Sudden Cardiac Death in Endurance Sports Professor Sanjay Sharma Disclosures: None
Objectives • To provide information about the incidence and causes of sudden death in sport from current literature. • To present death rates in the marathon and triathlon. To present death rates in the marathon and triathlon. • TTo study available information on cause of sudden death t d il bl i f ti f dd d th in triathletes • To discuss potential screening strategies in endurance athletes.
Sudden Death in Athletes Sudden Death in Athletes • Incidence approximately 1/25,000‐1/100,000 Incidence approximately 1/25 000‐1/100 000 • More common in males than females (9:1) ( ) • Over 80% of victims do not exhibit any warning symptoms y p • 80% deaths are due to an underlying cardiac disorder 80% deaths are due to an underlying cardiac disorder • 90% deaths during or immediately after exertion
Background: Causes of SCD in Sport g p
2.5 2 1.5 1 0.5 0
SD/100,000 SD/100 000 person yrs Athletes
Non‐ athletes
Potential triggers for Sudden Death Dehydration
Electrolyte y imbalance
Adrenergic surges
Acid/base Acid/base disturbance
Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy
Deaths in Individuals with Structurally Normal Hearts: The British Experience Hearts: The British Experience UK SCD, n=118, age range 7-59 yr atheroma other myocarditis valve 2% 2% 4% 3% ACA IF 6%
5%
normal 23%
ARVC 14% HCM 11%
LVH w/ IF
LVH 23%
8%
Electrical Disorders SCD With a Normal Heart LQTS
Brugada
WPW
Sudden Cardiac Death During Mass Participation Long Distance Running 500 500 races per year with up to 1 million participants ih 1 illi i i
Triathlon
Mean Age of Sudden Death in Athletes g SPORT Age (years old) _______________________________________________ Competitive soccer Competitive soccer 23 23 R Recreational sport ti l t
46
Marathon runner
42
Triathlete
44
Causes of Sudden Cardiac Death in Senior Athletes
5%
5%
5%
5% CAD SAD MVP Valves HCM
80%
Cardiac Arrest During Long Distance Running Kim J NEJM 2012
59 cardiac arrests 59 cardiac arrests 0.54/100,000 1 in 184 000 1 in 184,000 42 deaths (71%) 1 in 259,000 86% Male Mean age 42 ± 13 yrs Event rate increased in males in last half of study to 2.03/100,000
Independent predictors of survival were by‐ stander CPR and diagnosis other than HCM
Cause of Death in Long Distance Running Events g g Kim J NEJM 2012
Cardiac Arrest in the London Marathon 1981‐2012 1981 2012 (32 Year Experience) (32 Year Experience) 802 000 Finishers 802,000 Finishers 14 Cardiac Arrests. Mean age 49 8 Deaths (57%) SCA rate = 1.74/100,000 (1 in 57,000) Cardiac death rate = 1/100 000 Cardiac death rate = 1/100,000
Sudden Cardiac Arrest in the London M th Marathon 1 3
HCM IHD SADS
10
Sudden Deaths in Triathlon Sudden Deaths in Triathlon 2003‐2011. 2003 2011.
23,000 Sanctioned events 23,000 Sanctioned events
> 3 million participants 3 million participants 43 Race related fatalities; Fatality rate 1 in 76,000 3 ace e ated ata t es; ata ty ate 6,000 34 Male (80%) ( %)
9 Female (20%) ( %)
Age range 24‐76 years old. Mean age 48 years old g g y g y 70% of all deaths in swimming. g
Sudden Deaths in US Triathlon 2012 dd h hl
Possible Causes of Death During Swim Possible Causes of Death During Swim •
•
•
•
Drowning D i − Precipitated by water aspiration − Kicked and knocked unconscious Lung Problem – Swimming Induced Pulmonary Edema (SIPE) – Asthma attack – Anaphylaxis from jellyfish sting C di Problem Cardiac P bl – Long QT Syndrome (1 subtype provoked by swimming) – Myocardial infarction (older athlete) – Hypertrophic or other cardiomyopathy (younger athlete) Heat Stroke (rare)
Cause of Sudden Death in the Triathlon Harris et al. Sudden Death During the Triathlon,JAMA,2010
959,214 participants in 2971 USA Triathlons (2006 2008) (2006‐2008) 14 participants died during 14 triathlons 14 participants died during 14 triathlons Rate= 1.5 per 100 000 participants (95% CI, Rate 1 5 per 100 000 participants (95% CI 0.9‐2.5) Mean age: 44 years
Cause of Sudden Death During Swimming g g Harris et al. Sudden Death During the Triathlon,JAMA,2010
13 Deaths • 7 of 9 athletes with autopsy had cardiovascular abnormalities • 6 had left ventricular hypertrophy (wall thickness of 15 to 17mm, mean heart weight of 403 g) f 15 t 17 h t i ht f 403 ) • 1 had a congenital coronary artery anomaly 1h d it l t l • 2 had normal heart 2h d lh t
Diagnosis Clinical and family history y y Cardiac auscultation
12‐lead ECG/SAECG Echocardiography/CMR
Identify most conditions
24 hour ECG 24 hour ECG Exercise stress test Pharmacological provocation tests Electrophysiological tests
Management
Life style modification Life style modification Pharmacological therapy R di f Radiofrequency ablation bl i Implantation of ICD Cardiac surgery
Arguments For and Against Screening
Goals of Major Sporting Bodies Goals of Major Sporting Bodies • “The ultimate objective of the pre‐participation screening of athletes is the detection of ‘silent’ cardiovascular abnormalities that can lead to SCD.” – ACC 36th Bethesda Conference, 2005 • “The The main purpose of the consensus document is to main purpose of the consensus document is to reinforce the need for PPE medical clearance of all young athletes involved in organized sports programs young athletes involved in organized sports programs to prevent athletic field fatalities” ‐ ESC Consensus Statement, 2005 ESC C St t t 2005
Screening Athletes Condition
History
Examn
ECG
Echo
HCM
Pos/Neg
Pos in 25%
Positive
Pos
ARVC
Pos/Neg
Negative
Positive
Neg/Pos
WPW
Pos/Neg
Negative
Positive
Neg
LQTS
Pos/Neg
Negative
Positive
Neg
Marfan f
Pos/Neg /
Positive
Negative
Pos
CAA
Pos/Neg
Negative
Negative
Neg
Myocarditis
Pos/Neg
Pos/Neg
Pos/Neg
Pos
INCREASING COST
Young competitive athlete
Personal and family history Physical examination Physical examination 12‐lead rest ECG
Positive findings
Negative findings
Eligibility for competition
No cardiovascular disease
Further examination Cardiovascular disease Cardiovascular disease Management according to established protocols
Role of ECGs in Diagnosis of Cardiomyopathy Role of ECGs in Diagnosis of Cardiomyopathy
HCM 95%
ARVC 80%
Screening Athletes: Impact on SCD Screening Athletes: Impact on SCD • • • • •
1979‐2004 1979 2004 42,386 athletes (12‐35 years) Hi History, examination and 12‐lead ECG i i d 12 l d ECG Patient with abnormal findings investigated further C Compared death rates pre‐screening 1979‐1982 dd h i 1979 1982 early screening 1982‐1992 l t late screening 1992‐2004 i 1992 2004 • Death rates fell from 3.6/100,000/person years (pre‐ screening to 0 4/100 000/person years following screening to 0.4/100,000/person years following screening • Reduction in deaths mainly from cardiomyopathies Reduction in deaths mainly from cardiomyopathies
TIME‐TREND OF SUDDEN CARDIAC DEATH INCIDENCE IN ATHLETES VS NON‐ATHLETES ATHLETES VS NON ATHLETES
Veneto Region of Italy 1979‐2002 Veneto Region of Italy 1979 2002
Concerns Low incidence of sudden cardiac death High number of false positives Concerns relating to false negatives Cost Other issues
Concerns Low incidence of sudden cardiac death High number of false positives Concerns relating to false negatives Cost Other issues
Goals of Major Sporting Bodies Goals of Major Sporting Bodies • “The ultimate objective of the pre‐participation screening of athletes is the detection of ‘silent’ cardiovascular abnormalities that can lead to SCD.” – ACC 36th Bethesda Conference, 2005 • “The The main purpose of the consensus document is to main purpose of the consensus document is to reinforce the need for PPE medical clearance of all young athletes involved in organized sports programs young athletes involved in organized sports programs to prevent athletic field fatalities” ‐ ESC Consensus Statement, 2005 ESC C St t t 2005
Prevalence of Cardiovascular Disorders at Risk of SCD Prevalence
Ref:
Population
AHA (2007)
Competitive athletes (U.S.)
0.3%
Fuller (1997) Fuller (1997)
5 617 high school athletes (U S) 5,617 high school athletes (U.S)
0 4% 0.4%
Corrado (2006)
42,386 athletes age 12‐35 (Italy)
0.2%
Wilson (2008)
2,720 athletes /children age 10‐17 (U.K.)
0.3%
Bessem (2009)
428 athletes age 12‐35 428 athletes age 12 35 (Netherlands) (Netherlands)
0.7%
Baggish (2010)
510 collegiate athletes (U.S.)
0.6%
Concerns Low incidence of sudden cardiac death High number of false positives Concerns relating to false negatives Cost Other issues
Athlete’ss Heart Athlete Heart STRUCTURAL
ELECTRICAL
Increased c eased chamber wall thickness and cavity size
Bradycardia Repolarisation anomalies Voltage criteria for chamber enlargement FUNCTIONAL Enhanced diastolic filling Augmentation of stroke volume
Results of athletes screened in Veneto 1979‐2004‐ C Corrado; JAMA 2006 d JAMA 2006 Athletes screened: 42,386 Abnormal ECG: 3,914 (9%) Cardiac disorder: 879 (2%)
False Positive 7%
All disqualified ll d lf d Potentially lethal disorder: 91 (0.2%)
The Challenge g
Physiology
Pathology
Left Ventricular Hypertrophy R Repolarisation anomalies l i ti li
Diagnosis g Clinical and family history
Familial
Cardiac auscultation
Relatively rare Heterogeneous phenotypic manifestations
12-lead ECG
Symptoms of disease usually absent
Echocardiography
ECG overlap with athlete’s heart
24 hour ECG Exercise stress test Pharmacological tests Electrophysiological tests
Natural history not fully understood in all disorders Evaluation in an expert setting is important
Concerns Low incidence of sudden cardiac death High number of false positives Concerns relating to false negatives Cost Other issues
Deaths in Athletes and Non Non-Athletes Athletes Aged 35 Years in Veneto 1979-1996 – Corrado; NEJM 1988 Deaths in Athletes and Non-Athletes Aged 35 Years in Veneto 1979-1996 – Corrado; NEJM 1988 Corrado; NEJM 1988
CONDITION
ATHLETES N = 49
NON‐ATHLETES N = 220
TOTAL N = 269
CAD
9 (18.4)
36 (16.4)
45 (16.7)
CAA
6 (12.2)
1 (0.5)
7 (2.6)
HCM
1 (2)
16 (7.3)
17 (6.3)
Active senior
High intensity exercise Assessment by a physician Assessment by a physician H/E/Risk SCORE/ECG
Negative Can compete
P iti Positive Maximal ETT
Deaths Despite Screening with ECG p g
Success Rates for Defibrillation in Young Athletes Author Study Survival ____________________________________________ Maron
Commotio cordis
16%
Drezner
Survival trends
4‐21%
Drezner
Schools with AED
64%
Kim
Marathon runners
29%
L d M th London Marathon
43%
Gen Pop 10 75 Gen Pop 10‐75
16%
Marion Marion
Concerns Low incidence of sudden cardiac death High number of false postives Concerns relating to false negatives Cost Other issues
REAL ISSUES Low incidence of sudden death Low incidence of sudden death Low prevalence of conditions causing SCD
? COST EFFECTIVE ? COST EFFECTIVE
Heterogeneous disorders with H t di d ith broad phenotypic manifestations
EXPERT INPUT EXPERT INPUT
ECG overlap with physiological adaptation
FALSE POSITIVES
Disease manifestation may relate to age
FALSE NEGATIVES
Diseases such as CAA and CAD not identifiable with ECG alone
FALSE NEGATIVES
Problems with risk stratification
CANNOT PREDICT RISK
Prospect of litigation
Conclusions 1. Sudden cardiac death in endurance sports is rare. 1. Preliminary observations suggest a higher death rate in the triathlon compared to the marathon. ate t e t at o co pa ed to t e a at o . 2. Most triathlon deaths occur during swimming for which there are several potential explanations. hi h h l i l l i 3. Screening with ECG will detect electrical faults and g cardiomyopathies but will fail to identify most coronary artery abnormalities/disease. y y / 4. Screening of athletes MUST take place in an EXPERT tti EXPERT setting.
Harris et al. Sudden Death During the Triathlon, JAMA, 2010
Swimming Induced Pulmonary Edema (SIPE) • Acute pulmonary oedema and haemoptysis occurring in swimmers or divers. – Well‐known event in galloping race horses (due to high W ll k ti ll i h (d t hi h pulmonary vascular pressure). – Also reported in cyclists, marathoners and rugby players, Also reported in cyclists marathoners and rugby players but much less common. Symptoms: haemoptysis (pink frothy sputum) cough SOB • Symptoms: haemoptysis (pink frothy sputum), cough, SOB, wheezing, CP Seawater aspiration wouldn’tt do all this. do all this. • Seawater aspiration wouldn • Over‐hydration thought to contribute.
SIPE Pathophysiology p y gy • Effects of water immersion: – Cold water causes vasoconstriction and increase in both preload and afterload in heart afterload in heart. – Cold water results in decreased core temp and shifts blood from peripheral to thoracic vessels. – Causes central blood pooling which increases heart preload and pulmonary artery pressure. – These dramatic increases in pulmonary artery pressure damages alveolar capillary membrane and lead to pulmonary oedema.
Cause of Death in Long Distance Running Events g g Kim J NEJM 2012
Efficacy of Italian ECG Programme for Excluding HCM Excluding HCM Athletes cleared at national screening 4397 (98.8%)
4450
NEGATIVE PREDICTIVE VALUE 99.8%
Echocardiography (and other testing) Other structural disease
LVH 41 (0 9%) (0.9%)
No cardiac diseases
12 (0.3%)
37
4
(0.8%)
(0.1%)
Physiological LVH
“Grey zone”
1 HCM (0 025%) (0.025%)