SUDDEN CARDIAC DEATHS IN YOUNG ATHLETES

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SUDDEN CARDIAC DEATHS IN YOUNG ATHLETES

• Anjan Gupta M.D.
• Department of
• Cardiology
• Sinai Samaritan Med
• Center
• Milwaukee, Wisconsin.
• anjangupta_at_pol.net

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SUDDEN CARDIAC DEATH IN YOUNG ATHLETES

• A competitive athlete
• is one who participates
• in an organized team
• or individual sport that
• requires regular
• competition against
• others and requires
• vigorous training

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DEMOGRAPHICS

• Sudden cardiac death occurs most frequently
  during basketball and football
• Majority of deaths occur in men
• Most athletes are of high school age at the time
  of death
• Majority of the athletes who incur sudden death
  have been free of cardiovascular symptoms

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DEMOGRAPHICS

• Collapse is usually associated with intense
  physical exertion and most commonly occur in the
  afternoon and early evening hours
• Cardiovascular disease is usually unsuspected
  during life in these individuals and is rarely
  identified by preparticipation screening

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Cardiovascular causes of sudden cardiac deaths in
young competitive athletes
Maron et al, Cardiology Clinics 1996 14 196
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Noncardiovascular causes of death
Maron BJ et al, JAMA 1996 276 199 - 203
7
Annual incidence of sudden death among recruits
during military basic training
Kark et al, NEJM 1987 317 781 - 786
8
Risk for sudden cardiac death associated with
marathon running
Maron et al , JACC 1996 28 428 - 431
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Comparison of sports related and non-sports
related deaths
Burke et al, Am Hrt Jnl 1991 121 568-575
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Sports engaged in at the time of sudden death
Maron BJ et al, JAMA 1996 276 199 - 203
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Hourly distribution of sudden death
AM PM
Maron BJ et al, JAMA 1996 276 199 - 203
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Effect of race on cardiovascular causes of sudden
death
Maron BJ et al, JAMA 1996 276 199 - 203
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Participation in competitive and recreational
sports at the time of sudden cardiac death
Maron et al, NEJM , 1995 333 337 - 381
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Cardiovascular abnormalities detected
Primary Cardiovascular lesion No of
athletes Median age
HCM
48 (36) 17 (13 -
28) Possible HCM
14 (10) 17 (14 -
24) Aberrant coronary arteries
17 (13) 15 (12 - 23) Other
coronary anomalies 8
(6) 17.5 (14 - 40) Ruptured aortic
aneursyms 6 (5)
17 (16 - 31) Tunneled LAD
6 (5) 17.5
(14 - 20) Aortic stenosis
5 (4) 14 (14 -
17) Myocarditis
4 (3) 15.5 (13 -
16) Idiopathic dilated cardiomyopathy
4 (3) 18 (18 - 21) ARVD

4 (3) 16 (15 - 17) Idiopathic
myocardial scarring 4 (3)
20 (14 - 27) MVP
3 (2)
16 (15 - 23) Atherosclerotic CAD
3 (2)
19 (14 - 28)
Maron BJ et al, JAMA 1996 276 199 - 203
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Cardiovascular Abnormalities detected ( cont )
Primary Cardiovascular lesion No of athletes
Median age
Other cong heart disease 2
(1.5) 13.5 (12 - 15) Long QT syndrome
1 (0.5)
Sarcoidosis
1 (0.5) Sickle cell trait
1 (0.5) Normal
Heart 3 (2)
18 (16 - 21)
Maron BJ et al, JAMA 1996 276 199 - 203
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HYPERTROPHIC CARDIOMYOPATHY

• Competitive athletes dying suddenly of HCM
  usually are of 13 - 30 yrs of age
• LV wall thickening is usually asymmetric with
  distorted cellular architecture and abnormal
  intramural coronary arteries
• Death usually occurs without any premonitory
  symptoms and during moderate to severe exertion

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HYPERTROPHIC CARDIOMYOPATHY

• MECHANISMS OF SUDDEN DEATH
• Malignant ventricular arrhythmia
• Sudden hemodynamic instability involving increase
  in LVOT obstruction, exercise induced systemic
  hypotension, or bradyarrythmias

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Prevalence of severe and mild LVH in patients
with SCD and in surviving controls
Spirito et al, JACC 1990 15 1521 - 1526
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Symptomatic status at the time of sudden death in
a hospital-based population of patients with HCM
Maron BJ et al, Circulation 1982 65 1118
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Activity level at the time of death in a
hospital-based population of patients with HCM
Maron BJ et al, Circulation 1982 65 1118
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CONGENITAL CORONARY ARTERY ANOMALIES

• Most common is origin of LMCA from right sinus of
  valsalva
• 75 of the patients with this malformation die
  suddenly before the age of 20 and death occurs
  during or shortly after vigorous exertion
• A large proportion of these individuals may
  experience syncope or angina

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CONGENITAL CORONARY ARTERY ANOMALIES

• MECHANISMS OF CAUSING SCD
• Acute take-off angle of LMCA creates a slit-like
  narrowing of coronary ostium
• With increased stroke volume during exercise
  ascending aorta expands and the take-off angle is
  further exaggerated
• LMCA may also be compressed against root of
  pulmonary trunk during exercise

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CONGENITAL CORONARY ARTERY ANOMALIES

• OTHER CONGENITAL ANOMALIES OF
• CORONARY ARTERIES
• Hypoplasia of portions of coronary tree
• Origin of LAD from pulmonary trunk
• Intussuception and occlusion of coronary arterial
  lumen

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TUNNELED CORONARY ARTERY

• Myocardial bridges or tunneled coronary arteries
  may cause SCD
• Probably are subjected to critical degree of
  systolic compression resulting in myocardial
  ischemia
• In one series about 5 of athletic-field death
  victims have been found to have tunneled coronary
  arteries

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Nonatherosclerotic narrowing of the
atrioventricular node artery and sudden
deathHistologic findings
Control grp SCD grp ( n
17 ) ( n 27 )
Fibrointimal proliferation Absent
6
6 Present
7
3 Present with
destruction of 3
6 Internal Elastic
lamina (IEL) Present with destruction of
1
12 IEL and acid mucopoly-
saccharide deposition
p 0.02, p 0.006
Burke et al , JACC 1993 21 117 - 122
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AORTIC RUPTURE (Marfan Syndrome)

• Dissection and rupture of the aorta with or
  without cardiac tamponade
• Some of the individuals may have classic physical
  stigmata of Marfan syndrome
• Usually evident in necropsy is disruption of
  aortic media with cystic medial necrosis

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MYOCARDITIS

• Traditionally has been considered a cause of
  sudden unexplained deaths in young individuals
• Definitive diagnosis may be difficult at necropsy
• Usually triggered by viral infections or may also
  be the result of chronic cocaine abuse

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MITRAL VALVE PROLAPSE

• Not an important cause of SCD
• To date less than 100 individuals with MVP have
  been reported with SCD (average age of 35 yrs)
• Such deaths are uncommonly related to physical
  exertion or sporting activities and very few
  occurred in competitive athletes

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AORTIC VALVE STENOSIS

• Previously considered a common cause of sudden
  death in asymptomatic children and young adults
• However this lesion is likely to be identified
  early in life because of clinical findings
  leading to disqualification from the competitive
  athletic arena

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ARRYTHMOGENIC RIGHT VENTRICULAR DYSPLASIA

• Characterized morphologically by segmental or
  widespread fatty-fibrous replacement of myocytes
  in the right ventricular free wall
• Associated with recurrent or intractable
  ventricular or supraventricular arrythmias
• Familial occurrence

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ARRYTHMOGENIC RIGHT VENTRICULAR DYSPLASIA

• MRI appears to be more reliable than echo in
  noninvasive diagnosis
• T- wave inversions in V1 and V2 and isolated PVC
  s are common as well as LBBB morphology
• Most common cause of death of young trained
  athletes in Italy primarily in those involved in
  soccer competition

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CONDUCTION SYSTEM ABNORMALITIES

• Accessory atrioventricular pathways
• Morphological abnormalities of the small
  intramural artery to the sinoatrial node
• Abnormalities of the AV node

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ATHEROSCLEROTIC CORONARY ARTERY DISEASE

• Occasionally responsible for sudden deaths in
  young athletes
• Patients usually have history of exertional
  angina prior to episode of sudden cardiac death
• Patients may have other risk factors or a strong
  family history

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NORMAL HEARTS

• Drug abuse
• Wolff - Parkinson - White Syndrome
• Long QT syndrome
• Exercise induced coronary spasm
• Undetected right ventricular dysplasia

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COMMOTIO CORDIS

• Blunt chest impact produced either by a missile
  or by collision
• Probably induces lethal cardiac arrhythmia and
  instantaneous collapse
• Induction of PVC results from the blunt impact
  which may result in the fatal arrhythmia