arrhythmias

1. Updates on Sudden Cardiac Death
in Athletes and Young Generation
DR. TAMER TAHA ISMAIL TAHA
CLINICAL ASSOCIATE PROFESSOR AND SPECIALIST
DEPARTMENT OF CARDIOLOGY
THUMBAY HOSPITAL _DUBAI

2. EXERCISE IS GOOD

3. Outline
 Exercise : benefits and risk
 Athlete’s Heart
 Etiology of SCD in young athletes
 Etiology of SCD in old athletes
 Screening and Pre participation examination
 Lowering the risk of SCD

4. DEFINITIONS FOR THIS TALK
 EXERCISE: Any form of physical activity, done on a
regular basis, with the purpose of achieving a specific goal
• Low level to vigorous
• Recreational (including “play”) to competative
 ATHLETE: Anyone who is exercising
 YOUNG ATHLETE: Less than 35 years old
 ADULT ATHLETE: Greater than 35 years old

5. BENEFITS OF EXERCISE
• DISEASE PREVENTION
• Cardiovascular
• Diabetes
• Osteoporosis, joint health
• FITNESS
• WEIGHT CONTROL
• ENJOYMENT
• Personal Goals
• Competition

6. COULD “exercise ” CAUSE ANY
CARDIOVASCULAR HARM?
 ANSWER: YES
 THE RISK IS SMALL
 THE CONSEQUENCES ARE
SIGNIFICANT
 WHAT THE RISK IS AND WHAT
CONDITIONS ARE RESPONSIBLE FOR
THE RISK VARY BY AGE

7. DETERMINANTS OF EXERCISE
RISK
1. Probability of Cardiac Disease
2. Intensity and Duration of Exercise
RISK INCREASES WITH INCREASED RISK OF
UNDERLYING CVD, INTENSITY, DURATION OF EXERCISE

8. MEASURING INTENSITY
The Metabolic Equivalent or MET
is a physiological measure expressing the energy cost of physical activities and is defined
as the ratio of metabolic rate during a specific physical activity to a reference metabolic
rate
3.5 ml O2/kg/min

9. MET
1. Sitting……………………………………………….1.0
2. Walking at 2.5 m/h……………………………2.9
3. Biking at 10 m/h……………………………….4.0
4. Elliptical……………………………………………5.5
5. Jogging…………………………………………….7.0
6. Swimming (moderate)……………………..8.0
7. Swimming (hard)…………………………….12.0
8. Running 8 min mile…………………………12.5
9. Bike Racing (not drafting) > 20m/h….16.0

10. EXERCISE INTENSITY
• Light
• Daily activities, gentle walk
• < 3 METs
• Moderate
• Brisk walk, easy jog or bike
• < 6 METs
• Vigorous/Intense
• Running, Biking, High Intensity Interval, “Boot Camp”
• RPE 7 – 10, METs > 6

11. EXERCISE DURATION
 Dehydration
 Electrolyte changes
 Increased inflammation
 Hyperthermia
Most cardiac events during marathons
occur past the 22.5 mile marker

12. RECOMMENDED DURATION
(health and fitness goal)
American Heart Association
150 min/week of moderate exercise
75 min/week of vigorous exercise
OK to break it up

13. Gangasani, S. R. et al. Chest 2000;118:249-252
Physiologic alterations accompanying acute exercise and recovery,
and their possible sequelae

14. Definition of sudden cardiac
death
Non-traumatic, unexpected fatal event
occurring within 1 hour of the onset of symptoms
in an apparently healthy subject.
If death is not witnessed, the definition applies
when the victim was in good health 24 hours
before the event.

15. Who are we talking about, what are the numbers

16. THE YOUNG ATHLETE AND
THE RISK
(US numbers)
• All deaths related to exercise: 120/year (excluding trauma)
• Deaths caused by CVD: < 100/year
• Approximately 1 CVD death/100,000/year
• All the “conditions” that might harm athletes are just as
prevalent in non-athletes. Athletes are at higher risk.

17. THE YOUNG ATHLETE
A SAMPLING OF THE CAUSES
 Structural Heart Disease
• Hypertrophic Cardiomyopathy
• Anomalous Origin of the Coronary Arteries
• Arrhythmogenic Right Ventricular Cardiomyopathy
• Myocarditis/Cardiomyopathy
• Valvular Disease
 The “Channelopathies”
 Drugs

18. 18

19. THE ADULT ATHLETE
• Harder to define the numbers and risk
• Heart disease is common among adults
• Exercise programs vary
• No organized reporting program
• Marathoners: <1/100,000
• Recreational runners: 1/10,000/year .
• Individuals with disease are 2 -3-X more likely to have an
event during exertion.

20. THE ADULT ATHLETE
A SAMPLING OF THE CAUSES
Coronary Artery Disease
Valvular Heart Disease
Cardiomyopathy
“Young Athlete” Disease

21. THE YOUNG
ATHLETE
SPECIFIC EXAMPLES

22. HANK GATHERS
1967 - 1990

23. Fabrice Muamba
1988-2012

24. HYPERTROPHIC
CARDIOMYOPATHY

25. HYPERTROPHIC
CARDIOMYOPATHY
• Affects 1 in 500 individuals
• Genetically determined
• Sporadic or inherited
• At least 11 genes, 1400 mutations
• Accounts for 35 – 40% of athletic deaths
• Can be symptomatic/detectable before SCA
• Increased risk with age
• Ventricular arrhythmia is primary cause of death

26. Risk Factors for Sudden
Death in HOCM
Major
- Out of hosp arrest or VT
- FH sudden death and HOCM
Minor
- NSVT on Holter
- Drop in BP on TMET
- Thallium perfusion defects
- Young male
- History of syncope
- Septal thickness

27. ANOMALOUS ORIGIN OF
THE CORONARY ARTERIES

28. ANOMALOUS ORIGIN OF
THE CORONARY ARTERIES
• Accounts for 15 – 20% of sudden death in
young athletes
• Can be symptomatic (< 50%)
• Chest discomfort
• Shortness of breath
• Palpitations
• Fainting
• Treatment: Medical or Surgical
• May be “cleared” to participate if corrected

29. ARRYTHMOGENIC RIGHT
VENTRICULAR
CARDIOMYOPATHY

30. ARRHYTHMOGENIC RIGHT
VENTRICULAR
CARDIOMYOPATHY
 Prevalence: 1/1000 – 2000
 Genetic, 30% inherited.
 Accounts for 5% of sudden death in young
athletes
 Can be symptomatic: palpitations, fainting
 Treatment: medical, ICD
 Disqualified from competitive sports

31. MYOCARDITIS/CARDIOMYOPATHY

32. MYOCARDITIS/CARDIOMYOPATHY
 Accounts for 5 -10% of sudden cardiac
arrests in young athletes
 Causes: “viral”, inherited/genetic, idiopathic
 Can be symptomatic: shortness of breath,
palpitations, fatigue/weakness, fainting,
chest discomfort
 Disqualified from most competitive sports.
May return if recover.

33. COMMOTIO CORDIS
 Vulnerable moment
 High force, specific
area
 Baseball, hockey,
karate
 Kids more
vulnerable
 20% survival
 Boys > girls

34.  Ephedrine and its analogues
 Anabolic steroids
 Gama hydroxybutyrate
 Cocain
 Ephedrine and its analogues
 Anabolic steroids
 Gama hydroxybutyrate
 Cocain
Illicit Drugs Used By Athletes During
Competitive Sports
Illicit Drugs Used By Athletes During
Competitive Sports

35. INHERITED ARRHYTHMIA
and SUDDEN CARDIAC ARREST
THE “CHANNELOPATHIES”

36. WHAT IS A CHANNEL?

37. THE CHANNELOPATHIES AND
SUDDEN CARDIAC ARREST
 Long QT Syndrome
 Brugada Syndrome
 Catecholaminergic Polymorphic Ventricular
Tachycardia
 Short QT syndrome

38. THE CHANNELOPATHIES:
LONG QT
• Not rare: 3000 – 4000 deaths/y in children/adolescents
• Inherited/genetic
• 12 types/genes, hundreds of different mutations
• Variable “lethality”
• AR associated with deafness
• Variable expression
• Acquired form
• Medications/drugs
• Electrolyte changes
• Increased risk of SCA with exercise, risk variable based on type
• SCA in athletes: not rare, numbers not clear
• ECG + , gene +, symptom + : Disqualified from competitive sports

39. ACQUIRED LONG QT
• Medications: www.qtdrugs.org
• Antiarrhythmics
• Antibiotics: Levaquin, Zithromax (Z pack), erythromycin
• Antidepressants: Tricyclics, Prozac, Celexa
• Tamoxifen
• diuretics
• 140 other drugs
• Methadone
• Combinations of drugs
• Electrolytes: Low K+, Mg++, Ca++
• Genetic + Drugs, ? Unmasked congenital form
• Reversible

40. THE CANNELOPATHIES
BRUGADA SYNDROME
• Genetic
• Genetic testing variable
• Na+ channel
• EKG variable
• Provocative testing
• Multiple types
• Male > Female
• Avg age at DX: 41
• Fever/hyperthermia trigger
• Night time trigger
• Treatment: ICD, limited medications
• Caution advised for competitive
sports with no history of events
• With history of events or ICD low level
sports only

41. THE CHANNELOPATHIES:
CATECHOLAMINERGIC POLYMORPHIC VT

42. CPVT
• Genetic, at least 2 gene mutations
• Inherited
• Emotional and physical triggers. Symptoms: dizziness and
syncope
• Usually presents in childhood and adolescence
• Treatment: Medical therapy, ICD + medical,
Sympathectomy, Medical therapy for gene + asymptomatic.
• Generally recommend against competitive sports, ICD
precludes contact sports

43. OTHER ARRHYTHMIA
WOLFF PARKINSON WHITE
• 1/400
• Often Incidental finding
• Can present with
symptoms
• Often first diagnosed in
adulthood
• Risk of V-fibrillation
• Risk stratify asymptomatic
Pts
• Ablation
• OK to participate in
competitive sports once
treated

44. THE ADULT
ATHLETE
CARDIOVASCULAR DISEASE IS THE PRIMARY CAUSE
OF DEATH IN ADULT ATHLETES

45. WHAT IS THE RISK?
 800,000 Heart attacks/year
 400,000 Sudden Cardiac Death
 Sudden Death: First symptom in 50%
 2 – 3 X as likely to suffer a cardiac event during
exercise in those with disease

46. THE ADULT ATHLETE
 Primary Cause: Coronary Artery Disease
 Cardiomyopathy
 Vascular Disease
 Arrhythmia
 Valvular Heart Disease

47. THE ADULT ATHLETE
The adult athlete can still have almost any of
the conditions of the young athlete.

48. CORONARY
ARTERY
DISEASE
STILL NUMBER ONE

49. JIM FIXX
1932 - 1984

50. FACTORS INCREASING THE LIKLIHOOD
OF CORONARY ARTERY DISEASE
NON-TRADITIONAL
 Cholesterol variants
• Lp(a)
• Particle size
 Genetic
 Vascular physiology/metabolism
 Inflammation

51. GLOBAL RISK
THE GREATER THE NUMBER OF RISK
FACTORS, THE GREATER THE RISK

52. ISCHEMIA AND SCD
DEMAND > SUPPLY ISCHEMIA
CHEST PAIN
SOB
PERFORMANCE
NON-LETHAL ARRYTHMIA
LETHAL ARRHYTHMIA

53. OTHER POTENTIAL LETHAL CARDIAC
DISEASE AND EXERCISE
DILATED
CARDIOMYOPATHY
HYPERTROPHIC
CARDIOMYOPATY

54. OTHER POTENTIAL LETHAL CARDIAC
DISEASE AND EXERCISE
AORTIC DISSECTION
 Risk Factors: ASCVD,
especially hypertension
 Sporadic, associated
with aneurysm, genetic
 Sheer force
 Increased risk with high
static component
exercise

55. OTHER POTENTIAL LETHAL CARDIAC
DISEASE AND EXERCISE
VALVULAR HEART
DISEASE
 Aortic stenosis
 Aortic insufficiency
 Mitral Valve Prolapse

56. NONLETHAL ARRHYTHMIA
ATRIAL
FIBRILLATION
SUPRAVENTRICULAR
TACHYCARDIA

57. EXERCISE AND NONLETHAL
ARRHYTHMIA
 European Heart Journal 2014
 52,000 players
 Mean age: 38
 Twice the risk of non-athletes
 Higher risk with faster times
 Mechanism: ? inflammation

58. SCREENING GOAL
 To identify those at risk
 Prevent injury and lethal events
TO ASSIST YOUNG ATHLETES AND THEIR FAMILIES
IN MAKING
RATIONAL DECISIONS REGARDING THE RISK OF
ATHLETIC PARTICIPATION

59. Athlete’s Heart
 Isometric sporting activities cause structural
remodeling and increase in cardiac mass
(physiologic hypertrophy).
 Increased volume of ventricular chambers
 Increased size of L atrium and L ventricular wall thickness
 However, systolic/diastolic functions is maintained
 Occurs in M>F with size related to lean body mass.
 May be 2ry to genetics
 The amount of exercised-induced LVH in endurance athletes
associated with ACE genotype.

60. Athlete’s Heart
 ECG’s
 Findings in Athletes considered WNL
 Sinus Bradycardia – as low as 30-40 bpm
 Various A/V blocks occur in up to 33% of athletes
 First Degree (PR>0.2) – Most Common
 Second Degree (Mobitz-1 or Wenkeback)
 Increased R or S wave voltage without Left axis deviation,
QRS prolongation, or LAE
 U-waves with up-sloping ST segments and normal T waves
 Incomplete RBBB

61. SCREENING YOUNG ATHLETES
• Recommendations vary widely internationally.
• Recommendations vary widely based on level of
participation
• Not clear if definitely reduces risk
• Findings variable with time
• Variable age of onset
• These are relatively rare diseases
• Needs to be done regularly until adult age

62. THE PREPARTICIPATION
EXAM
 Review for symptoms
• Dizziness or fainting, shortness of breath, palpitations,
chest discomfort, can’t keep up
 Family History
• Premature death
• “Death under unusual circumstances”
 Physical exam
• Murmurs, build, pulses

63. WHAT ABOUT ECGs
• Not recommended routinely in US
• Required in Europe
• Controversial
• Not clear it helps
• Athletes often have ECG changes that are “normal”
• False negatives, False positives
• Cost of ECGs, Cost of additional testing, Cost of disqualifying
athletes
• Estimated $80,000 to find one case

64. LOWERING RISK IN THE YOUNG
ATHLETE
• Pre participation Exam
• Parental involvement in children and adolescents
• Coaches/trainer/athlete awareness
• Symptom awareness
• Workout/practice design
• Hydration/electrolyte replacement
• AEDs in close proximity when feasible and AED training
• CPR training of coaches/trainers/athletes

65. Take Home Messages
 EVERYBODY SHOULD EXERCISE
 EXERCISE CARRIES A SMALL RISK OF A CARDIAC
EVENT THAT IS “AGE” SPECIFIC
 GET APPROPRIATE “SCREENING”
 DON’T IGNORE SYMPTOMS. THERE IS NO
LIFETIME WARRANTY FROM A SINGLE
SCREENING

66. Take Home Messages
 Arrhythmias are very common in athletes.
 Those associated with structurally normal hearts are
benign and should not cause disqualification.
 Those with heart disease can cause serious or
catastrophic effects.

67. Take Home Messages
 The commonest diseases associated with life
threatening arrhythmias in the young are HOCM and
congenital coronary anomalies.
 The commonest disease associated with life
threatening arrhythmias in the older athletes is
premature ischemic heart disease.
 Screening of persons going into competitive games
is difficult but essential.