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  • 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

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • 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

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • 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%)

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Is the ECG-based preparticipation

    screening model cost-effective?

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    •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*

    mailto:alessandro.zorzi@unipd.it

  • Why can athletes die suddenly despite

    ECG preparticipation screening?

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • 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)

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • 27 year-old, professional soccer player

    No personal or family history

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • • ECG: infero-lateral T-wave inversion

    • 24 hours ECG-monitoring: frequent PVB with a RBBB-pattern

    • Echocardiography: normal

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Contrast-enhanced MRI

    – Morpho-functional evaluation: normal

    – Post-contrast sequences: infero- lateral subepicardial scar of unkown origin (post- myocarditis? Left-dominant ARVC?)

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Therapy:

    • Competitive sport restriction

    • Beta-blockers

    • ICD

    Dopo 33 mesi di follow- up while playing table tennis

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • 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.

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • 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

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

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

    mailto:alessandro.zorzi@unipd.it

  • Non ischemic left ventricular scar: an

    emerging cause of sudden death in the athlete

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    Zorzi et al, Circ Arrhythm Electrophysiol 2016 (open access)

    mailto:alessandro.zorzi@unipd.it

  • 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

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • 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

    Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • Alessandro Zorzi - University of Padova – alessandro.zorzi@unipd.it

    mailto:alessandro.zorzi@unipd.it

  • 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

  • Hx +

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