Athlete Sudden Cardiac Death

EMERGENCIES IN MEDICINE

Park City 2012

Jim Kyle, MD, FACSMEmergency Department Director, Beckley ARH

Team Physician Concord University

Associate Clinical Professor Marshall University

Sports Trauma Trends Head / Neck Case

Long term subtle neuro deficit

Heat Stress Injury

Performance enhancement supplements

Sudden Cardiac Arrest

Unrecognized congenital conditions

Cardiac concussion

Sudden Cardiac Death in Athletes

Incidence of SCD• high school athletes 1:100,000 to 200,000

VanCamp & Maron• college athletes 1:65,000 – 69,000 VanCamp

& Drezner• 1:50,000 marathoners, 1:15,000 joggers• ~ 110 athletic deaths per year in US Maron• no national surveillance system; true incidence

unknown; most likely underestimated

The Faces of SCA

1990 - Hank Gathers Tragedy

• DX: exercise related complex ventricular tachycardia

• RX: Beta Blocker- Inderal 200qd• Return to play in three weeks• Courtside cardiac monitor

defibrillator

Hank Gathers SCA• Medication had been

decreased due to side effects

• Cause of death -HCM

• Cardiac monitor defibrillator legal issue: $32 Million law suit

Cause of Sudden Cardiac Death Ten Year Review 158 Athletes

B. Maron, JAMA 1996

Cause of Sudden Cardiac Death Ten Year Review 158 Athletes

B. Maron, JAMA 1996

• 1985-95 sudden death organized sports

• 138 cases of Sudden Cardiac Death

• Ages 12-40, median age=17 90% Male

• 68% occurred in Football and Basketball

• 62% High School, 22% College, 7% Professional

The Faces of SCA

SCA in Athletes“The unexpected death of an athlete during exercise

is tragic irony. ... much remains unknown regarding optimal screening strategies, pathophysiologic mechanisms,and prevention”

Mark Link, MD

Tufts University

Cardiac Concussion

Little League Baseball Sudden Death

• A 16yo player was struck in the chest by the baseball thrown from home plate as he attempted to steal third base. Shortly after standing he collapsed with seizure like activity and stopped breathing.

Little League Baseball Sudden Death

• The coach initiated CPR and local EMS documented arrival of an ACLS team 8 minutes after receiving the call from the field. Attempts to resuscitate were unsuccessful.

Cardiac Concussion• Commotio Cordis - sudden death during sports

play after a blunt blow to the chest Maron, NEJM, 1995

• 25 case 1977-95, Average Age = 11 (3-19) 18 playing baseball or softball, “Little League Sudden Death” 24 male

• Vulnerable window 15-30 msec prior to peak of T wave inducing V- Fib Link, NEJM, 1998

Laboratory Cardiac Concussion

Sudden Death: Commotio Cordis

2001 Commotio Cordis Update

• 2001 update - 128 cases 84% cases fatal

• Early defibrillation with on site AED only effective treatment

• AED documented in 41 cases, 19 survived = 46%

Cause of Sudden Cardiac Death Ten Year Review 158 Athletes

B. Maron, JAMA 1996

“Sudden Death in Young Athletes” Maron NEJM 2003,

Sudden Death in 387 Young Athletes1. Hypertrophic Cardiomyopathy – 34 %2. Commotio Cordis – 20%3. Coronary-artery Anomalies – 14%

2010 Update: Cardiac Concussion

2010 Update: Cardiac Concussion

• 224 Cases: NEJM, B Maron, M Estes

• Mean Age = 15: 26% < 10yo Range: 6mos – 50yo

• 95% Male, 78% White

• Survival rate15% 1990-1999

35% 2000-2009 ( 2006-09 > 50% )

The Casino Project

The Casino Project

• 1997 – Security Guards at Star Dust trained by Clark County EMS, Richard Hardman in use of Life-Pak 500

• 1997- 2000: 200+ cases of witnessed SCA with 57% survival

• Time to AED- 3 mins, Shock 4 mins

• 6,500 Security Guards trained

Public School AED Program

• 1999: Planning for Scholastic Cardiac Emergencies, WV Med Jour. The Ripley Project

• 2000: Milwaukee City school after 4 case SCA Project ADAM

• 2001: Long Island schools lacrosse focus Acompora Foundation (www.la12.org)

• 2007: 91% College, 35% High School with AED

• 2011: Saves > Deaths Commotio Cordis

“Non V-Fib” Cardiac Concussion

Link,NEJM: 4/10 impacts during QRS = complete heart block

“Non V-Fib” Cardiac Concussion• 3* Heart Block

• LBBB

• ^ST segment

Athletes at Risk for SCA

• Chief complaint of syncope

• Chest Pain with or post activity

• History of palpitations

• Family History of Sudden death

• Abnormal EKG

Athlete SCA : Have We Changed the Playing Field ?

Emergency Department • Athlete Collapse – Assume Cardiac

Etiology (Sentinel Seizure)• EKG Attention: Delta and Epsilon Waves,

LQT• Syncope, Near Syncope, Chest Pain Work

Up: Consider advanced imaging, Cardiac CT, MRI* vs ECHO

ARVD – Prolonged QRS, Inverted T wave V1 – V2

ARVD – Arrhythmogenic Right Ventricular Dsyplasia

• Italian Sport Federation requires school athletes to have EKG and limited stress test on an annual basis

• EKG with prolonged QRS V1-V3 110 msec and inverted T wave

• Epsilon wave in 50%

ARVD Epsilon Wave

Athlete SCA : Have We Changed the Playing Field ?

Emergency Department • Athlete Collapse – Assume Cardiac

Etiology (Sentinel Seizure)• EKG Attention: Delta and Epsilon Waves,

LQT• Syncope, Near Syncope, Chest Pain Work

Up: Consider advanced imaging, Cardiac CT, MRI* vs ECHO

ARVD with fatty (dark, arrows)

RV myocardium

By Cardiac CT Angiography Study

N. Wilke, UF and Precision Imaging Centers, JAX, Florida

Cause of Sudden Cardiac Death Ten Year Review 158 Athletes

B. Maron, JAMA 1996

25%

Coronary Artery AnomaliesMagnetic Resonance Imaging

Möhlenkamp et al. Circulation 2002;106:2616-22.

Cardiac CTA: Common, Stenosed

Ostium of RCA and LM

N. Wilke, UF and Precision Imaging Centers, JAX, Florida

Athlete SCA : Have We Changed the Playing Field ?

Athlete Screening• Consider EKG – Corrado Italian Criteria• Heart Murmur – Baseline ECHO with potential

repeat to R/O HCM, Marfans• Palpitations or SVT suspicion - Holter

Monitor

*2006 World Cup: FIFA required EKG, ECHO, Stress Test after Cameroon SCA

Italian Guidelines for Sports Medicine1982 Law Competitive Athletes 12-35

• PSPE Screening : PMH , FH, Physical Exam, and 12 lead EKG

Positive findings: ECHO, Stress Test, Holter

• PMH: Syncope, Chest Pain, SOB, Palpitation• PSPE: Heart Murmur systolic >2/6 any diastolic,

Abnormal S2, Systolic Clicks, BP >140/90, Irr Rhythm, R/O Marfans

• EKG: Hypertrophy, Blocks, ST and T wave, Intervals

Italian Pre-Competition Screening

D. Corrado,et.al. Sports Medicine Data Base,Veneto region, Italy: NEJM 1998

• 20 year screening for HCM 33,735 athletes

• 3016 (9%) referred for echocardiogram

• 22 had HCM- 16 @ risk identified EKG

• 49 deaths (1.6 per 100,000) 1 from HCM, 11 from ARVD (22%)

Italian Guidelines for Sports Medicine

Abnormal EKG:• LAH, RAH, R axis, L axis,• LVH (20mm limb, 30mm pre-cordial),• AV Block, 1*,2*, 3* (1* >.21 not shorted with

hyperventilation) RBBB, LBBB• Long QT (>.44men, >.46 women)

Short PR (<0.12)• PVCs, AF, SVT • ST depression or T wave inversion 2 or more

leads, Q wave 2 leads, V1 R:S ratio >1

2007 NATA Position Paper SCA in Athletes Summit (Courson, Drezner)

• Most cases occur with Basketball, Football and Little League Baseball

• 9 to 1 Male/Female• Athlete Collapse – Suspect SCA Sentinel Seizure awareness• AED’s with time to shock < 4 minutes• Coach AED certification• Schools need a formal Emergency Medical Plan • Rapid ACLS availability

SCA in Athletes“The unexpected death of an athlete during exercise

is tragic irony. ... much remains unknown regarding optimal screening strategies, pathophysiologic mechanisms,and prevention”

Mark Link, MD

Tufts University