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Pediatric Update

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Pediatric Update

 
Fall 2006

Sudden Death in the Athletic Child

The death of a well-conditioned young person during athletic participation is both tragic and disturbing. Sudden death among athletes usually relates to an unsuspected congenital heart condition, most commonly hypertrophic cardiomyopathy. Although rare—approximately 100 incidents occur each year—these deaths have generated a great deal of publicity and have moved many in the medical community to advocate screening young athletes for cardiovascular abnormalities prior to participation in competitive sports. “

An even split exists among specialists in arrhythmia management as to whether or not we should be doing screening studies for young athletes, and there are passionate people on both sides,” says Kevin Shannon, M.D., pediatric cardiologist and co-director of the UCLA Cardiac Arrhythmia Center.

Dr. Shannon argues that the most effective way to identify athletes at risk is with a thorough personal and family history and evaluation, and referral of patients with suspicious findings for specialized testing. The evaluation should determine whether there is a family history of sudden death and/or cardiovascular disease in anyone under 30. Any history of unusual accidents—for example, a family member who drowned in a small amount of water or died in a single-car accident without any known cause for having lost control of the vehicle—also should arouse suspicion.

Certain symptoms also may indicate the need for further evaluation.While fainting episodes are not uncommon among adolescents, they are unusual enough to warrant an electrocardiogram. Other than shortness of breath, nearly all exercise-induced symptoms—palpitations, vision changes, nausea and chest pain—warrant follow-up. Patients should receive a careful cardiac exam and Valsalva maneuver, both looking for murmurs. Most patients with hypertrophic cardiomyopathy have a murmur, even if they don’t have obstruction, Dr. Shannon notes.

Dr. Shannon assesses the percentage risk that a patient with suspicious findings has a particular disease. “There is not always a definitive diagnosis, although we’re getting better, particularly with the availability of genetic screening,” he explains. In determining whether to recommend participation in competitive sports, he multiplies the percentage risk of the patient having a particular disease by the percentage risk that, if the patient does have that disease, participation would trigger a fatal event. “Occasionally, after looking at the family history, other family members’ findings and the severity of the patient’s findings, I might decide that even if the patient has the disease, it is such a mild form that his chances of sudden death are trivial and he should be allowed to participate,” Dr. Shannon says. “However, most of the time, when suspected disease exists and you multiply those two percentages, you wind up with a number too high to let the child compete.”

The most difficult patients to keep from participating are those with “grayzone” findings—a small risk, often without a definitive diagnosis. “For a lot of adolescents, even if you tell them there is a 5 percent chance of dying if they play, they want to play,” Dr. Shannon says. “They feel invincible.”

Even when risk factors for sudden death prevent patients from competing, conditioning remains important. For patients he prohibits from participation, Dr. Shannon conducts treadmill tests to gauge their ability to exercise and show them the level they should not exceed. Most are advised to remain involved in recreational sports in which they won’t feel compelled to continue when they become tired.

Those who advocate routine cardiovascular screening for all young athletes point to studies that show screening does detect patients with hypertrophic cardiomyopathy who would otherwise have been cleared to play. But Dr. Shannon notes that none of these studies was blinded or randomized; he also argues that the conclusions have been based on the false assumption that any abnormality detected is a death prevented. “The risk of dying if you have hypertrophic cardiomyopathy is not 100 percent. If you find the disease in an athlete, you are not necessarily preventing a death,” he says. “In addition, if you restrict that person from athletic participation, it doesn’t guarantee that the person won’t die from the disease.”

Screening all young athletes with echocardiograms would almost certainly identify some individuals with clear risk factors for sudden death who should not be participating. At the same time, for every positive finding there might be 10 to 20 athletes with borderline findings that would require expensive follow-up evaluations. During the evaluation time, he says, many would be restricted, and some might be told they can’t participate even if they were not found to have a disease. Due to liability concerns, “even when these athletes are cleared to participate, coaches and schools often don’t want to take that chance,” Dr. Shannon says.

Rather than routinely screening all young athletes, Dr. Shannon encourages greater emphasis on a thorough preparticipation history and physical. “For many of these athletes, this is the only time they will see a doctor during their adolescence,” he says, “This provides an opportunity not only to screen them for sudden-death risk factors, but to counsel on all areas of risk avoidance.”





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