Athlete Sudden Cardiac Death
EMERGENCIES IN MEDICINE
Park City 2012
Jim Kyle, MD, FACSM
Emergency Department Director, Beckley ARH
Team Physician Concord University
Associate Clinical Professor Marshall University
Sports Trauma Trends
Head / Neck Case
Long term subtle neuro deficit
Heat Stress Injury
Performance enhancement supplements
Sudden Cardiac Arrest
Unrecognized congenital conditions
Cardiac concussion
Sudden Cardiac Death in Athletes
Incidence of SCD
• high school athletes 1:100,000 to 200,000
VanCamp & Maron
• college athletes 1:65,000 – 69,000 VanCamp
& Drezner
• 1:50,000 marathoners, 1:15,000 joggers
• ~ 110 athletic deaths per year in US Maron
• no national surveillance system; true incidence
unknown; most likely underestimated
The Faces of SCA
1990 - Hank Gathers Tragedy
• DX: exercise related complex
ventricular tachycardia
• RX: Beta Blocker- Inderal 200qd
• Return to play in three weeks
• Courtside cardiac monitor
defibrillator
Hank Gathers SCA
• Medication had been
decreased due to side
effects
• Cause of death -HCM
• Cardiac monitor
defibrillator legal
issue: $32 Million
law suit
Cause of Sudden Cardiac Death
Ten Year Review 158 Athletes
B. Maron, JAMA 1996
Cause of Sudden Cardiac Death
Ten Year Review 158 Athletes
B. Maron, JAMA 1996
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1985-95 sudden death organized sports
138 cases of Sudden Cardiac Death
Ages 12-40, median age=17 90% Male
68% occurred in Football and Basketball
62% High School, 22% College,
7% Professional
The Faces of SCA
SCA in Athletes
“The unexpected death of an athlete during exercise
is tragic irony. ... much remains unknown
regarding optimal screening strategies,
pathophysiologic mechanisms,and prevention”
Mark Link, MD
Tufts University
Cardiac Concussion
Little League Baseball
Sudden Death
• A 16yo player was struck in the
chest by the baseball thrown from
home plate as he attempted to steal
third base. Shortly after standing
he collapsed with seizure like
activity and stopped breathing.
Little League Baseball
Sudden Death
• The coach initiated CPR and local
EMS documented arrival of an ACLS
team 8 minutes after receiving the call
from the field. Attempts to resuscitate
were unsuccessful.
Cardiac Concussion
• Commotio Cordis - sudden death during sports
play after a blunt blow to the chest Maron,
NEJM, 1995
• 25 case 1977-95, Average Age = 11 (3-19) 18
playing baseball or softball, “Little League
Sudden Death” 24 male
• Vulnerable window 15-30 msec prior to peak of T
wave inducing V- Fib Link, NEJM, 1998
Laboratory Cardiac Concussion
Sudden Death: Commotio Cordis
2001 Commotio
Cordis Update
• 2001 update - 128 cases
84% cases fatal
• Early defibrillation with on
site AED only effective
treatment
• AED documented in 41
cases, 19 survived = 46%
Cause of Sudden Cardiac Death
Ten Year Review 158 Athletes
B. Maron, JAMA 1996
“Sudden Death in Young Athletes”
Maron NEJM 2003,
Sudden Death in 387 Young Athletes
1. Hypertrophic Cardiomyopathy – 34 %
2. Commotio Cordis – 20%
3. Coronary-artery Anomalies – 14%
2010 Update: Cardiac Concussion
2010 Update: Cardiac Concussion
• 224 Cases: NEJM, B Maron, M Estes
• Mean Age = 15: 26% < 10yo
Range: 6mos – 50yo
• 95% Male, 78% White
• Survival rate
15% 1990-1999
35% 2000-2009
( 2006-09 > 50% )
The Casino Project
The Casino Project
• 1997 – Security Guards at Star Dust trained
by Clark County EMS, Richard Hardman in
use of Life-Pak 500
• 1997- 2000: 200+ cases of witnessed SCA
with 57% survival
• Time to AED- 3 mins, Shock 4 mins
• 6,500 Security Guards trained
Public School AED Program
• 1999: Planning for Scholastic Cardiac
Emergencies, WV Med Jour. The Ripley
Project
• 2000: Milwaukee City school after 4 case
SCA Project ADAM
• 2001: Long Island schools lacrosse focus
Acompora Foundation (www.la12.org)
• 2007: 91% College, 35% High School with
AED
• 2011: Saves > Deaths Commotio Cordis
“Non V-Fib” Cardiac
Concussion
Link,NEJM: 4/10 impacts during QRS = complete heart block
“Non V-Fib” Cardiac
Concussion
• 3* Heart Block
• LBBB
• ^ST segment
Athletes at Risk for SCA
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Chief complaint of syncope
Chest Pain with or post activity
History of palpitations
Family History of Sudden death
Abnormal EKG
Athlete SCA : Have We
Changed the Playing Field ?
Emergency Department
• Athlete Collapse – Assume Cardiac
Etiology (Sentinel Seizure)
• EKG Attention: Delta and Epsilon Waves,
LQT
• Syncope, Near Syncope, Chest Pain Work
Up: Consider advanced imaging, Cardiac
CT, MRI* vs ECHO
ARVD – Prolonged QRS,
Inverted T wave V1 – V2
ARVD – Arrhythmogenic
Right Ventricular Dsyplasia
• Italian Sport Federation requires school
athletes to have EKG and limited
stress test on an annual basis
• EKG with prolonged QRS V1-V3 110
msec and inverted T wave
• Epsilon wave in 50%
ARVD Epsilon Wave
Athlete SCA : Have We
Changed the Playing Field ?
Emergency Department
• Athlete Collapse – Assume Cardiac
Etiology (Sentinel Seizure)
• EKG Attention: Delta and Epsilon Waves,
LQT
• Syncope, Near Syncope, Chest Pain Work
Up: Consider advanced imaging, Cardiac
CT, MRI* vs ECHO
ARVD with fatty (dark, arrows)
RV myocardium
By Cardiac CT Angiography Study
N. Wilke, UF and Precision Imaging Centers, JAX, Florida
Cause of Sudden Cardiac Death
Ten Year Review 158 Athletes
B. Maron, JAMA 1996
25%
Coronary Artery Anomalies
Magnetic Resonance Imaging
Möhlenkamp et al. Circulation 2002;106:2616-22.
Cardiac CTA: Common, Stenosed
Ostium of RCA and LM
N. Wilke, UF and Precision Imaging Centers, JAX, Florida
Athlete SCA : Have We
Changed the Playing Field ?
Athlete Screening
• Consider EKG – Corrado Italian Criteria
• Heart Murmur – Baseline ECHO with
potential repeat to R/O HCM, Marfans
• Palpitations or SVT suspicion - Holter
Monitor
*2006 World Cup: FIFA required EKG, ECHO,
Stress Test after Cameroon SCA
Italian Guidelines for Sports Medicine
1982 Law Competitive Athletes 12-35
• PSPE Screening : PMH , FH, Physical Exam, and
12 lead EKG
Positive findings: ECHO, Stress Test, Holter
• PMH: Syncope, Chest Pain, SOB, Palpitation
• PSPE: Heart Murmur systolic >2/6 any diastolic,
Abnormal S2, Systolic Clicks, BP >140/90, Irr
Rhythm, R/O Marfans
• EKG: Hypertrophy, Blocks, ST and T wave,
Intervals
Italian Pre-Competition Screening
D. Corrado,et.al. Sports Medicine Data
Base,Veneto region, Italy: NEJM 1998
• 20 year screening for HCM 33,735 athletes
• 3016 (9%) referred for echocardiogram
• 22 had HCM- 16 @ risk identified EKG
• 49 deaths (1.6 per 100,000) 1 from HCM,
11 from ARVD (22%)
Italian Guidelines for Sports Medicine
Abnormal EKG:
• LAH, RAH, R axis, L axis,
• LVH (20mm limb, 30mm pre-cordial),
• AV Block, 1*,2*, 3* (1* >.21 not shorted with
hyperventilation) RBBB, LBBB
• Long QT (>.44men, >.46 women)
Short PR (<0.12)
• PVCs, AF, SVT
• ST depression or T wave inversion 2 or more
leads, Q wave 2 leads, V1 R:S ratio >1
2007 NATA Position Paper
SCA in Athletes Summit (Courson, Drezner)
• Most cases occur with Basketball, Football and
Little League Baseball
• 9 to 1 Male/Female
• Athlete Collapse – Suspect SCA
 Sentinel Seizure awareness
• AED’s with time to shock < 4 minutes
• Coach AED certification
• Schools need a formal Emergency Medical Plan
• Rapid ACLS availability
SCA in Athletes
“The unexpected death of an athlete during exercise
is tragic irony. ... much remains unknown
regarding optimal screening strategies,
pathophysiologic mechanisms,and prevention”
Mark Link, MD
Tufts University