2014 - sudden cardiac death in athletes - aoasm€¦ · sudden cardiac arrest in athletes kimberly...

11/4/14

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Sudden Cardiac Arrest in

Athletes

Kimberly G. Harmon, MD Professor, Department of Family Medicine and

Orthopaedics and Sports Medicine

Osteopathic Medicine Conference and Exposition Seattle, WA October 28, 2014

Hank Gathers

March 4, 1990

Marc Vivan Foe June 26, 2003

Reggie Lewis July 27, 1993

Sergei Grinkov 1995

Darryl Kile June 22, 2001

Atlanta Hawks

Damion Nash Denver Broncos February 24, 2007

Antonio Puerta 1984 - 2007

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Media Hype?

•  Incidence • E5ology

Maron, JACC, 2014

It is important to place into proper perspective these absolute numbers of sudden deaths, because the frequency of these events is a very important variable in the screening debate.

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Sudden deaths attributable to cardiovascular disease in young athletes in the United States occur at an annual rate similar to lightning strike fatalities.

http://www.lightningsafety.noaa.gov/fatalities.htm

Maron, JACC, 2014

http://www.lightningsafety.noaa.gov/fatalities.htm

In order to calculate a

RELIABLE INCIDENCE a precise number of events (numerator)

AND the popula5on at risk (denominator) needs to be iden5fied.

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Incidence of Death from Lightening Strikes

•  Average of 32 deaths/year over the last 8 years in the U.S.

•  361,100,000 people in the U.S. -‐ 2013

361,100,000 people 32 deaths from lightening

1 death in

11,284,375 people

High Risk Groups

1 in 614,749

1 in 249,550

Tradi5onal Es5mates

Sudden Cardiac Death

Incidence

1 : 200,000 – 1 : 300,000

•  Con5nues to be perpetuated despite more recent evidence with beXer methodology

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SCD Incidence Evalua&ng the Science

•  Difficult to compare studies with different methodologies

•  Need to compare similar cohorts

•  Type of popula5on – Compe55ve athletes

– Recrea5onal athletes – Exercisers – Youth

•  Age range studied •  Time frame

– Exer5onal death – Death at any 5me



•  Ac5ve Surveillance – Purposeful gathering of informa5on from a defined popula5on

– O_en mandatory repor5ng requirements

•  Passive Surveillance – Repor5ng of only those with disease (SCD) – No special effort is made to find those with unsuspected disease incidents

– Subject to ascertainment bias

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Where did tradi5onal es5mates come from?

1 : 200,000 – 1 : 300,000

•  Data from the Na5onal Center for Catastrophic Sports Injury Research 1983 -‐ 1993

•  Passive surveillance –  Informa5on from NCAA, NFHS, NJCAA, NAIA, Community College League of California

– Press clipping service – Deaths during or within 1 hour of par5cipa5ng on a college or high school team

VanCamp S, Bloor C, Mueller F, Cantu R, Olson H Med Sci Sports Exer;1995

•  17 sports selected for analysis •  Adjusted for athletes that par5cipated in more than one sport – 1.9 for high school, 1.2 for college – “based with discussion on the representa&ve from the na&onal athle&c organiza&ons”

•  Club and intramural teams not included

•  Incidence of SCD in high school and college athletes was 1 in 300,000

VanCamp S, Bloor C, Mueller F, Cantu R, Olson H Med Sci Sports Exer;1995

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Limita5ons

•  Passive surveillance •  Only exer5onal deaths •  Somewhat random denominator

•  Used insurance claims data –  In Minnesota all high school athletes are covered by death benefit of $10,000

•  Reviewed 1985-‐86 to 1996-‐1997 (12 years) •  Had a precise denominator

– Grades 10 – 12 – 3 death claims made – All male

JACC, 1998

•  There were 1,453,280 sports par5cipa5ons •  Average number of sports per athlete for 1996-‐1997 was 2.23

•  Total number of athletes was 651,695

•  Rate of SCD was 1 in 217,400

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Limita5ons

•  Only athletes par5cipa5ng in a school-‐sponsored team sport (no club or intramural) – Would not count:

•  Varsity soccer player who died playing on their club team

•  College football player who died playing intramural basketball

•  Only exer5onal deaths

Ac-vity at Time of Death

Study Popula-on Sleep Moderate/

vigorous physical ac-vity

Harmon 2014

NCAA athletes 17-‐24

41% (or non-‐exer5on) 59%

Winkle 2013

Children 1 -‐ 18

32% 14%

Pilmer Children 1-‐ 19 41% 16%

2013 15-‐19 30% 23%

Margey 2011

People 14 – 35


Harmon 2011

NCAA athletes 17-‐24


Eckart 2011 US military 18-‐35

-‐ 47%

Holst 2009

Persons 1 – 35

34%

•  Registry from the Department of Defense •  Ac5ve surveillance •  Mandatory; autopsy protocol

•  10 years; 15.2 million person-‐years

•  Incidence of SCD in 18-‐25 1 in 25,000 JACC 2011

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Incidence of SCD

  400,000 student athletes annually   Know sports, sex and ethnicity of par5cipants   High profile

•  NCAA has no requirement for repor5ng deaths

•  Case iden5fica5on – NCAA Memorial Resolu5ons List – Parent Heart Watch Database (media database)

– Catastrophic insurance claims

•  Capture-‐recapture analysis (90 – 100%)

Circulation. 2011;123:1594-600

Accidents 51%

Drug Overdose 2%

Cancer 7%

Cardiac 16%

Heat stroke 1%

Meningi-s 1%

Other medical 3%

Suicide 9% Homicide

6%

Unknown 2%

Heat stroke -‐ sickle cell related

2%

Harmon, Circulation, 2011

All Cause NCAA Death 2004 - 2008

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Risk break down

Group Incidence

Overall 1 in 43,770

Males 1 in 33,134

Females 1 in 76,746

African-‐American 1 in 17,696

Caucasian 1 in 58,653

Risk by sport

Sport Incidence

Basketball 1 in 11,394

Swimming 1 in 21,293

Lacrosse 1 in 23,357

Football 1 in 38,497

Cross-‐Country 1 in 41,695

Risk in Basketball Athletes

Group Incidence African American

Incidence Caucasian

Division I Male 1 in 2,976 1 in 3,324

Division II Male 1 in 5,832 -‐

Division III Male 1 in 4,488 -‐

Overall 1 in 3,947 1 in 14,184

Males 1 in 6,506

Females 1 in 34,344

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Cri5cisms

Maron, Heart Rhythm, 2013

Autopsies Requested

Autopsy Results

•  3 cases had no autopsy performed •  5 autopsies could not be obtained but had histories compa5ble with SCD

•  32 autopsies obtained –  1 autopsy with insufficient informa5on for a specific cardiac diagnosis

•  3 reports read over the phone •  2 reasonably determined without autopsy

–  1 Commo5o cordis –  1 case with Long QT -‐ 2 sisters with LQT

Harmon, Circ Arryth Elect, 2014

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Autopsy Results

•  One case not cardiac •  Other cardiac cases were found that were not included in the database

•  E5ology of death could be reasonably determined in 36 cases – 80%

HCM 3%

Possible HCM/LVH 8%

ARVC 3%

Dilated CM 8%

Coronary Artery Abnormality

14%

SUD 33%

MI 6%

Myocardi-s 8%

Aor-c dissec-on

8%

Other 6%

Possible HCM/SCT 3%

Results –E5ology of NCAA Deaths

Harmon, Circ Arrthm Elec, 2014

Tradi5onal E5ology of SCD in US

HCM 37%

Possible HCM/LVH 8%

ARVC 4% Dilated CM

2%


17%

SUD 6%

MI 3%

Myocardi-s 6%

Aor-c dissec-on 3%

Other 14%

Maron – 2009 N=690

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HCM 3%

Possible HCM/LVH 8% ARVC

3%

Dilated CM 8%


14%

SUD 33%

MI 6%

Myocardi5s 8%

Aor5c dissec5on

8%

Other 6%

Possible HCM/LV/SCT 3%

NCAA

HCM 37%

Possible HCM/LVH 8%

ARVC 4%

Dilated CM 2%


17%

SUD 6%

MI 3%

Myocardi5s 6%

Aor5c dissec5on

3% Other 14%

Maron -‐ 2009

HCM 7%

ARVC 10%

Dilated CM 5%

Coronary Artery

Abnormality 10%

SUD 28%

MI 20%

Aor5c dissec5on

5%

Other 15%

Corrado-‐ 2003 HCM 6%

Possible HCM/LVH 1%

ARVC 1%

Dilated CM 1%


27%

SUD 30%

MI 9%

Myocardi5s 12%

Other 13%

Eckart -‐ 2004

10-‐YEAR RESULTS

Methods

•  Data collected from 3 sources – NCAA Resolu5ons Database – Parent Heart Watch Database – NCAA Insurance Claims

•  2003 – 2004 school year to 2012 – 2013 – School year defined as July 1 to June 30 – Death at any 5me

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Methods

•  For cardiac cases and unknown cases autopsies were requested where possible – Autopsied were reviewed and adjudicated by panel of 7 experts

– Used standard accepted criteria •  If autopsies required NOK permission cases were discussed with coroner – Would o_en confirm if case was cardiac or give listed diagnosis

Results

•  4,242,519 athlete-‐years •  79 total cardiac deaths

– 59 autopsies obtained (74%) – 76 deaths “confirmed cardiac” (96%)

•  Coroner/medical examiner

•  ATC, Parents •  History consistent with commo5o

– 3 deaths “likely cardiac” based on history

Accident 50%

Suicide 8%

Homicide 8%

Cardiac 15%

Cardiac/SCT 0%

SCT 2%

Head injury 1%

Heat Stroke 1%

Drug/Etoh Overdose

3%

Cancer 7%

Medical -‐ other 3%

Meningi-s 1%

Unknown 1%

Causes of Death in NCAA Athletes 2003 -‐ 2013

N = 514

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Accidents 51%

Drug Overdose 2%

Cancer 7%

Cardiac 16%

Heat stroke 1%

Meningi-s 1%

Other medical 3%

Suicide 9%

Homicide 6%

Unknown 2%

Heat stroke -‐ sickle cell related

2%

Harmon, Circulation, 2011

All Cause NCAA Death 2004 - 2008

Risk break down

Group Incidence

Overall 1 in 53,703

Males 1 in 38,390

Females 1 in 121,593

African-‐American 1 in 20,147

Caucasian 1 in 59,153

Female 19%

Male 81%

Deaths by Gender

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Caucasian [PERCENTA

GE]

African American [PERCENTA

GE]

Other 14%

Deaths by Ethnicity

Risk by sport Sport Incidence

Men’s Basketball 1 in 8,978

Men’s Soccer 1 in 23,689

Football 1 in 35,951

Cross-‐Country 1 in 44,973

Baseball 1 in 50,023

Swimming 1 in 50,197

Volleyball 1 in 53,685

Lacrosse 1 in 54,401

Women’s Basketball 1 in 77,061

Risk in Basketball Athletes

Group Incidence African

American Incidence Caucasian

Total

Division I Male 1 in 4,380 1 in 5,230 1 in 5,200

Division II Male 1 in 8,241 -‐ 1 in 15,843

Division III Male

1 in 4,906 -‐ 1 in 14,266

Overall 1 in 5,348 1 in 14,184 1 in 8,978

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volleyball 4%

soccer 11%

swimming 5%

wrestling 2% crew

1% golf 1%

lacrosse 4%

football 23%

basketball 27%

cross country 8%

baseball 8%

track 4%

so^ball 1%

tennis 1% Sports

High Risk groups

•  Men’s basketball – 4% of NCAA athletes – 1/5 of NCAA cardiac deaths

•  Football and men’s basketball – 23% of NCAA athletes – ½ of NCAA cardiac deaths

NCAA Incidence 10-‐year data

Group 5 year incidence 10 year incidence

Overall 1 in 43,770 1 in 53,703

Males 1 in 33,134 1 in 38,390

Females 1 in 76,746 1 in 121,593

African-‐American 1 in 17,696 1 in 20,147

Caucasian 1 in 58,653 1 in 59,153

Basketball 1 in 11,394 1 in 15,462

Men’s basketball 1 in 6,506 1 in 8,978

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SUD 25%

Anomalous coronary 11%

Myocardi-s 9%

CAD 9%

Cardiomyopathy NOS 8%

idiopathic LVH/possible

cardiomyopathy 8%

Aor-c dissec-on 5%

HCM 6%

ARVC 5%

WPW 3%

DCM 3%

Long QT 2%

Commo-o 2%

Idiopathic LVH/SCT

2%

Kawasaki Disease 2%

Etiology of SCD in NCAA Athletes 2003-2013

SCD + SCA

•  8 SCA recorded in database from SY2003 – SY2013

•  4 in basketball – 3 in Division I African American male basketball

•  Overall rate of SCA+SCD = 1:48,765 •  Rate in Div I men’s basketball 1:4,000

Media Bias in Repor5ng

Level of Play NCAA Resolu-ons Media Database

Division I 87% 87%

Division II 83% 61%

Division III 89% 44%

High School -‐ ?

•  Gender or sport did not correlate with likelihood of death being reported

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•  Retrospec5ve study of death cer5ficates to iden5fy all sports-‐related SCD (SrSCD) in Denmark age 12-‐25 from 2000-‐2006

•  “To validate our methods, an extensive retrospec5ve search of media reports was performed.”

–  Infomedia – database of 400 printed, 2,200 web-‐based, na5onal and regional media, as well as major radio and television

•  15 cases of compe55ve athlete SrSCD

Holst et al. Heart Rhythm 2010

Media reports identified only 3 of 15 cases (20%)

Insurance Claims

Time Frame Resolu-ons List

PHW Database

Insurance Claims

2003-‐2008 83% 67% 9%

2009-‐2013 91% 70% 15%

2003-‐2013 86% 70% 11%

Comparisons to other Studies

Harmon Maron

Years Studied SY2003 – SY2013 2002 -‐ 2011

Total Deaths 514 182

Likely Cardiac Deaths 79 64

Autopsies/Cardiac Cases

59 59

Commo-o 1 2

Basketball athletes 21 23

Rate 1:53,000 1:62,000

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Next Steps

•  Death and catastrophic event repor5ng became mandatory in the NCAA in August of 2014

•  Na5onal Center for Catastrophic Sports Injury Research

•  Center for Sports Cardiology at the University of Washington

SCD in Athletes

•  You will miss deaths if: – You use passive surveillance – You depend on media reports – You only look at exer5onal deaths – You only look at deaths during school hours

•  It doesn’t maXer when or where a young person dies; it just maXers that they die and any screening program employed to prevent sudden death should prevent it all the 5me.

Explana5ons/Cri5cisms

•  “The college age group (18 – 25) were older than high school age group”

•  Perhaps college athletes are at higher risk of SCD? – Disease does not manifest itself un5l athletes are older

– NCAA athletes may prac5ce longer and more intensely

Roberts, JACC, 2013

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Risk in High School Athletes

•  Required PPE every 3 years •  Used catastrophic insurance claims to track deaths – Pay out a $10,000 death benefit – No mandatory repor5ng of deaths

•  4 SCDs during 20 year study period •  0 SCDs during the last 9 years of study

JACC, 2013

•  Incidence of SCD 1 in 416,666 for last 19 years •  1 in 909,090 in last decade •  Concluded that PPE in Minnesota was effec5ve and there was no need for addi5onal screening

JACC, 2013

Limita5ons of Catastrophic Insurance Claims

•  Only SCD cases during an official high school sponsored spor5ng event

•  No mechanism to make sure all deaths are reported

•  Does not include SCA with survival •  No results of the screening evalua5ons performed or the cardiac condi5ons iden5fied to link the PPE with low SCD rate

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SCD Rate Based on Media Reports

•  21 cases of SCD + SCA found •  10 cases of SCD

– 2 cases not high school athletes – 1 had graduated

•  11 case of SCA which survived – 4 not athletes par5cipa5ng on high school team

•  14 cases met criteria for inclusion (7 SCDs, 7 SCAs survived)

Results

•  1,906,014 Minnesota high school athlete par5cipants ages 14-‐18 (2002 – 2012)

Popula-on Unduplicated Athletes

Deaths Incidence

High school athlete 811,070 7 1:115,867

Male high school athlete

518,434 7 1:74,062

Male high school bball 139,716 3 1:46,572

Results SCD + SCA

•  Sudden cardiac arrest is an important endpoint


SCD + SCA Incidence

High school athlete SCA + SCD

811,070 14 57,934

Male high school athlete SCA + SCD

518,434 14 37,031

Male high school bball SCA + SCD

139,716 8 17,465

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Minnesota High School Athlete Deaths

•  Only 29% of athletes who died (2 of 7) were eligible to receive insurance benefit

•  Of the two that were eligible only one actually received the death benefit

•  3 (43%) Minnesota high school athletes died playing non-‐school sponsored sports

•  2 athletes died in their sleep •  All had been screened with a PPE!

Drezner, JACC, 2013 Harmon, BJSM, 2014

Catastrophic Insurance Claims

•  Not an accurate way to monitor deaths •  In the Minnesota study from 2002-‐2012 insurance claims iden5fied at a maximum 14% of SCDs in high school athletes

•  The PPE in Minnesota did not iden5fy at least 14 people who had SCA/SCD

Drezner, JACC, 2013 Harmon, BJSM, 2014

Inclusion Criteria

•  SY 2007-‐2008 to SY 2012-‐2013 •  School year defined from September 1 to August 31.

•  High school athlete who played on an organized team for their high school.

•  Sudden cardiac arrest/death

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•  Seven states were reviewed – California – Texas – New Jersey – Tennessee – Ohio – Minnesota – Florida

•  Autopsies available without next-‐of-‐kin permission in most cases

Results

•  16,390,405 high school athlete par5cipants (over 6 years)

•  Represented 36% of the US high school athlete popula5on

•  Resulted in 6,974,640 unduplicated athlete-‐years

Results – Death Rate


Deaths Incidence

High school athlete 6,974,640 75 1:92,995

Male high school athlete

4,124,534 64 1:64,446

Female high school athlete

2,850,106 11 1:259,100

Male high school bball 1,149,703 16 1:71,856

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Results SCD + SCA


SCD + SCA

Incidence

High school athlete SCA + SCD

6,974,640 110 1:63,406

Male high school athlete SCA + SCD

4,124,534 96 1:43,964


1,149,703 31 1:37,087

Results

•  59% of SCD/SCA occurred while prac5cing or playing for school team

•  85% of SCD occurred in males

Basketball


Number Events

Incidence


1,149,703 31 1:37,087

SCA + SCD without Texas

705,064 25 1: 28,203

•  Range was 1:13,801 (Minnesota) to 1:74,107 (Texas)

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Are Athletes at Greater Risk of SCD?

Marijon 2011

Corrado 2003

RR 4.0

RR 2.8

High School Student-‐Athlete vs. Non-‐Athlete

Toresdahl et al.

•  2,149 high schools followed for 2 years

•  > 1.5 million athlete years

•  > 2.5 million non-‐athlete years

0

0.2

0.4

0.6

0.8

1

1.2

Athlete Non-‐Athlete

Incidence per 100,000

RR 3.7

Incidence of SCA in High School Student Athletes… only on SCHOOL CAMPUS!

Popula-on = 1.5 million athlete-‐years

Cases of SCA over 2-‐Years

Popula-on (Per Year)

Incidence

Student athletes 18 788,683 1 in 87,000 Male student athletes 16 462,269 1 in 58,000 Female student athletes 2 326,414 1 in 323,000

Students non-‐athletes 8 1,280,804 1 in 323,000

•  50% of SCA cases occurred in football and boys’ basketball

•  Male student athletes vs. non-athlete: RR 4.95 (95% CI 1.6-14.8, P<0.01)

•  Female student athlete vs. non-athlete: RR 1.09 (95% CI 0.20-5.92, P 0.92)

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Prevalence of Cardiovascular Disorders at Risk for SCD

Study Popula-on Prevalence AHA (2007) Compe55ve athletes age 12-‐35 (US) 0.3% Fuller (1997) 5,617 high school athletes (US) 0.4% Corrado (2006) 42,386 athletes age 12-‐35 (Italy) 0.2% Wilson (2008) 2,720 athletes & children age 10-‐17 (UK) 0.3% Bessem (2009) 428 athletes age 12-‐35 (Netherlands) 0.7% Hevia (2009) 1,220 amateur athletes (Spain) 0.16% Baggish (2010) 510 college athletes (US) 0.6%

Contemporary Es5mates

1 in 11,000,000?

1 in 50,000? 1 in 25,000?

1 in 10,000? 1 in 3,000?

How Do We Prevent Sudden Cardiac Death?

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SCD in Athletes

•  Incidence numbers are highly dependent on study methodology

•  Insurance claims, media databases, passive surveillance all have inherent limita5ons that must be recognized

SCD in Athletes

•  The incidence of SCD in athletes is about 1:50,000

•  There are high risk groups – Males – African Americans

– Basketball athletes •  SUD is the leading cardiac cause of death in athletes

UW Medicine Center for Sports

Cardiology Jonathan A. Drezner, Director Kimberly G. Harmon Ashwin Rao Henry Pelto BreX Toreshdahl Dave Owens Jordan Prutkin Jack Salerno Karen Stout

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Thank you

2014 - sudden cardiac death in athletes - aoasm€¦ · sudden cardiac arrest in athletes kimberly...

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