Sudden Cardiac Death in Athletes. Cory J Keller, DO Assistant Professor Orthopedic Surgery and Sports Medicine LKSOM

Transcription

1 Sudden Cardiac Death in Athletes Cory J Keller, DO Assistant Professor Orthopedic Surgery and Sports Medicine LKSOM

2 Objectives Define Hypertrophic Cardiomyopathy (HCM) and HCMs clinical presentation Review screening methods for detecting HCM in athletes Review management strategies for Athletes with HCM

3 Risk of SCD in Exercise 1:15,000 in joggers per year 1:50,000 in marathon participants per year Maron, et al. Risk for sudden cardiac death in marathon runners. J Amer Coll Cardiology, :200, ,000 for high school/college per academic year Van Camp. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc

4 SCD +/- 35 Older than 35 mostly CAD >75% (coronary artery disease) Younger than 35 most commonly Hypertrophic Cardiomyopathy (HCM) Noakes. NEJM Thompson. JAMA Waller. Am J of Card

5 Other Etiologies of SCD < 35yo Coronary artery anomalies Myocarditis Dilated cardiomyopathy Aortic rupture (Marfan s) Genetic conductive system abnormalities Substance abuse (cocaine/steroids) Aortic stenosis Commotio cordis De Noronha. Aetiology of SCD in athletes in the UK. Heart Van Camp. Med Sci Sports Exerc

6 Sudden Cardiac Death Leading cause of death in young athletes 1 in 200,000 per year Males > females (5-9:1) Drezner. Effectiveness of emergency response planning for SCD in US high schools with AEDs. Circulation, Harmon. Incidence and etiology of sudden death in NCAA athletes. Circulation

7 Sudden Cardiac Death Football & basketball highest incidence 50% of all NCAA SCD cases 23% of athletic population 40% African American 1:17,000 vs 1:58,000 AA males 1:13,000 AA male basketball 1:4,000 Harmon. Incidence and etiology of sudden death in NCAA athletes. Circulation

8 Hypertrophic Cardiomyopathy (HCM) Single most common CV cause of SCD in young athletes in US (36%) Males > females Sudden death most common 35 yrs old Van Camp. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc

9 Sudden Cardiac Death < 35 yrs 1435 athletes ( ) 90% male 44% African American 68% football & basketball Maron. Minneaplis Heart Institue Foundation Registry.

10 HCM Characterized by abnormal cardiac wall thickening Typically develops in early adolescent or young adulthood Genetic 55% AD inheritance 45% sporadic mutation (12 mutant genes, 400+ mutations)

11 Hypertrophic Cardiomyopathy (HCM)

12 HCM Pathology LV hypertrophy Most common Subaortic, septal, anterolateral wall (70%) Concentric (8% 10 %) and apical (Japan, < 2%) Septal wall thickness > 16 mm Septum to free wall ratio > 1.3 Non-dilated LV Histology disorganized cellular architecture Maron. Relationship of race to sudden cardiac death in competitive athletes with HCM. J Am Coll Card, 2003.

13 HCM Anatomic Variants

14 Hypertrophic Cardiomyopathy (HCM) Pathology LVH with >16mm septal wall Non-dilated LV Disorganized cellular architecture Septal wall to free wall ratio > 1.3:1

15 Clinical Presentation Can occur at any age Maron. Sudden death in you competitive athletes. JAMA

16 Pathophysiology of HCM Dynamic LV outflow tract obstruction Diastolic dysfunction Myocardial ischemia Mitral regurgitation Arrhythmias

17 Pathophysiology of HCM Arrhythmias: Sustained V-Tach and V-Fib: most likely mechanism of syncope/ sudden death.

18 HCM Physical Exam Murmur with auscultation Harsh quality mid-systolic murmur (3/6) Heard best at left sternal border Louder with maneuvers that decrease preload Louder with Valsalva or standing Quieter with squatting or supine Quieter with maneuvers that increase afterload Isometric handgrip

19 HCM on EKG LVH high QRS voltage ST-T wave changes, often deep inverted T waves Q waves RAD or LAD PR prolongation BBB patterns Drezner. Current controversies in the CV screening of athletes. Curr Sports Med Rep. 2010

20 HCM vs Athlete s Heart Athlete's Heart HCM Septum thickness <15 mm >15 mm Symmetry Yes (for septum and LV wall) No (septum much thicker) Family history None Possibly Deconditioning Reduction within 3 months None Drezner. Current controversies in the CV screening of athletes. Curr Sports Med Rep. 2010

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22 Cardiac US Formerly the gold standard for assessment of HCM Intraventricular septum >13-15mm Left atrial enlargement Diastolic dysfunction Corrado. Screening for HCM in young athletes. NEJM, Now utilizing Cardiac MRI

23 Screening for HCM in Athletes History and Physical Exam EKG Cardiac US Cardiac MRI Considerations Incidence, Population, Cost, False Positives, Study Interpretation

24 ACC/AHA Recommendations 14-Element CV Screening Checklist for Congenital and Genetic Heart Disease Amer College of Cardiology (acc.org) Personal History Family History Physical Exam

25 ACC/AHA Recommendations Personal History 1) Chest pain/discomfort/tightness/pressure realted to exertion 2) Unexplained syncope/near-syncope 3) Excessive exertional and unexplained dyspnea/fatigue or palpitations, associated with exercise 4) Prior recognition of a heart murmur 5) Elevated systemic BP 6) Prior restriction for participation in sports 7) Prior testing for the heart, ordered by a physician

26 ACC/AHA Recommendations Family History 1) Premature death, before age 50 attributable to heart disease in 1 or more relatives 2) Disability from heart disease in close relative <50yo 3) Hypertrophic or dilated cardiomyopathy, long-qt syndrom, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias, specific knowledge of certain cardiac conditions in family members

27 ACC/AHA Recommendations Physical Exam 1) Heart Murmur 2) Femoral pulses to exclude aortic coarctation 3) Physical stigmata of Marfan Syndrome 4) Brachial artery BP (sitting)

28 Interassociation Consensus Statement on CV Care of College Student-Athletes Primary focus of this statement was SCD and the utility of screening with and without EKG Hainline, et al. Journal of the American College of Cardiology. June 2016.

29 Interassociation Consensus Statement on CV Care of College Student-Athletes Recommend History and Physical similar to ACC/AHA guidelines ECG screening can increase the sensitivity to detect potentially lethal cardiac conditions if physician training is improved and cardiology expertise is available. - Using modern standards, distinguishing physiologic changes from those associated with cardiac disorders

30 Sport Classification

31 HCM Return to Play? 36 th Bethesda Conference Guidelines NO participation except Class IA sports (low static, low dynamic)

32 Management All first degree relatives: screening echocardiography/genetic counseling Avoid competitive athletics Prophylactic antibiotics before medical & dental procedures Holter x 48 hours Maron,et al. HCM. Present and Future, with Translation into Contemporary CV Medicine. Jour of Amer College of Cardiology. July 2014.

33 Medical Treatment β- Blockers: Slow HR longer diastolic filling me myocardial O2 consump on myocardial ischemia & LVOT obstruc on CaCh- Blockers Combination of both Maron,et al. HCM. Present and Future, with Translation into Contemporary CV Medicine. Jour of Amer College of Cardiology. July 2014.

34 If Medical Therapy Fails Surgery (Myomectomy) ICD Alcohol Septal Ablation Maron,et al. HCM. Present and Future, with Translation into Contemporary CV Medicine. Jour of Amer College of Cardiology. July 2014.

35 ACLS AED Acute Treatment

36 SCD in Young Athletes Time until Defibrillation Survival declines 7-10% every minute defibrillation is delayed Survival rate as high as 89% in studentathletes

37 Emergency Action Plan Practice, Practice, Practice Account for location, venue, personnel

38 Summary HCM is leading cause of death in athletes <35yrs old Clinical presentation of HCM is variable HCM can have hallmark findings on PE, EKG Screening recommendations for HCM vary Know where the AED is located