Transcript Diapositiva 1 - Gastaldi Congressi

RISK FACTORS FOR SUDDEN DEATH
Exercise:
How and When Does it Lead to Sudden Death?
Prof. Massimo Santini
Exercise - Sport and
Sudden Cardiac Death
Sport-related Sudden Cardiac
Death
Sudden cardiac death during sport activity is an
unexpexted death of cardiovascular etiology in
which there is loss of consciousness within an hour
of onset of symptoms.
(80%)
Trauma or thechnical accidents during sport activity
are not inclusive of this definition.
Sport-related SCD
Epidemiology
< 35 yrs
1:100.000 - 1:300.000
> 35 yrs
1:15.000 - 1:50.000
Risk in males >>> than in females
5:1
Sudden Death During Different
Types of Sport
Maron BJ Circ 2009
Wrestling
Tennis
Marathon
Boxing
hockey
Volley
Swimm
Basebal
Soccer
Track
Football
Basket
600
500
400
300
200
100
0
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.
de Noronha S V et al. Heart 2009;95:1409-1414
©2009 by BMJ Publishing Group Ltd and British Cardiovascular Society
Hourly distribution of Sudden Cardiac
Death
Time of Day
Maron BJ JAMA 1996
9
8
7
6
5
4
3
2
1
no
on
11
10
9
8
7
6
5
4
18
16
14
12
10
8
6
4
2
0
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 SCD
35 yrs
1:15.000 - 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 autopsy in
athletes ≥35 yrs who died suddenly
HCM
80%
Coronary artery
disease
MVP
Unexplained
Aquired Valve
Disease
Flow response to Higher
Myocardial Demand
Mechanism of Acute Coronary Events
During Exercise
 Placque rupture
aggregation
Enhanced cathecolamine- induced platelet
 Exercise induced
coronary artery spasm
Sport-related SCD
< 35 yrs
1:100.000 - 1:300.000
Causes of Sudden Cardiac Death in
Young Athletes (<35 yrs)
(n°158 athletes;1985-95)
10%
19%
5%
4%
3%
3%
2%
2% 6%
Cor An
HCM
Other
CAD
MVP
ARVD
Myoc
AO Sten
Rupt AO
Incres Mass
36%
Maron BJ JAMA 1996
ARVD 23%
Anomalous
c.a. origin 12%
(Corrado et al. NEJM 1998)
Premature
CAD 18%
Anomalous
c.a. origin 19%
ARVD 3%
HCM 2%
(Maron et al. JAMA 1996)
Atherosclerotic
HCM 36% c.a. disease 2%
- 89%
The Hank Gathers Case
H.G. was a 23-year-old basketball star .
His first symptom was a syncopal spell, which
occurred during a game.
He underwent to a cardiologic evaluation performed by a group
of expert cardiologist and electrophysiologist.
ECG Holter showed only VPB and an exercise test
trhee-beat runs of VT.
The coronaries were normal.
At electrophysiologic study, polymorphic VT was
induced with triple extrastimuli.
A later Holter, acquired while he was playing very
active, disclosed repetitive VT up to 21 beats in
duration at 200 bpm.
A divergence of opinion arose between the
cardiologist and electrophysiologist as to
wheter the patient should play basketball
The electrophysiologist said that
H.G. SHOULD NOT PLAY
The family was hurt and angered at this
recommendation
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 without
structural cardiac abnormalities
Canalopatie
• Long QT syndrome
• Short QT Syndrome
• Catecholaminergic
polymorphic ventricular
tachycardia
• Brugada Syndrome
Patologia del Sistema di
conduzione
• WPW
• Lown Gannon Levine
Idiopatic ventricular fibrillation
de Noronha S V et al. Heart 2009;95:1409-1414
©2009 by BMJ Publishing Group Ltd and British Cardiovascular Society
Pathogenesis of Sudden Cardiac
Death in Athletes
+++
Structure
HCM
ARVC
CAA
CAD
Myocarditis
…….
Exercise
Elect Instab
BPV
TV/FV
Function
Transient ischemia
Acidosis
Hypoxemia
Increased
sympathetic drive
Ventricular Fibrillation
In 95% of cases
Minimize the risk of athletic field deaths:
the great challange of Sports Cardiology
The secret of longevity: No Sport, just whisky and cigars