sudden cardiac death in young athletes common

a sudden death in young people especially athletes who are previosly healthy is a painful scenario especially during a game. most of these deaths are preventable if every athlete undergoes a routine medical examination & history taking

1. Sudden Cardiac Death Sudden Cardiac Death
in Young Athletes in Young Athletes
Yann Ping Pan, MDYann Ping Pan, MD
Ruey-Kang Chang, MD, MPHRuey-Kang Chang, MD, MPH

2. What do they have in common?What do they have in common?

Hank Gathers (1967-1990)Hank Gathers (1967-1990)

Reggie Lewis (1965-1993)Reggie Lewis (1965-1993)

Flo Hyman (1954-1986)Flo Hyman (1954-1986)

Sergei Grinkov (1967-1995)Sergei Grinkov (1967-1995)

Pete Maravich (1947-1988)Pete Maravich (1947-1988)

7. Athlete SCD– why is it importantAthlete SCD– why is it important

Family physicians see a lot of athletes for sports Family physicians see a lot of athletes for sports
related issuesrelated issues

Family physicians are involved in school health Family physicians are involved in school health
and pre-participation examinationsand pre-participation examinations

It is important to know the clinical It is important to know the clinical
characteristics of SCD and identify athletes who characteristics of SCD and identify athletes who
are at risk are at risk

It is important to know the current It is important to know the current
recommendations for pre-participation recommendations for pre-participation
examinationsexaminations

8. What do we know about SCD in Athletes?What do we know about SCD in Athletes?

12-15 million young (<30 years) competitive 12-15 million young (<30 years) competitive
athletes in the US athletes in the US

Estimated incidence of sudden cardiac death at Estimated incidence of sudden cardiac death at
2.1 per 100 000 athletes per year 2.1 per 100 000 athletes per year

Estimated 200 athletes in the US die per year of Estimated 200 athletes in the US die per year of
sudden cardiac deathsudden cardiac death

Sudden death of the young athletes is mostly Sudden death of the young athletes is mostly
unexpected, dramatic, tragic and carries huge unexpected, dramatic, tragic and carries huge
emotional impact on the society emotional impact on the society

9. Epidemiology Based on Autopsy SeriesEpidemiology Based on Autopsy Series

Age--Age--

9% in middle school9% in middle school

62% in high school62% in high school

22% in college22% in college

7% in professional7% in professional

Sex—90% male, 10% femaleSex—90% male, 10% female

Caucasians at highest risk Caucasians at highest risk
Sudden Cardiac Death of Athletes
Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

10. Sports engaged in at the Sports engaged in at the
time of sudden deathtime of sudden death
0
10
20
30
40
50
B
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F
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T
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S
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B
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No of athletes
Maron BJ et al, JAMA 1996 ; 276 : 199 - 203
Sudden Cardiac Death of Athletes

11. Causes of Sudden Cardiac Deaths Causes of Sudden Cardiac Deaths
in Young Athletesin Young Athletes
Sudden Cardiac Death of Athletes
Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

12. Research QuestionsResearch Questions

What are the epidemiologic characteristics of What are the epidemiologic characteristics of
athlete SCD from the an active surveillance, athlete SCD from the an active surveillance,
population-based sample?population-based sample?

What are the major causes for athlete SCD from What are the major causes for athlete SCD from
the an active surveillance, population-based the an active surveillance, population-based
sample?sample?

13. ObjectivesObjectives

To evaluate an active surveillance system of To evaluate an active surveillance system of
athlete SCD from a population-based sample athlete SCD from a population-based sample
using Google Internet search engineusing Google Internet search engine

To compare the active surveillance of athlete To compare the active surveillance of athlete
SCD by Google with reported athlete SCD data SCD by Google with reported athlete SCD data
using autopsy or passive report systems using autopsy or passive report systems

14. MethodsMethods

Advanced Google Internet search was conducted once Advanced Google Internet search was conducted once
a week (every Friday) from April 2007 to March 2008a week (every Friday) from April 2007 to March 2008

Combinations of keywords were used– athlete, player, Combinations of keywords were used– athlete, player,
practice, game, collapse, pass out, die, gym class, etc.practice, game, collapse, pass out, die, gym class, etc.

Only US athletes died in a game or practice or Only US athletes died in a game or practice or
immediately after, occurred in the USimmediately after, occurred in the US

Age 11 to 30 years, death between 4/07 to 3/08Age 11 to 30 years, death between 4/07 to 3/08

Exclusions– known cardiac history, trauma, non-US Exclusions– known cardiac history, trauma, non-US
athletes, died in sleep or at home, possible drugs or athletes, died in sleep or at home, possible drugs or
alcohol, alcohol,

17. MethodsMethods

First 200 Google search results are carefully First 200 Google search results are carefully
examinedexamined

For cases that fulfill inclusion criteria, the web For cases that fulfill inclusion criteria, the web
pages are printed/savedpages are printed/saved

All demographic data, history and circumstances All demographic data, history and circumstances
(CPR, use of AED), are recorded and compiled (CPR, use of AED), are recorded and compiled
for analysisfor analysis

Autopsy results are searched 1 month to 12 Autopsy results are searched 1 month to 12
months later to determine the cause of death months later to determine the cause of death

18. ResultsResults

Total of 74 athletes died in April 2007 to March Total of 74 athletes died in April 2007 to March
2008 in a game or during or after practice 2008 in a game or during or after practice
(comotio cordis are excluded)(comotio cordis are excluded)

25 athletes died in a game (34%), and 49 died in 25 athletes died in a game (34%), and 49 died in
or after practice (66%)– consistent with the or after practice (66%)– consistent with the
literature or 1:2literature or 1:2

Most common sports are basketball and Most common sports are basketball and
football– consistent with the literaturefootball– consistent with the literature

19. ResultsResults
Age at Death
0
2
4
6
8
10
12
14
1112131415161718192021222526272830
Age (yrs)
N
u
m
b
e
r

o
f

D
e
a
t
h
s

20. F:M= 1:3
Sudden Cardiac Death of Athletes
Female Male

21. Race and EthnicityRace and Ethnicity
Asian, 3%
Black, 28%
Hispanic, 4%
White, 54%
Unknown, 11%

22. Baseball
Boxing
Dancing
Martial arts
physical training
Running
video game
Water ski
World's strongest
man competitor
Basketball, 28%
Gym class, 15%
Football, 12%
Running, 9%
Track, 8%
Cross country, 3%
Hockey, 3%
Lacrosse, 3%
Marathon, 3%
Soccer, 3%
Swimming, 3%
Others, 11%
Sports Associated with SCD

23. Sudden Cardiac Death of Athletes
Maron BJ et al, JAMA 1996 ; 276 : 199 - 203
Basketball, 28%
Gym class, 15%
Football, 12%
Running, 9%
Track, 8%
Cross country, 3%
Hockey, 3%
Lacrosse, 3%
Marathon, 3%
Soccer, 3%
Swimming, 3%
Others, 11%
0
10
20
30
40
50
B
a
s
k
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t
b
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F
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b
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B
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No of athletes

24. HCM, 33%
Cardiac, 19%Inconclusive, 12%
Arrhythmia, 10%
Coronary, 10%
Marfan, 10%
Myocarditis, 4%
Atherosclerosis,
2%
MVP, 2%
Causes of SCD

25. Maron BJ et al, JAMA 1996 ; 276 : 199 - 203
HCM, 33%
Cardiac, 19%Inconclusive, 12%
Arrhythmia, 10%
Coronary, 10%
Marfan, 10%
Myocarditis, 4%
Atherosclerosis,
2%
MVP, 2%

26. ConclusionConclusion

Excluding comotio cordis, there are 74 SCD of young Excluding comotio cordis, there are 74 SCD of young
athletes in the US in 2007-2008athletes in the US in 2007-2008

1/3 SCD occurs in a game, 2/3 in practice1/3 SCD occurs in a game, 2/3 in practice

Including gym class death, there are more females than Including gym class death, there are more females than
previously describedpreviously described

Blacks may be at higher risk, ore studies neededBlacks may be at higher risk, ore studies needed

Basketball and football are common sports associated Basketball and football are common sports associated
with SCDwith SCD

HOCM/LVH accounts for almost 50%, coronary HOCM/LVH accounts for almost 50%, coronary
anomaly and arrhythmia are next common causesanomaly and arrhythmia are next common causes

28. Circulation 2007;115;1643-1655
Sudden Cardiac Death of Athletes

29. Endorsement of AHA GuidelinesEndorsement of AHA Guidelines

American Academy of Family PhysiciansAmerican Academy of Family Physicians

American Academy of PediatricsAmerican Academy of Pediatrics

American College of CardiologyAmerican College of Cardiology

American College of Sports MedicineAmerican College of Sports Medicine

American Medical Society for Sports MedicineAmerican Medical Society for Sports Medicine

American Orthopaedic Society for Sports American Orthopaedic Society for Sports
Medicine Medicine

American Osteopathic Academy of Sports American Osteopathic Academy of Sports
Medicine Medicine

30. European Guidelines for PPEEuropean Guidelines for PPE

In 2005, The European Society of Cardiology In 2005, The European Society of Cardiology
issued official recommendation for PPE, issued official recommendation for PPE,
including 12-lead ECGincluding 12-lead ECG

31. Coronary Artery AnomalyCoronary Artery Anomaly
Sudden Cardiac Death of Athletes

32. Coronary Artery AnomalyCoronary Artery Anomaly

With increased stroke volume during exercise ascending With increased stroke volume during exercise ascending
aorta expands and the take-off angle is further aorta expands and the take-off angle is further
exaggeratedexaggerated

LMCA may also be compressed against root of LMCA may also be compressed against root of
pulmonary trunk during exercisepulmonary trunk during exercise

ECG is likely normalECG is likely normal

Very difficult to screen or diagnose even with Very difficult to screen or diagnose even with
echocardiogramechocardiogram

Treatment: Surgery for coronary reimplantation Treatment: Surgery for coronary reimplantation
Sudden Cardiac Death of Athletes

33. Commotio CordisCommotio Cordis

Sudden disturbance of heart rhythm as the result of a Sudden disturbance of heart rhythm as the result of a
blunt, non-penetrating impact to the precordial regionblunt, non-penetrating impact to the precordial region

Impact occurring within a specific 10-20 millisecond Impact occurring within a specific 10-20 millisecond
portion of the cardiac cycle in the ascending phase of the portion of the cardiac cycle in the ascending phase of the
T wave, when the ventricular myocardium is T wave, when the ventricular myocardium is
repolarizing, moving from systole to diastolerepolarizing, moving from systole to diastole

Most effective preventions are:Most effective preventions are:

Chest shieldChest shield

Automatic External Defibrillator Automatic External Defibrillator
(AED)(AED)
Sudden Cardiac Death of Athletes

34. Sudden Cardiac Death of Athletes
J Am Coll Cardiol 2008;52:1990–6

35. Sudden Cardiac Death of Athletes