sudden cardiac death in · pdf file sudden cardiac death in athletes alessandro zorzi, md...

SUDDEN CARDIAC DEATH IN
ATHLETES…
Alessandro Zorzi, MD Department of cardiac, thoracic and
vascular sciences
University of Padova
… and strategies for prevention
Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it
mailto:alessandro.zorzi@unipd.it

Common causes of sudden cardiac death in the athlete
Young athletes (under 35):
Hypertrophic cardiomyopathy
Arrhythmogenic cardiomyopathy
Congenital coronary arteries anomalies
Myocarditis
Aortic dissection
Premature coronary atherosclerosis
Ventricular pre-excitation
Arrhythmic mitral valve prolapse
Congenital heart disease
Isolated non-ischemic left ventricular scar
Structurally normal heart

Annual Incidence Rates of Sudden Cardiovascular Death in Screened Competitive Athletes and
Unscreened Nonathletes Aged 12 to 35 Years in the Veneto Region of Italy (1979-2004)
Corrado et al JAMA 2006;296:1593-1601
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
1979- 1980
1981- 1982
1983- 1984
1985- 1986
1987- 1988
1989- 1990
1991- 1992
1993- 1994
1995- 1996
1997- 1998
1999- 2000
2001- 2002
2003- 2004
S u
d d
e n
d e
a th
p e
r 1
0 0
0 0
0 p
e rs
o n
-y e
a rs
Years

ROLE OF PREPARTICIPATION SCREENING
Two possible strategies
(Centro di Medicina dello Sport; Padova 1982-1996)
Disease
History, PE,
ECG
(N=43)
History and PE
alone
(N=10)
HCM 22 (51%) 5 (50%)
ARVC 8 (19%) 2 (20%)
DCM 4 (9%) -
Marfan sdr. 3 (7%) 1 (10%)
Long QT 2 (5%) 1 (10%)
Coronary artery disease 2 (5%) -
Myocarditis 1 (2%) -
Congenital heart disease 1 (2%) 1 (10%)

Is the ECG-based preparticipation
screening model cost-effective?

•If one assumes that universal screening of young competitive athletes is
justified on ethical and medical ground (AHA/ACC/ESC)
•If one recognizes that
•1) history and physical examination are of marginal value for identification of
athletes at risk and
•2) ECG is much more sensitive than history and physical examination (although
it has a low specificity that translates into limited cost-effectiveness)
•Then, the screening protocol has to include ECG
*a formal argument in logic that is formed by two statements and a conclusion which must be true if the two statements are true
The preparticipation screening
Aristotelian syllogism*

Why can athletes die suddenly despite
ECG preparticipation screening?

The problem of false negatives
For some cardiovascular diseases at risk of sudden
cardiac death in the athlete, ECG preparticipation
screening is not sensitive enough:
• Congenital abnormalities of coronary arteries
• “Commotio Cordis”
• Acute myocardities
• Mild cardiomyopathy phenotypes
• ISOLATED (IDIOPATHIC) NON-ISCHEMIC LEFT
VENTRICULAR SCAR
• CORONARY ARTERY DISEASE (OLDER ATHLETES)

27 year-old, professional soccer player
No personal or family history

• ECG: infero-lateral T-wave inversion
• 24 hours ECG-monitoring: frequent PVB with a RBBB-pattern
• Echocardiography: normal

Contrast-enhanced MRI
– Morpho-functional evaluation: normal
– Post-contrast sequences: infero- lateral subepicardial scar of unkown origin (post- myocarditis? Left-dominant ARVC?)

Therapy:
• Competitive sport restriction
• Beta-blockers
• ICD
Dopo 33 mesi di follow- up while playing table tennis

PIERMARIO MOROSINI
Family history: negative
Personal history: negative
ECG: normal
Ecocardiography: normale
Stress test: normal
Autopsy: left-dominant arrhythmogenic
cardiomyopathy with subepicardial fibro-
fatty scar of the left-ventricular lateral
wall. Focal fibrofatty infiltration also of
the right ventricle.

D’Amati et al. Int J Cardiol 2016;206:84–86

BEFORE 1999
80%: CLASSICAL
RIGHT DOMINANT
VARIANTS
AFTER 1999
ALL LEFT DOMINANT
OR BIVENTRICULAR
VARIANTS
IN THE VENETO REGION OF ITALY
ARRHYTHMOGENIC CARDIOMYOPATHY REMAINS
THE MAIN CAUSE OF SUDDEN CARDIAC DEATH IN
YOUNG ATHLETES BUT THE PHENOTYPE HAS
CHANGED BECAUSE OF PREPARTICIPATION
SCREENING:
Sudden cardiac death registry– Veneto Region courtesy Prof.ssa C. Basso

Di Gioia et al, Human Patology 2016 (in press)

Non ischemic left ventricular scar: an
emerging cause of sudden death in the athlete
Zorzi et al, Circ Arrhythm Electrophysiol 2016 (open access)

Senior (> 35):
Ischemic cardiac disease
Patients with coronary artery disease risk factors are the one who most benefit from physical activity, but they are also those at higher risk of acute coronary syndrome and ventricular fibrillation during exercise
“doing sport is good... If you don’t die suddently”
Common causes of sudden cardiac death in the athlete

Data from the “Castelli Foundation” (collected from the press)
2006 – 2012
592 cases of cardiac arrest during physical activity
3 professional athletes
80 competitive non-professional athletes
>80% amateur athletes /leisure time sports activity

ACTIVE
Adult/senior
Moderate intensity activity High intensity activity
Self-assessment of risk
Screening by physician:
Hx, Phys.exam., RISK SCORE, ECG
NO on every
question YES on every
question
Maximal exercise testing
High riskLow risk
Negative Positive Eligible
Further evaluation,
Appropriate
treatment and
individually
prescribed
physical activity
Low intensity activity
Consensus document of EACPR

sudden cardiac death in · pdf file sudden cardiac death in athletes alessandro zorzi, md...

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