39 th National Conference on Pediatric Health Care March 19-22, 2018 CHICAGO Disclosures When the Game Stops: Prevention of Sudden Death in Athletes I have no financial disclosures and will not be discussing any off label use of medications Teresa Whited, DNP,APRN, CPNP PC Learning Objectives Identify risk factors and red flags associated with sudden death in adolescent athletes. Incorporate interventions targeted at primary, secondary, and tertiary prevention of sudden death in adolescent athletes. Evaluate the pediatric nurse practitioner s role in clearance for sports and ongoing evaluation of student athletes to prevent sudden death. 406 Introduction Interest in promoting sports participation Physical health Combat obesity Mental health An estimated 213 million children age 6 and over took part in sports activities in the US in the last year 5 million estimated high school athletes Risk of sudden death increases with sports participation by 2 3 fold Introduction Sudden Death in Young Athletes Sudden collapse of young athlete Wide attention: disproportionate? Was it SCD or something else? No one wants responsibility for missing the athlete at risk who later dies suddenly 1
Incidence of Sudden Death in Young Risk of SD (5% of all deaths) Gen. Pediatric population 1:20 50K Apparently normal child 1:100K Post TOF repair <1:700 Post Senning/Mustard 1:180 Hypertrophic CM 1:167 Brugada syndrome 1:10 Long QT 1:111 Wolff Parkinson White 1:670 ARVD (Arryth. RV dysplasia) 1:50 Incidence of SD in Young Athletes US Studies 1 case:50 100K competitive athletes/yr Male predilection: 5 10 times higher More males participate Intensity of training Independent risk factor for CAD,CM NCCSIR: 16 deaths per year in HS/college 52% white, 44% black European/Italian Ethnic, genetic factors (ARVD) Characteristics of SD in Young Athletes Causes of Sudden Cardiac Death 90% occur after training session or formal athletic contest Nearly 90% occur in presence of teacher or coach 85 95% of SD caused by cardiac sources Hypertrophic Cardiomyopathy Estimated 1:500 general population Most common cause of sudden cardiac death in US in athletes <35 years old Mutation identified in 10 different genes encoding sarcomeric and regulatory proteins Increased Risk Factors: prior aborted arrest, sustained VT,Fam hx of SD,multiple runs of nonsust VT,recurrent exertional syncope,lv wall thickness >30 mm Hypertrophic Cardiomyopathy 90% of athletic deaths in males 70% in football, basketball 60% were high school age Usually asymptomatic prior to collapse, usually in late afternoon or early evening (nonathletes in AM) >40% African Americans (disproportionately high) Inherited form: little LVH <14 yrs old, then rapid progression to maturity Only 3% who died suspected by prior exam 2
Hypertrophic Cardiomyopathy Morphology LV wall thickening with normal or small cavity 75% nonobstructive Heterogeneous Anterior IVS most common 30% only one LV area Apical Average thickness 21 22 mm Coronary Artery Abnormalities Anomalous origin from opposite sinus of Valsalva Anomalous origin from PA Coronary artery fistula Post Kawasaki Early coronary atherosclerosis Other Structural HD assoc w/ SD Myocarditis Dilated cardiomyopathy Aortic rupture Marfan Mitral valve prolapse Congenital Heart Disease Postop TOF, TGA Cong. Corrected TGA AS/AI HLHS (pre stage 2) PVOD Ebstein s Primary Electrical Abnormalities in SCD Inherited or acquired long QT QTc > 460 480 ms, T wave alternans Brugada syndrome RBBB/LAD,inverted T in R precordium Autosomal dominant Primary Electrical Abnormalities in SCD Arrhythmogenic RV dysplasia Prolonged QRS,ST upsloping, T inversion Difficult diagnosis Wolff Parkinson White syndrome 1.5 3.1 : 100,000 in general population SD risk in adults: 1% per 10 years HCM and WPW: familial Catecholamine sensitive VT Bidirectional, polymorphic VT High mortality Commotio Cordis in Young Athletes Approx. 2/3 occur during sports (baseball, hockey, lacrosse, karate) Mechanical injury to chest wall at critical timing 10 30 ms before T wave peak Young more susceptible due to compliant chest wall allowing more energy transfer to heart Reduced risk with safety baseball 3
Primary Prevention Preparticipation Screening Exams Bethesda Conference and AHA recommendations PPE every 2 years, History on intervening years 49 of 50 states require some type of screening 17% of high schools used history form which screened for cardiac SD 97% of NCAA programs required PPE, only 26% met most of AHA recommendations 21 allow nurses or PA s to perform 11 allow chiropractors to perform 78% PPE represents only periodic health exam History Most important Key symptoms Syncope Chest pain Palpitations Dizziness Association with exercise most valuable Family history very significant SD Arrhythmia Inherited diseases (long QT, HCM, Marfan) Medications: prescription, OTC, illicit Components of PPE Components of PPE Examination VS s Weight BP check in sitting position with appropriate size cuff, recheck in 5 10 min if elevated General appearance Marfanoid features Pulses: upper and lower extremity Cardiac auscultation Supine and standing 3.2 13.5% of screened athletes require further testing 0.3 1.3% are denied participation Screening Cardiac Tests for Young Athletes ECG Not specific, not recommended in US Italy: part of PPE for 25 years ECG may be as sensitive as echo as screen for HCM Other ECG detectable diseases ARVD Long QT Brugada WPW Short QT PPE including ECG resulted in 1.8% disqualified In HCM, significant reduction in sports related CV events (2% Italy vs. 24% US) Screening Cardiac Exams for Young Athletes Echocardiograms More sensitive Cost prohibitive e.g. to detect one case of HCM it would cost $250,000 200,000 would have to be screened to find 1,000 at risk and one who would die Exercise Testing MR/High resolution CT Selected cases for suspected coronary anomalies, ARVD Cardiac Cath EP Study Red Flags for SCD in Young Athletes Relationship with presentation Chest pain 4% cardiac cause Syncope <1% cardiac cause Historical clues Association with exercise Palpitations preceding pain/syncope Family history of sudden death, cardiomyopathy, refractory seizures, one car accidents History of prior cardiac surgery Fontan, TOF, L TGA, Mustard/Senning repair for D TGA History of Kawasaki disease, Marfan s, myocarditis,or arrythmia 4
Red Flags for SCD in Young Athletes Physical exam clues Murmur of LVOT obstruction Severe cyanosis Gallop, poor pulses Scar of cardiac surgery Abnormal murmur Arrythmia Referral Indications for referral Frequent or sustained palpitations Syncope or severe dizziness with palpitations Exercise associated palpitations Abnormal resting EKG Family history of HCM,LQTS,sudden death Secondary Prevention for SCD in Young Athletes AED/Lay rescuer Programs Survival drops by 7 10% for every minute AED is not available Increases chance of survival by 9% with lay CPR 24% 60% with AED application 17% of teachers in Midwest study had responded to one or more life threatening emergencies in their careers 1/3 had no CPR training Secondary Prevention for SCD in Young Athletes Project ADAM Not for profit aimed at placing AED and CPR curriculum in high schools Following SCD while playing sports Saved over 100 lives since implementation of the program in 1999 AED s for first responders probably as effective Treatment of Sudden Cardiac Arrest Medical treatment Acute Adenosine Procainamide Esmolol Amiodarone Lidocaine Epinephrine Electrical cardioversion Excellent PALS resuscitation Access to PICU services Access to Ped CV Team Treatment Ablation therapy AV reentrant tachycardia AV nodal reentry tachycardia Automatic ectopic atrial tachycardia Atrial flutter/fibrillation Ventricular tachycardia Pacemakers Anti bradycardia pacing Postoperative sinus/av node dysfunction Anti tachycardia pacing 5
Treatment Defibrillators Primary prevention of sudden cardiac arrest Long QT syndrome Severe HCM ARVD (Arrythmogenic Right Ventricular Dysplasia) Secondary prevention Once in place can abort an arrest scenario by detecting arrhythmia Tertiary No need for external defibrillator unless malfunctioning Tertiary Prevention Restriction Recommendations Resumption of sports in patients with ICD Participation in sports classified as IA (billards, bowling, cricket, curling, golf, riflery) for athletes with an ICD is reasonable if they are free of episodes of ventricular flutter or ventricular fibrillation requiring device therapy for 3 months (Class IIa; Level of Evidence C). Participation in sports with higher peak static and dynamic components than class IA may be considered if the athlete is free of episodes of ventricular flutter or ventricular fibrillation requiring device therapy for 3 months. The decision regarding athletic participation should be made with consideration of, and counseling of, the athlete regarding the higher likelihood of appropriate and inappropriate shocks and the potential for device related trauma in high impact sports (Class IIb; Level of Evidence C). ICD Video: Conclusion MSK injuries are important but do not kill athletes Need to screen for cardiac issues Refer for Red Flags It is essential at all athletic events AEDs CPR training Rapid response Treat appropriately Restrict when needed Allow participation References Bagnall, R.D., et al. (2016). A prospective study of sudden cardiac death among children and young adults. The New England Journal of Medicine, 374 (25), 2441 2452. Chatard, J.C., Goiriena, J.J. & Carre, F. (2016). Screening young athletes for prevention of sudden cardiac death: Practical recommendations for sports physicians. Scandinavian Journal of Medicine & Science in Sports, 26, 362 374. Harmon, K.G., et al. (2015). Incidence, etiology, and comparative frequency of sudden cardiac death in NCAA athletes: A decade in review. Circulation, 1 28. Idriss, S.F, et al. (2017). Prevention of sudden cardiac death in the young: developing a rational, reliable, and sustainable national health care resource. A report from the cardiac safety research consortium. Journal of the American College of Cardiology, 190, 123 131. Lear, A., Hoang, M.H. & Zyzanski, S.J. (2015). Prevention of sudden cardiac death: Automated external defibrillators in Ohio high schools. Journal of Athletic Training, 50 (10), 1054 1058. Lu, J.C., et al. (2017). Development of quality metrics for ambulatory pediatric cardiology: Chest pain. European Society of Cardiology: ESC Virtual Issue: Heart failure, 1 8. Maron, B.J., et al. (2015). AHA/ACC scientific statement: Eligibility and disqualification recommendations for competitive athlets with cardiovascular abnormalities: Task Force 3: Hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis. Journal of the American College of Cardiology, 66 (21), 2362 2371. Piper, S. & Stainsby, B. (2013). Addressing the risk factors and prevention of sudden cardiac death in young athletes: A case report. The Journal of the Canadian Chiropractor Association, 57 (4), 350 355. Project ADAM. (2018). Project ADAM Share of Memory. Retrieved from www.projectadam.com/adamslegacy Rao, A.L, Asif, I.M. & Drezner, J.A. (2013). Secondary Prevention of Sudden Death in Athletes. Cardiac Electrophysiology Clinics, 5, 23 31. Schmied, C. & Borjesson, M. (2013). Sudden cardiac death in athletes. Journal of Internal Medicine, 275, 93 103. Wagener, M.A., Diamond, A.B. & Karpinos, A.R. (2017). Parental knowledge of cardiovascular screening and prevention of sudden cardiac arrest in young athletes. Journal of Community Health, 42, 716 723. 6