Sudden Cardiac Death in Athletes - American Osteopathic Academy

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Sudden Cardiac Arrest
in
Athletes
Kimberly G. Harmon, MD
Professor, Department of Family Medicine and
Orthopaedics and Sports Medicine
Osteopathic Medicine Conference and Exposition
Seattle, WA October 28, 2014
Hank Gathers March 4, 1990
Reggie Lewis
July 27, 1993
Darryl Kile
June 22, 2001
Damion
Nash
Marc Vivan
Foe
Denver
June 26,
2003Broncos
February 24, 2007
Antonio Puerta
Sergei Grinkov
1984 - 2007
1995
Atlanta Hawks
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Media Hype? •  Incidence •  E5ology Maron, JACC, 2014
It is important to place into proper perspective
these absolute numbers of sudden deaths,
because the frequency of these events is a very
important variable in the screening debate.
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Maron, JACC, 2014
Sudden deaths attributable to cardiovascular
disease in young athletes in the United
States occur at an annual rate similar to
lightning strike fatalities.
http://www.lightningsafety.noaa.gov/fatalities.htm
http://www.lightningsafety.noaa.gov/fatalities.htm
In order to calculate a RELIABLE INCIDENCE a precise number of events (numerator) AND the popula5on at risk (denominator) needs to be iden5fied. 3
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Incidence of Death from Lightening Strikes •  Average of 32 deaths/year over the last 8 years in the U.S. •  361,100,000 people in the U.S. -­‐ 2013 1 death
361,100,000 people
in
32 deaths from lightening
11,284,375 people
High Risk Groups 1 in 249,550
1 in 614,749
Tradi5onal Es5mates Sudden Cardiac Death Incidence 1 : 200,000 – 1 : 300,000 •  Con5nues to be perpetuated despite more recent evidence with beXer methodology 4
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SCD Incidence Evalua&ng the Science •  Difficult to compare studies with different methodologies •  Need to compare similar cohorts SCD Incidence Evalua&ng the Science •  Type of popula5on –  Compe55ve athletes –  Recrea5onal athletes –  Exercisers –  Youth •  Age range studied •  Time frame –  Exer5onal death –  Death at any 5me SCD Incidence Evalua&ng the Science •  Ac5ve Surveillance –  Purposeful gathering of informa5on from a defined popula5on –  O_en mandatory repor5ng requirements •  Passive Surveillance –  Repor5ng of only those with disease (SCD) –  No special effort is made to find those with unsuspected disease incidents –  Subject to ascertainment bias 5
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Where did tradi5onal es5mates come from? 1 : 200,000 – 1 : 300,000 VanCamp S, Bloor C, Mueller F, Cantu R, Olson H
Med Sci Sports Exer;1995
•  Data from the Na5onal Center for Catastrophic Sports Injury Research 1983 -­‐ 1993 •  Passive surveillance –  Informa5on from NCAA, NFHS, NJCAA, NAIA, Community College League of California –  Press clipping service –  Deaths during or within 1 hour of par5cipa5ng on a college or high school team VanCamp S, Bloor C, Mueller F, Cantu R, Olson H
Med Sci Sports Exer;1995
•  17 sports selected for analysis •  Adjusted for athletes that par5cipated in more than one sport –  1.9 for high school, 1.2 for college –  “based with discussion on the representa&ve from the na&onal athle&c organiza&ons” •  Club and intramural teams not included •  Incidence of SCD in high school and college athletes was 1 in 300,000 6
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Limita5ons •  Passive surveillance •  Only exer5onal deaths •  Somewhat random denominator JACC, 1998
•  Used insurance claims data –  In Minnesota all high school athletes are covered by death benefit of $10,000 •  Reviewed 1985-­‐86 to 1996-­‐1997 (12 years) •  Had a precise denominator –  Grades 10 – 12 –  3 death claims made –  All male •  There were 1,453,280 sports par5cipa5ons •  Average number of sports per athlete for 1996-­‐1997 was 2.23 •  Total number of athletes was 651,695 •  Rate of SCD was 1 in 217,400 7
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Limita5ons •  Only athletes par5cipa5ng in a school-­‐
sponsored team sport (no club or intramural) –  Would not count: •  Varsity soccer player who died playing on their club team •  College football player who died playing intramural basketball •  Only exer5onal deaths Ac-vity at Time of Death Study Popula-on Sleep Moderate/ vigorous physical ac-vity Harmon 2014 NCAA athletes 17-­‐24 41% (or non-­‐exer5on) 59% Winkle 2013 Children 1 -­‐ 18 32% 14% Pilmer Children 1-­‐ 19 41% 16% 2013 15-­‐19 30% 23% Margey 2011 People 14 – 35 45% (or non-­‐exer5on) Harmon 2011 NCAA athletes 17-­‐24 33% (or non-­‐exer5on) Eckart 2011 US military 18-­‐35 -­‐ Holst 2009 Persons 1 – 35 34% • 
• 
• 
• 
• 
8% 58% 47% Registry from the Department of Defense Ac5ve surveillance Mandatory; autopsy protocol 10 years; 15.2 million person-­‐years Incidence of SCD in 18-­‐25 1 in 25,000 JACC 2011
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Incidence of SCD   400,000 student athletes annually   Know sports, sex and ethnicity of par5cipants   High profile Circulation. 2011;123:1594-600
•  NCAA has no requirement for repor5ng deaths •  Case iden5fica5on –  NCAA Memorial Resolu5ons List –  Parent Heart Watch Database (media database) –  Catastrophic insurance claims •  Capture-­‐recapture analysis (90 – 100%) All Cause NCAA Death 2004 - 2008
Unknown 2% Suicide 9% Heat stroke -­‐ sickle cell related 2% Homicide 6% Other medical 3% Meningi-s 1% Heat stroke 1% Accidents 51% Cardiac 16% Cancer 7% Drug Overdose 2% Harmon, Circulation, 2011
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Risk break down Group Incidence Overall 1 in 43,770 Males 1 in 33,134 Females 1 in 76,746 African-­‐American 1 in 17,696 Caucasian 1 in 58,653 Risk by sport Sport Incidence Basketball 1 in 11,394 Swimming 1 in 21,293 Lacrosse 1 in 23,357 Football 1 in 38,497 Cross-­‐Country 1 in 41,695 Risk in Basketball Athletes Group Division I Male Incidence African American 1 in 2,976 Division II Male 1 in 5,832 Division III Male 1 in 4,488 Overall 1 in 3,947 Males 1 in 6,506 Females 1 in 34,344 Incidence Caucasian 1 in 3,324 -­‐ -­‐ 1 in 14,184 10
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Cri5cisms Maron, Heart Rhythm, 2013
Autopsies Requested Autopsy Results •  3 cases had no autopsy performed •  5 autopsies could not be obtained but had histories compa5ble with SCD •  32 autopsies obtained –  1 autopsy with insufficient informa5on for a specific cardiac diagnosis •  3 reports read over the phone •  2 reasonably determined without autopsy –  1 Commo5o cordis –  1 case with Long QT -­‐ 2 sisters with LQT Harmon, Circ Arryth Elect, 2014
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Autopsy Results •  One case not cardiac •  Other cardiac cases were found that were not included in the database •  E5ology of death could be reasonably determined in 36 cases – 80% Results –E5ology of NCAA Deaths Possible HCM/
SCT HCM 3% 3% Possible HCM/
LVH 8% Other 6% Aor-c dissec-on 8% ARVC 3% Dilated CM 8% Myocardi-s 8% MI 6% Coronary Artery Abnormality 14% SUD 33% Harmon, Circ Arrthm Elec, 2014
Tradi5onal E5ology of SCD in US Other 14% Aor-c dissec-on 3% HCM 37% Myocardi-s 6% MI 3% SUD 6% Maron – 2009 N=690 Coronary Artery Abnormality 17% Dilated CM 2% ARVC 4% Possible HCM/
LVH 8% 12
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Corrado-­‐ 2003 ARVC 10% Aor5c dissec5on 5% MI 20% Possible HCM/
LV/SCT 3% Other 6% Aor5c dissec5on 8% Dilated CM 5% Coronary Artery Abnormality 10% Dilated CM 1% Myocardi5s 12% Coronary Artery Abnormality 27% MI 9% SUD 30% NCAA Maron -­‐ 2009 HCM Possible HCM/
LVH 3% 8% ARVC 3% Aor5c dissec5on 3% Dilated CM 8% Coronary Artery Abnormality 14% MI 6% HCM 6% Other 13% SUD 28% Myocardi5s 8% Possible HCM/
ARVC LVH 1% 1% Eckart -­‐ 2004 HCM 7% Other 15% Other 14% HCM 37% Myocardi5s 6% MI 3% SUD 6% SUD 33% Coronary Artery Abnormality 17% Dilated CM 2% ARVC 4% Possible HCM/
LVH 8% 10-­‐YEAR RESULTS Methods •  Data collected from 3 sources –  NCAA Resolu5ons Database –  Parent Heart Watch Database –  NCAA Insurance Claims •  2003 – 2004 school year to 2012 – 2013 –  School year defined as July 1 to June 30 –  Death at any 5me 13
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Methods •  For cardiac cases and unknown cases autopsies were requested where possible –  Autopsied were reviewed and adjudicated by panel of 7 experts –  Used standard accepted criteria •  If autopsies required NOK permission cases were discussed with coroner –  Would o_en confirm if case was cardiac or give listed diagnosis Results •  4,242,519 athlete-­‐years •  79 total cardiac deaths –  59 autopsies obtained (74%) –  76 deaths “confirmed cardiac” (96%) •  Coroner/medical examiner •  ATC, Parents •  History consistent with commo5o –  3 deaths “likely cardiac” based on history Causes of Death in NCAA Athletes 2003 -­‐ 2013 Drug/Etoh Overdose Heat Stroke 3% 1% Head injury 1% SCT 2% Unknown Medical -­‐ Meningi-s 1% other 1% 3% N = 514
Cancer 7% Accident 50% Cardiac/SCT 0% Cardiac 15% Homicide 8% Suicide 8% 14
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All Cause NCAA Death 2004 - 2008
Unknown 2% Homicide 6% Suicide 9% Heat stroke -­‐ sickle cell related 2% Other medical 3% Meningi-s 1% Heat stroke 1% Accidents 51% Cardiac 16% Cancer 7% Drug Overdose 2% Harmon, Circulation, 2011
Risk break down Group Incidence Overall 1 in 53,703 Males 1 in 38,390 Females 1 in 121,593 African-­‐American 1 in 20,147 Caucasian 1 in 59,153 Deaths by Gender Female 19% Male 81% 15
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Deaths by Ethnicity Other 14% Caucasian [PERCENTA
GE] African American [PERCENTA
GE] Risk by sport Sport Men’s Basketball Incidence 1 in 8,978 Men’s Soccer 1 in 23,689 Football 1 in 35,951 Cross-­‐Country 1 in 44,973 Baseball 1 in 50,023 Swimming 1 in 50,197 Volleyball 1 in 53,685 Lacrosse 1 in 54,401 Women’s Basketball 1 in 77,061 Risk in Basketball Athletes Incidence African American Division I Male 1 in 4,380 Incidence Caucasian 1 in 5,230 1 in 5,200 1 in 8,241 -­‐ 1 in 15,843 1 in 4,906 -­‐ 1 in 14,266 1 in 5,348 1 in 14,184 1 in 8,978 Group Division II Male Division III Male Overall Total 16
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tennis so^ball 1% volleyball 1% 4% Sports baseball 8% cross country 8% track 4% soccer 11% swimming 5% wrestling crew 2% 1% golf 1% lacrosse 4% basketball 27% football 23% High Risk groups •  Men’s basketball –  4% of NCAA athletes –  1/5 of NCAA cardiac deaths •  Football and men’s basketball –  23% of NCAA athletes –  ½ of NCAA cardiac deaths NCAA Incidence 10-­‐year data Group 5 year incidence 10 year incidence Overall 1 in 43,770 1 in 53,703 Males 1 in 33,134 1 in 38,390 Females 1 in 76,746 1 in 121,593 African-­‐American 1 in 17,696 1 in 20,147 Caucasian 1 in 58,653 1 in 59,153 Basketball 1 in 11,394 1 in 15,462 Men’s basketball 1 in 6,506 1 in 8,978 17
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Etiology of SCD in NCAA Athletes 2003-2013
Idiopathic Kawasaki Disease Commo-o LVH/SCT 2% 2% Long QT 2% DCM 2% WPW 3% 3% SUD 25% ARVC 5% HCM 6% Aor-c dissec-on 5% Anomalous coronary 11% idiopathic LVH/
possible cardiomyopathy 8% Cardiomyopathy NOS 8% CAD 9% Myocardi-s 9% SCD + SCA •  8 SCA recorded in database from SY2003 – SY2013 •  4 in basketball –  3 in Division I African American male basketball •  Overall rate of SCA+SCD = 1:48,765 •  Rate in Div I men’s basketball 1:4,000 Media Bias in Repor5ng Level of Play NCAA Resolu-ons Media Database Division I 87% 87% Division II 83% 61% Division III 89% 44% High School -­‐ ? •  Gender or sport did not correlate with likelihood
of death being reported
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Holst et al. Heart Rhythm 2010
•  Retrospec5ve study of death cer5ficates to iden5fy all sports-­‐
related SCD (SrSCD) in Denmark age 12-­‐25 from 2000-­‐2006 •  “To validate our methods, an extensive retrospec5ve search of media reports was performed.” –  Infomedia – database of 400 printed, 2,200 web-­‐based, na5onal and regional media, as well as major radio and television •  15 cases of compe55ve athlete SrSCD Media reports identified only
3 of 15 cases (20%)
Insurance Claims Time Frame Resolu-ons List 2003-­‐2008 83% 2009-­‐2013 91% 2003-­‐2013 86% PHW Database 67% 70% 70% Insurance Claims 9% 15% 11% Comparisons to other Studies Harmon Maron Years Studied SY2003 – SY2013 2002 -­‐ 2011 Total Deaths 514 182 Likely Cardiac Deaths 79 64 59 59 Autopsies/Cardiac Cases Commo-o 1 2 Basketball athletes 21 23 Rate 1:53,000 1:62,000 19
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Next Steps •  Death and catastrophic event repor5ng became mandatory in the NCAA in August of 2014 •  Na5onal Center for Catastrophic Sports Injury Research •  Center for Sports Cardiology at the University of Washington SCD in Athletes •  You will miss deaths if: –  You use passive surveillance –  You depend on media reports –  You only look at exer5onal deaths –  You only look at deaths during school hours •  It doesn’t maXer when or where a young person dies; it just maXers that they die and any screening program employed to prevent sudden death should prevent it all the 5me. Explana5ons/Cri5cisms •  “The college age group (18 – 25) were older than high school age group” Roberts, JACC, 2013
•  Perhaps college athletes are at higher risk of SCD? –  Disease does not manifest itself un5l athletes are older –  NCAA athletes may prac5ce longer and more intensely 20
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Risk in High School Athletes JACC, 2013
•  Required PPE every 3 years •  Used catastrophic insurance claims to track deaths –  Pay out a $10,000 death benefit –  No mandatory repor5ng of deaths •  4 SCDs during 20 year study period •  0 SCDs during the last 9 years of study JACC, 2013
•  Incidence of SCD 1 in 416,666 for last 19 years •  1 in 909,090 in last decade •  Concluded that PPE in Minnesota was effec5ve and there was no need for addi5onal screening Limita5ons of Catastrophic Insurance Claims •  Only SCD cases during an official high school sponsored spor5ng event •  No mechanism to make sure all deaths are reported •  Does not include SCA with survival •  No results of the screening evalua5ons performed or the cardiac condi5ons iden5fied to link the PPE with low SCD rate 21
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SCD Rate Based on Media Reports •  21 cases of SCD + SCA found •  10 cases of SCD –  2 cases not high school athletes –  1 had graduated •  11 case of SCA which survived –  4 not athletes par5cipa5ng on high school team •  14 cases met criteria for inclusion (7 SCDs, 7 SCAs survived) Results •  1,906,014 Minnesota high school athlete par5cipants ages 14-­‐18 (2002 – 2012) Popula-on High school athlete Male high school athlete Male high school bball Unduplicated Athletes 811,070 Deaths Incidence 7 1:115,867 518,434 7 1:74,062 139,716 3 1:46,572 Results SCD + SCA •  Sudden cardiac arrest is an important endpoint Popula-on High school athlete SCA + SCD Male high school athlete SCA + SCD Male high school bball SCA + SCD Unduplicated SCD + SCA Incidence Athletes 811,070 14 57,934 518,434 14 37,031 139,716 8 17,465 22
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Minnesota High School Athlete Deaths •  Only 29% of athletes who died (2 of 7) were eligible to receive insurance benefit •  Of the two that were eligible only one actually received the death benefit •  3 (43%) Minnesota high school athletes died playing non-­‐school sponsored sports •  2 athletes died in their sleep •  All had been screened with a PPE! Drezner, JACC, 2013
Harmon, BJSM, 2014
Catastrophic Insurance Claims •  Not an accurate way to monitor deaths •  In the Minnesota study from 2002-­‐2012 insurance claims iden5fied at a maximum 14% of SCDs in high school athletes •  The PPE in Minnesota did not iden5fy at least 14 people who had SCA/SCD Drezner, JACC, 2013
Harmon, BJSM, 2014
Inclusion Criteria •  SY 2007-­‐2008 to SY 2012-­‐2013 •  School year defined from September 1 to August 31. •  High school athlete who played on an organized team for their high school. •  Sudden cardiac arrest/death 23
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•  Seven states were reviewed –  California –  Texas –  New Jersey –  Tennessee –  Ohio –  Minnesota –  Florida •  Autopsies available without next-­‐of-­‐kin permission in most cases Results •  16,390,405 high school athlete par5cipants (over 6 years) •  Represented 36% of the US high school athlete popula5on •  Resulted in 6,974,640 unduplicated athlete-­‐
years Results – Death Rate Popula-on High school athlete Male high school athlete Female high school athlete Male high school bball Unduplicated Athletes 6,974,640 Deaths Incidence 75 1:92,995 4,124,534 64 1:64,446 2,850,106 11 1:259,100 1,149,703 16 1:71,856 24
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Results SCD + SCA Popula-on High school athlete SCA + SCD Male high school athlete SCA + SCD Male high school bball SCA + SCD Unduplicated Athletes 6,974,640 SCD + SCA 110 Incidence 4,124,534 96 1:43,964 1,149,703 31 1:37,087 1:63,406 Results •  59% of SCD/SCA occurred while prac5cing or playing for school team •  85% of SCD occurred in males Basketball •  Range was 1:13,801 (Minnesota) to 1:74,107 (Texas) Popula-on Male high school bball SCA + SCD SCA + SCD without Texas Unduplicated Number Athletes Events 1,149,703 31 705,064 25 Incidence 1:37,087 1: 28,203 25
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Are Athletes at Greater Risk of SCD? RR
2.8
RR
4.0
Corrado
2003
Marijon
2011
High School Student-­‐Athlete vs. Non-­‐Athlete Toresdahl et al. •  2,149 high schools followed for 2 years Incidence per 100,000 1.2 RR
3.7
1 •  > 1.5 million athlete years 0.8 0.6 0.4 •  > 2.5 million non-­‐
athlete years 0.2 0 Athlete Non-­‐Athlete Incidence of SCA in High School Student Athletes… only on SCHOOL CAMPUS! Popula-on = 1.5 million athlete-­‐years Cases of SCA over 2-­‐Years Popula-on Incidence (Per Year) Student athletes 18 Male student athletes 16 Female student athletes 2 788,683 462,269 326,414 1 in 87,000 1 in 58,000 1 in 323,000 Students non-­‐athletes 1,280,804 1 in 323,000 8 •  50% of SCA cases occurred in football and boys’
basketball
•  Male student athletes vs. non-athlete: RR 4.95 (95% CI
1.6-14.8, P<0.01)
•  Female student athlete vs. non-athlete: RR 1.09 (95% CI
0.20-5.92, P 0.92)
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Prevalence of Cardiovascular Disorders at Risk for SCD Study
Popula-on
AHA (2007)
Compe55ve athletes age 12-­‐35 (US)
Prevalence
0.3%
Fuller (1997)
5,617 high school athletes (US)
0.4%
Corrado (2006) 42,386 athletes age 12-­‐35 (Italy)
0.2%
Wilson (2008)
0.3%
2,720 athletes & children age 10-­‐17 (UK)
Bessem (2009) 428 athletes age 12-­‐35 (Netherlands)
0.7%
Hevia (2009)
0.16%
1,220 amateur athletes (Spain)
Baggish (2010) 510 college athletes (US)
0.6%
Contemporary Es5mates 1 in 11,000,000? 1 in 50,000? 1 in 25,000? 1 in 10,000? 1 in 3,000? How Do We Prevent Sudden Cardiac Death? 27
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SCD in Athletes •  Incidence numbers are highly dependent on study methodology •  Insurance claims, media databases, passive surveillance all have inherent limita5ons that must be recognized SCD in Athletes •  The incidence of SCD in athletes is about 1:50,000 •  There are high risk groups –  Males –  African Americans –  Basketball athletes •  SUD is the leading cardiac cause of death in athletes UW Medicine Center for Sports Cardiology Jonathan A. Drezner, Director Kimberly G. Harmon Ashwin Rao Henry Pelto BreX Toreshdahl Dave Owens Jordan Prutkin Jack Salerno Karen Stout 28
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Thank you 29