In The News

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In The News

• Sudden Cardiac Death in Athletes

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SCD in the Athlete Overview

• What is it?
• Who does it affect?
• How prevalent is it?
• How is it prevented?

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SCD in the Athlete What is it?

• Sudden cardiac death (SCD)
• Sudden, unexpected death caused by loss of heart
  function (sudden cardiac arrest)
• The  largest cause of natural death in the United
  States, causing about 325,000 adult deaths each
  year

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SCD in the Athlete What is it?

• Sudden cardiac death (SCD) (cont.)
• In athletes less than 35 years of age, congenital
  cardiovascular disease is usually responsible
• Typically occurs during or shortly after training
  or competition, suggesting intense physical
  exertion is a precipitating factor
• Recently, the list of recognized cardiovascular
  risks during athletic competition has been
  expanded to include cardiac arrest resulting from
  blunt trauma to the chest wall in the absence of
  underlying cardiovascular disease

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SCD in the Athlete What is it?

• Most common causes
• Hypertrophic cardiomyopathy
• Idiopathic left ventricular hypertrophy
• Congenital coronary artery anomalies

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SCD in the Athlete What is it?

• Less common causes
• Ruptured aortic aneurysm
• Myocarditis
• Dilated cardiomyopathy
• Arrhythmogenic right ventricular dysplasia
• Aortic valve stenosis
• Tunneled left anterior descending coronary artery
• Atherosclerotic coronary artery disease

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SCD in the Athlete What is it?

• Rare causes
• Wolff-Parkinson-White syndrome
• Long QT syndrome
• Mitral valve prolapse
• Commotio cordis
• Drugs
• Unknown/other

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Multiple CausesSame Result
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SCD in the Athlete What is it?

• Sudden cardiac death (SCD) (cont.)
• Earliest documented case occurred in 490 BC, when
  Pheidippides, a Greek soldier and conditioned
  runner, ran from Marathon to Athens to announce
  military victory over Persia, only to deliver his
  message, then collapse and die

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SCD in the Athlete Who does it affect?

• The athlete
• One who participates in an organized team or
  individual sport requiring systematic training
  and regular competition against others while
  placing a high premium on athletic excellence.
• Maron et al. Circulation 199694850-867.

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SCD in the Athlete Who does it affect?

• 25 million children and young adults play sports
• 4,000,000 high school (grades 9-12) athletes
• 500,000 college athletes
• 5000 professional athletes
• Maron suggests that as many as 1 in 500 of all
  Americans has Hypertrophic Cardiomyopathy

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A Rare, But Tragic Event

• Prevalence of athletic deaths
• High school athletes 1 in 300,000
• Older athletes 1 in 15,000 healthy male joggers
• In runners, 1 fatality for every 1 million hours
  of exercise

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U.S. Vital Statistics

• Causes Deaths per year
• Accidents 13,966 700x
• Homicide 8,424 421x
• Suicide 4,849 242x
• Cancer 1,738 87x
• Congenital Heart Dz 981 49x
• HIV 609 30x
• SCD in the athlete 15-25

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SCD in the Athlete How is it Prevented?

• Primary Prevention of SCD (Screening)
• Secondary Prevention of SCD

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Screening

• American Heart Association Science Advisory and
  Coordinating Committee (1996)
• Screening history and physical examination on all
  athletes before participation in high school and
  collegiate sports
• For high school athletes, screening repeated
  every 2 years and an interim history should be
  obtained in the intervening years
• For college athletes, history and blood pressure
  measurement should be obtained each year after
  the initial evaluation

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Screening

• Standardized questionnaire is helpful in guiding
  examiner
• Cardiovascular history should include questions
  about prior exertional chest pain or discomfort,
  exertional light-headedness, dyspnea or fatigue
  disproportionate to the degree of exertion, and
  any history of palpitations or irregular heart
  beats

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Screening

• Previous detection of a heart murmur?
• Elevated blood pressure?
• Use of cocaine or other drugs?
• Family history of premature sudden death (before
  age 50) or cardiovascular disease?
• Related cardiovascular disease?

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Screening

• Purpose
• To provide medical clearance for participation in
  competitive sports
• Assumption
• Intense training will increase the risk of sudden
  cardiac death or disease progression in trained
  athletes
• Expected Outcome
• to reduce the risks associated with organized
  sports

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Cause of SCD of Elite Athletes

• Jim Fixx ASCVD
• Len Bias Cocaine
• Reggie Lewis Focal Myocarditis
• Flo Hyman Marfans/Aortic rupture
• Hank Gathers Hypertrophic Cardiomyop.
• Pete Maravich Hypoplastic Coronary Art.

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Screening

• Physicians physical exam
• Brachial blood pressure measurement in sitting
• Palpation of the femoral artery pulses
• Recognition of the physical stigmata of Marfan
  syndrome
• Precordial auscultation in both supine and
  standing positions in a quiet environment

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Screening

• Controversy surrounding testing
• American Heart Association does not recommend
  noninvasive diagnostic tests such as
  electrocardiography or echocardiography in the
  routine screening of asymptomatic athletes for
  cardiovascular disease
• Low incidence of disease and relatively high
  frequency of normal morphologic and ECG
  alterations occurring in athlete's heart poor
  specificity of electrocardiography and
  echocardiography in correctly diagnosing
  cardiovascular disease
• Number of false-positive results, which would
  very likely exceed the number of true-positive
  results, would lead to the unnecessary
  disqualification of athletes

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Screening

• Controversy surrounding testing
• Screening echocardiography is costly
• Example Taking the prevalence of hypertrophic
  cardiomyopathy in the general US population as 1
  per 500 and the cost of an echocardiogram as 500
  per study, it would cost an estimated 250,000 to
  detect just one previously undiagnosed case of
  hypertrophic cardiomyopathy

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AHA Recommendations

• Careful, detailed history and physical exam every
  2 years by qualified care providers
• Intervening years, obtain an interim history

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AHA Recommendations

• Selectively perform exercise tolerance testing in
  men (gt40 yo) and women (gt50 yo) having a high
  risk for coronary artery disease who wish to
  begin regular physical training
• Develop a national standard for pre-participation
  medical evaluation

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Glover, Maron BJ. JAMA 19982791817-1819.
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Cummins RO et al. Circulation 1991831832-1847.
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Summary

• Sudden cardiac death (SCD) in the athlete is rare
• Identifying individuals at risk for SCD (i.e.,
  primary prevention) is very difficult
• Guidelines for individuals with known
  cardiovascular disease (i.e., secondary
  prevention) have been published

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Summary

• A detailed history and physical exam should be
  performed on all athletes
• Noninvasive testing should be used selectively