• Possible causes for a 25 year old
  • electrical problems, structural heart diseases, genetics, drugs
    

Hypertrophic Cardiomyopathy

• Prevalence:
  • 1/500 in general population
  • 1/2000 in athletes
• Cause of SCD in 2-36% of cases in athletes
• Heterogeneous genetic disorder resulting in asymmetric LV hypertrophy, myocardial disarray on histology and fibrosis
• Variable penetrance with some never developing phenotype of HCM
• Might be asymptomatic for long time ->screening needs to continue until young adulthood

Symptoms

• SCA (80% of the time) - risk is higher with intense exercise
• dyspnoea on exertion
• atypical or anginal chest pain on exertion
• presyncope and syncope
  • particularly during or immediately following exertion
• palpitations
• fatigue

Diagnosis

• ECG - abnormal in 90-95%
  • P-wave abnormalities
  • Left axis deviation
  • Deeply inverted T-waves ‘(V2-V4)
  • Pathological Q-waves – reflective of septal depolarization
  • High QRS voltages
  • ST-depressions
    

After the diagnosis

• No cure, but focus on prevention of complications/adverse events
• Risk factors for SCD in patients with HCM
  • Unexplained syncope
  • Family history of SCD
  • Severe LVH (> 30 mm)
  • Sustained or non-sustained VT
  • Attenuated BP response to training/testing
• low positive predictive value, high negative predictive value
  • ICD
    

Arrhythmogenic Cardiomyopathy

• Prevalence: 1/1000 – 1/5000 in general population
• Cause of death in 3-29% of athletes
• Progressive inherited heart muscle disease characterized clinically by ventricular electrical instability and pathologically by progressive loss of myocardium with subsequent myocyte death and fibro-fatty scar
• Exercise causes progression of the disease
• Risk of SCA: 2-5 times higher in competitive athletes vs recreational or non competitive sports

Symptoms

• Exercise-induced palpitations
• Presyncope
• Syncope
• Shortness of breath
• Sudden Cardiac Death

Diagnosis

Recommendations

Commotio Cordis

• Sudden cardiac arrest triggered by a blunt, nonpenetrating, and often innocent appearing blow to the chest, without damage to the ribs, sternum or heart and in the absence of underlying cardiovascular disease
• 2nd leading cause of SCD in athletes in US
• Male > female

Important Variables and Mechanism

• Primary prevention
  • avoidance of chest blows
  • chest wall protection
  • softening the ball
• Secondary prevention
  • increased recognition that a person is in cardiac arrest
  • early CPR and defibrillation

Myocarditis

• Acute inflammatory process of the myocardium
• Caused by variety of infectious agents, systemic diseases, drugs, toxins
• 2-31% of SCD in athletes
• Associated with
  • atrial and (lethal) ventricular tachyarrhythmias, bradyarrhythmia
  • dilated cardiomyopathy
• Suspicion in:
  • Individuals with systemic viral symptoms
  • Developing cardiac-related symptoms
• Vigorous exercise might accelerate and worsen myocardial affectation in systemic viral and autoimmune processes
• Primary prevention
  • restriction of sport in case of infection (neck check) and systemic symptoms (fever, myalgias, diarrhoea, elevated resting heart rate)
  • Education - Avoidance of recreational drugs or doping agents

Recommendations

Coronary Artery Anomalies

• Coronary arteries arising from an anomalous sinus in the aortic root
  • Left coronary artery origin in right sinus of Valsalva
  • Right coronary artery origin in the left sinus of Valsalva
• 0.5-1/100 of all healthy individuals
• 4-16% % of SCD in young athletes
• Clinical manifestation
  • With or Without hemodynamic consequences
  • Usually asymptomatic
  • If symptoms: angina, syncope, presyncope
  • Difficult diagnosis: MRI, CT angio
• Therapy: surgical correction
• Wolff-Parkinson White syndrome (A)
  • Most common abnormal finding on ECG in screening programs
  • 1/1000 in population has WPW
  • Tachyarrhythmias due to an accessory pathway (bundle of Kent)
  • Short PR, delta waves (slurred QRS upstroke), widened QRS
  • Palpitations, syncope, near-syncope, SDC
  • Therapy: ablation
• Long QT syndrome
  • Ion channelopathy
  • 1/2000-1/5000
  • Qtc > 400ms (470 athletes) in males and > 460 (480 athletes) ms in females
  • Return-to-sport: shared decision
  • ICD if
    • History of SCD – recurrent syncope and polymorphic VT despite B-blocker therapy
• Brugada syndrome
  • Ion channelopathy - ICD
  • Syncope/ SCD during SLEEP
  • Coved-type and downsloping ST-segment Elevations (V1-V3)
  • Return-to-sport: shared decision