sudden cardiac death in - european society of cardiology · common causes of sudden cardiac death...
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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]
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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
Alessandro Zorzi - University of Padova – [email protected]
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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
Alessandro Zorzi - University of Padova – [email protected]
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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%)
Alessandro Zorzi - University of Padova – [email protected]
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Is the ECG-based preparticipation
screening model cost-effective?
Alessandro Zorzi - University of Padova – [email protected]
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Alessandro Zorzi - University of Padova – [email protected]
•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*
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Why can athletes die suddenly despite
ECG preparticipation screening?
Alessandro Zorzi - University of Padova – [email protected]
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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)
Alessandro Zorzi - University of Padova – [email protected]
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27 year-old, professional soccer player
No personal or family history
Alessandro Zorzi - University of Padova – [email protected]
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• ECG: infero-lateral T-wave inversion
• 24 hours ECG-monitoring: frequent PVB with a RBBB-pattern
• Echocardiography: normal
Alessandro Zorzi - University of Padova – [email protected]
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Contrast-enhanced MRI
– Morpho-functional evaluation: normal
– Post-contrast sequences: infero-lateral subepicardial scar of unkown origin (post-myocarditis? Left-dominantARVC?)
Alessandro Zorzi - University of Padova – [email protected]
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Therapy:
• Competitive sport restriction
• Beta-blockers
• ICD
Dopo 33 mesi di follow- up while playing table tennis
Alessandro Zorzi - University of Padova – [email protected]
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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.
Alessandro Zorzi - University of Padova – [email protected]
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D’Amati et al. Int J Cardiol 2016;206:84–86
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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
Alessandro Zorzi - University of Padova – [email protected]
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Alessandro Zorzi - University of Padova – [email protected]
Di Gioia et al, Human Patology 2016 (in press)
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Non ischemic left ventricular scar: an
emerging cause of sudden death in the athlete
Alessandro Zorzi - University of Padova – [email protected]
Zorzi et al, Circ Arrhythm Electrophysiol 2016 (open access)
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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
Alessandro Zorzi - University of Padova – [email protected]
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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
Alessandro Zorzi - University of Padova – [email protected]
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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
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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
Alessandro Zorzi - University of Padova – [email protected]
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Alessandro Zorzi - University of Padova – [email protected]
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
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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
Alessandro Zorzi - University of Padova – [email protected]