The time you won your town the race We chaired you through the market-place; Man and boy stood cheering by, And home we brought you shoulder high. To-day the road all runners come, Shoulder-high we bring you home, And set you at your threshold down, Townsmen of a stiller town.” ―To An Athlete Dying Young Alfred Edward Housman, 1895 Cardiovascular Diseases (69%) Trauma (16%) Commotio Cordis (6%) Other Non-CV (4%) Heat Stroke (3%) Drugs (2%)
Transcript
The time you won your town the raceWe chaired you through the market-place;Man and boy stood cheering by,And home we brought you shoulder high.
To-day the road all runners come,Shoulder-high we bring you home,And set you at your threshold down,Townsmen of a stiller town.”
Comparison of Cardiovascular Disease Mortality in YoungU.S. and Italian Competitive Athletes
Comparison of Cardiovascular Disease Mortality in YoungU.S. (Minnesota) & Italian (Veneto) Competitive Athletes
Ath
lete
De
ath
s/1
00
,000
Per
so
n-Y
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
79-8
0
81-8
2
83-8
4
85-8
6
87-8
8
89-9
0
91-9
2
93-9
4
95-9
6
97-9
8
99-0
0
01-0
2
03-0
4
05-0
6
Veneto
Minnesota
Years
p=0.38
p=0.02
ObstaclesObstacles to the Italian Screening Initiative in the U.S.
• Too many athletes; but,why not study all young people?• Very uncommon events • Too many false positives; also false negatives• Cost / efficacy considerations • Too many lawyers: liability considerations
• Would require mandatory system, based in
law, in which physicians would be deciders
and enforcers• No one to perform examinations / interpret ECGs
0
2
4
6
8
10
12
14
16
18
20
% O
f E
ach
Gro
up
Cardiovascular Cause of Death
p < 0.001
p = 0.004
p = 0.001
White
Non-White
HCM
Probable/D
efinite
Coronary
Anomalies
Myocarditis
CAD
Coronary
Bridging
ARVCIon
Channelopathies
MVPAorti
c
Stenosis
Bethesda Conference # 36
ClassificationSports (#8)
Consensus Panels
#2 #3 #4 #5 #6 #7
#1 #9 #10 #11 #12
Congenital Valvular
Screening / Dx
HCMOther C-M
MVPMyocarditis
Drugs
HTN
AED
CAD
Commotio Legal
Arrhythmias
Bethesda Conference # 36Recommendations
Athletes with the unequivocal diagnosis of hypertrophic cardiomyopathy should notparticipate in most competitive sports, with the possible exception of those of low intensity. This recommendation includes those athletes with or without symptoms and with or without left ventricular outflowobstruction.
Diseases not reliablydetectable byhistory / physical / ECG
= 30% (of ~ 75/y)
Therefore, ECG preparticipation screening would identify = 50 athletes/y
Corrado D et al. JAMA 2006
Comparison of Cardiovascular Disease Mortality in YoungU.S. (Minnesota) & Italian (Veneto) Competitive Athletes
Ath
lete
De
ath
s/1
00
,000
Per
so
n-Y
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
79-8
0
81-8
2
83-8
4
85-8
6
87-8
8
89-9
0
91-9
2
93-9
4
95-9
6
97-9
8
99-0
0
01-0
2
03-0
4
05-0
6
Veneto
Minnesota
Years
p=0.38
p=0.02
(0.87/100,000)
(0.93/100,000)
Cardiovascular Diseases
(69%)
Trauma
(16%)
Commotio Cordis
(6%)
Other Non-CV
(4%)
Heat Stroke
(3%)
Drugs
(2%)
Sudden Death In Young Athletes
0
20
40
60
80
100
120
CV Blunt Trauma All Other
Year
Nu
mb
er
of
Ath
lete
s
1980
1982
1984
1986
1988
1990
2000
1992
1998
1994
1996
2002
2004
2006
U.S. Sudden Death in Young Competitive Athletes Registry, l980-2006(n=1,866)
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
% o
f N
CA
A S
ch
oo
ls
0 1 2 3 4 5 6 7 8 9 10 11 12
No. of AHA Recommendations Achieved
ADEQUACY OF SCREENING FORMS FOR DETECTION OF C-V DISEASE IN U.S.
COLLEGES AND UNIVERSITIES
26%
24%
0 1 2 3 4 5 6 7 8 9 10 11 12 13
5
10
15
20
25
No. of AHA Recommendations Achieved
% o
f 43
Sta
tes
28%
40%
Sports Screening Process in U.S. High School Athletes
Comparison of State History and Physical Examination Preparticipation Screening Forms,
1997 vs. 2005
0
5
10
15
20
25
30
35
0 1 2 3 4 5 6 7 8 9 10 11 12
No. Recommended AHA Screening Items
% o
f S
tate
s
1997
2005
Items: 6.7 to 10.1↑ 66%
M.D./ D.O. R.N. ChiropractorP.A. Others0
10
20
30
40
50
60
70
80
90
100
% O
F 4
5 S
TA
TE
S
DESIGNATED EXAMINERS
45
20 20
9
2
Comparison of Approved Examiners for Preparticipation Screening, 1997 vs. 2005
0
20
40
60
80
100
120
MD/DO NursePractitioner
PhysicianAssistant
Chiropractor NaturopathicClinicians
Examiners
% o
f S
tate
s
1997
2005
HCM and Race
Hospital – BasedHCM Patients
(n=1,986)
Competitive Athletes:HCM-related
Sudden Death (n=102)
White(45%)
White(92%)
African-American (55%)
African-American (5%)
Cardiovascular Diseases
(69%)
Trauma
(16%)
Commotio Cordis
(6%)
Other Non-CV
(4%)
Heat Stroke
(3%)
Drugs
(2%)
Sudden Death In Young Athletes
Highest 2005/2006 = 76 / y
0
20
40
60
80
100
120
CV Blunt Trauma All Other
Year
Nu
mb
er
of
Ath
lete
s
1980
1982
1984
1986
1988
1990
2000
1992
1998
1994
1996
2002
2004
2006
U.S. Sudden Death in Young Competitive Athletes Registry, 1980-2006(n=1,866)
Last 6 years = avg. 66 / y
Diseases not reliablydetectable byhistory / physical / ECG
= 30% (of ~ 75/y)
Therefore, ECG preparticipation screening would identify = 50 athletes/y
Preparticipation Athletic ScreeningUSA vs. Italy
Criteria USA ItalyBasis customary law
practice
Design history/P.E. also,testing(ECG)
Population size too large small enough
Examiners M.D. + accreditednon-M.D. Sports Med.
Legal consequences no precedent civil / criminal
ITALY
ARVC
Corrado D et al. JAMA 2006
U.S. (Minnesota) Italy (Veneto)
Comparison of Cardiovascular Disease Mortality in YoungU.S. (Minnesota) & Italian (Veneto) Competitive Athletes
Ath
lete
De
ath
s/1
00
,000
Per
so
n-Y
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
79-8
0
81-8
2
83-8
4
85-8
6
87-8
8
89-9
0
91-9
2
93-9
4
95-9
6
97-9
8
99-0
0
01-0
2
03-0
4
05-0
6
Veneto
Minnesota
Years
p=0.38
p=0.02
(0.87/100,000)
(0.93/100,000)
Pediatric cardiologists in the U.S.
# of athletes to be screened
# of exams/ECGs to be performed
= 1,521
= 12 million
= 7,890 / year= 658 / month= 150 / week
0
20
40
60
80
100
120
CV Blunt Trauma All Other
Year
Nu
mb
er
of
Ath
lete
s
1980
1982
1984
1986
1988
1990
2000
1992
1998
1994
1996
2002
2004
2006
U.S. Sudden Death in Young Competitive Athletes Registry, 1980-2006(n=1,866)
Commotio Cordis:
Sudden Death From Blunt,Non-Penetrating andRelatively Innocent
Chest Impact
Age in Years
No
. of
Vic
tim
s
0
10
20
30
1-3 4-6 7-9 10-12 13-15 16-18 19-21 22-24 >25
Survivors
Non-survivors
Age at Which 154 Commotio CordisEvents Occurred
0
10
20
30
40
50
60
Baseball Softball Hockey Football Soccer Lacrosse Karate Cricket RugbyBasketball Boxing
Competitive sports(n=78)
Recreational sports(n=28)
No
. of
Vic
tim
s
Blunt Chest Blow and Cardiac Arrest : Sports
Commotio Cordis Events Unassociated With Sports
Plastic (hollow) toy bat 1Plastic sledding saucer 1Playful (“shadow”)boxing 6Hiccups remedy (by friend) 1Head of pet dog (Collie) 1Scuffle 2Parent-to-child disipline 3Gang rituals 2Snowball 1Tennis ball (coin filled) 1Swing carriage 1
Commotio Cordis : Protection
SportsAED
Chest protectors & Safety-balls
EverydayActivities
Education(never strike
the chest)
Commotio Cordis : Protection
SportsAED
Chest protectors & Safety-balls
EverydayActivities
Education(never strike
the chest)
Robert Gordon
•Father age 35•Inflicted 2 modest chest blows during
tutorial session•11-year old son collapsed immediately•Autopsy diagnosis : commotio cordis•Father charged with first degree murder•Admitted to psychiatric facility•Plea bargained involuntary manslaughter•Judge imposed 6-18 year sentence
Commotio Cordis : Determinants
•Location
•Timing
•Force
•Compliant chest wall
Commotio Cordis : Determinants
•Location
•Timing
•Force
•Compliant chest wall
ice hockey puck
baseball/softball
lacrosse ball
Implement of Chest Impact (n=22)Implement of Chest Impact (n=22)
knee
Chest Impact SitesChest Impact Sites
Lacrosse Chest Wall Protection
Brin
e P
ro
De
Be
er
Ico
n
GB
P C
en
ter
GB
P S
ide
ST
X
Wa
rrio
r C
en
ter
Wa
rrio
r S
ide
No
ne
0
0.1
0.2
0.3
0.4
0.5
0.6
Inci
denc
e of
Ven
tric
ula
r F
ibril
latio
n
Veneto Minnesota
No. deaths 12 11
Person-y 1,379,000 1,179,690
Death rate/person-y 0.87 0.93
Direct Comparison of Death Rates inVeneto & Minnesota, 1993-2004
p = 0.87
• HISTORY
• PHYSICAL EXAM
syncope
family history of SD
Nonobstructive HCM
ECG
ECHO
heart murmur
Can “Athletic Field Deaths”Be Prevented?
35 y – Brother SD (age 39)
36 y – ICD
40 y – Generator replaced
41 y – Appropriate shock #1
50 y – Appropriate shock #2
52 y – Present
5 y
9 y
Preparticipation Screening: Is It Worth It?
• Screening is already customary practice for
most high school and college athletes
• Improved screening on national basis would
mean many more new diagnoses
• 5% of new HCM diagnoses are via
screening
Warrior CP Millennium Pro Gear Lacrosse Goalie Chest Pad
Wilson Youth Baseball Catchers A3225 Chest
Protector
ObstaclesObstacles to the Italian Screening Initiative in the U.S.
• Too many athletes
• Very uncommon events
• No one to perform examination / ECGs
• No one to interpret tests
• Too many false positives
• Cost / efficacy considerations and BUSH
• Too many lawyers: liability considerations
Sudden Death in Young Athletes in U.S.
One athlete dies q 3 days …
One athlete w/ HCM dies q 2 wks
Unusual Patterns of LVH
LV Cavity < 45mm
LV Cavity > 55mm
LA Enlargement
Bizarre ECG Patterns
Abnormal LV Filling
Female Gender
Familial HCM/mutation
>50ml / kg / min max V02
Thickness w/ Decondition
“Gray Zone”LV Wall Thickness (13-15mm)
HCMAthlete’s
Heart
ICD - HCM: Appropriate Shocks: 2007
505
102
5.4% / yr
Follow-up = 3.7 years
ICD DischargeRate
AppropriateShocks (20%)
11% 4%
2º prevention 1º prevention
No evaluation
4
130
115
4 15
Preparticipationevaluation
Standardscreening Cardiovascular
evaluation
Suspicion ofC-V disease
1 7Correctdiagnosis
0 2Disqualified
134
Consequences of Medical Evaluations inYoung Competitive Athletes Who Died Suddenly
149
78
40 22
56
1 55
(<3 min.) (>3 min.)
Survived
Unsuccessful
Died
CardiacRhythmRestored
Coma
Died
16
38
Survival Data in Commotio Cordis and Relationto Promptness of CPR by Bystanders
Unsuccessful
Died
(2%)(28%)
15 NoCPR
HCM CA
Anomalie
s**
Possible
HCM‡
Myocarditi
s
ARVCIo
n
ChannelMVP
LAD
Bridge CAD
Aortic
Rupture AS
Dilate
d
CM WPW
Other
251 36†14232457 19 111723253041119
690ConfirmedCV event359
Considered CV event
(no precisediagnosis)
1049(56%)
844205Non-
exertional Exertional
Cardiovascular
1866
65(4%)
416(22%)
Commotio Cordis
Blunt Trauma
Injury
154(8%)Unresolved Cases
182(10%)
Miscellaneous
35(2%)67
(4%)
46(2%)
34(2%)
Heat Stroke
DrugsPulmonary
Other*
Pediatric cardiologists in the U.S.
# of athletes to be screened
# of exams/ECGs to be performed
= 1,521
= 12 million
= 7,890 / year= 658 / month= 150 / week
The time you won your town the raceWe chaired you through the market-place;Man and boy stood cheering by,And home we brought you shoulder high.
To-day the road all runners come,Shoulder-high we bring you home,And set you at your threshold down,Townsmen of a stiller town.”
―To An Athlete Dying Young
Alfred Edward Housman, 1895
Cardiovascular Diseases
(69%)
Trauma
(16%)
Commotio Cordis
(6%)
Other Non-CV
(4%)
Heat Stroke
(3%)
Drugs
(2%)
HC(36%)
CoronaryAnomalies
(17%)
Myo
card
itis
(6%
)
AR
VC
(4%
)
Ion
Cha
nnel
(4%
)
MVP
(4%
)
LAD Brid
ge (3%
)
CAD (3%)Aortic Rupture (3%)AS (3%)
Other †(5%)
Dilated CM (2%)
WPW (2%)
Possible HCM* ( 8%
)
Sudden Death in Young Athletes
Maron, BJ et. alCirculation 2009119:1085-1092
0
20
40
60
80
100
120
CV Blunt Trauma All Other
Year
Nu
mb
er o
f A
thle
tes
1980
1982
1984
1986
1988
1990
2000
1992
1998
1994
1996
2002
2004
2006
U.S. Sudden Death in Young Competitive Athletes Registry, 1980-2006(n=1,866)
Highest 2005/2006 = 76 / y
Diseases not reliablydetectable byhistory / physical / ECG
= 30% (of ~ 75/y)
Therefore, ECG preparticipation screening would identify = 50 athletes/y
Obstacles To Screening
Denominator
Numerator
Event Infrequency
Participation Rates For Competitive Athletes in U.S.
0High School College Pro
1
2
3
4
5
6
7
Mill
ion
s o
f A
thle
tes
HC=35%
HC=0.2%
ATHLETES OF THE WORLD
SUDDEN DEATH IN ATHLETES
Frequency Estimates forSudden Cardiac Death In Athletes
• Competitive athletes appear to be the healthiest segment of society
• Symbolic issue
• Media driven
Preparticipation Athletic ScreeningUSA vs. Italy
Criteria USA ItalyBasis customary law
practice
Design history/P.E. also,testing(ECG)
Population size too large small enough
Examiners M.D. + accreditednon-M.D. Sports Med.
Legal consequences no precedent civil / criminal
Corrado D et al. JAMA 2006
U.S. (Minnesota) Italy (Veneto)
Comparison of Cardiovascular Disease Mortality in YoungU.S. (Minnesota) & Italian (Veneto) Competitive Athletes
Ath
lete
De
ath
s/10
0,0
00 P
ers
on
-Y
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
79-8
0
81-8
2
83-8
4
85-8
6
87-8
8
89-9
0
91-9
2
93-9
4
95-9
6
97-9
8
99-0
0
01-0
2
03-0
4
05-0
6
Veneto
Minnesota
Years
p=0.38
p=0.02
(0.87/100,000)
(0.93/100,000)
ObstaclesObstacles to the NationalNational MandatoryMandatoryItalian Screening Initiative in the U.SU.S.
• Too many athletes; could screening really be limited to athletes?
• Very uncommon events • Too many false positives; also false negatives• Cost / efficacy considerations• Infringement on individual prerogative • Too many lawyers: liability considerations
• Would require mandatory system, based in
law, in which physicians would be deciders
and enforcers
• No one to perform examinations / interpret ECGs
Bethesda Conference # 36Recommendations
Athletes with the unequivocal diagnosis of hypertrophic cardiomyopathy should notparticipate in most competitive sports, with the possible exception of those of low intensity. This recommendation includes those athletes with or without symptoms and with or without left ventricular outflowobstruction.
Commotio Cordis:
Sudden Death From Blunt,Non-Penetrating andRelatively Innocent
Chest Impact
Age in Years
No
. of
Vic
tim
s
0
10
20
30
1-3 4-6 7-9 10-12 13-15 16-18 19-21 22-24 >25
Survivors
Non-survivors
Age at Which Commotio CordisEvents Occurred
0
10
20
30
40
50
60
Baseball Softball Hockey Football Soccer Lacrosse Karate Cricket RugbyBasketball Boxing
Competitive sports(n=78)
Recreational sports(n=28)
No
. of
Vic
tim
s
Blunt Chest Blow and Cardiac Arrest : Sports
Commotio Cordis Events Unassociated With Sports
Plastic (hollow) toy bat 1Plastic sledding saucer 1Playful (“shadow”)boxing 6Hiccups remedy (by friend) 1Head of pet dog (Collie) 1Scuffle 2Parent-to-child disipline 3Gang rituals 2Snowball 1Tennis ball (coin filled) 1Swing carriage 1
Commotio Cordis : Determinants
•Location
•Timing
•Force
•Compliant chest wall
ice hockey puck
baseball/softball
lacrosse ball
Implement of Chest Impact (n=22)Implement of Chest Impact (n=22)
knee
Chest Impact SitesChest Impact Sites
Commotio Cordis : Determinants
•Location
•Timing
•Force
•Compliant chest wall
Commotio Cordis : Protection
SportsAED
Chest protectors & Safety-balls
EverydayActivities
Education(never strike
the chest)
Commotio Cordis : Protection
SportsAED
Chest protectors & Safety-balls
EverydayActivities
Education(never strike
the chest)
Robert Gordon
•Father age 35•Inflicted 2 modest chest blows during
tutorial session•11-year old son collapsed immediately•Autopsy diagnosis : commotio cordis•Father charged with first degree murder•Admitted to psychiatric facility•Plea bargained involuntary manslaughter•Judge imposed 6-18 year sentence
ITALY
ARVC
1 2
3 4
5 6
7 8
9 10
11 12
13 14
15 16
17 18
19 20
21 22
23 0
5
10
15
20
No
. of
Ath
lete
s
Hours
HCNon - HC
Diurnal Distribution of Sudden Death in Young Athletes
Pediatric cardiologists in the U.S.
# of athletes to be screened
# of exams/ECGs to be performed
= 1,521
= 12 million
= 7,890 / year= 658 / month= 150 / week
Comparison of State History and Physical Examination Preparticipation Screening Forms,
