Exercise Associated collapse. ACSM Team Physician Course Part II 2/4/2017 Jerrad Zimmerman MD

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1 Exercise Associated collapse ACSM Team Physician Course Part II 2/4/2017 Jerrad Zimmerman MD

2 Exercise Associated Collapse Characterized by collapse after completion of an intense exercise event in the absence of neurological, biochemical or thermal abnormalities Usually occurs after passing the finish line Most common event seen by providers caring for participants of endurance athletes at the finish line % of all visits after marathons and ultramarathons Exercise-associated collapse: an evidence-based review and primer for clinicians Br J Sports Med 2011;45: doi: /bjsports

EAC Etiology Postural hypotension caused by pooling of blood in the lower extremities Secondary to decreased vascular resistance Attenuated cardiac baroreflex response Women may sustain

3 EAC Etiology Postural hypotension caused by pooling of blood in the lower extremities Secondary to decreased vascular resistance Attenuated cardiac baroreflex response Women may sustain EAC more from decreased cardiac filling Exercise-associated collapse: an evidence-based review and primer for clinicians Br J Sports Med 2011;45: doi: /bjsports

EAC Treatment Symptomatic Oral hydration and a Trendelenburg position Total body cooling, intravenous hydration or advanced therapies are generally not

4 EAC Treatment Symptomatic Oral hydration and a Trendelenburg position Total body cooling, intravenous hydration or advanced therapies are generally not needed. Exercise-associated collapse: an evidence-based review and primer for clinicians Br J Sports Med 2011;45: doi: /bjsports

5 Post Exertional Collapse Exercise-associated collapse Collapse in conscious athletes who are unable to stand or walk unaided as a result of light headedness, faintness and dizziness or syncope causing a collapse that occurs after completion of an exertional event or stopping exercise. Exercise-associated postural hypotension Postexercise symptoms caused by a decline in systolic blood pressure by at least 20 mm Hg below supine values on assuming the upright posture. Orthostatic intolerance Symptoms caused by orthostatic hypotension, which is a sustained reduction of systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of 10 mm Hg within 3 min of standing.

6 Exercise-associated hyponatraemia (EAH) Characterized by a decrease in serum sodium (<135 mmol/l) and mental status changes. Athletes with EAH may have true syncope, confusion or disorientation but will have alteration in serum sodium.

7 Exercise and Risk SCD and AMI 6-17 times more likely to occur during physical activity Still very low risk overall SCD overall occurs around once per 1.5 million episodes of vigorous exertion in men and once per 36.5 million hours of vigorous exertion in women

8 Exercise and Risk About one death per 396,000 hours of jogging One death per 2,897,057 person-hours at a YMCA More than 10 million marathon and ½ marathon participants reviewed and found a rate of 1/184,000 runners with cardiac arrest and 1/296,000 suffered a SCD

9 Physical Activity Still has a Risk Onset study Twice the risk of an AMI during vigorous activity than at rest for those that exercise 1hr 5 days a week The inactive group had an AMI rate 50 times higher than the exercise group at vigorous exercise

10 Physical Activity Onset study also showed that the in regular exercisers the rate of CVD events decreased by 50% for 24 hour during and after the vigorous exercise

11 Divergent Etiology Over 35 y/o majority of cases are CAD Under 35 y/o usual etiology of SCD is structural.

12 Incidence of Sudden Cardiac Death in NCAA Athletes Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review. Harmon, Kimberly; Asif, Irfan; Maleszewski, Joseph; Owens, David; MD, MS; Prutkin, Jordan; MD, MHS; Salerno, Jack; Zigman, Monica; Ellenbogen, Rachel; Rao, Ashwin; Ackerman, Michael; MD, PhD; Drezner, Jonathan Circulation. 132(1):10-19, July 7, DOI: /CIRCULATIONAHA by the American College of Cardiology Foundation and the American Heart Association, Inc.. Published by American Heart Association. 5

Causes of Sudden Cardiac Death in Athletes Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review.

13 Causes of Sudden Cardiac Death in Athletes Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review. Harmon, Kimberly; Asif, Irfan; Maleszewski, Joseph; Owens, David; MD, MS; Prutkin, Jordan; MD, MHS; Salerno, Jack; Zigman, Monica; Ellenbogen, Rachel; Rao, Ashwin; Ackerman, Michael; MD, PhD; Drezner, Jonathan Circulation. 132(1):10-19, July 7, DOI: /CIRCULATIONAHA Figure 2. A, Causes of sudden cardiac death in athletes. B, Cause and activity at time of death. One person figure equals 1 death; female figures follow male figures, unless no male deaths were present. AN-SUD indicates autopsynegative sudden unexplained death; ARVC, arrhythmogenic right ventricular cardiomyopathy; CAD, coronary artery disease; DCM, dilated cardiomyopathy; HCM, hypertrophic cardiomyopathy; LVH, left ventricular hypertrophy; NOS, not otherwise specified; SCT, sickle cell trait; SUD, sudden unexplained death; and WPW, Wolff-Parkinson-White by the American College of Cardiology Foundation and the American Heart Association, Inc.. Published by American Heart Association. 9

14 Activity at time of SCD 56% with exertion 22% at rest 14% during sleep 9% unknown

Incidence of Sudden Cardiac Death in Sports Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review.

15 Incidence of Sudden Cardiac Death in Sports Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review. Harmon, Kimberly; Asif, Irfan; Maleszewski, Joseph; Owens, David; MD, MS; Prutkin, Jordan; MD, MHS; Salerno, Jack; Zigman, Monica; Ellenbogen, Rachel; Rao, Ashwin; Ackerman, Michael; MD, PhD; Drezner, Jonathan Circulation. 132(1):10-19, July 7, DOI: /CIRCULATIONAHA by the American College of Cardiology Foundation and the American Heart Association, Inc.. Published by American Heart Association. 7

Incidence of Sudden Cardiac Death in Male Basketball Athletes Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in

16 Incidence of Sudden Cardiac Death in Male Basketball Athletes Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review. Harmon, Kimberly; Asif, Irfan; Maleszewski, Joseph; Owens, David; MD, MS; Prutkin, Jordan; MD, MHS; Salerno, Jack; Zigman, Monica; Ellenbogen, Rachel; Rao, Ashwin; Ackerman, Michael; MD, PhD; Drezner, Jonathan Circulation. 132(1):10-19, July 7, DOI: /CIRCULATIONAHA by the American College of Cardiology Foundation and the American Heart Association, Inc.. Published by American Heart Association. 6

17 Where Do We Go? Current recommendation is the screening PPE cardiac questions. Consider and studies ongoing on using an EKG High level or High risk ( Male Division 1 basketball) consider EKG and/or echocardiogram Interesting point is SCD incidence is much higher in NCAA sports than both heat illness and sickle cell trait reported death.

18 Thank You?

Sudden Cardiac Death

Sudden Cardiac Death Exercise and Risk SCD and AMI 6-17 times more likely to occur during physical activity Still very low risk overall SCD overall occurs around once per 1.5 million episodes of vigorous