Download Sudden cardiac death in Children participating in organised sport

Sudden cardiac death in Children participating in organised sport
There has been concern in the media about sudden cardiac death in children during
sport, particularly following the collapse of Fabrice Muamba.
There are calls being made that all children should be screened prior to taking part in
sport.
Whilst every child dying is a tragedy, it is often not preventable.
The main causes of sudden cardiac death in school age children are congenital heart
disease such as Valvular or anomalous coronary arteries, or due to one of the
inherited cardiac myopathies. Asthma and other non-cardiac disease can also lead
to sudden death.
Sudden cardiac death in children is rare, affecting 1 in 200,000 young athletes. It is
2 to 4 times more common in children taking part in sport, than in children who don’t.
As many children do not take part in organised sport, more sudden deaths may occur
in children who don’t take part in sport.
The main suggested screening tool is an ECG. It is unable to identify premature
coronary artery disease and congenital coronary anomalies, which account for a
major proportion of sudden cardiac death in young athletes. It will detect
cardiomyopathy, but not necessarily in younger children. There are also a relatively
high number of false positives, 10 to 20%, which will generate anxiety, and
unnecessary investigation.
It is also not clear that telling children not to participate in sport will prevent a cardiac
event and there may be other psychological impacts from the screening.
There is no support from the National Screening committee for screening of children
before exercise. There has been a recent review 1 which found the benefit of
screening children prior to exercise was equivocal, due to it being a rare condition
and no very sensitive or specific screening tool.
If a parent and child present asking for cardiac screening due to the publicity in the
media, a suggested approach is to take a family history about any sudden deaths,
and do physical examination (see guide line below). The evidence shows this has
limited sensitivity.
American Heart Association guidelines for preparticipation cardiovascular screening of young, competitive
athletes
Medical history*
Chest pain or discomfort on exertion
Unexplained syncope or near syncope
† Excessive exertional dyspnoea or fatigue
Prior recognition of a heart murmur
Raised systemic blood pressure
Family history
Premature death (<50 years) from heart disease, in one or more relatives
Disability from heart disease in a close relative aged less than 50
Specific knowledge of certain cardiac conditions in family members: hypertrophic and dilated cardiomyopathy,
long QT syndrome or other ion channelopathies, Marfan’s syndrome, or clinically important arrhythmias
1 Preparticipation screening for cardiovascular abnormalities in young competitive athletes (BMJ
2008;337:a1596 doi:10.1136/bmj.a1596)
Physical examination
Heart murmur‡
Femoral pulses to exclude aortic coarctation
Physical stigmata of Marfan’s syndrome
Brachial artery blood pressure (sitting position, taken in
both arms)
*Parental verification is recommended for high school and middle school athletes
†Judged not to be vasovagal; of particular concern when related to exertion
‡Auscultation should be done both while supine and while standing or with Valsalva manoeuvre, specifically to
identify murmurs of dynamic left ventricular outflow tract obstruction
A 12 lead ECG should not normally be required, but would be the first investigation if
any further investigation is thought to be necessary.
It would be helpful to discuss the comparative risks with the parents. We don’t have
figures for Liverpool immediately available, but it is likely to be 1 to 2 children dying
from sudden cardiac death per year at the most. More children die from traffic
accidents and alcohol misuse is likely to have a much greater impact on the health of
young people.
Dr Ewan Wilkinson
Public Health
Liverpool PCT
April 2012