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1、Sudden Cardiac Death and SportDr Deirdre WardDirector, Centre for Cardiovascular Risk in Younger PersonsAdelaide and Meath Hospital, Tallaght(and St James, St Vincents University Hospitals)Blackrock Clinic and Charlemont Clinic Centre for Cardiac Risk in Younger Persons (CRYP Centre)nService begins
2、Jan 2007Out-of-hours clinics, 600 patientsnFull-time, staffed Centre opens Nov 2008All-day clinics, 1500 patients per yearNurse, 2 Technicians, Admin Officer, (Doctor)nFundingCardiac Risk in the Young Charity (CRY-Ireland)Adelaide SocietyTallaght Hospital VolunteersPfizerPrivate donationsContinuous
3、fundraisingTallaght Hospital and TCDnAim : provide timely, comprehensive assessment of families where SCD has occurred or young people with worrying cardiac symptomsnTests : ECG, Echo, Exercise Test, Heart rhythm monitor all on one day, followed by Consultation with Consultant (family tree etc)Overv
4、iew of Sudden Cardiac DeathnSize of the problemnCauses of sudden cardiac deathnSport and SCDnIdentifying those at risknManaging risknGeneral screening ?nPublic access defibrillators ?BackgroundnSudden Cardiac Death = death from definite or probable cardiac causes within 1 hour of symptom onsetnIncid
5、ence from International Studies1 to 3 per 100,000 in those 1 to 35 yrs of age10 to 75 per 100,000 in those 35 to 64 yrsnIncidence in IrelandExtrapolation from other studies suggestnapprox 5,000 SCD annually RoI, 2000 NI n60 - 80 deaths 25 (NI)nFrom 2005 study of Coroners data 5 per 100,000 males (14
6、-35 yrs) 1 in 500 people carry gene11000 in 32 counties90% of cases thought to be inherited (runs in family)10% sporadic pass on to their children?Approx 50% who inherit genetic change develop full-blown condition (incomplete penetrance)nInheritance pattern Autosomal Dominant= 50% risk of inheriting
7、 gene if parent affectedHCMnSymptoms include :Shortness of breath with exercisechest pain (usually with exercise) Diziness (at rest or with exercise) blackouts PalpitationsNo symptomsnRisk of sudden death 1% per yearnIntensive exercise can increase risknUsually identifiable on ECG and EchoEcho Cardi
8、ac UltrasoundRight ventricleLeft ventricleSeptum Wall between2 sides of heartUsually 10 mmHeart valvesAortic + MitralHCM - TreatmentnNo cure, but can prevent complicationsnManage symptomsMedications (Beta-blocker tablets)Modify lifestyleSurgery (only in very limited circumstances)nEnsure family memb
9、ers checkednAssess risk of sudden deathLow-risk, reassure, but still avoid intense exerciseHigh-risk, recommend implantable defibrillator (ICD)ICDOther Cardiomyopathies - DilatedHeart stretches in sizePump function reducesOther Cardiomyopathies- DilatednMay be inherited, much less common 1000 people
10、 in countrynOther causes include viral illness, drugs, alcoholnMay cause shortness of breath, palpitations, blackout, sudden deathnECG and echo usually identifiesnOther tests may be necessarynTreatmentMedicationsOccasionally pacemakers and/or ICDnRisk of SCD usually highest in those with poorest pum
11、p function, who usually have symptomsOther Cardiomyopathies Arrhythmogenic (aka ARVC or ARVD)nHeart may become enlargednScarring develops in heart nCauses palpitations, dizzy spells, blackouts, shortness of breath, sudden deathnOften inheritednMay need several tests to diagnoseECG, echo, Exercise te
12、st, heart rhythm monitor, MRI scan of heartnMilder cases can be missed (even in Italy with compulsory screening programme)nTreatmentMedicationsLifestyle modificationIf considered high risk of rhythm problems, recommend ICDOther inherited conditionsnMarfans syndromeWeakness of walls or large blood ve
13、sselsMay be associated with tall stature and hyperflexibility, eye problemsIdentified on physical exam, echo and X-ray scansnCongenital heart diseaseAbnormal development of cardiac structure(s) in the wombRange from blue baby to small holes in heartMilder forms generally not life-threatening 10 % in
14、herited, most occur spontaneouslynMitral valve prolapse1% of population have at least mild caseSevere cases may be associated with sudden deathMay be over-estimated as cause of sudden deathOther conditionsnValve diseaseUsually causes a murmurMay cause reduction in exercise tolerancenAnomalous corona
15、riesAnatomical variant in placement of blood vesselsSome may reduce blood supply during stress or exercise but most probably dont cause problem and may be over-estimated as cause of SCDnMyocarditisInflammation of heart muscleUsually thought to follow viral infection1/8 people with virus + fever have
16、 ECG changeProbably should avoid exercise during viral infectionPossible genetic predisposition to being affected by virusSudden Arrhythmic (Adult) Death Syndrome (SADS)nDiagnosis of exclusionnSudden death occurs, and is consistent with cardiac rhythm disturbance, but post-mortem examination finds n
17、o abnormalitynCurrently no standardization of post-mortem examination in Ireland (improving)nCurrently no Specialist Cardiac Pathologist with specific responsibilitynIf post-mortem not carefully doneStructural cause of death may be missedMinor abnormalities may be incorrectly recorded as cause of su
18、dden death True number of SCD which are actually due to SADS probably under-estimatednElectrical problem is cause of death, but no electrical activity after death so not detectable at post-mortemElectrical problems also known as ChannelopathiesnElectricity in heart is generated by pump channels in w
19、alls of each cell in heart pump salts (Na, K, Ca) in and out of cellPump channel = ion channelnIf pump malfunctions (under or over-active) changes electrical activation of heart which causes electrical instability and increases chance of arrhythmianMay not cause symptoms unless palpitations, dizzy e
20、pisodes or blackoutsnUsually detectable on ECG (if looking for it) nDifferent genes code for different pumps and mutations cause different conditions : Long QT syndromeBrugada SyndromeCatecholaminergic Polymorphic Ventricular Tachycardia (CPVT)nNot identifiable on PMnCan be identified on ECG (+/- ex
21、ercise test and rhythm monitor) in livingn40% of families of those who die of SADS have inherited cause identified (mostly LQT syndrome and Brugada syndrome)Influence of sporting activity on risk nIn younger people over all, sporting activity increases risk x 2.5nOlder adults who exercise frequently
22、 have 5x increased risk of sudden cardiac arrest during vigorous activity (coronary disease)nOlder adults who do not exercise frequently have 56 x risk of SCA during vigorous activity (NEJM 1984)Sport and sudden cardiac deathnIf you have one of these cardiac conditions intense sporting activity will
23、 double risk of dying suddenly (eg increase from 1% to 2% in HCM)nYou do NOT have to be an athlete to die from SCDnYou CAN die from SCD at rest or during sleepIdentifying those at risknFamily historyPremature sudden deaths definitely or possibly cardiacRelatives diagnosed with above conditionsnSympt
24、omsSOB or chest pain that limit exerciseUnexplained dizzy spells / blackouts (especially if on exertion)Prolonged palpitationsnScreeningPhysical exam?ECG?Other?Management of at risk peoplenNot everyone with these conditions has high risk of sudden deathnRisk varies with each condition and even withi
25、n families (the same gene will behave differently in everyone who inherits it)nSystem for identifying at risk people developed in most conditions Managing risknAvoid competitive sport or very strenuous exertionnRecreational sport, PE classes etc usually safe nMedications in some (eg b-blockers)nCont
26、inued observation in allnImplantable defibrillators in someCost implicationsComplicationsWhy screen relatives, or people with suggestive symptoms?nMany conditions relatively easy to identify (if you know what youre looking for)nNot everyone affected is at risknVarying success rates at accurately ide
27、ntifying at risk peoplenSome can be treated with medicationnHigh risk people offered implantable defibrillator (ICD or shock-box)nFuture generations at riskCardiac evaluation for families or symptomatic individualsnCurrent optionsGP evaluationLocal physicianGeneral CardiologistSpecialist CentrenCent
28、re for Cardiac Risk in Younger Persons (Tallaght / St James / St Vincents)nFamily Heart Screening Clinic (Mater and Blanchardstown Hospitals)Athlete / Population screeningnCurrently no government resources for screening high-risk populationnRisk in general population approx 1to 3 per 100,000 athlete
29、s/yrnPotential downside to screeningSport can bring on changes in cardiac tests (espec ECG but also Echo) that may be difficult to distinguish from cardiomyopathyAdditional testing in perhaps 10% of all those screenedBorderline cases may never be resolved completelyn? affect life insurance in future
30、n? Restrict ability to play sport n? Restrict career choicesIf considering Irish National programmenQuestions :Who would oversee (GP vs Cardiologist)?Who (athletes only or every person?), when (at what age?) and how often (repeated?)What form should it take?Who pays?Who deals with fall-out from abno
31、rmal resultsVoluntary or compulsory? AHA Consensus Panel Recommendations For Pre-participation ScreeningFamily History:1. Premature sudden death2. Heart disease in surviving relativesPersonal History:3. Heart murmur4. Systemic hypertension5. Fatigability6. Syncope7. Exertional dyspnoea8. Exertional
32、chest painPhysical examination:9. Heart murmur (supine / sitting / standing)10. Femoral pulses11. Stigmata of Marfan Syndrome12. Blood pressure measurementYoung Young competitivecompetitiveathletesathletesFamily and personal history,Family and personal history,physical examination, 12 lead ECGphysic
33、al examination, 12 lead ECGNegativeNegativeEligible Eligible for competitionfor competitionFurther ExaminationFurther Examination(echo, stress test, 24 hr Holter(echo, stress test, 24 hr HolterMRI, angio/EMB, EPSMRI, angio/EMB, EPSManagementManagementPositivePositiveEur Heart J 2005Eur Heart J 2005E
34、uropean ApproachDifficulties with screeningnLow prevalence diseases so prior probability lownQuestionnaire aloneFamily history may not be knownConditions can occur without SCDSymptoms not recognised or suppressedn+ Physical examinationAllows potential pick-up cardiac murmurs (HCM, bicuspid aortic va
35、lve, MVP) and coarctation, MarfansHCM may be present without murmur, misses other cardiomyopathiesn+ ECGImproves pick-up of cardiomyopathies, LQT etcChanges may be subtleWill not identify anomalous coronaries Benefits of Italian programme(Corrado et al, JAMA 2006)nScreening by law since 1982nEveryon
36、e 12 yrs of age or older engaged in formal competitive sportnRepeated every 2 yearsnPerformed by Sports CardiologistnPublished review of athlete screening, and causes of SCD in athlete and non-athlete population in 2006n9% of athletes required further screeningn2% of athletes disqualified Numbers of
37、 CardiologistsAutomatic Defibrillators (AEDs)nProminent placement in public locations (? remote rural towns also)nComputer analyses heart rhythm and decides if shock is requirednIdeally personnel using should be trained (and training updated ? every 3 months)nHave been successfully used by untrained
38、 good samaritansnMaintenance issuesnPublic liability (Duty of Care issues)nIf cardiac arrest during sport more difficult to resuscitateData from US Schoolsn15 year period reviewednNumber of schools needed to generate 1 cardiac arrest per year167 schools8 colleges / universitiesnOf those who had card
39、iac arrest15 % were 35 years of age10% were students (half of them were already known to have health problems)In SummarynSCD is not commonnHigh-risk people usually identified by symptoms or family history priority for evaluationnCure not possible, but correct management can prevent complicationsSymp
40、toms to be aware ofnAwareness of unusual symptoms important:Chest discomfort and/or Shortness of Breath that significantly limits ability to exerciseUnexplained blackoutsProlonged palpitations (especially if associated with diziness)Reducing the risknIdentify those with underlying conditionsnOlder p
41、eople returning to sport get checked by GPnImprove response in the event of a cardiac arrestAvailability of AEDsTraining of population in Basic Life SupportImproved ambulance response timesCardiac screening for sports or entire population?nHard to justify compulsory testingEthical right not to know about health issuesnCurrently no resources in public health system for statistically low-risknPrivately funded facilities existBeware variable standard of expertise and focus on profit
