sudden death in athletes - ucsf cme byron lee... · sudden death in athletes: what is the role of...
Post on 08-Jun-2020
4 Views
Preview:
TRANSCRIPT
1
Sudden Death in Athletes: What is the role of ECG Screening?
Byron K. Lee MD
Professor of Medicine
Director of EP Laboratory
leeb@medicine.ucsf.edu
Division of Cardiology
Cardiac Electrophysiology
Arrhythmias, Heart Failure, and
Structural Heart Disease
Honolulu, Hawaii
October 8, 2015
Disclosures
• Research
– Medtronic
– Zoll
– Boston Scientific
– Apama
• Consulting
– Cardionet
– Biotronik
– Janssen
• Honorarium
– St. Jude
– Biotronik
2
2
Pheidippides Run: Marathon to Athens
3
• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
4
3
450,000
1 U.S. Census Bureau, Statistical Abstract of the United States: 2001. 2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001. 3 2002 Heart and Stroke Statistical Update, American Heart Association. 4 Circulation. 2001;104:2158-2163.
Magnitude of SCD in the US
Breast Cancer2
SCD 4
42,156
40,600
157,400
167,366
AIDS1
Lung Cancer2
Stroke3 SCD claims
more lives
each year
than these
other
diseases
combined
#1 Killer
in the U.S.
SCD Landscape
Huikuri et. al. NEJM 2001 (adapted from Myerburg)
SCD-HeFT
AVID
MADIT
4
• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
7
Causes of SCD (Age>35)
8
Huikuri et al. NEJM 2001
5
SCD due to CAD: Darryl Kile
9
Causes of SCD (Age<35)
10
Huikuri et al. NEJM 2001
6
11
Maron NEJM 2003
Causes of SCD (age<35) • #1: Hypertrophic CM
– 1 in 500
– Scarred and disordered myocardium
– Confirmed HCM in 26.4% of SCDs
– Probable HCM in 7.5% additional cases of SCD
– Diagnosis
• PE
• ECG
• Echo
12
Maron NEJM 2003
7
ECG in Hypertrophic CM
13
Hypertrophic CM: Hank Gathers
14
8
Causes of SCD (age<35)
• #2: Commotio Cordis
– Blunt blow to the chest 15-30ms before T-wave peak (vulnerable phase of repolarization)
– Mean age 13 years old
• Compliant chest wall
– 19.9% of SCDs
– Structural normal heart
– Normal ECG
15
Commotio Cordis
16
9
Protection Against Commotio Cordis
17
Causes of SCD (age<35)
• #3: Congenital Coronary Artery Anomalies
– Artery arises from wrong aortic sinus
– Classic presentation: CP or syncope with exercise
– 13.7% of SCDs
– Diagnosis:
• Stress test
• Echo
• MRI
• CT
• Cath
– Normal ECG
18
10
Coronary-Artery Anomalies:Pete Maravich
19
• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
20
11
Pre-participation Screening in Italy
21
Corrado et al. JAMA 2006
Seattle Criteria: Normal Findings
22
12
Seattle Criteria: Abnormal Findings
23
24
Seattle Criteria: Abnormal Findings
13
Cleared to play sports?
Cleared to play sports?
14
Torsade de Pointes
• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
28
15
29
Corrado et al. JAMA 2006
AHA Recommendation
30
Maron et al. Circulation 2007
If age >35, add ETT if RF for CAD
If age >65, add ETT
16
AHA Cost Analysis for U.S.
• 10M middle school and high school athletes
• Initial Screen
– $25 for H&P
– $50 for ECG
• Follow-up Screen
– $100 for H&P
– $400 for Echo
• Administrative Cost: 500M
• Total Cost: $2B
• $330,000 for every relevant disease diagnosed
31
Other Cost Effectiveness Analysis
32
HRS 2011
Annals of Internal Medicine 2010
17
AHA Recommendation
33
Maron et al. Circulation 2007
If age >35, add ETT if RF for CAD
If age >65, add ETT
• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
34
18
Athlete’s Heart
• Triggers
– Endurance sports (rowing, cross country skiing, swimming)
– Isometric sports (weightlifting, wrestling)
• Cardiac changes
– Heart size and chamber enlargement
– Increased LV wall thickness
– Increased LA
– Preservation of systolic and diastolic function
• Associated with abnormal ECG patterns
• Considered a benign adaptation to training
35
Pelliccia A, et al. Circulation 2000;102:278-284
19
• Referred for Abnormal ECG
• Sees you for evaluation
– No syncope
– No symptoms of cardiac disease
– No FH of SCD
– Appears to be extremely physically fit
– Rest of exam benign except for a soft systolic murmur
37
17 year old Swimmer
Basavarajaiah et al. Br J of Sports Med 2006
17 year old Swimmer
38
Basavarajaiah et al. Br J of Sports Med 2006
20
• Echo
– Significant concentric LVH with maximal wall thickness of 14 mm (normal <12 mm)
– Normal LV cavity of 48 mm
– Normal systolic and diastolic function
– Normal valves
• MRI normal except for wall thickening
• ETT normal
• 24 hour holter normal
• Now what?
39
17 year old Swimmer
Basavarajaiah et al. Br J of Sports Med 2006
After 8 week of Deconditioning
40
Basavarajaiah et al. Br J of Sports Med 2006
LVH regressed from 14 mm to 11 mm
21
• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
42
22
44
23
45
46
24
47
48
Conclusions
• Most SCDs occur in otherwise healthy individuals
• Main cause of SCD
– Over 35: CAD
– Under 35: HCM, Commotio Cordis, Coronary Anomalies
• Young athletes screening:
– H&P
– ECG?
• Master athletes (age >35) screening:
– H&P
– ETT (if RFs for CAD or age>65)
• Community based programs can find new disease and save lives
• ICDs save lives without limiting physical activity
SECTION HEADING
25
ICDs Do Save Lives
Israel and Minnesota Data
50
Steinvil et al. JACC 2011
Maron et al. Am J Cardiol 2009
26
51
Detraining in 40 Elite Athletes
• Pelliccia A, et al. Circulation 2002;105:944-949
27
Detraining in 40 Elite Athletes
Pelliccia A, et al. Circulation 2002;105:944-949
Cleared to play sports?
top related