Sanjay Sharma - Sudden cardiac death in endurance
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Transcript of Sanjay Sharma - Sudden cardiac death in endurance
Sudden Cardiac Death in Endurance Sports
Professor Sanjay Sharma
Disclosures: None
ObjectivesObjectives
• To provide information about the incidence and causes of sudden death in sport from current literature.
• To present death rates in the marathon and triathlon.To present death rates in the marathon and triathlon.
T t d il bl i f ti f dd d th• To study available information on cause of sudden death in triathletes
• To discuss potential screening strategies in endurance athletes.
Sudden Death in Athletes
• Incidence approximately 1/25 000‐1/100 000
Sudden Death in Athletes
• Incidence approximately 1/25,000‐1/100,000
( )• More common in males than females (9:1)
• Over 80% of victims do not exhibit any warning symptomsy p
• 80% deaths are due to an underlying cardiac disorder• 80% deaths are due to an underlying cardiac disorder
• 90% deaths during or immediately after exertion
Background: Causes of SCD in Sportg p
2.5
1.5
2
2.5
SD/100 000
0
0.5
1 SD/100,000 person yrs
0Athletes Non‐
athletes
Potential triggers for Sudden Death
Dehydration Adrenergic surgessurges
Electrolyte Acid/baseyimbalance
Acid/base disturbance
Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy
Deaths in Individuals with Structurally Normal Hearts: The British Experience
UK SCD, n=118, age range 7-59 yr
Hearts: The British Experience
A
atheroma2% myocarditis
3%
valve2%
other4%
normal23%
IF6%
ACA
5%
LVH
ARVC14% LVH
23%LVH w/ IF8%
HCM11%
14%
Electrical DisordersSCD With a Normal Heart
LQTS
Brugada
WPW
Sudden Cardiac Death During Mass
500 i h 1 illi i i
Participation Long Distance Running
500 races per year with up to 1 million participants
Triathlon
Mean Age of Sudden Death in Athletes
SPORT Age (years old)
g
_______________________________________________
Competitive soccer 23Competitive soccer 23
R ti l t 46Recreational sport 46
Marathon runner 42
Triathlete 44
Causes of Sudden Cardiac Death in Senior Athletes
5% 5% 5%5%
5%
CAD
SADSAD
MVP
Valves
80%
HCM
Cardiac Arrest During Long Distance Running
59 cardiac arrests
Kim J NEJM 2012
59 cardiac arrests0.54/100,000 1 in 184 0001 in 184,000
42 deaths (71%)1 in 259,00086% Male
Independent predictors of survival were by‐
Mean age 42 ± 13 yrs stander CPR and diagnosis other than
HCM Event rate increased in males in last half of
study to 2.03/100,000
Cause of Death in Long Distance Running Eventsg g
Kim J NEJM 2012
Cardiac Arrest in the London Marathon
1981‐2012 (32 Year Experience)1981 2012 (32 Year Experience)
802 000 Finishers802,000 Finishers
14 Cardiac Arrests. Mean age 49
8 Deaths (57%)
SCA rate = 1.74/100,000 (1 in 57,000)Cardiac death rate = 1/100 000Cardiac death rate = 1/100,000
Sudden Cardiac Arrest in the London M thMarathon
31
HCM
IHD
SADSSADS
10
Sudden Deaths in TriathlonSudden Deaths in Triathlon
2003‐2011. 23,000 Sanctioned events2003 2011. 23,000 Sanctioned events
> 3 million participants 3 million participants
43 Race related fatalities; Fatality rate 1 in 76,0003 ace e ated ata t es; ata ty ate 6,000
34 Male (80%) 9 Female (20%)( %) ( %)
Age range 24‐76 years old. Mean age 48 years oldg g y g y
70% of all deaths in swimming. g
dd h hlSudden Deaths in US Triathlon 2012
Possible Causes of Death During Swim
D i
Possible Causes of Death During Swim
• 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)
Cause of Sudden Death in the TriathlonHarris et al. Sudden Death During the Triathlon,JAMA,2010
959,214 participants in 2971 USA Triathlons (2006‐2008)(2006 2008)
14 participants died during 14 triathlons14 participants died during 14 triathlons
Rate 1 5 per 100 000 participants (95% CIRate= 1.5 per 100 000 participants (95% CI, 0.9‐2.5)
Mean age: 44 years
Cause of Sudden Death During Swimmingg gHarris et al. Sudden Death During the Triathlon,JAMA,2010
13 Deaths
• 7 of 9 athletes with autopsy had cardiovascular abnormalities
• 6 had left ventricular hypertrophy (wall thickness f 15 t 17 h t i ht f 403 )of 15 to 17mm, mean heart weight of 403 g)
1 h d it l t l• 1 had a congenital coronary artery anomaly
2 h d l h t• 2 had normal heart
Diagnosis
Clinical and family historyClinical and family history
Diagnosis
y y
Cardiac auscultation
y y
Cardiac auscultation
12‐lead ECG/SAECG12‐lead ECG/SAECGIdentify most conditions
Echocardiography/CMR
24 hour ECG
Echocardiography/CMR
24 hour ECG
conditions
24 hour ECG
Exercise stress test
24 hour ECG
Exercise stress test
Pharmacological provocation testsElectrophysiological tests
ManagementManagement
Life style modificationLife style modificationPharmacological therapyR di f bl iRadiofrequency ablationImplantation of ICDCardiac surgery
Arguments For and Against Screening
Goals of Major Sporting BodiesGoals of Major Sporting Bodies
• “The ultimate objective of the pre‐participation screening of athletes is the detection of ‘silent’ cardiovascular abnormalities that can lead to SCD.”
– ACC 36th Bethesda Conference, 2005
• “The main purpose of the consensus document is to• The main purpose of the consensus document is to reinforce the need for PPE medical clearance of all young athletes involved in organized sports programsyoung athletes involved in organized sports programs to prevent athletic field fatalities”
ESC C St t t 2005‐ ESC Consensus Statement, 2005
Screening Athletes
Condition 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
INCREASING COST
Young competitive athlete
Personal and family historyPhysical examinationPhysical examination12‐lead rest ECG
Negative findings Positive findings
Eligibility forcompetition
Further examination
No cardiovascular disease
Cardiovascular disease
competition examinationdisease
Management according
Cardiovascular disease
to established protocols
Role of ECGs in Diagnosis of CardiomyopathyRole of ECGs in Diagnosis of Cardiomyopathy
HCM ARVC95% 80%95% 80%
Screening Athletes: Impact on SCD
1979 2004
Screening Athletes: Impact on SCD
• 1979‐2004 • 42,386 athletes (12‐35 years)Hi i i d 12 l d ECG• History, examination and 12‐lead ECG
• Patient with abnormal findings investigated furtherC d d h i 1979 1982• Compared death rates pre‐screening 1979‐1982
early screening 1982‐1992l t i 1992 2004late screening 1992‐2004
• Death rates fell from 3.6/100,000/person years (pre‐screening to 0 4/100 000/person years followingscreening to 0.4/100,000/person years following screening
• Reduction in deaths mainly from cardiomyopathiesReduction in deaths mainly from cardiomyopathies
TIME‐TREND OF SUDDEN CARDIAC DEATH INCIDENCE IN ATHLETES VS NON‐ATHLETESATHLETES VS NON ATHLETES
Veneto Region of Italy 1979‐2002Veneto Region of Italy 1979 2002
ConcernsConcerns
Low incidence of sudden cardiac death
High number of false positives
Concerns relating to false negatives
Cost
Other issues
ConcernsConcerns
Low incidence of sudden cardiac death
High number of false positives
Concerns relating to false negatives
Cost
Other issues
Goals of Major Sporting BodiesGoals of Major Sporting Bodies
• “The ultimate objective of the pre‐participation screening of athletes is the detection of ‘silent’ cardiovascular abnormalities that can lead to SCD.”
– ACC 36th Bethesda Conference, 2005
• “The main purpose of the consensus document is to• The main purpose of the consensus document is to reinforce the need for PPE medical clearance of all young athletes involved in organized sports programsyoung athletes involved in organized sports programs to prevent athletic field fatalities”
ESC C St t t 2005‐ ESC Consensus Statement, 2005
Prevalence of Cardiovascular Disorders at Risk of SCD
Ref: Population Prevalence
AHA (2007) Competitive athletes (U.S.) 0.3%
Fuller (1997) 5 617 high school athletes (U S) 0 4%Fuller (1997) 5,617 high school athletes (U.S) 0.4%
Corrado (2006) 42,386 athletes age 12‐35 (Italy) 0.2%
Wilson (2008) 2,720 athletes /children age 10‐17 (U.K.) 0.3%
Bessem (2009) 428 athletes age 12‐35 (Netherlands) 0.7%Bessem (2009) 428 athletes age 12 35 (Netherlands) 0.7%
Baggish (2010) 510 collegiate athletes (U.S.) 0.6%
ConcernsConcerns
Low incidence of sudden cardiac death
High number of false positives
Concerns relating to false negatives
Cost
Other issues
Athlete’s Heart
ELECTRICAL STRUCTURAL
Athlete s Heart
ELECTRICAL STRUCTURAL
Bradycardia Increased Bradycardia
Repolarisation anomalies
c easedchamber wall thickness and
cavity size
Voltage criteria for chamber
cavity size
FUNCTIONAL
enlargement
FUNCTIONAL
Enhanced diastolic filling
Augmentation of stroke volumeAugmentation of stroke volume
Results of athletes screened in Veneto 1979‐2004‐C d JAMA 2006Corrado; JAMA 2006
Athletes screened: 42,386
Abnormal ECG: 3,914 (9%)False
Cardiac disorder: 879 (2%)
ll d l f d
Positive
7%All disqualified
7%
Potentially lethal disorder: 91 (0.2%)
The Challengeg
Physiology PathologyPhysiology Pathology
Left Ventricular HypertrophyR l i ti liRepolarisation anomalies
Diagnosis
Clinical and family history Familial
g
Cardiac auscultation Relatively rare
Heterogeneous phenotypic
12-lead ECGmanifestations
Symptoms of disease usually absentEchocardiography
24 hour ECG
absent
ECG overlap with athlete’s heart
Exercise stress testheart
Natural history not fully understood in all disorders
Pharmacological testsEvaluation in an expert setting is important
Pharmacological testsElectrophysiological tests
ConcernsConcerns
Low incidence of sudden cardiac death
High number of false positives
Concerns relating to false negatives
Cost
Other issues
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; NEJM 1988
Years in Veneto 1979-1996 – Corrado; NEJM 1988
CONDITION ATHLETES NON‐ATHLETES TOTALN = 49 N = 220 N = 269
CAD 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)
Active senior
High intensity exercise
Assessment by a physicianAssessment by a physicianH/E/Risk SCORE/ECG
P itiNegative Positive
Can compete Maximal ETT
Deaths Despite Screening with ECGp g
Success Rates for Defibrillation in Young AthletesAthletes
Author Study Survival____________________________________________Maron Commotio cordis 16%
Drezner Survival trends 4‐21%
Drezner Schools with AED 64%
Kim Marathon runners 29%
L d M th 43%London Marathon 43%
Marion Gen Pop 10 75 16%Marion Gen Pop 10‐75 16%
ConcernsConcerns
Low incidence of sudden cardiac death
High number of false postives
Concerns relating to false negatives
Cost
Other issues
REAL ISSUES
Low incidence of sudden death ? COST EFFECTIVELow incidence of sudden death ? COST EFFECTIVE Low prevalence of conditions causing SCD
H t di d ith EXPERT INPUTHeterogeneous disorders with EXPERT INPUT broad phenotypic manifestations
ECG overlap with physiological FALSE POSITIVES adaptation
Disease manifestation may relate FALSE NEGATIVES to age
Diseases such as CAA and CAD FALSE NEGATIVES not identifiable with ECG alone
Problems with risk stratification CANNOT PREDICT RISK
Prospect of litigation
Conclusions
1. Sudden cardiac death in endurance sports is rare.
1. Preliminary observations suggest a higher death rate in the triathlon compared to the marathon.ate t e t at o co pa ed to t e a at o .
2. Most triathlon deaths occur during swimming for hi h h l i l l iwhich there are several potential explanations.
3. Screening with ECG will detect electrical faults and gcardiomyopathies but will fail to identify most coronary artery abnormalities/disease.y y /
4. Screening of athletes MUST take place in an EXPERT ttiEXPERT setting.
Harris et al. Sudden Death During the Triathlon, JAMA, 2010
Swimming Induced PulmonaryEdema (SIPE)
• Acute pulmonary oedema and haemoptysis occurring in swimmers or divers.
W ll k t i ll i h (d t hi h– Well‐known event in galloping race horses (due to high pulmonary vascular pressure).
Also reported in cyclists marathoners and rugby players– Also reported in cyclists, marathoners and rugby players, but much less common.
• Symptoms: haemoptysis (pink frothy sputum) cough SOBSymptoms: haemoptysis (pink frothy sputum), cough, SOB, wheezing, CP
• Seawater aspiration wouldn’t do all this.Seawater aspiration wouldn t do all this.
• Over‐hydration thought to contribute.
SIPE Pathophysiologyp y gy
• Effects of water immersion:– Cold water causes vasoconstriction and increase in both preload and
afterload in heartafterload in heart.
– Cold water results in decreased core temp and shifts blood from peripheral to thoracic vessels.
– Causes central blood pooling which increases heart preload and pulmonary artery pressure.
– These dramatic increases in pulmonary artery pressure damages alveolar capillary membrane and lead to pulmonary oedema.
Cause of Death in Long Distance Running Eventsg g
Kim J NEJM 2012
Efficacy of Italian ECG Programme for Excluding HCM
Athletes cleared at
Excluding HCMNEGATIVE
4450Athletes cleared at national screening PREDICTIVE
VALUE 99.8%
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%)