Sudden Cardiac DeathUniversity College DublinUCD is …心脏性猝死都柏林学院大学是… .ppt

Sudden Cardiac Death and Sport,Dr Deirdre WardDirector,Centre for Cardiovascular Risk in Younger PersonsAdelaide and Meath Hospital,Tallaght(and St James,St Vincents University Hospitals)Blackrock Clinic and Charlemont Clinic,Centre for Cardiac Risk in Younger Persons(CRYP Centre),Service begins Jan 2007Out-of-hours clinics,600 patientsFull-time,staffed Centre opens Nov 2008All-day clinics,1500 patients per yearNurse,2 Technicians,Admin Officer,(Doctor)FundingCardiac Risk in the Young Charity(CRY-Ireland)Adelaide SocietyTallaght Hospital VolunteersPfizerPrivate donationsContinuous fundraisingTallaght Hospital and TCDAim:provide timely,comprehensive assessment of families where SCD has occurred or young people with worrying cardiac symptomsTests:ECG,Echo,Exercise Test,Heart rhythm monitor all on one day,followed by Consultation with Consultant(family tree etc),Overview of Sudden Cardiac Death,Size of the problemCauses of sudden cardiac deathSport and SCDIdentifying those at riskManaging riskGeneral screening?Public access defibrillators?,Background,Sudden Cardiac Death=death from definite or probable cardiac causes within 1 hour of symptom onsetIncidence from International Studies1 to 3 per 100,000 in those 1 to 35 yrs of age10 to 75 per 100,000 in those 35 to 64 yrsIncidence in IrelandExtrapolation from other studies suggestapprox 5,000 SCD annually RoI,2000 NI 60-80 deaths 25(NI)From 2005 study of Coroners data 5 per 100,000 males(14-35 yrs)1 per 100,000 females(14-35 yrs),In context,134 drug-related deaths in Dublin in 200787 murder/manslaughters in State 2007336 road deaths in 200782 pedestrians138 drivers70 passengers,Causes of SCD,Over 35 yrs of age Coronary Heart Disease(hardening of the arteries)Under 35 yrs Cardiomyopathies(heart muscle disorder)Congenital Heart Disease(hole in heart,blue baby)Structurally Normal Heart(ion channel disorders,conduction disease)=SADSAnomalous coronaries(abnormal anatomical position of coronary blood vessels)Myocarditis(infection or inflammation of heart muscle),Hypertrophic cardiomyopathy(HCM or HOCM),Increased thickness of heart muscleMost common inherited cardiac diseasePrevalence 1 in 500 people carry gene11000 in 32 counties90%of cases thought to be inherited(runs in family)10%sporadic pass on to their children?Approx 50%who inherit genetic change develop full-blown condition(incomplete penetrance)Inheritance pattern Autosomal Dominant=50%risk of inheriting gene if parent affected,HCM,Symptoms include:Shortness of breath with exercisechest pain(usually with exercise)Diziness(at rest or with exercise)blackouts PalpitationsNo symptomsRisk of sudden death 1%per yearIntensive exercise can increase riskUsually identifiable on ECG and Echo,Echo Cardiac Ultrasound,Right ventricle,Left ventricle,Septum Wall between2 sides of heartUsually 10 mm,Heart valvesAortic+Mitral,HCM-Treatment,No cure,but can prevent complicationsManage symptomsMedications(Beta-blocker tablets)Modify lifestyleSurgery(only in very limited circumstances)Ensure family members checkedAssess risk of sudden deathLow-risk,reassure,but still avoid intense exerciseHigh-risk,recommend implantable defibrillator(ICD),ICD,Other Cardiomyopathies-Dilated,Heart stretches in sizePump function reduces,Other Cardiomyopathies-Dilated,May be inherited,much less common 1000 people in countryOther causes include viral illness,drugs,alcoholMay cause shortness of breath,palpitations,blackout,sudden deathECG and echo usually identifiesOther tests may be necessaryTreatmentMedicationsOccasionally pacemakers and/or ICDRisk of SCD usually highest in those with poorest pump function,who usually have symptoms,Other Cardiomyopathies Arrhythmogenic(aka ARVC or ARVD),Heart may become enlargedScarring develops in heart Causes palpitations,dizzy spells,blackouts,shortness of breath,sudden deathOften inheritedMay need several tests to diagnoseECG,echo,Exercise test,heart rhythm monitor,MRI scan of heartMilder cases can be missed(even in Italy with compulsory screening programme)TreatmentMedicationsLifestyle modificationIf considered high risk of rhythm problems,recommend ICD,Other inherited conditions,Marfans syndromeWeakness of walls or large blood vesselsMay be associated with tall stature and hyperflexibility,eye problemsIdentified on physical exam,echo and X-ray scansCongenital heart diseaseAbnormal development of cardiac structure(s)in the wombRange from blue baby to small holes in heartMilder forms generally not life-threatening 10%inherited,most occur spontaneouslyMitral valve prolapse1%of population have at least mild caseSevere cases may be associated with sudden deathMay be over-estimated as cause of sudden death,Other conditions,Valve diseaseUsually causes a murmurMay cause reduction in exercise toleranceAnomalous coronariesAnatomical variant in placement of blood vesselsSome may reduce blood supply during stress or exercise but most probably dont cause problem and may be over-estimated as cause of SCDMyocarditisInflammation of heart muscleUsually thought to follow viral infection1/8 people with virus+fever have ECG changeProbably should avoid exercise during viral infectionPossible genetic predisposition to being affected by virus,Sudden Arrhythmic(Adult)Death Syndrome(SADS),Diagnosis of exclusionSudden death occurs,and is consistent with cardiac rhythm disturbance,but post-mortem examination finds no abnormalityCurrently no standardization of post-mortem examination in Ireland(improving)Currently no Specialist Cardiac Pathologist with specific responsibilityIf post-mortem not carefully doneStructural cause of death may be missedMinor abnormalities may be incorrectly recorded as cause of sudden death True number of SCD which are actually due to SADS probably under-estimatedElectrical problem is cause of death,but no electrical activity after death so not detectable at post-mortem,Electrical problems also known as Channelopathies,Electricity in heart is generated by pump channels in walls of each cell in heart pump salts(Na,K,Ca)in and out of cellPump channel=ion channelIf pump malfunctions(under or over-active)changes electrical activation of heart which causes electrical instability and increases chance of arrhythmiaMay not cause symptoms unless palpitations,dizzy episodes or blackoutsUsually detectable on ECG(if looking for it)Different genes code for different pumps and mutations cause different conditions:Long QT syndromeBrugada SyndromeCatecholaminergic Polymorphic Ventricular Tachycardia(CPVT)Not identifiable on PMCan be identified on ECG(+/-exercise test and rhythm monitor)in living40%of families of those who die of SADS have inherited cause identified(mostly LQT syndrome and Brugada syndrome),Influence of sporting activity on risk,In younger people over all,sporting activity increases risk x 2.5Older adults who exercise frequently have 5x increased risk of sudden cardiac arrest during vigorous activity(coronary disease)Older adults who do not exercise frequently have 56 x risk of SCA during vigorous activity(NEJM 1984),Sport and sudden cardiac death,If you have one of these cardiac conditions intense sporting activity will double risk of dying suddenly(eg increase from 1%to 2%in HCM)You do NOT have to be an athlete to die from SCDYou CAN die from SCD at rest or during sleep,Identifying those at risk,Family historyPremature sudden deaths definitely or possibly cardiacRelatives diagnosed with above conditionsSymptomsSOB or chest pain that limit exerciseUnexplained dizzy spells/blackouts(especially if on exertion)Prolonged palpitationsScreeningPhysical exam?ECG?Other?,Management of at risk people,Not everyone with these conditions has high risk of sudden deathRisk varies with each condition and even within families(the same gene will behave differently in everyone who inherits it)System for identifying at risk people developed in most conditions,Managing risk,Avoid competitive sport or very strenuous exertionRecreational sport,PE classes etc usually safe Medications in some(eg b-blockers)Continued observation in allImplantable defibrillators in someCost implicationsComplications,Why screen relatives,or people with suggestive symptoms?,Many conditions relatively easy to identify(if you know what youre looking for)Not everyone affected is at riskVarying success rates at accurately identifying at risk peopleSome can be treated with medicationHigh risk people offered implantable defibrillator(ICD or shock-box)Future generations at risk,Cardiac evaluation for families or symptomatic individuals,Current optionsGP evaluationLocal physicianGeneral CardiologistSpecialist CentreCentre for Cardiac Risk in Younger Persons(Tallaght/St James/St Vincents)Family Heart Screening Clinic(Mater and Blanchardstown Hospitals),Athlete/Population screening,Currently no government resources for screening high-risk populationRisk in general population approx 1to 3 per 100,000 athletes/yrPotential downside to screeningSport can bring on changes in cardiac tests(espec ECG but also Echo)that may be difficult to distinguish from cardiomyopathyAdditional testing in perhaps 10%of all those screenedBorderline cases may never be resolved completely?affect life insurance in future?Restrict ability to play sport?Restrict career choices,If considering Irish National programme,Questions:Who would oversee(GP vs Cardiologist)?Who(athletes only or every person?),when(at what age?)and how often(repeated?)What form should it take?Who pays?Who deals with fall-out from abnormal resultsVoluntary or compulsory?,AHA Consensus Panel Recommendations For Pre-participation Screening,Family History:1.Premature sudden death2.Heart disease in surviving relativesPersonal History:3.Heart murmur4.Systemic hypertension5.Fatigability6.Syncope7.Exertional dyspnoea8.Exertional chest painPhysical examination:9.Heart murmur(supine/sitting/standing)10.Femoral pulses11.Stigmata of Marfan Syndrome12.Blood pressure measurement,Young competitiveathletes,Family and personal history,physical examination,12 lead ECG,Negative,Eligible for competition,Further Examination(echo,stress test,24 hr HolterMRI,angio/EMB,EPS,Management,Positive,Eur Heart J 2005,European Approach,Difficulties with screening,Low prevalence diseases so prior probability lowQuestionnaire aloneFamily history may not be knownConditions can occur without SCDSymptoms not recognised or suppressed+Physical examinationAllows potential pick-up cardiac murmurs(HCM,bicuspid aortic valve,MVP)and coarctation,MarfansHCM may be present without murmur,misses other cardiomyopathies+ECGImproves pick-up of cardiomyopathies,LQT etcChanges may be subtleWill not identify anomalous coronaries,Benefits of Italian programme(Corrado et al,JAMA 2006),Screening by law since 1982Everyone 12 yrs of age or older engaged in formal competitive sportRepeated every 2 yearsPerformed by Sports CardiologistPublished review of athlete screening,and causes of SCD in athlete and non-athlete population in 20069%of athletes required further screening2%of athletes disqualified,Numbers of Cardiologists,Automatic Defibrillators(AEDs),Prominent placement in public locations(?remote rural towns also)Computer analyses heart rhythm and decides if shock is requiredIdeally personnel using should be trained(and training updated?every 3 months)Have been successfully used by untrained good samaritansMaintenance issuesPublic liability(Duty of Care issues)If cardiac arrest during sport more difficult to resuscitate,Data from US Schools,15 year period reviewedNumber of schools needed to generate 1 cardiac arrest per year167 schools8 colleges/universitiesOf those who had cardiac arrest15%were 35 years of age10%were students(half of them were already known to have health problems),In Summary,SCD is not commonHigh-risk people usually identified by symptoms or family history priority for evaluationCure not possible,but correct management can prevent complications,Symptoms to be aware of,Awareness of unusual symptoms important:Chest discomfort and/or Shortness of Breath that significantly limits ability to exerciseUnexplained blackoutsProlonged palpitations(especially if associated with diziness),Reducing the risk,Identify those with underlying conditionsOlder people returning to sport get checked by GPImprove response in the event of a cardiac arrestAvailability of AEDsTraining of population in Basic Life SupportImproved ambulance response times,Cardiac screening for sports or entire population?,Hard to justify compulsory testingEthical right not to know about health issuesCurrently no resources in public health system for statistically low-riskPrivately funded facilities existBeware variable standard of expertise and focus on profit,