Sudden death in young athletesSudden death in young athletes

Rare eventRare event - actual rate uncertain - actual rate uncertain

USAUSA - retrospective analysis in High School and College athletes – less than 1 : 100 - retrospective analysis in High School and College athletes – less than 1 : 100

000 participants per year000 participants per year

ItalyItaly – incidence 3 : 100 000 athletes less than 35 years – incidence 3 : 100 000 athletes less than 35 years

Male/female ratioMale/female ratio - 2-10 : 1 - 2-10 : 1

Men-higher prevalenceMen-higher prevalence of cardiac disease at the age12 - 35 years (probably of cardiac disease at the age12 - 35 years (probably

phenotypic expression)phenotypic expression)

Men-higher participationMen-higher participation rate in competitive sports (football, basketball, ice-hockey) rate in competitive sports (football, basketball, ice-hockey)

Causes of sudden death in athletes less than 35 years

Causes of sudden death in athletes less than 35 years

Nonpenetrating strike to the chest wallNonpenetrating strike to the chest wall

CCommotio cordis ommotio cordis ((trigger of abrupt ventricular fibrillation trigger of abrupt ventricular fibrillation in in

interval 15-30 ms before T-wave peak on ECGinterval 15-30 ms before T-wave peak on ECG))

Competitive sports increase likelihood of cardiac arrestCompetitive sports increase likelihood of cardiac arrest

Most fatalities-in basketball,Most fatalities-in basketball, football,football, ice-hockey ice-hockey ((USAUSA)),, soccer,soccer, ice hockey ice hockey

((EuropeEurope))

ItalyItaly -- young adults involved in sportsyoung adults involved in sports -- 25-fold greater risk of sudden death 25-fold greater risk of sudden death

than their non-athletic counterpartsthan their non-athletic counterparts

Causes of sudden death in athletes less than 35 years

Causes of sudden death in athletes less than 35 years

Hypertrophic cardiomyopathy - more than 1/3 of casesHypertrophic cardiomyopathy - more than 1/3 of cases Cardiac congenital anomalies Cardiac congenital anomalies

arrhytmogenic right ventricle cardiomyopathyarrhytmogenic right ventricle cardiomyopathy premature atherosclerotic coronary artery diseasepremature atherosclerotic coronary artery disease dilated cardiomyopathydilated cardiomyopathy mitral valve prolapsmitral valve prolaps conduction system diseases - conduction system diseases -

WPW-syndrome, prolonged QT - interval, Brugada WPW-syndrome, prolonged QT - interval, Brugada syndrome, Lenégre syndrome, Lenégre disease, A-V block, sudden disease, A-V block, sudden unexplained nocturnal death syndrome unexplained nocturnal death syndrome (SUNDS)(SUNDS)

aortic rupture (bicuspid aortic valve, Marfan syndrome)aortic rupture (bicuspid aortic valve, Marfan syndrome)

Causes of sudden death in athletes less than 35 years

Causes of sudden death in athletes less than 35 years

Non-cardiacNon-cardiac

exercise induced bronchoconstriction-BHRexercise induced bronchoconstriction-BHR

cerebral aneurysma rupturecerebral aneurysma rupture

use of performance - enhancing drugs (deleterious health use of performance - enhancing drugs (deleterious health problems-problems-heart attacks)heart attacks)

vigorous exercise (sudden death due to to undiagnosed vigorous exercise (sudden death due to to undiagnosed heart disease)heart disease)

London marathon runners – 650 000 completed runs London marathon runners – 650 000 completed runs - 5 - 5 deaths, 6 resuscitations – 1 death per 80 000 runnersdeaths, 6 resuscitations – 1 death per 80 000 runners

Extreme sport activitiesExtreme sport activities

decrease of heart function and its fatiguedecrease of heart function and its fatigue

AshleyAshley -- echocardiographic evaluation before and echocardiographic evaluation before and after a 48after a 4800 km competition km competition ((running,running, swimming,swimming, bicyclingbicycling) ) -- lasting about 90 hourslasting about 90 hours - 13 % decrease - 13 % decrease of cardiac contractilityof cardiac contractility

Assessment of the risk for sudden death in young poeple in competitive sports

AHA-1996, ESC-2005 Consensus Guidelanes

Assessment of the risk for sudden death in young poeple in competitive sports

AHA-1996, ESC-2005 Consensus Guidelanes

Family history:Family history: of of sudden death,sudden death, heart disease before 5heart disease before 500 years, years, cardiomyopathy,cardiomyopathy, arrhythmias,arrhythmias, Marfan syndromeMarfan syndrome

Athletes medical history:Athletes medical history: chestchest papain,in, palpitations,palpitations, syncope,syncope, tachycardia,tachycardia, dyspnoea,dyspnoea, fatigue,fatigue, heart heart murmur,murmur, hypertensionhypertension

Physical examination:Physical examination: heart murmurs,heart murmurs, arrhythmias,arrhythmias, femoral artery puls femoral artery puls ((coarctation of aortacoarctation of aorta)),, Marfan syndromeMarfan syndrome

ItalyItaly -- addition of 12-lead ECG-identification of up to 6addition of 12-lead ECG-identification of up to 600% of the potential % of the potential

lethal condition of sudden deathlethal condition of sudden death

All investigationsAll investigations -- marginal use in detecting heart disorders and preventing marginal use in detecting heart disorders and preventing

fatalitiesfatalities

Echocardiography + tissue Doppler echocardiography Echocardiography + tissue Doppler echocardiography –– differentiation differentiation

pathologic from adaptational changes of the heart musclepathologic from adaptational changes of the heart muscle

In 2In 2 -- 5% of sudden cardiac deaths cases5% of sudden cardiac deaths cases -- no definitiveno definitive cause even after autopsy cause even after autopsy

detecteddetected

Guidelines for management of athletes with identified cardiovascular disease

are available

Guidelines for management of athletes with identified cardiovascular disease

are available

withdrawal of competitive sport activities withdrawal of competitive sport activities

- reduced risk of sudden death- reduced risk of sudden death

suggestion to the type and degree of sport activity suggestion to the type and degree of sport activity

that can be done safelythat can be done safely

Examples of sudden death in young athletesExamples of sudden death in young athletes

Pheidipphides (490 BC) Pheidipphides (490 BC) A greek soldier and conditioned runner, Pheidippides ran from A greek soldier and conditioned runner, Pheidippides ran from

Marathon to Athens to announce military victory over Persia. He Marathon to Athens to announce military victory over Persia. He delivered his message, then collapsed and died.delivered his message, then collapsed and died.

Flo Hyman (1986) Flo Hyman (1986) Flo Hyman was captain of the 1984 US Women´s Olympic volleyball Flo Hyman was captain of the 1984 US Women´s Olympic volleyball

team that won silver. She died aged 30 years of congenital heart team that won silver. She died aged 30 years of congenital heart disorder Marfan´s syndrome while playing a Japanese league game.disorder Marfan´s syndrome while playing a Japanese league game.

Daniel Yorath (1992) Daniel Yorath (1992) A 15-year-old football player who had just been signed by the UK team A 15-year-old football player who had just been signed by the UK team

Leeds United, Leeds United, DDaniel Yorath died from hypertrophic caniel Yorath died from hypertrophic cardioardiomyopathy myopathy while playing football with his father in the garden.while playing football with his father in the garden.

Examples of sudden death in young athletesExamples of sudden death in young athletes

Reggie Lewis (1993) Reggie Lewis (1993) Boston Celtic´s star and sixth captain Reggie Lewis was 27 year old Boston Celtic´s star and sixth captain Reggie Lewis was 27 year old

when he died while shooting baskets at an off-seasons practice.when he died while shooting baskets at an off-seasons practice.

Sergei Grinkov (1995) Sergei Grinkov (1995) An Olympic gold medal skater, Sergei Grinkov collapsed An Olympic gold medal skater, Sergei Grinkov collapsed

and died from a heart attack at age 28 years while training at and died from a heart attack at age 28 years while training at an ice rink in Lake Placid, NY, USA. An autopsy showed that he had an ice rink in Lake Placid, NY, USA. An autopsy showed that he had arteries of a 70-year-old man, though had never arteries of a 70-year-old man, though had never mentioned any chest pain.mentioned any chest pain.

Case reportCase reportHistoryHistory

16 years old athlete-attacks of tachycardia 16 years old athlete-attacks of tachycardia ((220/min220/min)) during long distance running during long distance running - - faintness,faintness, disappearing immediately after stopping exercisedisappearing immediately after stopping exercise

Physical examinationPhysical examination Signs of anemia on oral mucosa,Signs of anemia on oral mucosa, lips,lips, conjunctivesconjunctives

Systolic murmur 3/6 in praecordium,Systolic murmur 3/6 in praecordium, irradiating into carotidesirradiating into carotides

ErgometryErgometry:: Rest Rest ExerciseExercise

HR HR 97/min 97/min 24240/0/minmin

BP BP 145/11145/1100 mmHg mmHg 220000/110 mmHg/110 mmHg

Klidové EKG – tachykardie, jinak normální nálezKlidové EKG – tachykardie, jinak normální nález

Při výkonu 90 W se začaly objevovat ojedinělé SVES.

Jejich počet se v první minutě výkonu 150 W zvětšil.Jejich počet se v první minutě výkonu 150 W zvětšil.

Ve 2. minutě výkonu 150 W vznikl náhle záchvat SV tachykardie (s frekvencí 240 tepů/min) a vyšetřovaný začal pociťovat mdlobu.

V době uklidňování SV tachykardie opět náhle vymizela.V době uklidňování SV tachykardie opět náhle vymizela.

Ve 3. minutě uklidňování již vidíme sinusový rytmus s Ve 3. minutě uklidňování již vidíme sinusový rytmus s výraznou dechovou arytmií.výraznou dechovou arytmií.

Laboratory resultsLaboratory results HB-79 g/lHB-79 g/l; ; Htc – Htc – 0 0.25.25; ;

EryEry -- 4,4,0011; ; FW FW -- 25/3425/34

Cardiologic evaluationCardiologic evaluation EchocardiographyEchocardiography -- hypertrophy hypertrophy

and dilatation of left ventricle, a mild decrease of ejection fraction of left ventricle, and dilatation of left ventricle, a mild decrease of ejection fraction of left ventricle,

interventricular septum thickeness at high normal limit interventricular septum thickeness at high normal limit ( (1.1 cm1.1 cm) )

Right and left heart catheterisationRight and left heart catheterisation --

normal pressure,normal pressure, normal flow values,normal flow values, no gradient even after Isuprel applicationno gradient even after Isuprel application

TreatmentTreatment Ferronat p.os,Ferronat p.os, no no

exercise until next control examination exercise until next control examination will be donewill be done

Follow up Follow up

3 weeks3 weeks after medical examination while playing football after medical examination while playing football

sudden syncope,sudden syncope, resuscitation,resuscitation, defibrillation,defibrillation, sudden death.sudden death.

Autopsy findingAutopsy finding - Hypertrophic cardiomyopathy- Hypertrophic cardiomyopathy -interventricular -interventricular

septum thickenessseptum thickeness -18 mm,-18 mm,

A thickenning of posterior left ventricle wallA thickenning of posterior left ventricle wall –– 33 xx 3 cm3 cm..

Výsledek pitvyVýsledek pitvy: mezikomorové septum 18 mm, na zadní stěně LK je : mezikomorové septum 18 mm, na zadní stěně LK je ztluštění 3x3 cm, histologický nález odpovídá hypertrofické ztluštění 3x3 cm, histologický nález odpovídá hypertrofické kardiomyopatii.kardiomyopatii.