SUDDEN CARDIAC DEATH IN - European Society of Cardiology · Common causes of sudden cardiac death...

SUDDEN CARDIAC DEATH IN

ATHLETES…

Alessandro Zorzi, MDDepartment of cardiac, thoracic and

vascular sciences

University of Padova

… and strategies for prevention

Alessandro Zorzi - University of Padova – [email protected]

mailto:[email protected]

Common causes of sudden cardiac death in the athlete

Young athletes (under 35):

Hypertrophic cardiomyopathy

Arrhythmogenic cardiomyopathy

Congenital coronary arteries anomalies

Myocarditis

Aortic dissection

Premature coronary atherosclerosis

Ventricular pre-excitation

Arrhythmic mitral valve prolapse

Congenital heart disease

Isolated non-ischemic left ventricular scar

Structurally normal heart



Annual Incidence Rates of Sudden Cardiovascular Death in Screened Competitive Athletes and

Unscreened Nonathletes Aged 12 to 35 Years in the Veneto Region of Italy (1979-2004)

Corrado et al JAMA 2006;296:1593-1601

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

1979-1980

1981-1982

1983-1984

1985-1986

1987-1988

1989-1990

1991-1992

1993-1994

1995-1996

1997-1998

1999-2000

2001-2002

2003-2004

Su

dd

en

de

ath

pe

r 1

00

00

0 p

ers

on

-ye

ars

Years



ROLE OF PREPARTICIPATION SCREENING

Two possible strategies

(Centro di Medicina dello Sport; Padova 1982-1996)

Disease

History, PE,

ECG

(N=43)

History and PE

alone

(N=10)

HCM 22 (51%) 5 (50%)

ARVC 8 (19%) 2 (20%)

DCM 4 (9%) -

Marfan sdr. 3 (7%) 1 (10%)

Long QT 2 (5%) 1 (10%)

Coronary artery disease 2 (5%) -

Myocarditis 1 (2%) -

Congenital heart disease 1 (2%) 1 (10%)



Is the ECG-based preparticipation

screening model cost-effective?




•If one assumes that universal screening of young competitive athletes is

justified on ethical and medical ground (AHA/ACC/ESC)

•If one recognizes that

•1) history and physical examination are of marginal value for identification of

athletes at risk and

•2) ECG is much more sensitive than history and physical examination (although

it has a low specificity that translates into limited cost-effectiveness)

•Then, the screening protocol has to include ECG

*a formal argument in logic that is formed by two statements and a conclusion which mustbe true if the two statements are true

The preparticipation screening

Aristotelian syllogism*


Why can athletes die suddenly despite

ECG preparticipation screening?



The problem of false negatives

For some cardiovascular diseases at risk of sudden

cardiac death in the athlete, ECG preparticipation

screening is not sensitive enough:

• Congenital abnormalities of coronary arteries

• “Commotio Cordis”

• Acute myocardities

• Mild cardiomyopathy phenotypes

• ISOLATED (IDIOPATHIC) NON-ISCHEMIC LEFT

VENTRICULAR SCAR

• CORONARY ARTERY DISEASE (OLDER ATHLETES)



27 year-old, professional soccer player

No personal or family history



• ECG: infero-lateral T-wave inversion

• 24 hours ECG-monitoring: frequent PVB with a RBBB-pattern

• Echocardiography: normal



Contrast-enhanced MRI

– Morpho-functional evaluation: normal

– Post-contrast sequences: infero-lateral subepicardial scar of unkown origin (post-myocarditis? Left-dominantARVC?)



Therapy:

• Competitive sport restriction

• Beta-blockers

• ICD

Dopo 33 mesi di follow- up while playing table tennis



PIERMARIO MOROSINI

Family history: negative

Personal history: negative

ECG: normal

Ecocardiography: normale

Stress test: normal

Autopsy: left-dominant arrhythmogenic

cardiomyopathy with subepicardial fibro-

fatty scar of the left-ventricular lateral

wall. Focal fibrofatty infiltration also of

the right ventricle.



D’Amati et al. Int J Cardiol 2016;206:84–86

BEFORE 1999

80%: CLASSICAL

RIGHT DOMINANT

VARIANTS

AFTER 1999

ALL LEFT DOMINANT

OR BIVENTRICULAR

VARIANTS

IN THE VENETO REGION OF ITALY

ARRHYTHMOGENIC CARDIOMYOPATHY REMAINS

THE MAIN CAUSE OF SUDDEN CARDIAC DEATH IN

YOUNG ATHLETES BUT THE PHENOTYPE HAS

CHANGED BECAUSE OF PREPARTICIPATION

SCREENING:

Sudden cardiac death registry– Veneto Region courtesy Prof.ssa C. Basso




Di Gioia et al, Human Patology 2016 (in press)


Non ischemic left ventricular scar: an

emerging cause of sudden death in the athlete


Zorzi et al, Circ Arrhythm Electrophysiol 2016 (open access)


Senior (> 35):

Ischemic cardiac disease

Patients with coronary artery disease risk factors are the one who most benefit from physical activity, but they are also those at higher risk of acute coronary syndrome and ventricular fibrillation during exercise

“doing sport is good... If you don’t die suddently”

Common causes of sudden cardiac death in the athlete



Data from the “Castelli Foundation” (collected from the press)

2006 – 2012

592 cases of cardiac arrest during physical activity

3 professional athletes

80 competitive non-professional athletes

>80% amateur athletes /leisure time sports activity



ACTIVE

Adult/senior

Moderate intensity activity High intensity activity

Self-assessment of risk

Screening by physician:

Hx, Phys.exam., RISK SCORE, ECG

NO on every

questionYES on every

question

Maximal exercise testing

High riskLow risk

Negative PositiveEligible

Further evaluation,

Appropriate

treatment and

individually

prescribed

physical activity

Low intensity activity

Consensus document of EACPR

Hx + Phys

ECG

AED

60%

20%20%

As for some diseases that

can cause sudden cardiac

death primary prevention is

not feasible…

… the only preventive

strategy is immediate

resuscitation of cardiac

arrest victims




1982:

Cardiovascular screening for all

competitive athletes (including

stress test for athletes older

than 35)

9th in the Rio Olympic medal standings but

1st in prevention of sudden cardiac death of

the athletes

2012:

1) Screening (with resting

ECG) also for non-

competitive amateur athletes

2) AED+trained personnel in all

sports facilities


Primary prevention by means of athletes pre-partecipation screening

including 12-leads ECG is an effective strategy that led to a significant

reduction in the incidence of sudden cardiac death in the athletes.

Future studies to further refine ECG pre-partecipation screening to

further improve the sensitivity (e.g. to identifiy concealed substrates like

the non-ischemic scar) are very important.

To significantly decrease sudden cardiac death rate in sports, however, it

is also very important to:

1) Improve preventive strategies in middle-aged leisure time athletes;

2) Improve secondary prevention strategies by implementing

resuscitation strategies.

CONCLUSIONS



SUDDEN CARDIAC DEATH IN - European Society of Cardiology · Common causes of sudden cardiac death...

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