BYPROF.DR.KAMAL

MAHMOUDAHMAD

HEAD OF

THE CARDIOLOGY &

ANGIOLOGY UNITMEDICAL RESEARCH

INSTITUTEALEXANDRIA UNIVERSITY

SUDDEN CARDIAC DEATH IN YOUNG ATHLETES

A competitive athlete

is one who participates

in an organized team

or individual sport that

requires regular

competition against

others and requires

vigorous training

What do these elite athletes look like?

athletes had a 46% larger left ventricle than non-conditioned

people .They also had a 33%increase in

stroke volume. Resting heart rates is low

How do we measure the Athletes Heart?a

The size of the left ventricle when fully expanded, the thickness of its walls, and the amount of blood it pumps with each beat, (called stroke volume) are all key stats in assessing the heart. A technique using ultra sound technology called echocardiography allows doctors to watch the heart in action, freeze the image, and then take measurements to establish the athlete’s heart.

DEMOGRAPHICS

Sudden cardiac death occurs most frequently during basketball and football

Majority of deaths occur in menMost athletes are of high school age at the

time of deathMajority of the athletes who incur sudden

death have been free of cardiovascular symptoms

Collapse is usually associated with intense physical exertion and most commonly occur in the afternoon and early evening hours

Cause of Death

85% died of cardiovascular causes

15% died of non cardiovascular causes -

CRADIOVASCULAR CAUSES

Cardiac History ScreeningCardiac History Screening

Previous murmur or high BPPrevious murmur or high BPFamily history of early MI or sudden deathFamily history of early MI or sudden deathExercise-related symptomsExercise-related symptoms

CASE PRESENTATION

TIMING OF SCD IN ATHLETES

90% of deaths among young athletes occur during training or competition

These observations substantiate the finding that in the presence of certain cardiovascular diseases, vigorous physical exertion represents a trigger for lethal arrhythmias and sudden death on the athletic field

Many of the athletes who've died playing their sport either had very subtle symptoms they didn't understand,or they didn't appreciate the risk.

The events are sudden and tragic. There are cardiac programs

specifically designed for these athletes to catch their condition before it's too late.

In SCA, the heart suddenly stops beating normally. The electrical impulses that control the rhythm of the heart become so disorganized that the heart can no longer effectively pump oxygenated blood to the brain and the body's vital organs, and death occurs

Etiology of life threatening arrhythmias and sudden cardiac death

Coronary artery disease. (MI) Heart failure.Cardiomyopathies. Hypertrophic cardiomyopathy (HCM) Dilated cardiomyopathy (DCM) Arrhytythmogenic RV cardiomyopathy (ARVD)Primary electrophysiologic disorders. Long QT syndrome Brugada syndrome Aortic stenosis Anomalous origin of coronary arteries

Coronary artery disease.

8o % of fatal arrhythmias and SCDThe culprit arrhythmia is;VT/VF in 95% and Asystole in 5 %

Predictors of arrhythmias

LARGE infarction.Impaired LV systolic function.Presence of occluded artery.

Anomalous Coronary arteries

Type of Anomalous Coronary arteries

Origin of the left main coronary artery (LMCA) from the right or non coronary sinus

Origin of the right coronary artery (RCA) from the left coronary sinus.

Both coronary arteries arising from the same coronary ostium .

Absent right coronary artery in one case.

Cardiomyopathies

Cardiomyopathies are defined by the World Health Organization

(WHO) as Diseases of the myocardium which

result in cardiac dysfunction.

The WHO Classification of Cardiomyopathies Includes:

HYPERTROPHIC.DILATED.RESTRICTIVE.

AndArrhythmogenic right ventricular

cardiomyopathies.

HYPERTROPHIC CM

Prevalence and Genetics

Most common cause of sudden death in young athlete Prevalence: 0.2% (1:500) in the adult general population

Most common genetic cardiovascular disease

< 1% of patient in cardiology practice

Genetics: autosomal dominant trait, caused by mutations in genes encoding proteins of the cardiac sarcomeres

In hypertrophic Cardiomyopathy

The ventricular walls are

hypertrophied.

The cavity is small.

The ventricular function is

normal or hyperkinetic.

Hypertrophic CM

Fatal arrhythmias and SCD can occur throughout life particularly in young patients.

Hypertrophic CM

The disease is the most common cause of sudden death in atheletes, and the genetic defects responsible may have a prevalence in the population as high as 1 in 2000..

Hypertrophic CM

The consequences of the heart muscle thickening are restriction of blood flow into and out of the heart, interruption of the heart's own blood supply, the development of heart rhythm irregularities.

Predictors of FA & SCD IN HOCM

symptoms such as chest pain, headaches and black-outs.

Next attempts are made to distinguish those patients who may be at risk for sudden death from those who are not

Predictors of FA & SCD IN HOCM

Family history of SCD.Syncope.IVS > 30 mm.Non sustained VT.Sustained VT & VF.

ARVDARVD

Normal heart tissue is replaced by Normal heart tissue is replaced by fibrofatty tissue fibrofatty tissue

Dilatation or formation of aneurysms in the Dilatation or formation of aneurysms in the right ventricular wall right ventricular wall

THE ATHELETES HEART

LEFT VENTRICULAR DD >45 mm.MAXIMAL DIASTOLIC WALL

THICKNESS < 15mmNO FAMILY HISTORYNO LEFT ATRIAL ENLARGEMENT.NORMAL DIASTOLIC FUNCTION.

Athletic HEART

Habitual physical activity reduces the overall risk of myocardial infarction and sudden coronary death by preventing development and progression of atherosclerotic coronary artery disease.

Athletic HEART

However vigorous exertion increases the incidence of acute coronary events in individuals who did not exercise regularly.

Athletic HEART

Sport acts as a trigger of cardiac arrest in those athletes who are affected by silent cardiovascular conditions;

Cardiomyopathy, premature coronary artery disease and congenital coronary anomalies, which predispose to life-threatening ventricular arrhythmias during physical exercise

cigarette smoking

continued cigarette smoking is associated with a significant increase in the risk of life-threatening tachyarrhythmias and SCD

The Impacts of Smoking on Diving

The effects of smoking are especially significant for persons who participate in scuba diving.

A review of scientific literature about the body's reaction to smoking and nicotine illustrates how smoking can effect diving performance

The Impacts of Smoking on Diving

Nicotine promotes platelet aggregation and fibrinogen formation, which are precursors to the clots that obstruct small blood vessels. An obstruction initiates negative repercussions that increases the risk of diving and decompression. The heart rate increases, elevating oxygen consumption and the shrinking of small blood vessels increases total peripheral resistance , increased blood pressure and poor circulation in the periphery of the body.

The Impacts of Smoking on Diving

Peripheral circulation involves the miles of very small blood vessels all over the body. The vessels are problematic in efficient inert gas elimination. For example, the extremities contain numerous areas of reduced circulatory efficiency such as the joints (responsible for the majority of decompression sickness). When divers begin to get chilled, a natural reduction in blood circulation to the peripheral system occurs to maintain a reasonable core temperature.

Potassium disorders

Potassium disorders (hyperkalemia & hypokalemia ) may precipitate cardiac arrhythmias or cardiopulmonary arrest.

They are an anticipated complication in

patients with renal failure, but may also occur in patients with no previous history of renal disease.

long QT syndrome

Occurring especially during conditions of increased sympathetic activity.

mortality is high among untreated, symptomatic individuals

QTc   =   QT interval  ÷  square root of the RR interval (in msec)

long QT syndrome

Congenital long QT syndrome (LQTS) is a genetic disorder characterized by prolongation of the QT interval on the electrocardiogram and by life-threatening cardiac arrhythmias.

Short QT syndrome

Short QT syndrome is an inheritable primary electrical disease of the heart that was discovered in 1999.

The disorder is characterized by an abnormally short QT interval (<300 ms) and a propensity to atrial fibrillation, sudden cardiac death or both.

so far two relevant genetic mutation has been identified that can lead to a short QT interval on the ECG

AWAY FROM THE HEART

Food Additives And The Artificial Sweetener Aspartame

there is one mechanism that's getting no attention at all: the excitotoxin damage caused by food additives and the artificial sweetener aspartame.

An alarming number of SCD, in high schools and colleges as well as among professional athletes.

IT was thought that food additives, cause their damage in the cardiovascular centers in the brain stem and/or by over-stimulating sympathetic centers in the hypothalamus of the brain.

herbal remedies

Extracts from the plant Aconitum species have been used as anti-inflammatory and analgesic agents.

Many of these alkaloids are extremely potent cardiotoxins resulting in various fatal arrhythmias as ;

severe bradycardia, sinus inactivity, AV dissociation with idiojunctional rhythm and LBBB resulting in hypotension and syncope.

Prevention of Fatal Arrhythmias by Fish Oil

Fatty Acid Intake

The long-chain n-3 fatty acids in fish have been demonstrated to have antiarrhythmic properties in experimental models and to prevent sudden cardiac death in a randomized trial of post–myocardial infarction patients.

Circulation. 2005;112:2762-2768.)

Melatonin

The pineal secretory product, melatonin, is known to be a potent free radical scavenger, antioxidant and can inhibit the intracellular calcium overload. ischemia-reperfusion injury.

Incidence of SCD is high in the morning hours.

It has been shown that melatonin levels are significantly low at these times and patients with coronary heart disease have lower levels than normal individuals.

Melatonin

These findings thought that melatonin would be valuable to test in clinical trials for prevention of possible ischemia-reperfusion-induced injury, especially life threatening arrhythmias and infarct size,

Anadolu Kardiyol Derg. 2006 Jun;6(2):

Better understanding of the interaction among various functional, structural, and genetic factors underlying the susceptibility to, and initiation of, fatal arrhythmias is a major goal and will provide new tools for the prediction, prevention, and therapy of SCD

To initiate A program that combines cardiology and sports medicine.

These clinics not only treat athletes with obvious symptoms but test those without as well.

السالم عليكم ورحمة الله وبركاته