RISK FACTORS FOR SUDDEN DEATH

Exercise: How and When Does it Lead to Sudden Death?

Prof. Massimo Santini

Exercise - Sport and Exercise - Sport and Sudden Cardiac DeathSudden Cardiac Death

Sport-related Sudden Sport-related Sudden Cardiac DeathCardiac Death

Sudden cardiac death during sport Sudden cardiac death during sport activity is an unexpexted death of activity is an unexpexted death of

cardiovascular etiology in which there is cardiovascular etiology in which there is loss of consciousness within an hour of loss of consciousness within an hour of

onset of symptoms. onset of symptoms. (80%)(80%)

Trauma or thechnical accidents during Trauma or thechnical accidents during sport activity are not inclusive of this sport activity are not inclusive of this

definition.definition.

Sport-related SCDSport-related SCDEpidemiologyEpidemiology

< 35 yrs< 35 yrs1:100.000 - 1:300.0001:100.000 - 1:300.000

> 35 yrs> 35 yrs1:15.000 - 1:50.0001:15.000 - 1:50.000

Risk in males >>> than in Risk in males >>> than in females females 5 : 15 : 1

0

100

200

300

400

500

600

Bas

ket

Foot

ball

Tra

ck

Socc

er

Bas

ebal

Swim

m

Vol

ley

hock

ey

Box

ing

Mar

atho

n

Ten

nis

Wre

stli

ng

Sudden Death During Sudden Death During Different Types of SportDifferent Types of Sport

Maron BJ Circ 2009 Maron BJ Circ 2009

de Noronha S V et al. Heart 2009;95:1409-1414

©2009 by BMJ Publishing Group Ltd and British Cardiovascular Society

Bar chart showing the number of sudden deaths in athletes in relation to age in 118 deaths in sportsmen referred to a

tertiary centre in the UK over a 12-year period.

Hourly distribution of Sudden Hourly distribution of Sudden Cardiac DeathCardiac Death

02468

1012141618

4 5 6 7 8 9 10 11noon 1 2 3 4 5 6 7 8 9

Time of DayTime of Day

N°

of

Ath

lete

sN

° o

f A

thle

tes

Maron BJ JAMA 1996 Maron BJ JAMA 1996

Couses of sudden cardiac death in 118 sports deaths referred to a tertiary cardiac centre in

the UK over 12 years.

de Noronha S V et al. Heart 2009;95:1409-1414

©2009 by BMJ Publishing Group Ltd and British Cardiovascular Society

Prof Henschen 1899 “

“The largest heart will win the race”

But others were not so convinced!!!

Sport-related SCDSport-related SCD35 yrs35 yrs

1:15.000 - 1:50.0001:15.000 - 1:50.000

THE DOCTOR'S WORLD; JAMES FIXX: THE ENIGMA OF HEART DISEASE

Best-selling book ''The Complete Book of Running''

Father died at 43 yrs.

At 35 had Heart attact.

Had been a smoker (40 die)

heavy yung man (110 kg for years)

All three coronary were damaged:

Cx: 100%

CDx: 80%

DA: 50%.

Ateriosc. Damage of aorta and

Femoral.

CV Abnormalities found at CV Abnormalities found at

autopsy autopsy in in athletes athletes ≥≥35 yrs35 yrs who died suddenlywho died suddenly

80%

Coronary Coronary arteryartery

diseasedisease

HCMHCM

MMVVPP

UnexpUnexpllained ained

Aquired Aquired Valve Valve

Disease Disease

Flow response to Higher Flow response to Higher Myocardial DemandMyocardial Demand

Mechanism of Acute Coronary Mechanism of Acute Coronary Events During ExerciseEvents During Exercise

Placque rupturePlacque rupture

Enhanced cathecolamine- induced Enhanced cathecolamine- induced platelet aggregationplatelet aggregation

Exercise inducedExercise induced coronary artery spasmcoronary artery spasm

Sport-related SCDSport-related SCD < 35 yrs< 35 yrs1:100.000 - 1:300.0001:100.000 - 1:300.000

Causes of Sudden Cardiac DeathCauses of Sudden Cardiac Death inin Young Athletes (<35 yrs)Young Athletes (<35 yrs)

(n°158 athletes;1985-95)(n°158 athletes;1985-95)

19%

36%

6%2%

2%

3%

3%

4%

5%

10%Cor AnHCMOtherCAD MVPARVDMyocAO StenRupt AOIncres Mass

Maron BJ JAMA 1996 Maron BJ JAMA 1996

(Corrado et al. NEJM 1998)

(Maron et al. JAMA 1996)

ARVD 23%ARVD 23% AnomalousAnomalousc.a. origin 12%c.a. origin 12%

HCM 2%HCM 2%

PrematurePrematureCAD 18%CAD 18%

HCM 36%HCM 36%AtheroscleroticAtheroscleroticc.a. disease c.a. disease 22%%

ARVD 3%ARVD 3%

AnomalousAnomalousc.a. origin 19%c.a. origin 19%

- 89%

H.G. was a 23-year-old basketball starH.G. was a 23-year-old basketball star . .

His first symptom was a syncopal spell, whichHis first symptom was a syncopal spell, whichoccurred during a game.occurred during a game.He underwent to a cardiologic evaluation He underwent to a cardiologic evaluation performed by a group of expert cardiologist and performed by a group of expert cardiologist and electrophysiologist.electrophysiologist.ECG Holter showed only VPB and an exercise test ECG Holter showed only VPB and an exercise test trhee-beat runs of VT.trhee-beat runs of VT.The coronaries were normal.The coronaries were normal.

At electrophysiologic study, polymorphic VT was At electrophysiologic study, polymorphic VT was induced with triple extrastimuli.induced with triple extrastimuli.

A later Holter, acquired while he was playing very A later Holter, acquired while he was playing very active, disclosed repetitive VT up to 21 beats in active, disclosed repetitive VT up to 21 beats in

duration at 200 bpm.duration at 200 bpm.

The Hank Gathers CaseThe Hank Gathers Case

A divergence of opinion arose A divergence of opinion arose between the cardiologist and between the cardiologist and

electrophysiologist as to wheter electrophysiologist as to wheter the patient should play basketballthe patient should play basketball

The electrophysiologist said that The electrophysiologist said that H.G. H.G. SHOULD NOT PLAY SHOULD NOT PLAY

The family was hurt and angered at this The family was hurt and angered at this recommendationrecommendation

Finally all agreed that a trial of high dosage propanolol (200mg/day)

should be tried.

Surprisingly, on basket Holters, this regimen suppressed the VT nearly

completely.A series of Holter was done with different reduced dosage of the

drug.

Tha athlete cut back the dosage to 40 mg/day on his own and did not show up for his next basket ball

Holter

He died on march 4, 1990 during a game National television

SCD in young athletes SCD in young athletes without structural without structural

cardiac abnormalitiescardiac abnormalitiesCanalopatieCanalopatie• Long QT syndromeLong QT syndrome• Short QT SyndromeShort QT Syndrome• Catecholaminergic Catecholaminergic

polymorphic ventricular polymorphic ventricular tachycardia tachycardia

• Brugada SyndromeBrugada Syndrome

Patologia del Sistema di Patologia del Sistema di conduzioneconduzione

• WPW • Lown Gannon Levine

Idiopatic ventricular Idiopatic ventricular fibrillationfibrillation

de Noronha S V et al. Heart 2009;95:1409-1414

©2009 by BMJ Publishing Group Ltd and British Cardiovascular Society

BPV

TV/FV

StructurStructuree FunctionFunction

ExerciseExercise+ + ++ + +

Pathogenesis of Sudden Pathogenesis of Sudden Cardiac Death in AthletesCardiac Death in Athletes

Elect InstabElect Instab

HCMHCMARVCARVCCAACAACADCADMyocarditisMyocarditis…………..

Transient Transient ischemiaischemiaAcidosisAcidosisHypoxemiaHypoxemiaIncreasedIncreased sympathetic sympathetic drivedrive

Ventricular FibrillationVentricular FibrillationIn 95% of casesIn 95% of cases

Minimize the risk of athletic field Minimize the risk of athletic field deaths: deaths:

the great challange of Sports the great challange of Sports CardiologyCardiology

The secret of longevity: No Sport, just whisky and cigars