SCREENING AND PREVENTING SUDDEN CARDIAC DEATH IN EXERCISE
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1 SCREENING AND PREVENTING SUDDEN CARDIAC DEATH IN EXERCISE Adj Assc Prof Tong Khim Leng MBBS MRCP FACC FASE FAMS FRCP Chief, Sn Consultant Department of Cardiology Changi General Hospital
2 My Disclosures No Money When I was still young.
3 Did Pheidippides die from SCD or was it heat stroke? Pheidippides, a running courier, ran the 40 km (25 miles) from Marathon to Athens to announce the Greek victory (490BC), and then collapsed and died of sudden death.
4 Modern day Pheidippides
5 Definition of Sudden Cardiac Death Death from cardiac causes, heralded by abrupt loss of consciousness, within 1 hour of the onset of acute symptoms
6 Epidemiology of SD on athletes 90% of SD in athletes are SCD, without prior warning Only minority ( 11%) survive a SCA despite witnessed collapse and prompt resus
7 Risk of SCD during exercise Physician Health Study 12 yrs, male physicians 40 to 84 yrs old 1. Relative risk of SD after vigorous exertion was Absolute risk is v low 1 per 1.51 million - Sports Paradox 3. Habitual vigorous exercise attenuate the risk of SD
8
9 Young Athlete < 35 yrs old Older Athlete 35 yrs old Hereditary causes of SCD occurs mainly in the young athletes, acquired CAD mainly in older athletes, but there is no absolute cut-offs. Thus, athletes in their thirties and forties are at greatest risk of sudden cardiac death caused by both inherited and acquired causes. J Am Coll Cardiol Img. 2013;6(9): doi: /j.jcmg Date of download: 7/22/2015 Copyright The American College of Cardiology. All rights reserved.
10 Sports engaged in at the time of sudden death (SD) in 820 sports participants. Eloi Marijon et al. Circulation. 2011;124: Copyright American Heart Association, Inc. All rights reserved.
11 VT/VF is the final common pathway (so, exercise with AED nearby, within 3 mins ) Possible triggers include: 1. Sympathetic activation 2. Electrolytes abnormalities 3. Haemostasis 4. Haemodynamic factors
12 Individualised Risk of SCD = 1. Desired exercise intensity x Subjective measures Physiological measures Absolute Intensity Talk Test Maximal HR% METs Light Talk and sing <64 <3 Moderate Talk but can t sing Vigorous Difficult talking >76 >6 Predicted max HR = age 2. Number of CAD risk factors / underlying CVS disease/cad equivalents (DM, PVD, Symptomatic carotid disease, Framingham risk score 20%) x 3. Male:female = 9:1 x 4. Age
13 How can we prevent SCD during exercise? 1. Preparticipaton Screening 3. Educating doctors 5. Resus personel and equipments 2. Eligibility for competition per established guidelines 4. Educating athletes, laymen (bystander CPR) ACSM /AHA : Exercuse and Acute Cardiovascular events: placing the risks into perspective. Med Sci Sports Exerc. 2007;39(5):886-97
14 Objective of Preparticipation Screening To identify and withdraw from intense exercise (eg weight loss program, loss to win) and competition those perceived to be at risk in an effort to reduce likelihood of SCD and to allow preventive interventions... Predicated on the likelihood that intense exercise increases risk of SCD Universal consensus that some kind of PPS is necessary, question is what?
15 Clinical approach to PPS and CVS risk reduction in exercise: Greatest utility in the previously sedentary individual Date of download: 3/19/2016 Copyright The American College of Cardiology. All rights reserved.
16 PAR-Q Step 1. Self Assessment of Risk Balady et al Circulation 1998;97:
17 AHA recommends - Hx - PE (1996, 2007, 2014) Basic Hx and PE are still key
18 No Consensus on the screening ECG - To mandate or not to mandate?
19 Values of ECG Gold standard for detection of WPW, ionchannelopathies eg long and short QT syndrome, Brugada syndrome True positives 95% of HCM, 80% ARVD, 85% Long QT syndrome, Brugada syndrome. High negative predictive value (99%) in excluding cardiomyopathy Increase the sensitivity of detection of lethal CVS conditions
20 False negatives Limitations of ECG Miss congenital coronary anomalies and premature CAD Miss intermittent QT prolongation, concealed WPW, some HCM / ARVDs High false positives (20% ) in athletes Training-related physiological ECG changes mimic pathological changes Leads to more unneccessary investigations and more costs Recent Guidelines on ECG interpretations in Athletes (Seattle and Refined Criterias in Athlete) reduces false positives to <6% ( FOC!!
21 Population wide screening ECG is not cost effective due to low prevalence rate of SCD Italy state sponsored, 30 euros pp Screen 1 million young athletes to save 36 lives 1 million euros to save 1 life USA (assuming 10 million athletes, prevelence 1.8/10000) USD $3.4 million to prevent 1 death Independent self financed sports organisations eg. NBA, singapore sports school, FAS
22 NCAA guidelines 18 April All NCAA member schools must have and practice a response plan to aid a victim of cardiac arrest in both competition and practice settings. 2. The team physician should review or conduct the sports physical. 3. Said sports physical should include the AHA's 14-point cardiac health questionnaire and a physical exam. 4. If the screening ECG is used, it should be interpreted with modern standards.
23 Sokolow Criterias for LVH -> 35 mm if > 40 yrs -> 40 mm if yrs -> 60 mm if yrs Cornell Criteria (most accurate) -R avl + S V3 ->28 in males ->20 in females Look for associated left atrial enlargement, left axis deviation, repolarisation abnormalities ST-T changes, pathological Q waves S V1 + R V5 or V6 = = 46 mm (?LVH)
24 ESC criteria 2010
25 Seattle Criterias 2013
26
27 Refined Criteria is best for now!
28 Issues: Screening Echo in Athletes 10X more expensive than ECG (S$350), greater costeffectiveness issue than ECG Limitations: False Positive Differentiation between athlete s heart and mild dcmp or HCM False Negative <14 yrs old patients with HCM Values, mainly in young athletes: identify coronary anomalies imaging modality of choice in detection of HCM (only 5%) Potential role of cheaper abbreviated 5 min echo
29 PPS for the Older Athletes Focus on detection of CAD Resting 12 lead ECG is inaccurate in detecting CAD. Role of screening treadmill test who needs it? Limitations of treadmill test in asymptomatic individual
30 Typical profile of middle-aged SCD during Marathon Asymptomatic Male (male: female = 9:1) No prior documentation of heart disease Cardiac arrest due to VF Post-mortem : obstructive epicardial coronary plaques in 71 87% 1 mile away from finishing line
31 Limitations of Screening Exercise Testing Good prognostic value in symptomatic patients Low sensitivity and specificity, poor positive predictive value and high false positives in prediction of exercise-related MI and SD in asymptomatic individuals due to low event rates Symptomatic Sens 68% Spec 77% Asymptomatic Sens 46% Spec 16% False negative Treadmill testing marathon/triathlon Prevalence rate of SCD in marathons/triathlons is too low to warrant routine screening
32 Other reasons for exercise testing Indications for ETT that are not related to prediction of MI or SD - Exericse prescripton - Exercise related arrhythmias, abnormal BP responses - Reassurance from normal test might encourage more vigorous exercise - Intensify risk factors control if ETT suggests increased risk of all cause death
33 ACSM 2015 Based on 1. current level of physical activity 2. Desired exercise intensity 3. Presence of signs or symptoms or/and known CVS, metabolic and renal disease
34 Who are considered high CVS risk? 1. Known CVS, renal and metabolic disease (ACSM) 2. CAD equivalents (NCEP) 1. DM 2. PVD 3. Symptomatic carotid disease 4. Framingham risk score 20% 3. Master Athletes 65yrs 4. Master Athletes male>40yrs, female>50 yrs with 1 risk factor 5. Multiple risk factors 6. Anyone with symptoms
35 Effectiveness of CPR and AEDs in a collapsed athlete Results: Of 10.9 million runners, 59 cardiac arrest ( incidence rate 0.54 per participants)... Incidence rate significantly higher during marathons than half-marathons (1.01 vs 0.27).. among men than women (0.9 vs 0.16 per ).... Initiation of bystander CPR and an underlying diagnosis other than hypertrophic CMP were the strongest predictors of survival. Conclusions: Marathons and half marathons are a/w low risk of SCA... Occurs primarily in male marathon participants; the incidence rate in this group has increased during past decade (0.71 to 2.03 per , p =0.01).
36 18 April 2016
37 Eligibility Recommendations for Competitive Sports in Athletes with CVS abnormalities
38
39 Benefits of exercise negated at > 7 miles (11.2km) /hr Benefits of exercise negated at > 20 miles (32 km) /wk n= 52000, fu 30 yrs 19% mortality reduction in runners Lee DC, Blair SN et al. Med & Science in Sports & Exercise 2012;44(5):S699
40 The right amount of nourishment and exercise, not too much, not too little, is the safest way to health HIPPOCRATES ( BC) Father of Medicine Contemporary of Pheidippides
41
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