The time you won your town the race
We chaired you through the market-place;
Man and boy stood cheering by,
And home we brought you shoulder high.
To-day the road all runners come,
Shoulder-high we bring you home,
And set you at your threshold down,
Townsmen of a stiller town.”
―To An Athlete Dying Young
Alfred Edward Housman, 1895
Other Non-CV
(4%)
Heat Stroke
(3%)
Drugs
(2%)
Commotio Cordis
(6%)
Trauma
(16%)
Cardiovascular Diseases
(69%)
Sudden Death in Young Athletes
Normal heart (3%)
Other (3%)
Other congenital HD
Ion channelopathies
Aortic rupture (2%)
Sarcoidosis (1%)
Dilated C-M (2%)
AS (3%)
CAD (3%)
HCM
(36%)
Tunneled LAD (3%)
MV P
(4%)
)
)
%
(6
s
iti
d
r
ca
yo
M
Coronary artery
anomalies (17%)
VC
AR
(4%
Indeterminate LVH possible HCM (8%)
Tennis
Wrestling
Ice - Skating
Crew
Boxing
Volleyball
Ice - Hockey
Swimming
Soccer
Baseball
Football
Track and
Running
50
45
40
35
30
25
20
15
10
5
0
Basketball
Number of Athletes
Sudden Cardiac Death in Competitive Athletes
Sports
Diurnal Distribution of Sudden Death in Young Athletes
No. of Athletes
20
HCM
Non - HCM
15
10
5
0
1
2
3
4
5
6
7
8
9
11 13 15 17 19 21 23
10 12 14 16 18 20 22
Hours
120
U.S. Sudden Death in Young Competitive Athletes Registry, 1980-2006
(n=1,866)
Number of Athletes
100
CV
Blunt Trauma
All Other
80
60
40
20
20
06
20
04
20
02
20
00
19
98
19
96
19
94
19
90
19
92
19
88
19
86
19
82
19
84
19
80
0
Year
Highest 2005/2006 = 76 / y
120
U.S. Sudden Death in Young Competitive Athletes Registry, 1980-2006
(n=1,866)
CV
Blunt Trauma
All Other
80
60
40
20
Year
20
06
20
04
20
02
20
00
19
98
19
96
19
94
19
90
19
92
19
88
19
86
19
82
19
84
0
19
80
Number of Athletes
100
Last 6 years = avg. 66 / y
Diseases not reliably
detectable by
history / physical / ECG
= 30% (of ~ 75/y)
Therefore, ECG preparticipation
screening would identify = 50 athletes/y
Obstacles To Screening
Denominator
Numerator
Event Infrequency
Participation Rates For
Competitive Athletes in U.S.
Millions of Athletes
7
6
5
4
3
2
1
0
High School
ATHLETES OF
THE WORLD
College
Pro
SUDDEN DEATH
IN ATHLETES
HCM=35%
HCM=
0.2%
Frequency Estimates for
Sudden Cardiac Death In Athletes
Young (high school / college) :
~1 : 200,000
Older (runners, including
marathon)
~1 : 15,000 /
~1 : 50,000
:
Importance of Sudden
Cardiac Death in Athletes
• Commands our attention ― a
riveting issue
• Competitive athletes appear to
be the healthiest segment of
society
• Symbolic issue
• Media driven
Preparticipation Athletic Screening
USA
vs.
Italy
Criteria
USA
Italy
Basis
customary
practice
law
Design
history/P.E.
also,testing(ECG)
Population size
too large
small enough
Examiners
M.D. +
non-M.D.
accredited
Sports Med.
no precedent
civil / criminal
Legal
consequences
AHA Consensus Panel Recommendations for
Preparticipation Athletic Screening
Family History:
1. Premature sudden cardiac death
2. Heart disease in surviving relatives
Personal History:
3.
4.
5.
6.
7.
8.
Heart murmur
Systemic hypertension
Fatigue
Syncope/near-syncope
Excessive/ unexplained exertional dyspnea
Exertional chest pain
Physical examination:
9. Heart murmur (supine / standing)
10. Femoral arterial pulses
11. Stigmata of Marfan syndrome
12. Brachial blood pressure measurement (sitting)
ITALY
ARVC
Sudden Death in Young Athletes-Veneto
Other (2%)
Other congenital HD (1%)
Ion channelopathies (2%)
Normal heart (2%)
Aortic rupture (1%)
Sarcoidosis (1%)
Dilated C-M (1%)
AS (2%)
ARVC
(36%)
CAD
(20%)
(4
ard
itis
%
)
(5%
)
)
%
(3
HC
M
M
VP
My
oc
Tunneled LAD (2%)
Coronary artery
anomalies (13%)
Indeterminate LVH possible HCM (5%)
USA
HCM
Sudden Death in
Young Athletes
Normal heart (3%)
Other (3%)
Other congenital HD
Ion channelopathies
Aortic rupture (2%)
Sarcoidosis (1%)
Dilated C-M (2%)
AS (3%)
CAD (3%)
HCM
(36%)
Tunneled LAD (3%)
MV P
(4%)
)
)
%
(6
s
iti
d
r
ca
yo
M
Coronary artery
anomalies (17%)
VC
AR
(4%
Indeterminate LVH possible HCM (8%)
Center for Sports Medicine
Padua, Italy (1979-96)
33,735
(0.07%)
3
Family History
22
Athletes
screened
HCM By Echo
5
2
PVC
Murmur
16
Abnormal ECG
Corrado D et al. JAMA 2006
U.S. (Minnesota)
Italy (Veneto)
Comparison of Cardiovascular Disease Mortality in Young
U.S. and Italian Competitive Athletes
Veneto
Population (million)
Race (white)
Size (km2)
Years screening
Total years
Total person-y
Sudden CV deaths
Minnesota
4.38
4.66
~90%
90%
26,000
206,000
1979-2004
1985-2007
26
23
2.93 M
2.07 M
55
22
23 y
17 y
Deaths 1993-2004
12
11
Deaths 2001-2004
2
4
Age at death (mean)
Comparison of Cardiovascular Disease Mortality in Young
U.S. (Minnesota) & Italian (Veneto) Competitive Athletes
p=0.02
Athlete Deaths/100,000 Person-Y
4.5
4
3.5
3
2.5
Veneto
2
1.5
1
p=0.38
0.5
Minnesota
0
0
-8
79
2
-8
81
4
-8
83
6
-8
85
8
-8
87
0
-9
89
2
-9
91
4
-9
93
6
-9
95
8
-9
97
0
-0
99
2
-0
01
4
-0
03
6
-0
05
Years
Obstacles to the Italian
Screening Initiative in the U.S.
•
•
•
•
•
•
Too many athletes; but,why not study all young people?
Very uncommon events
Too many false positives; also false negatives
Cost / efficacy considerations
Too many lawyers: liability considerations
Would require mandatory system, based in
law, in which physicians would be deciders
and enforcers
• No one to perform examinations / interpret ECGs
p < 0.001
20
18
White
16
Non-White
% Of Each Group
14
12
p = 0.001
10
8
6
4
p = 0.004
2
0
o
Pr
M fin
HC /De
e
bl
ba
ite
ry
na s
ro alie
Co o m
An
yo
M
rd
ca
iti
s
D
CA
ry
na
ro ing
Co ridg
B
V
AR
C
h
n
Io pat
lo
ne
ies
VP
M
rtic is
Ao nos
e
St
an
Ch
Cardiovascular Cause of Death
Bethesda Conference # 36
Classification
Sports (#8)
Consensus Panels
#2
#3
Congenital Valvular
#1
#4
#5
#6
HCM
Other C-M
MVP
Myocarditis
HTN
CAD
Screening / Dx
#9
Drugs
#10
AED
#7
Arrhythmias
#11
Commotio
#12
Legal
Bethesda Conference # 36
Recommendations
Athletes with the unequivocal diagnosis
of hypertrophic cardiomyopathy should not
participate in most competitive sports, with
the possible exception of those of low
intensity. This recommendation includes
those athletes with or without symptoms
and with or without left ventricular outflow
obstruction.
Knapp v. Northwestern
School
(university)
Team physician
consultants
Expert consensus
recommendations
(e.g. Bethesda Conference #36)
Diseases not reliably
detectable by
history / physical / ECG
= 30% (of ~ 75/y)
Therefore, ECG preparticipation
screening would identify = 50 athletes/y
Corrado D et al. JAMA 2006
Comparison of Cardiovascular Disease Mortality in Young
U.S. (Minnesota) & Italian (Veneto) Competitive Athletes
p=0.02
Athlete Deaths/100,000 Person-Y
4.5
4
3.5
3
2.5
Veneto (0.87/100,000)
2
1.5
1
p=0.38
0.5
Minnesota (0.93/100,000)
0
0
-8
79
2
-8
81
4
-8
83
6
-8
85
8
-8
87
0
-9
89
2
-9
91
4
-9
93
Years
6
-9
95
8
-9
97
0
-0
99
2
-0
01
4
-0
03
6
-0
05
Sudden Death In Young Athletes
Other Non-CV
(4%)
Heat Stroke
(3%)
Drugs
(2%)
Commotio Cordis
(6%)
Trauma
(16%)
Cardiovascular Diseases
(69%)
U.S. Sudden Death in Young Competitive Athletes Registry, l980-2006
(n=1,866)
120
CV
Blunt Trauma
All Other
Number of Athletes
100
80
60
40
20
20
06
20
04
20
02
20
00
19
98
19
96
19
94
19
90
19
92
19
88
19
86
19
82
19
84
19
80
0
Year
ADEQUACY OF SCREENING FORMS FOR
DETECTION OF C-V DISEASE IN U.S.
COLLEGES AND UNIVERSITIES
% of NCAA Schools
18%
26%
16%
14%
12%
10%
24%
8%
6%
4%
2%
0%
0 1 2 3 4 5 6 7 8 9 10 11 12
No. of AHA Recommendations Achieved
Sports Screening Process in U.S. High School Athletes
% of 43 States
25
40%
20
15
28%
10
5
0
1
2
3
4
5
6
7
8
9
10 11 12 13
No. of AHA Recommendations Achieved
35
30
25
20
15
10
5
0
1997
Items: 6.7 to 10.1
↑ 66%
2005
0
1
2
3
4
5
6
7
8
9
10 11 12
No. Recommended AHA Screening Items
45
100
% OF 45 STATES
90
80
70
60
20
50
20
40
9
30
20
2
10
0
M.D./ D.O.
R.N.
P.A.
Chiropractor Others
DESIGNATED EXAMINERS
Comparison of Approved Examiners for
Preparticipation Screening, 1997 vs. 2005
120
% of States
% of States
Comparison of State History and Physical
Examination Preparticipation Screening Forms,
1997 vs. 2005
1997
2005
100
80
60
40
20
0
M D/DO
Nurse
Practitioner
Physician
Assistant
Examiners
Chiropractor Naturopathic
Clinicians
HCM and Race
AfricanAmerican (5%)
White
(45%)
AfricanAmerican (55%)
Competitive Athletes:
HCM-related
Sudden Death (n=102)
White
(92%)
Hospital – Based
HCM Patients
(n=1,986)
Sudden Death In Young Athletes
Other Non-CV
(4%)
Heat Stroke
(3%)
Drugs
(2%)
Commotio Cordis
(6%)
Trauma
(16%)
Cardiovascular Diseases
(69%)
Highest 2005/2006 = 76 / y
U.S. Sudden Death in Young Competitive Athletes Registry, 1980-2006
(n=1,866)
120
CV
Blunt Trauma
All Other
80
60
40
20
20
06
20
04
20
02
20
00
19
98
19
96
19
94
19
90
19
92
19
88
19
86
19
82
19
84
0
19
80
Number of Athletes
100
Year
Last 6 years = avg. 66 / y
Diseases not reliably
detectable by
history / physical / ECG
= 30% (of ~ 75/y)
Therefore, ECG preparticipation
screening would identify = 50 athletes/y
Preparticipation Athletic Screening
USA
vs.
Italy
Criteria
USA
Italy
Basis
customary
practice
law
Design
history/P.E.
also,testing(ECG)
Population size
too large
small enough
Examiners
M.D. +
non-M.D.
accredited
Sports Med.
no precedent
civil / criminal
Legal
consequences
ITALY
ARVC
Corrado D et al. JAMA 2006
U.S. (Minnesota)
Italy (Veneto)
Comparison of Cardiovascular Disease Mortality in Young
U.S. (Minnesota) & Italian (Veneto) Competitive Athletes
p=0.02
Athlete Deaths/100,000 Person-Y
4.5
4
3.5
3
2.5
Veneto (0.87/100,000)
2
1.5
1
p=0.38
0.5
Minnesota (0.93/100,000)
0
0
-8
79
2
-8
81
4
-8
83
6
-8
85
8
-8
87
0
-9
89
2
-9
91
4
-9
93
6
-9
95
8
-9
97
0
-0
99
2
-0
01
4
-0
03
6
-0
05
Years
Pediatric cardiologists in the U.S.
= 1,521
# of athletes to be screened
= 12 million
# of exams/ECGs to be performed
= 7,890 / year
= 658 / month
= 150 / week
U.S. Sudden Death in Young Competitive Athletes Registry, 1980-2006
(n=1,866)
120
CV
Blunt Trauma
All Other
80
60
40
20
Year
Commotio Cordis:
Sudden Death From Blunt,
Non-Penetrating and
Relatively Innocent
Chest Impact
20
06
20
04
20
02
20
00
19
98
19
96
19
94
19
90
19
92
19
88
19
86
19
82
19
84
0
19
80
Number of Athletes
100
Age at Which 154 Commotio Cordis
Events Occurred
No. of Victims
30
Survivors
Non-survivors
20
10
0
1-3
4-6 7-9
10-12 13-15 16-18 19-21 22-24 >25
Age in Years
Blunt Chest Blow and Cardiac Arrest : Sports
60
No. of Victims
50
40
Recreational sports
(n=28)
Competitive sports
(n=78)
30
20
10
0
Baseball Softball Hockey Football Soccer Lacrosse Karate Cricket RugbyBasketball Boxing
Commotio Cordis Events Unassociated
With Sports
Plastic (hollow) toy bat
Plastic sledding saucer
Playful (“shadow”)boxing
Hiccups remedy (by friend)
Head of pet dog (Collie)
Scuffle
Parent-to-child disipline
Gang rituals
Snowball
Tennis ball (coin filled)
Swing carriage
1
1
6
1
1
2
3
2
1
1
1
Commotio Cordis : Protection
Everyday
Activities
Education
(never strike
the chest)
AED
Sports
Chest protectors
& Safety-balls
Commotio Cordis : Protection
Everyday
Activities
Education
(never strike
the chest)
AED
Sports
Chest protectors
& Safety-balls
Robert Gordon
•Father age 35
•Inflicted 2 modest chest blows during
tutorial session
•11-year old son collapsed immediately
•Autopsy diagnosis : commotio cordis
•Father charged with first degree murder
•Admitted to psychiatric facility
•Plea bargained involuntary manslaughter
•Judge imposed 6-18 year sentence
Commotio Cordis : Determinants
•Location
•Timing
•Force
•Compliant chest wall
Commotio Cordis : Determinants
•Location
•Timing
•Force
•Compliant chest wall
Chest Impact Sites
Implement of Chest Impact (n=22)
baseball/softball
ice hockey puck
lacrosse ball
knee
None
Warrior Side
Warrior Center
STX
GBP Side
GBP Center
DeBeer Icon
Brine Pro
Incidence of Ventricular Fibrillation
Lacrosse Chest Wall Protection
0.6
0.5
0.4
0.3
0.2
0.1
0
Direct Comparison of Death Rates in
Veneto & Minnesota, 1993-2004
Veneto
Minnesota
12
11
1,379,000
1,179,690
0.87
0.93
No. deaths
Person-y
Death rate/person-y
p = 0.87
syncope

• HISTORY
• PHYSICAL
EXAM
family history of SD
heart murmur
ECG
ECHO
Nonobstructive HCM
Can “Athletic Field Deaths”
Be Prevented?
35 y – Brother SD
(age 39)
36 y – ICD
5y
9y
40 y – Generator
replaced
41 y – Appropriate
shock #1
50 y – Appropriate
shock #2
52 y – Present
Preparticipation Screening:
Is It Worth It?
• Screening is already customary practice for
most high school and college athletes
• Improved screening on national basis would
mean many more new diagnoses
• 5% of new HCM diagnoses are via
screening
Wilson Youth Baseball
Catchers A3225 Chest
Protector
Warrior CP Millennium Pro Gear
Lacrosse Goalie Chest Pad
Obstacles to the Italian
Screening Initiative in the U.S.
•
•
•
•
•
•
•
Too many athletes
Very uncommon events
No one to perform examination / ECGs
No one to interpret tests
Too many false positives
Cost / efficacy considerations and BUSH
Too many lawyers: liability considerations
Sudden Death in Young
Athletes in U.S.
One athlete dies q 3 days …
One athlete w/ HCM dies q 2 wks
“Gray Zone”
LV Wall Thickness (13-15mm)
Athlete’s
Heart
HCM
Unusual Patterns of LVH
LV Cavity < 45mm
LV Cavity > 55mm
LA Enlargement
Bizarre ECG Patterns
Abnormal LV Filling
Female Gender
Thickness w/ Decondition
Familial HCM/mutation
>50ml / kg / min max V02
ICD - HCM: Appropriate Shocks: 2007
505
102 Appropriate
Shocks (20%)
Follow-up =
3.7 years
5.4% / yr
ICD Discharge
Rate
11%
4%
2º prevention
1º prevention
Consequences of Medical Evaluations in
Young Competitive Athletes Who Died Suddenly
134
4
Preparticipation
evaluation
No
evaluation
130
Standard
screening
115
Cardiovascular
evaluation
4
Suspicion of
C-V disease
1
Correct
diagnosis
7
Disqualified
2
0
15
Survival Data in Commotio Cordis and Relation
to Promptness of CPR by Bystanders
149
15 No
78
(<3 min.)
16
40
Coma
Died
Died
65
(4%)
Commot
io Cordi
s
416
(22%)
uma
t Tra
Blun jury
In
22 Survived
(28%)
1
55
(2%)
Unsuccessful
Died
C
olved
Unres
ases
154
(8%)
1866
Mis
cell
ane
ous
Drug
s
(10%)
Pu
lm
O
th
205
41
CA
M
35
(2%)
1049
(56%)
s
iti
rd
ca
yo
Exertional
844
359
57
*
le
s*
ib
ie
al
ss ‡
Po CM
om
H
An
*
er
M
HC
119
34
(2%)
on
ary
67
(4%)
Nonexertional
251
46
(2%)
ke
Heat Stro
182
Cardiovascular
Considered
CV event
(no precise
diagnosis)
(>3 min.)
Cardiac
Rhythm
Restored
38
Unsuccessful
56
CPR
690
30
VC
AR
25
l
n
Io nne
a
Ch
24
M
VP
Confirmed
CV event
23
D
LA dge
i
Br
23
19
D
CA
c
rti re
Ao ptu
Ru
17
14
AS
d
te
la
Di CM
11
36
PW
W
O
†
er
th
Pediatric cardiologists in the U.S.
= 1,521
# of athletes to be screened
= 12 million
# of exams/ECGs to be performed
= 7,890 / year
= 658 / month
= 150 / week
The time you won your town the race
We chaired you through the market-place;
Man and boy stood cheering by,
And home we brought you shoulder high.
To-day the road all runners come,
Shoulder-high we bring you home,
And set you at your threshold down,
Townsmen of a stiller town.”
―To An Athlete Dying Young
Alfred Edward Housman, 1895
Drugs
(2%)
Heat Stroke
(3%)
Other Non-CV
(4%)
Commotio Cordis
(6%)
Trauma
(16%)
Cardiovascular Diseases
(69%)
Sudden Death in Young Athletes
ss
Po
HC
(36%)
ib
le
H
C
%)
8%
er †
(5
*(
M
O th
)
WPW (2%
)
Dilated CM (2%)
120
itis (6%)
Myocard
4%
)
)
(4
%
)
)
%
(3
Ion
M
VP
D
LA
ge
id
Br
Ch
an
D
CA
)
(3%
ARVC
(4%
re
uptu
ic R
Aort
)
%
3
(
nel
(
AS (3%)
Coronary
Anomalies
(17%)
Maron, BJ et. al
Circulation 2009
119:1085-1092
U.S. Sudden Death in Young Competitive Athletes Registry, 1980-2006
(n=1,866)
CV
Blunt Trauma
All Other
80
60
40
20
Year
20
06
20
04
20
02
20
00
19
98
19
96
19
94
19
92
19
90
19
88
19
86
19
82
19
84
0
19
80
Number of Athletes
100
Highest 2005/2006 = 76 / y
Diseases not reliably
detectable by
history / physical / ECG
= 30% (of ~ 75/y)
Therefore, ECG preparticipation
screening would identify = 50 athletes/y
Obstacles To Screening
Denominator
Numerator
Event Infrequency
Participation Rates For
Competitive Athletes in U.S.
Millions of Athletes
7
6
5
4
3
2
1
0
High School
ATHLETES OF
THE WORLD
College
Pro
SUDDEN DEATH
IN ATHLETES
HC=35%
HC=
0.2%
Frequency Estimates for
Sudden Cardiac Death In Athletes
Young (high school / college) :
~1 : 200,000
Older (runners, including
marathon)
~1 : 15,000 /
~1 : 50,000
:
Importance of Sudden
Cardiac Death in Athletes
• Commands our attention ― a
riveting issue
• Competitive athletes appear to
be the healthiest segment of
society
• Symbolic issue
• Media driven
Preparticipation Athletic Screening
USA
vs.
Italy
Criteria
USA
Italy
Basis
customary
practice
law
Design
history/P.E.
also,testing(ECG)
Population size
too large
small enough
Examiners
M.D. +
non-M.D.
accredited
Sports Med.
no precedent
civil / criminal
Legal
consequences
Corrado D et al. JAMA 2006
U.S. (Minnesota)
Italy (Veneto)
Athlete Deaths/100,000 Person-Y
Comparison of Cardiovascular Disease Mortality in Young
U.S. (Minnesota) & Italian (Veneto) Competitive Athletes
p=0.02
4.5
4
3.5
3
2.5
Veneto (0.87/100,000)
2
1.5
1
p=0.38
0.5
Minnesota (0.93/100,000)
0
0
-8
79
2
-8
81
4
-8
83
6
-8
85
8
-8
87
0
-9
89
2
-9
91
4
-9
93
Years
6
-9
95
8
-9
97
0
-0
99
2
-0
01
4
-0
03
6
-0
05
Obstacles to the National Mandatory
Italian Screening Initiative in the U.S.
U.S
• Too many athletes; could screening really be limited to
athletes?
• Very uncommon events
• Too many false positives; also false negatives
• Cost / efficacy considerations
• Infringement on individual prerogative
• Too many lawyers: liability considerations
• Would require mandatory system, based in
law, in which physicians would be deciders
and enforcers
• No one to perform examinations / interpret ECGs
Bethesda Conference # 36
Recommendations
Athletes with the unequivocal diagnosis
of hypertrophic cardiomyopathy should not
participate in most competitive sports, with
the possible exception of those of low
intensity. This recommendation includes
those athletes with or without symptoms
and with or without left ventricular outflow
obstruction.
Commotio Cordis:
Sudden Death From Blunt,
Non-Penetrating and
Relatively Innocent
Chest Impact
Age at Which Commotio Cordis
Events Occurred
No. of Victims
30
Survivors
Non-survivors
20
10
0
1-3
4-6 7-9
10-12 13-15 16-18 19-21 22-24 >25
Age in Years
Blunt Chest Blow and Cardiac Arrest : Sports
60
No. of Victims
50
40
Recreational sports
(n=28)
Competitive sports
(n=78)
30
20
10
0
Baseball Softball Hockey Football Soccer Lacrosse Karate Cricket RugbyBasketball Boxing
Commotio Cordis Events Unassociated
With Sports
Plastic (hollow) toy bat
Plastic sledding saucer
Playful (“shadow”)boxing
Hiccups remedy (by friend)
Head of pet dog (Collie)
Scuffle
Parent-to-child disipline
Gang rituals
Snowball
Tennis ball (coin filled)
Swing carriage
1
1
6
1
1
2
3
2
1
1
1
Commotio Cordis : Determinants
•Location
•Timing
•Force
•Compliant chest wall
Chest Impact Sites
Implement of Chest Impact (n=22)
baseball/softball
ice hockey puck
lacrosse ball
knee
Commotio Cordis : Determinants
•Location
•Timing
•Force
•Compliant chest wall
Commotio Cordis : Protection
Everyday
Activities
Education
(never strike
the chest)
AED
Sports
Chest protectors
& Safety-balls
Commotio Cordis : Protection
Everyday
Activities
Education
(never strike
the chest)
AED
Sports
Chest protectors
& Safety-balls
Robert Gordon
•Father age 35
•Inflicted 2 modest chest blows during
tutorial session
•11-year old son collapsed immediately
•Autopsy diagnosis : commotio cordis
•Father charged with first degree murder
•Admitted to psychiatric facility
•Plea bargained involuntary manslaughter
•Judge imposed 6-18 year sentence
ITALY
ARVC
Diurnal Distribution of Sudden Death in Young Athletes
No. of Athletes
20
HC
Non - HC
15
10
5
0
1
2
3
4
5
6
7
8
9
11 13 15 17 19 21 23
10 12 14 16 18 20 22
Hours
Pediatric cardiologists in the U.S.
= 1,521
# of athletes to be screened
= 12 million
# of exams/ECGs to be performed
= 7,890 / year
= 658 / month
= 150 / week
% of States
Comparison of State History and Physical
Examination Preparticipation Screening Forms,
1997 vs. 2005
35
30
25
20
15
10
5
0
1997
Items: 6.7 to 10.1
↑ 66%
2005
0
1
2
3
4
5
6
7
8
9
10 11 12
No. Recommended AHA Screening Items
Knapp v. Northwestern
School
(university)
Team physician
Consultants
Expert consensus
recommendations
(e.g. Bethesda Conference #36)
AHA Consensus Panel Recommendations for
Preparticipation Athletic Screening
Family History:
1. Premature sudden cardiac death
2. Heart disease in surviving relatives
Personal History:
3.
4.
5.
6.
7.
8.
Heart murmur
Systemic hypertension
Fatigue
Syncope/near-syncope
Excessive/ unexplained exertional dyspnea
Exertional chest pain
Physical examination:
9. Heart murmur (supine / standing)
10. Femoral arterial pulses
11. Stigmata of Marfan syndrome
12. Brachial blood pressure measurement (sitting)
HC and Race
AfricanAmerican (5%)
White
(45%)
AfricanAmerican (55%)
Competitive Athletes:
HC-related
Sudden Death (n=102)
White
(92%)
Hospital – Based
HC Patients
(n=1,986)
Football
Basketball
50
45
40
35
30
25
20
15
10
5
0
Wrestling
Tennis
Ice - Skating
Crew
Boxing
Ice - Hockey
Volleyball
Swimming
Baseball
Soccer
Track and
Running
Number of Athletes
Sudden Cardiac Death in Competitive Athletes
Sports