Disclosures

• None

2

Objectives

• Identify the most common causes of sudden death in athletesDiscuss incidence and etiologies of sudden death in both younger and middle-aged athletes

• Describe the concept of the “Athlete’s

• Review current pre-participation screening strategies and controversy

Sudden Cardiac Death

Catastrophic Deathprompts a controversial debate

on appropriate pre-participation screening and emergency preparedness

Case presentation

• 18 yo female college athlete referred for cardiac murmur on pre-participation screening.

• 2/6 systolic murmur at LUSB

• ECG: SR, IRBBB, and right axis deviation.

ECG

Case presentation

Case presentation

Sudden Cardiac Arrest

VF is the most frequent initial rhythm in sudden cardiac arrestVF is a useless quivering of the heart that results in no blood flowDefibrillation is the only effective treatment for VF

Heart Attack

1. Vessel lining splits2. Fat deposits

collecting3. Artery narrows

SUDDEN DEATH IN ATHLETES AGE GREATER THAN THIRTY

• Coronary artery disease-97%

• Hypertrophic cardiomyopathy

• Congenital coronary anomalies

• Primary ventricular rhythm disturbances

The Honolulu Advertiser, Sunday, March 12, 2006

CARDIAC EVALUATIONAGE GREATER THAN THIRTY

Considerations

• Assess risk profile

• Exercise stress test for symptoms or abnormal ECG

• Coronary calcium scoring

• Risk factor modification or treatment

• Other testing (ECHO, etc.) based on clinical indications

SCD in the Athlete < 30 yearsPopulation at Risk

• 7 million high school athletes in the United States

• 500,000 college athletes

• 5,000 professional athletes

• Rate has previously been estimated to be 1/200,000 athletes per year

Sudden Cardiac Death

• Sudden cardiac arrest (SCA) in athletes occurs most predominantly between 15-25 years of age

• 60-80% of athletes have no symptoms prior to their SCA

• 90% of SCA occurs during training or competition

PrevalenceYoung Athletes

• Exact numbers unknown – no national

database

• 5X more common in males than females

• Estimated that up to 300 high school

athletes die at an organized sporting

event each year from SCA

Incidence of SCD in NCAA Athletes

• 2004-2008 2 million athlete participation-years

• SCD incidence- 1:43,770

• 2x more common in males (33,134) vs. females (76,646)

• Black > white: 1:17,696 vs 1:58,653

• Highest in Division 1 black male basketball

1:3, 126 vs white 1:12,810.

• Basketball >swimming >lacrosse >football >CC

Asif IM et al Circulation 2011,123:1594-1600

Detection of causes of Sudden Death in Athletes

• Hypertrophic cardiomyopathy (up to 10% have normal ECG)

• Commotio cordis

• Coronary artery abnormalities (Echo)

• LVH of indeterminate causation

• Myocarditis

• Ruptured AA (Marfan syndrome)

• Arrhythmogenic RV cardiomyopathy

• Tunneled (bridged) coronary artery

• Aortic valve stenosis

• Artherosclerotic CAD

• Dilated cardiomyopathy

• Myxomatous mitral valve BJ Maron, et al. JACC 2005;45:1318-21

Distribution of cardiovascular causes of sudden death in 1435 young

competitive athletes.

Maron B J et al. Circulation. 2007;115:1643-1655

Copyright © American Heart Association, Inc. All rights reserved.

Hypertrophic Cardiomyopathy

• Most common cause of SCD in youth

• Familial disorder of increased wall thickness with normal LV size (family history)

• Most have premonitory symptoms

• Most (75%) non-obstructive “no murmur”

• ECG is normal in up to 10%

• Echo for diagnosis vs. “Athlete’s heart”

• Recommendations: no competitive sports

ECG

Hypertrophic Cardiomyopathy

Hypertrophic Cardiomyopathy

Coronary Anatomy

Normal Abnormal

Anomalous RCA

Causes of Sudden CardiacDeath in Young Athletes

Less common

• Coronary artery anomalies• Myocarditis• Wolf-Parkinson-White Syndrome• Long QT Syndrome• Dilated cardiomyopathy• Marfan’s Syndrome• Drugs • Other (sickle cell trait, wt. loss/fluid-

electrolyte imbalances – bulimia)

16 yo athlete with tachycardia and near syncope

Athlete’s Heart

• Structural changes related to intensity

of training

• Physiologic, not pathologic

• Not related to sudden cardiac death

• No long term associated risk

• Regresses with stopping training

Athlete’s Heart

• Structural changes related to intensity of training

• Physiologic, not pathologic

• Not related to sudden cardiac death

• No long term associated risk

• Regresses with stopping training

BJ Maron, et al. JACC 2005;45:1322-6

Gray Areas of Overlap BetweenAthlete’s Heart and Cardiomyopathy

Pre-participation Screening Controversy

• Sudden death in a young athlete is a rare but tragic event

• Most die from previously unsuspected heart disease…

• That more comprehensive screening would likely have identified (ECG and Echocardiogram)

• So why not screen everyone?

Pre-participation challenge:Can we prevent SCD?

• How do you do it? Logistics

• Can it be accomplished? Qualified

personnel

• Is it truly effective?

false positives/negatives

• Cost concerns

• Prospective Data

AHA Consensus Panel Recommendations for

Preparticipation Athletic ScreeningFamily History

– Premature sudden cardiac death– Heart disease in surviving relatives < 50 years old

Personal History– Heart murmur– Systemic HTN– Fatigue– Syncope/near-syncope– Excessive/unexplained exertional dyspnea– Exertional chest pain

Physical Examination– Heart murmur (supine/standing*)– Femoral arterial pulses (to exclude coarctation of aorta)– Stigmata of Marfan syndrome– Brachial blood pressure measurement (sitting)

BJ Maron, et al. JACC 2005;45:1322-6 BJ Maron et al. Circ 2007;115:1643-1655

ECG Screening: Reframing the Debate

• Insufficient evidence for any strategy to show accurate identification of athletes at risk and/or prevention of SCD.

• It is reasonable to screen with ECG and it is reasonable not to.

• Potential benefits and potential harms

• Education of physicians and communities is key

35Drezner JA. Br J Sports Med Jan 2013 47:1;4-5

A.Magalski et al. J Am Coll Cardiol 2008;51:2250-5

Relation of Abnormal and Normal ECG Pattern to Race in 1,959 Professional Football

Players

*p<0.0001, †p=0.0005 for comparisons by race.

1.8

11.2

87

5.8

24.2

70

0

10

20

30

40

50

60

70

80

90

100

Distinctly abnormal Mildly abnormal Normal

% A

thle

tes

White

Black

*

†

Distinct ECG Abnormalities in 964 Collegiate Athletes

14.7

18.1

5.5

8.3

0

2

4

6

8

10

12

14

16

18

20

Perc

en

tag

e (

%)

P<0.001 P<0.001

Male Female Black White

Magalski et al. Am J Med (2011) 124:511-518

ECG in collegiate athleteNormal or Abnormal?

18 yo asymptomatic collegiate basketball player

ECG Screening Interpretation Standards

• “Seattle criteria” with MAHI modifications:

Normal

PR interval (>0.2)

R or S voltage (>25 mm)

Sinus Bradycardia (<60/minute)

ST elevation (> 2 mm), > 2 leads

Incomplete RBBB, RSR’ (<0.12 sec), V1V2

Sinus arrhythmia

PR interval (< 0.12 sec)

Q waves (2-3 mm) depth, > 2 leads

T wave flat, min inverted or tall (> 15 mm), > 2 leads40

ECG Screening Interpretation Standards

“Seattle criteria” with MAHI modifications:

Normal

Abnormal R wave progression

Ectopic atrial rhythm

Wenchebach 2nd degree AV block

PVC (< 2)

PAC (s)

Isorhythmic dissociation

Low voltage

41

Distinctly Abnormal Electrocardiograms1

Pellicia

Criteria2

Uberoi

Criteria3

Abnormal (n) 136 67

Abnormal (%) 10% 4.9%

Sensitivity 91.7 91.7

Specificity 90.8 95.8

Positive predictive value 8.1 16.4

Negative predictive value 99.9 99.9

1. Magalski A et al Am J Med 2012 May 125(5):e132. Pelliccia A et al Circulation. 2000:102(3):278-284

3. Uberoi A et al Circulation 2011:124(6):746-757

Screening with ECG and Echo:Athlete-specific criteria

• 2239 consecutive collegiate varsity athletes at The University of Kansas from 2004-present. (51% female)

• History and Physical, ECG, and Echo in all

• 18 (0.8%) serious findings: 11 WPW

• 4 (0.2%) excluded: 1 Long QT, 1 HCM, 1 dilated aorta, 1 anomalous coronary artery

• 16 other important findings: Ebstein’s, Bicuspid AoV, MVP, ASD, VSD, and dilated aorta - all played

Evaluation Protocol

• Prospective registry of consecutive varsity collegiate athletes

• Extensive questionnaire: personal health history, symptoms, and family history

• Physical exam

• ECG (Seattle criteria)

• Echocardiogram

44Magalski et al. Am J Med (2011) 124:511-518

Cayman Island Athletic Heart Clinic

45

KU athlete

• 20 yo track/cross country athlete with palpitations and tachycardia

• Previously evaluated at Big 10 school for same

• Near syncope with training

• ECG- Normal

• Exam- unremarkable

46

Bizarre finding:Single coronary artery

47

48

Echo Findings in Athletes

Number of

Athletes

Black%

Male%

Any Cardiac

DisorderSerious Minor

DQ (Disqualification)

Baggish et alAnn Int Med2010;152:269-275 510 4% 61%

11 (2.2%)

5 (.98%)

6 (1.2%)

3 (0.6%)

Sheikh et alCirc2014;129:1637-49 3210 33% 94%

40 (1.2%)

15 (.47%)

25 (.78%)

~0.3%

Magalski et alAm J of Med2011;124:511-518 1763 24% 49%

25 (1.6%)

15 (.85%)

14 (.78%)

4(0.23%)

Serious Cardiac Findings in5483 Athletes

49

• Hypertrophic CM- 7 (1,5,1)

• Wolff-Parkinson-White- 15 (0,5,10)

• Long-QT syndrome- 4 (0,3,1)

• Brugada- 1 (0,1,0)

• Anomalous coronary origin from wrong sinus-

1 (0,1,0)

• Severe pulmonic stenosis- 1 (1,0,0)

• Dilated cardiomyopathy- 2 (1,0,1)

Baggish et al. Ann Int Med, Sheikh et al. Circ, Magalski

Other Echo Findings (n=5483)

• Bicuspid aortic valve- 17 (2, 10, 5)

• Mitral valve prolapse- 14 (3, 7, 4)

• VSD- 2 (0,1,1)

• ASD- 5 (0,3,2)

• Dilated aorta- 4 (0,0,4)

• Ebstein’s-1 (0,0,1)

• LVH- 1 (1,0,0)

50

Baggish et al, Sheikh et al, Magalski

Echo Summary

• 1% Serious

• 1% Less Serious

• Disqualification:

0.2 - 0.6%: (1/500 – 1/200)

51

Cost-Effectiveness

• Addition of ECG to pre-participation screening saves 2.06 life-years per 1000 athletes: $42,900- 68,800 per life year saved.

• ECG alone: $37,700 • Cost: $600-900,000 per life saved• Additional general health benefits

Wheeler et al Ann Intern Med 2010; 152: 276-286Schoenbaum et al Pediatrics 2012;130:e380-e389

Reframing the Debate

• Screening is supported!

• Limited outcomes research - more needed

• Intention is to detect potentially lethal cardiovascular disease

• Active management/counseling /informed decision making

• Early detection may not equal disqualification

• Prior eligibility guidelines conservative

53Drezner JA. et al Heart Rhythm 2013;10:454-455

Athlete’s Heart Summary

• Sudden Cardiac Death is uncommon but devastating

• Pursue thorough pre-participation screening-extent of which continues to evolve

• More comprehensive evaluation is feasible, cost-effective, and beneficial