Cardiovascular Risk Factors/Sudden Death

Transcription

1 Cardiovascular Risk Factors/Sudden Death SPORTS MEDICINE AND THE NFL: The Playbook for 2013 Gary W. Dorshimer, MD, FACP Thursday May 9, 2013 DISCLOSURE Neither I, Gary W. Dorshimer, MD, nor any family member(s), author(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation. 1

2 Goals and Objectives Participants should be able to recognize risk factors for cardiovascular disease in athletes Recognize the role of pre-participation screening and essential parts of the PPE Recommend possible diagnostic tests that may detect sports participants that are at elevated risk for cardiovascular complications Definitions Sudden Cardiac Death (SCD) = Nontraumatic and unexpected sudden cardiac arrest that occurs within 6 hours of previously normal state of health Athlete = person who participates in team or individual sports. Young = less than 35 years old 2

3 History 1 st case B.C. - Pheidippides More recent athletes Hank Gathers (1990) Pete Pistol Maravich (1980) Reggie Lewis (1993) Jason Collier Thomas Herrion Jiri Fischer 3

4 Epidemiology of Sudden Cardiac Death Incidence: 1 in 100, ,000 overall annually in US 30% of non-traumatic deaths In athletes, 2:1 cause of death vs. trauma Male:Female ratio = 5:1 to 9:1 68% in basketball and football African Americans >40% of cases > 80% cases occur during or immediately after exercise Epidemiology SCD NCAA Recent study by Harmon, et al showed incidence of SCD in NCAA was 1: participants per year Division I male basketball players, the rate of SCD was 1:3100 per year 2011: 444,000 student athletes (NCAA) Approx 10 deaths per year Harmon, et al. Circulation April 19;123(15):

5 Causes of Sudden Death Maron, Cardiol Clin (2007) Hypertrophic Cardiomyopathy (HCM; HOCM old term) #1 cause of SCD in US athletes (36%) #1 genetic cardiac malformation (1 in 500) 11 sarcomere gene mutations indentified Over 400 individual mutations Highly variable phenotypes Asymmetric thickening of LV wall No LV dilation No other attributable cause 5

6 Hypertrophic Cardiomyopathy 1-5% rate of SCD per year Disordered cell structure -> dysrhythmias Generally asymptomatic until collapse Those with symptoms of LV outflow tract obstruction less likely to die suddenly Hypertrophic Cardiomyopathy 6

7 Hypertrophic Cardiomyopathy Dx: End systolic murmur Increased by Valsalva or standing Radiates to axilla, not carotids EKG Signs of LV/septal hypertrophy Abnormal Q waves Abnormal ST segments HCM (Continued) Echocardiogram Septal wall to posterior wall - 1.3:1 or greater (90% sensitivity, 90% specificity) Gray Area HCM & Athlete s Heart Genetic Screening Cardiac MRI distorted muscle structure Hard to diagnose Of those who died of SCD with HCM, 21% had prior symptoms 36% had prior cardiac evaluation 7

8 Coronary Artery Abnormalities 2 nd most common cause of SCD Most common anomaly = Left main from right sinus of Valsalva Mechanism myocardial hypo-perfusion ventricular dysrhythmias Compression Acute angle takeoff Coronary Artery Abnormalities Symptoms Syncope, palpitations, or angina (31%) ECHO MRI, MRA, Cardiac CT, Cath Recommendations: Restrict from activity Treatment: Depends on anomaly Anomalous left coronary resect & attach to aorta. CABG 8

9 Acute Myocarditis 6% of SCD in athletes Coxsackie B virus in 50%, but few with prodromal symptoms Inflammatory infiltrates in myocardium Ventricular dysfunction -> dysrhythmia Early symptoms: exercise intolerance, dyspnea, orthopnea EKG: diffuse ST segment elevations Acute Myocarditis Usual resolves without sequelae Clear for return to play after: 6 month recovery resolution of ECG/echo abnormalities Occasional complication -> dilated cardiomyopathy Then no competitive sports! 9

10 Other Causes of Sudden Cardiac Death Marfan Syndrome (aortic aneurysms, dilated aortic arch) Long QT syndrome Brugada syndrome Wolff-Parkinson-White Syndrome Arrhythmogenic RV Dysplasia (Italy) Aortic stenosis Mitral valve prolapse (rare in those with it) Proarrhythmic Epinephrine Ephedrine (ma huang) Cocaine Erythropoeitin Anabolic Steroids Medications & SCD Cardiac hypertrophy Myocardial fibrosis Accelerated Atherosclerosis 10

11 Commotio Cordis Agitation of the heart Estimated deaths yearly (3%) National Commotio Cordis Registry: 224 cases reported since 1996 Blunt impact to precordium produces V fib Blow alters electrical stability of myocardium Timing: during repolarization phase Only moderate forces necessary 30-40mph pitch, karate contact Kids: thinner, more compliant chest wall Commotio Cordis Survival rate improving: 15% to 35% Rapid CPR and defibrillation Burton

12 Objectives of the PPE Detect conditions that may limit sports participation Detect conditions that may predispose to injury Meet legal and insurance requirements To determine the general health of the athlete To counsel the athlete In adolescents, to assess maturity To assess fitness level and performance Objectives of the Cardiovascular Part of the Pre-Participation Exam Screen for disqualifying conditions Screen for cardiovascular disorders that require further evaluation and/or future follow-up Prevent sudden death 12

13 Cardiovascular Screening in the Older Athlete Different risk factors to consider vs the young athlete: Hypertension High cholesterol Diabetes mellitus Sedentary lifestyle Smoking history Any family history of heart problems Any prior cardiac tests screening or diagnostic 13

14 The Medical History in the PPE Past illnesses Past surgeries Past injuries, especially those causing missed time from athletic participation Medications attention to those that could affect heart rate or heat intolerance Allergies medications, bee stings Smoking or smokeless tobacco history Alcohol use Drug abuse The Pre-Participation Evaluation: Family History Premature death (sudden and unexpected, or otherwise) before age 50 years due to heart disease, in >1 relative Disability from heart disease in a close relative <50 years of age 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 14

15 The Pre-Participation Evaluation: Physical Examination Heart murmur Auscultation should be performed in supine and standing positions (or with Valsalva) Dynamic murmurs: left ventricular outflow tract obstruction. Femoral pulses to exclude aortic coarctation Physical stigmata of Marfan syndrome Brachial artery blood pressure (sitting position) Preferably taken In both arms. Pre-Participation Screening AHA Guidelines: CV screening in all high school and college athletes before participation in organized sports Repeat every 2 years with interim year history If suspect underlying cardiac disease, refer to specialist (cardiologist) 15

16 AHA Protocol for Screening Easy to implement Replicable Inexpensive Disadvantages: 80% of athletes who die of SCD are asymptomatic Physical exam rarely identifies causes of SCD Benefits of EKG Screening 95% of patients with HCM have abnormal EKG 80% of patients with Right Ventricle Arrhythmias have abnormal EKG A NORMAL EKG has a high negative predictive value (99.98%) for excluding HCM Prospective Italian study showed 90% reduction in SCD when EKG was added 16

17 Is EKG Cost Effective? Cost Considerations of routine EKG Screening ~10,000,000 high school and middle school athletes ($25 per H&P + $50 per EKG) = $750,000,000 15% positive results (false positives, too) of 10,000,000=1,500,000 Repeat H&P=$ D ECHO=$400 $500 x 1,500,000 = $750,000,000 TOTAL for screening= $1.5 BILLION/YEAR Administrative costs ~ $500,000,000 TOTAL for screening= $2.0 BILLION/YEAR AIM 2010 Editorial by Maron: Is ECG Screening Feasible? 15 million athletes and 75 million people under 18 years of age Fewer than 100 sudden deaths in young athletes yearly Inclusion of ECG s may lead to screenings with low specificity and positive predictive value, and 10-20% false positive results 17

18 AIM 2010 Editorial by Maron: Is ECG Screening Feasible? 17% of false-positive results require extensive testing that could promote inappropriate disqualifications and unnecessary anxiety Issues of cost-effectiveness and total national costs Societal, legal and cultural considerations may limit acceptance of mandatory screening Lack of physician and ECG resources Legal liability to physicians responsible for establishing diagnoses and enforcing disqualification Echocardiograms and Screening 1997 Fuller study cost of $200,000 per estimated year of life saved (vs. $44,000 if just use Hx, PE, and ECG) Issues of availability of clinicians and echo machines to screen all young athletes Issues of false positive results and borderline septal and wall thickness results 18

19 Examples of Public Education for Awareness and Treatment of Causes of Sudden Cardiac Death State of Pennsylvania Athlete/Parent/Guardian Sudden Cardiac Arrest Symptoms and Warning Signs Information Sheet and Acknowledgement of Receipt and Review Form What is sudden cardiac arrest? Sudden cardiac arrest (SCA) is when the heart stops beating, suddenly and unexpectedly. When this happens blood stops flowing to the brain and other vital organs. SCA is NOT a heart attack. A heart attack may cause SCA, but they are not the same. A heart attack is caused by a blockage that stops the flow of blood to the heart. SCA is a malfunction in the heart s electrical system, causing the heart to suddenly stop beating. 19

20 Continued How common is sudden cardiac arrest in the United States? There are about 300,000 cardiac arrests outside hospitals each year. About 2,000 patients under 25 die of SCA each year. Are there warning signs? Although SCA happens unexpectedly, some people may have signs or symptoms, such as: dizziness lightheadedness shortness of breath difficulty breathing racing or fluttering heartbeat (palpitations) syncope (fainting) fatigue (extreme tiredness) weakness nausea vomiting chest pains These symptoms can be unclear and confusing in athletes. Often, people confuse these warning signs with physical exhaustion. SCA can be prevented if the underlying causes can be diagnosed and treated. Continued What are the risks of practicing or playing after experiencing these symptoms? There are risks associated with continuing to practice or play after experiencing these symptoms. When the heart stops, so does the blood that flows to the brain and other vital organs. Death or permanent brain damage can occur in just a few minutes. Most people who have SCA die from it. PA Department of Health: Sudden Cardiac Arrest Symptoms and Warning Signs Information Sheet and Acknowledgement of Receipt and Review Form. 7/

21 Continued Act 59 The Sudden Cardiac Arrest Prevention Act (the Act) The Act is intended to keep student-athletes safe while practicing or playing. The requirements of the Act are: Information about SCA symptoms and warning signs. Every student-athlete and their parent or guardian must read and sign this form. It must be returned to the school before participation in any athletic activity. A new form must be signed and returned each school year. Schools may also hold informational meetings. The meetings can occur before each athletic season. Meetings may include studentathletes, parents, coaches and school officials. Schools may also want to include doctors, nurses and athletic trainers. Continued Removal from play/return to play Any student-athlete who has signs or symptoms of SCA must be removed from play. The symptoms can happen before, during or after activity. Play includes all athletic activity. Before returning to play, the athlete must be evaluated. Clearance to return to play must be in writing. The evaluation must be performed by a licensed physician, certified registered nurse practitioner or cardiologist(heart doctor).the licensed physician or certified registered nurse practitioner may consult any other licensed or certified medical professionals. Signature of Student-Athlete, Print Student Athlete s Name,Date Signature of Parent/Guardian,Print Parent/Guardian s Name,Date 21

22 Sudden Cardiac Arrest Education and Information For Coaches What is sudden cardiac arrest? How common is sudden cardiac arrest? Are there warning signs? What are the risks of practicing or playing after experiencing these symptoms? What is the best way to treat Sudden Cardiac Arrest? PA Department of Health: Sudden Cardiac Arrest Symptoms and Warning Signs Information Sheet 7/2012 What is the best way to treat Sudden Cardiac Arrest? Early Recognition of SCA Early access Early CPR Early Defibrillation Early Advance Care PA Department of Health: Sudden Cardiac Arrest Symptoms and Warning Signs Information Sheet 7/

23 PA Act 59 the Sudden Cardiac Arrest Prevention Act (the Act) The Act is intended to keep student athletes safe while practicing or playing. The Act requires: Any student athlete who has signs or symptoms of SCA must be removed from play. The symptoms can happen before, during or after activity. Play includes all athletic activity. Before returning to play, the athlete must be evaluated. Clearance to return to play must be in writing. The evaluation must be performed by a licensed physician, certified registered nurse practitioner or cardiologist (heart doctor). The licensed physician or certified registered nurse practitioner may consult any other licensed or certified medical professionals. I acknowledge that I have reviewed and understand the symptoms and warning signs of SCA. Signature Date References Sudden Death in Young Athletes Maron, BJ, NEJM 2003; 349: Sudden cardiac death in athletes: a guide for emergency physicians Germann, CA; Perron, AD. Am Jour EM 2005; 23: Task Force 1: Preparticipation Screening and Diagnosis of Cardiovascular Disease in Athletes Maron, BJ et al. JACC 2005; 45: Cardiovascular Screening of Student Athletes Lyzinicki, JM et al. Am Fam Physican 2000; 62:

24 References Trends in Sudden Cardiovascular Death in Young Competitive Athletes After Implementation of a Preparticipation Screening Program Corrado, D et al. JAMA 2006; 296(13): Dysrhythmias and the Athlete Trusty, JM et al. AACN 2004; 15(3): Cost Effectiveness analysis of screening of high school athletes for risk of sudden cardiac death Fuller, CM. Med & Sci in Sports Exerc (5): References Baggish AL et al. Cardiovascular Screening in College Athletes With and Without Electrocardiography: A Cross-sectional Study Ann Intern Med. 2010; 152: Lawless, CE and TM Best. Electrocardiograms in Athletes: Interpretation and Diagnostic Accuracy. Med Sci Sports Exerc May; 40(5): Maron, BJ. Hypertrophic Cardiomyopathy and Other Causes of Sudden Cardiac Death in Young Competitive Athletes, with Considerations for Preparticipation Screening and Criteria for Disqualification Cardiol Clin 2007; 25: Mason, PK and JP Mounsey. Common Issues in Sports Cardiology Clin Sports Med 2005; 24:

25 References Diagnostic strategies for common medical problems. Black, Edgar R, et al. Amer Coll of Physicians. 2 nd Edition Harmon, et al. Circulation Apr 19;123(15): Van Camp, Med Sci Sports Exer. 27:641-7,1995 American College of Cardiology Foundation, Sports Cardiology Summit 2012: Protecting the Heart of the American Athlete. October 2012, Washington, DC. 25