Sudden Cardiac Death in Young Athletes Yann Ping Pan, MD Ruey-Kang Chang, MD, MPH

What do they have in common? Hank Gathers (1967-1990) Reggie Lewis (1965-1993) Flo Hyman (1954-1986) Sergei Grinkov (1967-1995) Pete Maravich (1947-1988)

Athlete SCD– why is it important Family physicians see a lot of athletes for sports related issues Family physicians are involved in school health and pre-participation examinations It is important to know the clinical characteristics of SCD and identify athletes who are at risk It is important to know the current recommendations for pre-participation examinations

What do we know about SCD in Athletes? 12-15 million young (<30 years) competitive athletes in the US Estimated incidence of sudden cardiac death at 2.1 per 100 000 athletes per year Estimated 200 athletes in the US die per year of sudden cardiac death Sudden death of the young athletes is mostly unexpected, dramatic, tragic and carries huge emotional impact on the society

Epidemiology Based on Autopsy Series Sudden Cardiac Death of Athletes Epidemiology Based on Autopsy Series Age-- 9% in middle school 62% in high school 22% in college 7% in professional Sex—90% male, 10% female Caucasians at highest risk Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

Sports engaged in at the time of sudden death Sudden Cardiac Death of Athletes Sports engaged in at the time of sudden death Here are the sports, the most common ones are basketball and football, which probably does not reflect the nature of the sports, but the number of players in the sports Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

Causes of Sudden Cardiac Deaths in Young Athletes Sudden Cardiac Death of Athletes Causes of Sudden Cardiac Deaths in Young Athletes These are the underlying cardiac causes of SD of 1435 athletes found at autopsies– HCM is the most common, 36%, plus some LVH that could be HCM, followed by CA anomalies, together accounting for 2/3 cases. Then you have myocarditis, MVP and aortic rupture, which are seen in Marfan’s. Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

Research Questions What are the epidemiologic characteristics of athlete SCD from the an active surveillance, population-based sample? What are the major causes for athlete SCD from the an active surveillance, population-based sample?

Objectives To evaluate an active surveillance system of athlete SCD from a population-based sample using Google Internet search engine To compare the active surveillance of athlete SCD by Google with reported athlete SCD data using autopsy or passive report systems

Methods Advanced Google Internet search was conducted once a week (every Friday) from April 2007 to March 2008 Combinations of keywords were used– athlete, player, practice, game, collapse, pass out, die, gym class, etc. Only US athletes died in a game or practice or immediately after, occurred in the US Age 11 to 30 years, death between 4/07 to 3/08 Exclusions– known cardiac history, trauma, non-US athletes, died in sleep or at home, possible drugs or alcohol,

Methods First 200 Google search results are carefully examined For cases that fulfill inclusion criteria, the web pages are printed/saved All demographic data, history and circumstances (CPR, use of AED), are recorded and compiled for analysis Autopsy results are searched 1 month to 12 months later to determine the cause of death

Results Total of 74 athletes died in April 2007 to March 2008 in a game or during or after practice (comotio cordis are excluded) 25 athletes died in a game (34%), and 49 died in or after practice (66%)– consistent with the literature or 1:2 Most common sports are basketball and football– consistent with the literature

Results

F:M= 1:3 Female Male Sudden Cardiac Death of Athletes This is the data I collected, by googling athlete sudden death once a week for one year, collected 80 cases. Male to female ratio was 3:1, the age of female spread throughout, but none after 18. In male, you can see really rises in High school, but continues to age 30. Of the cases I collected, it seems AA are at high risk, which is also different from the literature.

Race and Ethnicity

Sports Associated with SCD Baseball Boxing Dancing Martial arts physical training Running video game Water ski World's strongest man competitor

Sudden Cardiac Death of Athletes Maron BJ et al, JAMA 1996 ; 276 : 199 - 203 These are the underlying cardiac causes of SD of 1435 athletes found at autopsies– HCM is the most common, 36%, plus some LVH that could be HCM, followed by CA anomalies, together accounting for 2/3 cases. Then you have myocarditis, MVP and aortic rupture, which are seen in Marfan’s.

Causes of SCD

Maron BJ et al, JAMA 1996 ; 276 : 199 - 203 These are the underlying cardiac causes of SD of 1435 athletes found at autopsies– HCM is the most common, 36%, plus some LVH that could be HCM, followed by CA anomalies, together accounting for 2/3 cases. Then you have myocarditis, MVP and aortic rupture, which are seen in Marfan’s.

Conclusion Excluding comotio cordis, there are 74 SCD of young athletes in the US in 2007-2008 1/3 SCD occurs in a game, 2/3 in practice Including gym class death, there are more females than previously described Blacks may be at higher risk, ore studies needed Basketball and football are common sports associated with SCD HOCM/LVH accounts for almost 50%, coronary anomaly and arrhythmia are next common causes

Sudden Cardiac Death of Athletes Circulation 2007;115;1643-1655

Endorsement of AHA Guidelines American Academy of Family Physicians American Academy of Pediatrics American College of Cardiology American College of Sports Medicine American Medical Society for Sports Medicine American Orthopaedic Society for Sports Medicine American Osteopathic Academy of Sports Medicine

European Guidelines for PPE In 2005, The European Society of Cardiology issued official recommendation for PPE, including 12-lead ECG

Coronary Artery Anomaly Sudden Cardiac Death of Athletes Coronary Artery Anomaly

Coronary Artery Anomaly Sudden Cardiac Death of Athletes Coronary Artery Anomaly 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 ECG is likely normal Very difficult to screen or diagnose even with echocardiogram Treatment: Surgery for coronary reimplantation

Sudden Cardiac Death of Athletes Commotio Cordis Sudden disturbance of heart rhythm as the result of a blunt, non-penetrating impact to the precordial region Impact occurring within a specific 10-20 millisecond portion of the cardiac cycle in the ascending phase of the T wave, when the ventricular myocardium is repolarizing, moving from systole to diastole Most effective preventions are: Chest shield Automatic External Defibrillator (AED) Sudden disturbance of heart rhythm as the result of a blunt, non-penetrating impact to the precordial region Impact occurring within a specific 10-30 millisecond portion of the cardiac cycle in the ascending phase of the T wave, when the ventricular myocardium is repolarizing, moving from systole to diastole Most effective preventions are: Chest shield Automatic External Defibrillator (AED)

Sudden Cardiac Death of Athletes Now let’s talk about the differences between the US and Europe. This Table highlights the differences in the recommendation for sports participation of young athletes who are known to have certain cardiovascular abnormalities. BC#36 is Bethesda Conference 36, which is the current US standard. ESC is European Society of Cardiology guidelines in 2005. In general, the US standards are more forgiving. One of the biggest obstacles to implement an athlete screening program is how you disqualify someone from sports based on what you find. For many athletes, sports is not just a career, it’s the dream, it’s life. J Am Coll Cardiol 2008;52:1990–6

Sudden Cardiac Death of Athletes What about preparticipation screening? AHA made its recommendations in 1996 to emphasize these 12 points: Then you ask yourself the question, how truthful or reliable would the high school player, or parents, answer these questions? What about an ECG?