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Finocchiaro G, Westaby J, Sheppard MN, Papadakis M, Sharma S. Sudden Cardiac Death in Young Athletes: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:350-370. [PMID: 38199713 DOI: 10.1016/j.jacc.2023.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 01/12/2024]
Abstract
Athletes epitomize the healthiest segment of society. Despite this premise, sudden cardiac death may occur in apparently healthy athletes, attracting significant attention not only in the medical community but also in laypersons and media. The incidence of sudden cardiac death is variably reported, and epidemiological burden differs among cohorts. Athletes appear to be at risk of developing fatal arrhythmias when harboring a quiescent cardiac disorder. Primary cardiomyopathies, ion channelopathies, and coronary artery anomalies are prevalent causes in young individuals. Cardiac assessment of athletes can be challenging because these individuals exhibit a plethora of electrical, structural, and functional physiological changes that overlap with cardiac pathology. A diagnosis of cardiac disease in a young athlete is not necessarily an indication to terminate competition and sports participation. International guidelines, traditionally focused on disqualification of individuals with cardiac disease, have recently adopted a more liberal attitude, based on a careful assessment of the risk and on a shared-decision making approach.
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Affiliation(s)
- Gherardo Finocchiaro
- Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom
| | - Joseph Westaby
- Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom
| | - Mary N Sheppard
- Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom
| | - Michael Papadakis
- Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom
| | - Sanjay Sharma
- Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom.
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Corneil H, Liblik K, Varghese SS, Masotti B, Moulson N, McKinney J, Allan KS, Phelan D, Thakrar A, Johri AM, Grubic N. Shared Decision-Making in Athletes Diagnosed With a Cardiovascular Condition: A Scoping Review. Curr Probl Cardiol 2023; 48:101815. [PMID: 37211302 DOI: 10.1016/j.cpcardiol.2023.101815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
This scoping review summarizes existing approaches, benefits, and barriers to shared decision-making (SDM) in the context of sports cardiology. Among 6,058 records screened, 37 articles were included in this review. Most included articles defined SDM as an open dialogue between the athlete, healthcare team, and other stakeholders. The benefits and risks of management strategies, treatment options, and return-to-play were the focus of this dialogue. Key components of SDM were described through various themes, such as emphasizing patient values, considering nonphysical factors, and informed consent. Benefits of SDM included enhancing patient understanding, implementing a personalized management plan, and considering a holistic approach to care. Barriers to SDM included pressure from institutions, consideration of multiple perspectives in decision-making, and the potential liability of healthcare providers. The use of SDM when discussing management, treatment, and lifestyle modification for athletes diagnosed with a cardiovascular condition is necessary to ensure patient autonomy and engagement.
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Affiliation(s)
- Heidi Corneil
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kiera Liblik
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sonu S Varghese
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Bruce Masotti
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nathaniel Moulson
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - James McKinney
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Katherine S Allan
- Division of Cardiology, Unity Health Toronto - St Michael's Hospital, Toronto, Ontario, Canada
| | - Dermot Phelan
- The Gragg Center for Cardiovascular Performance, Sanger Heart & Vascular Institute, Atrium Health, Charlotte, North Carolina, United States
| | - Amar Thakrar
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Amer M Johri
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nicholas Grubic
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.
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Ghani U, Farooq O, Alam S, Khan MJ, Rahim O, Rahim S. Sudden Cardiac Death in Athletes: Consensuses and Controversies. Cureus 2023; 15:e39873. [PMID: 37404395 PMCID: PMC10315103 DOI: 10.7759/cureus.39873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 07/06/2023] Open
Abstract
Exercise is widely considered beneficial for cardiovascular health. However, on rare occasions, athletes experience sudden cardiac death without any preceding symptoms. The devastating nature of these events necessitates us to understand the underlying causes. In younger athletes (age <35), the underlying causes are usually hereditary/genetic, whereas in older athletes (age >35), coronary artery disease is prevalent. Sudden cardiac death in athletes can occur regardless of the presence of any structural abnormality in the heart. Despite divergence between guidelines, the majority of cardiology societies recommend at least taking a comprehensive history and performing physical examinations for initial screening for all athletes. This article reviews the consensuses and controversies regarding the incidence, causes, and prevention of sudden cardiac death in athletes.
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Affiliation(s)
- Usman Ghani
- Cardiology, Northwest General Hospital and Research Center, Peshawar, PAK
| | - Omer Farooq
- Internal Medicine, Presence Saint Francis Hospital, Evanston, USA
| | - Sundus Alam
- Cardiology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, GBR
| | - Muhammad Junaid Khan
- Orthopaedic Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, GBR
| | - Omar Rahim
- Internal Medicine, Naseer Teaching Hospital, Peshawar, PAK
| | - Sarah Rahim
- Cardiology, Rehman Medical Institute, Peshawar, PAK
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Sarto P, Zorzi A, Merlo L, Vessella T, Pegoraro C, Giorgiano F, Graziano F, Basso C, Drezner JA, Corrado D. Value of screening for the risk of sudden cardiac death in young competitive athletes. Eur Heart J 2023; 44:1084-1092. [PMID: 36760222 PMCID: PMC10027466 DOI: 10.1093/eurheartj/ehad017] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/17/2022] [Accepted: 01/05/2023] [Indexed: 02/11/2023] Open
Abstract
AIMS This study aimed to report the long-term findings of the Italian programme of cardiovascular preparticipation screening (PPS) in young, competitive athletes. METHODS AND RESULTS The study assessed the diagnostic yield for diseases at risk of sudden cardiac death (SCD), the costs of serial evaluations, and the long-term outcomes of PPS in a large population of Italian children (age range, 7-18 years). The PPS was repeated annually and included medical history, physical examination, resting electrocardiogram, and stress testing; additional tests were reserved for athletes with abnormal findings. Over an 11-year study period, 22 324 consecutive children [62% males; mean age, 12 (interquartile range, 10-14) years at first screening] underwent a total of 65 397 annual evaluations (median 2.9/child). Cardiovascular diseases at risk of SCD were identified in 69 children (0.3%) and included congenital heart diseases (n = 17), channelopathies (n = 14), cardiomyopathies (n = 15), non-ischaemic left ventricular scar with ventricular arrhythmias (n = 18), and others (n = 5). At-risk cardiovascular diseases were identified over the entire age range and more frequently in children ≥12 years old (n = 63, 91%) and on repeat evaluation (n = 44, 64%). The estimated cost per diagnosis was 73 312€. During a follow-up of 7.5 ± 3.7 years, one child with normal PPS findings experienced an episode of resuscitated cardiac arrest during sports activity (event rate of 0.6/100.000 athletes/year). CONCLUSION The PPS programme led to the identification of cardiovascular diseases at risk of SCD over the whole study age range of children and more often on repeat evaluations. Among screened children, the incidence of sport-related cardiac arrest during long-term follow-up was low.
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Affiliation(s)
- Patrizio Sarto
- Sports Medicine Unit regional referral center for exercise prescription in young patients with heart diseases, AULSS 2, Via Castellana, 2, 31100 Treviso, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via n. Giustiniani 2, 35121 Padova, Italy
| | - Laura Merlo
- Sports Medicine Unit regional referral center for exercise prescription in young patients with heart diseases, AULSS 2, Via Castellana, 2, 31100 Treviso, Italy
| | - Teresina Vessella
- Sports Medicine Unit regional referral center for exercise prescription in young patients with heart diseases, AULSS 2, Via Castellana, 2, 31100 Treviso, Italy
| | - Cinzia Pegoraro
- Sports Medicine Unit regional referral center for exercise prescription in young patients with heart diseases, AULSS 2, Via Castellana, 2, 31100 Treviso, Italy
| | - Flaviano Giorgiano
- Sports Medicine Unit regional referral center for exercise prescription in young patients with heart diseases, AULSS 2, Via Castellana, 2, 31100 Treviso, Italy
| | - Francesca Graziano
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via n. Giustiniani 2, 35121 Padova, Italy
| | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via n. Giustiniani 2, 35121 Padova, Italy
| | - Jonathan A Drezner
- Center for Sports Cardiology, University of Washington, 3800 Montlake Blvd NE, Box 354060, Seattle, WA 98195, USA
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via n. Giustiniani 2, 35121 Padova, Italy
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Sudden Cardiac Death in Athletes: Facts and Fallacies. J Cardiovasc Dev Dis 2023; 10:jcdd10020068. [PMID: 36826564 PMCID: PMC9965876 DOI: 10.3390/jcdd10020068] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/23/2023] [Accepted: 01/29/2023] [Indexed: 02/09/2023] Open
Abstract
The benefits of exercise for cardiovascular and general health are many. However, sudden cardiac death (SCD) may occur in apparently healthy athletes who perform at the highest levels. A diverse spectrum of diseases is implicated in SCD in athletes, and while atherosclerotic coronary artery disease predominates in individuals of >35 years of age, primary cardiomyopathies and ion channelopathies are prevalent in young individuals. Prevention of SCD in athletes relies on the implementation of health policies aimed at the early identification of arrhythmogenic diseases (such as cardiac screening) and successful resuscitation (such as widespread utilization of automatic external defibrillators and training members of the public on cardiopulmonary resuscitation). This review will focus on the epidemiology and aetiologies of SCD in athletes, and examine fallacies in the approach to this controversial field. Furthermore, potential strategies to prevent these tragic events will be discussed, analysing current practice, gaps in knowledge and future directions.
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Finocchiaro G, Magavern EF, Georgioupoulos G, Maurizi N, Sinagra G, Carr-White G, Pantazis A, Olivotto I. Sudden cardiac death in cardiomyopathies: acting upon "acceptable" risk in the personalized medicine era. Heart Fail Rev 2022; 27:1749-1759. [PMID: 35083629 DOI: 10.1007/s10741-021-10198-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2021] [Indexed: 11/04/2022]
Abstract
Patients with cardiomyopathies are confronted with the risk of sudden cardiac death (SCD) throughout their lifetime. Despite the fact that SCD is relatively rare, prognostic stratification is an integral part of physician-patient discussion, with the goal of risk modification and prevention. The current approach is based on a concept of "acceptable risk." However, there are intrinsic problems with an algorithm-based approach to risk management, magnified by the absence of robust evidence underlying clinical decision support tools, which can make high- versus low-risk classifications arbitrary. Strategies aimed at risk reduction range from selecting patients for an implantable cardioverter defibrillator (ICD) to disqualification from competitive sports. These clinical options, especially when implying the use of finite financial resources, are often delivered from the physician's perspective citing decision-making algorithms. When the burden of intervention-related risks or financial costs is deemed higher than an "acceptable risk" of SCD, the patient's perspective may not be appropriately considered. Designating a numeric threshold of "acceptable risk" has ethical implications. One could reasonably ask "acceptable to whom?" In an era when individual choice and autonomy are pillars of the physician-patient relationship, the subjective aspects of perceived risk should be acknowledged and be part of shared decision-making. This is particularly true when the lack of a strong scientific evidence base makes a dichotomous algorithm-driven approach suboptimal for unmitigated translation to clinical practice.
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Affiliation(s)
- Gherardo Finocchiaro
- Cardiothoracic Centre, Guy's and St Thomas' Hospital, London, UK. .,King's College London, London, UK. .,Royal Brompton Hospital, Sydney St, London, SW3 6NP, UK. .,Cardiovascular Clinical Academic Group, St George's, University of London, London, UK.
| | - Emma F Magavern
- The London School of Medicine and Dentistry, William Harvey Research Institute, Barts, London, UK.,Department of Clinical Pharmacology, Cardiovascular Medicine, Barts Health NHS Trust, London, UK
| | | | - Niccolo' Maurizi
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Gerald Carr-White
- Cardiothoracic Centre, Guy's and St Thomas' Hospital, London, UK.,King's College London, London, UK
| | | | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
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Chin TJ, Lee ACL, Fulcher ML. Professional footballers have a limited understanding of the precompetition medical assessment and the possible outcomes including disqualification: a cross-sectional survey. BMJ Open Sport Exerc Med 2021; 7:e001006. [PMID: 33768962 PMCID: PMC7944969 DOI: 10.1136/bmjsem-2020-001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives To determine professional footballers’ level of understanding of the purpose of the precompetition medical assessment (PCMA) and to evaluate their knowledge of potential outcomes following a PCMA, including disqualification. Methods Professional footballers from the Australasian A-League and Westfield W-League were asked to complete a 25-question survey. The relationship between dichotomised outcomes and explanatory variables was analysed with multivariate logistic regression; p<0.05 was considered statistically significant. Results A total of 212 players participated (response rate=48.8%). Most respondents selected ‘To detect medical conditions that may affect performance’ and ‘To detect current injuries’ (n=137, 64.6%; n=130, 61.3%) as the purpose of a PCMA. Approximately one-third (n=74, 38.1%) were neutral or believed that a normal PCMA prevented cardiac arrest. Receiving more PCMAs (p<0.0003) and receiving an explanation during their PCMA (p=0.0175) led to greater awareness of the assessment’s limitations. Most participants did not know the definitions of syncope (n=181, 93.3%) or Marfan syndrome (n=183, 94.3%). Fifty players (28.1%) did not know that disqualification was a possible outcome of a PCMA, and younger players were less aware of this possible outcome (p=0.0216). Conclusion Professional footballers appear to have a limited understanding of the purpose of a PCMA, emphasising the musculoskeletal system and performance. They also appear unfamiliar with the components of the PCMA and medical terms. Finally, many are unaware that disqualification can result from an abnormal PCMA. Player health knowledge must be improved; the informed consent process appears an ideal time to provide this education.
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Affiliation(s)
- Thomas J Chin
- Anglesea Sports Medicine, Hamilton, New Zealand.,Summit Sports Medicine, Mount Maunganui, New Zealand
| | - Arier C L Lee
- Department of Epidemiology and Biostatistics, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Mark L Fulcher
- Axis Sports Medicine Specialists, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
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Orchard JJ, Neubeck L, Orchard JW, Puranik R, Raju H, Freedman B, La Gerche A, Semsarian C. ECG-based cardiac screening programs: Legal, ethical, and logistical considerations. Heart Rhythm 2019; 16:1584-1591. [DOI: 10.1016/j.hrthm.2019.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Indexed: 01/02/2023]
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