Sports-related and non-sports-related sudden cardiac death in young adults

The autopsy study of 553 cases of sudden cardiac death in Chinese adults

Despite a recent epidemiological study reporting a lower incidence of sudden cardiac death (SCD) in China as compared with that in Western countries, the exact causes of SCD are still unknown. Using a uniform review protocol and diagnostic criteria, a retrospective autopsy study identified 553 cases of SCD in 14,487 consecutive autopsies from eight regions in China representing different geographic and population features. Their ages ranged from 18 to 80 years (median 43.0 years) with a ratio of 4.3/1.0 for male/female. Out-of-hospital deaths and unwitnessed cases accounted for 74.3 and 22.6 %, respectively. The main causes of death were coronary atherosclerotic disease (CAD 50.3 %), myocarditis (14.8 %), and hypertrophic cardiomyopathy (4.5 %), with unexplained sudden death accounting for 12.1 % of the cases. CAD had a proportion of 10.4 % in victims <35 years, lower as compared with 59.0 and 83.0 % in victims aged 35-54 and in victims ≥55 years. On the other hand, myocarditis and unexplained sudden death were major causes and accounted for 34.7 and 22.5 % in victims <35 years. In order to differentiate the degree of the cause-effect relationship between autopsy findings and sudden death, a grading method was used in this series and characterized 24.3 % of findings as certain, 52.9 % as highly probable, and 22.8 % as uncertain. Our data indicated that there most likely are less CAD but more myocarditis and unexplained sudden death in Chinese youth with SCD than in populations from Western countries. Molecular genetic testing should be conducted in those cases with uncertain findings and unexplained sudden death in routine autopsy.

Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review

Sudden cardiac death (SCD) in young competitive athletes (<35 years old) is a tragic event that has been brought to public attention in the past few decades. The incidence of SCD is reported to be 1-2/100,000 per year, with athletes at a 2.5 times higher risk. Soccer is the most popular sport in the world, played by people of all ages. However, unfortunately it is cardiovascular diseases such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy that have subtly missed screening and claimed the lives of soccer stars such as Marc Vivien Foe and Antonio Puerta during live action on the field and on an internationally televised stage. This paper covers the physiological demands of soccer and the relationship between soccer and SCD. It also reviews the most common causes of SCD in young athletes, discusses the current guidelines in place by The Fédération Internationale de Football Association (FIFA) for screening among professional soccer players, and the precautions that have been put in place to prevent SCD on the field in professional soccer.

A rare case of a coronary artery anomaly detected on multidetector computed tomography

An anomalous aortic origin of the coronary artery arising from the opposite sinus with an interarterial course is a rare condition that is associated with a high risk of sudden cardiac death during or after strenuous exertion. We herein report the case of a 47-year-old woman presenting with chest pain, syncope and palpitations who presented with a rare coronary artery anomaly on multidetector computed tomography coronary artery (MDCT-CA) with prospective electrocardiogram (ECG) gating.

The molecular autopsy: an indispensable step following sudden cardiac death in the young?

Annually thousands of sudden deaths involving young individuals (<35 years of age) remain unexplained following a complete medicolegal investigation that includes an autopsy. In fact, epidemiological studies have estimated that over half of sudden deaths involving previously healthy young individuals have no morphological abnormalities identifiable at autopsy. Cardiac channelopathies associated with structurally normal hearts such as long QT syndrome (LQTS), catecholaminergic polymorphic ventricular tachycardia (CPVT), and Brugada syndrome (BrS), leave no evidence to be found at autopsy, leaving investigators to only speculate that a lethal arrhythmia might lie at the heart of a sudden unexplained death (SUD). In cases of autopsy-negative SUD, continued investigation, through the use of a cardiological and genetic evaluation of first- or second-degree relatives and/or a molecular autopsy, may pinpoint the underlying mechanism attributing to the sudden death and allow for the identification of living family members with the pathogenic substrate that renders them vulnerable to an increased risk for cardiac events, including sudden death.

[Anomalous origin of the right coronary artery and acute myocardial infarction: cause or coincidence?]

Congenital coronary artery anomalies are one of the causes of myocardial ischemia and sudden death in the young, mainly during sports. Origin of the right coronary artery from the left anterior descending artery is very rare, with a prevalence of 0.015%, corresponding to 1.2% of all coronary artery anomalies. The authors present the case of a 22-year-old man, with a history of cocaine use, admitted to hospital with a non-ST elevation acute myocardial infarction. Coronary angiography revealed the presence of this rare coronary anomaly and the absence of atherosclerotic luminal stenosis, and so it was assumed to be a type II infarction caused by cocaine-induced vasospasm of the anomalous vessel.

Syncope in the athlete

Syncope in the athlete requires a complete evaluation, as this may be the only warning prior to an episode of sudden cardiac death. This should include a detailed history which includes specific details of the event as well as bystander descriptions when possible. Following the history should be a careful physical examination and subsequent diagnostic testing based on the individual's needs. The purpose of the evaluation is to determine if structural or electrical heart disease is present that may lead to sudden death. If absent, the patient, family and staff can be reassured that it is safe to resume athletic activity. Careful attention to the athlete with syncope may both prevent potential disasters in some, while at the same time enjoyment of intense physical activity in others.

Coronary artery abnormalities and sudden cardiac death

Anomalous origin of a coronary artery (AOCA) can be associated with sudden cardiac death (SCD), particularly in young athletes. The diagnosis usually can be made by transthoracic echocardiography. In the case of patients for whom this method is not diagnostic, other methods are available including transesophageal echocardiography, cardiac magnetic resonance imaging (CMRI), and computed tomographic (CT) angiography. The decision to intervene is dependent on the type of lesion, the course of the coronary artery, its known association with SCD, and any symptoms present at the time of diagnosis. For patients without symptoms who have lesions less clearly associated with SCD [e.g., anomalous origin of the right coronary artery (AORCA)], the decision to intervene is more controversial. Further prospective studies hopefully will elucidate the optimum treatment pathway for such patients.

The molecular autopsy: should the evaluation continue after the funeral?

Sudden cardiac death (SCD) is one of the most common causes of death in developed countries, with most SCDs involving the elderly, and structural heart disease evident at autopsy. Each year, however, thousands of sudden deaths involving individuals younger than 35 years of age remain unexplained after a comprehensive medicolegal investigation that includes an autopsy. In fact, several epidemiologic studies have estimated that at least 3% and up to 53% of sudden deaths involving previously healthy children, adolescents, and young adults show no morphologic abnormalities identifiable at autopsy. Cardiac channelopathies associated with structurally normal hearts such as long QT syndrome (LQTS), catecholaminergic polymorphic ventricular tachycardia (CPVT), and Brugada syndrome (BrS) yield no evidence to be found at autopsy, leaving coroners, medical examiners, and forensic pathologists only to speculate that a lethal arrhythmia might lie at the heart of a sudden unexplained death (SUD). In cases of autopsy-negative SUD, continued investigation through either a cardiologic and genetic evaluation of first- or second-degree relatives or a molecular autopsy may elucidate the underlying mechanism contributing to the sudden death and allow for identification of living family members with the pathogenic substrate that renders them vulnerable, with an increased risk for cardiac events including syncope, cardiac arrest, and sudden death.

Accuracy of interpretation of preparticipation screening electrocardiograms

OBJECTIVE

To evaluate the accuracy of pediatric cardiologists' interpretations of electrocardiograms (ECGs).

STUDY DESIGN

A series of 18 ECGs that represented conditions causing pediatric sudden cardiac death or normal hearts were interpreted by 53 members of the Western Society of Pediatric Cardiology. Gold-standard diagnoses and recommendations were determined by 2 electrophysiologists (100% concordance).

RESULTS

The average number of correct ECG interpretations per respondent was 12.4 ± 2.2 (69%, range 34%-98%). Respondents achieved a sensitivity of 68% and a specificity of 70% for recognition of any abnormality. The false-positive and false-negative rates were 30% and 32%, respectively. Based on actual ECG diagnosis, sports participation was accurately permitted in 74% of cases and accurately restricted in 81% of cases. Respondents gave correct sports guidance most commonly in cases of long QT syndrome and myocarditis (98% and 90%, respectively) and least commonly in cases of hypertrophic cardiomyopathy, Wolff-Parkinson-White syndrome, and pulmonary hypertension (80%, 64%, and 38%, respectively). Respondents ordered more follow-up tests than did experts.

CONCLUSIONS

Preparticipation screening ECGs are difficult to interpret. Mistakes in ECG interpretation could lead to high rates of inappropriate sports guidance. A consequence of diagnostic error is overuse of ancillary diagnostic tests.

Anomalous Aortic Origin of a Coronary Artery: Preoperative Diagnosis and Surgical Planning

Background: Anomalous aortic origin of a coronary artery (AAOCA), the anomalous coronary artery arises from an inappropriate coronary sinus and travels between the aorta and pulmonary artery. Proper surgical management depends upon correct diagnosis and accurate characterization of the origin and course of the coronary artery. Transthoracic echocardiography (TTE) has been the mainstay for diagnosis, but magnetic resonance imaging (MRI) and computed tomographic angiography (CTA) have been increasingly utilized. In this study, we report the largest series of surgically repaired AAOCA and accuracy of preoperative diagnostic studies. Methods: A review of 53 consecutive patients (mean age 13.9 years, range 4-65 years) undergoing repair of an AAOCA from 1995 to 2009 was performed. In all, 40 patients were identified with an anomalous right coronary artery (ARCA) from the left sinus of Valsalva, 13 patients had an anomalous left coronary artery (ALCA) arising from the opposite sinus. Symptoms of angina or syncope were present in 58% and 46% of cases with ARCA and ALCA, respectively. Results of preoperative diagnostic testing were compared to actual surgical findings to determine the accuracy of the tests. Results: Lack of an intramural course was observed intraoperatively in 7 cases (5 ARCA and 2 ALCA). Preoperative TTE accurately predicted whether the AAOCA was intramural or extramural in 49 (92.5%) of 53 cases. Magnetic resonance imaging was predictive in 5 (83.3%) of 6 patients and CTA in 11 (64.7%) of 17. Survival was 100%. Complications occurred in 4 (7.5%) of 53 patients (mean follow-up 29 months). Patency was confirmed in 97.7% with TTE, and 23 (95.8%) of 24 patients had a negative postoperative functional study. Conclusions: Transthoracic echocardiography was found to be very accurate at defining the presence or absence of an intramural course in AAOCA. Both MRI and CTA can provide additional information but may not be as accurate as TTE.

Effects of nicotine administration in a mouse model of familial hypertrophic cardiomyopathy, α-tropomyosin D175N

The effects of nicotine (NIC) on normal hearts are fairly well established, yet its effects on hearts displaying familial hypertrophic cardiomyopathy have not been tested. We studied both the acute and chronic effects of NIC on a transgenic (TG) mouse model of FHC caused by a mutation in α-tropomyosin (Tm; i.e., α-Tm D175N TG, or Tm175). For acute effects, intravenously injected NIC increased heart rate, left ventricular (LV) pressure, and the maximal rate of LV pressure increase (+dP/dt) in non-TG (NTG) and Tm175 mice; however, Tm175 showed a significantly smaller increase in the maximal rate of LV pressure decrease (-dP/dt) compared with NTGs. Western blots revealed phosphorylation of phospholamban Ser16 and Thr17 residue increased in NTG mice following NIC injection but not in Tm175 mice. In contrast, phosphorylation of troponin I at serine residues 23 and 24 increased equally in both NTG and Tm175. Thus the attenuated increase in relaxation in Tm175 mice following acute NIC appears to result primarily from attenuated phospholamban phosphorylation. Chronic NIC administration (equivalent to smoking 2 packs of cigarettes/day for 4 mo) also increased +dP/dt in NTG and Tm175 mice compared with chronic saline. However, chronic NIC had little effect on heart rate, LV pressure, -dP/dt, LV wall and chamber dimensions, or collagen content for either group of mice.

Prevalence of coronary artery anomalies in 12,457 adult patients who underwent coronary angiography

BACKGROUND

Coronary artery anomalies are found in 0.2% to 1.3% of patients undergoing coronary angiography and 0.3% of an autopsy series. We aimed to estimate the frequency of coronary artery anomalies in our patient population.

METHODS

The data were collected retrospectively by analyzing the angiographic data of 12 457 consecutive adult patients undergoing coronary angiography between September 2002 and October 2007.

RESULTS

Coronary artery anomalies were found in 112 patients (0.9% incidence), 100 patients (89.3%) had origin and distribution anomalies, and 12 patients (10.7%) had coronary artery fistulae. Their mean age was 52 ± 8 years (range, 22-79 y). Separate origins of left anterior descending and left circumflex coronary artery from the left sinus of Valsalva was the most common anomaly (63.4%). The right coronary artery rising from the left coronary sinus of Valsalva was found in 10 (8.9%) patients. Anomalous origin of the left circumflex coronary artery from the right sinus of Valsalva was seen in 10 (8.9%) patients. The left main coronary artery from the right coronary sinus of Valsalva was found in 1 (0.89%) patient while an isolated single coronary artery was seen in 2 (1.78%) patients.

CONCLUSION

The incidence and the pattern of coronary artery anomalies in our patient population were almost identical with previous studies. Cardiologists should be aware of the coronary anomalies which may be associated with potentially serious cardiac events, because recognition of these coronary anomalies is mandatory in order to prescribe appropriate therapy.

Incidence of sudden cardiac death in National Collegiate Athletic Association athletes

BACKGROUND

The true incidence of sudden cardiac death (SCD) in US athletes is unknown. Current estimates are based largely on case identification through public media reports and estimated participation rates. The purpose of this study was to more precisely estimate the incidence of SCD in National Collegiate Athletic Association (NCAA) student-athletes and assess the accuracy of traditional methods for collecting data on SCD.

METHODS AND RESULTS

From January 2004 through December 2008, all cases of sudden death in NCAA student-athletes were identified by use of an NCAA database, weekly systematic search of public media reports, and catastrophic insurance claims. During the 5-year period, there were 273 deaths and a total of 1 969 663 athlete participant-years. Of these 273 deaths, 187 (68%) were due to nonmedical or traumatic causes, 80 (29%) to medical causes, and 6 (2%) to unknown causes. Cardiovascular-related sudden death was the leading cause of death in 45 (56%) of 80 medical cases, and represented 75% of sudden deaths during exertion. The incidence of SCD was 1:43 770 participants per year. Among NCAA Division I male basketball players, the rate of SCD was 1:3100 per year. Thirty-nine (87%) of the 45 cardiac cases were identified in the NCAA database, only 25 (56%) by use of public media reports, and 9 (20%) from catastrophic claims data.

CONCLUSIONS

SCD is the leading medical cause of death and death during exercise in NCAA student-athletes. Current methods of data collection underestimate the risk of SCD. Accurate assessment of SCD incidence is necessary to shape appropriate health policy decisions and develop effective strategies for prevention.

Sudden cardiac death in young athletes; a literature review and special considerations in Asia

Sudden cardiac death (SCD) in a young athlete is rare, but catastrophic. Exercise acts as a risk factor for SCD in people with cardiovascular disease. A diversity of cardiovascular disorders including hypertrophic cardiomyopathy, congenital coronary anomalies, arrhythmogenic right ventricular dysplasia, dilated cardiomyopathy, aortic rupture due to Marfan syndrome, myocarditis, valvular disease and electrical disorders (Wolff-Parkinson-White syndrome, long QT syndrome, Brugada syndrome), as well as commotio cordis represent the common causes of SCD in young athletes.As the outcome of lethal cardiovascular disorders is not reversible except in few cases, effective measures should be addressed to reduce the burden of sudden cardiac death in young athletes. Currently, two types of recommendations are proposed by American and European countries.It seems that there are some special considerations in Asia, entirely different from North America or Europe, which warrant more comprehensive research on epidemiology and etiology of SCD in young Asian athletes by country and evaluation of current national preventive strategies and their achievements in decreasing the risk. Using these data and considering regional restrictions, an expert group will be able to plan a practical and feasible preventive strategy.

Increase in sudden death from coronary artery disease in young adults

BACKGROUND

Sudden cardiac death (SCD) is the most common cause of death in adults aged <65 years, making it a major public health problem. A growing incidence in coronary artery disease (CAD) in young individuals has been predicted in developed countries, which could in turn be associated with an increase in SCD in this population. The aim of the study was to assess the prevalence of CAD among autopsies of young individuals (<40 years) who had sudden death (SD).

METHODS

We selected all the autopsies referred to the Montreal Heart Institute and Maisonneuve-Rosemont Hospital from January 2002 to December 2006 that corresponded to individuals <40 years old who had died suddenly. For each decedent, the following data were collected: cause of death, autopsy findings, available clinical history, toxicological findings, and cardiovascular risk factors.

RESULTS

From a total of 1,260 autopsies, 243 fulfilled the inclusion criteria. Coronary artery disease was the main cause of SCD from age 20 years, representing the 37% of deaths in the group of 21 to 30 years old, and up to 80% of deaths in the group of 31 to 40 years old. Among individuals who died of CAD, 3-vessel disease was observed in 39.7% of cases. Moreover, among the whole population <40 years old, at least 1 significant coronary lesion was observed in 39.5% of cases, irrespective to the cause of death. In the multivariable analysis, an increased BMI (hazard ratio 1.1 for each kg/m(2), 95% CI 1.01-1.1) and hypercholesterolemia (hazard ratio 2.4, 95% CI 1.7-333.3) showed to be the modifiable factors related to an increased risk of SD from CAD.

CONCLUSIONS

In our population, CAD was the main cause of SD from age 20 years. These data bring into question whether present prevention strategies are sufficient and reinforce the need to extend prevention to younger ages.

Imaging spectrum of sudden athlete cardiac death

Sudden athlete death (SAD) is a widely publicized and increasingly reported phenomenon. For many, the athlete population epitomize human physical endeavour and achievement and their unexpected death comes with a significant emotional impact on the public. Sudden deaths within this group are often without prior warning. Preceding symptoms of exertional syncope and chest pain do, however, occur and warrant investigation. Similarly, a positive family history of sudden death in a young person or a known family history of a condition associated with SAD necessitates further tests. Screening programmes aimed at detecting those at risk individuals also exist with the aim of reducing fatalities. In this paper we review the topic of SAD and discuss the epidemiology, aetiology, and clinical presentations. We then proceed to discuss each underlying cause, in turn discussing the pathophysiology of each condition. This is followed by a discussion of useful imaging methods with an emphasis on cardiac magnetic resonance and cardiac computed tomography and how these address the various issues raised by the pathophysiology of each entity. We conclude by proposing imaging algorithms for the investigation of patients considered at risk for these conditions and discuss the various issues raised in screening.

Cardiovascular screening in young athletes in Sarajevo Canton

Potential risk of sudden death during sports participation makes screening of competitive athletes of vital importance. Congenital cardiac anomalies and non-atherosclerotic, acquired myocardial conditions are primary causes underlying exercise-induced cardiac death in young patients. Since cardiovascular conditions are the leading causes of non-traumatic, exercise-induced cardiac events, cardiovascular screening preceding sports participation in mandatory. The objectives of this study were to determine prevalence of cardiac conditions through cardiovascular screening of young athletes and to establish preventive strategy. The study was conducted at the Sports Medicine Center of Sarajevo Canton and at the Pediatric Clinic of University of Sarajevo Clinics Centre in the period 2007-2009. The study was supported by Canton Sarajevo Ministry of Health and Ministry of sports, science and culture. The study targeted a group of 214 athletes, 8-18 years of age with average age being 15.26. The group was subdivided into five groups according to the age. After taking the anamnesis (family, personal and cardiological) patients were subjected to the measuring of body mass and height, blood pressure and heart rate and oxygen saturation, recording of 12-lead ECG, specialist examination (pediatrician, sports medicine specialist and cardiologist) and complete heart echocardiography. No examined athletes expressed subjective discomfort. Congenital cardiac anomalies were not diagnosed in any athlete. Also, cardiovascular abnormalities requiring additional evaluation, positive cardiac anamnesis, abnormal auscultatory findings, hypertension or abnormal ECG findings were not recognized in any patient. Moderate correlation was found among the left ventricle mass and heart rate (p<0.05). In order to minimalize or even possibly prevent the risk of sudden cardiac death it is necessary to establish an adequate strategy of cardiovascular screening of young athletes.

Long-term outcome and impact of surgery on adults with coronary arteries originating from the opposite coronary cusp

BACKGROUND

An anomalous coronary artery from the opposite sinus of Valsalva may increase sudden death risk in children and young adults, and surgical intervention is often recommended. The impact of this lesion when recognized in the adult and its management are ill defined.

METHODS AND RESULTS

We reviewed 210 700 cardiac catheterizations performed over a 35-year period at a single institution and identified 301 adults with an anomalous coronary artery from the opposite sinus of Valsalva, either anomalous right coronary artery from the left cusp or anomalous left main coronary artery from the right cusp. Patients were stratified by the pathway of the anomalous artery and the chosen treatment. Among the 301 patients with anomalous coronary artery from the opposite sinus of Valsalva (0.14% of the cohort), 79% had anomalous right coronary artery from the left cusp, and 18% had an interarterial course (IAC). Patients with IAC were younger (52±13 versus 59±13 years; P=0.001) and more likely to undergo surgical intervention (52% versus 27%; P<0.001), but mortality was not increased with IAC. Among the 54 patients with IAC, 28 underwent surgical repair with no perioperative deaths. Patients evaluated since 2000 were significantly more likely to be referred for surgery (P=0.004). Surgical patients were more likely to have abnormal stress tests (90% versus 43%; P=0.01) and had more extensive atherosclerosis but less diabetes mellitus (0% versus 23%; P=0.01). Long-term survival at 10 years appeared similar in both groups.

CONCLUSIONS

In this single-center cohort study of patients with an anomalous coronary artery from the opposite sinus of Valsalva, surgical management appears to have been favored recently. Despite no perioperative mortality, a positive impact on long-term survival was not observed. The impact of surgery in older adults with anomalous coronary arteries arising from the opposite coronary sinus with IAC deserves further study.

Prevalence of anomalous origin of coronary artery detected by multi-detector computed tomography at one center

BACKGROUND

Anomalous origin of coronary artery (AOCA) has been described by coronary angiography or autopsy. However the actual prevalence of such abnormalities is unknown. Multi-detector computed tomography (MDCT) offers the possibility to visualize AOCA non-invasively. The purpose of this study was to report the prevalence AOCA by MDCT.

METHODS AND RESULTS

In 5869 consecutive subjects who underwent coronary MDCT (Aquilion 64, Toshiba Medical Systems Corporation, Otowara, Japan) at one center, the prevalence of AOCA was 89 (1.52%) patients. The most common abnormality (33 cases, 0.56%) was the origin of the coronary artery or branch from the opposite or non-coronary sinus. The right coronary arteries (RCA) arising from the left coronary artery sinus (LCS) was observed in 27 cases (0.46%). Vascular cross-sectional area of such RCA arising from LCS was significantly smaller in 11 patients with angina than in 10 patients without symptoms [3.02 (1.68-7.67) mm² vs 5.93 (2.54-12.04) mm² p < 0.05]. The left coronary artery arising from the non-coronary sinus was observed in 2 cases (0.03%), and the left anterior descending coronary artery (LAD) or left circumflex coronary artery (LCX) arising from the right coronary sinus was observed in 4 cases (0.07%). Single coronary arteries were found in 5 cases (0.09%). Fifteen patients (0.26%) presented multiple coronary ostia, all of 15 (0.26%) had the LAD and LCX separately arising from the left coronary sinus. High take off was found in 36 cases (0.60%).

CONCLUSION

MDCT can accurately detect and characterize the type of AOCA.

Nationwide study of sudden cardiac death in persons aged 1-35 years

AIMS

The aim of this investigation was to study the incidence of sudden cardiac death (SCD) in persons aged 1-35 years in a nationwide setting (5.38 million people) by systematic evaluation of all deaths.

METHODS AND RESULTS

All deaths in persons aged 1-35 years in Denmark in 2000-06 were included. Death certificates were read independently by two physicians. The National Patient Registry was used to retrieve information on prior medical history. All autopsy reports were read and the cause of death was revised based on autopsy findings. We identified 625 cases of sudden unexpected death (10% of all deaths), of which 156 (25%) were not autopsied. Of the 469 autopsied cases, 314 (67%) were SCD. The most common cardiac cause of death was ischaemic heart disease (13%); 29% of autopsied sudden unexpected death cases were unexplained. In 45% of SCD cases, the death was witnessed; 34% died during sleep; 89% were out-of-hospital deaths. Highest possible incidence rate of SCD in the young was 2.8 per 100 000 person-years including non-autopsied cases of sudden unexpected death. Excluding those, the incidence rate declined to 1.9 per 100 000 person-years.

CONCLUSIONS

A total of 7% of all deaths in the young can be attributed to SCD, when including non-autopsied cases (autopsy ratio 75%). The incidence rate of SCD in the young of 2.8 per 100 000 person-years is higher than previously reported.

The electrocardiogram as an adjunct in diagnosing congenital coronary arterial anomalies

Congenital coronary arterial abnormalities as isolated lesions are exceedingly rare. The electrocardiogram, while a reasonable adjunct in the diagnosis of coronary arterial abnormalities, should not supplant a good history and physical examination. Careful attention must be devoted to any signs or symptoms of ischaemic pain in the chest or syncope, which must not be overlooked. Exertional pain in the chest and exertional syncope should prompt an extensive evaluation by both the echocardiographer and the electrophysiologist. Clearance for participation in sports should be curtailed until a complete evaluation has ruled out the presence of any of the following disorders: a channelopathic mutation, a cardiomyopathy, or a congenital coronary arterial anomaly. Major abnormalities in the coronary arteries may present in the first few months of life or remain dormant until the exertional demands of adolescence unmask symptoms of myocardial ischaemia. Congenital coronary arterial anomalies may be analysed in the following major diagnostic groups: anomalous origin of the left coronary artery from the pulmonary artery, anomalous aortic origin of a coronary artery from the wrong aortic sinus of Valsalva, atresia of the left main coronary artery, myocardial bridges, and coronary arterial fistulas. The advent of state-of-the-art modalities of imaging seems, at times, to have supplanted the electrocardiogram in making the diagnosis of potentially serious coronary artery abnormalities, especially in asymptomatic patients. However, as is also the case for a detailed history and physical examination, the electrocardiogram provides a potentially insightful look at the coronary arteries. Furthermore, the past decade has witnessed an increase in the use of the electrocardiogram as a screening tool in the assessment of the risk of sudden cardiac death in athletes in high school.

Pre-participation examination of competitive athletes: role of the ECG

Sudden cardiac death in athletes is rare but has a wide social impact because it confronts the general population with the paradox that athletes perceived and admired as the fittest and healthiest suddenly drop dead during their sport. Mass media coverage is guaranteed in the case of sudden cardiac death of a top athlete, while other competitive and noncompetitive athletes of all ages, team members, sponsors, as well as huge parts of society remain puzzled and frightened. Therefore, debate is ongoing regarding how to minimize the number of fatalities, and the search continues for a cost-effective preparticipation screening for competitive athletes. Despite the fact that routine ECG screening would be widely available and rather inexpensive, debate continues regarding whether this should be part of initial screening for every athlete before starting to train at high intensity as well as during annual checkups. The role of ECGs in preparticipation examinations of competitive athletes is intensively discussed because there is a lack of strict criteria for which ECG findings should generate further workup. In this article, we analyze the main publications on sudden cardiac death, focusing on the benefit of ECG screening in preparticipation examination as it has been shown to be feasible and effective in identifying athletes at risk of sudden cardiac death.

Sudden death in persons younger than 40 years of age: incidence and causes

BACKGROUND

The problem of sudden death in the young is currently debated and measures for prevention are being evaluated worldwide. Information on the incidence and causes of sudden (cardiac) death in the young (1-40 years) is essential for the development of these preventive strategies.

METHODS

Incidence estimates and causes of death were determined using death certificate data of out-of-hospital sudden deaths recorded by Statistics Netherlands from 1996 to 2006. To define sudden death, International Classification of Diseases codes were selected based on a systematic review of the literature assessing the most common causes of sudden death in the young.

RESULTS

The incidence of sudden death was 2.07 (2.06-2.07 per 100 000 person-years). The incidence was higher for men (2.86 per 100 000 person-years) than for women (1.24 per 100 000 person-years) and increased by age. The majority of sudden deaths was of cardiac origin. Sudden cardiac death incidence was 1.62 (1.61-1.62 per 100 000 person-years). In 9% the cause of death remained unexplained.

CONCLUSION

The incidence of sudden death in the young is 2.07 per 100 000 person-years. Treatable cardiac causes (such as coronary atherosclerosis and inherited cardiac diseases) are often underlying for the sudden death. This information is helpful in the development of preventive strategies.

Pre-participation Cardiovascular Screening of Elderly Wrestlers

Purpose

Sudden death of a competitive athlete is a tragedy that is usually caused by a previously unsuspected cardiovascular disease. The aim of this study was to clarify the role of noninvasive testing in pre-participation cardiovascular evaluation of elderly wrestlers.

Methods

We included 63 Iranian elderly wrestlers who participated in Tehran international elderly wrestlers’ preparation camping by census method. A questionnaire including past medical and family history as well as coronary risk factors was filled out and then a complete physical examination of the cardiovascular system was done by an internist for all wrestlers. Electrocardiogram (ECG), complete echocardiographic examination and then symptom limited exercise test were performed and reported by the cardiologists who did not know the other examinations results.

Results

Exertional dyspnea and typical chest pain (FC=I or II) were present in 5% and 1.7% of the examinees, respectively. There were one or more risk factors in 64.5% of the cases. Cardiovascular examination revealed abnormal heart sounds in 27.1%. ECG showed ischemic changes in 13.6% and premature atrial contractions and premature ventricular contractions in 11.4%. Echocardiography showed mild left ventricular systolic dysfunction in 3.4%, regional wall motion abnormality in 8.5%, valvular disease in 32.3%, diastolic dysfunction in 45.7%, and left ventricular hypertrophy in 16.9% of the cases. Exercise test results were negative, equivocal, positive and highly positive in 70.4%, 15.8%, 5.2%, and 8.6% of cases, respectively.

Conclusion

Beside physical examination, pre-participation screening of elderly wrestling athletes with ECG and exercise testing is feasible and recommended in the presence of coronary risk factors or cardiac symptoms. Echocardiography can also be recommended to detect other relevant abnormalities when there is a clue in the standard history, physical examination or ECG.

Visualization of anomalous origin and course of coronary arteries in 748 consecutive symptomatic patients by 64-slice computed tomography angiography

Background

Coronary artery anomalies (CAAs) are currently undergoing profound changes in understanding potentially pathophysiological mechanisms of disease. Aim of this study was to investigate the prevalence of anomalous origin and course of coronary arteries in consecutive symptomatic patients, who underwent cardiac 64-slice multidetector-row computed tomography angiography (MDCTA).

Methods

Imaging datasets of 748 consecutive symptomatic patients referred for cardiac MDCTA were analyzed and CAAs of origin and further vessel course were grouped according to a recently suggested classification scheme by Angelini et al.

Results

An overall of 17/748 patients (2.3%) showed CAA of origin and further vessel course. According to aforementioned classification scheme no Subgroup 1- (absent left main trunk) and Subgroup 2- (anomalous location of coronary ostium within aortic root or near proper aortic sinus of Valsalva) CAA were found. Subgroup 3 (anomalous location of coronary ostium outside normal "coronary" aortic sinuses) consisted of one patient with high anterior origin of both coronary arteries. The remaining 16 patients showed a coronary ostium at improper sinus (Subgroup 4). Latter group was subdivided into a right coronary artery arising from left anterior sinus with separate ostium (subgroup 4a; n = 7) and common ostium with left main coronary artery (subgroup 4b; n = 1). Subgroup 4c consisted of one patient with a single coronary artery arising from the right anterior sinus (RAS) without left circumflex coronary artery (LCX). In subgroup 4d, LCX arose from RAS (n = 7).

Conclusions

Prevalence of CAA of origin and further vessel course in a symptomatic consecutive patient population was similar to large angiographic series, although these patients do not reflect general population. However, our study supports the use of 64-slice MDCTA for the identification and definition of CAA.

Young Swedish patients with sudden cardiac death have a lifestyle very similar to a control population

OBJECTIVES

To study the association between lifestyle and sudden cardiac death (SCD) in the young with special respect to athletic activities.

DESIGN

We compared lifestyle factors, collected from forensic and medical reports and from interviews with family members, in the Swedish cohort of individuals 15-35 years of age who had suffered an SCD during 1992-1999, with those of the control population of the same age group, obtained from national health registries.

RESULTS

Physical activity and body mass index (BMI) in men were the same as in the controls, whilst women had a higher BMI and a lower level of physical activity in the SCD group. Twenty-three per cent (32/138) were competing athletes in the SCD group and 29% in the control group (622/2131). Death during physical activity was more common in athletes (20/32) than in non-athletes (18/106) (p<0.001). In coronary artery disease deaths, 11/15 (73%) were smokers and BMI was significantly higher than in the controls in both sexes.

CONCLUSIONS

Young Swedish persons suffering SCD were very similar to the normal population with regard to lifestyle factors.

Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006

BACKGROUND

Sudden deaths in young competitive athletes are highly visible events with substantial impact on the physician and lay communities. However, the magnitude of this public health issue has become a source of controversy.

METHODS AND RESULTS

To estimate the absolute number of sudden deaths in US competitive athletes, we have assembled a large registry over a 27-year period using systematic identification and tracking strategies. A total of 1866 athletes who died suddenly (or survived cardiac arrest), 19+/-6 years of age, were identified throughout the United States from 1980 to 2006 in 38 diverse sports. Reports were less common during 1980 to 1993 (576 [31%]) than during 1994 to 2006 (1290 [69%], P<0.001) and increased at a rate of 6% per year. Sudden deaths were predominantly due to cardiovascular disease (1049 [56%]), but causes also included blunt trauma that caused structural damage (416 [22%]), commotio cordis (65 [3%]), and heat stroke (46 [2%]). Among the 1049 cardiovascular deaths, the highest number of events in a single year was 76 (2005 and 2006), with an average of 66 deaths per year (range 50 to 76) over the last 6 years; 29% occurred in blacks, 54% in high school students, and 82% with physical exertion during competition/training, whereas only 11% occurred in females (although this increased with time; P=0.023). The most common cardiovascular causes were hypertrophic cardiomyopathy (36%) and congenital coronary artery anomalies (17%).

CONCLUSIONS

In this national registry, the absolute number of cardiovascular sudden deaths in young US athletes was somewhat higher than previous estimates but relatively low nevertheless, with a rate of <100 per year. These data are relevant to the current debate surrounding preparticipation screening programs with ECGs and also suggest the need for systematic and mandatory reporting of athlete sudden deaths to a national registry.

Pre-participation screening of young competitive athletes for prevention of sudden cardiac death

In 1982 a nationwide program of pre-participation screening including 12-lead electrocardiography (ECG) was launched in Italy. The aim of this article is to examine whether this 25-year screening program should be considered a valid and advisable public health strategy. The analysis of data coming from the long-running Italian experience indicates that ECG screening has provided adequate sensitivity and specificity for detection of potentially lethal cardiomyopathy or arrhythmias and has led to substantial reduction of mortality of young competitive athletes by approximately 90%. Screening was feasible thanks to the Italian Health System, which is developed in terms of health care and prevention services, and because of the limited costs of cardiovascular evaluation in the setting of a mass program. On the basis of current scientific evidence the implementation of a mass-screening program aimed to prevent athletic-field sudden cardiac death should be at least carefully considered by public health administrators worldwide.

Exercise performance and quality of life following surgical repair of anomalous aortic origin of a coronary artery in the pediatric population

OBJECTIVE

We sought to evaluate exercise performance and quality of life in children after surgical repair of anomalous aortic origin of a coronary artery with an interarterial course.

METHODS

Patients who had surgery from October 2001 to January 2007 were eligible for inclusion. Exercise performance and quality of life were prospectively assessed by maximal exercise tests and age-appropriate questionnaires, respectively. We used t tests to compare pre- and postoperative exercise data and quality-of-life scores to published normative data. We performed linear regression analyses to assess associations between demographic, anatomic, and exercise variables and quality-of-life score.

RESULTS

Of 25/27 patients, 64% were boys, 68% had anomalous right coronary, 32% were asymptomatic. Average age at surgery was 10.8 (+/-4.1) years; median follow-up was 14.5 (2 to 48) months. Postoperative percent-predicted exercise values were: peak heart rate 97 (+/-6), working capacity 91 (+/-15), maximal oxygen consumption 82 (+/-16). In those who had preoperative exercise testing (n = 11), resting and maximal heart rates decreased significantly without significant change in exercise performance. Average child quality of life was 85/100 (+/-13) and parent-proxy 88 (+/-11) compared with normal scores of 83 (+/-15) and 88 (+/-12), respectively.

CONCLUSION

There is mild chronotropic impairment in children and adolescents following anomalous coronary artery repair without a decline in exercise performance. This does not appear to impair their overall quality of life. Because long-term effects on heart rate, exercise performance, and quality of life are unknown, serial exercise tests should be included as routine care of these patients.

Sudden death due to congenital pericardial defect: an autopsy case

Pericardial defects are rare in childhood and outcome is usually benign. Patients may be asymptomatic, but chest pain, emboli, arrhythmia, and sudden death have been described in the literature. We report the case of a 12-year-old boy who suddenly died after mild exercise. A left-sided pericardial defect with a diameter of 8 cm was detected on medico-legal autopsy.

The Risk in Exercise Training

Although exercise training is unequivocally of benefit relative to the risk of cardiovascular disease, there is a definable risk of complications during exercise training. In younger individuals, the risk is almost exclusively related to the presence of congenital abnormalities, whereas in older (∼40 years) individuals, the risk is largely related to atherosclerotic disease. In both groups, the risk of the underlying pathology leading to clinical presentation is increased by higher intensity exercise. In older individuals, preexercise screening is of potential benefit but is not generally well done. Exercise prescription should favor lower intensity exercise during the early weeks of an exercise program. Subjective methods, which do not rely on the results of an exercise test, including the Rating of Perceived Exertion and the Talk Test, are to be recommended because preliminary exercise testing is performed inconsistently. There are inadequate data regarding the spontaneous exercise training intensity in both healthy individuals and patients.

Sudden cardiac death in young athletes: time for a Nordic approach in screening?

In 2005, the European Society of Cardiology published recommendations for cardiovascular screening in athletes. Discussion on whether screening is beneficial is ongoing. Recently, the first prospective results on effectiveness of screening in preventing sudden deaths were published from Italy. The results were supportive of screening, but did not provide conclusive evidence. Our suggestion for a Nordic approach on this issue is a directed cardiovascular examination initially involving elite athletes, because this is feasible with respect to the Nordic health care systems and the organization and logistics of elite competitive sports, but also because of the negative aspects of screening large populations. This directed cardiovascular examination would include personal and family history, clinical examination, and electrocardiography (ECG). Further examinations should thereafter be carried out in athletes with suggestive findings in the initial evaluation. The directed cardiovascular examination should be voluntary. It should be conducted at least once, with information on alarming symptoms (syncope, chest pain or dizziness during exercise) and heredity (sudden cardiac death or hereditary heart disease in near relatives) stressed to the athlete as indications for necessary check-ups in the future. The examination would also provide the athlete with an ECG recording, which is valuable as a reference at a later time.

Coronary artery anomalies — a short review

Coronary artery anomalies are rare but sometimes important findings in the evaluation of the coronary artery. The majority of the anomalies are of benign prognosis, but others can be associated with cardiac symptoms and syndromes (angina, dyspnea, syncope, congestive heart failure, myocardial infarction and sudden death). The potentially serious anomalies include: ectopic coronary origin from the pulmonary artery; ectopic coronary origin from the opposite aortic sinus; and large coronary fistulae. Appropriate diagnosis is critical for recognition and management. Treatment can be performed by surgical or percutaneous approach. However, management is conservative in the majority of them. Contemporary diagnosis and clinical management of these anomalies are briefly reviewed and discussed in this article.

Sudden cardiac death in athletes: the Lausanne Recommendations

OBJECTIVES

This study reports on sudden cardiac death (SCD) in sport in the literature and aims at achieving a generally acceptable preparticipation screening protocol (PPSP) endorsed by the consensus meeting of the International Olympic Committee (IOC).

BACKGROUND

The sudden death of athletes under 35 years engaged in competitive sports is a well-known occurrence; the incidence is higher in athletes (approximately 2/100,000 per year) than in non-athletes (2.5 : 1), and the cause is cardiovascular in over 90%.

METHODS

A systematic review of the literature identified causes of SCD, sex, age, underlying cardiac disease and the type of sport and PPSP in use. Methods necessary to detect pre-existing cardiac abnormalities are discussed to formulate a PPSP for the Medical Commission of the IOC.

RESULTS

SCD occurred in 1101 (1966-2004) reported cases in athletes under 35 years, 50% had congenital anatomical heart disease and cardiomyopathies and 10% had early-onset atherosclerotic heart disease. Forty percent occurred in athletes under 18 years, 33% under 16 years; the female/male ratio was 1/9. SCD was reported in almost all sports; most frequently involved were soccer (30%), basketball (25%) and running (15%). The PPSP were of varying quality and content. The IOC consensus meeting accepted the proposed Lausanne Recommendations based on this research and expert opinions (http://multimedia.olympic.org/pdf/en_report_886.pdf).

CONCLUSION

SCD occurs more frequently in young athletes, even those under the age of 18 years, than expected and is predominantly caused by pre-existing congenital cardiac abnormalities. Premature atherosclerotic disease forms another important cause in these young adults. A generally acceptable PPSP has been achieved by the IOC's acceptance of the Lausanne Recommendations.

CT of Coronary Artery Disease

The clinical relevance of coronary artery disease has considerably driven the recent development of radiologic tools for noninvasive cardiac imaging. Modern multidetector row computed tomographic (MDCT) systems combine high temporal and spatial resolution, electrocardiographic synchronization, and ease of use. In cardiac imaging, MDCT has not only replaced electron-beam CT, but also challenges competing methods such as magnetic resonance imaging, echocardiography, or even coronary catheterization. Noncontrast material-enhanced assessment of atherosclerotic plaques (CT calcium scoring) seems useful for the cardiac risk stratification in asymptomatic patients and monitoring of medical (statin) therapy. Contrast material-enhanced CT coronary angiography has become established as a valuable method for several clinical indications such as evaluation of coronary artery anomalies, bypass patency, or preoperative planning. Particularly, the high negative predictive value of a normal CT coronary angiogram allows reliable exclusion of coronary artery stenosis. Plaque characterization is another promising area of research in MDCT cardiac imaging. However, with current technology a reliable distinction between atheroma and fibroatheroma is impaired by restrictions in spatial resolution. Recent studies indicate that CT angiography may also be suited for other clinical applications such as triage of patients with acute coronary syndrome and inconclusive clinical presentation, patients with symptomatic chest pain, and intermediate risk profile or cardiac risk stratification in asymptomatic patients.