cardiac clearance and sudden cardiac death in athletes mazen kawji, md
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Cardiac Clearance and Sudden Cardiac Death in Athletes Mazen Kawji, MD Slide 2 Disclosures I have nothing to disclose Slide 3 I wouldn't ever set out to hurt anyone deliberately unless it was, you know, important like a league game or something. Dick Butkus Firstdo no harm Slide 4 Outline Epidemiology Etiology Athletes Heart Pre-participation Physicals Additional Testing Common Red Flags Causes of Sudden Cardiac Death 26 th Bethesda Conference Guidelines for Athletic Participation Slide 5 Epidemiology College and Professional Athletes 500,000 participants each year Competitive Athletics: Several million high school students participate in competitive athletics each year in the United States. Other Organized Sports Participation 25 million children and young adults Slide 6 Epidemiology Incidence of Sudden Cardiac Death: Organized High School/College Athletes 1:134,000/Year (Male) (7.47:million/Year) 1:750,000/Year (Female) (1.33/million/Year) Air Force Recruits 1:735,000/Year Marathon Runners 1:50,000 Race Finishers (Mean Age 37yo) In brief, ~ 300 deaths/year. But the media attention and legal implications, make these events standout. Slide 7 Etiology based on largest US data set 1)HCM 36% 2)Coronary Anomalies 17% 3)Increased Cardiac Mass (possible HCM) 10% 4)Ruptured Aorta/Dissect 5% 5)Tunneled LAD 5% 6)Aortic Stenosis 5% 7)Myocarditis 3% 8)Dilated CM 3% 9)Idiopathic Myocdardial scarring 3% 10)Arrhythmogenic RV dysplasia 3% OTHERS MVP CAD ASD Brugada Syndrome Commotio Cordis Complete heart block QT prolongation syndrome Ebsteins anomaly Marfans Syndrome Wolff-Parkinson White Syndrome WPW Ruptured AVM SAH Slide 8 When in Rome.. Arrhythmogenic RV dysplasia (22%) is the most common cause of SCD in athletes. Slide 9 Screening requirements In the US competitive athletes are screened by means of history and physical examination. Only Europe mandates a resting ECG. In 1982 the incidence of SCD in Italy was 4.2/100,000 athletes. In 2004 the incidence of SCD decreased markedly to 0.9/100,000. Due to Arrhythmogenic RV dysplasia. Slide 10 Sports at time of death Maron BJ et al, JAMA 1996 ; 276 : 199 - 203 Slide 11 Pre-Participation Physicals History Screen for medications and drugs of abuse that can have potential cardiotoxic effects (Beta agonists, Theophylline, TCAs, Macrolides, Pseudoephedriine, Phenypropanolamine, Tobacco, Alcohol, Cocaine, Amphetamines, Ephedrine, and Anabolic Steroids) Questions to ask************************ Have you ever passed out during or after exercise? Have you ever been dizzy during or after exercise? Have you ever had chest pain during or after exercise? Do you get tired more quickly than your friends do during exercise? Have you ever had racing of your heart or skipped heart beats? Slide 12 Pre-Participation Physicals Yes, more questions Have you had high blood pressure or high cholesterol? Have you ever been told you have a heart murmur? Has any family member or relative died of heart problems or sudden death before age 50? Have you had a severe viral infection within the last month (ie. Myocarditis or mononucleosis) Has a physician ever denied or restricted your participation in sports for any heart problems? Slide 13 Pre-Participation Physicals Contd Physical Exam Gen: physical appearance ie Marfans Syndrome Slide 14 Pre-Participation Physicals Contd Physical Exam Vitals: BP: Elevated readings confirmed Proper technique Pulse: Rate of rise, Contour, Volume, consistency Normal Pulsus Bisferiens Seen in AS, Aortic regurge, HCM - Coarctation of aorta ie. HTN in arms, but weak femoral pulses AND/OR femoral pulse lags behind that of the radial artery Slide 15 Pre-Participation Physicals Contd Standing/Squatting: STANDING decreases venous return and reduces the intensity of innocent murmurs (as well as BAD murmurs of AS). BUT, STANDING accentuates the murmur of obstructive hypertrophic cardiomyopathy! Squatting will DECREASE the intensity of the murmur of obstructive hypertrophic cardiomyopathy. Therefore, the cardiac exam on athletes first supine, then seated, then standing. Slide 16 Pre-Participation Physicals Contd Indications for echo: All Diastolic Murmurs Holosystolic murmurs Murmurs Grade 3/6 and above Any murmur that examiner isnt sure aboutie. CYA? Features of Innocent Murmurs: Low in intensity and midsystolic in timing, normal splitting, normal DYNAMIC auscultation, absence of a specific pattern of radiation, asymptomatic. Slide 17 Additional Testing American Heart Assoc. Guidelines: exercise ECG screening test men > 40-45 years of age women > 50-55 years of age (or postmenopausal) with 1 independent coronary risk factor hypercholesterolemia or dyslipidemia including low HDL systemic hypertension current or recent cigarette smoking diabetes mellitus a history of myocardial infarction or SCD in a first-degree relative aged < 60 years. Slide 18 Additional Testing EKGs Findings in Athletes considered WNL Sinus Bradycardia as low as 30-40 bpm Various A/V blocks occur in up to 33% of athletes First Degree (PR>0.2) Most Common Second Degree (Mobitz-1 or Wenkeback) Increased R or S wave voltage without Left axis deviation, QRS prolongation, or LAE U-waves with up-sloping ST segments and normal T waves Incomplete RBBB Slide 19 Athletes Heart Endurance and Isometric sporting activities cause structural remodeling and increase in cardiac mass (physiologic hypertrophy). Increased volume of ventricular chambers Increased size of L atrium and L ventricular wall thickness Vary according to sport Extreme changes reported in Crew, XC skiing, Cycling, Swimming However, systolic/diastolic fxn is maintained Occurs in M>F with size related to lean body mass. May be 2 to genetics The amount of exercised-induced LVH in endurance athletes associated with ACE genotype. Slide 20 Additional Testing EKGs Slide 21 Symptoms In a recent autopsy study in young military recruits in the US Army with SCD in relation to exercise about half of the deceased recruits complained of premortem symptoms. Slide 22 Quick abbreviations ARVD = arrhythmogenic right ventricular dysplasia AS = aortic stenosis CAA = coronary artery anomoly DC = dilated cardiomyopathy HB = heart block LQTS = long QT syndrome MC = myocarditis MVP = mitral valve prolapse NMS = neurally mediated syncope TCA = tunneled coronary artery VP = ventricular preexcitation Slide 23 Exertional Syncope CV Causes CAA, LQTS, HCM, MC, DC, AS, WPW, NMS, HB Additional Testing Needed EKG, Echo, Exercise Stress Testing - 64 slice CT scan? for CAA Slide 24 Exertional Chest Pain or dyspnea CV Causes HCM, CAA, Marfans, TCA, MVP, MC, ARVD, AS Slide 25 Palpitations CV Causes WPW, LQTS, MVP Non-CV Causes Hyperthyroidism, Supplements, Stimulant meds Slide 26 Causes of Sudden Death Hypertrophic Cardiomyopathy********************** Sporatic or inherited (autosomal-dominant) Can predispose to malignant ventricular arrhythmias leading to syncope or sudden death S/S: Dyspnea (initially exertional in onset), Angina, Exertional syncope, exertional presyncope, fatigue, palpitations Exam: Systolic murmur that increases with valsalva Testing: CXR: cardiomegaly EKG: LVH Echo: confirmation of HCM Tx: B-Blockers ICD Septal artery ethanol ablation Slide 27 ECG of HOCM patient Slide 28 Causes of Sudden Death Coronary Artery Anomalies In one review of 78 cases of CAA who died of sudden death, 62% of those were asymptomatic S/S: Only ~ 1/3 of pts have any symptoms of exertional syncope ( ARVD cont. Global or regional right ventricular dysfunction, and late evolution to right or biventricular heart failure. Incomplete or complete RBBB Inverted T waves in the anterior precordial leads Localized prolongation of the QRS complex in leads V1 and V2 Epsilon waves visible as sharp discrete deflections at the terminal portion of the QRS complex in the anterior precordial leads Use QRS width in Lead I which is always S S wave upstroke in V1 - V3 >55ms was found in 95 percent of ARVD******** Slide 34 ARVD examples, look at V1 - V3 also Slide 35 Common Board Exam Topic 26 th Bethesda Conference Guidelines for Athletic Participation************* Slide 36 References AAFP Sports Medicine: Strategies for Treating Athletes. Breckinridge, CO. 2004. Francis OConner, MD. Sudden Cardiac Death and Arrhythmias in Athletes Beckerman J, Wang P, Hlatky M. Cardiovascular Screening of Athletes. Clin J Sport Med. 2004;Vol 14, Number 3:127-133. Mellion, Walsh, et al. Team Physicians Handbook. 3 rd edition. Hanley & Belfus; 2002. Maron, B. Sudden Death in Young Athletes. NEJM. 2003; Vol 349, Number 11:1064-1075. Pelliccia A, Maron B, et al. Remodeling of left ventricular hypertrophy in elite athletes after long- term deconditioning. Circulation 2002;105:944- 949.