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