Preventing sudden death in young athletes

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Hypertrophy of  the cardiac interventricular septum.
Hypertrophy of the cardiac interventricular septum.

Identifying at-risk athletes

The AHA and ACC state that covering the 14 elements can be useful in identifying at-risk athletes; however, available data show that this method tends to be insensitive in identifying athletes at risk for SD for various reasons, the most important of which is the frequent lack of physical findings in ion channelopathies, WPW syndrome, and some of the less common structural cardiac diseases that can be responsible for SD. However, the technique can be more successful in identifying athletes with HCM. In fact, a systolic heart murmur (indicating left ventricular outflow obstruction) is identified in 25% of individuals with HCM while they are at rest, and in an additional 50% while they are a standing position or during the Valsalva maneuver. This finding is important to consider because HCM is the most common cause of SD. Additionally, most at-risk athletes have warning signs and symptoms of HCM. However, such symptoms must be reported accurately if they are to be taken into consideration. The frequent lack of disclosure of important symptoms, such as chest pain and syncopal episodes, can prevent the identification of risk factors. Finally, it can be challenging for the examiner to determine the importance of the history and physical examination findings. Differentiating between a functional and an organic heart murmur can be difficult, as can determining whether or not chest pain is a significant finding.1 Table 1 lists for examiners the characteristics  of pathologic murmurs and their associated conditions.

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Despite the readily apparent insensitivity of the history and physical examination, the AHA and ACC still do not think that mass screening with 12-lead ECG will improve the identification of at-risk athletes.1 The data regarding the efficacy of 12-lead ECG screening in reducing SD are too conflicting to support 12-lead ECG screening once the financial and logistical burden of a widespread screening program has been taken into consideration. Administering 12-lead ECG to all young athletes would cost $51 billion to $69 billion dollars a year.2 In addition, the results of 12-lead ECG may not be abnormal in the setting of dangerous cardiovascular abnormalities, and alterations on 12-lead ECG do not always indicate a pathologic process.1,2 Physiologic processes can often mimic pathologic processes on ECG, resulting in false-positive results, and false-negative results can be seen in more than 10% of patients who have HCM, with completely normal findings in a significant number of these individuals.1 In addition, the interpretation of ECG results varies according to the knowledge and skills of the interpreter, further increasing their lack of reliability.2 Finally, the AHA and ACC note that mass screening with 12-lead ECG does not meet the World Health Organization (WHO) criteria for screening because 12-lead ECG is not a “a precise, validated, and suitable screening test known to reliably distinguish the affected from the nonaffected.”1

For the reasons presented above, the AHA and ACC stand by their recommendation for use of the 14 elements to screen all athletes. Athletes who are thought to be at risk on the basis of the history and physical examination should then be referred for aggressive follow-up testing (including 12-lead ECG) with appropriate specialists.1,2 It is strongly felt that standardization of the questionnaire that examiners use for preparticipation evaluations is necessary to improve consistency among examiners. The recommendation remains that universal mass screening of all individuals 12 to 25 years of age, whether by history and physical examination or 12-lead ECG, is not necessary.1

Evaluating risk factors for sudden death remains difficult

Even with the AHA and ACC recommendations regarding the 14 elements, evaluating the risk factors for SD in young athletes remains difficult. The preliminary or screening examinations, including family history, personal history, physical examination, and even 12-lead ECG, are primary tools to prevent SD in young athletes. Although primary prevention tools have been the major focus of the AHA and ACC, false-negative and false-positive results continue to be a major issue limiting their effectiveness.5 Because a measurement of true risk has not been established to date and because events are often spontaneous, secondary prevention strategies must be implemented to achieve a significant reduction in overall mortality.3,5 Having AEDs available in high-risk areas, along with individuals trained in cardiopulmonary resuscitation (CPR) and emergency management, is necessary to respond effectively to unpredictable events. According to Piper and Stainsby, secondary prevention strategies have received less attention than primary prevention strategies, especially in high school sports; however, the recent changes in the CPR guidelines support the need for an increased focus on secondary prevention and the use of AEDs.5 

The AHA guidelines for CPR have shifted from airway, breathing, and chest compression (ABC) to chest compression, airway, and breathing (CAB) techniques for emergency cardiovascular care.5 With this recommendation that chest compression begin immediately, the availability of AEDs at high school sports events is paramount. The overall goal of the AHA is to reduce mortality rates by applying  CPR and defibrillation within 3 to 5 minutes.6 Practice guidelines for incorporating an emergency response, the availability of trained staff, and the distribution of AEDs have the potential to increase survival rates.7 Although the guidelines differ in their approaches to reduce the risk for SD, a holistic approach incorporating updated screening techniques as primary prevention and emergency management as secondary prevention can decrease overall mortality rates. 

Angelique B. Allemand, DNP, RN, ACNP-BC, FNP-C, CNS, is an associate professor of nursing at Nicholls State University, and Bridget Miller Guidry, DNP, FNP-C, WHNP-C, RN, is an associate professor of nursing at Nicholls State University in Thibodaux, Louisiana.

Reference

  1. Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology. Circulation. 2014;130:1303-1334.
  2. Jacob JA. Interassociation task force punts decision on universal ECG screenings for athletes. JAMA. 2016;316:19-21.
  3. Schmied C, Borjesson M. Sudden cardiac death in athletes. J Intern Med. 2014;275:93-103.
  4. Hauk L. Preparticipation screening for CVD in competitive athletes: recommendations from the AHA/ACC. Am Fam Physician. 2016;94:170.
  5. Piper S, Stainsby B. Addressing the risk factors and prevention of sudden cardiac death in young athletes: a case report.  J Can Chiropr Assoc. 2013;57:350-355.
  6. Higgins J, Ananaba I, Higgins C. Sudden cardiac death in young athletes: preparticipation screening for underlying cardiovascular abnormalities and approaches to prevention. Phys Sportsmed. 2013;41:81-93.
  7. Garritano N, Willmarth-Stec M. Student athletes, sudden cardiac death, and lifesaving legislation: a review of the literature. J Pediatr Health Care. 2015;29:233-242.
  8. Cornelius J. Disorders of cardiac function. In: Grossman SC, Porth CM, eds. Porth's Pathophysiology: Concepts of Altered Health States. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014:665-667.
  9. Crawley S. Diastolic murmurs. In: Walker HK, Hall WD, Hurst JW, eds. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston, MA: Butterworths; 1990. https://www.ncbi.nlm.nih.gov/books/NBK346/. Accessed July 8, 2017.

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