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Shlobin NA, Thijs RD, Benditt DG, Zeppenfeld K, Sander JW. Sudden death in epilepsy: the overlap between cardiac and neurological factors. Brain Commun 2024; 6:fcae309. [PMID: 39355001 PMCID: PMC11443455 DOI: 10.1093/braincomms/fcae309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/21/2024] [Accepted: 09/25/2024] [Indexed: 10/03/2024] Open
Abstract
People with epilepsy are at risk of premature death, of which sudden unexpected death in epilepsy (SUDEP), sudden cardiac death (SCD) and sudden arrhythmic death syndrome (SADS) are the primary, partly overlapping, clinical scenarios. We discuss the epidemiologies, risk factors and pathophysiological mechanisms for these sudden death events. We reviewed the existing evidence on sudden death in epilepsy. Classification of sudden death depends on the presence of autopsy and expertise of the clinician determining aetiology. The definitions of SUDEP, SCD and SADS lead to substantial openings for overlap. Seizure-induced arrhythmias constitute a minority of SUDEP cases. Comorbid cardiovascular conditions are the primary determinants of increased SCD risk in chronic epilepsy. Genetic mutations overlap between the states, yet whether these are causative, associated or incidentally present is often unclear. Risk stratification for sudden death in people with epilepsy requires a multidisciplinary approach, including a review of clinical history, toxicological analysis and complete autopsy with histologic and, preferably, genetic examination. We recommend pursuing genetic testing of relatives of people with epilepsy who died suddenly, mainly if a post-mortem genetic test contained a Class IV/V (pathogenic/likely pathogenic) gene variant. Further research may allow more precise differentiation of SUDEP, SCD and SADS and the development of algorithms for risk stratification and preventative strategies.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW Heemstede, The Netherlands
- Department of Neurology and Clinical Neurophysiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW Heemstede, The Netherlands
- Department of Neurology and Clinical Neurophysiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- UCL Queen Square Institute of Neurology, NIHR University College London Hospitals Biomedical Research Centre, London WC1N 3BG, UK
| | - David G Benditt
- Cardiac Arrhythmia and Syncope Center, University of Minnesota, Minneapolis, MN 55455, USA
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW Heemstede, The Netherlands
- UCL Queen Square Institute of Neurology, NIHR University College London Hospitals Biomedical Research Centre, London WC1N 3BG, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, UK
- Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China
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2
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Thuraiaiyah J, Philbert BT, Jensen AS, Xing LY, Joergensen TH, Lim CW, Jakobsen FN, Bække PS, Schmidt MR, Idorn L, Holdgaard Smerup M, Johansen JB, Riahi S, Nielsen JC, De Backer O, Sondergaard L, Jons C. Implantable cardioverter defibrillator therapy in paediatric patients for primary vs. secondary prevention. Europace 2024; 26:euae245. [PMID: 39345160 PMCID: PMC11440178 DOI: 10.1093/europace/euae245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/20/2024] [Indexed: 10/01/2024] Open
Abstract
AIMS The decisions about placing an ICD in a child are more difficult than in an adult due to longer expected lifespan and the complication risk. Young patients gain the most years from ICDs, despite higher risk of device-related complications. The secondary prevention ICD indication is clear, and device is implanted regardless of potential complications. For primary prevention, risk of sudden cardiac death and complications need to be evaluated. We aimed to compare outcomes for primary and secondary prevention ICDs. METHODS AND RESULTS Retrospective nationwide cohort study including paediatric patients identified from the Danish ICD registry with ICD implanted at an age ≤ 15 from 1982-21. Demographics, complications (composite of device-related infections or lead-failure requiring re-operation, mortality because of arrhythmia, or unknown cause), and mortality were retrieved from medical charts. Endpoint was appropriate therapy (shock or anti-tachycardia pacing for ventricular tachycardia or fibrillation). Of 72 receiving an ICD, the majority had channelopathies (n = 34) or structural heart diseases (n = 28). ICDs were implanted in 23 patients for primary prevention and 49 for secondary prevention, at median ages of 13.8 and 11.6 years (P-value 0.01), respectively. Median follow-up was 9.0 (interquartile ranges: 4.7-13.5) years. The 10-year cumulative incidence of first appropriate therapy was 70%, with complication and inappropriate therapy rates at 41% and 15%, respectively. No difference was observed between prevention groups for all outcomes. Six patients died during follow-up. CONCLUSION In children, two-thirds are secondary prevention ICDs. Children have higher appropriate therapy and complication rates than adults, while the inappropriate therapy rate was low.
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MESH Headings
- Humans
- Defibrillators, Implantable
- Male
- Child
- Retrospective Studies
- Secondary Prevention/methods
- Adolescent
- Female
- Primary Prevention
- Death, Sudden, Cardiac/prevention & control
- Death, Sudden, Cardiac/epidemiology
- Denmark/epidemiology
- Registries
- Treatment Outcome
- Electric Countershock/instrumentation
- Electric Countershock/adverse effects
- Electric Countershock/mortality
- Risk Factors
- Child, Preschool
- Tachycardia, Ventricular/therapy
- Tachycardia, Ventricular/prevention & control
- Tachycardia, Ventricular/mortality
- Time Factors
- Age Factors
- Arrhythmias, Cardiac/therapy
- Arrhythmias, Cardiac/mortality
- Ventricular Fibrillation/prevention & control
- Ventricular Fibrillation/therapy
- Ventricular Fibrillation/mortality
- Risk Assessment
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Affiliation(s)
- Jani Thuraiaiyah
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Berit Thornvig Philbert
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Annette Schophuus Jensen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Lucas Yixi Xing
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Troels Hoejsgaard Joergensen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Chee Woon Lim
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | | | - Pernille Steen Bække
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Michael Rahbek Schmidt
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Lars Idorn
- Department of Paediatrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Morten Holdgaard Smerup
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ole De Backer
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | | | - Christian Jons
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
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Oliveira C, Pinho A, Santos L, Pinto RA, Oliveira S, Moreira H, Rocha M, Palma P, Pestana G, Madeira M, Lebreiro A, Adão L. Long-term prognosis of idiopathic ventricular fibrillation: An eighteen-year experience from a tertiary center. Rev Port Cardiol 2024; 43:331-336. [PMID: 38615880 DOI: 10.1016/j.repc.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/22/2024] [Accepted: 04/02/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION AND OBJECTIVES Idiopathic ventricular fibrillation (IVF) is diagnosed in patients who survive sudden cardiac arrest (SCA), preferably with documented ventricular fibrillation (VF), without any identifiable structural or electrical abnormality. Current evidence provides limited guidance on the diagnosis and follow-up of these patients. Our aim was to assess the clinical outcomes of survivors of an aborted SCA attributed to IVF. METHODS We retrospectively collected clinical data from all patients who survived SCA and implanted a cardiac defibrillator (ICD) between 2005 and 2023. RESULTS A total of 38 patients, 36.8% female, with a mean age of 44±14 years old were included. Median follow-up time was 8.7 years (interquartile range (IQR) 4.7-14.7 years). All patients underwent a comprehensive diagnostic evaluation that excluded structural and coronary disease. During follow-up, underlying diagnoses were established in 34.2% of the whole cohort. Genetic testing, performed in 37.2%, revealed underlying diagnoses in 57.1% of those tested, compared to only 26.3% of patients who did not undergo genetic testing [p=0.035, OR=5.1 (95% confidence interval (CI) 1.2-21.5)]. Mortality was 10.5% (due to non-arrhythmic causes) and 36.8% patients received appropriate therapies with a median time to first ICD therapy of 39 [5.4-47.3] months. CONCLUSION(S) Etiological diagnosis and recurrence prediction in patients with IVF remains challenging, even with extensive diagnostic evaluation and long-term follow-up. In our study, genetic testing enhanced diagnostic yield. Consistent with previous findings, our cohort experienced a notable arrhythmic recurrence, with no cardiac deaths, underlining the pivotal role of ICD implantation in these patients.
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Affiliation(s)
- Cátia Oliveira
- Department of Cardiology, Local Health Unit of São João, E.P.E., Porto, Portugal.
| | - Ana Pinho
- Department of Cardiology, Local Health Unit of São João, E.P.E., Porto, Portugal
| | - Luís Santos
- Department of Cardiology, Local Health Unit of São João, E.P.E., Porto, Portugal
| | - Ricardo Alves Pinto
- Department of Cardiology, Local Health Unit of São João, E.P.E., Porto, Portugal
| | - Sílvia Oliveira
- Faculty of Medicine of University of Oporto, Porto, Portugal
| | - Helena Moreira
- Department of Cardiology, Local Health Unit of São João, E.P.E., Porto, Portugal
| | - Miguel Rocha
- Department of Cardiology, Local Health Unit of São João, E.P.E., Porto, Portugal
| | - Pedro Palma
- Department of Cardiology, Local Health Unit of São João, E.P.E., Porto, Portugal
| | - Gonçalo Pestana
- Department of Cardiology, Local Health Unit of São João, E.P.E., Porto, Portugal
| | - Marta Madeira
- Department of Cardiology, Local Health Unit of São João, E.P.E., Porto, Portugal
| | - Ana Lebreiro
- Department of Cardiology, Local Health Unit of São João, E.P.E., Porto, Portugal
| | - Luís Adão
- Department of Cardiology, Local Health Unit of São João, E.P.E., Porto, Portugal
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Zylyftari N, Lee CJY, Gnesin F, Møller AL, Mills EHA, Møller SG, Jensen B, Ringgren KB, Kragholm K, Christensen HC, Blomberg SNF, Tan HL, Folke F, Køber L, Gislason G, Torp-Pedersen C. Registered prodromal symptoms of out-of-hospital cardiac arrest among patients calling the medical helpline services. Int J Cardiol 2023; 374:42-50. [PMID: 36496039 DOI: 10.1016/j.ijcard.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/12/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Background Early identification of warning symptoms among out-of-hospital cardiac arrest (OHCA) patients remains challenging. Thus, we examined the registered prodromal symptoms of patients who called medical helpline services within 30-days before OHCA. Methods Patients unwitnessed by emergency medical services (EMS) aged ≥18 years during their OHCA were identified from the Danish Cardiac Arrest Registry (2014-2018) and linked to phone records from the 24-h emergency helpline (1-1-2) and out-of-hours medical helpline (1813-Medical Helpline) in Copenhagen before the arrest. The registered symptoms were categorized into chest pain; breathing problems; central nervous system (CNS)-related/unconsciousness; abdominal/back/urinary; psychiatric/addiction; infection/fever; trauma/exposure; and unspecified (diverse from the beforementioned categories). Analyses were divided by the time-period of calls (0-7 days/8-30 days preceding OHCA) and call type (1-1-2/1813-Medical Helpline). Results Of all OHCA patients, 18% (974/5442) called helpline services (males 56%, median age 76 years[Q1-Q3:65-84]). Among these, 816 had 1145 calls with registered symptoms. The most common symptom categories (except for unspecified, 33%) were breathing problems (17%), trauma/exposure (17%), CNS/unconsciousness (15%), abdominal/back/urinary (12%), and chest pain (9%). Most patients (61%) called 1813-Medical Helpline, especially for abdominal/back/urinary (17%). Patients calling 1-1-2 had breathing problems (24%) and CNS/unconsciousness (23%). Nearly half of the patients called within 7 days before their OHCA, and CNS/unconsciousness (19%) was the most registered. The unspecified category remained the most common during both time periods (32%;33%) and call type (24%;39%). Conclusions Among patients who called medical helplines services up to 30-days before their OHCA, besides symptoms being highly varied (unspecified (33%)), breathing problems (17%) were the most registered symptom-specific category.
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Affiliation(s)
- Nertila Zylyftari
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark.
| | - Christina Ji-Young Lee
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark; Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Filip Gnesin
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | | | - Elisabeth Helen Anna Mills
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Sidsel G Møller
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Denmark; Copenhagen Emergency Medical Services, Denmark
| | - Britta Jensen
- Public Health and Epidemiology, Department of Health Science and Technology, Aalborg University, Denmark
| | - Kristian Bundgaard Ringgren
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Department of Anesthesia and Intensive Care, North Denmark Regional Hospital, Denmark
| | - Kristian Kragholm
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | - Hanno L Tan
- Department of Clinical and Experimental Cardiology, Amsterdam University Medical Center AMC, University of Amsterdam, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Fredrik Folke
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark; Copenhagen Emergency Medical Services, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Lars Køber
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
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5
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 890] [Impact Index Per Article: 445.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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6
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Butters A, Arnott C, Sweeting J, Winkel BG, Semsarian C, Ingles J. Sex Disparities in Sudden Cardiac Death. Circ Arrhythm Electrophysiol 2021; 14:e009834. [PMID: 34397259 DOI: 10.1161/circep.121.009834] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The overall incidence of sudden cardiac death is considerably lower among women than men, reflecting significant and often under-recognized sex differences. Women are older at time of sudden cardiac death, less likely to have a prior cardiac diagnosis, and less likely to have coronary artery disease identified on postmortem examination. They are more likely to experience their death at home, during sleep, and less likely witnessed. Women are also more likely to present in pulseless electrical activity or systole rather than ventricular fibrillation or ventricular tachycardia. Conversely, women are less likely to receive bystander cardiopulmonary resuscitation or receive cardiac intervention post-arrest. Underpinning sex disparities in sudden cardiac death is a paucity of women recruited to clinical trials, coupled with an overall lack of prespecified sex-disaggregated evidence. Thus, predominantly male-derived data form the basis of clinical guidelines. This review outlines the critical sex differences concerning epidemiology, cause, risk factors, prevention, and outcomes. We propose 4 broad areas of importance to consider: physiological, personal, community, and professional factors.
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Affiliation(s)
- Alexandra Butters
- Cardio Genomics Program at Centenary Institute (A.B., J.I.), The University of Sydney.,Faculty of Medicine and Health (A.B., C.S., J.I.), The University of Sydney
| | - Clare Arnott
- Department of Cardiology, Royal Prince Alfred Hospital (C.A., C.S., J.I.), Sydney, Australia.,The George Institute for Global Health (C.A.), Sydney, Australia
| | | | - Bo Gregers Winkel
- Department of Cardiology, Copenhagen University Hospital, Denmark (B.G.W.)
| | - Christopher Semsarian
- Faculty of Medicine and Health (A.B., C.S., J.I.), The University of Sydney.,Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.S.), The University of Sydney.,Department of Cardiology, Royal Prince Alfred Hospital (C.A., C.S., J.I.), Sydney, Australia
| | - Jodie Ingles
- Cardio Genomics Program at Centenary Institute (A.B., J.I.), The University of Sydney.,Faculty of Medicine and Health (A.B., C.S., J.I.), The University of Sydney.,Department of Cardiology, Royal Prince Alfred Hospital (C.A., C.S., J.I.), Sydney, Australia
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7
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Svane J, Lynge TH, Hansen CJ, Risgaard B, Winkel BG, Tfelt-Hansen J. Witnessed and unwitnessed sudden cardiac death: a nationwide study of persons aged 1-35 years. Europace 2021; 23:898-906. [PMID: 33595080 DOI: 10.1093/europace/euab017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/10/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS The aim of this study is to compare clinical characteristics and causes of death among witnessed and unwitnessed sudden cardiac death (SCD) cases aged 1-35 years. METHODS AND RESULTS In this retrospective nationwide study, all deaths in persons aged 1-35 years in Denmark during 2000-09 were included (23.7 million person-years). Using the in-depth descriptive Danish death certificates and Danish nationwide registries, 860 cases of sudden, unexpected death were identified. Through review of autopsy reports and register data, we identified 635 cases of SCD of which 266 (42%) were witnessed and 326 (51%) were unwitnessed. In 43 cases (7%), witnessed status was missing. Clinical characteristics were overall similar between the two groups. We found a male predominance among unwitnessed SCD compared to witnessed SCD (71% and 62%, respectively, P-value 0.012), as well as more psychiatric comorbidity (20% and 13%, respectively, P-value 0.029). Unwitnessed SCD more often occurred during sleep whereas witnessed SCD more often occurred while the individual was awake and relaxed (P-value < 0.001). The autopsy rate among all SCD cases was 70% with no significant difference in autopsy rate between the two groups. Sudden unexplained death, which was the leading autopsy conclusion in both groups, was more frequent among unwitnessed SCD (P-value 0.001). CONCLUSION Several clinical characteristics and autopsy findings were similar between witnessed and unwitnessed SCD cases. Our data support the inclusion of both witnessed and unwitnessed cases in epidemiological studies of SCD cases aged 1-35 years, although the risk of misclassification is higher among unwitnessed and non-autopsied cases of SCD.
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Affiliation(s)
- Jesper Svane
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100 Copenhagen, Denmark.,Section of Forensic Pathology, Department of Forensic Medicine, Copenhagen University, Copenhagen, Denmark
| | - Thomas Hadberg Lynge
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Carl Johann Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100 Copenhagen, Denmark.,Section of Forensic Pathology, Department of Forensic Medicine, Copenhagen University, Copenhagen, Denmark
| | - Bjarke Risgaard
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Bo Gregers Winkel
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jacob Tfelt-Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100 Copenhagen, Denmark.,Section of Forensic Pathology, Department of Forensic Medicine, Copenhagen University, Copenhagen, Denmark
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8
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Stiles MK, Wilde AAM, Abrams DJ, Ackerman MJ, Albert CM, Behr ER, Chugh SS, Cornel MC, Gardner K, Ingles J, James CA, Juang JMJ, Kääb S, Kaufman ES, Krahn AD, Lubitz SA, MacLeod H, Morillo CA, Nademanee K, Probst V, Saarel EV, Sacilotto L, Semsarian C, Sheppard MN, Shimizu W, Skinner JR, Tfelt-Hansen J, Wang DW. 2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families. J Arrhythm 2021; 37:481-534. [PMID: 34141003 PMCID: PMC8207384 DOI: 10.1002/joa3.12449] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 12/26/2022] Open
Abstract
This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.
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Affiliation(s)
- Martin K Stiles
- Waikato Clinical School Faculty of Medicine and Health Science The University of Auckland Hamilton New Zealand
| | - Arthur A M Wilde
- Heart Center Department of Clinical and Experimental Cardiology Amsterdam University Medical Center University of Amsterdam Amsterdam the Netherlands
| | | | | | | | - Elijah R Behr
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute St George's University of London, and St George's University Hospitals NHS Foundation Trust London UK
| | | | - Martina C Cornel
- Amsterdam University Medical Center Vrije Universiteit Amsterdam Clinical Genetics Amsterdam Public Health Research Institute Amsterdam the Netherlands
| | | | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute The University of Sydney Sydney Australia
| | | | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology Department of Internal Medicine National Taiwan University Hospital and National Taiwan University College of Medicine Taipei Taiwan
| | - Stefan Kääb
- Department of Medicine I University Hospital LMU Munich Munich Germany
| | | | | | | | - Heather MacLeod
- Data Coordinating Center for the Sudden Death in the Young Case Registry Okemos MI USA
| | | | - Koonlawee Nademanee
- Chulalongkorn University Faculty of Medicine, and Pacific Rim Electrophysiology Research Institute at Bumrungrad Hospital Bangkok Thailand
| | | | - Elizabeth V Saarel
- Cleveland Clinic Lerner College of Cardiology at Case Western Reserve University Cleveland OH USA
- St Luke's Medical Center Boise ID USA
| | - Luciana Sacilotto
- Heart Institute University of São Paulo Medical School São Paulo Brazil
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute The University of Sydney Sydney Australia
| | - Mary N Sheppard
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute St George's University of London, and St George's University Hospitals NHS Foundation Trust London UK
| | - Wataru Shimizu
- Department of Cardiovascular Medicine Nippon Medical School Tokyo Japan
| | | | - Jacob Tfelt-Hansen
- Department of Forensic Medicine Faculty of Medical Sciences Rigshospitalet Copenhagen Denmark
| | - Dao Wu Wang
- The First Affiliated Hospital of Nanjing Medical University Nanjing China
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9
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Stormholt ER, Svane J, Lynge TH, Tfelt-Hansen J. Symptoms Preceding Sports-Related Sudden Cardiac Death in Persons Aged 1-49 Years. Curr Cardiol Rep 2021; 23:8. [PMID: 33409809 DOI: 10.1007/s11886-020-01438-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Sports-related sudden cardiac death (Sr-SCD) is a leading natural cause of death in young athletes. To prevent Sr-SCD in athletes, it is important to identify individuals at risk. This review sought to summarize the current knowledge of symptoms prior to Sr-SCD in athletes aged 1-49 years. RECENT FINDINGS Cardiovascular screening of athletes is a subject of interest. However, the cost of ECG screening in a young population is relatively high compared to potential benefits, and systematic screening of athletes is heavily debated. In the background population, both cardiac and non-specific symptoms are often present prior to SCD. Both cardiac and non-specific symptoms are present in up to 74% prior to Sr-SCD. The main symptoms are syncope, chest pain, palpitations and dizziness. Knowledge of symptoms could potentially be used in combination with non-invasive prediction models to prevent Sr-SCD and treat athletes at risk.
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Affiliation(s)
- Emma Ritsmer Stormholt
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.
| | - Jesper Svane
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
- Section of Forensic Pathology, Department of Forensic Medicine, Copenhagen University, Copenhagen, Denmark
| | - Thomas Hadberg Lynge
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - Jacob Tfelt-Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
- Section of Forensic Pathology, Department of Forensic Medicine, Copenhagen University, Copenhagen, Denmark
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10
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Stiles MK, Wilde AAM, Abrams DJ, Ackerman MJ, Albert CM, Behr ER, Chugh SS, Cornel MC, Gardner K, Ingles J, James CA, Jimmy Juang JM, Kääb S, Kaufman ES, Krahn AD, Lubitz SA, MacLeod H, Morillo CA, Nademanee K, Probst V, Saarel EV, Sacilotto L, Semsarian C, Sheppard MN, Shimizu W, Skinner JR, Tfelt-Hansen J, Wang DW. 2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families. Heart Rhythm 2021; 18:e1-e50. [PMID: 33091602 PMCID: PMC8194370 DOI: 10.1016/j.hrthm.2020.10.010] [Citation(s) in RCA: 147] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 12/13/2022]
Abstract
This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.
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Affiliation(s)
- Martin K Stiles
- Waikato Clinical School, Faculty of Medicine and Health Science, The University of Auckland, Hamilton, New Zealand
| | - Arthur A M Wilde
- Amsterdam University Medical Center, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam, the Netherlands
| | | | | | | | - Elijah R Behr
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sumeet S Chugh
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Martina C Cornel
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Clinical Genetics, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | | | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Stefan Kääb
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | | | - Andrew D Krahn
- The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Heather MacLeod
- Data Coordinating Center for the Sudden Death in the Young Case Registry, Okemos, Michigan, USA
| | | | - Koonlawee Nademanee
- Chulalongkorn University, Faculty of Medicine, and Pacific Rim Electrophysiology Research Institute at Bumrungrad Hospital, Bangkok, Thailand
| | | | - Elizabeth V Saarel
- Cleveland Clinic Lerner College of Cardiology at Case Western Reserve University, Cleveland, Ohio, and St Luke's Medical Center, Boise, Idaho, USA
| | - Luciana Sacilotto
- Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Mary N Sheppard
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Jonathan R Skinner
- Cardiac Inherited Disease Group, Starship Hospital, Auckland, New Zealand
| | - Jacob Tfelt-Hansen
- Department of Forensic Medicine, Faculty of Medical Sciences, Rigshospitalet, Copenhagen, Denmark
| | - Dao Wu Wang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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11
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Döbel T, Stöbe S, Marshall RP, Hepp P, Fikenzer S, Fikenzer K, Tautenhahn S, Laufs U, Hagendorff A. Possible new options and benefits to detect myocarditis, right ventricular remodeling and coronary anomalies by echocardiography in systematic preparticipation screening of athletes. Int J Cardiovasc Imaging 2020; 36:1855-1885. [PMID: 32462448 PMCID: PMC7497512 DOI: 10.1007/s10554-020-01899-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/21/2020] [Indexed: 01/27/2023]
Abstract
Exclusion of cardiac abnormalities should be performed at the beginning of the athlete's career. Myocarditis, right ventricular remodeling and coronary anomalies are well-known causes of life-threatening events of athletes, major cardiovascular events and sudden cardiac death. The feasibility of an extended comprehensive echocardiographic protocol for the detection of structural cardiac abnormalities in athletes should be tested. This standardized protocol of transthoracic echocardiography includes two- and three-dimensional imaging, tissue Doppler imaging, and coronary artery scanning. Post processing was performed for deformation analysis of all compounds including layer strain. During 2017 and 2018, the feasibility of successful image acquisition and post processing analysis was retrospectively analyzed in 54 male elite athletes. In addition, noticeable findings inside the analyzed cohort are described. The extended image acquisition and data analyzing was feasible from 74 to 100%, depending on the used modalities. One case of myocarditis was detected in the present cohort. Coronary anomalies were not found. Right ventricular size and function were within normal ranges. Isovolumetric right ventricular relaxation time showed significant regional differences. One case of hypertrophic cardiomyopathy and two subjects with bicuspid aortic valves were found. Due to the excessive cardiac stress in highly competitive sports, high-quality and precise screening modalities are necessary, especially with respect to acquired cardiac diseases like acute myocarditis and pathological changes of left ventricular and RV geometry. The documented feasibility of the proposed extended protocol underlines the suitability to detect distinct morphological and functional cardiac alterations and documents the potential added value of a comprehensive echocardiography.
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Affiliation(s)
- Tom Döbel
- University Hospital Leipzig Department for Internal Medicine Neurology and Dermatology, Department of Cardiology, University Hospital Leipzig, Leipzig, Sachsen, Germany.
| | - Stephan Stöbe
- University Hospital Leipzig Department for Internal Medicine Neurology and Dermatology, Department of Cardiology, University Hospital Leipzig, Leipzig, Sachsen, Germany
| | | | - Pierre Hepp
- Department of Orthopedics, University Hospital Leipzig, Leipzig, Sachsen, Germany
| | - Sven Fikenzer
- University Hospital Leipzig Department for Internal Medicine Neurology and Dermatology, Department of Cardiology, University Hospital Leipzig, Leipzig, Sachsen, Germany
| | - Kati Fikenzer
- University Hospital Leipzig Department for Internal Medicine Neurology and Dermatology, Department of Cardiology, University Hospital Leipzig, Leipzig, Sachsen, Germany
| | - Sandra Tautenhahn
- University Hospital Leipzig Department for Internal Medicine Neurology and Dermatology, Department of Cardiology, University Hospital Leipzig, Leipzig, Sachsen, Germany
| | - Ulrich Laufs
- University Hospital Leipzig Department for Internal Medicine Neurology and Dermatology, Department of Cardiology, University Hospital Leipzig, Leipzig, Sachsen, Germany
| | - Andreas Hagendorff
- University Hospital Leipzig Department for Internal Medicine Neurology and Dermatology, Department of Cardiology, University Hospital Leipzig, Leipzig, Sachsen, Germany
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12
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Stampe NK, Jespersen CB, Glinge C, Bundgaard H, Tfelt‐Hansen J, Winkel BG. Clinical characteristics and risk factors of arrhythmia during follow‐up of patients with idiopathic ventricular fibrillation. J Cardiovasc Electrophysiol 2020; 31:2677-2686. [DOI: 10.1111/jce.14696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Niels K. Stampe
- Department of Cardiology, The Heart Centre Copenhagen University Hospital Rigshospitalet Denmark
| | - Camilla B. Jespersen
- Department of Cardiology, The Heart Centre Copenhagen University Hospital Rigshospitalet Denmark
| | - Charlotte Glinge
- Department of Cardiology, The Heart Centre Copenhagen University Hospital Rigshospitalet Denmark
| | - Henning Bundgaard
- Department of Cardiology, The Heart Centre Copenhagen University Hospital Rigshospitalet Denmark
| | - Jacob Tfelt‐Hansen
- Department of Cardiology, The Heart Centre Copenhagen University Hospital Rigshospitalet Denmark
- Department of Forensic Medicine, Faculty of Medical Sciences University of Copenhagen Denmark
| | - Bo G. Winkel
- Department of Cardiology, The Heart Centre Copenhagen University Hospital Rigshospitalet Denmark
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13
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Dorian P, Goodman JM, Connelly KA. Policies to Prevent Sudden Cardiac Death in Young Athletes: Challenging, But More Testing Is Not the Answer. J Am Heart Assoc 2020; 9:e016332. [PMID: 32306795 PMCID: PMC7428526 DOI: 10.1161/jaha.120.016332] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paul Dorian
- Division of Cardiology Department of Medicine St. Michael's Hospital University of Toronto Ontario Canada
| | - Jack M Goodman
- Faculty of Kinesiology and Physical Education University of Toronto Canada
| | - Kim A Connelly
- Division of Cardiology Department of Medicine St. Michael's Hospital University of Toronto Ontario Canada
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14
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Glinge C, Engstrøm T, Midgley SE, Tanck MWT, Madsen JEH, Pedersen F, Ravn Jacobsen M, Lodder EM, Al-Hussainy NR, Kjær Stampe N, Trebbien R, Køber L, Gerds T, Torp-Pedersen C, Kølsen Fischer T, Bezzina CR, Tfelt-Hansen J, Jabbari R. Seasonality of ventricular fibrillation at first myocardial infarction and association with viral exposure. PLoS One 2020; 15:e0226936. [PMID: 32101559 PMCID: PMC7043782 DOI: 10.1371/journal.pone.0226936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 11/25/2019] [Indexed: 11/19/2022] Open
Abstract
AIMS To investigate seasonality and association of increased enterovirus and influenza activity in the community with ventricular fibrillation (VF) risk during first ST-elevation myocardial infarction (STEMI). METHODS This study comprised all consecutive patients with first STEMI (n = 4,659; aged 18-80 years) admitted to the invasive catheterization laboratory between 2010-2016, at Copenhagen University Hospital, Rigshospitalet, covering eastern Denmark (2.6 million inhabitants, 45% of the Danish population). Hospital admission, prescription, and vital status data were assessed using Danish nationwide registries. We utilized monthly/weekly surveillance data for enterovirus and influenza from the Danish National Microbiology Database (2010-2016) that receives copies of laboratory tests from all Danish departments of clinical microbiology. RESULTS Of the 4,659 consecutively enrolled STEMI patients, 581 (12%) had VF before primary percutaneous coronary intervention. In a subset (n = 807), we found that VF patients experienced more generalized fatigue and flu-like symptoms within 7 days before STEMI compared with the patients without VF (OR 3.39, 95% CI 1.76-6.54). During the study period, 2,704 individuals were diagnosed with enterovirus and 19,742 with influenza. No significant association between enterovirus and VF (OR 1.00, 95% CI 0.99-1.02), influenza and VF (OR 1.00, 95% CI 1.00-1.00), or week number and VF (p-value 0.94 for enterovirus and 0.89 for influenza) was found. CONCLUSION We found no clear seasonality of VF during first STEMI. Even though VF patients had experienced more generalized fatigue and flu-like symptoms within 7 days before STEMI compared with patients without VF, no relationship was found between enterovirus or influenza exposure and occurrence of VF.
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Affiliation(s)
- Charlotte Glinge
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Thomas Engstrøm
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, University of Lund, Lund, Sweden
| | - Sofie E. Midgley
- Department of Virus and Microbiological Special Diagnostics, Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Michael W. T. Tanck
- Amsterdam UMC, University of Amsterdam, Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Public Health (APH), Amsterdam, The Netherlands
| | - Jeppe Ekstrand Halkjær Madsen
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Section of Biostatistics, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Frants Pedersen
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mia Ravn Jacobsen
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Elisabeth M. Lodder
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Nour R. Al-Hussainy
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Niels Kjær Stampe
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ramona Trebbien
- Department of Virus and Microbiological Special Diagnostics, Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Lars Køber
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Gerds
- Section of Biostatistics, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Clinical Investigation and Cardiology, Nordsjaellands Hospital, Hillerød, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Thea Kølsen Fischer
- Department of Virus and Microbiological Special Diagnostics, Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
- Department of Infectious Diseases and Department of Global Health, Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Connie R. Bezzina
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jacob Tfelt-Hansen
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Reza Jabbari
- The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- International External Collaborator Sponsored Staff at Division of Preventive Medicine, Brigham & Women's Hospital, Boston, MA, United States of America
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15
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Skjelbred T, Lynge TH, Nielsen J, Winkel BG, Tfelt-Hansen J. Symptoms and healthcare contact preceding sudden cardiac death in persons aged 1-49 years. Trends Cardiovasc Med 2020; 31:119-124. [PMID: 31987774 DOI: 10.1016/j.tcm.2020.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 01/17/2023]
Abstract
Sudden Cardiac Death (SCD) is a leading cause of death among persons in their youth and early middle-age. To prevent SCD it is crucial to identify persons at high-risk of SCD. Knowledge of symptoms and medical contact prior to SCD could potentially aid in the identification of high-risk persons in the general population who would benefit from further investigation. This review aims to summarize the current knowledge of symptoms and healthcare contact preceding SCD in persons aged 1-49 years, and to explore how the symptoms differ according to SCD cause and age of the deceased. There was a high frequency of both cardiac and non-specific symptoms prior to SCD. Additionally, many SCD victims contacted the healthcare system prior to death on the basis of their symptoms and only a few were diagnosed with cardiovascular disease. This information underlines that young persons reporting potential cardiac symptoms should also be thoroughly examined. Furthermore, such symptoms could be used in combination with other easily accessible information in non-invasive prediction models aiming at identifying persons at high risk of SCD that would benefit from further investigation and possibly treatment.
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Affiliation(s)
- Tobias Skjelbred
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Thomas Hadberg Lynge
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Jakob Nielsen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Bo Gregers Winkel
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jacob Tfelt-Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Section 2142, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Medicine and Surgery, University of Copenhagen, Copenhagen, Denmark
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16
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Hadji-Turdeghal K, Andreasen L, Hagen CM, Ahlberg G, Ghouse J, Bækvad-Hansen M, Bybjerg-Grauholm J, Hougaard DM, Hedley P, Haunsø S, Svendsen JH, Kanters JK, Jepps TA, Skov MW, Christiansen M, Olesen MS. Genome-wide association study identifies locus at chromosome 2q32.1 associated with syncope and collapse. Cardiovasc Res 2020; 116:138-148. [PMID: 31049583 PMCID: PMC6918066 DOI: 10.1093/cvr/cvz106] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 04/25/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS Syncope is a common condition associated with frequent hospitalization or visits to the emergency department. Family aggregation and twin studies have shown that syncope has a heritable component. We investigated whether common genetic variants predispose to syncope and collapse. METHODS AND RESULTS We used genome-wide association data on syncope on 408 961 individuals with European ancestry from the UK Biobank study. In a replication study, we used the Integrative Psychiatric Research Consortium (iPSYCH) cohort (n = 86 189), to investigate the risk of incident syncope stratified by genotype carrier status. We report on a genome-wide significant locus located on chromosome 2q32.1 [odds ratio = 1.13, 95% confidence interval (CI) 1.10-1.17, P = 5.8 × 10-15], with lead single nucleotide polymorphism rs12465214 in proximity to the gene zinc finger protein 804a (ZNF804A). This association was also shown in the iPSYCH cohort, where homozygous carriers of the C allele conferred an increased hazard ratio (1.30, 95% CI 1.15-1.46, P = 1.68 × 10-5) of incident syncope. Quantitative polymerase chain reaction analysis showed ZNF804A to be expressed most abundantly in brain tissue. CONCLUSION We identified a genome-wide significant locus (rs12465214) associated with syncope and collapse. The association was replicated in an independent cohort. This is the first genome-wide association study to associate a locus with syncope and collapse.
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Affiliation(s)
- Katra Hadji-Turdeghal
- Laboratory for Molecular Cardiology, Department of Cardiology, The Heart Centre, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Laura Andreasen
- Laboratory for Molecular Cardiology, Department of Cardiology, The Heart Centre, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christian M Hagen
- Department of Congenital Disorders, Statens Serum Institute, Copenhagen, Denmark
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark
| | - Gustav Ahlberg
- Laboratory for Molecular Cardiology, Department of Cardiology, The Heart Centre, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas Ghouse
- Laboratory for Molecular Cardiology, Department of Cardiology, The Heart Centre, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marie Bækvad-Hansen
- Department of Congenital Disorders, Statens Serum Institute, Copenhagen, Denmark
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark
| | - Jonas Bybjerg-Grauholm
- Department of Congenital Disorders, Statens Serum Institute, Copenhagen, Denmark
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark
| | - David M Hougaard
- Department of Congenital Disorders, Statens Serum Institute, Copenhagen, Denmark
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark
| | - Paula Hedley
- Department of Congenital Disorders, Statens Serum Institute, Copenhagen, Denmark
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark
| | - Stig Haunsø
- Laboratory for Molecular Cardiology, Department of Cardiology, The Heart Centre, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jesper H Svendsen
- Laboratory for Molecular Cardiology, Department of Cardiology, The Heart Centre, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jørgen K Kanters
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas A Jepps
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten W Skov
- Laboratory for Molecular Cardiology, Department of Cardiology, The Heart Centre, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Michael Christiansen
- Department of Congenital Disorders, Statens Serum Institute, Copenhagen, Denmark
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Copenhagen, Denmark
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten S Olesen
- Laboratory for Molecular Cardiology, Department of Cardiology, The Heart Centre, Rigshospitalet (Copenhagen University Hospital), Copenhagen, Denmark
- Danish National Research Foundation Centre for Cardiac Arrhythmia, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
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17
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Canadian Cardiovascular Society Cardiovascular Screening of Competitive Athletes: The Utility of the Screening Electrocardiogram to Predict Sudden Cardiac Death. Can J Cardiol 2019; 35:1557-1566. [PMID: 31679625 DOI: 10.1016/j.cjca.2019.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/01/2019] [Accepted: 08/01/2019] [Indexed: 01/12/2023] Open
Abstract
Prevention of sudden cardiac arrest/death (SCA/D) among athletes is a universal goal, although the optimal strategy for its achievement is controversial, with the inclusion of the 12-lead electrocardiogram (ECG) at the center of the debate. The ECG exhibits superior sensitivity over history and physical examination to detect conditions associated with SCA/D. However, the identification of disease does not necessarily lead to a significant reduction in SCA/D. The "Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes" recommended against the routine performance of an ECG for the initial cardiovascular screening of competitive athletes. The incidence of SCA/D among athletes (<35 years of age), the risk of SCA/D during sport participation among individuals with abnormalities found on screening ECG, the efficacy of the ECG to identify conditions associated with SCA/D, and the positive predictive value of an abnormal ECG to predict SCA/D are critically examined. This review presents the evidence informing the panel's recommendation.
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18
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Lynge TH, Nielsen TS, Gregers Winkel B, Tfelt-Hansen J, Banner J. Sudden cardiac death caused by myocarditis in persons aged 1-49 years: a nationwide study of 14 294 deaths in Denmark. Forensic Sci Res 2019; 4:247-256. [PMID: 31489390 PMCID: PMC6713107 DOI: 10.1080/20961790.2019.1595352] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/11/2019] [Indexed: 02/08/2023] Open
Abstract
Myocarditis is associated with an increased risk of sudden cardiac death (SCD) in the young. However, information on nationwide burden of SCD caused by myocarditis (SCD-myocarditis) is sparse. For this study all deaths among persons in Denmark aged 1–35 years in 2000–2009 and 36–49 years in 2007–2009 (27.1 million person-years) were included. Autopsy reports, death certificates, discharge summaries, and nationwide registries were used to identify all cases of SCD-myocarditis. In the 10-year study period, there were 14 294 deaths, of which we identified 1 363 (10%) SCD. Among autopsied SCD (n = 753, 55%), cause of death was myocarditis in 42 (6%) cases corresponding to an SCD-myocarditis incidence of 0.16 (95%CI: 0.11–0.21) per 100 000 person-years. Males had significantly higher incidence rates of SCD-myocarditis compared to females with an incidence rate ratio of 2.2 (95%CI: 1.1–4.1). Myocarditis was not registered as cause of death in any of the non-autopsied SCD (n = 610, 45%). In conclusion, after nationwide unselected inclusion of 14 294 deaths, we found that 6% of all autopsied SCD was caused by myocarditis. No cases of SCD-myocarditis were reported in the non-autopsied SCD, which could reflect underdiagnosing of myocarditis in non-autopsied SCD. Furthermore, our data suggest a female protection towards SCD-myocarditis.
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Affiliation(s)
| | - Trine Skov Nielsen
- Department of Forensic Medicine, Section of Forensic Pathology, Aarhus University, Aarhus, Denmark
| | | | - Jacob Tfelt-Hansen
- Department of Cardiology, Rigshospitalet, Denmark.,Department of Forensic Medicine, Section of Forensic Pathology, Copenhagen University, Copenhagen, Denmark
| | - Jytte Banner
- Department of Forensic Medicine, Section of Forensic Pathology, Copenhagen University, Copenhagen, Denmark
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19
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Abstract
Sudden cardiac death in the young (SCDY) is always a devastating event. The death is sudden and unexpected and often in a person who was thought to be healthy. In recent years our understanding of these tragic events have drastically improved; 10-20years ago we did not know how often SCD occurred in the young, and we had sparse knowledge on the role of inheritance. We have found that SCD corresponds to 7% of all deaths with an overall (highest possible) incidence rate of 2.8 per 100,000 person-years (autopsy rate of sudden death cases of 75%). This incidence rate is higher than in the Veneto region (1.0), in the Netherlands (1.6), and in the UK (1.8), but can be explained by differences in definition and methodological factors. Cause of death in SCDY also differs to some extent between countries. Recent data suggest that there are identifiable risk factors for SCDY such as symptoms, comorbidities and polypharmacy. SCDY is to some extent preventable and this can be achieved through several initiatives: 1. better OCHA treatment including readily available AEDs, 2. family screening on the families left behind, and 3. better diagnostics and treatment for patients at risk for SCDY.
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20
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Abstract
Sudden cardiac death (SCD) is a rare but devastating event in children and adolescents. Etiologies include congenital heart disease, cardiomyopathies, primary arrhythmia syndromes, and miscellaneous conditions. Challenges in the diagnosis and prevention of SCD in the young are reviewed.
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Affiliation(s)
- Elizabeth D Sherwin
- Division of Cardiology, Children's National Health System, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; Department of Pediatrics, George Washington University School of Medicine, 2300 Eye Street NW, Washington, DC 20037, USA.
| | - Charles I Berul
- Division of Cardiology, Children's National Health System, 111 Michigan Avenue Northwest, Washington, DC 20010, USA; Department of Pediatrics, George Washington University School of Medicine, 2300 Eye Street NW, Washington, DC 20037, USA
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21
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Koene RJ, Adkisson WO, Benditt DG. Syncope and the risk of sudden cardiac death: Evaluation, management, and prevention. J Arrhythm 2017; 33:533-544. [PMID: 29255498 PMCID: PMC5728985 DOI: 10.1016/j.joa.2017.07.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 06/04/2017] [Accepted: 07/04/2017] [Indexed: 12/17/2022] Open
Abstract
Syncope is a clinical syndrome defined as a relatively brief self-limited transient loss of consciousness (TLOC) caused by a period of inadequate cerebral nutrient flow. Most often the trigger is an abrupt drop of systemic blood pressure. True syncope must be distinguished from other common non-syncope conditions in which real or apparent TLOC may occur such as seizures, concussions, or accidental falls. The causes of syncope are diverse, but in most instances, are relatively benign (e.g., reflex and orthostatic faints) with the main risks being accidents and/or injury. However, in some instances, syncope may be due to more worrisome conditions (particularly those associated with cardiac structural disease or channelopathies); in such circumstances, syncope may be an indicator of increased morbidity and mortality risk, including sudden cardiac death (SCD). Establishing an accurate basis for the etiology of syncope is crucial in order to initiate effective therapy. In this review, we focus primarily on the causes of syncope that are associated with increased SCD risk (i.e., sudden arrhythmic cardiac death), and the management of these patients. In addition, we discuss the limitations of our understanding of SCD in relation to syncope, and propose future studies that may ultimately address how to improve outcomes of syncope patients and reduce SCD risk.
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Affiliation(s)
| | | | - David G. Benditt
- From the Cardiac Arrhythmia Center, Division of Cardiovascular Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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22
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Ågesen FN, Risgaard B, Zachariasardóttir S, Jabbari R, Lynge TH, Ingemann-Hansen O, Ottesen GL, Thomsen JL, Haunsø S, Krieger DW, Winkel BG, Tfelt-Hansen J. Sudden unexpected death caused by stroke: A nationwide study among children and young adults in Denmark. Int J Stroke 2017; 13:285-291. [DOI: 10.1177/1747493017724625] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Stroke is the fifth leading cause of death in young individuals globally. Data on the burden of sudden death by stroke are sparse in the young. Aims The aim of this study was to report mortality rates, cause of death, stroke subtype, and symptoms in children and young adults who suffered sudden death by stroke. Methods We conducted a retrospective, nationwide study including all deaths within Danish borders between 2000–2009 and 2007–2009 in persons aged 1–35 years and 36–49 years, respectively. Two physicians identified all sudden death cases through review of all death certificates. All available autopsy reports and records from hospitals and general practitioners were retrieved and a neurologist identified all sudden death by stroke cases. Results Of the 14,567 deaths in the 10-year period, there were 1,698 sudden death cases, of which 52 (3%) were sudden death by stroke. There was a male predominance (56%) and the median age was 33 years. The incidence of sudden death by stroke in individuals aged 1–49 years was 0.19 deaths per 100,000 person-years. Stroke was hemorrhagic in 94% of cases, whereof subarachnoid hemorrhage was the cause of death in 63% of cases. Seventeen (33%) cases contacted the healthcare system because of neurological symptoms, whereof one was suspected of having a stroke (6%). Conclusions Sudden death by stroke in children and young adults occurs primarily due to hemorrhagic stroke. We report a high frequency of neurological symptoms prior to sudden death by stroke. Increased awareness among healthcare professionals towards stroke symptoms in children and young adults may lead to earlier detection of stroke, and thereby potentially lowering the incidence of sudden death by stroke.
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Affiliation(s)
| | - Bjarke Risgaard
- The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Reza Jabbari
- The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | | | - Gyda Lolk Ottesen
- Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jørgen Lange Thomsen
- Department of Forensic Medicine, University of Southern Denmark, Odense, Denmark
| | - Stig Haunsø
- The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
- The Danish National Research Foundation Centre for Cardiac Arrhythmia (DARC), University of Copenhagen, Denmark
- Department of Medicine and Surgery, University of Copenhagen, Denmark
| | | | - Bo Gregers Winkel
- The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jacob Tfelt-Hansen
- The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
- The Danish National Research Foundation Centre for Cardiac Arrhythmia (DARC), University of Copenhagen, Denmark
- Department of Medicine and Surgery, University of Copenhagen, Denmark
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23
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Zachariasardóttir S, Risgaard B, Ågesen FN, Jabbari R, Glinge C, Ingemann-Hansen O, Ottesen GL, Thomsen JL, Haunsø S, Banner J, Winkel BG, Tfelt-Hansen J. Sudden cardiac death and coronary disease in the young: A nationwide cohort study in Denmark. Int J Cardiol 2017; 236:16-22. [DOI: 10.1016/j.ijcard.2017.01.118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/13/2017] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
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24
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Laszlo R, Scharhag J, Burgstahler C, Striegel H, Steinacker JM. [Sports cardiology : Overview of relevant clinical topics]. Herz 2017; 43:53-60. [PMID: 28116464 DOI: 10.1007/s00059-016-4521-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 11/26/2016] [Indexed: 10/20/2022]
Abstract
Physical activity is nowadays an established therapeutic principle concerning primary and secondary prevention of cardiovascular diseases; therefore, in internal sports medicine various aspects go beyond basic cardiological knowledge and require special medical expertise (sports cardiology). Acute cardiac risk is increased during physical activity; therefore, physical activity should be individually phased under consideration of the whole clinical situation. Physical training results in a functional adaptation of the cardiovascular system. Moreover, a structural adaptation can also be observed in competitive athletes but a differentiation between athlete's heart and cardiomyopathy is sometimes challenging. Preparticipation screening verifiably reduces the incidence of sudden cardiac death in athletes. Respective recommendations for the required diagnostics have been published and statutory health insurances are increasingly more willing to bear the incurred costs. Statistically, doping is more frequent in performance-orientated leisure time sports than in competitive sports. Drugs which are relevant for doping have partially irreversible cardiac side effects.
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Affiliation(s)
- R Laszlo
- Sektion Sport- und Rehabilitationsmedizin, Universitätsklinikum Ulm, Leimgrubenweg 14, 89070, Ulm, Deutschland.
| | - J Scharhag
- Institut für Sport- und Bewegungsmedizin, Universität des Saarlandes, Saarbrücken, Deutschland
| | - C Burgstahler
- Abteilung für Sportmedizin, Medizinische Klinik V, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - H Striegel
- Abteilung für Sportmedizin, Medizinische Klinik V, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - J M Steinacker
- Sektion Sport- und Rehabilitationsmedizin, Universitätsklinikum Ulm, Leimgrubenweg 14, 89070, Ulm, Deutschland
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