division of Cardiology, The Children’s Hospital of Philadelphia
Sudden Cardiac Arrest (SCA) is a condition in which the heartbeat stops suddenly and unexpectedly. It is the immediate loss of electrical heart function. This usually is caused by ventricular fibrillation (VF), an abnormality in the heart's electrical system
which causes the heart to quiver and blood flow to the body and brain to stop.
Sudden Cardiac Death (SCD) occurs if emergency treatment with CPR/AED or spontaneous recovery does not occur.
Scope of the Problem
SCA is the leading cause of death in young athletes – accounting for 75% of all deaths. Maron; Circulation 2006
Who is At Risk? 2010-2011 High School Sports Participants 7,667,955 60 % of HS Students Females 3,173,549 41% Males 4,494,406 59%
>30 million US children not on school sports teams
Athlete: A participant in a sport, exercise, or game requiring physical skill. Dictionary.com
Type of Sport and SCD
Epidemiology of SCD in Children • Incidence: 3-6/100,000 per-yrs ~1,000 deaths/yr in USA
• Greatest in 10-19 yr age group • Male: Female 4:1
Winkel
2.8
Shen
6.2
Corrado
• Two-thirds occur with exercise or activity • Estimated 1:9000 (Military 1835 yrs) to 1:27,000 (Atkins) to 1:200,000 (Maron)
2.7
Eckart
13
Liberthson
4.9
Maron
0.6
Atkins
6.37
Drezner
4.4 0
Only
5
% of cases found in media reports
10
15
Death Rates 2005-2007: 5-17 yrs/100,000
SCD 3-6/100,000 person-years
High School/College Basketball Players
Etiology of Sudden Cardiac Death in Children •
Cardiomyopathy HCM, ARVC , DCM, LVNC
• Primary Electrical Disease LQTS, SQTS, Brugada CPVT, Primary VF WPW • Congenital Heart Disease – AF, VT/VF, SSS, CHB • Coronary Artery Anomalies • Acquired Heart Disease Myocarditis Drugs Marfan Syndrome Commotio Cordis/Blow to chest
Parent Heart Watch Database 2007 Myocarditis 5%
Commotio Cordis 5%
Cor Art 12%
HCM 43%
ARVD/CM 5% CHD 8% WPW 2%
Marfan 5%
LQT/Electrical Disease
15%
Prevalence: 1:500- 1:3000
What We Don’t Know about SCA in the Young • We don’t know how often these conditions result in death. • We don’t know how prevalent the SCA high risk conditions are in the young. • So…are we just looking at the tip of the iceberg with our current information? There is no required reporting or Registry for SCA/SCD in the US
Diagnosis of HCM Hypertrophied, non-dilated left ventricle
ECG Abnormal in 95%
Long QT Syndrome Characteristics • Prolonged QT Interval • Syncope/Fainting • Malignant Ventricular Arrhythmias Torsades de Pointes • Sudden Death
Survival Following Sudden Cardiac Arrest • SCA in athletes is a
catastrophic event with a low survival rate (1116%) •Low survival rate demands re-evaluation of our current screening and prevention practices.
How Can We Prevent Sudden Cardiac Death
Primary Prevention Preparticipation Evaluation/PPE – Goal of Screening is to detect potentially lifethreatening conditions (Prevalence 0.2-0.4% by estimate, or 1:250-500 young persons). – Risk stratification to determine who will have a SCA is imperfect.
Methods of Preparticipation Evaluation • History – Personal and Family
• Physical Exam – – – –
Murmurs Hypertension Stigmata of Marfan Syndrome Femoral Pulses
• ECG • Echocardiogram • Genetic testing
Preparticipation Physical Evaluation –4th Edition
• Provides a uniform comprehensive history and physical form • Endorsed by 6 national organizations • Describes the important questions AAFP, AAP, ACSM, AMSSM, AOSSM, AOASM
PPE 4th Edition
Recommended Personal & Family History Questions Have you ever passed out or nearly passed out during or after exercise? Have you ever had discomfort, pain, pressure, or tightness in your chest during exercise? Do you get lightheaded or feel more short of breath than expected during exercise? Does your heart ever race or skip beats (irregular beats) during exercise? Has a doctor ever told you that you have: any heart problem, high blood pressure, high cholesterol, a heart murmur, a heart infection, or an unexplained seizure disorder? Has a doctor ever ordered a test for your heart (for example, ECG or echocardiogram)? Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, car accident, or sudden infant death syndrome)?
Has anyone in your family had unexplained fainting, seizures, or near drowning? Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator? Does anyone in your family have: hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?
US AHA Strategy to Deal with the Problem Maron et al: Circ. 2007
2007: AHA 12 element program: The recommendations included ”…a complete medical history and physical examination, including brachial artery blood pressure measurement.” Comprehensive screen repeated every 2 years for high school athletes with annual updates Noninvasive testing was not recommended but not, “actively discouraged.”
Problems with Identification of Conditions that Cause SCA • Symptoms Occur in 30-50% May not be present prior to the SCA SCA 1st symptom: 30-80% • Family History Often not known Positive family history: 20-30% • Physical Exam The conditions that cause Sudden Cardiac Arrest may be subtle and not apparent on routine physical exam. No study has shown that History & Physical can adequately find athletes at risk and prevent SCD.
Methods of Preparticipation Evaluation
Use of ECG to Screen for Cardiac Conditions Associated with SCA WPW HCM
75-95% Abnormal
LQTS ECG Rarely Identifies • CPVT • Coronary Artery Anomalies Not identified by H & P either
Who Uses the ECG to Screen for SCD? Japan 1973 1st, 7th, 10th graders
IOC
Italy 1979 12-35 yo athletes
12 EU countries
Italian Athletic Screening Program Medical Protection Athletes Act – 1979 25
All 12-35 yo who compete in sports History ,Physical Exam, and ECG • More cases found with ECG than history & physical exam • ECG had 77% greater power to detect HCM than History and Physical Exam alone
20
# HCM
22 82%
15 10 5
ABN ECG 0.07%
23% Pos. FH/M
0
Corrado NEJM 1998
Would Identifying the Condition Make a Difference?
Italian Athletic Screening Program
1979-2004: 42,386 athletes screened in Padua, Italy
89% Decrease in Sudden Cardiac Death
Corrado, JAMA 2006
Concerns Regarding ECG Screening • Low disease prevalence, Low PPV • Current ECG standards may not correctly identify all abnormalities. Develop more specific new reference
standards with norms for race, ethnicity and gender.
• False positives anxiety and costs Improve test characteristics
• Athletic training affects ECG
Corrado 2009
Recent data suggests this can be distinguished from pathologic changes
• Limited manpower to interpret ECG: Use remote reading and computers
• Disqualification concerns: 2%0.2%
•Lack of proof for ID of conditions and prevention of SCA Same for ECG and History and Physical
ECG Screening Cost Effectiveness/Year of Life Saved $50,000 $45,000 $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0
$44,000
$42,900
$40,855
$15,926 $8,800
Japan
Italy Neo
Nevada HS
Wheeler
Anderson
Cost Effectiveness Analysis
Fuller et al. , Med Sci Sports Exerc 2000
Am Heart J 2011 Previously undiagnosed CV abnormalities 10.75% –Hypertension >98th % 5% (20) –Important CV Abnormalities 2.5% (10)
400 healthy children –Ages 5-19 years recruited from pediatric practices in Philadelphia area –Questionnaire with patient medical and family history –Physical Exam, ECG, Echocardiogram
Community School Screening Model CHOP Heart Health Screening Study • 2781 children 5-19 years screened • Conditions requiring treatment:17 • 2 Atrial Septal Defects • 7 LQTS • 7 WPW • 1 Marfan Syndrome • 2 Potential cardiomyopathies for follow-up • Other potentially significant • Ventricular couplets, 2AV block, Aortic root dilation
Prevention of Sudden Cardiac Death –Secondary Prevention •Lifestyle modification, Medication, ICD implants •Implement CPR/AED Programs –AEDs can be safely placed in schools
National Registry for AED Use in Sports Survey Total Schools
1710 high schools with on-site AED programs
Interval
2006-07
Emergency Response Plan
83%
Practice Plan Annually
40%
SCA
36 (2.1%) 14 student athletes (16, 14-17 yrs) 22 non-students (57, 42-71 yrs)
Witnessed SCA
35 (97%)
Bystander CPR
34 (95%)
AED shock
30 (83%)
Survival to Hospital Discharge
23 (64%) 9 of 15 students
Drezner et al, Circulation 2009; 120: 518-525
14 of 22 non-students
Who Has Laws for AEDs in Schools? • 24 states have some type of legislation regarding AEDs in schools but only 17 mandate AEDs on a continuing basis • 7 provide a lower level of coverage • Other states have laws on CPR, AED teaching
STATE SCHOOL AED LEGISLATION
Ongoing Programs
Al, AR, CT, FL, DE, GA, IL, MD,ME, NV, NY, OH, OK, OR,SC,TN,TX
One time Program or limited by funds or group (e.g. College only)
CA, CO, MI, ND, NH,PA,RI
CPR/AED Instruction
WI, IA
What happens next? It’s up to YOU……………………
Make a difference in YOUR community. Thank you!
