The time you won your town the race We chaired you through the market-place; Man and boy stood cheering by, And home we brought you shoulder high.

Transcription

1 The time you won your town the race We chaired you through the market-place; Man and boy stood cheering by, And home we brought you shoulder high. To-day the road all runners come, Shoulder-high we bring you home, And set you at your threshold down, Townsmen of a stiller town. To An Athlete Dying Young Alfred Edward Housman, 1895 Commotio Cordis (6%) Other Non-CV (4%) Heat Stroke (3%) Drugs (2%) Trauma (16%) Cardiovascular Diseases (69%)

2 Tunneled LAD (3%) Sudden Death in Young Athletes Other congenital HD Ion channelopathies Aortic rupture (2%) Sarcoidosis (1%) Dilated C-M (2%) AS (3%) CAD (3%) MVP (4%) ARVC (4%) Other (3%) Normal heart (3%) Myocarditis (6%) Coronary artery anomalies (17%) HCM (36%) Indeterminate LVH - possible HCM (8%) Sudden Cardiac Death in Competitive Athletes Sports Number of Athletes Basketball Football Track and Running Soccer Baseball Swimming Volleyball Ice - Hockey Boxing Crew Ice - Skating Tennis Wrestling Diurnal Distribution of Sudden Death in Young Athletes No. of Athletes HCM Non - HCM Hours

3 12 U.S. Sudden Death in Young Competitive Athletes Registry, (n=1,866) 1 Number of Athletes CV Blunt Trauma All Other Year Highest 25/26 = 76 / y 12 U.S. Sudden Death in Young Competitive Athletes Registry, (n=1,866) 1 Number of Athletes CV Blunt Trauma All Other Year

4 Last 6 years = avg. 66 / y Diseases not reliably detectable by history / physical / ECG = 3% (of ~ 75/y) Therefore, ECG preparticipation screening would identify = 5 athletes/y

5 Obstacles To Screening Denominator Numerator Event Infrequency Participation Rates For Competitive Athletes in U.S. 7 Millions of Athletes High School College Pro ATHLETES OF THE WORLD SUDDEN DEATH IN ATHLETES HCM=35% HCM=.2%

6 Frequency Estimates for Sudden Cardiac Death In Athletes Young (high school / college) : ~1 : 2, Older (runners, including : ~1 : 15, / marathon) ~1 : 5, Importance of Sudden Cardiac Death in Athletes Commands our attention a riveting issue Competitive athletes appear to be the healthiest segment of society Symbolic issue Media driven Preparticipation Athletic Screening USA vs. Italy Criteria USA Italy Basis customary law practice Design history/p.e. also,testing(ecg) Population size too large small enough Examiners M.D. + accredited non-m.d. Sports Med. Legal consequences no precedent civil / criminal

7 AHA Consensus Panel Recommendations for Preparticipation Athletic Screening Family History: 1. Premature sudden cardiac death 2. Heart disease in surviving relatives Personal History: 3. Heart murmur 4. Systemic hypertension 5. Fatigue 6. Syncope/near-syncope 7. Excessive/ unexplained exertional dyspnea 8. Exertional chest pain Physical examination: 9. Heart murmur (supine / standing) 1. Femoral arterial pulses 11. Stigmata of Marfan syndrome 12. Brachial blood pressure measurement (sitting) ITALY ARVC Sudden Death in Young Athletes-Veneto Other congenital HD (1%) Other (2%) Ion channelopathies (2%) Normal heart (2%) Aortic rupture (1%) Sarcoidosis (1%) Dilated C-M (1%) AS (2%) CAD (2%) ARVC (36%) Tunneled LAD (2%) MVP (3%) HCM (4%) Myocarditis (5%) Coronary artery anomalies (13%) Indeterminate LVH - possible HCM (5%)

8 USA HCM Tunneled LAD (3%) Sudden Death in Young Athletes Other congenital HD Ion channelopathies Aortic rupture (2%) Sarcoidosis (1%) Dilated C-M (2%) AS (3%) CAD (3%) MVP (4%) ARVC (4%) Other (3%) Normal heart (3%) Myocarditis (6%) Coronary artery anomalies (17%) HCM (36%) Indeterminate LVH - possible HCM (8%) Center for Sports Medicine Padua, Italy ( ) 33,735 Athletes screened (.7%) 22 HCM By Echo Family History PVC Murmur Abnormal ECG

9 Corrado D et al. JAMA 26 U.S. (Minnesota) Italy (Veneto) Comparison of Cardiovascular Disease Mortality in Young U.S. and Italian Competitive Athletes Veneto Minnesota Population (million) Race (white) ~9% 9% Size (km 2 ) 26, 26, Years screening Total years Total person-y 2.93 M 2.7 M Sudden CV deaths Age at death (mean) 23 y 17 y Deaths Deaths

10 Comparison of Cardiovascular Disease Mortality in Young U.S. (Minnesota) & Italian (Veneto) Competitive Athletes 4.5 p=.2 Athlete Deaths/1, Person-Y Veneto Minnesota p= Years Obstacles to the Italian Screening Initiative in the U.S. Too many athletes; but,why not study all young people? Very uncommon events Too many false positives; also false negatives Cost / efficacy considerations Too many lawyers: liability considerations Would require mandatory system, based in law, in which physicians would be deciders and enforcers No one to perform examinations / interpret ECGs

11 2 p < White Non-White % Of Each Group p =.1 4 p =.4 2 HCM Probable/Definite Coronary Anomalies Myocarditis CAD Coronary Bridging ARVC Cardiovascular Cause of Death Ion Channelopathies MVP Aortic Stenosis Bethesda Conference # 36 Classification Sports (#8) Consensus Panels #2 #3 #4 #5 #6 #7 Congenital Valvular #1 #9 #1 #11 #12 Screening / Dx HCM Other C-M MVP Myocarditis Drugs HTN AED CAD Commotio Arrhythmias Legal Bethesda Conference # 36 Recommendations Athletes with the unequivocal diagnosis of hypertrophic cardiomyopathy should not participate in most competitive sports, with the possible exception of those of low intensity. This recommendation includes those athletes with or without symptoms and with or without left ventricular outflow obstruction.

12 Knapp v. Northwestern School (university) Team physician consultants Expert consensus recommendations (e.g. Bethesda Conference #36)

13 Diseases not reliably detectable by history / physical / ECG = 3% (of ~ 75/y) Therefore, ECG preparticipation screening would identify = 5 athletes/y Corrado D et al. JAMA 26 Comparison of Cardiovascular Disease Mortality in Young U.S. (Minnesota) & Italian (Veneto) Competitive Athletes 4.5 p=.2 Athlete Deaths/1, Person-Y Veneto (.87/1,) p=.38 Minnesota (.93/1,) Years

14 Sudden Death In Young Athletes Commotio Cordis (6%) Other Non-CV (4%) Heat Stroke (3%) Drugs (2%) Trauma (16%) Cardiovascular Diseases (69%)

15 12 U.S. Sudden Death in Young Competitive Athletes Registry, l98-26 (n=1,866) CV Blunt Trauma All Other 1 Number of Athletes Year ADEQUACY OF SCREENING FORMS FOR DETECTION OF C-V DISEASE IN U.S. COLLEGES AND UNIVERSITIES % of NCAA Schools 18% 26% 16% 14% 12% 1% 24% 8% 6% 4% 2% % No. of AHA Recommendations Achieved Sports Screening Process in U.S. High School Athletes 25 4% % of 43 States % No. of AHA Recommendations Achieved

16 % of States Comparison of State History and Physical Examination Preparticipation Screening Forms, 1997 vs Items: 6.7 to % No. Recommended AHA Screening Items % OF 45 STATES M.D./ D.O. R.N. P.A. Chiropractor Others DESIGNATED EXAMINERS 9 2 Comparison of Approved Examiners for Preparticipation Screening, 1997 vs. 25 % of States MD/DO Nurse Practitioner Physician Chiropractor Assistant Examiners Naturopathic Clinicians

17 HCM and Race African- American (5%) White (45%) African- American (55%) White (92%) Competitive Athletes: HCM-related Sudden Death (n=12) Hospital Based HCM Patients (n=1,986) Sudden Death In Young Athletes Commotio Cordis (6%) Other Non-CV (4%) Heat Stroke (3%) Drugs (2%) Trauma (16%) Cardiovascular Diseases (69%) Highest 25/26 = 76 / y

18 12 U.S. Sudden Death in Young Competitive Athletes Registry, (n=1,866) 1 Number of Athletes CV Blunt Trauma All Other Year Last 6 years = avg. 66 / y Diseases not reliably detectable by history / physical / ECG = 3% (of ~ 75/y) Therefore, ECG preparticipation screening would identify = 5 athletes/y

19 Preparticipation Athletic Screening USA vs. Italy Criteria USA Italy Basis customary law practice Design history/p.e. also,testing(ecg) Population size too large small enough Examiners M.D. + accredited non-m.d. Sports Med. Legal consequences no precedent civil / criminal ITALY ARVC Corrado D et al. JAMA 26

20 U.S. (Minnesota) Italy (Veneto) Comparison of Cardiovascular Disease Mortality in Young U.S. (Minnesota) & Italian (Veneto) Competitive Athletes 4.5 p=.2 Athlete Deaths/1, Person-Y Veneto (.87/1,) p=.38 Minnesota (.93/1,) Years Pediatric cardiologists in the U.S. = 1,521 # of athletes to be screened = 12 million # of exams/ecgs to be performed = 7,89 / year = 658 / month = 15 / week

21 12 U.S. Sudden Death in Young Competitive Athletes Registry, (n=1,866) 1 Number of Athletes CV Blunt Trauma All Other Year Commotio Cordis: Sudden Death From Blunt, Non-Penetrating and Relatively Innocent Chest Impact

22 Age at Which 154 Commotio Cordis Events Occurred 3 No. of Victims 2 1 Survivors Non-survivors >25 Age in Years Blunt Chest Blow and Cardiac Arrest : Sports 6 No. of Victims Recreational sports (n=28) Competitive sports (n=78) 1 Baseball Softball Hockey Football Soccer Lacrosse Karate Cricket RugbyBasketball Boxing

23 Commotio Cordis Events Unassociated With Sports Plastic (hollow) toy bat 1 Plastic sledding saucer 1 Playful ( shadow )boxing 6 Hiccups remedy (by friend) 1 Head of pet dog (Collie) 1 Scuffle 2 Parent-to-child disipline 3 Gang rituals 2 Snowball 1 Tennis ball (coin filled) 1 Swing carriage 1 Commotio Cordis : Protection Everyday Activities Sports Education (never strike the chest) AED Chest protectors & Safety-balls

24 Commotio Cordis : Protection Everyday Activities Sports Education (never strike the chest) AED Chest protectors & Safety-balls

25 Robert Gordon Father age 35 Inflicted 2 modest chest blows during tutorial session 11-year old son collapsed immediately Autopsy diagnosis : commotio cordis Father charged with first degree murder Admitted to psychiatric facility Plea bargained involuntary manslaughter Judge imposed 6-18 year sentence

26 Commotio Cordis : Determinants Location Timing Force Compliant chest wall Commotio Cordis : Determinants Location Timing Force Compliant chest wall

27 Chest Impact Sites Implement of Chest Impact (n=22) baseball/softball ice hockey puck lacrosse ball knee

28 Lacrosse Chest Wall Protection Incidence of Ventricular Fibrillation Brine Pro DeBeer Icon GBP Center GBP Side STX Warrior Center Warrior Side None

29 Direct Comparison of Death Rates in Veneto & Minnesota, Veneto Minnesota No. deaths Person-y 1,379, 1,179,69 Death rate/person-y p =.87 HISTORY PHYSICAL EXAM syncope family history of SD heart murmur ECG ECHO Nonobstructive HCM

30 Can Athletic Field Deaths Be Prevented? 35 y Brother SD (age 39) 36 y ICD 5 y 9 y 4 y Generator replaced 41 y Appropriate shock #1 5 y Appropriate shock #2 52 y Present Preparticipation Screening: Is It Worth It? Screening is already customary practice for most high school and college athletes Improved screening on national basis would mean many more new diagnoses 5% of new HCM diagnoses are via screening

31 Wilson Youth Baseball Catchers A3225 Chest Protector Warrior CP Millennium Pro Gear Lacrosse Goalie Chest Pad Obstacles to the Italian Screening Initiative in the U.S. Too many athletes Very uncommon events No one to perform examination / ECGs No one to interpret tests Too many false positives Cost / efficacy considerations and BUSH Too many lawyers: liability considerations

32 Sudden Death in Young Athletes in U.S. One athlete dies q 3 days One athlete w/ HCM dies q 2 wks Gray Zone LV Wall Thickness (13-15mm) HCM Athlete s Heart Unusual Patterns of LVH LV Cavity < 45mm LV Cavity > 55mm LA Enlargement Bizarre ECG Patterns Abnormal LV Filling Female Gender Thickness w/ Decondition Familial HCM/mutation >5ml / kg / min max V 2 ICD - HCM: Appropriate Shocks: Follow-up = 3.7 years % / yr Appropriate Shocks (2%) ICD Discharge Rate 11% 4% 2º prevention 1º prevention

33 Consequences of Medical Evaluations in Young Competitive Athletes Who Died Suddenly 134 Preparticipation evaluation 13 4 No evaluation Standard screening 115 Cardiovascular evaluation 4 Suspicion of 15 C-V disease 1 Correct 7 diagnosis 2 Disqualified Survival Data in Commotio Cordis and Relation to Promptness of CPR by Bystanders 149 (<3 min.) No 56 (>3 min.) CPR 38 Cardiac Rhythm Restored Survived 1 55 Unsuccessful Coma (28%) (2%) Unsuccessful Died Died Died 65 (4%) 416 (22%) Commotio Cordis Blunt Trauma Injury 1866 Unresolved Cases Miscellaneous 154 (8%) 182 (1%) Heat Stroke Drugs 46 (2%) Cardiovascular Other* Pulmonary 34 (2%) Nonexertional (56%) 844 Exertional 67 (4%) 35 (2%) Considered CV event (no precise diagnosis) Confirmed CV event HCM CA Anomalies** Possible HCM Myocarditis ARVC Ion Channel MVP LAD Bridge CAD Aortic Rupture AS Dilated CM WPW Other

34 Pediatric cardiologists in the U.S. = 1,521 # of athletes to be screened = 12 million # of exams/ecgs to be performed = 7,89 / year = 658 / month = 15 / week The time you won your town the race We chaired you through the market-place; Man and boy stood cheering by, And home we brought you shoulder high. To-day the road all runners come, Shoulder-high we bring you home, And set you at your threshold down, Townsmen of a stiller town. To An Athlete Dying Young Alfred Edward Housman, 1895

35 Commotio Cordis (6%) Other Non-CV (4%) Heat Stroke (3%) Drugs (2%) Trauma (16%) Cardiovascular Diseases (69%) Sudden Death in Young Athletes Other (5%) HC (36%) WPW (2%) Possible HCM* ( 8%) Dilated CM (2%) AS (3%) Aortic Rupture (3%) CAD (3%) LAD Bridge (3%) MVP (4%) ARVC (4%) Ion Channel (4%) Myocarditis (6%) Coronary Anomalies (17%) Maron, BJ et. al Circulation : U.S. Sudden Death in Young Competitive Athletes Registry, (n=1,866) 1 Number of Athletes CV Blunt Trauma All Other Year

36 Highest 25/26 = 76 / y Diseases not reliably detectable by history / physical / ECG = 3% (of ~ 75/y) Therefore, ECG preparticipation screening would identify = 5 athletes/y

37 Obstacles To Screening Denominator Numerator Event Infrequency Participation Rates For Competitive Athletes in U.S. 7 Millions of Athletes High School College Pro ATHLETES OF THE WORLD SUDDEN DEATH IN ATHLETES HC=35% HC=.2%

38 Frequency Estimates for Sudden Cardiac Death In Athletes Young (high school / college) : ~1 : 2, Older (runners, including : ~1 : 15, / marathon) ~1 : 5, Importance of Sudden Cardiac Death in Athletes Commands our attention a riveting issue Competitive athletes appear to be the healthiest segment of society Symbolic issue Media driven Preparticipation Athletic Screening USA vs. Italy Criteria USA Italy Basis customary law practice Design history/p.e. also,testing(ecg) Population size too large small enough Examiners M.D. + accredited non-m.d. Sports Med. Legal consequences no precedent civil / criminal

39 Corrado D et al. JAMA 26 U.S. (Minnesota) Italy (Veneto) Comparison of Cardiovascular Disease Mortality in Young U.S. (Minnesota) & Italian (Veneto) Competitive Athletes Athlete Deaths/1, Person-Y p=.2 Veneto (.87/1,) p=.38 Minnesota (.93/1,) Years

40 Obstacles to the National Mandatory Italian Screening Initiative in the U.S. Too many athletes; could screening really be limited to athletes? Very uncommon events Too many false positives; also false negatives Cost / efficacy considerations Infringement on individual prerogative Too many lawyers: liability considerations Would require mandatory system, based in law, in which physicians would be deciders and enforcers No one to perform examinations / interpret ECGs Bethesda Conference # 36 Recommendations Athletes with the unequivocal diagnosis of hypertrophic cardiomyopathy should not participate in most competitive sports, with the possible exception of those of low intensity. This recommendation includes those athletes with or without symptoms and with or without left ventricular outflow obstruction.

41 Commotio Cordis: Sudden Death From Blunt, Non-Penetrating and Relatively Innocent Chest Impact

42 Age at Which Commotio Cordis Events Occurred 3 No. of Victims 2 1 Survivors Non-survivors >25 Age in Years Blunt Chest Blow and Cardiac Arrest : Sports 6 No. of Victims Recreational sports (n=28) Competitive sports (n=78) 1 Baseball Softball Hockey Football Soccer Lacrosse Karate Cricket RugbyBasketball Boxing Commotio Cordis Events Unassociated With Sports Plastic (hollow) toy bat 1 Plastic sledding saucer 1 Playful ( shadow )boxing 6 Hiccups remedy (by friend) 1 Head of pet dog (Collie) 1 Scuffle 2 Parent-to-child disipline 3 Gang rituals 2 Snowball 1 Tennis ball (coin filled) 1 Swing carriage 1

43 Commotio Cordis : Determinants Location Timing Force Compliant chest wall Chest Impact Sites Implement of Chest Impact (n=22) baseball/softball ice hockey puck lacrosse ball knee Commotio Cordis : Determinants Location Timing Force Compliant chest wall

44 Commotio Cordis : Protection Everyday Activities Sports Education (never strike the chest) AED Chest protectors & Safety-balls

45 Commotio Cordis : Protection Everyday Activities Sports Education (never strike the chest) AED Chest protectors & Safety-balls

46 Robert Gordon Father age 35 Inflicted 2 modest chest blows during tutorial session 11-year old son collapsed immediately Autopsy diagnosis : commotio cordis Father charged with first degree murder Admitted to psychiatric facility Plea bargained involuntary manslaughter Judge imposed 6-18 year sentence ITALY ARVC

47 Diurnal Distribution of Sudden Death in Young Athletes No. of Athletes HC Non - HC Hours Pediatric cardiologists in the U.S. = 1,521 # of athletes to be screened = 12 million # of exams/ecgs to be performed = 7,89 / year = 658 / month = 15 / week % of States Comparison of State History and Physical Examination Preparticipation Screening Forms, 1997 vs Items: 6.7 to % No. Recommended AHA Screening Items

48 Knapp v. Northwestern School (university) Team physician Consultants Expert consensus recommendations (e.g. Bethesda Conference #36) AHA Consensus Panel Recommendations for Preparticipation Athletic Screening Family History: 1. Premature sudden cardiac death 2. Heart disease in surviving relatives Personal History: 3. Heart murmur 4. Systemic hypertension 5. Fatigue 6. Syncope/near-syncope 7. Excessive/ unexplained exertional dyspnea 8. Exertional chest pain Physical examination: 9. Heart murmur (supine / standing) 1. Femoral arterial pulses 11. Stigmata of Marfan syndrome 12. Brachial blood pressure measurement (sitting) HC and Race African- American (5%) White (45%) African- American (55%) White (92%) Competitive Athletes: HC-related Sudden Death (n=12) Hospital Based HC Patients (n=1,986)

49 Sudden Cardiac Death in Competitive Athletes Sports Number of Athletes Basketball Football Track and Running Soccer Baseball Swimming Volleyball Ice - Hockey Boxing Crew Ice - Skating Tennis Wrestling