1. 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

2. Disclosures
None

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

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

8. 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

9. 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

11. 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 Jun 28;67(25):
Steinvil et al. Mandatory electrocardiographic screening to reduce their risk of sudden death. JACC. 2011; 57:

12. Etiology

13. Marathons and SCD
Marathons and Half Marathons from

14. 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

15. 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

16. 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 /- 9.5

17. 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?

18. Hyperthermia and SCD

19. Hyperthermia and SCD
All long distance races in Tel Aviv, Israel
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

20. NCAA and SCD

21. 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”

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

23. 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)

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

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

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

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

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

29. ICDs and Sports Participation
ICD Sports Safety Registry
Patients with ICDs, 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:

30. 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:

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

32. 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:

33. 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

34. Thank you!