Sudden Cardiac Death in Young Athletes: Prevention and Evaluation

Sudden Cardiac Death in Young Athletes: Prevention and Evaluation Colin Fuller MD, FACC Northern Nevada Cardiology With Northern Nevada Medical Center...
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Sudden Cardiac Death in Young Athletes: Prevention and Evaluation Colin Fuller MD, FACC Northern Nevada Cardiology With Northern Nevada Medical Center

Nevada Women’s Cross Country All-State Race 2014

Fox News- Sunday, April 13, 2014

“Two runners (ages 31 and 34) die near finish line of half marathon in North Carolina.”

Sudden Cardiac Death • 1. What causes it? • 2. Are there warning symptoms weeks before collapse? • 3. Does the “usual” pre-participation history and physical examination detect those at risk for it? • 4. Will adding an ECG to the “usual” screening examination detect those at risk for it.

1991

Autopsy- Hypertrophic Cardiomyopathy • Primary care physician who performed preparticipation examination asked me: • “Did I do something wrong?” • “Should I have done an ECG?”

My Response:

“I have no idea.” “I will look into it.”

Young Athletes– Deaths on the Playing Field • Prior to the past 20 years, 2/3 were traumatic • Now 2/3 are non traumatic

Traumatic

Non traumatic Cardiac:

Head Spine Non penetrating blows

Hypertrophic cardiomyopathy (HCM) Coronary artery anomaly Myocarditis Aortic stenosis Dilated cardiomyopathy Aortic rupture WPW, ARVD, long QT Other

Non cardiac: Hyperthermia Rhabdomydysis & SST Asthma Lightning Other

Sudden Cardiac Death in Young Athletes – Causes (in Order of Frequency) • • • • • • • •

*Hypertrophic cardiomyopathy Anomalous coronary artery Ruptured aorta *Myocarditis *Aortic stenosis *Dilated cardiomyopathy *Right ventricular dysplasia *Primary conduction abnormalities *typically have abnormal ECG

Sudden Cardiac Death in Young Athletes – Causes (in Order of Frequency) • • • • • • • •

*Hypertrophic cardiomyopathy Anomalous coronary artery Ruptured aorta *Myocarditis *Aortic stenosis *Dilated cardiomyopathy *Right ventricular dysplasia *Primary conduction abnormalities *typically have abnormal ECG

Hypertrophic Cardiomyopathy •Autosomal dominant with high degree of penetrance •Occasionally sporadic •1/500 adults •Clinical manifestations increase with age •EKG usually abnormal

Hypertrophic Cardiomyopathy

Anomalous Coronary Artery

Myocarditis • Inflammation – focal or diffuse ▫ idiopathic or infectious

• Clinical: asymptomatic – pulmonary edema – SCD • Exam: ↑HR, S3 gallop • EKG: almost always abnormal ▫ ST and/or T wave changes ▫ PVCs ▫ Conduction abnormalities

Myocarditis - Microscopic

Marfan’s Syndrome • Prevalence

1/10,000

▫ Familial (autosomal dominant) ▫ Sporadic 20%

• Manifestation

▫ Visual – myopia, lens dislocation, flat cornea ▫ Cardiovascular – mitral valve disease 80% increased aortic root 80% ▫ Skeletal – arachnodactyly (long thin fingers) arm span > height ▫ Scoliosis, long face with retrognathia, pectus excavatum, high arched palate

Cystic Medial Necrosis of Aorta Marfan’s Syndrome

Congenital Aortic Stenosis • • • •

Male : Female 4:1 Often asymptomatic Lift, thrill, murmur-can be soft EKG: Typically abnormal with LVH

Congenital Aortic Valve Stenosis

Dilated Cardiomyopathy • Final common pathway as end result of myocardial damage: Toxic, Metabolic, Infectious • Exam: BP low, narrow pulse pressure ↑JVD, S3, ↑liver or normal exam • EKG: usually abnormal ▫ ST & T wave changes ▫ PVCs ▫ Q waves

Greatly Dilated and Moderately Hypertrophied Heart

Arrythmogenic Right Ventricular Dysplasia (ARVD) • Partial or total replacement of a portion of RV myocardium with adipose and/or fibrous tissue • Males > females; familial predisposition • Exam: normal • EKG: usually abnormal: PVCs, T↓V1 –V4 • Echo: dilated RV; often normal • MRI very helpful

Primary Conduction Abnormalities • Long QT syndrome 1/2000 • WPW syndrome 1/1000 • Brugada’s Syndrome ? • ECG’s Abnormal 99% of the time.

Sudden Cardiac Death in Young Athletes – Causes (in Order of Frequency) • • • • • • • •

*Hypertrophic cardiomyopathy Anomalous coronary artery Ruptured aorta *Myocarditis *Aortic stenosis *Dilated cardiomyopathy *Right ventricular dysplasia *Primary conduction abnormalities *typically have abnormal ECG

Overview on Screening of Young Athletes • 1/500 have congenital cardiovascular disease putting them at risk of sudden cardiac arrest during intense physical activity. • Each of those 1/500 young athletes with serious congenital CV disease has a annual risk of death of 1%. • 5 million high school athletes: 10,000 have disease: 100 die per year

Prospective Screening of 5615 High School Athletes in Nevada: ’91-’94 Findings: • Outcome measures were found in 1/255 athletes • Cardiac history led to detection in 0 athletes • Auscultation 1/6000 • BP Measurement 1/1000 • ECG 1/350

Prospective Screening on 5615 High School Athletes in Nevada: ‘91-’94 Conclusion: ECG was a much more effective screening tool than cardiac history or physical examination for detection of CV abnormalities requiring further testing before approval for participation could be given

American Heart Association 1996: Recommended Cardiac PreParticipation Screening as: • Cardiac Personal History • Cardiac Family History • Cardiac Physical Exam

No ECG • Impractical • Too many false positives

So why are the ECGs of young athletes abnormal so often?

Athlete’s Heart • Systematic training in predominately endurance sports (dynamic or aerobic) or isometric sports (static or power) triggers increases in cardiac mass and structural remodeling in many athletes • This physiologic form of hypertrophy, or athletic heart, is regarded as a benign adaptation to systematic athletic training with no adverse cardiovascular consequences.

Athlete’s Heart •Bigger •Thicker •Slower

Athlete’s Heart Autonomic nervous system and structural changes lead to electrical changes in 40-50% of athletes.

Year 2000 • NIAA – Nevada Interscholastic Activity Association Medical Advisory Committee ▫ ▫ ▫ ▫ ▫ ▫

Pat Colletti, MD Dave Fiore, MD Colin Fuller, MD Jim Pappas, MD Carol Scott, MD Jim Porter

AHA– Recommended Cardiac Preparticipation Screening • HISTORY:

▫ Exercise associated symptoms ▫ Past history of hypertension or murmur ▫ Family history of premature CV death or disability from CV causes before age 50 ▫ Family history of hypertrophic cardiomyopathy, dilated cardiomyopathy, long QT syndrome, Marfan’s Syndrome, or clinically important arrhythmias

AHA– Recommended Cardiac Preparticipation Screening • PHYSICAL EXAMINATION: ▫ Precordial auscultation in both supine and standing positions to identify murmurs associated with dynamic LV outflow obstruction ▫ Assessment of femoral pulse to rule out coarctation of the aorta ▫ Inspection for Marfanoid appearance ▫ Blood pressure determination

Pre-Participation Examination: Realities • Only yearly health exam some children ever receive • As of 1998: ▫ 8 states had no standardized questionnaire ▫ 1 state had no formal screening requirement at all ▫ 12 states had screening forms that were judged to be inadequate (containing < 4 of the AHA screening questions) ▫ At the college level only 26% of programs were deemed adequate (defined as including at least 9/12 AHA recommended items)

Pre-Participation Examination in Italy 1974-2004 For over 25 years, as a result of the Medical Protection Athletic Activity Act, Italy has mandated preparticipation screening which includes history, physical examination, and 12 lead ECG.

2007 AHA Update on Recommended Cardiac Pre-Participation Screening

• Cardiac Personal History • Cardiac Family History • Cardiac Physical Exam No ECG- “Impractical, too many false positives, costly.”

University of Nevada Sports Medicine Program ECG Screening Study • 2008-2013, prospective observational study • ECG added to history and physical exam • Strict ECG criteria

University of Nevada Sports Medicine Program ECG Screening Study

Results: •874 athletes screened •6.6% by ECG required further testing •2 athletes by ECG found to have HCM- both had negative initial history and exam.

University of Nevada Sports Medicine Program ECG Screening Study Results • 1/437 athletes found to have CV problem putting them at risk of sudden cardiac arrest on the playing fields. • For every 30 athletes requiring further CV testing by ECG, 1 was found to have hypertrophic cardiomyopathy.

University of Nevada Sports Medicine Program ECG Screening Study Conclusion ECG screening at Division 1 university: • Practical • Better than history and physical exam at detecting serious CV abnormalities • False positive rate is 6.6%

Overview of Screening Young Athletes

Screening HX and PE Screening ECG

Sensitivity 7%

False Positive Rate 3%

70%

6.6%

Overview of Screening Young Athletes

Number of athletes requiring additional CV testing for each one found with disease. •Screening HX and PE: 214 •Screening ECG: 48

Screening Young Athletes for Risk of Sudden Cardiac Arrest- Conclusions • UNR- we have made the playing fields safer by adding screening ECG to the pre-participation history and physical examination. The screening ECG appears to be cost effective. • In Nevada high schools our present screening program is better than that found in most other states. • Nationally, cardiologists through their professional societies need to arrive at a consensus for strict ECG standards for interpretation of ECGs in young athletes and then train physicians in those standards.

Sudden Cardiac Death in Young Athletes

• 1. What causes it? • 2. Are there warning symptoms weeks before collapse? • 3. Does the “usual” pre-participation history and physical examination detect those at risk for it? • 4. Will adding an ECG to the “usual” screening examination detect those at risk for it.

•19 year old track star had syncope a year previously during exchange of baton during relay race. Temperature 105*. He felt dehydrated. No other symptoms. Has been dizzy after runs in the past. No further syncope over past year with better hydration. •Family history unremarkable. •Physical exam within normal limits.

•Treadmill test: went 15 minutes using the Bruce protocol to heart rate of 179. Stopped due to fatigue. No arrhythmias. No ST shift. Blood pressure rose appropriately. 1. Excellent exercise tolerance. 2. Negative for ischemia.

What next? •1. Clear to play sports. •2. Order an echo.

•19 year old soccer player syncope while running. No other symptoms. •Father has LVH. •Physical exam within normal limits.

What next? •1. Clear to play sports. •2. Order an echo.

•Echo revealed findings of hypertrophic cardiomyopathy. •AICD placed. •Athlete is now playing intramural soccer.

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