Slide 1. Slide 2. Slide 3. Sudden Cardiac Death In Athletes. Epidemiology. Epidemiology. Shaun McMurtry, MD Primary Care Sports Medicine

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1 Slide 1 Sudden Cardiac Death In Athletes Shaun McMurtry, MD Primary Care Sports Medicine Slide 2 Epidemiology College and Professional Athletes 500,000 participants each year Competitive Athletics Estimated 7.8 million students participate in high school athletics Slide 3 Epidemiology Incidence of Sudden Cardiac Death Between 1:50,000 and 1:300,000 per year in athletes under age 35 Males: 1:134,000 per year Females 1:750,000 per year Black males disproportionately higher incidence Basketball highest incidence

2 Slide 4 Epidemiology HCM--36% Anomalous origin of coronary artery--17% Myocarditis--6% Arrhythmogenic right ventricular CM--4% Mitral Valve Prolapse--4% Aortic Stenosis--3% Tunneled Coronary Artery--3% Coronary Atherosclerosis--3% Ruptured Aortic Aneurysm--2% Slide 5 Epidemiology Athletes over 35 years of age typically cardiovascular disease Nonstructural Heart Disease Inherited syndromes Long QT syndrome Brugada syndrome WPW syndrome Catecholaminergic Polymorphic V Tach. Commotio cordis Slide 6 Screening Requirements In the US, athletes are screened by means of history and physical exam Europe mandates a 12 lead EKG in addition to history and physical exam In Europe from 1979 to 2004 incidence of SCD decreased from 3.6/100,000 person-years to 0.4/100,000 person-years Of note, leading cause of SCD is ARVD, not HCM

3 Slide 7 Pre-Participation Exam 14 point CV checklist per ACC/AHA Personal History Exertional chest pain/pressure/tightness Unexplained syncope/near syncope* SOB or fatigue out of proportion to level of exercise History of heart murmur Elevated blood pressure Prior medical restriction from sports Prior heart testing ordered by physician Slide 8 Pre-Participation Exam Family History Premature death under the age of 50 due to heart disease in 1 or more relatives Cardiac disability in relative under 50 yo Significant fam hx of cardiac abnormality such as HCM, Long QT syndrome, Marfan s Physical Exam Heart murmur** Physical stigmata of Marfan s Brachial artery blood pressure*** Slide 9 Pre-Participation Exam Caveats * not related to vasovagal syncope; most concerning when occurring during or immediately after exercise **murmurs not judged to be innocent; should auscultate in supine and standing position (or during valsalva maneuver). Specifically trying to find murmurs of dynamic LVOT obstruction ***BP bilateral arm preferred

4 Slide 10 Pre-Participation Exam Indication for Echo All diastolic murmurs Holosystolic murmurs Murmur grade 3/6 or above Features of Innocent Murmurs Low in intensity and midsystolic in timing, normal splitting, normal DYNAMIC auscultation, absence of radiation, asymptomatic Slide 11 Exertional Syncope CV causes Coronary art anomaly, Long QT, HCM, Dilated Cardiomyopathy, Aortic Stenosis, WPW, Heart Block Additional testing needed EKG, Echo, Stress test Slide 12 Exertional Chest Pain or Dyspnea CV causes HCM, Cor Art Anomaly, Marfan s, Mitral Valve Prolapse, ARVD, Aortic Stenosis, Tunneled Coronary Art, Myocarditis, CAD

5 Slide 13 Palpitations CV causes WPW, Long QT, Mitral Valve Prolapse Non CV causes Hyperthyroid, Supplements, Stimulant Meds, Nicotine, Anxiety Slide 14 Causes of Sudden Cardiac Death Hypertophic Cardiomyopathy Sporadic or inherited (autosomal dominant) Can predispose to ventricular arrhythmias leading so syncope or sudden cardiac death Signs/Sx Dyspnea (initially on exertion), angina, syncope on exertion, presyncope on exertion, fatigue, palpitations Exam Systolic murmur increasing with valsalva or standing Testing CXR: cardiomegaly. EKG: LVH. Echo: confirms Treatment B-Blocker, ICD, Ablation Slide 15 EKG HCM

6 Slide 16 EKG HCM Slide 17 Coronary Artery Anomalies Signs/Sx Only 1/3 of pts thought to have symptoms of exertional syncope or chest pain Exam: typically normal Testing EKG: usually normal or Q waves showing infarct Treatment: Immediate exclusion from ALL participation in competitive sport; may need surgical intervention. Slide 18 Coronary Artery Anomalies

7 Slide 19 Arrhythmogenic Right Ventricular Dysplasia Replacement of the right ventricular muscle by fatty and fibrous tissue. Arrhythmia of right ventricular origin that range from PVC to V. tach and V. Fib. Slide 20 ARVD EKG Patterns Incomplete or complete RBBB Inverted T waves in the anterior precordial leads Localized prolongation of QRS in v1 and v2 Epsilon waves visible as sharp discrete deflections at terminal portion of QRS in precordial leads QRS width in lead 1 always <120 ms Lead III R>S S wave upstroke in V1-V3 >55ms found in majority or ARVD Slide 21 ARVD EKG

8 Slide 22 Bethesda Conference Guidelines for Athletic Participation Slide 23 References Pelliccia A, Link M. Risk of Sudden Cardiac Death in Athletes. UpToDate Link M, Pelliccia A. Screening to Prevent Sudden Cardiac Death in Athletes. UpToDate AAFP Sports Medicine: Strategies for Treating Athletes. Breckinridge, CO Francis O Conner, MD. Sudden Cardiac Death and Arrhythmias in Athletes Beckerman J, Wang P, Hlatky M. Cardiovascular Screening of Athletes. Clin J Sports Med. 2004; Vol 14, Number 3: Mellion, Walsh, et al. Team Physician s Handbook. 3 rd Edition, Hanley & Belfus; 2002 Maron, B. Sudden Death in Young Athletes. NEJM. 2003; Vol 349, Number 11: Surawicz B et al. ACC/AHA recommendations for the standardization and interpretation of the EKG. Circulation. 2009;119:e Chou s Electrocardiography in Clinical Practice Adult and Pediatric, 6e

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