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

2. What do they have in common?
Hank Gathers ( )
Reggie Lewis ( )
Flo Hyman ( )
Sergei Grinkov ( )
Pete Maravich ( )

7. 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

8. 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 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

9. 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 :

10. 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 :

11. 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 :

12. 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?

13. 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

14. 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,

17. 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

18. 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

19. Results

20. 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.

21. Race and Ethnicity

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

23. Sudden Cardiac Death of Athletes
Maron BJ et al, JAMA 1996 ; 276 :
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.

24. Causes of SCD

25. Maron BJ et al, JAMA 1996 ; 276 :
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.

26. Conclusion
Excluding comotio cordis, there are 74 SCD of young athletes in the US in
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

28. Sudden Cardiac Death of Athletes
Circulation 2007;115;

29. 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

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

31. Coronary Artery Anomaly
Sudden Cardiac Death of Athletes
Coronary Artery Anomaly

32. 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

33. 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 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 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)

34. 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 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

35. 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?