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Sudden Cardiac Death in Endurance Sports

Professor Sanjay Sharma

Disclosures: None

ObjectivesObjectives

• To provide information about the incidence and causes of sudden death in sport from current literature.

• To present death rates in the marathon and triathlon.To present death rates in the marathon and triathlon.

T t d il bl i f ti f dd d th• To study available information on cause of sudden death in triathletes

• To discuss potential screening strategies in endurance athletes.

Sudden Death in Athletes

• Incidence approximately 1/25 000‐1/100 000

Sudden Death in Athletes

• Incidence approximately 1/25,000‐1/100,000

( )• More common in males than females (9:1)

• Over 80% of victims do not exhibit any warning symptomsy p

• 80% deaths are due to an underlying cardiac disorder• 80% deaths are due to an underlying cardiac disorder

• 90% deaths during or immediately after exertion

Background: Causes of SCD in Sportg p

2.5

1.5

2

2.5

SD/100 000

0

0.5

1 SD/100,000 person yrs

0Athletes Non‐

athletes

Potential triggers for Sudden Death

Dehydration Adrenergic surgessurges

Electrolyte Acid/baseyimbalance

Acid/base disturbance

Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy

Deaths in Individuals with Structurally Normal Hearts: The British Experience

UK SCD, n=118, age range 7-59 yr

Hearts: The British Experience

A

atheroma2% myocarditis

3%

valve2%

other4%

normal23%

IF6%

ACA

5%

LVH

ARVC14% LVH

23%LVH w/ IF8%

HCM11%

14%

Electrical DisordersSCD With a Normal Heart

LQTS

Brugada

WPW

Sudden Cardiac Death During Mass

500 i h 1 illi i i

Participation Long Distance Running

500 races per year with up to 1 million participants

Triathlon

Mean Age of Sudden Death in Athletes

SPORT Age (years old)

g

_______________________________________________

Competitive soccer 23Competitive soccer 23

R ti l t 46Recreational sport 46

Marathon runner 42

Triathlete 44

Causes of Sudden Cardiac Death in Senior Athletes

5% 5% 5%5%

5%

CAD

SADSAD

MVP

Valves

80%

HCM

Cardiac Arrest During Long Distance Running

59 cardiac arrests

Kim J NEJM 2012

59 cardiac arrests0.54/100,000 1 in 184 0001 in 184,000

42 deaths (71%)1 in 259,00086% Male

Independent predictors of survival were by‐

Mean age 42 ± 13 yrs stander CPR and diagnosis other than

HCM Event rate increased in males in last half of

study to 2.03/100,000

Cause of Death in Long Distance Running Eventsg g

Kim J NEJM 2012

Cardiac Arrest in the London Marathon

1981‐2012 (32 Year Experience)1981 2012 (32 Year Experience)

802 000 Finishers802,000 Finishers

14 Cardiac Arrests. Mean age 49

8 Deaths (57%)

SCA rate = 1.74/100,000 (1 in 57,000)Cardiac death rate = 1/100 000Cardiac death rate = 1/100,000

Sudden Cardiac Arrest in the London M thMarathon

31

HCM

IHD

SADSSADS

10

Sudden Deaths in TriathlonSudden Deaths in Triathlon

2003‐2011. 23,000 Sanctioned events2003 2011. 23,000 Sanctioned events

> 3 million participants 3 million participants

43 Race related fatalities; Fatality rate 1 in 76,0003 ace e ated ata t es; ata ty ate 6,000

34 Male (80%) 9 Female (20%)( %) ( %)

Age range 24‐76 years old. Mean age 48 years oldg g y g y

70% of all deaths in swimming. g

dd h hlSudden Deaths in US Triathlon 2012

Possible Causes of Death During Swim

D i

Possible Causes of Death During Swim

• Drowning

− Precipitated by water aspiration

− Kicked and knocked unconsciousKicked and knocked unconscious

• Lung Problem

– Swimming Induced Pulmonary Edema (SIPE)

– Asthma attack

– Anaphylaxis from jellyfish sting

C di P bl• Cardiac Problem

– Long QT Syndrome (1 subtype provoked by swimming)

– Myocardial infarction (older athlete)Myocardial infarction (older athlete)

– Hypertrophic or other cardiomyopathy (younger athlete)

• Heat Stroke (rare)

Cause of Sudden Death in the TriathlonHarris et al. Sudden Death During the Triathlon,JAMA,2010

959,214 participants in 2971 USA Triathlons (2006‐2008)(2006 2008)

14 participants died during 14 triathlons14 participants died during 14 triathlons

Rate 1 5 per 100 000 participants (95% CIRate= 1.5 per 100 000 participants (95% CI, 0.9‐2.5)

Mean age: 44 years

Cause of Sudden Death During Swimmingg gHarris et al. Sudden Death During the Triathlon,JAMA,2010

13 Deaths

• 7 of 9 athletes with autopsy had cardiovascular abnormalities

• 6 had left ventricular hypertrophy (wall thickness f 15 t 17 h t i ht f 403 )of 15 to 17mm, mean heart weight of 403 g)

1 h d it l t l• 1 had a congenital coronary artery anomaly

2 h d l h t• 2 had normal heart

Diagnosis

Clinical and family historyClinical and family history

Diagnosis

y y

Cardiac auscultation

y y

Cardiac auscultation

12‐lead ECG/SAECG12‐lead ECG/SAECGIdentify most conditions

Echocardiography/CMR

24 hour ECG

Echocardiography/CMR

24 hour ECG

conditions

24 hour ECG

Exercise stress test

24 hour ECG

Exercise stress test

Pharmacological provocation testsElectrophysiological tests

ManagementManagement

Life style modificationLife style modificationPharmacological therapyR di f bl iRadiofrequency ablationImplantation of ICDCardiac surgery

Arguments For and Against Screening

Goals of Major Sporting BodiesGoals of Major Sporting Bodies

• “The ultimate objective of the pre‐participation screening of athletes is the detection of ‘silent’ cardiovascular abnormalities that can lead to SCD.”

– ACC 36th Bethesda Conference, 2005

• “The main purpose of the consensus document is to• The main purpose of the consensus document is to reinforce the need for PPE medical clearance of all young athletes involved in organized sports programsyoung athletes involved in organized sports programs to prevent athletic field fatalities”

ESC C St t t 2005‐ ESC Consensus Statement, 2005

Screening Athletes

Condition History Examn ECG Echo

HCM Pos/Neg Pos in 25% Positive Pos

ARVC Pos/Neg Negative Positive Neg/PosARVC Pos/Neg Negative Positive Neg/Pos

WPW Pos/Neg Negative Positive Neg

LQTS Pos/Neg Negative Positive Neg

f /Marfan Pos/Neg Positive Negative Pos

CAA Pos/Neg Negative Negative Neg

Myocarditis Pos/Neg Pos/Neg Pos/Neg Pos

INCREASING COST

Young competitive athlete

Personal and family historyPhysical examinationPhysical examination12‐lead rest ECG

Negative findings Positive findings

Eligibility forcompetition

Further examination

No cardiovascular disease

Cardiovascular disease

competition examinationdisease

Management according

Cardiovascular disease

to established protocols

Role of ECGs in Diagnosis of CardiomyopathyRole of ECGs in Diagnosis of Cardiomyopathy

HCM ARVC95% 80%95% 80%

Screening Athletes: Impact on SCD

1979 2004

Screening Athletes: Impact on SCD

• 1979‐2004 • 42,386 athletes (12‐35 years)Hi i i d 12 l d ECG• History, examination and 12‐lead ECG

• Patient with abnormal findings investigated furtherC d d h i 1979 1982• Compared death rates pre‐screening 1979‐1982

early screening 1982‐1992l t i 1992 2004late screening 1992‐2004

• Death rates fell from 3.6/100,000/person years (pre‐screening to 0 4/100 000/person years followingscreening to 0.4/100,000/person years following screening

• Reduction in deaths mainly from cardiomyopathiesReduction in deaths mainly from cardiomyopathies

TIME‐TREND OF SUDDEN CARDIAC DEATH INCIDENCE IN ATHLETES VS NON‐ATHLETESATHLETES VS NON ATHLETES

Veneto Region of Italy 1979‐2002Veneto Region of Italy 1979 2002

ConcernsConcerns

Low incidence of sudden cardiac death

High number of false positives

Concerns relating to false negatives

Cost

Other issues

ConcernsConcerns




Cost

Other issues

Goals of Major Sporting BodiesGoals of Major Sporting Bodies

• “The ultimate objective of the pre‐participation screening of athletes is the detection of ‘silent’ cardiovascular abnormalities that can lead to SCD.”

– ACC 36th Bethesda Conference, 2005

• “The main purpose of the consensus document is to• The main purpose of the consensus document is to reinforce the need for PPE medical clearance of all young athletes involved in organized sports programsyoung athletes involved in organized sports programs to prevent athletic field fatalities”

ESC C St t t 2005‐ ESC Consensus Statement, 2005

Prevalence of Cardiovascular Disorders at Risk of SCD

Ref: Population Prevalence

AHA (2007) Competitive athletes (U.S.) 0.3%

Fuller (1997) 5 617 high school athletes (U S) 0 4%Fuller (1997) 5,617 high school athletes (U.S) 0.4%

Corrado (2006) 42,386 athletes age 12‐35 (Italy) 0.2%

Wilson (2008) 2,720 athletes /children age 10‐17 (U.K.) 0.3%

Bessem (2009) 428 athletes age 12‐35 (Netherlands) 0.7%Bessem (2009) 428 athletes age 12 35 (Netherlands) 0.7%

Baggish (2010) 510 collegiate athletes (U.S.) 0.6%

ConcernsConcerns




Cost

Other issues

Athlete’s Heart

ELECTRICAL STRUCTURAL

Athlete s Heart

ELECTRICAL STRUCTURAL

Bradycardia Increased Bradycardia

Repolarisation anomalies

c easedchamber wall thickness and

cavity size

Voltage criteria for chamber

cavity size

FUNCTIONAL

enlargement

FUNCTIONAL

Enhanced diastolic filling

Augmentation of stroke volumeAugmentation of stroke volume

Results of athletes screened in Veneto 1979‐2004‐C d JAMA 2006Corrado; JAMA 2006

Athletes screened: 42,386

Abnormal ECG: 3,914 (9%)False

Cardiac disorder: 879 (2%)

ll d l f d

Positive

7%All disqualified

7%

Potentially lethal disorder: 91 (0.2%)

The Challengeg

Physiology PathologyPhysiology Pathology

Left Ventricular HypertrophyR l i ti liRepolarisation anomalies

Diagnosis

Clinical and family history Familial

g

Cardiac auscultation Relatively rare

Heterogeneous phenotypic

12-lead ECGmanifestations

Symptoms of disease usually absentEchocardiography

24 hour ECG

absent

ECG overlap with athlete’s heart

Exercise stress testheart

Natural history not fully understood in all disorders

Pharmacological testsEvaluation in an expert setting is important

Pharmacological testsElectrophysiological tests

ConcernsConcerns




Cost

Other issues

Deaths in Athletes and Non-Athletes Aged 35

Deaths in Athletes and Non-Athletes Aged 35 Years in Veneto 1979-1996 – Corrado; NEJM 1988

Deaths in Athletes and Non Athletes Aged 35 Years in Veneto 1979-1996 – Corrado; NEJM 1988

Years in Veneto 1979-1996 – Corrado; NEJM 1988

CONDITION ATHLETES NON‐ATHLETES TOTALN = 49 N = 220 N = 269

CAD 9 (18.4) 36 (16.4) 45 (16.7)

CAA 6 (12.2) 1 (0.5) 7 (2.6)

HCM 1 (2) 16 (7.3) 17 (6.3)

Active senior

High intensity exercise

Assessment by a physicianAssessment by a physicianH/E/Risk SCORE/ECG

P itiNegative Positive

Can compete Maximal ETT

Deaths Despite Screening with ECGp g

Success Rates for Defibrillation in Young AthletesAthletes

Author Study Survival____________________________________________Maron Commotio cordis 16%

Drezner Survival trends 4‐21%

Drezner Schools with AED 64%

Kim Marathon runners 29%

L d M th 43%London Marathon 43%

Marion Gen Pop 10 75 16%Marion Gen Pop 10‐75 16%

ConcernsConcerns


High number of false postives


Cost

Other issues

REAL ISSUES

Low incidence of sudden death ? COST EFFECTIVELow incidence of sudden death ? COST EFFECTIVE Low prevalence of conditions causing SCD

H t di d ith EXPERT INPUTHeterogeneous disorders with EXPERT INPUT broad phenotypic manifestations

ECG overlap with physiological FALSE POSITIVES adaptation

Disease manifestation may relate FALSE NEGATIVES to age

Diseases such as CAA and CAD FALSE NEGATIVES not identifiable with ECG alone

Problems with risk stratification CANNOT PREDICT RISK

Prospect of litigation

Conclusions

1. Sudden cardiac death in endurance sports is rare.

1. Preliminary observations suggest a higher death rate in the triathlon compared to the marathon.ate t e t at o co pa ed to t e a at o .

2. Most triathlon deaths occur during swimming for hi h h l i l l iwhich there are several potential explanations.

3. Screening with ECG will detect electrical faults and gcardiomyopathies but will fail to identify most coronary artery abnormalities/disease.y y /

4. Screening of athletes MUST take place in an EXPERT ttiEXPERT setting.

Harris et al. Sudden Death During the Triathlon, JAMA, 2010

Swimming Induced PulmonaryEdema (SIPE)

• Acute pulmonary oedema and haemoptysis occurring in swimmers or divers.

W ll k t i ll i h (d t hi h– Well‐known event in galloping race horses (due to high pulmonary vascular pressure).

Also reported in cyclists marathoners and rugby players– Also reported in cyclists, marathoners and rugby players, but much less common.

• Symptoms: haemoptysis (pink frothy sputum) cough SOBSymptoms: haemoptysis (pink frothy sputum), cough, SOB, wheezing, CP

• Seawater aspiration wouldn’t do all this.Seawater aspiration wouldn t do all this.

• Over‐hydration thought to contribute.

SIPE Pathophysiologyp y gy

• Effects of water immersion:– Cold water causes vasoconstriction and increase in both preload and

afterload in heartafterload in heart.

– Cold water results in decreased core temp and shifts blood from peripheral to thoracic vessels.

– Causes central blood pooling which increases heart preload and pulmonary artery pressure.

– These dramatic increases in pulmonary artery pressure damages alveolar capillary membrane and lead to pulmonary oedema.

Cause of Death in Long Distance Running Eventsg g

Kim J NEJM 2012

Efficacy of Italian ECG Programme for Excluding HCM

Athletes cleared at

Excluding HCMNEGATIVE

4450Athletes cleared at national screening PREDICTIVE

VALUE 99.8%

Echocardiography (and other testing)4397

(98.8%)

Other structural

No cardiac 41

(0 9%)

LVH Other structural disease

No cardiac diseases

(0.9%)12

(0.3%)

37 437

(0.8%)

4

(0.1%) 1 HCM

(0 025%)Physiological LVH “Grey zone”(0.025%)

Download - Sanjay Sharma - Sudden cardiac death in endurance

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