SUDDEN CARDIAC DEATH IN YOUNG ATHLETES Can the Cardiac - PowerPoint PPT Presentation

SUDDEN CARDIAC DEATH IN YOUNG ATHLETES Can the Cardiac Pre-participation Examination Save Lives? Joel Brenner, MD Director, Pediatric Cardiology Johns Hopkins Hospital

Wall S treet Journal, 6/ 23/ 05

Sudden Cardiovascular Death During Sports Participation: Goals • Prevent the event • Prevent death due to the event

Sudden Cardiovascular Death During Sports Participation • The young, competitive athlete represents the popular ideal of cardiac fitness and well- being • The sudden death of a well-trained athlete tends to be well-publicized, and often poorly understood

Rate of sudden death during sports participation in the U.S. is not known • No central registry – Maron estimates 250-300 deaths/year • Unclear number of sports participants – 7 million high school athletes – 400,000 NCAA athletes – -5 million recreational athletes (?)

Rate of sudden cardiac death during sports participation in the U.S. is not known Generally accepted U.S. estimate is 0.5-2.0/100,000 Maron’s estimate of 300 deaths/year would require an at risk population of 15,000,000 sports participants to result in a death rate of 2/100,000 Italian experience in a fixed geographic area with known number of 12-35 year old sports participants is 2.1/100, 000

Marc Vivien Foe (Camerun)

Sudden Death Rates: young athletes vs non-athletes Incidence rates Sudden (100,000 deaths person-years) Athletes 55 2.3 Non-athletes 245 0.9 Corrado et al. J Am Coll Cardiol 2003; 42:1959-63

Relative risk of SD Young athletes vs non-athletes (Veneto region of Italy; 1979-1999) 4 RR = 2.5 SD per 100,000 person-years CI = 1.8-3.4 3,5 p < 0.001 3 2,5 Athletes 2 Non-athletes 1,5 1 0,5 0 Corrado et al. J Am Coll Cardiol 2003; 42:1959-63

Causes of Sudden Cardiac Death in Young Competitive Athletes in the U.S. Most common : Hypertrophic Cardiomyopathy Congenital coronary artery anomaly Less common : Myocarditis Aortic rupture (Marfan syndrome) Mitral valve prolapse Uncommon : Arrhythmogenic RV Cardiomyopathy Atherosclerotic coronary artery disease Conduction system abnormalities Aortic valve stenosis

Causes of SD in Athletes vs Non-athletes: The Italian Experience Cause Athletes Nonathletes Total (N=55) (N=245) (N=300) 12 (22%) 25 (10%)* 37 (12%) Arrhythmogenic RV CM 10 (18%) 48 (19%) 58 (19%) Atherosclerotic CAD Anomalous CA origin 7 (12%) 1 (0.4%)* 8 (3%) 5 (9%) 27(11%) 32 (11%) Myocarditis 6 (11%) 21 (8%) 27 (9%) Mitral valve prolapse Conduction system dis. 4 (7%) 21 (8%) 25 (8%) Hypertrophic CM 1 (2%) 22 (9%) 23 (7.5%) Aortic rupture 1(2%) 11(5%) 12(4%) Dilated CM 1(2%) 10(4%) 11(4%) 8 (20%) 59 (24%) 67 (22%) Other

0.6 Athletes 0.5 Non-athletes SD per 100,000 athletes 0.4 0.3 0.2 0.1 0 . s s D P D A i i d t V V A C i d m M R C C r e A a t c s o y y s M n o i t c u d n Corrado et al. J Am Coll o C Cardiol 2003; 42:1959-63

Sudden Death in Young Competitive Athletes • Sport activity in adolescent and young adults is associated with an increase in the risk of sudden death (relative risk=2.5) • Given the substrate of underlying cardiovascular disease such as congenital coronary anomaly, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and premature coronary atherosclerosis, strenuous physical activity may trigger life-threatening ventricular arrhythmias • Therefore, every effort should be made to recognize the cardiac abnormalities implicated in sudden death during preparticipation screening examination

Preparticipation Athletic Screening (Padua:1979-1996) • Athletes screened: 33,735 • Athletes disqualified: 1,058 (3%) • Cardiovascular causes of disqualification: 621 (59%) • Hypertrophic Cardiomyopathy: 22 (0.07% of 33,735) Corrado et al. N Engl J Med 1998; 339: 364-9

Prevalence of HCM in young white people ECHO ECG ECG: 0.07% (22 of 33,735) Corrado D. NEJM, 1998 ECHO: 0.10% (2 of 2,030) Maron B. Circulation, 1995

Sensitivity of 12-lead ECG in SD victims of HCM 78 SD victims of HCM 53 Prior 12-lead ECG 51/53 (96%) Positive ECG (LVH, ST-T changes, q waves) Maron B. Circulation 1982; 65: 1388-94

Sensitivity of preparticipation screening for the detection of patient with HCM at risk for SD Negative History, Physical exam, & ECG 4,469 No HCM by Echo Pelliccia A & Maron BJ - JACC 2001;151A

Clinical Characteristics of Athletes Disqualified for Hypertrophic Cardiomyopathy N.: 22 Age: 20±4 yrs Sex (% male): 90 Reason for echo: ECG changes (80%) LV wall Thickness: 19±3 mm LV cavity: 43±2 mm LVH after detraining: unchanged Corrado D. N Engl J Med 1998; 339: 364-369

Sudden Death in Young Competitive Athletes • Systematic exposure of the athletic young population to preparticipation screening successfully identified and disqualified athletes with HCM and prevented sudden death Corrado et al N Engl J Med 1998; 339: 364-369

Screening of young athletes for Hypertrophic Cardiomyopathy Athletes screened 33,735 Positive findings 3,016 (9%) HCM diagnosis by echo 22 (0.07%) Corrado et al. Circulation 2004; 110:III-694

Cost per year of life saved Hx & Physical Exam Hx & Physical Parameters 12-Lead ECG Exam ( ∈ 30) ( ∈ 20) Specificity 91% 95% ∈ 1,012,050 ∈ 674,700 Cost to screen 33,735 athl. Cost to evaluate abnormal ∈ 211,120 ∈ 125,440 findings in 33,735 athl. Total cost to screen/ evaluate ∈ 1,223,170 ∈ 754,990 33,735 athl. Number of athl. with HCM 43 10 (77% less identified at screening sensitive) Cost for each correct 28,450 75,500 diagnosis ∈ 14,220 ∈ 37,750 Cost per year of life saved* *Based on the assumption that 10% of affected athletes identifierd and disqualified by both PPS modalities willl live an additional 20 years

Comparison of 2 decades of screening 1982-1991 vs 1992-2001* Causes of Time interval P disqualification ___________________________________________________ value 1982-1991 1992-2001 Cardiovascular 421 388 ns diseases ARVC 2 13 0.003 (0.5%) (3.3%) *Center for Sports Medicine, National Health Service, Padova, Italy

ARVC and Sudden Cardiac Death • ARVC has been discovered only 20 years ago and for a long time it was either underdiagnosed or regarded with skepticism by the medical community • In the last 10 years, with increased awareness of clinical findings suggestive of ARVC more and more athletes are now being identified by preparticipation screening in the Veneto Region of Italy and this is expected to result in further reduction of athletic field deaths

PREPARTICIPATION SCREENING: USOC POLICY WITH SPECIAL THANKS TO ED RYAN Director, Division of Sports Medicine USOC, Colorado Springs, CO, USA

U.S.OLYMPIC TRAINING CENTER MEDICAL HISTORY QUESTIONNAIRE PREVIOUS FORMAT • 2 page health survey • 3 questions potentially regarding cardiovascular integrity – Have you ever had a seizure? – Have you ever been told you have epilepsy? – Do you have … heart disease? (murmur, rheumatic fever, stenosis)

SUDDEN DEATH IN ATHLETES: USOC EXPERIENCE • 18 yo male boxer, DOD 2/25/90 – Passed routine pre-fight physical exam between 4-5:30, 2/25/90. – Went out to jog on track with teammate. Jogged several laps, complained of chest pain. Continued to jog, collapsed. CPR begun. 911 called. EMT response in 5 minutes, defib in ambulance, died after 45 minutes of continuous CPR. – Autopsy done, results not known.

SUDDEN DEATH IN ATHLETES: EXPERIENCE OF USOC • 13 yo male gymnast, DOD 10/11/01 – Finished routine on pommel horse – Complained of shortness of breath, staggered, collapsed, seized. CPR unsuccessful. – Past history of fainting while on high bar – Autopsy negative • Presumed arrhythmia • Family counseled to seek medical evaluation

USOC TRAINING CENTER ELITE ATHLETE PROFILE MEDICAL HISTORY QUESTIONNAIRE REVISED FORMAT • 6 page health survey, lifestyle inquiry, medication/drug use survey • 21 questions related to cardiac concerns

Preparticipation Cardiovascular Screening for US Collegiate Student-Athletes Adequate (>9/12) Recommended Elements Division I n=286 30% Division III n=337 14% Total 26% 40% of screening forms omitted questions related to exertional chest pain, dyspnea, fatigue, familial heart disease, premature sudden death, Marfan syndrome Pfister GC. JAMA 2000

Preparticipation Cardiovascular Screening for US Collegiate Student-Athletes Survey of 879 NCAA Schools Formal screening 855 97% On-campus 719 81% Off-campus 164 19% Required yearly 446 51% Routine non-invasive 58 7% testing Formal CV training 44 5% Prister GC 2000. JAMA