Sudden Death in Young Athletes

Case

A fourteen year old boy comes to your office for a physical exam prior to entering high school. He is planning to play soccer. What are the important areas to cover in your history and physical exam? 

Approximately 50 young athletes die suddenly each year. Sudden death in athletes is defined as a cardiac arrest up to 6 hours after initial onset of symptoms in an individual who has not previously been recognized to have cardiovascular disease. It is estimated that 5/100,000 children have an underlying condition that makes them vulnerable to sudden death.

The American Heart Association recommends a pre-participation physical every two years by a healthcare worker who is able to obtain a complete cardiovascular history, physical exam, and recognize heart disease. An EKG is optional unlike Europ where it is a required part of all pre-participation physicals.

The physical exam should be done in a quiet area and the parent should be present. A thorough history and review of systems is important.

Pre-participation Screening

  1. Has there been any exertional chest pain or discomfort
  2. Has there been any family history of death in members less than 50 years old other than by accident?
  3. Family history of members less than 50 years old with disability from heart disease
  4. Any history of chest pain without exercise?
  5. Any history of shortness of breath?
  6. Any history of unexplained syncope other than vagovagal episone?  Any syncope related to exercise?
  7. Any history of heart murmur?
  8. Have their been palpitations?
  9. Any history of elevated blood pressure
  10. History of rheumatic fever, hypertension, or Kawasaki's disease?
  11. Physical exam should include blood pressure, heart rate, palpation of pulses, and chest and heart auscultation. In addition, physical stigmata of Marfan's should be ooked for.
The purpose of the athletic pre-participation evaluation is to identify athletes at risk and not to disqualify any athlete unnecessarily. If there is any suspicion, the patient should be further evaluated by a cardiologist. There is no recommendation to screen all athletes with EKGs and Echocardiograms. 

Conditions associated with sudden unexpected death

  1. Hypertrophic Cardiomyopathy
    1. Most common cause of sudden death in US and most commonly in Afro-Americans
    2. Left ventricular hypertrophy with poor filling is the hallmark and orften there is asymmetric septal hypertrophy creating an impedance to outflow.
    3. Symptoms-dyspnea, syncope, angina, seizures, sudden death
    4. may have harsh systolic murmur increased with Valsalva or or on standing.  This is due to reduced LV volume and worsened outflow obstruction.
    5. may have EKG (increased volotage, prominent Q-waves, or deep T-wave inversions) and ECHO changes
  2. Coronary artery abnormalities
    1. Second most common cause in the US
    2. Usually an aberrant origin of left main  or right coronary artery
    3. Sympoms may include angina, syncope, or sudden death
    4. Physical exam is normal
    5. Without prior infarction or arrhythmia, athletes with surgically corrected abnormalities may participate in sports.
  3. History of Kawasaki's Disease
    1. If there have been no coronary artery changes or patient has resolution of coronary artery disease, patient should be cleared for competition.
  4. Myocarditis
    1. Usually have a history of being ill including CHF
    2. Associated with atrial and ventricular tachyarrhythmias or bradyarrhythmias
    3. Sudden deaths probably related to conduction system inflammation.
    4. Should abstain from spoorts for 6 months.
  5. Marfan's Syndrome
    1. Autosomal dominant
    2. Sudden death from aotic dissection
    3. Pectus deformities, > 95% for height, long spindly fingers, ectopic lens, high palate, kyphoscoliosis, inguinal hernias.
    4. Should see cardiologist.
  6. Mitral Valve Prolapse
    1. If there are cardiac symptoms, should see cardiologist
  7. Arrhythmogenic Right Ventricular Cardiomyopathy
    1. Fibrofatty infiltraqtion of the RV myocardium
    2. Syncope, exercise induced palpations.
    3. Dhould not participate in competetive sports
  8. Arrhythmias
    1. sinus node disturbance
    2. WPW
    3. Exercise induced ventricular ectopy
    4. Prolonged QT -high risk for ventricular arrhythmia (torsades de pointes)
      1. Jervell-Lange-Nielsen syndrome associated with congenital hearing loss(auto dom)
      2. Romano Ward syndrome (autosomal recessive)
  9. Atherosclerotic coronary heart disease 
    1. Family history of hyperlipidemias should be discussed
References
  1. Berger S. Dhala A and Friedberg DZ. Sudden Cardiac Death in Infants, Children and Adolescents. Pediatric Clinics of North America. 1999; 46(2):221-234.
  2. McCaffrey, FM, Braden, MC, Strong WB. Sudden Cardiac Death in Young Athletes. AJDC Vol 145, February 1991
  3. Van Camp, Steven P. Sudden Death. Clinics in Sports Medicine Vol 11 Number 2 April 1992
  4. Braunwald Eugend.  Hypertrophic Cardiomyopathy-The Benefits of a Multidisciplinary Approach NEJM Vol. 347 No. 17 pg.1306 October 24, 2002
  5. Maron B.J. Sudden Death in Young Athletes. NEJM September 11, 2003 Vol 349 No. 11 pg 1064
  6. NishimuraR. Holmes D. Hypertrophic Obstructive Cardiomyopathy NEJM 350:13;1320 March 25, 2004
  7. Case Records off the Massachusettes General Hospital.  NEJM August 25, 2005
  8. Ellison Alison, et al. Preventing-with the goal of eradicating- sudden cardiac death in children.  Contemporaray Pediatrics October 2005