John Hatzenbuehler MD, FACSM ACSM Team Physician Course Jacksonville, FL February 2016

Transcription

1 John Hatzenbuehler MD, FACSM ACSM Team Physician Course Jacksonville, FL February 2016

2 None

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7 Define the common causes of the collapsed athlete Outline the workup for the collapsed athlete

8 Exertional syncope A transient LOC with loss of postural tone During exercise Immediate post exertion period Pre-syncope Near collapse associated with lightheadedness Exercise associated collapse (EAC) Unable to stand unaided with dizziness, lightheadedness, or syncope

9 Peripheral re-distribution of blood flow Decrease in peripheral vascular resistance Calf pump mechanism Abrupt cessation of pump in setting of vasodilation causes syncope/presyncope/collapse Also Exercise associated Postural Hypotension (EAPH) Asplund C et al. BJSM 2011

10 Exacerbated by heat, hypoglycemia Most in correlation with fastest and slowest Dehydration levels were not different than controls Oral rehydration vs IV fluids No change in discharge time Anley et al. BJSM 2011.

11 Treatment Education Keep moving Trendelenberg position Oral hydration Most resolve within min Consider dehydration/other if persistent sxs

12 Syncope is generally benign in young athletes May be a prodrome to Sudden Cardiac Death 17-23% of athletes who died of SCD had syncopal event (Kramer 1988, Maron 1980) Reported prodromal symptoms suspected higher (76%*) Present in 40% of the general populaion Little data on athletes 6.2% in recent literature (Colivicchi 2004)

13 History can help guide workup Family hx can be very helpful Neurally mediated syncope Bradyarrythmias Supraventricular arrhythmias WPW, AV nodal re-entry Ventricular arrythmias HCM, CAD, Myopathy

14 Exhaustion Asthma Hypoglycemia Dehydration Seizure Heat stroke Hyponatremia Sickle cell disease/trait Marfan s syndrome Valvular dz Aortic dissection Psychogenic

15 Syncope during exertion is more concerning than syncope at rest Syncope post-exertion is generally not lifethreatening Colivicchi et al 7568 athletes 86% syncope not related to exercise benign 12% post exertion workups negative 1.3% during exertion all had significant disease

16 Clinical Characteristics Prodrome Neurocardiogenic or n0narrhythmic Lightheadedness, warmth, nausea Arrhythmic None # of episodes Multiple Few or none Situational factors Fear, fright, upright posture Exertional, unrelated to posture Post-syncopal symptoms Frequently fatigue Usually none Injury Unusual Common Underlying heart disease Unusual Common Adapted from Link MS, Estes M. How to manage syncope in athletes. Cardio Clin 2007.

17 Guided by history Symptoms How old? Controversy as to the extent If you start the work you should finish the workup but when is it finished? ECG Tilt-table Echo Stress test Electrophysiology studies Cardiac MRI Etc.

18 ECG Readily accessible Relatively inexpensive Interpretation issues in athletes Physiological adaptation vs pathology High false + rates Arrhythmia may not be present Tilt Table Non-invasive Unknown sensitivity and specificity May mask more serious pathology

19 Echocardiogram Detects structural disease Non-invasive Moderately expensive Operator dependent Physiological adaptation vs pathology Not useful for arrhytmias Stress testing Exertional testing Non-invasive Unknown sensitivity and specificity in young athletes

20 Electrophysiological studies Detailed mapping of electrical system Invasive No clear recommendations on indications Holter/event monitor Non-invasive Moderate expense Holter may miss events Event monitor requires patient activation

21 Let history guide work up Consider CAD in older athletes (>35) and with strong family history Post-exertional or non-exertoinally related syncope with neurocardiogenic symptoms generally do not require further work up Athletes with exertional syncope need a complete work up What this means is still unclear

22 One of the most polarizing topics in sports medicine Emotionally charged and usually highly publicized Screening and prevention is controversial Secondary prevention may be more successful than previously believed

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24 Initial thought was that athletes were less likely to respond to ACLS and particularly defibrillation Structural disease catecholamines Newer data suggest improved survival with early defibrillation times Probability of successful defibrillation for VF SCA diminishes rapidly over time.

25 Exercise related SCD in US Youth N=486 Overall survival rate of 11% Drezner J. Heart Rhythm 2008.

26 Larsen. Ann Emerg Med 1993

27 Cross sectional survey Comprehensive survey on emergency response planning and details of SCA case 1,710 High Schools with on-site AEDs (july 2006-July 2007)

28 36 case (22 adults, 14 student athletes) 35/36 (97%) SCA cases witnessed 34/36 (94%) received bystander CPR AED deployed a shock in 30/36 (83%) cases

29 Student athletes 64% - 9/14 Non-students 64% - 14/22 Overall 64% - 23/36

30 Early recognition +Early CPR + Early AED = improved survival

31 Collapse after exercise, typically EAC, is usually benign Collapse during exercise may signal underlying cardiac issue. Exertional syncope workup can be extensive and expensive AED s with good response system save lives

32 1. Asplund C, Oconnor F, Noakes T. Exercise associated collapse: an evidence-based review and primer for clinicians. BJSM. 2011;45: Anley C, Noakes T, Collins M, Schwellnus M. A comparison of two treatment protocols in the management of exercise-associated postural hypotension: a randomised clinical trial. BJSM. 2011;45: Colivicchi F, Ammirati F, Santini M. Epidemiology and prognostic implications of syncope in young completing athletes. Eur Heart J. 2004;25(19): Link M, Estes N. Howe to manage athletes with syncope. Cardiol Clin. 2007;25(3): Lawless C, Best T. Electrocardiograms in athletes: interpretation and diagnostic accuracy. MSSE. 2008;40(5): Harmon K, Asif I, Klossner D, Drezner J. Incidence of Sudden Cardiac Death in National Collegiate Athletic Association Athletes. Circulation. 2011;123(15): Drezner J, et al. Accuracy of ECG interpretation in competitive athletes: the impact of using standardised ECG criteria. BJSM. 2012;46: Dresner J, et al. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation. 2009;120:

33 Thank you