Athlete Sudden Cardiac Death EMERGENCIES IN MEDICINE Park City 2012 Jim Kyle, MD, FACSM Emergency Department Director, Beckley ARH Team Physician Concord University Associate Clinical Professor Marshall University

Sports Trauma Trends Head / Neck Case Long term subtle neuro deficit Heat Stress Injury Performance enhancement supplements Sudden Cardiac Arrest Unrecognized congenital conditions Cardiac concussion

Sudden Cardiac Death in Athletes Incidence of SCD high school athletes 1:100,000 to 200,000 VanCamp & Maron college athletes 1:65,000 – 69,000 VanCamp & Drezner 1:50,000 marathoners, 1:15,000 joggers ~ 110 athletic deaths per year in US Maron no national surveillance system; true incidence unknown; most likely underestimated

The Faces of SCA

Hank Gathers Tragedy DX: exercise related complex ventricular tachycardia RX: Beta Blocker- Inderal 200qd Return to play in three weeks Courtside cardiac monitor defibrillator

Hank Gathers SCA Medication had been decreased due to side effects Cause of death -HCM Cardiac monitor defibrillator legal issue: $32 Million law suit

Cause of Sudden Cardiac Death Ten Year Review 158 Athletes B. Maron, JAMA 1996

sudden death organized sports 138 cases of Sudden Cardiac Death Ages 12-40, median age=17 90% Male 68% occurred in Football and Basketball 62% High School, 22% College, 7% Professional

The Faces of SCA

SCA in Athletes “The unexpected death of an athlete during exercise is tragic irony.... much remains unknown regarding optimal screening strategies, pathophysiologic mechanisms,and prevention” Mark Link, MD Tufts University

Cardiac Concussion

Little League Baseball Sudden Death A 16yo player was struck in the chest by the baseball thrown from home plate as he attempted to steal third base. Shortly after standing he collapsed with seizure like activity and stopped breathing.

Little League Baseball Sudden Death The coach initiated CPR and local EMS documented arrival of an ACLS team 8 minutes after receiving the call from the field. Attempts to resuscitate were unsuccessful.

Cardiac Concussion Commotio Cordis - sudden death during sports play after a blunt blow to the chest Maron, NEJM, case , Average Age = 11 (3-19) 18 playing baseball or softball, “Little League Sudden Death” 24 male Vulnerable window msec prior to peak of T wave inducing V- Fib Link, NEJM, 1998

Laboratory Cardiac Concussion

Sudden Death: Commotio Cordis

2001 Commotio Cordis Update 2001 update cases 84% cases fatal Early defibrillation with on site AED only effective treatment AED documented in 41 cases, 19 survived = 46%

Cause of Sudden Cardiac Death Ten Year Review 158 Athletes B. Maron, JAMA 1996

“Sudden Death in Young Athletes” Maron NEJM 2003, Sudden Death in 387 Young Athletes  1. Hypertrophic Cardiomyopathy – 34 %  2. Commotio Cordis – 20%  3. Coronary-artery Anomalies – 14%

2010 Update: Cardiac Concussion

224 Cases: NEJM, B Maron, M Estes Mean Age = 15: 26% < 10yo Range: 6mos – 50yo 95% Male, 78% White Survival rate  15%  35% ( > 50% )

The Casino Project

1997 – Security Guards at Star Dust trained by Clark County EMS, Richard Hardman in use of Life-Pak : 200+ cases of witnessed SCA with 57% survival Time to AED- 3 mins, Shock 4 mins 6,500 Security Guards trained

Public School AED Program 1999: Planning for Scholastic Cardiac Emergencies, WV Med Jour. The Ripley Project 2000: Milwaukee City school after 4 case SCA Project ADAM 2001: Long Island schools lacrosse focus Acompora Foundation ( 2007: 91% College, 35% High School with AED 2011: Saves > Deaths Commotio Cordis

“Non V-Fib” Cardiac Concussion Link,NEJM: 4/10 impacts during QRS = complete heart block

“Non V-Fib” Cardiac Concussion 3* Heart Block LBBB ^ST segment

Athletes at Risk for SCA Chief complaint of syncope Chest Pain with or post activity History of palpitations Family History of Sudden death Abnormal EKG

Athlete SCA : Have We Changed the Playing Field ? Emergency Department Athlete Collapse – Assume Cardiac Etiology (Sentinel Seizure) EKG Attention: Delta and Epsilon Waves, LQT Syncope, Near Syncope, Chest Pain Work Up: Consider advanced imaging, Cardiac CT, MRI* vs ECHO

ARVD – Prolonged QRS, Inverted T wave V1 – V2

ARVD – Arrhythmogenic Right Ventricular Dsyplasia Italian Sport Federation requires school athletes to have EKG and limited stress test on an annual basis EKG with prolonged QRS V1-V3 110 msec and inverted T wave Epsilon wave in 50%

ARVD Epsilon Wave

Athlete SCA : Have We Changed the Playing Field ? Emergency Department Athlete Collapse – Assume Cardiac Etiology (Sentinel Seizure) EKG Attention: Delta and Epsilon Waves, LQT Syncope, Near Syncope, Chest Pain Work Up: Consider advanced imaging, Cardiac CT, MRI* vs ECHO

ARVD with fatty (dark, arrows) RV myocardium By Cardiac CT Angiography Study N. Wilke, UF and Precision Imaging Centers, JAX, Florida

Cause of Sudden Cardiac Death Ten Year Review 158 Athletes B. Maron, JAMA %

Coronary Artery Anomalies Magnetic Resonance Imaging

Möhlenkamp et al. Circulation 2002;106:

Cardiac CTA: Common, Stenosed Ostium of RCA and LM N. Wilke, UF and Precision Imaging Centers, JAX, Florida

Athlete SCA : Have We Changed the Playing Field ? Athlete Screening Consider EKG – Corrado Italian Criteria Heart Murmur – Baseline ECHO with potential repeat to R/O HCM, Marfans Palpitations or SVT suspicion - Holter Monitor *2006 World Cup: FIFA required EKG, ECHO, Stress Test after Cameroon SCA

Italian Guidelines for Sports Medicine 1982 Law Competitive Athletes PSPE Screening : PMH, FH, Physical Exam, and 12 lead EKG Positive findings: ECHO, Stress Test, Holter PMH: Syncope, Chest Pain, SOB, Palpitation PSPE: Heart Murmur systolic >2/6 any diastolic, Abnormal S2, Systolic Clicks, BP >140/90, Irr Rhythm, R/O Marfans EKG: Hypertrophy, Blocks, ST and T wave, Intervals

Italian Pre-Competition Screening D. Corrado,et.al. Sports Medicine Data Base,Veneto region, Italy: NEJM year screening for HCM 33,735 athletes 3016 (9%) referred for echocardiogram 22 had HCM- risk identified EKG 49 deaths (1.6 per 100,000) 1 from HCM, 11 from ARVD (22%)

Italian Guidelines for Sports Medicine Abnormal EKG: LAH, RAH, R axis, L axis, LVH (20mm limb, 30mm pre-cordial), AV Block, 1*,2*, 3* (1* >.21 not shorted with hyperventilation) RBBB, LBBB Long QT (>.44men, >.46 women) Short PR (<0.12) PVCs, AF, SVT ST depression or T wave inversion 2 or more leads, Q wave 2 leads, V1 R:S ratio >1

2007 NATA Position Paper SCA in Athletes Summit (Courson, Drezner) Most cases occur with Basketball, Football and Little League Baseball 9 to 1 Male/Female Athlete Collapse – Suspect SCA  Sentinel Seizure awareness AED’s with time to shock < 4 minutes Coach AED certification Schools need a formal Emergency Medical Plan Rapid ACLS availability

SCA in Athletes “The unexpected death of an athlete during exercise is tragic irony.... much remains unknown regarding optimal screening strategies, pathophysiologic mechanisms,and prevention” Mark Link, MD Tufts University