RISK FACTORS FOR SUDDEN DEATH Exercise: How and When Does it Lead to Sudden Death? Prof. Massimo Santini

Exercise - Sport and Sudden Cardiac Death

Sport-related Sudden Cardiac Death Sudden cardiac death during sport activity is an unexpexted death of cardiovascular etiology in which there is loss of consciousness within an hour of onset of symptoms. (80%) Trauma or thechnical accidents during sport activity are not inclusive of this definition.

Sport-related SCD Epidemiology < 35 yrs < 35 yrs 1: : > 35 yrs 1: : Risk in males >>> than in females 5 : 1 5 : 1

Sudden Death During Different Types of Sport Maron BJ Circ 2009

Bar chart showing the number of sudden deaths in athletes in relation to age in 118 deaths in sportsmen referred to a tertiary centre in the UK over a 12-year period.

Hourly distribution of Sudden Cardiac Death Time of Day N° of Athletes Maron BJ JAMA 1996

Couses of sudden cardiac death in 118 sports deaths referred to a tertiary cardiac centre in the UK over 12 years.

Prof Henschen 1899 “ “The largest heart will win the race” But others were not so convinced!!!

Sport-related SCD  35 yrs 1: :50.000

THE DOCTOR'S WORLD; JAMES FIXX: THE ENIGMA OF HEART DISEASE B est-selling book ''The Complete Book of Running'' Father died at 43 yrs. At 35 had Heart attact. Had been a smoker (40 die) heavy yung man (110 kg for years) All three coronary were damaged: Cx: 100% CDx: 80% DA: 50%. Ateriosc. Damage of aorta and Femoral.

CV Abnormalities found at autopsy in athletes ≥35 yrs who died suddenly 80% Coronary artery disease HCM MVPMVPMVPMVP Unexplained Unexplained Aquired Valve Disease

Flow response to Higher Myocardial Demand

Mechanism of Acute Coronary Events During Exercise  Placque rupture  Enhanced cathecolamine- induced platelet aggregation  Exercise induced coronary artery spasm coronary artery spasm

Sport-related SCD < 35 yrs < 35 yrs 1: :

Causes of Sudden Cardiac Death in Young Athletes (<35 yrs) (n°158 athletes; ) Maron BJ JAMA 1996

(Corrado et al. NEJM 1998) (Maron et al. JAMA 1996) ARVD 23% Anomalous c.a. origin 12% HCM 2% Premature CAD 18% HCM 36% Atherosclerotic c.a. disease 2% ARVD 3% Anomalous c.a. origin 19%

- 89%

H.G. was a 23-year-old basketball star. His first symptom was a syncopal spell, which occurred during a game. He underwent to a cardiologic evaluation performed by a group of expert cardiologist and electrophysiologist. ECG Holter showed only VPB and an exercise test trhee-beat runs of VT. The coronaries were normal. At electrophysiologic study, polymorphic VT was induced with triple extrastimuli. A later Holter, acquired while he was playing very active, disclosed repetitive VT up to 21 beats in duration at 200 bpm. The Hank Gathers Case

A divergence of opinion arose between the cardiologist and electrophysiologist as to wheter the patient should play basketball The electrophysiologist said that H.G. SHOULD NOT PLAY The family was hurt and angered at this recommendation

Finally all agreed that a trial of high dosage propanolol (200mg/day) should be tried. Surprisingly, on basket Holters, this regimen suppressed the VT nearly completely. A series of Holter was done with different reduced dosage of the drug. Tha athlete cut back the dosage to 40 mg/day on his own and did not show up for his next basket ball Holter

He died on march 4, 1990 during a game National television

SCD in young athletes without structural cardiac abnormalities Canalopatie Long QT syndromeLong QT syndrome Short QT SyndromeShort QT Syndrome Catecholaminergic polymorphic ventricular tachycardiaCatecholaminergic polymorphic ventricular tachycardia Brugada SyndromeBrugada Syndrome Patologia del Sistema di conduzione WPW Lown Gannon Levine Idiopatic ventricular fibrillation

BPV TV/FV Structure Function Exercise Pathogenesis of Sudden Cardiac Death in Athletes Elect Instab HCMARVCCAACADMyocarditis……. Transient ischemia AcidosisHypoxemiaIncreased sympathetic drive sympathetic drive

Ventricular Fibrillation In 95% of cases

Minimize the risk of athletic field deaths: the great challange of Sports Cardiology

The secret of longevity: No Sport, just whisky and cigars