update on sudden cardiac death in athletes and young generation
TRANSCRIPT
Updates on Sudden Cardiac Death in Athletes and Young Generation
DR. TAMER TAHA ISMAIL TAHA CLINICAL ASSOCIATE PROFESSOR AND SPECIALIST
DEPARTMENT OF CARDIOLOGY
THUMBAY HOSPITAL _DUBAI
EXERCISE IS GOOD
Outline Exercise : benefits and risk
Athlete’s Heart
Etiology of SCD in young athletes
Etiology of SCD in old athletes
Screening and Pre participation examination
Lowering the risk of SCD
DEFINITIONS FOR THIS TALK EXERCISE: Any form of physical activity, done on a
regular basis, with the purpose of achieving a specific goal
• Low level to vigorous
• Recreational (including “play”) to competative
ATHLETE: Anyone who is exercising
YOUNG ATHLETE: Less than 35 years old
ADULT ATHLETE: Greater than 35 years old
BENEFITS OF EXERCISE
• DISEASE PREVENTION• Cardiovascular• Diabetes• Osteoporosis, joint health
• FITNESS• WEIGHT CONTROL• ENJOYMENT
• Personal Goals• Competition
COULD “exercise ” CAUSE ANY CARDIOVASCULAR HARM?
ANSWER: YES
THE RISK IS SMALL
THE CONSEQUENCES ARE SIGNIFICANT
WHAT THE RISK IS AND WHAT CONDITIONS ARE RESPONSIBLE FOR THE RISK VARY BY AGE
DETERMINANTS OF EXERCISE RISK
1. Probability of Cardiac Disease2. Intensity and Duration of Exercise
RISK INCREASES WITH INCREASED RISK OF
UNDERLYING CVD, INTENSITY, DURATION OF EXERCISE
MEASURING INTENSITYThe Metabolic Equivalent or MET
is a physiological measure expressing the energy cost of physical activities and is defined
as the ratio of metabolic rate during a specific physical activity to a reference metabolic
rate
3.5 ml O2/kg/min
MET
1. Sitting……………………………………………….1.02. Walking at 2.5 m/h……………………………2.93. Biking at 10 m/h……………………………….4.04. Elliptical……………………………………………5.55. Jogging…………………………………………….7.06. Swimming (moderate)……………………..8.0 7. Swimming (hard)…………………………….12.08. Running 8 min mile…………………………12.59. Bike Racing (not drafting) > 20m/h….16.0
EXERCISE INTENSITY• Light
• Daily activities, gentle walk• < 3 METs
• Moderate• Brisk walk, easy jog or bike• < 6 METs
• Vigorous/Intense• Running, Biking, High Intensity Interval, “Boot Camp”• RPE 7 – 10, METs > 6
EXERCISE DURATION Dehydration Electrolyte changes Increased inflammation Hyperthermia
Most cardiac events during marathonsoccur past the 22.5 mile marker
RECOMMENDED DURATION(health and fitness goal)American Heart Association
150 min/week of moderate exercise
75 min/week of vigorous exercise
OK to break it up
Gangasani, S. R. et al. Chest 2000;118:249-252
Physiologic alterations accompanying acute exercise and recovery, and their possible sequelae
Definition of sudden cardiac death
Non-traumatic, unexpected fatal event
occurring within 1 hour of the onset of symptoms
in an apparently healthy subject.
If death is not witnessed, the definition applies
when the victim was in good health 24 hours
before the event.
Who are we talking about, what are the numbers
THE YOUNG ATHLETE AND THE RISK(US numbers)
• All deaths related to exercise: 120/year (excluding trauma)
• Deaths caused by CVD: < 100/year
• Approximately 1 CVD death/100,000/year
• All the “conditions” that might harm athletes are just as
prevalent in non-athletes. Athletes are at higher risk.
THE YOUNG ATHLETEA SAMPLING OF THE CAUSES
Structural Heart Disease
• Hypertrophic Cardiomyopathy
• Anomalous Origin of the Coronary Arteries
• Arrhythmogenic Right Ventricular Cardiomyopathy
• Myocarditis/Cardiomyopathy
• Valvular Disease
The “Channelopathies”
Drugs
18
THE ADULT ATHLETE• Harder to define the numbers and risk
• Heart disease is common among adults
• Exercise programs vary
• No organized reporting program
• Marathoners: <1/100,000
• Recreational runners: 1/10,000/year .
• Individuals with disease are 2 -3-X more likely to have an event during exertion.
THE ADULT ATHLETEA SAMPLING OF THE CAUSES
Coronary Artery DiseaseValvular Heart DiseaseCardiomyopathy “Young Athlete” Disease
THE YOUNG ATHLETESPECIFIC EXAMPLES
HANK GATHERS1967 - 1990
HYPERTROPHIC CARDIOMYOPATHY
HYPERTROPHIC CARDIOMYOPATHY
• Affects 1 in 500 individuals• Genetically determined
• Sporadic or inherited• At least 11 genes, 1400 mutations
• Accounts for 35 – 40% of athletic deaths• Can be symptomatic/detectable before SCA• Increased risk with age• Ventricular arrhythmia is primary cause of death
Risk Factors for Sudden Death in HOCM
Major- Out of hosp arrest or VT- FH sudden death and
HOCM
Minor- NSVT on Holter- Drop in BP on TMET- Thallium perfusion defects- Young male- History of syncope- Septal thickness
ANOMALOUS ORIGIN OF THE CORONARY ARTERIES
ANOMALOUS ORIGIN OF THE CORONARY ARTERIES• Accounts for 15 – 20% of sudden death in
young athletes• Can be symptomatic (< 50%)
• Chest discomfort• Shortness of breath• Palpitations• Fainting
• Treatment: Medical or Surgical• May be “cleared” to participate if corrected
ARRYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY
ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY
Prevalence: 1/1000 – 2000 Genetic, 30% inherited. Accounts for 5% of sudden death in young
athletes Can be symptomatic: palpitations, fainting Treatment: medical, ICD Disqualified from competitive sports
MYOCARDITIS/CARDIOMYOPATHY
MYOCARDITIS/CARDIOMYOPATHY
Accounts for 5 -10% of sudden cardiac arrests in young athletes
Causes: “viral”, inherited/genetic, idiopathic Can be symptomatic: shortness of breath,
palpitations, fatigue/weakness, fainting, chest discomfort
Disqualified from most competitive sports. May return if recover.
COMMOTIO CORDIS Vulnerable moment High force, specific
area Baseball, hockey,
karate Kids more
vulnerable 20% survival Boys > girls
Ephedrine and its analogues
Anabolic steroids
Gama hydroxybutyrate
Cocain
Illicit Drugs Used By Athletes During Competitive Sports
INHERITED ARRHYTHMIAand SUDDEN CARDIAC ARREST
THE “CHANNELOPATHIES”
WHAT IS A CHANNEL?
THE CHANNELOPATHIES AND SUDDEN CARDIAC ARREST
Long QT Syndrome
Brugada Syndrome
Catecholaminergic Polymorphic Ventricular
Tachycardia
Short QT syndrome
THE CHANNELOPATHIES: LONG QT• Not rare: 3000 – 4000 deaths/y in children/adolescents• Inherited/genetic
• 12 types/genes, hundreds of different mutations
• Variable “lethality”
• AR associated with deafness
• Variable expression• Acquired form
• Medications/drugs
• Electrolyte changes
• Increased risk of SCA with exercise, risk variable based on type• SCA in athletes: not rare, numbers not clear• ECG + , gene +, symptom + : Disqualified from competitive sports
ACQUIRED LONG QT• Medications: www.qtdrugs.org
• Antiarrhythmics
• Antibiotics: Levaquin, Zithromax (Z pack), erythromycin
• Antidepressants: Tricyclics, Prozac, Celexa
• Tamoxifen
• diuretics
• 140 other drugs
• Methadone
• Combinations of drugs
• Electrolytes: Low K+, Mg++, Ca++
• Genetic + Drugs, ? Unmasked congenital form
• Reversible
THE CANNELOPATHIESBRUGADA SYNDROME
• Genetic• Genetic testing variable• Na+ channel
• EKG variable• Provocative testing
• Multiple types• Male > Female• Avg age at DX: 41• Fever/hyperthermia trigger• Night time trigger• Treatment: ICD, limited medications• Caution advised for competitive
sports with no history of events• With history of events or ICD low
level sports only
THE CHANNELOPATHIES: CATECHOLAMINERGIC POLYMORPHIC VT
CPVT• Genetic, at least 2 gene mutations
• Inherited
• Emotional and physical triggers. Symptoms: dizziness and
syncope
• Usually presents in childhood and adolescence
• Treatment: Medical therapy, ICD + medical,
Sympathectomy, Medical therapy for gene + asymptomatic.
• Generally recommend against competitive sports, ICD
precludes contact sports
OTHER ARRHYTHMIAWOLFF PARKINSON WHITE• 1/400
• Often Incidental finding• Can present with
symptoms• Often first diagnosed in
adulthood• Risk of V-fibrillation• Risk stratify
asymptomatic Pts• Ablation• OK to participate in
competitive sports once treated
THE ADULT ATHLETECARDIOVASCULAR DISEASE IS THE PRIMARY CAUSE OF DEATH IN ADULT ATHLETES
WHAT IS THE RISK? 800,000 Heart attacks/year
400,000 Sudden Cardiac Death
Sudden Death: First symptom in 50%
2 – 3 X as likely to suffer a cardiac event during
exercise in those with disease
THE ADULT ATHLETE Primary Cause: Coronary Artery Disease
Cardiomyopathy
Vascular Disease
Arrhythmia
Valvular Heart Disease
THE ADULT ATHLETE
The adult athlete can still have almost any of the conditions of the young athlete.
CORONARY ARTERY DISEASESTILL NUMBER ONE
JIM FIXX1932 - 1984
FACTORS INCREASING THE LIKLIHOOD OF CORONARY ARTERY DISEASENON-TRADITIONAL
Cholesterol variants
• Lp(a)
• Particle size
Genetic
Vascular physiology/metabolism
Inflammation
GLOBAL RISK
THE GREATER THE NUMBER OF RISK FACTORS, THE GREATER THE RISK
ISCHEMIA AND SCD
DEMAND > SUPPLY ISCHEMIA
CHEST PAINSOB
PERFORMANCENON-LETHAL ARRYTHMIA
LETHAL ARRHYTHMIA
OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISE
DILATED CARDIOMYOPATHYHYPERTROPHIC
CARDIOMYOPATY
OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISE
AORTIC DISSECTION Risk Factors: ASCVD,
especially hypertension Sporadic, associated
with aneurysm, genetic Sheer force Increased risk with high
static component exercise
OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISE
VALVULAR HEART DISEASE Aortic stenosis Aortic insufficiency Mitral Valve Prolapse
NONLETHAL ARRHYTHMIA
ATRIAL FIBRILLATIONSUPRAVENTRICULAR
TACHYCARDIA
EXERCISE AND NONLETHAL ARRHYTHMIA European Heart Journal 2014
52,000 players
Mean age: 38
Twice the risk of non-athletes
Higher risk with faster times
Mechanism: ? inflammation
SCREENING GOAL To identify those at risk
Prevent injury and lethal events
TO ASSIST YOUNG ATHLETES AND THEIR FAMILIES IN MAKING
RATIONAL DECISIONS REGARDING THE RISK OF ATHLETIC PARTICIPATION
Athlete’s Heart 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 However, systolic/diastolic functions is maintained Occurs in M>F with size related to lean body mass.
May be 2ry to genetics The amount of exercised-induced LVH in endurance athletes
associated with ACE genotype.
Athlete’s Heart ECG’s
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
SCREENING YOUNG ATHLETES
• Recommendations vary widely internationally.
• Recommendations vary widely based on level of
participation
• Not clear if definitely reduces risk• Findings variable with time
• Variable age of onset
• These are relatively rare diseases
• Needs to be done regularly until adult age
THE PREPARTICIPATION EXAM
Review for symptoms
• Dizziness or fainting, shortness of breath, palpitations,
chest discomfort, can’t keep up
Family History
• Premature death
• “Death under unusual circumstances”
Physical exam
• Murmurs, build, pulses
WHAT ABOUT ECGs• Not recommended routinely in US
• Required in Europe
• Controversial
• Not clear it helps
• Athletes often have ECG changes that are “normal”
• False negatives, False positives
• Cost of ECGs, Cost of additional testing, Cost of disqualifying athletes
• Estimated $80,000 to find one case
LOWERING RISK IN THE YOUNG ATHLETE
• Pre participation Exam• Parental involvement in children and adolescents• Coaches/trainer/athlete awareness• Symptom awareness• Workout/practice design• Hydration/electrolyte replacement• AEDs in close proximity when feasible and AED training• CPR training of coaches/trainers/athletes
Take Home Messages EVERYBODY SHOULD EXERCISE
EXERCISE CARRIES A SMALL RISK OF A CARDIAC
EVENT THAT IS “AGE” SPECIFIC
GET APPROPRIATE “SCREENING”
DON’T IGNORE SYMPTOMS. THERE IS NO
LIFETIME WARRANTY FROM A SINGLE SCREENING
Take Home Messages
Arrhythmias are very common in athletes.
Those associated with structurally normal hearts are
benign and should not cause disqualification.
Those with heart disease can cause serious or
catastrophic effects.
Take Home Messages The commonest diseases associated with life
threatening arrhythmias in the young are HOCM and
congenital coronary anomalies.
The commonest disease associated with life
threatening arrhythmias in the older athletes is
premature ischemic heart disease.
Screening of persons going into competitive games
is difficult but essential.
