update on sudden cardiac death in athletes and young generation

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  • Updates on Sudden Cardiac Death in Athletes and Young GenerationDR. TAMER TAHA ISMAIL TAHA CLINICAL ASSOCIATE PROFESSOR AND SPECIALIST DEPARTMENT OF CARDIOLOGY THUMBAY HOSPITAL _DUBAI

  • EXERCISE IS GOOD

  • OutlineExercise : benefits and risk Athletes HeartEtiology of SCD in young athletes Etiology of SCD in old athletes Screening and Pre participation examination Lowering the risk of SCD

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  • DEFINITIONS FOR THIS TALKEXERCISE: Any form of physical activity, done on a regular basis, with the purpose of achieving a specific goal

    Low level to vigorousRecreational (including play) to competativeATHLETE: Anyone who is exercisingYOUNG ATHLETE: Less than 35 years oldADULT ATHLETE: Greater than 35 years old

  • BENEFITS OF EXERCISEDISEASE PREVENTIONCardiovascularDiabetesOsteoporosis, joint healthFITNESSWEIGHT CONTROLENJOYMENTPersonal GoalsCompetition

  • COULD exercise CAUSE ANY CARDIOVASCULAR HARM?ANSWER: YESTHE RISK IS SMALLTHE CONSEQUENCES ARE SIGNIFICANTWHAT THE RISK IS AND WHAT CONDITIONS ARE RESPONSIBLE FOR THE RISK VARY BY AGE

  • DETERMINANTS OF EXERCISE RISK Probability of Cardiac Disease Intensity and Duration of ExerciseRISK INCREASES WITH INCREASED RISK OF UNDERLYING CVD, INTENSITY, DURATION OF EXERCISE

  • MEASURING INTENSITYThe Metabolic Equivalent or METis aphysiologicalmeasure expressing the energy cost ofphysical activitiesand is defined as the ratio of metabolic rate during a specific physical activity to a reference metabolic rate3.5 ml O2/kg/min

  • METSitting.1.0Walking at 2.5 m/h2.9Biking at 10 m/h.4.0Elliptical5.5Jogging.7.0Swimming (moderate)..8.0 Swimming (hard).12.0Running 8 min mile12.5Bike Racing (not drafting) > 20m/h.16.0

  • EXERCISE INTENSITYLight Daily activities, gentle walk< 3 METsModerateBrisk walk, easy jog or bike < 6 METsVigorous/IntenseRunning, Biking, High Intensity Interval, Boot CampRPE 7 10, METs > 6

  • EXERCISE DURATIONDehydrationElectrolyte changesIncreased inflammationHyperthermia

    Most cardiac events during marathonsoccur past the 22.5 mile marker

  • RECOMMENDED DURATION(health and fitness goal)American Heart Association150 min/week of moderate exercise 75 min/week of vigorous exerciseOK to break it up

  • Gangasani, S. R. et al. Chest 2000;118:249-252Physiologic 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/yearApproximately 1 CVD death/100,000/yearAll the conditions that might harm athletes are just as prevalent in non-athletes. Athletes are at higher risk.

  • THE YOUNG ATHLETEA SAMPLING OF THE CAUSESStructural Heart Disease

    Hypertrophic Cardiomyopathy Anomalous Origin of the Coronary ArteriesArrhythmogenic Right Ventricular CardiomyopathyMyocarditis/CardiomyopathyValvular DiseaseThe ChannelopathiesDrugs

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  • THE ADULT ATHLETEHarder to define the numbers and riskHeart disease is common among adultsExercise programs varyNo organized reporting programMarathoners:
  • THE ADULT ATHLETEA SAMPLING OF THE CAUSES

    Coronary Artery DiseaseValvular Heart DiseaseCardiomyopathyYoung Athlete Disease

  • THE YOUNG ATHLETESPECIFIC EXAMPLES

  • HANK GATHERS1967 - 1990

  • Fabrice Muamba 1988-2012

  • HYPERTROPHIC CARDIOMYOPATHY

  • HYPERTROPHIC CARDIOMYOPATHYAffects 1 in 500 individualsGenetically determinedSporadic or inheritedAt least 11 genes, 1400 mutationsAccounts for 35 40% of athletic deathsCan be symptomatic/detectable before SCAIncreased risk with ageVentricular arrhythmia is primary cause of death

  • Risk Factors for Sudden Death in HOCMMajorOut of hosp arrest or VTFH sudden death and HOCMMinorNSVT on HolterDrop in BP on TMETThallium perfusion defectsYoung maleHistory of syncopeSeptal thickness

  • ANOMALOUS ORIGIN OF THE CORONARY ARTERIES

  • ANOMALOUS ORIGIN OF THE CORONARY ARTERIESAccounts for 15 20% of sudden death in young athletesCan be symptomatic (< 50%)Chest discomfortShortness of breathPalpitationsFaintingTreatment: Medical or SurgicalMay be cleared to participate if corrected

  • ARRYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY

  • ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHYPrevalence: 1/1000 2000Genetic, 30% inherited.Accounts for 5% of sudden death in young athletesCan be symptomatic: palpitations, faintingTreatment: medical, ICDDisqualified from competitive sports

  • MYOCARDITIS/CARDIOMYOPATHY

  • MYOCARDITIS/CARDIOMYOPATHYAccounts for 5 -10% of sudden cardiac arrests in young athletesCauses: viral, inherited/genetic, idiopathicCan be symptomatic: shortness of breath, palpitations, fatigue/weakness, fainting, chest discomfortDisqualified from most competitive sports. May return if recover.

  • COMMOTIO CORDIS

    Vulnerable momentHigh force, specific areaBaseball, hockey, karateKids more vulnerable20% survivalBoys > girls

  • Ephedrine and its analoguesAnabolic steroidsGama hydroxybutyrateCocain Illicit Drugs Used By Athletes During Competitive Sports

  • INHERITED ARRHYTHMIAand SUDDEN CARDIAC ARRESTTHE CHANNELOPATHIES

  • WHAT IS A CHANNEL?

  • THE CHANNELOPATHIES AND SUDDEN CARDIAC ARREST

    Long QT SyndromeBrugada SyndromeCatecholaminergic Polymorphic Ventricular TachycardiaShort QT syndrome

  • THE CHANNELOPATHIES: LONG QTNot rare: 3000 4000 deaths/y in children/adolescentsInherited/genetic12 types/genes, hundreds of different mutationsVariable lethalityAR associated with deafnessVariable expressionAcquired formMedications/drugsElectrolyte changesIncreased risk of SCA with exercise, risk variable based on typeSCA in athletes: not rare, numbers not clearECG + , gene +, symptom + : Disqualified from competitive sports

  • ACQUIRED LONG QTMedications: www.qtdrugs.org AntiarrhythmicsAntibiotics: Levaquin, Zithromax (Z pack), erythromycinAntidepressants: Tricyclics, Prozac, CelexaTamoxifendiuretics140 other drugsMethadoneCombinations of drugsElectrolytes: Low K+, Mg++, Ca++Genetic + Drugs, ? Unmasked congenital formReversible

  • THE CANNELOPATHIESBRUGADA SYNDROMEGeneticGenetic testing variableNa+ channel EKG variableProvocative testingMultiple typesMale > FemaleAvg age at DX: 41Fever/hyperthermia triggerNight time triggerTreatment: ICD, limited medicationsCaution advised for competitive sports with no history of eventsWith history of events or ICD low level sports only

  • THE CHANNELOPATHIES: CATECHOLAMINERGIC POLYMORPHIC VT

  • CPVTGenetic, at least 2 gene mutationsInheritedEmotional and physical triggers. Symptoms: dizziness and syncopeUsually presents in childhood and adolescenceTreatment: Medical therapy, ICD + medical, Sympathectomy, Medical therapy for gene + asymptomatic.Generally recommend against competitive sports, ICD precludes contact sports

  • OTHER ARRHYTHMIAWOLFF PARKINSON WHITE1/400Often Incidental findingCan present with symptomsOften first diagnosed in adulthoodRisk of V-fibrillationRisk stratify asymptomatic PtsAblationOK 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/year400,000 Sudden Cardiac DeathSudden Death: First symptom in 50%2 3 X as likely to suffer a cardiac event during exercise in those with disease

  • THE ADULT ATHLETEPrimary Cause: Coronary Artery DiseaseCardiomyopathyVascular DiseaseArrhythmiaValvular Heart Disease

  • THE ADULT ATHLETEThe 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-TRADITIONALCholesterol variants

    Lp(a)Particle sizeGeneticVascular physiology/metabolismInflammation

  • GLOBAL RISKTHE GREATER THE NUMBER OF RISK FACTORS, THE GREATER THE RISK

  • ISCHEMIA AND SCDDEMAND > SUPPLYISCHEMIA

    CHEST PAINSOBPERFORMANCENON-LETHAL ARRYTHMIA

    LETHAL ARRHYTHMIA

  • OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISEDILATED CARDIOMYOPATHYHYPERTROPHIC CARDIOMYOPATY

  • OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISEAORTIC DISSECTIONRisk Factors: ASCVD, especially hypertensionSporadic, associated with aneurysm, geneticSheer forceIncreased risk with high static component exercise

  • OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISEVALVULAR HEART DISEASEAortic stenosisAortic insufficiencyMitral Valve Prolapse

  • NONLETHAL ARRHYTHMIAATRIAL FIBRILLATIONSUPRAVENTRICULAR TACHYCARDIA

  • EXERCISE AND NONLETHAL ARRHYTHMIAEuropean Heart Journal 201452,000 players Mean age: 38Twice the risk of non-athletesHigher risk with faster timesMechanism: ? inflammation

  • SCREENING GOALTo 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

  • Athletes HeartIsometric sporting activities cause structural remodeling and increase in cardiac mass (physiologic hypertrophy).Increased volume of ventricular chambersIncreased size of L atrium and L ventricular wall thicknessHowever, systolic/diastolic functions is maintainedOccurs in M>F with size related to lean body mass.May be 2ry to geneticsThe amount of exercised-induced LVH in endurance athletes associated with ACE genotype.

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  • Athletes HeartECGsFindings in Athletes considered WNLSinus Bradycardia as low as 30-40 bpmVarious A/V blocks occur in up to 33% of athletesFirst Degree (PR>0.2) Most CommonSecond Degree (Mobitz-1 or Wenkeback) Increased R or S wave voltage without Left axis deviation, QRS prolongation, or LAEU-waves with up-sloping ST segments and normal T wavesIncomplete RBBB

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  • SCREENING YOUNG ATHLETESRecommendations vary widely internationally.Recommendations vary widely based on level of participationNot clear if definitely reduces riskFindings variable with timeVariable age of onsetThese are relatively rare diseasesNeeds to be done regularly until adult age

  • THE PREPARTICIPATION EXAMReview for symptoms

    Dizziness or fainting, shortness of breath, palpitations, chest discomfort, cant keep upFamily History

    Premature deathDeath under unusual circumstancesPhysical exam

    Murmurs, build, pulses

  • WHAT ABOUT ECGsNot recommended routinely in USRequired in EuropeControversialNot clear it helpsAthletes often have ECG changes that are normalFalse negatives, False positivesCost of ECGs, Cost of additional testing, Cost of disqualifying athletesEstimated $80,000 to find one case

  • LOWERING RISK IN THE YOUNG ATHLETEPre participation ExamParental involvement in children and adolescentsCoaches/trainer/athlete awarenessSymptom awarenessWorkout/practice designHydration/electrolyte replacementAEDs in close proximity when feasible and AED trainingCPR training of coaches/trainers/athletes

  • Take Home Messages EVERYBODY SHOULD EXERCISEEXERCISE CARRIES A SMALL RISK OF A CARDIAC EVENT THAT IS AGE SPECIFICGET APPROPRIATE SCREENINGDONT 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.

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