sudden cardiac death

New Study Confirms Value and Raises Questions About Cardiac Screening for Young, Competitive Athletes

August 9, 2018 By Larry Creswell, MD Leave a Comment

SoccerSCD

In a study reported today in the New England Journal of Medicine, Dr. Sanjay Sharma and colleagues from the University of London offer the most comprehensive look yet at the utility of cardiac screening for young, competitive athletes—in this case, specifically for elite, adolescent British soccer players.

We’ve long known about the small risk of sudden cardiac death (SCD) among young, competitive athletes, but very few datasets have been assembled to look carefully at the value of cardiac screening in these athletes.

The Study

Over a 20-year period from 1996 through 2016, the English Football Association used a combination of health questionnaire, physical examination, electrocardiogram (ECG), and echocardiogram to assess the heart health of all 11,168 potential soccer players, aged 15-17 years, who were joining the Association. Because the ECG and echocardiogram were included, we might characterize the cardiac screening as comprehensive, or “aggressive.” Information was then gathered about any of these players who later died, with a focus specifically on deaths due to heart-related conditions. The investigators were then able to return to the athlete victims’ initial cardiac screening to see what lessons could be learned.

The Findings

The investigators report that with the initial cardiac screening (with health questionnaire, physical examination, ECG, and echocardiogram):

The cost of the initial cardiac screening was $342 per athlete.
42 athletes (0.38%) were found to have cardiac diseases that could cause sudden cardiac death (SCD). Among these 42 athletes, all of those with forms of cardiomyopathy or long Q-T syndrome were advised not to participate in sports.
Another 225 athletes (2%) were found to have other, non life-threatening cardiac diseases such as heart valve problems or congenital heart conditions. In many cases, these athletes received medical or surgical treatment that allowed them to return to play.
A total of 830 athletes (7%) required additional testing to sort out any potential heart problems detected by the initial screening procedure.
After complete evaluation, 544 athletes (5%) required long-term monitoring for non life-threatening heart conditions.

During a follow-up period of 118,531 person-years, there were 23 deaths from any cause, including 8 from a cardiac cause. The incidence, then, of SCD in this cohort of athletes is 1 per 14,794, which is greater than previously reported for most young, competitive athletes and similar to the rate reported for NCAA basketball players. In this report, all 8 of the cardiac deaths were sudden and occurred during exercise. Among these 8 victims:

The deaths occurred anywhere from 0.1 to 13.2 years after the initial cardiac screening.
7 deaths (88%) were caused by hypertrophic cardiomyopathy (HCM), which is known to be associated with SCD.
- 5 of these 7 deaths due to HCM occurred in athletes with a completely normal screening examination.
- 2 of these 7 deaths due to HCM occurred in athletes in whom HCM was diagnosed at the initial screening, but who chose to continue to participate in sports and exercise gainst medical advice.

My Take

This study is important because it provides a “real world” look at the use of cardiac screening for young, competitive athletes.

Here, we see that an “aggressive” approach to cardiac screening that includes health questionnaire, physical examination, ECG, and echocardiogram is useful to identify athletes at risk for SCD as well as those who require some sort of evaluation and treatment for non life-threatening forms of heart disease. The findings of the study in this regard are not surprising.

In a setting in which comprehensive, long-term follow-up is possible, this study’s estimate of the risk of SCD among the screened athletes is likely to be very accurate. Moreover, the incidence of SCD at approximately 1 per 15,000 is a bit greater than previously thought. There should be no doubt, though, that the incidence of SCD will vary among different cohorts of athletes, of different abilities, and participating in different sports.

The study raises some worry, though, about the effectiveness of “aggressive” cardiac screening programs. First, it is not clear why 2 athletes diagnosed with HCM would be allowed to continue to participate against medical advice and it is truly sad that these athletes later died. But more worrisome, though, is the finding that 5 other athletes died because of HCM that was not detected during the cardiac screening. Review of ECGs of these athletes confirmed, in fact, that they were normal. Perhaps we have an undue faith in the ability of ECG and echocardiogram to identify HCM and other potentially life-threatening conditions. These findings raise the possibility that an initially negative cardiac screening cannot provide complete reassurance that athletes are risk-free for SCD and raise the question about the need for periodic cardiac re-testing in the years after an initially negative screen.

I think there will be a bunch of headlines in the press about this study and most of the reporting will focus on the athletes who died after a supposedly normal cardiac screening exam. We will need to keep in mind, though, the positives about cardiac screening—namely, the many other athletes who learned they had a variety of heart conditions that could be treated successfully and allow them to return to play.

Japan and Triathlon Fatalities

February 25, 2016 By Larry Creswell, MD 2 Comments

I’ve recently returned from a trip to Tokyo, Japan, where I was the guest of the Japan Triathlon Union (JTU). The occasion was their organization’s 5th Annual Forum, which this year was devoted to the issue of triathlon race safety.

I appreciate the kind invitation from Mr. Otsuka and Mr. Nakayama, the help of JTU’s Kenta Kodama with the travel arrangements, and the tremendous help with translation from Ms. Tomoko Wada. My hosts were gracious in every way. I must also thank the kind folks at USA Triathlon (USAT)–Terri Waters and Kathy Matejka, for help with gathering some updated information to present in Japan, and USAT President Barry Siff for making the necessary connections with JTU.

As readers here will know, I’ve had an interest in triathlon-related fatalities and the broader issue of sudden cardiac death among endurance athletes. I had the opportunity to lead a recent USAT effort to learn more about triathlon-related fatalities and our work resulted in a 2012 report entitled “Fatality Incidents Study.” As I’ve said before, this report is good reading for athletes and event organizers who are looking for recommendations about how to race safely and conduct events with athlete safety as a first priority.

Sadly, there were 6 triathlon-related fatalities in Japan in 2015, the most ever in a single year there. Dr. Ryoji Kasanami, the Chairman of the JTU’s Medical Committee, had become familiar with our work here in the USA and was interested in learning how our findings might help JTU with better safety planning, on the parts of both athletes and event organizers.

I gave a talk at the Forum where I outlined the USAT experience with fatalities since 2003. In large part, the information is summarized in my previous blog post, Triathlon Fatalities: 2013 in review. I was able to include some updates through the 2015 season, but the central themes were the same now as then:

There is variation in the fatality rate from year to year, with an overall fatality rate of ~1 per 70,000 participants
Most fatalities occur during the swim portion of events
Most victims are male
Fatalities are most common among middle-aged athletes
There have been no fatalities among elite (professional) athletes
Among victims, there is a wide range in athlete experience and ability
There is a small number of trauma-related fatalities, arising from bicycle crashes
Among non-traumatic fatalities, the vast majority suffered cardiac arrest at the race venue
Available autopsy information for non-traumatic fatalities has shown heart abnormalities in the majority

Dr. Kevin Harris, from the Minneapolis Heart Institute, and I will be presenting an abstract at the upcoming American College of Cardiology meeting in April in Chicago on this topic. We’ll be sharing consolidated information about 106 fatalities, including the autopsy findings from 41 of the non-traumatic fatalities. I’ll report back here at the blog with an update in April.

Dr. Kasanami shared information about the Japanese experience with 37 fatalities over the past 3 decades. There were many similarities to the experience in the USA:

Some years were “safer” than others
Most fatalities occurred during the swim portion of events
Most victims were male
Fatalities were most common among middle-aged athletes
There have been no fatalities among elite athletes
There were no fatalities in young athletes

There were also some notable differences:

There were no fatalities during the bike portion
Autopsy was seldom performed in the victims

Interestingly, the bike course is always closed to vehicular traffic during triathlons in Japan, and this might obviously have an impact on the number of crashes and trauma-related fatalities. One interesting anecdote shared by a pathologist attendee related to the finding of inner ear bleeding (hemorrhage) in 2 victims. I’m not sure about the significance of this observation.

I’m intrigued by the many similarities of the Japanese experience with race-related fatalities. I also know from preliminary discussions with officials at Triathlon Australia that the experience in Australia is similar as well. I suspect that the causes of cardiac arrest in participating athletes are common broadly, and are more dependent on simply the human condition rather than race-related factors that might be specific to one region or another (eg, race safety or technical rules, approach to medical care on site, warm-up, etc.).

I’ll mention here that the Medical Committee of the International Triathlon Union (ITU) is very interested in this issue, particularly as it relates to elite athletes. I understand that efforts are being made to implement the requirement for mandatory periodic health evaluations, including EKG screening, for youth, U23, and elite athletes who participate in ITU races, perhaps beginning in the 2017 season. This follows on the heels of the international rowing federation adopting a similar policy, gradually, during the 2014 and 2015 seasons.

I worry a little about the ITU focus on elite athletes, since the problem of race-related fatalities seems to be largely one of age-group athletes, but I hope that age-group athletes will be paying attention to any recommendations that are implemented.

Lastly, I’ll close with some photographs from the trip. Since this was my first-ever visit to Tokyo and Japan, my hosts graciously afforded me about 8 hours of free time one day for the purpose of sightseeing and I took advantage. I hope to return to Japan soon to see even more.

Debate Continues on Cardiac Screening for Youth Athletes

November 25, 2013 By Larry Creswell, MD Leave a Comment

This post is for the parents out there. I don’t have many youth athlete readers here at the blog, but I’ll bet there are more than a few parents.

We’re all familiar with the sad stories of young athletes who die suddenly while playing their sports. According to most estimates, about 1 young athlete per 50,000 to 100,000 per year will have sudden cardiac death during practice or competition. These incidents often receive a great deal of attention in the media. They also have a lasting impact on families, schools, and communities that struggle afterwards to deal with the tragedy.

The medical community also struggles with this issue. There are very legitimate differences of opinion about what best to do. We know that most of these young athletes die from some sort of unrecognized heart problem, so there’s an obvious motivation for cardiac screening programs to find these heart problems before a young athlete dies as a result. Yet we also know that such screening programs are costly in both monetary terms and in the needed resources. We also know they’re not foolproof.

In last week’s November 21, 2013 edition of the New England Journal of Medicine, a Clinical Decisions feature was devoted to the topic of “Cardiac Screening before Participation in Sports,” focusing on school-aged athletes. This feature asked experts in the field to respond to 2 related questions.

The first question asked: Should young athletes be required to undergo cardiac screening before participating in sports?

Dr. Sanjay Sharma, a cardiologist from the St. George’s University of London answered YES.
Dr. Mark Estes, a cardiologist from Tufts University in Boston answered NO.

The second question asked: If an athlete does undergo screening, should the screening involve only a history and physical examination, or should electrocardiography (ECG) also be required?

Dr. Victoria Vetter, a pediatric cardiologist from Children’s Hospital in Philadelphia, recommended AGAINST the ECG.
Dr. Domenico Corrado, a cardiologist from the University of Padua in Italy advocated FOR the ECG.

The position statements are intended for a physician audience, but even non-medical folks will be able to read them and learn something. Take a moment to read what these doctors say. In just a few short paragraphs, each summarizes the important arguments. You won’t find a better summary of the arguments.

The journal also has an online poll for readers to weigh in on the issue. The poll asks readers to consider the expert opinions and then answer the 2 questions for themselves. I answered YES for screening and YES for an ECG. As I sit here writing on Sunday afternoon, nearly 900 readers have responded to the poll, with the following results:

18% voted for requiring NO screening
23% voted for screening with medical history and physical examination alone
57% voted for screening that also included an ECG.

At the level of schools, communities, and states, there is increasing awareness about the issues surrounding cardiac screening for young athletes. Some have created screening programs that are available to athletes, often at little or no cost. In the end, though, in most communities parents will need to make appropriate decisions about cardiac screening for their children. Be informed.

2. Ask the experts: Pre-participation heart screening for adult endurance athletes.

ESPN Outside the Lines: Triathlon Safety

October 27, 2013 By Larry Creswell, MD Leave a Comment

Last weekend’s ESPN Outside the Lines show devoted to triathlon race safety is now available on podcast.

The show included a video report from ESPN reporter, T.J. Quinn and then a panel discussion that I joined along with Dr. John Mandrola and ESPN reporter Bonnie Ford.

If you missed the television broadcast, the podcast would be good listening for any triathlete.

Triathlon Safety, ESPN Outside the Lines, and Me

October 19, 2013 By Larry Creswell, MD 3 Comments

I had a chance today to be a panelist for an episode of ESPN’s Outside the Lines that will be broadcast on Sunday morning at 8 am Eastern on ESPN2. The show is devoted to triathlon safety, particularly as it relates to the swim portion of races. I joined host, Bob Ley, ESPN reporter, Bonnie Ford, and Louisville, Kentucky electrophysiology cardiologist, John Mandrola for a discussion about race-related fatalities and efforts to improve race safety. I appreciate the opportunity and I hope you can tune in on Sunday.

ESPN this afternoon posted a related on-line article by Bonnie Ford, entitled “Trouble Beneath the Surface.” I didn’t have an opportunity to read the article before the TV show taping. I wish I’d had that opportunity. I might have done better with the questions. At any rate, I tweeted the link for the article earlier this evening and I’m sharing the link here as well. The story is good reading for any triathlete. The article continues to bring attention to the problem of sports-related sudden cardiac death. As a triathlon community we need to have an ongoing discussion about this problem.

Also posted online–and used as an introduction to the OTL show–is a ~9-minute video clip by ESPN reporter, T.J. Quinn. As a means of introducing the topic, the video clip uses the tale of 46-year-old Ross Ehlinger who died during the swim portion of this spring’s Escape from Alcatraz Triathlon. The tale is poignant. It’s a very personal look at the tragedy through the eyes of the Ehlinger family. I participated in that race and I’ve written here at the blog about my experience that day.

But reading through the “Trouble Beneath the Surface” article, I see that I might have a different take on a few things. And maybe I can fill in some gaps. Here are some of my thoughts:

How Big is the Problem?

Any death at a triathlon is a tragedy. But fatalities at triathlon races are very rare. Based on USAT’s 2003-2011 data, that risk is about 1 per 75,000 participants. In other words….if your local annual triathlon had 200 participants each year, you could reasonably expect to have a fatality every 150 years. I’ve lived near the Mississippi River for 26 years now. Those numbers remind me of planning for the “100-year flood.” And I know that many communities don’t prepare for the 500-year flood.

In the past couple years, I’ve heard the entire range of reaction to this risk. At one end of the spectrum is the person who says that even a single fatality is too many….and that we simply shouldn’t have triathlon. At the other end of the spectrum is the person who says that when the risk is only 1 per 75,000, we should devote our energies to solving other, more common problems.

Somewhere in between those extremes, we need to find a way forward.

What’s Known About the Cause?

The article, video, and upcoming OTL show focus on the swim. Indeed, most race-related deaths have occurred during that portion of the event. But not all. Perhaps 25% have occurred during bike or run portions–or even after the race is completed.

The common thread seems to be cardiac arrest. We know from autopsy reports in triathlon victims as well as running race victims of cardiac arrest that there is an underlying (almost always unsuspected) heart abnormality in the vast majority. And that turn’s out to be the situation in Ehlinger’s case. His autopsy findings are typical.

We don’t yet know what triggers the electrical problem of cardiac arrest during a triathlon. I suspect that the autonomic (involuntary) nervous system’s interaction with the heart plays an important role. I’ve written about possible mechanisms and triggers here at the blog.

There is debate about the utility of screening athletes to find such heart abnormalities. The controversy relates to the expense and the accuracy of the available tests.

But what about the individual athlete–particularly the middle-aged male athlete–who asks the question: What can I do to reduce my chance of dying at a triathlon? Given that heart problems are found in upwards of 65% or more of victims, it seems obvious to me that cardiac screening would be the starting point. I’ve written about the issue of pre-participation screening here at the blog. If you’re an athlete, you should discuss this with your doctor.

As USAT Event Services Director, Kathy Matejka, pointed out, there will be further investigation about the victims’ medical histories, on-scene and hospital treatment, and autopsy reports. Stay tuned.

Safety In the Water

There’s no doubt in my mind that, for most triathletes, the swim portion is the most stressful for the heart. I bet that if we had heart rate information for large numbers of athletes, we’d find higher heart rates during the swim than any other portion of the race. That can be a set-up for arrhythmias.

I don’t doubt that a warm-up is helpful, from a performance standpoint, to any athlete before competing. I’m sure it’s true for triathlon. But there is no evidence that a warm-up–or lack of warm-up–has any bearing on the risk of cardiac arrest during a race. None. And I’m not aware of data about cardiac arrest in any setting where there’s a reasonable hypothesis that an antecedent period of exercise, or warm-up, would mitigate that risk.

The article raises the issue of water temperature and race safety. Over the years, swimming deaths at triathlon races have occurred in water with temperatures over a very wide range. No particular temperature appears to be safest. The various governing bodies related to open water swimming have reached varying conclusions about water temperature and event safety. USAT is currently considering whether there should be upper and/or lower limits of temperature for races.

The USAT report concluded that the fatality rate was unrelated to the type of race start. In truth, very few triathlons historically have begun with a mass start. The Ironman triathlons are one example. The Ironman races this year has experimented with a variety of start methods to replace the mass start. The underlying motive was to improve the ability of rescuers to identify an incapacitated swimmer at the start and respond appropriately, if assistance was needed. That’s impossible when 2000+ swimmers start at the same time. But it’s important to note that none of the handful of fatalities during Ironman swims occurred at the very beginning of a race with a mass start.

What Can We Do?

I think that every reasonable strategy for improving race safety and decreasing the chances for a race-related fatality is included in the recommendations from the 2012 USAT Fatalities Report. If you are an athlete or race director, you should use these recommendations as a checklist.

In the framework of those recommendations, the athlete assumes the responsibility to show up for the race HEALTHY, FIT, and PREPARED. Nobody can do that except the athlete. It’s critical that an athlete’s health, fitness, and preparedness be matched to the demands of a planned race. In the end, only the athlete can make the decision to participate.

The race director assumes the responsibility to have a robust safety plan. Nobody can do that except the race director. It’s not that a given number of lifeguards is on duty, but rather that there is a rehearsed plan for identifying the victim of cardiac arrest, rescuing that athlete, and providing CPR and defibrillation within minutes. This is a formidable challenge.

And as I said on the OTL show, the buck stops with USAT. It’s USAT’s responsibility to provide resources, oversight, education, and monitoring. I give a great deal of credit to USAT for initiating its Fatalities Study, for sharing information about the fatalities, for developing specific recommendations, and for partnering with scientists for current and future studies related to the fatalities. I’m not aware of a similar commitment by any other foreign or international triathlon governing body. I suspect we could learn from the worldwide, pooled experience.

Some rambling thoughts! I could talk about this all night….and maybe tomorrow, too. Maybe it’s just my reaction to having only a few minutes on the OTL show. Hoping you can tune in on Sunday.