sanjay sharma - sudden cardiac death in endurance

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science+triathlon, 2013, Magglingen, Švica

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  • Sudden Cardiac Death in Endurance Sports

    Professor Sanjay Sharma

    Disclosures: None

    ObjectivesObjectives

    Toprovideinformationabouttheincidenceandcausesofsuddendeathinsportfromcurrentliterature.

    To present death rates in the marathon and triathlon.Topresentdeathratesinthemarathonandtriathlon.T t d il bl i f ti f dd d th Tostudyavailableinformationoncauseofsuddendeathintriathletes

    Todiscusspotentialscreeningstrategiesinenduranceathletes.

  • Sudden Death in Athletes

    Incidence approximately 1/25 0001/100 000SuddenDeathinAthletes

    Incidenceapproximately1/25,0001/100,000( ) Morecommoninmalesthanfemales(9:1)

    Over80%ofvictimsdonotexhibitanywarningsymptomsy p

    80% deaths are due to an underlying cardiac disorder 80%deathsareduetoanunderlyingcardiacdisorder 90%deathsduringorimmediatelyafterexertion

    Background:CausesofSCDinSportg p

    2.5

    1.52

    2.5

    SD/100 000

    00.51 SD/100,000

    personyrs0

    Athletes Nonathletes

  • PotentialtriggersforSuddenDeathDehydration Adrenergic

    surgessurges

    Electrolyte Acid/baseyimbalance

    Acid/basedisturbance

    Hypertrophic CardiomyopathyHypertrophicCardiomyopathy

  • DeathsinIndividualswithStructurallyNormalHearts: The British ExperienceUK SCD, n=118, age range 7-59 yr

    Hearts:TheBritishExperience

    A

    atheroma2% myocarditis

    3%

    valve2%

    other4%

    normal23%

    IF6%

    ACA5%

    LVHARVC14% LVH

    23%LVHw/IF8%

    HCM11%

    14%

    ElectricalDisordersSCDWithaNormalHeartLQTS

    Brugada

    WPW

  • SuddenCardiacDeathDuringMass500 i h 1 illi i i

    ParticipationLongDistanceRunning500racesperyearwithupto1millionparticipants

    Triathlon

  • MeanAgeofSuddenDeathinAthletesSPORT Age(yearsold)

    g

    _______________________________________________Competitive soccer 23Competitivesoccer 23R ti l t 46Recreationalsport 46Marathonrunner 42Triathlete 44

    CausesofSuddenCardiacDeathinSeniorAthletes5% 5% 5%5% 5%

    CADSADSADMVPValves

    80%HCM

  • CardiacArrestDuringLongDistanceRunning59 cardiac arrests

    KimJNEJM201259cardiacarrests0.54/100,0001 in 184 0001in184,000

    42deaths(71%)1in259,00086%Male Independentpredictorsofsurvivalwereby

    Meanage42 13yrs standerCPRanddiagnosisotherthan

    HCMEventrateincreasedinmalesinlasthalfof

    studyto2.03/100,000

    CauseofDeathinLongDistanceRunningEventsg gKimJNEJM2012

  • CardiacArrestintheLondonMarathon19812012 (32 Year Experience)1981 2012(32YearExperience)802 000 Finishers802,000Finishers14CardiacArrests.Meanage498Deaths(57%)SCArate=1.74/100,000 (1in57,000)Cardiac death rate = 1/100 000Cardiacdeathrate=1/100,000

    SuddenCardiacArrestintheLondonM thMarathon

    31

    HCMIHDSADSSADS

    10

  • Sudden Deaths in TriathlonSuddenDeathsinTriathlon20032011. 23,000 Sanctioned events2003 2011. 23,000Sanctionedevents> 3 million participants3millionparticipants43Racerelatedfatalities;Fatalityrate1in76,0003 ace e ated ata t es; ata ty ate 6,00034Male(80%) 9Female(20%)( %) ( %)Agerange2476yearsold.Meanage48yearsoldg g y g y70%ofalldeathsinswimming.g

    dd h hlSuddenDeathsinUSTriathlon2012

  • Possible Causes of Death During Swim

    D i

    PossibleCausesofDeathDuringSwim 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)

    CauseofSuddenDeathintheTriathlonHarrisetal.SuddenDeathDuringtheTriathlon,JAMA,2010

    959,214participantsin2971USATriathlons(20062008)(2006 2008)14 participants died during 14 triathlons14participantsdiedduring14triathlonsRate 1 5 per 100 000 participants (95% CIRate=1.5per100000participants(95%CI,0.92.5)Meanage:44years

  • CauseofSuddenDeathDuringSwimmingg gHarrisetal.SuddenDeathDuringtheTriathlon,JAMA,2010

    13Deaths 7of9athleteswithautopsyhadcardiovascularabnormalities

    6hadleftventricularhypertrophy(wallthicknessf 15 t 17 h t i ht f 403 )of15to17mm,meanheartweightof403g)

    1 h d it l t l 1hadacongenitalcoronaryarteryanomaly2 h d l h t 2hadnormalheart

  • DiagnosisClinicalandfamilyhistoryClinicalandfamilyhistory

    Diagnosisy y

    Cardiacauscultationy y

    Cardiacauscultation12leadECG/SAECG12leadECG/SAECG Identifymost

    conditionsEchocardiography/CMR

    24 hour ECG

    Echocardiography/CMR

    24 hour ECG

    conditions

    24hourECGExercisestresstest24hourECGExercisestresstestPharmacologicalprovocationtestsElectrophysiologicaltests

    ManagementManagement

    Life style modificationLifestylemodificationPharmacologicaltherapyR di f bl iRadiofrequencyablationImplantationofICDCardiacsurgery

  • ArgumentsForandAgainstScreening

    Goals of Major Sporting BodiesGoalsofMajorSportingBodies TheultimateobjectiveofthepreparticipationscreeningofathletesisthedetectionofsilentcardiovascularabnormalitiesthatcanleadtoSCD.

    ACC36th BethesdaConference,2005 The main purpose of the consensus document is to ThemainpurposeoftheconsensusdocumentistoreinforcetheneedforPPEmedicalclearanceofallyoung athletes involved in organized sports programsyoungathletesinvolvedinorganizedsportsprogramstopreventathleticfieldfatalities

    ESC C St t t 2005 ESCConsensusStatement,2005

  • ScreeningAthletesCondition 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

    INCREASINGCOST

    Youngcompetitiveathlete

    PersonalandfamilyhistoryPhysical examinationPhysicalexamination12leadrestECG

    Negative findings Positivefindings

    Eligibilityforcompetition

    Furtherexamination

    Nocardiovasculardisease

    Cardiovascular disease

    competition examinationdisease

    ManagementaccordingCardiovasculardisease

    toestablishedprotocols

  • Role of ECGs in Diagnosis of CardiomyopathyRoleofECGsinDiagnosisofCardiomyopathy

    HCM ARVC95% 80%95% 80%

    Screening Athletes: Impact on SCD

    1979 2004

    ScreeningAthletes:ImpactonSCD 19792004 42,386athletes(1235years)Hi i i d 12 l d ECG History,examinationand12leadECG

    PatientwithabnormalfindingsinvestigatedfurtherC d d h i 1979 1982 Compareddeathratesprescreening19791982

    earlyscreening19821992l t i 1992 2004latescreening19922004

    Deathratesfellfrom3.6/100,000/personyears(prescreening to 0 4/100 000/person years followingscreeningto0.4/100,000/personyearsfollowingscreening

    Reduction in deaths mainly from cardiomyopathiesReductionindeathsmainlyfromcardiomyopathies

  • TIMETRENDOFSUDDENCARDIACDEATHINCIDENCEINATHLETES VS NONATHLETESATHLETESVSNON ATHLETES

    Veneto Region of Italy 19792002VenetoRegionofItaly1979 2002

    ConcernsConcerns

    LowincidenceofsuddencardiacdeathHighnumberoffalsepositivesConcernsrelatingtofalsenegativesCost

    Otherissues

  • ConcernsConcerns

    LowincidenceofsuddencardiacdeathHighnumberoffalsepositivesConcernsrelatingtofalsenegativesCost

    Otherissues

    Goals of Major Sporting BodiesGoalsofMajorSportingBodies TheultimateobjectiveofthepreparticipationscreeningofathletesisthedetectionofsilentcardiovascularabnormalitiesthatcanleadtoSCD.

    ACC36th BethesdaConference,2005 The main purpose of the consensus document is to ThemainpurposeoftheconsensusdocumentistoreinforcetheneedforPPEmedicalclearanceofallyoung athletes involved in organized sports programsyoungathletesinvolvedinorganizedsportsprogramstopreventathleticfieldfatalities

    ESC C St t t 2005 ESCConsensusStatement,2005

  • PrevalenceofCardiovascularDisordersatRiskofSCD

    Ref: Population Prevalence

    AHA(2007) Competitiveathletes(U.S.) 0.3%Fuller (1997) 5 617 high school athletes (U S) 0 4%Fuller(1997) 5,617highschoolathletes(U.S) 0.4%Corrado (2006) 42,386athletesage1235(Italy) 0.2%Wilson(2008) 2,720athletes/childrenage1017(U.K.) 0.3%Bessem (2009) 428 athletes age 1235 (Netherlands) 0.7%Bessem (2009) 428athletesage12 35(Netherlands) 0.7%Baggish (2010) 510collegiateathletes(U.S.) 0.6%

    ConcernsConcerns

    LowincidenceofsuddencardiacdeathHighnumberoffalsepositivesConcernsrelatingtofalsenegativesCost

    Otherissues

  • Athletes Heart

    ELECTRICAL STRUCTURAL

    Athlete sHeartELECTRICAL STRUCTURAL

    Bradycardia Increased Bradycardia

    Repolarisation anomalies

    c easedchamber wall thickness and

    cavity sizeVoltage criteria

    for chamber

    cavity size

    FUNCTIONAL

    enlargement

    FUNCTIONALEnhanced diastolic filling

    Augmentation of stroke volumeAugmentation of stroke volume

  • ResultsofathletesscreenedinVeneto19792004C d JAMA 2006Corrado;JAMA2006

    Athletesscreened:42,386AbnormalECG:3,914(9%)

    False Cardiacdisorder:879(2%)

    ll d l f d

    Positive

    7%Alldisqualified 7%Potentiallylethaldisorder:91

    (0.2%)

    TheChallengeg

    Physiology PathologyPhysiology Pathology

    LeftVentricularHypertrophyR l i ti liRepolarisationanomalies

  • DiagnosisClinical and family history Familial

    g

    Cardiac auscultation Relatively rareHeterogeneous phenotypic

    12-lead ECGmanifestations

    Symptoms of disease usually absentEchocardiography

    24 hour ECG

    absent

    ECG overlap with athletes heart

    Exercise stress testheart

    Natural history not fully understood in all disorders

    Pharmacological testsEvaluation in an expert setting is important

    Pharmacological testsElectrophysiological tests

    ConcernsConcerns

    LowincidenceofsuddencardiacdeathHighnumberoffalsepositivesConcernsrelatingtofalsenegativesCost

    Otherissues

  • 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;NEJM1988

    Years in Veneto 1979-1996 Corrado;NEJM1988CONDITION ATHLETES NONATHLETES TOTAL

    N=49 N=220 N=269CAD 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)

    Activesenior

    Highintensityexercise

    Assessment by a physicianAssessmentbyaphysicianH/E/RiskSCORE/ECG

    P itiNegative Positive

    Cancompete MaximalETT

  • DeathsDespiteScreeningwithECGp g

    SuccessRatesforDefibrillationinYoungAthletesAthletes

    Author Study Survival____________________________________________Maron Commotiocordis 16%Drezner Survivaltrends 421%Drezner SchoolswithAED 64%Kim Marathonrunners 29%

    L d M th 43%LondonMarathon 43%Marion Gen Pop 10 75 16%Marion GenPop1075 16%

  • ConcernsConcerns

    LowincidenceofsuddencardiacdeathHighnumberoffalsepostivesConcernsrelatingtofalsenegativesCost

    Otherissues

    REALISSUESLow incidence of sudden death ? COST EFFECTIVELowincidenceofsuddendeath ?COSTEFFECTIVELowprevalenceofconditionscausingSCDH t di d ith EXPERT INPUTHeterogeneousdisorderswith EXPERTINPUTbroadphenotypicmanifestationsECGoverlapwithphysiological FALSEPOSITIVESadaptation

    Diseasemanifestationmayrelate FALSENEGATIVEStoageDiseasessuchasCAAandCAD FALSENEGATIVESnotidentifiablewithECGaloneProblemswithriskstratification CANNOTPREDICT

    RISK

    Prospectoflitigation

  • Conclusions1.Suddencardiacdeathinendurancesportsisrare.1. Preliminaryobservationssuggestahigherdeath

    rateinthetriathloncomparedtothemarathon.ate t e t at o co pa ed to t e a at o .2. Mosttriathlondeathsoccurduringswimmingfor

    hi h h l i l l iwhichthereareseveralpotentialexplanations.3. ScreeningwithECGwilldetectelectricalfaultsandg

    cardiomyopathiesbutwillfailtoidentifymostcoronaryarteryabnormalities/disease.y y /

    4. ScreeningofathletesMUSTtakeplaceinanEXPERT ttiEXPERTsetting.

    Harrisetal.SuddenDeathDuringtheTriathlon,JAMA,2010

  • SwimmingInducedPulmonaryEdema(SIPE)

    Acutepulmonaryoedemaandhaemoptysisoccurringinswimmersordivers.

    W ll k t i ll i h (d t hi h Wellknowneventingallopingracehorses(duetohighpulmonaryvascularpressure).Also reported in cyclists marathoners and rugby players Alsoreportedincyclists,marathonersandrugbyplayers,butmuchlesscommon.

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

    Seawater aspiration wouldnt do all this.Seawateraspirationwouldn tdoallthis. Overhydrationthoughttocontribute.

    SIPEPathophysiologyp y gy Effectsofwaterimmersion:

    Coldwatercausesvasoconstrictionandincreaseinbothpreloadandafterload in heartafterloadinheart.

    Coldwaterresultsindecreasedcoretempandshiftsbloodfromperipheraltothoracicvessels.

    Causescentralbloodpoolingwhichincreasesheartpreloadandpulmonaryarterypressure.

    Thesedramaticincreasesinpulmonaryarterypressuredamagesalveolarcapillarymembraneandleadtopulmonaryoedema.

  • CauseofDeathinLongDistanceRunningEventsg gKimJNEJM2012

  • EfficacyofItalianECGProgrammeforExcluding HCM

    Athletes cleared at

    ExcludingHCMNEGATIVE

    4450Athletes cleared at national screening PREDICTIVEVALUE99.8%

    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%)