Sudden Cardiac Death:
The hystorical background
• Bibble
• Chineese:association shortened life span with
irregularity of the pulse
• Hyppocrates “Frequent recurrence of
cardialgia in an ederly person announces
sudden death”
• Leonardo d Vinci old men who died without
warning while was talking with him.
“si dolce morte”
Competitive Athlete
A competitive athlete is defined as one who partecipates in
an organized team or individual sport that requires regular
competition against others as a central component,places a
high premium on excellence and achievement, and requires
vigorous and intense training in a systematic fashion.It
should also be emphasized that many individuals
partecipate in “recreational” sports in a truly competitive
fashion.
B.J.Maron 2000
Sudden Cardiac Death
Sudden cardiac death is natural death due to
cardiac causes,heralded by abrupt loss of
consciuosness within 1 hour of the onset of acute
symptoms.Preexisting heart disease may or may
not have been known to be present but the time
and mode of death are unexpected.
E.Braunwald Heart Disease 2001
Sudden Cardiac Death during
Sport Activity
Sudden cardiac death during sport activity is an
unexpexted death without preceeding symptoms which
gets within 15 min from symptoms beginning.Preexisting
heart disease may or may not have been known to be
present but the time and mode of death are unexpected.
Trauma or thechnical accidents during sport activity are
not inclusive of this definition.
Sudden Death during Sport
1:200.000 or 1:300.000 student for academic year
1:70.000 athlete for academic year
1:15.000 jogging for year
Sudden Death During Different
Types of Sport
Types of Sport
Athletes
Total Number
Jogging
4,3
27
Tennis
3,2
17
Soccer
2,6
49
Other Ball Ga
1,6
28
Leisure sport
0,4
25
CRMS
(x100.000 >35 yo)
0
CRMS
Wrestling
Tennis
Crew
Boxing
hockey
Volley
Swimm
Basebal
Soccer
Track
Football
Basket
Sudden Death During Different
Types of Sport
50
40
30
20
10
Am.Med.ASS
Hourly distribution of Sudden Death
16
14
12
10
8
6
4
2
0
4
6
8
CRMS
10
noon
2
Time of Day
4
6
8
Am.Med.ASS
Causes of Sudden Death in Young
Athletes (n°158 athletes-period 1985-95)
10%
5%
19%
5%
4%
3%
3%
3%
2%
2%
6%
CRMS
36%
Cor An
HCM
Other
CAD
MVP
ARVD
DilCM
Myoc
AO Sten
Tunn Lad
Rupt AO
Incres Mass
Am.Med.ASS
Causes of Sudden Death in Young
Athletes > 35 years old
5%
6%
4%
5%
CAD
HCM
MVP
VD
Other
80%
CRMS
Am.Med.ASS
Noncardiovascular Causes of Death in High
School and College Athletes
•
•
•
•
•
•
Hypertermia
Rhabdomyolisis
Asthma
Gastrointestinal bleed
Exercise anafilaxis
Unknown
CRMS
Cardiovascular Causes of SuddenDeath
 Hypertrophic cardiomyopathy
 Coronary Artery Disease
 Arrhythmogenic Right V.D.
 Anomalus coronary artery
 Left Ventricular Hypertrophy
 Myocarditis
 Mitral valve prolapse
 Congenital heart disease
 Valvular heart disease
 Aortic dissection
 Arteriovenuos malformation
 Wolf-Parkinson-White
 Myocardial bridge
 Coronary aneursim
 Long QT syndrome
 Idiopatrhic ventricular fibrillation
 Dilated cardiomyopathy
CRMS
Cardiovascular Causes of
Sudden Death in Athletes
 Hypertrophic cardiomyopathy
 Coronary Artery Disease
 Arrhythmogenic Right V.D.
 Anomalus coronary artery
 Left Ventricular Hypertrophy
 Myocarditis
 Mitral valve prolapse
 Congenital heart disease
 Valvular heart disease
 Aortic dissection
 Arteriovenuos malformation
 Wolf-Parkinson-White
 Myocardial bridge
 Coronary aneursim
 Long QT syndrome
 Idiopatrhic ventricular fibrillation
 Dilated cardiomyopathy
CRMS
Causes of Sudden Cardiac Death
in Athletes
•
•
•
•
•
•
•
Age < 35 years
Hypertrophic cardiomyopathy
Arrhythmogenic Right V.D.
Anomalus coronary artery
Mitral valve prolapse
Congenital QT sindrome
Myocarditis DCM
• Age > 35 years
• Coronary Artery Disease
CRMS
Relative Incidence of SD in
Adolescents and Young Adults
Coronary Atherosclerosis
80
Myocarditis
Cardiomyopathies Hypertrophic---Dilated
%
Coronary Anomalies
Congenital Q-T Syndrome
10
RV dysplasia
CRMS
15
30
40
Age Range
Relative Incidence of SD
inAthletes
Coronary Atherosclerosis
80
Cardiomyopathies Hypertrophic---Dilated
Coronary Anomalies
%
Myocarditis
Aortic Sten-Ao Disease
10
RV dysplasia
CRMS
15
30
40
Age Range
Etiologic Basis of Sudden Cardiac
Death
Coronary Artery Disease
Acute ischemic events
Cronic Ischemic heart disease
80%
Cardiomyopathies
10-15%
Dilated - Hypertrophic
Valvular/inflammation/infiltration
Subtle poorly defined lesion
Lesion of Molecolar structure
Normal heart (Idiopathic VF)
±5%
?%
Mechanism of Acute Coronary Events
with Exercise
 Placque rupture
 Conctraction of noncompliant
atherosclerotic placque
producing rupture
 Alteration of epicardial
contour of coronary placque
 Enhanced cathecolamineinduced platelet aggregation
 Exercise induced coronary
artery spasm
 Increased shear force
CRMS
Anatomical Section Through
the Short Axis of Left Ventricle
Hypertrophic Myocardiopathy
Coronary Arteries
Left Coronary in Athlete
Rigth Coronary in Athlete
Congenital coronary artery
anomalies
Sudden Cardiac Death during
Exercise
Ventricular Fibrillation
In 95% of cases
Risposta Cardiovascolare
all’Esercizio Acuto
Risposta Cardiovascolare
all’Esercizio Acuto
1. Fase preparatoria
iniziale
Stimolazione adrenergica
Vasocostrizione distrettuale
2. Fase intermedia
metabolica
Fattori locali
Stimolazione adrenergica
Risposta Cardiovascolare
all’Esercizio Acuto
•
•
•
Fase preparatoria iniziale
Stimolazione adrenergica
(cuore)
vasocostrizione distrettuale
Vasoconstrictors,Vasodilators and
Vascular Tone
Accsap 2000
Effetti della Vasocostrizione sul
Flusso Coronarico
Vasoconstrictors,Vasodilators and
Vascular Tone and Acute Exercise
Exercise +
Accsap 2000
Exercise,Vasoconstriction
and Coronary Flow
25% Radius
63% Area
Vasoconstriction
(Acute Exercise)
No Ischemia
17% Radius
96% Area
Ischemia
Accsap 2000
Pro/Antithrombothic and Hemostatic
Balance
Accsap 2000
Pro/Antithrombothic and Hemostatic
Balance and Acute Exercise
Exercise +
Accsap 2000
Coronary Flow and exercise
Accsap 2000
Pathogenesis of Sudden
Cardiac Death
Elect Instab
Structure
BPV
Myocard Inf
Hypertrophy
Hyschem-Riperf
TV/FV
Myocardioph
Struct Elect Abn
Function
Systm fact
Auton Fluct
CRMS
Cardiotox fact
Pathogenesis of Sudden
Cardiac Death in Athletes
Exercise
+++
Elect Instab
Structure
BPV
Myocard Inf
Hypertrophy
Hyschem-Riperf
TV/FV
Myocardioph
Struct Elect Abn
Function
Systm fact
Auton Fluct
CRMS
Cardiotox fact
Stimolanti SNC
Cocaina
“Drugs and sport research:
findings and limitations”
“The few studies of cocaine and exercise
suggest that little to no performance
gains are incurred from cocaine use.
Moreover,the sense of euphoria may
provide the illusion of better performance
when,in actuality,performance was not improved
or was impaired.”
Clarkson PM,Thompson HS. Sport Med 1997
Cocaina
Circulation 2000
Screening per la morte improvvisa:
domande durante la visita
• Ha mai avuto perdita di coscienza durante o dopo
esercizio?
• Ha mai avuto vertigine durante o dopo esercizio?
• Ha mai avuto dolore toracico durante o dopo esercizio?
• Ti stanchi più velocemente dei tuoi compagni?
• Hai la pressione alta?
• Sai di avere un soffio cardiaco?
• Hai mai avuto palpitazioni?
• Esiste familiarità per M.I prima dei 50 anni?
• Hai avuto recentemente una forma virale?
• Fai uso di farmaci,steroidi o cocaina?
• Sei stato riformato al servizio di leva?
Screening per la morte improvvisa:
fatti che emergono durante la visita e che
necessitano di approfondimento diagnostico
•
•
•
•
Comparsa di un nuovo soffio sistolico 3/6
Soffio diastolico
Comparsa di aritmie
Lento recupero da una malattia virale o
sistemica
• Dolore toracico,affaticabilità,dispnea o sincope
durante esercizio
• Familiarità per CAD,Morte improvvisa,S. Marfan
• Prescrizione di attività fisica in soggetti
sedentari
Possible Community-Initiated Screening
Strategies for identifying the athlete at risk
Screening Battery
Hystory Auscul
Will Detect
All AS,25% of all HCM
some CMN
Hystory Auscul+RX
All AS,25% of all HCM
many CMN
Hystory
All AS,most HCM at
Auscul+RX+ECG
risk of SD
Hystory
All AS,most HCM
Ausc+RX+ECG +echo most CMN
Hystory Auscul+RX
All AS,most HCM
+ECG +echo+exer
most CMN 20%
CAD/CAA at risk
Will Miss
75% of HCM all CAD
CAA most CMN
75% of HCM all CAD
CAA many CMN
Many CMN Virtually
all CAD/CAA
Virtually all CAD/CAA
80% of CAD/CAA at
risk og SD
CRMS
Possible Individual-Initiated Screening
Strategies for identifying athlete at risk of SD
Strategy
Will Detect
Will Miss
Athletes < 35 yo
Hyst Ausc Rx
ECG Echo
All AS,most HCM Virtually all CAD
most CMN
(Prevalence low)
Athletes > 35 yo
Hyst Ausc Rx
All AS,most HCM 80% of CAD at
ECG Echo +exerc most CMN 20%
risk of SD
CAD at risk
CRMS