Download Sudden Cardiac Death in the High School Athlete

Sudden Cardiac Death in the
High School Athlete
Mary Vajgrt M.D.
Primary Care Sports Medicine
Kalamazoo Orthopedic Clinic
Sudden Cardiac Death
• Currently a hot topic in sports medicine– very
emotionally touching and much media coverage
• Questionable effectiveness at current screening
measures
• Better preparation for when it DOES happen
Statistics: Sudden Cardiac Death
• Leading cause of death in young athletes
• 1 in 200,000 athletes per year
• 16-17 deaths per year in the United States
– At least 47 Michigan high school athletes
since 1999
Statistics: Sudden Cardiac Death
• Risk increases with increasing level of
competition
– Higher rate in college athletes: 1 in 50,000
• More prevalent in basketball and football
• Occurs 2X more frequently in African
Americans
Sudden Cardiac Collapse
• Sudden collapse of an athlete: no trauma
• Pulseless
• Without IMMEDIATE response of AED or
CPR, very high risk of death: 95% (estimate)
• Each minute before defibrillation increases risk
of death by about 10%
– Action PLAN
Why do Athletes Collapse?
•  UNDERLYING CARDIAC ABNORMALITY
• Secondary causes:
– Heat stroke
– Sickle Cell disease/trait (could explain why
higher in African Americans)
– Drug use (amphetamines?)
Secondary Causes: Preventable
• Proper Hydration
• Practice in cooler times of day
• Vary practice intensity to heat/humidity
• No helmets/pads at initial practices
• Allow acclimatization to heat/practice effort
• ALLOW athletes to drink (fluids AND
electrolytes)!
Underlying Cardiac Abnormality
• Difficult to pick up on pre-participation physical
exam
• OFTEN asymptomatic: first problem is the “big
one”
• Without early response to collapse, death is
likely to occur
Underlying Cardiac Abnormality
• Hypertrophic Cardiomyopathy (HCM)
• Coronary artery anomalies
• Rhythm abnormalities
• Valve abnormalities
• Aortic abnormalities
• Coronary Artery Disease
• Myocarditis
Hypertrophic Cardiomopathy
(HCM)
• Leading cause of sudden cardiac death
• Genetic: often die suddenly before 50 yrs of age
• Often asymptomatic but may have
– Shortness of breath; syncope; chest pain
• May have a heart murmur
• Changes on EKG/ ECHO
Hypertrophic Cardiomyopathy
• Treatable
– Medications
– Implantable defibillator
• SPORTS: may not compete except for maybe
low intensity sports
– Risk of death is high–even if no symptoms
Marfan’s Syndrome
• Common connective tissue disorder
• Tall, long-limbed, long fingers
• “loose” joints/hyperflexible
• Spine abnormalities (kyphosis)
• Eye problems
• Risk for aortic dissection
– Yearly checkups with ECHO/EKG
Marfan’s Syndrome
Marfan’s Syndrome
• No Heavy Lifting
• No contact sports
Other Cardiac Abnormalities
• Often asymptomatic
• Any symptoms need to be taken seriously!
– Dizziness/”feel faint”
– Shortness of breath
– Chest pain
– Heart feels “too fast”
Table of sports intensities
Current Screening Guidelines
• Preparticipation Physical Exam (PPE)
– Cardiac focused symptoms
– Cardiac focused family history
– Cardiac focused Physical exam
• Currently, EKG and ECHO are NOT
recommended as screening tool for high school
athletes!
Symptom Questions
• Dizzy with exercise
• Passed out during or after exercise
• Chest pain with exercise
• Racing of heart or skipped beats
• Tire more quickly than friends
• Heart murmur
• High blood pressure or high cholesterol
Family History Questions
• Does anyone in your family have a heart
problem(cardomyopathy/long QT/arrhythmia)?
• Has any family member died of heart problems
or sudden death before age 50?
• Does anyone in your family have Marfan’s
Syndrome?
Physical Exam
• Blood Pressure
• Heart rate (pulse)
• Heart sounds (in 2 different positions)
• Pulses (are they equal)
• Marfan”like” features
Electrocardiogram (ECG)
• Measures the “electric” conduction of the heart
– Conduction abnormalities/arrhythmias
– Voltage changes that may indicate structural
abnormalities
Echocardiogram (ECHO)
• Ultrasound of the heart
– Gives structural
appearance of heart
• Heart walls
• Valves
• Aorta/other vessels
ECG and ECHO
• Currently NOT recommended as screening
tools
• May be useful if symptoms, family history, or
physical exam abnormalities warrant it.
• Add significant cost to screening for rare
problem… is it worth it??
ECG and ECHO
• Some communities have funding or cardiology
groups that do screening ECG +/- ECHO for
discounted rate/free
– Normal cost of ECG: $30-$75
– Normal cost of ECHO: $300-$700
Emergency Preparedness
• Written Emergency Action Plan (EAP) specific
for each athletic venue
• PRACTICE the action plan (at least yearly)!
– ATC, team physician, ATC students, school
administrators, and coaches
• AED on site???
• Coaches/sideline personnel CPR trained
SCA Action Plan
• SUSPECT cardiac arrest in any collapsed
athlete
• Early activation of EMS
• Early CPR
• Early defibrillation (AED)
– All three will improve survival!
SCA Action Plan
• Most likely first responders
– Referees
– Coaches
– Athletic Trainers
• Currently NO rules mandating CPR
certification for coaches (in Michigan)!
SCA Action Plan
• CPR (Cardiopulmonary Resuscitation)
– Generally a 3-4 hour training course
– Most now include how to use an AED
– Cost??? ($25-$50)
– American Red Cross website to find locations
for classes
SCA Action Plan
• AED (Automated External Defibrillator)
– Computer that check’s a heart’s rhythm
– Delivers shock as necessary
– Cost: $1500-$3000:
– In MI: no training or registration
requirements
SCA Action Plan
• Each minute to shock/treatment decreases
chance of survival by up to 10%!
• TIME is of utmost importance!!!!
Summary
• Sudden cardiac death is relatively rare
• Most cardiac problems are asymptomatic
• Abnormalities are difficult to pick up on
preparticipation physicals
• Action plans for sudden cardiac collapse may
have the most impact on survival
Resources
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http://www.michigan.gov/mdch
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Preparticipation Physical Evaluation (3rd ed)
Exercise and Acute cardiovascular Events: Placing the Risks into Perspective, Position Statement of American
College of sports Medicine and American Heart Association
Inter-Association Task Force Recommendations on Emergency Preparedness and Management of Sudden
Cardiac Arrest in High School and College Athletic Programs: a Consensus Statement; Dresner,et.al, 2007
36th Bethesda Conference: Eligibility Recommendations for Competitive Athletes with Cardiovascular
Abnormalities; Maron, et.al; Journal of the American College of Cardiology, 2005
Cost-effectiveness of Preparticipation Screening for Prevention of Sudden Cardiac Death in Young Athletes;
Annals of Internal Medicine, Wheeler,et.al; 2010
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