1. Sudden Cardiac Death in Athletes Bryan R. Prine, Jr
Sudden Cardiac Death in Athletes Bryan R. Prine, Jr., MD, CAQSM July 27, 2016

2. Sudden Death in an Athlete
Our Worst Nightmare
Young, Healthy, Athletic Kid
Hank Gathers
March 4, 1990

3. March 9, 2011 Eastside High School Gainesville, FL Gainesville Sun
April 4, 2012

4. Nontraumatic Sudden Death in Sports
The top 4 killers
Cardiovascular conditions
Hyperthermia (Heat Stroke)
Acute Rhabdomyolysis from Sickle Cell Trait
Asthma

5. Goals Familiarize you with the common causes of athlete death
Screening athletes for cardiac conditions
How to recognize these events when they occur
Management and Treatment of cardiac arrest
New Evidence

6. Common Causes of Cardiac Death
HCM
Commotio Cordis
Coronary anomalies
Arrhythmias-Ion channelopathies
Long QT Syndrome
Brugada Syndrome
Myocarditis
Dilated cardiomyopathy
Aortic dissection

7. Incidence Maron, et al. SCD in general population athletes: 1:164,000
SCD in high school athletes: 1:150,000
SCD in college athletes: 1:83,000
NCAA male basketball players: 1:7000
SCD rate Black 3.8 vs. White 0.7 per 100,000
Estimates up to 110 deaths per year in young athletes (1 death every 3 days in the US)
Harmon, et al.
SCA in high school athletes: 1:64,000
SCD in college athletes: 1:43,770
Estimates SCD rate to be minimum of 1:50,000 – 1:80,000 in HS athletes

8. Take Home Message
Incidences from prior studies have shown rates of SCD that varied from 1:917,000 to 1:3000.
Studies with higher quality methods consistently yield rates between 1:40,000 and 1:80,000, which is much more common than previously thought (1:200,000).

9. Cardiac Conditions Leading Cause of Sudden Death in athletes
New evidence may show that the common cardiac causes are not as previously thought and that the rate of occurrence is underestimated.

10. Cardiac Causes Harmon, et al. Maron, et al.
Structurally normal heart (autopsy-negative sudden unexplained death) 31%
Coronary artery anomalies 14%
HCM, aortic dissection, myocarditis, DCM 8%
Arrhythmias, Commotio Cordis 3%
Maron, et al.
Structural abnormality
Hypertrophic Cardiomyopathy (HCM) 25%
Coronary Anomalies 14%
Commotio Cordis 3%
Arrhythmias (ion channel, Long QT)
Normal structure 2%

11. Take Home Message
Two recent studies found different common cardiac causes of SCD
This makes developing cost-effective screening strategies more difficult when it remains uncertain what the most common problems are that should be screened for in PPEs.

12. Hypertrophic Cardiomyopathy (HCM)
As the muscle thickens, obstruction can occur
Fatal ventricular arrhythmias are cause of death
Unfortunately, most cases are asymptomatic until collapse

13. Commotio Cordis
An often lethal disruption of heart rhythm that occurs as a result of blunt trauma to the area directly over the heart at a critical time during the cycle of a heart beat causing cardiac arrest.
It is a form of ventricular fibrillation (V-Fib), not mechanical damage to the heart muscle or surrounding organs, and not the result of heart disease.
The fatality rate is about 65%.
It can sometimes be reversed by defibrillation

14. Coronary Anomalies Congenital anomaly in heart vessel anatomy
Occur in less than 1% of population
There can be normal variants of coronary artery placement which can make diagnosis somewhat difficult.

15. Arrhythmias
Long QT Syndrome- ion channelopathy

16. Myocarditis Inflammation of myocardium
Can be caused by virus, bacteria (rheumatic fever), autoimmune disease, sarcoidosis
Can occur in otherwise healthy person

17. Dilated Cardiomyopathy
Heart becomes weakened and dilated which causes inefficient pumping and can lead to heart failure.
Can be seen in alcohol abuse, pregnancy, thyroid disease.
Most commonly seen in ages 20-60

18. Dilated Cardiomyopathy

19. Aortic Dissection
Occurs when a tear of the inner wall of the aorta causes blood to flow between the layers which forces them apart.
Surgical emergency that can lead to rapid death
Rare: 2-3/100,000, M>F, usually age 60s
Can be seen in Marfans syndrome and Ehlers Danlos at higher rates

20. Aortic Dissection

21. Prevention/ Screening
PPE- current standard of care (includes history and physical exam)
ECG?
Echocardiogram?

22. PPE- Prevention/ Screening
Our FHSAA forms have been created to cover the high risk screening questions.
PPE focus on history of any dizziness, chest pain, family history of sudden death, or exercise intolerance
Physical exam may be able to pick up some murmurs, abnormal BP
Unfortunately 80% of SCD patients are asymptomatic prior to their cardiac arrest

23. PPE

24. Future Screening Recommendations
ECG
Low false positive rates (5%) using modern standards for interpretation, improves detection of electrical disease at risk for SCA. (Fudge, J, et al, Br J Sports Med, 2014)
Echocardiograms
Evidence that use can improve false positive rates and broaden the spectrum of disease detected in PPEs (Yim, ES, et al, J Ultrasound Med 2014.)

25. ECG Examples

26. Athlete ECG

27. HCM ECG

29. How do we proceed?
Do we have the infrastructure to handle ECG screening on all HS athletes?
Can we afford to do it?
Can we afford not to?

30. Cost
Estimated cost using cost projection model based on Italian study for annual screening with ECG $ billion/ year using Medicare reimbursement rates (8.5 million athletes)
Estimated cost per life saved $10-14 million
Estimated 7.7 million HS athletes in US

31. Cost

32. Texas HB 677

33. Florida HB 533
Student Eligibility for Extracurricular Activities; Revision includes, “Requires FHSAA bylaws to specify that pre-participation physical evaluation form advise students to complete cardiovascular assessment that includes electrocardiogram.”
As of 5/2/14: Died in Education Committee

34. Future of screening?? To be determined……
Until then, what can you do as doctors, athletic trainers, coaches, administrators, teachers, and parents to help?

35. Recognizing Cardiac Arrest
Sudden Cardiac Arrest should be suspected in any athlete who has collapsed and is unresponsive
Seizure-like jerking or agonal air gasping should not be mistaken for seizure or normal breathing
Apply AED and start CPR as soon as possible if any suspicion that cardiac event is occurring

36. Management/ Treatment
Emergency Action Plan (EAP)
Call 911
CPR should be provided while AED is being retrieved, and the AED should be applied as soon as possible
Interruptions in chest compressions should be minimized by stopping only for rhythm analysis and defibrillation

37. Treatment Access to early defibrillation is ESSENTIAL.
A goal of less than 3-5 minutes from the time of collapse to delivery of the first shock
High School AED programs demonstrate high survival rates for students (85%) and adults (61%).
Survival rates decrease approximately 10% each minute that a shock is delayed.

38. JAMA July 21, 2015

39. Return To Play
Guided by physician with expertise in etiology of collapse. Return will be dependant on normalization of labs and assessment of risk of future occurrence.
Cardiologist
Sports Medicine

40. Summary Screening those at risk: Treatment: Education
Preparticipation Exam (PPE)
ECG, Echocardiogram?
Treatment:
Emergency Action Plan
AED
Basic CPR
Education

41. Headlines

42. Sickle Cell Trait What is it?
Inherited disorder that causes the shape of the RBC to change from round to quarter moon during extensive exertion
This new shape causes the RBCs to logjam blood vessels, causing rapid breakdown of the muscle starved of blood (ischemic rhabdomyolysis)

43. Sickle Cell Trait Prevalence
African Americans 1:12
White Americans 1:2000
Also increased in those of Mediterranean, Indian decent
In the past 7 years alone, sickling has killed 9 athletes age 12-19

44. Sickle Cell Trait US Military data
Recruits with SCT are 30x more likely to die in basic training
Exertional Rhabdo 200x greater in SCT
Systemic dehydration worsens sickling
13 College FB players have died after sickle cell collapse.

45. Acute Rhabdomyolysis Sickle Cell Collapse
Freshman DB Rice University 2006
16 sprints of 100 yards each
Died the next morning
March 18, 2008 UCF FB player Ereck Plancher died after a preseason practice from complications of sickle cell trait
Most cases are with gassers, stadiums, sprints
The harder and faster athletes go, the greater the sickling

46. Acute Rhabdomyolysis
Brandon Antwine
October 9, 2007

47. Acute Rhabdomyolysis
Prevention
Recognition
Treatment

48. Prevention Identify athletes at risk From FHSAA form added 2011
Many Colleges test for SCT as part of screening labs on admission
All 50 states screen for sickle cell as part of newborn testing

49. Prevention
Targeted education and tailored precautions may provide a margin of safety for the athlete with SCT
Athletes with SCT should be allowed longer periods of rest and recovery between conditioning repetitions
Adjust rest cycles in presence of extreme heat stress
Emphasize hydration

50. Recognition Know the signs and symptoms of exertional sickling
Severe muscle cramping
Pain, weakness
Swelling of limb(s)
Inability to catch breath, fatigue

51. Comparison Sickle Cell Collapse Cardiac Collapse Heat Illness
Leading Symptoms present
Instantaneous
Responsive during early sx
Unresponsive
Onset <30 min of intense exercise
No specific relation to time
Onset >30 min of intense exercise
Temp <104 degrees F
Temp >104 degrees F
Cramps: No muscle twinge, generalized location, severe pain, muscles feel normal
No cramps
Cramps: Muscle twinge, pinpoint location, severe pain, muscles are rock hard and locked up
Prine 8/2013

52. Treatment Immediately withdraw from activity when signs appear
Monitor vital signs
Hydrate, High flow oxygen if available, Cool down
If worsen, activate Emergency Action Plan (call 911, attach AED, inform medical team of sickle cell status)

53. References
Casa et al, National Athletic Trainers’ Association Position Statement: Preventing Sudden Death in Sports, Journal of Athletic Training 2011:47(1):1-24
NATA Consensus Statement: Sickle Cell Trait and the Athlete, Anderson, S; Eichner, R.
Casa, D et al, The Inter-Association Task Force for Preventing Sudden Death in Collegiate Conditioning Sessions: Best Practices Recommendations, Journal of Athletic Training 2012;47(4):
Fudge, J, et al, Cardiovascular screening in adolescents and young adults: a prospective study comparing the Pre-participation Physical Evaluation Monograph 4th Edition and ECG. Br J Sports Med 2014; 48:
Brosnan, M, et al, The Seattle Criteria increase the specificity of preparticipation ECG screening among elite athletes. Br J Sports Med 2014; 48:
Womack, J, Proper Screening for Sudden Cardiac Death in the Young Athlete. Clinical Pediatrics 2014; Mar 20 [Epub ahead of print]

54. References
O'Connor FG, et al. ACSM and CHAMP summit on sickle cell trait: mitigating risks for warfighters and athletes. Med Sci Sports Exerc 2012 Nov;44(11):
Harmon KG, Drezner JA, Wilson MG, et al. Incidence of sudden cardiac death in athletes: a state-of-the-art review. Br J Sports Med 2014; 48:
Maron BJ, et al. Sudden Deaths in Young Competitive Athletes Analysis of 1866 Deaths in the United States, Circulation 2009;119:
Yim ES, et al. Early Screening for Cardiovascular Abnormalities with Preparticipation Echocardiography. J Ultrasound Med 2014; 33:
Halkin A, et al. Preventing sudden death of athletes with electrocardiographic screening: what is the absolute benefit and how much will it cost? J Am Coll Cardiol 2012 Dec 4;60(22):2271-6
Maron BJ, et al. Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age) A Scientific Statement From the American Heart Association and the American College of Cardiology. J Am Coll Cardiol Oct 7;64(14):

55. References
Malta HC, et al. Association of Bystander and First Responder Intervention With Survival After Out-of-Hospital Cardiac Arrest in North Carolina JAMA 2015 Jul 21;314(3):255-64
Nichol G, Kim F. Bystander Interventions Can Improve Outcomes From Out-of-Hospital Cardiac Arrest. JAMA 2015 Jul 21;314(3):231-2
Menafoglio A, et al. Costs and yield of a 15-month preparticipation cardiovascular examination with ECG in 1070 young athletes in Switzerland: implications for routine ECG screening. Br J Sports Med Aug;48(15):
Wheeler MT, et al. Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med Mar 2;152(5):276-86

56. Thank You!!
Questions?