Athletes and Sudden Cardiac Death Eli M Friedman, MD Cardiovascular Diseases Fellow, University of Pittsburgh Medical Center Director Rapid Response Team and Finish Line Medical Care, Pittsburgh Marathon

Disclosures None

Case 1 26 year old professional Cameroonian soccer player collapses on the field while playing in a match

Case 2 25 year old healthy white male, multiple long distance races, starts the Pittsburgh Marathon…

Overview History Incidence Etiology Running and Sudden Cardiac Death (SCD) Cardiac versus others NCAA and SCD ECG screening Implantable Cardio Defibrilators (ICDs) and sports participation

History Pheidippides Inspiration for marathon Ran from Marathon to Athens to deliver news of a Greek military victory against the Persians at the Battle of Marathon Suddenly collapsed and died

Incidence of SCD 2.3-4.4/100,000 in American athletes 3.6/100,000 prior to screening laws in Italy Now 0.3/100,000 5.6/100,000 in Black athletes College: 1/54,000 athletes/year during or soon after exertion 1 in 38,000 male; 1 in 122,000 female exertion-related 1 in 22,000 Black; 1 in 68,000 White Compare 5/100,000 homicides in the US each year (CDC) 10.2/100,000 motor vehicle deaths in 2014 in the US (IIHS) Hainline, B., Drezner, J., Baggish, A., et al. Interassociation consensus statement on cardiovascular care of student-athletes. J Am Coll Cardiol. 2016 Jun 28;67(25):2981-95. Steinvil et al. Mandatory electrocardiographic screening to reduce their risk of sudden death. JACC. 2011; 57: 1291-1296

Etiology

Marathons and SCD Marathons and Half Marathons from 2000-2010

Marathons and SCD 59 cardiac arrests Mean age 42 +/- 13 years 40 marathons, 19 half Mean age 42 +/- 13 years 51/59 (86%) men Incidence of 0.54/100,000 1.01/100,000 for marathons Male marathon runners at highest risk 1.41/100,000

Marathons and SCD 42/59 (71%) died Only 31/59 had an identifiable cause 23 of these runners died Hypertrophic cardiomyopathy (HCM), 8/23 “Possible” HCM 7/23 Other causes hyperthermia, hyponatremia, arrhythmogenic right ventricular dysplasia Myocardial ischemia most common amongst survivors, 5/8

Marathons and SCD What led to positive outcomes? Strongest predictors were bystander CPR and diagnosis other than HCM Completed more distance races More likely to have CAD risk factor Survivors OLDER 53.1 +/- 6 versus 33.9 +/- 9.5

Marathons and SCD So… More high risk men running? Study showed incidence rate increasing Overall case fatality rate 71% Favorable comparison to general population SCD More “help” around Myocardial ischemia, not acute plaque rupture ACS responsible (i.e. Supply-demand mismatch) Would screening stress tests help in the appropriate population?

Hyperthermia and SCD

Hyperthermia and SCD All long distance races in Tel Aviv, Israel 2007-2013 137,580 runners 2 Serious cardiac events 1 MI, 1 unstable SVT 21 serious cases of Heat Stroke 2 fatal, 12 life threatening 1 serious cardiac event for every 10 serious heat events

NCAA and SCD

NCAA and SCD Emergency Action Plan Establish a national registry CPR training and AED availability Establish a national registry Pre-participation evaluation with ECG screening IF able to be done “right”

Screening and ECGs In the USA American Heart Association 14 point screen

Screening and ECGs Personal history 1. Exertional chest pain/discomfort 2. Unexplained syncope/near-syncope 3. Excessive exertional and unexplained dyspnea/fatigue, associated with exercise 4. Prior recognition of a heart murmur 5. Elevated systemic blood pressure 6. Prior sport restriction 7. Prior cardiac testing Family history 8. Premature death before age 50 years due to heart disease in ≥1 relative 9. Disability from heart disease in a close relative <50 years of age 10. Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias Physical examination 11. Heart murmur 12. Femoral pulses to exclude aortic coarctation 13. Physical stigmata of Marfan syndrome 14. Brachial artery blood pressure (sitting position)

Screening and ECGs Europe, Israel and International Olympic Committee Add ECG

Why the ECG Debate? Italian study 1979-1980, 3.6/100,000 incidence of SCD in Italy Mandatory screening ECG for all athletes enacted SCD fell to 0.3/100,000 in 2003-2004 Criminal laws against physicians Steinvil et al. Mandatory electrocardiographic screening to reduce their risk of sudden death. JACC. 2011; 57: 1291-1296

Screening and ECGs NCAA Data, >5,200 athletes Hainline et al. JACC. 2016; 67 (25): 2981-2995

Why the ECG Debate? Steinvil et al. Mandatory Electrocradiographic Screening of Athletes to Reduce Their Risk for Sudden Death. JACC. 2011;57:1291-1296

ICDs and Sports Participation “For athletes with ICDs, all moderate and high intensity sports are contraindicated. Class IA sports are permitted.” 36th Bethesda Conference

ICDs and Sports Participation ICD Sports Safety Registry Patients with ICDs, 10-60 years old and participating in organized sports More vigorous than golf or bowling 372 total patients (long QT, HOCM, ARVD) Participating in running, basketball, soccer, skiing Lampert R et al. Safety of Sports for Athletes With Implantable Cardioverter-Defibrillators: Results of a Prospective, Multinational Registry. Circulation. 2013; 127:2021-2030

ICDs and Sports Participation Median 31 month follow up No deaths or resuscitated arrhythmias 10% had shocks during competition or practice 8% during other physical activity 6% at rest 97% free from lead malfunction at 5 years, 90% at 10 Lampert R et al. Safety of Sports for Athletes With Implantable Cardioverter-Defibrillators: Results of a Prospective, Multinational Registry. Circulation. 2013; 127:2021-2030

ICDs and Sports Participation 13% had at least 1 appropriate shock 11% had at least 1 inappropriate shock

ICDs and Sports Participation Lampert R et al. Safety of Sports for Athletes With Implantable Cardioverter-Defibrillators: Results of a Prospective, Multinational Registry. Circulation. 2013; 127:2021-2030

Conclusion SCD in athletes is a rare, but highly visible event Early recognition and rapid response are key Diverse range of causes May be preventable in some cases Increasing awareness and increasing controversy

Thank you! Friedmanem@upmc.edu