Sudden Cardiac Death in Athletes
Valve Disorders: Problems Opening
(Stenosis) - if the valve doesn't open all the way, less blood is able to move through the smaller opening
Valve Disorders: Problems Closing
(insufficiency or regurgitation) -blood may leak back in the wrong direction
Wolff-Parkinson-White Syndrome: Diagnosis
- 12-lead ECG - exercise testing - echo cardiogram to rule out other cardiovascular
On-field management
- EAP - Know it and follow it! A formal EAP should be written for each site. - Activate EMS - Care includes BLS and use of AED
Diagnostics
- EKG/ECG - Echocardiogram - Holter Monitor
Pre-Participation - Medical Hx: Personal History
- Exertional chest pain/discomfort - Unexplained syncope/near-syncope - Excessive exertional and unexplained dyspnea/fatigue, associated with exercise - Prior recognition of a heart murmur - Elevated systemic blood pressure
Contributing factors in sudden cardiac death
- High intensity exercise - electrolyte imbalances (a consequences of dehydration) - high body temperature (from exercise in extreme heat and humidity) - sudden cessation of intense physical activity (causing vasodilation and falling BP, similar to shock) - performance enhancing substances - dietary supplements
Incidence of Sudden Death
- Highly Publicized - Difficult to estimate true incidence of defect - Rare 7.5 per million per year for males 1.3 per million per year for females Male > female by five fold
Paroxysmal Supraventricular Tachycardia
- Intermittently occurring very rapid heart rate at rest, exceeding 150 bpm - Attacks can last minutes or hours - Heart rate returns to normal between attacks - Most common in children and may be observed in adolescents - Attacks can be brought on by caffeine, alcohol, nicotine, or drugs - Not life-threatening
Wolff-Parkinson-White Syndrome: Management
- Medication to limit heart rate - surgery to obliterate the additional conduction pathway - necessary for individuals that have multiple accessory pathways or demonstrate ventricular rates greater than 240 bpm
Pre-Participation - Medical Hx: Family History
- Premature death (sudden and unexpected, or otherwise) before age 50 years due to heart disease, in 1 relative - Disability from heart disease in a close relative <50 years of age - Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias
Heart Murmurs
- Reflect turbulence - High flow rates - Damaged valves - Dilated chambers or vessels - Backward flow - May or may not be pathological
Wolff-Parkinson-White Syndrome Mechanisms
- accessory conduction pathway conducts more rapidly than the AV node, and the result is that on of the ventricles depolarizes just slightly before the other - results in a loop of depolarization that causes ventricular fibrillation, which is fatal unless defibrillation occurs within minutes
Marfan Syndrom
- arachnodactyly - chest wall deformity - soliosis - high arched palate - acromegaly - joint hypermobility - increased arm span relative to height - myopia - retinal detachment
Hypertrophic Cardiomyopathy
- autosomal dominant disorder - left ventricular outflow obstruction - predisposes athletes to ventricular arrhythmias - PE presents a murmur that decreases in intensity in the supine position and increases with Valsalva maneuver
HCM Diagnosis & Treatment
- chest x-ray and electrocardiography are okay - gold standard is 2-D echo (approx $900) - in Italy all athletes must undergo an echo - Beta Blockers are used as treatment - Class 1A according to Bethesda
Marfan Syndrome
- hereditary connective tissue disease - present in 1 in 20,000 - results in weakened aortic arch, mitral valve prolapse or regurgitation
Coronary Artery Anomolies
- most common in anomalous origin of the left main from the right sinus Valsalva - 1/3rd are symptomatic - sx: c/o early fatigue, chest pain or dizziness with exercise
MItral Valve Prolapse: Sx
- none - chest pain - palpitations - dyspnea - fatigue - murmur @ apex during systole
Coronary Conduction Disorders
1. Wolfe-Parkinson-White syndrome 2. Long Q-T syndrome 3. Paroxysmal supraventricular tachycardia
Pre-Participation Exam
AMA released a consensus statement in 1996 due to confusion - Should be mandatory for all secondary and college athletes - Should include a history and physical examination - Should be conducted by a health care worker - Should be done every two years in HS (hx in interim)
MItral Valve Prolapse: Rx
Abx prophylaxis, surgery
Congenital Coronary Artery Abnormalities
Activity restriction - 36th Bethesda Conference recommends no competitive sports participation
Long QT Syndrome
An abnormality of heart's electrical system - may be hereditary or acquire - see a prolonged QT segment on ECG - prolonged segment occurs during repolarization of heart
Commotio Cordis
Arrythmia from blow to chest Most common in baseball
Wolff-Parkinson-White Syndrome: Restriction Activity
Athletes may continue participation in all sports if... - they have no history of palpitations or structural abnormalities - they do not present with tachycardia
Long QT Syndrome: Treatment
Beta blockers
AED
CPR is holding action until defribrillation AED is critical for arrhythmias: - HCM - Myocarditis - Long QT syndrome - Commotio Cordis
Valve Disorders
Cause the heart to work harder Cause murmurs on auscultation swishing, rushing sound produced by turbulent blood flow through defective valve Often association with other CV conditions
Mitral Valve Prolapse
Cusps or mitral valve prolapse into L atrium during systole
Wolff-Parkinson-White Syndrome Clinical Presentation
Exertional syncope increased HR and palpitations
Sport Classifications
I. Low (<20% MVC) II. Moderate (20%-50% MVC) III. High (>50% MVC) Class A (<40% Max O2) Class B (40-70% Max O2) Class C (>70% Max O2)
Myocarditis
Inflammation of the heart muscle - can be viral, bacterial, fungal, or protozoal infection or complication of another disease - acute viral infection most often caused by Coxsacki B virus (over 50%) - sx: exercise intolerance, signs of congestive heart failure, tachycardia, cough, dyspnea, viral sx, abnormal heart sounds - sudden death due to ventricular arrhythmia
Paroxysmal Supraventricular Tachycardia: Diagnosis
Physical examination - very rapid, but regular and strong, heart rate - an ECG monitor may have to be worn for 24 hours or longer to detect the syndrome because between attacks the ECG trace is normal
Marfan Syndrome Activity Restriction
The 36th Bethesda Conference recommended that athletes with Marfan syndrome can participate in competitive sports (Class IA or IIA only) IF "they do not have one or more of the following: (1) aortic root dilation (2) moderate to severe mitral regurgitation, (3) family history of dissection or sudden death in a Marfan relative
Incidence in Adults and Young Athletes
The following theme has evolved: - Sudden death before age 35 is typically a congenital cardiovascular disorder - Sudden death after age 35 is associated with atherosclerotic disease
Valve Disroders
When valves don't work the way they should.. - problems opening (stenosis) - problems closing
Paroxysmal Supraventricular Tachycardia: Mechanism
a defect in the discharge pattern of the SA node, atria, or AV node that causes a drastic increase in heart rate
Acromegaly
abnormal growth of the extremities, caused by overproduction of growth hormones from the pituitary gland
Wolff-Parkinson-White Syndrome
an accessory conduction pathway between the atria and ventricles
Valve Disorders can affect...
any of 4 valves - aortic - pulmonary - tricuspid - mitral (most commonly affected)
Sudden death after age 35 is typically....
artherosclerotic disease
Arachnodactyly
condition in which the fingers are long, slender, and curves (look like spider legs)
Sudden death before age 35 is typically...
congenital cardiovascular
Pre-Participation - Physical Examination
heart murmur Femoral pulses to exclude aortic coarctation Physical stigmata of Marfan syndrome Brachial artery blood pressure (sitting position)
"Valsalva Maneuver"
maneuver in which a patient tries to exhale forcibly with a closed glottis so that no air can goes out through the nose or mouth
Sudden Death Definition:
non-traumatic, nonviolent, unexpected event resulting from sudden cardiac arrest within six hours of a previously witnessed state of normal health
Paroxysmal Supraventricular Tachycardia: Clinical Presentation (during attack)
palpitations anxiety dyspnea chest pain or tightness syncope
Coronary Conduction Disorder
results in arrhythmias, which can lead to - ventricular fibrilation - acute heart failure
Heart Murmurs: Description
timing, intensity, quality, pitch, location, radiation
Long QT Syndrome S&S
ventricular tachycardia, syncope and death