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

2. 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 important Family physicians see a lot of athletes for sports related issues Family physicians see a lot of athletes for sports related issues Family physicians are involved in school health and pre-participation examinations Family physicians are involved in school health and pre-participation examinations It is important to know the clinical characteristics of SCD and identify athletes who are at risk It is important to know the clinical characteristics of SCD and identify athletes who are at risk It is important to know the current recommendations for pre-participation examinations It is important to know the current recommendations for pre-participation examinations

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

9. Epidemiology Based on Autopsy Series Age-- Age-- 9% in middle school 9% in middle school 62% in high school 62% in high school 22% in college 22% in college 7% in professional 7% in professional Sex—90% male, 10% female Sex—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 time of sudden death Maron BJ et al, JAMA 1996 ; 276 : 199 - 203 Sudden Cardiac Death of Athletes

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

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

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

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

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

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

19. Results

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

21. Race and Ethnicity

22. Baseball Boxing Dancing Martial arts physical training Running video game Water ski World's strongest man competitor Sports Associated with SCD

23. Sudden Cardiac Death of Athletes Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

24. Causes of SCD

25. Maron BJ et al, JAMA 1996 ; 276 : 199 - 203

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

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

29. Endorsement of AHA Guidelines American Academy of Family Physicians American Academy of Family Physicians American Academy of Pediatrics American Academy of Pediatrics American College of Cardiology American College of Cardiology American College of Sports Medicine American College of Sports Medicine American Medical Society for Sports Medicine American Medical Society for Sports Medicine American Orthopaedic Society for Sports Medicine American Orthopaedic Society for Sports Medicine American Osteopathic Academy of Sports Medicine American Osteopathic Academy of Sports Medicine

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

31. Coronary Artery Anomaly Sudden Cardiac Death of Athletes

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

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

34. J Am Coll Cardiol 2008;52:1990–6

35. Sudden Cardiac Death of Athletes