Sudden death in young athletes

1
Sudden death in young athletes

• Rare event - actual rate uncertain
• USA - retrospective analysis in High School and
  College athletes less than 1 100 000
  participants per year
• Italy incidence 3 100 000 athletes less than
  35 years
• Male/female ratio - 2-10 1
• Men-higher prevalence of cardiac disease at the
  age12 - 35 years (probably phenotypic expression)
• Men-higher participation rate in competitive
  sports (football, basketball, ice-hockey)

2
Causes of sudden death in athletes less than 35
years

• Nonpenetrating strike to the chest wall
• Commotio cordis (trigger of abrupt ventricular
  fibrillation in interval 15-30
  ms before T-wave peak on ECG)
• Competitive sports increase likelihood of cardiac
  arrest
• Most fatalities-in basketball, football,
  ice-hockey (USA), soccer, ice hockey (Europe)
• Italy - young adults involved in sports - 25-fold
  greater risk of sudden death than their
  non-athletic counterparts

3
Causes of sudden death in athletes less than 35
years

• Hypertrophic cardiomyopathy - more than 1/3 of
  cases
• Cardiac congenital anomalies
• arrhytmogenic right ventricle cardiomyopathy
• premature atherosclerotic coronary artery disease
• dilated cardiomyopathy
• mitral valve prolaps
• conduction system diseases -
  
  WPW-syndrome, prolonged QT - interval,
  Brugada syndrome, Lenégre disease, A-V block,
  sudden unexplained nocturnal death syndrome
  (SUNDS)
• aortic rupture (bicuspid aortic valve, Marfan
  syndrome)

4
Causes of sudden death in athletes less than 35
years

• Non-cardiac
• exercise induced bronchoconstriction-BHR
• cerebral aneurysma rupture
• use of performance - enhancing drugs (deleterious
  health problems-heart attacks)
• vigorous exercise (sudden death due to to
  undiagnosed heart disease)
• London marathon runners 650 000 completed runs
  - 5 deaths, 6 resuscitations
  1 death per 80 000 runners

5
Extreme sport activities

• decrease of heart function and its fatigue
• Ashley - echocardiographic evaluation before and
  after a 480 km competition (running, swimming,
  bicycling) - lasting about 90 hours - 13
  decrease of cardiac contractility

6
Assessment of the risk for sudden death
in young poeple in competitive sports
AHA-1996, ESC-2005 Consensus Guidelanes

• Family history
  
  of sudden death, heart disease before 50 years,
  cardiomyopathy, arrhythmias, Marfan syndrome
• Athletes medical history
  chest pain,
  palpitations, syncope, tachycardia, dyspnoea,
  fatigue, heart murmur, hypertension
• Physical examination
  heart
  murmurs, arrhythmias, femoral artery puls
  (coarctation of aorta), Marfan syndrome

7

• Italy - addition of 12-lead ECG-identification of
  up to 60 of the potential lethal condition of
  sudden death
• All investigations - marginal use in detecting
  heart disorders and preventing fatalities
• Echocardiography tissue Doppler
  echocardiography differentiation pathologic
  from adaptational changes of the heart muscle
• In 2 - 5 of sudden cardiac deaths cases - no
  definitive cause even after autopsy detected

8
Guidelines for management of athletes
with identified cardiovascular disease
are available

• withdrawal of competitive sport activities
  -
  reduced risk of sudden death
• suggestion to the type and degree of sport
  activity that can be done
  safely

9
Examples of sudden death in young athletes

• Pheidipphides (490 BC)
• A greek soldier and conditioned runner,
  Pheidippides ran from Marathon to Athens to
  announce military victory over Persia. He
  delivered his message, then collapsed and died.

• Flo Hyman (1986)
• Flo Hyman was captain of the 1984 US Womens
  Olympic volleyball team that won silver. She died
  aged 30 years of congenital heart disorder
  Marfans syndrome while playing a Japanese league
  game.

• Daniel Yorath (1992)
• A 15-year-old football player who had just been
  signed by the UK team Leeds United, Daniel Yorath
  died from hypertrophic cardiomyopathy while
  playing football with his father in the garden.

10
Examples of sudden death in young athletes

• Reggie Lewis (1993)
• Boston Celtics star and sixth captain Reggie
  Lewis was 27 year old when he died while shooting
  baskets at an off-seasons practice.

• Sergei Grinkov (1995)
• An Olympic gold medal skater, Sergei Grinkov
  collapsed
  and died from a heart attack at age 28 years
  while training at an ice rink in Lake Placid, NY,
  USA. An autopsy showed that he had arteries
  of a 70-year-old man, though had
  never mentioned any chest pain.

11
Case report

• History
• 16 years old athlete-attacks of tachycardia
  (220/min) during long distance running -
  faintness, disappearing immediately after
  stopping exercise
• Physical examination
• Signs of anemia on oral mucosa, lips,
  conjunctives
• Systolic murmur 3/6 in praecordium, irradiating
  into carotides
• Ergometry Rest Exercise
• HR 97/min 240/min
• BP 145/110 mmHg 200/110 mmHg

12
Klidové EKG tachykardie, jinak normální nález
13
Pri výkonu 90 W se zacaly objevovat ojedinelé
SVES.
14
Jejich pocet se v první minute výkonu 150 W
zvetil.
15
Ve 2. minute výkonu 150 W vznikl náhle záchvat SV
tachykardie (s frekvencí 240 tepu/min) a
vyetrovaný zacal pocitovat mdlobu.
16
V dobe uklidnování SV tachykardie opet náhle
vymizela.
17
Ve 3. minute uklidnování ji vidíme sinusový
rytmus s výraznou dechovou arytmií.
18

• Laboratory results
  HB-79
  g/l Htc 0.25 Ery - 4,01 FW - 25/34
• Cardiologic evaluation
  Echocardiography -
  hypertrophy and dilatation of left ventricle, a
  mild decrease of ejection fraction of left
  ventricle, interventricular septum thickeness at
  high normal limit
  (1.1 cm)
  
  Right and left heart catheterisation - normal
  pressure, normal flow values, no gradient even
  after Isuprel application
• Treatment
  
  Ferronat p.os, no exercise until next control
  examination will be done

19

• Follow up
  
  3 weeks after medical examination
  while playing football sudden syncope,
  resuscitation, defibrillation, sudden death.
• Autopsy finding - Hypertrophic cardiomyopathy
  -interventricular septum thickeness -18 mm,
• A thickenning of posterior left ventricle wall
  3 x 3 cm.

20
Výsledek pitvy mezikomorové septum 18 mm, na
zadní stene LK je ztlutení 3x3 cm, histologický
nález odpovídá hypertrofické kardiomyopatii.