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update on sudden cardiac death in athletes and young generation

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update on sudden cardiac death in athletes and young generation

  1. 1. Updates on Sudden Cardiac Death in Athletes and Young Generation DR. TAMER TAHA ISMAIL TAHA CLINICAL ASSOCIATE PROFESSOR AND SPECIALIST DEPARTMENT OF CARDIOLOGY THUMBAY HOSPITAL _DUBAI
  2. 2. EXERCISE IS GOOD
  3. 3. Outline  Exercise : benefits and risk  Athlete’s Heart  Etiology of SCD in young athletes  Etiology of SCD in old athletes  Screening and Pre participation examination  Lowering the risk of SCD
  4. 4. DEFINITIONS FOR THIS TALK  EXERCISE: Any form of physical activity, done on a regular basis, with the purpose of achieving a specific goal • Low level to vigorous • Recreational (including “play”) to competative  ATHLETE: Anyone who is exercising  YOUNG ATHLETE: Less than 35 years old  ADULT ATHLETE: Greater than 35 years old
  5. 5. BENEFITS OF EXERCISE • DISEASE PREVENTION • Cardiovascular • Diabetes • Osteoporosis, joint health • FITNESS • WEIGHT CONTROL • ENJOYMENT • Personal Goals • Competition
  6. 6. COULD “exercise ” CAUSE ANY CARDIOVASCULAR HARM?  ANSWER: YES  THE RISK IS SMALL  THE CONSEQUENCES ARE SIGNIFICANT  WHAT THE RISK IS AND WHAT CONDITIONS ARE RESPONSIBLE FOR THE RISK VARY BY AGE
  7. 7. DETERMINANTS OF EXERCISE RISK 1. Probability of Cardiac Disease 2. Intensity and Duration of Exercise RISK INCREASES WITH INCREASED RISK OF UNDERLYING CVD, INTENSITY, DURATION OF EXERCISE
  8. 8. MEASURING INTENSITY The Metabolic Equivalent or MET is a physiological measure expressing the energy cost of physical activities and is defined as the ratio of metabolic rate during a specific physical activity to a reference metabolic rate 3.5 ml O2/kg/min
  9. 9. MET 1. Sitting……………………………………………….1.0 2. Walking at 2.5 m/h……………………………2.9 3. Biking at 10 m/h……………………………….4.0 4. Elliptical……………………………………………5.5 5. Jogging…………………………………………….7.0 6. Swimming (moderate)……………………..8.0 7. Swimming (hard)…………………………….12.0 8. Running 8 min mile…………………………12.5 9. Bike Racing (not drafting) > 20m/h….16.0
  10. 10. EXERCISE INTENSITY • Light • Daily activities, gentle walk • < 3 METs • Moderate • Brisk walk, easy jog or bike • < 6 METs • Vigorous/Intense • Running, Biking, High Intensity Interval, “Boot Camp” • RPE 7 – 10, METs > 6
  11. 11. EXERCISE DURATION  Dehydration  Electrolyte changes  Increased inflammation  Hyperthermia Most cardiac events during marathons occur past the 22.5 mile marker
  12. 12. RECOMMENDED DURATION (health and fitness goal) American Heart Association 150 min/week of moderate exercise 75 min/week of vigorous exercise OK to break it up
  13. 13. Gangasani, S. R. et al. Chest 2000;118:249-252 Physiologic alterations accompanying acute exercise and recovery, and their possible sequelae
  14. 14. Definition of sudden cardiac death Non-traumatic, unexpected fatal event occurring within 1 hour of the onset of symptoms in an apparently healthy subject. If death is not witnessed, the definition applies when the victim was in good health 24 hours before the event.
  15. 15. Who are we talking about, what are the numbers
  16. 16. THE YOUNG ATHLETE AND THE RISK (US numbers) • All deaths related to exercise: 120/year (excluding trauma) • Deaths caused by CVD: < 100/year • Approximately 1 CVD death/100,000/year • All the “conditions” that might harm athletes are just as prevalent in non-athletes. Athletes are at higher risk.
  17. 17. THE YOUNG ATHLETE A SAMPLING OF THE CAUSES  Structural Heart Disease • Hypertrophic Cardiomyopathy • Anomalous Origin of the Coronary Arteries • Arrhythmogenic Right Ventricular Cardiomyopathy • Myocarditis/Cardiomyopathy • Valvular Disease  The “Channelopathies”  Drugs
  18. 18. 18
  19. 19. THE ADULT ATHLETE • Harder to define the numbers and risk • Heart disease is common among adults • Exercise programs vary • No organized reporting program • Marathoners: <1/100,000 • Recreational runners: 1/10,000/year . • Individuals with disease are 2 -3-X more likely to have an event during exertion.
  20. 20. THE ADULT ATHLETE A SAMPLING OF THE CAUSES Coronary Artery Disease Valvular Heart Disease Cardiomyopathy “Young Athlete” Disease
  21. 21. THE YOUNG ATHLETE SPECIFIC EXAMPLES
  22. 22. HANK GATHERS 1967 - 1990
  23. 23.  Fabrice Muamba 1988-2012
  24. 24. HYPERTROPHIC CARDIOMYOPATHY
  25. 25. HYPERTROPHIC CARDIOMYOPATHY • Affects 1 in 500 individuals • Genetically determined • Sporadic or inherited • At least 11 genes, 1400 mutations • Accounts for 35 – 40% of athletic deaths • Can be symptomatic/detectable before SCA • Increased risk with age • Ventricular arrhythmia is primary cause of death
  26. 26. Risk Factors for Sudden Death in HOCM Major - Out of hosp arrest or VT - FH sudden death and HOCM Minor - NSVT on Holter - Drop in BP on TMET - Thallium perfusion defects - Young male - History of syncope - Septal thickness
  27. 27. ANOMALOUS ORIGIN OF THE CORONARY ARTERIES
  28. 28. ANOMALOUS ORIGIN OF THE CORONARY ARTERIES • Accounts for 15 – 20% of sudden death in young athletes • Can be symptomatic (< 50%) • Chest discomfort • Shortness of breath • Palpitations • Fainting • Treatment: Medical or Surgical • May be “cleared” to participate if corrected
  29. 29. ARRYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY
  30. 30. ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY  Prevalence: 1/1000 – 2000  Genetic, 30% inherited.  Accounts for 5% of sudden death in young athletes  Can be symptomatic: palpitations, fainting  Treatment: medical, ICD  Disqualified from competitive sports
  31. 31. MYOCARDITIS/CARDIOMYOPATHY
  32. 32. MYOCARDITIS/CARDIOMYOPATHY  Accounts for 5 -10% of sudden cardiac arrests in young athletes  Causes: “viral”, inherited/genetic, idiopathic  Can be symptomatic: shortness of breath, palpitations, fatigue/weakness, fainting, chest discomfort  Disqualified from most competitive sports. May return if recover.
  33. 33. COMMOTIO CORDIS  Vulnerable moment  High force, specific area  Baseball, hockey, karate  Kids more vulnerable  20% survival  Boys > girls
  34. 34.  Ephedrine and its analogues  Anabolic steroids  Gama hydroxybutyrate  Cocain  Ephedrine and its analogues  Anabolic steroids  Gama hydroxybutyrate  Cocain Illicit Drugs Used By Athletes During Competitive Sports Illicit Drugs Used By Athletes During Competitive Sports
  35. 35. INHERITED ARRHYTHMIA and SUDDEN CARDIAC ARREST THE “CHANNELOPATHIES”
  36. 36. WHAT IS A CHANNEL?
  37. 37. THE CHANNELOPATHIES AND SUDDEN CARDIAC ARREST  Long QT Syndrome  Brugada Syndrome  Catecholaminergic Polymorphic Ventricular Tachycardia  Short QT syndrome
  38. 38. THE CHANNELOPATHIES: LONG QT • Not rare: 3000 – 4000 deaths/y in children/adolescents • Inherited/genetic • 12 types/genes, hundreds of different mutations • Variable “lethality” • AR associated with deafness • Variable expression • Acquired form • Medications/drugs • Electrolyte changes • Increased risk of SCA with exercise, risk variable based on type • SCA in athletes: not rare, numbers not clear • ECG + , gene +, symptom + : Disqualified from competitive sports
  39. 39. ACQUIRED LONG QT • Medications: www.qtdrugs.org • Antiarrhythmics • Antibiotics: Levaquin, Zithromax (Z pack), erythromycin • Antidepressants: Tricyclics, Prozac, Celexa • Tamoxifen • diuretics • 140 other drugs • Methadone • Combinations of drugs • Electrolytes: Low K+, Mg++, Ca++ • Genetic + Drugs, ? Unmasked congenital form • Reversible
  40. 40. THE CANNELOPATHIES BRUGADA SYNDROME • Genetic • Genetic testing variable • Na+ channel • EKG variable • Provocative testing • Multiple types • Male > Female • Avg age at DX: 41 • Fever/hyperthermia trigger • Night time trigger • Treatment: ICD, limited medications • Caution advised for competitive sports with no history of events • With history of events or ICD low level sports only
  41. 41. THE CHANNELOPATHIES: CATECHOLAMINERGIC POLYMORPHIC VT
  42. 42. CPVT • Genetic, at least 2 gene mutations • Inherited • Emotional and physical triggers. Symptoms: dizziness and syncope • Usually presents in childhood and adolescence • Treatment: Medical therapy, ICD + medical, Sympathectomy, Medical therapy for gene + asymptomatic. • Generally recommend against competitive sports, ICD precludes contact sports
  43. 43. OTHER ARRHYTHMIA WOLFF PARKINSON WHITE • 1/400 • Often Incidental finding • Can present with symptoms • Often first diagnosed in adulthood • Risk of V-fibrillation • Risk stratify asymptomatic Pts • Ablation • OK to participate in competitive sports once treated
  44. 44. THE ADULT ATHLETE CARDIOVASCULAR DISEASE IS THE PRIMARY CAUSE OF DEATH IN ADULT ATHLETES
  45. 45. WHAT IS THE RISK?  800,000 Heart attacks/year  400,000 Sudden Cardiac Death  Sudden Death: First symptom in 50%  2 – 3 X as likely to suffer a cardiac event during exercise in those with disease
  46. 46. THE ADULT ATHLETE  Primary Cause: Coronary Artery Disease  Cardiomyopathy  Vascular Disease  Arrhythmia  Valvular Heart Disease
  47. 47. THE ADULT ATHLETE The adult athlete can still have almost any of the conditions of the young athlete.
  48. 48. CORONARY ARTERY DISEASE STILL NUMBER ONE
  49. 49. JIM FIXX 1932 - 1984
  50. 50. FACTORS INCREASING THE LIKLIHOOD OF CORONARY ARTERY DISEASE NON-TRADITIONAL  Cholesterol variants • Lp(a) • Particle size  Genetic  Vascular physiology/metabolism  Inflammation
  51. 51. GLOBAL RISK THE GREATER THE NUMBER OF RISK FACTORS, THE GREATER THE RISK
  52. 52. ISCHEMIA AND SCD DEMAND > SUPPLY ISCHEMIA CHEST PAIN SOB PERFORMANCE NON-LETHAL ARRYTHMIA LETHAL ARRHYTHMIA
  53. 53. OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISE DILATED CARDIOMYOPATHY HYPERTROPHIC CARDIOMYOPATY
  54. 54. OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISE AORTIC DISSECTION  Risk Factors: ASCVD, especially hypertension  Sporadic, associated with aneurysm, genetic  Sheer force  Increased risk with high static component exercise
  55. 55. OTHER POTENTIAL LETHAL CARDIAC DISEASE AND EXERCISE VALVULAR HEART DISEASE  Aortic stenosis  Aortic insufficiency  Mitral Valve Prolapse
  56. 56. NONLETHAL ARRHYTHMIA ATRIAL FIBRILLATION SUPRAVENTRICULAR TACHYCARDIA
  57. 57. EXERCISE AND NONLETHAL ARRHYTHMIA  European Heart Journal 2014  52,000 players  Mean age: 38  Twice the risk of non-athletes  Higher risk with faster times  Mechanism: ? inflammation
  58. 58. SCREENING GOAL  To identify those at risk  Prevent injury and lethal events TO ASSIST YOUNG ATHLETES AND THEIR FAMILIES IN MAKING RATIONAL DECISIONS REGARDING THE RISK OF ATHLETIC PARTICIPATION
  59. 59. Athlete’s Heart  Isometric sporting activities cause structural remodeling and increase in cardiac mass (physiologic hypertrophy).  Increased volume of ventricular chambers  Increased size of L atrium and L ventricular wall thickness  However, systolic/diastolic functions is maintained  Occurs in M>F with size related to lean body mass.  May be 2ry to genetics  The amount of exercised-induced LVH in endurance athletes associated with ACE genotype.
  60. 60. Athlete’s Heart  ECG’s  Findings in Athletes considered WNL  Sinus Bradycardia – as low as 30-40 bpm  Various A/V blocks occur in up to 33% of athletes  First Degree (PR>0.2) – Most Common  Second Degree (Mobitz-1 or Wenkeback)  Increased R or S wave voltage without Left axis deviation, QRS prolongation, or LAE  U-waves with up-sloping ST segments and normal T waves  Incomplete RBBB
  61. 61. SCREENING YOUNG ATHLETES • Recommendations vary widely internationally. • Recommendations vary widely based on level of participation • Not clear if definitely reduces risk • Findings variable with time • Variable age of onset • These are relatively rare diseases • Needs to be done regularly until adult age
  62. 62. THE PREPARTICIPATION EXAM  Review for symptoms • Dizziness or fainting, shortness of breath, palpitations, chest discomfort, can’t keep up  Family History • Premature death • “Death under unusual circumstances”  Physical exam • Murmurs, build, pulses
  63. 63. WHAT ABOUT ECGs • Not recommended routinely in US • Required in Europe • Controversial • Not clear it helps • Athletes often have ECG changes that are “normal” • False negatives, False positives • Cost of ECGs, Cost of additional testing, Cost of disqualifying athletes • Estimated $80,000 to find one case
  64. 64. LOWERING RISK IN THE YOUNG ATHLETE • Pre participation Exam • Parental involvement in children and adolescents • Coaches/trainer/athlete awareness • Symptom awareness • Workout/practice design • Hydration/electrolyte replacement • AEDs in close proximity when feasible and AED training • CPR training of coaches/trainers/athletes
  65. 65. Take Home Messages  EVERYBODY SHOULD EXERCISE  EXERCISE CARRIES A SMALL RISK OF A CARDIAC EVENT THAT IS “AGE” SPECIFIC  GET APPROPRIATE “SCREENING”  DON’T IGNORE SYMPTOMS. THERE IS NO LIFETIME WARRANTY FROM A SINGLE SCREENING
  66. 66. Take Home Messages  Arrhythmias are very common in athletes.  Those associated with structurally normal hearts are benign and should not cause disqualification.  Those with heart disease can cause serious or catastrophic effects.
  67. 67. Take Home Messages  The commonest diseases associated with life threatening arrhythmias in the young are HOCM and congenital coronary anomalies.  The commonest disease associated with life threatening arrhythmias in the older athletes is premature ischemic heart disease.  Screening of persons going into competitive games is difficult but essential.

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