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Courtney Moore April 3, 2014 ENC 1102 Literature Review: Sudden cardiac death: What is it and what can we do? Ive decided to look into is a typical controversial topic of death that can take place among athletes. This occurrence is referred to as sudden cardiac death (SCD) and is usually rare. Although rare, it is none the less a frightening event to witness. This conversation is important because with the addition of existing technology and eventually future improvements and further d advances into the medical field perhaps one day we can prevent SCD from happening at all. It is also important because it is informational to many people including but not limited to: patients, athletes, doctors, coaches, trainers, and parents. It may also be helpful to any college students who may take an interest in the cardiovascular subject and want to gather further information about sudden cardiac death in athletes. SCD can be due to a number of pre-existing cardiac disease and underlying heart defects. Physicians have thought to have narrowed down the causes to two specific diseases: hypertrophic cardiomyopathy disease (HCM) and congenital coronary artery disease (CAA). Since SCD is such a rare occurrence among the population, when it does eventually happens to an athlete it can most likely be found on the news. Its a media frenzy and the population and surrounding community are in shock. Coaches and trainers want to prevent their athletes from being affected by this occurrence and therefore require mandatory physicals prior to the start of the season to that specific sport. Surprisingly most SCD cases have taken place in start-stop sports such as, but not limited, to football and basketball. The combination of the momentum it takes to propel their

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bodies forward on the start and the chance of being slammed into by another player significantly increases the athletes risk for SCD. Another factor that actually increases SCD in athletes is by exercise. Exercise, as it is already, increases the heart rate which causes the heart to work twice as hard to pump and circulate the blood throughout your body. If a pre-existing heart disease or abnormality is present and goes undiagnosed, the athlete is likely to put their health and heart at risk during exercise or training for competitive sports. Due to the rarity of SCD, the athlete is often asymptomatic (not exhibiting any known symptoms) and death is unfortunately the first sign. In fact, pre-existing heart diseases and abnormalities can be treated if caught in time by the use of an EKG or electrocardiogram. An EKG is a test that is administered through the use of a 12-lead machine which records and monitors the electrical activity of the heart. It allows the physician or cardiologist to detect any electrical abnormalities or defects that may be present in an individuals heart. Usually if a severe defect is detected the diagnosing doctor may recommend the discontinuance or disqualification of participation in a competitive sport. Another action the physician may take if the defect is severe enough is through cardiovascular surgery where the surgeon implants a defibrillator that sends impulses or shocks to the heart when an arrhythmia is detected. Since medicine is evolving every day, the studies and articles I looked into are fairly recent within the last 2 years in order to receive the most advanced information and new findings on sudden cardiac death. Doctors have come to somewhat of a conclusion that Sudden Cardiac death (SCD) in athletes can be caused by two main causes due to structural defects. The most common cause is known as hypertrophic cardiomyopathy (HCM). HCM is a disease in which the heart muscle, referred to as, myocardium, becomes abnormally thick. The thickened heart muscle can make it

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harder for the heart to pump blood. Patients with HCM are likely to be at the highest risk for SCD. (Law, et al. 388) The second most common cause can be congenital coronary artery disease. If a disease is congenital it means the individual was born with it. Coronary arteries in your body are the major blood vessels that supply your heart with blood and oxygen. Coronary artery disease is often cause by plaque which can be from cholesterol containing deposits in your arteries. If the plaque begins to build up we begin to see the coronary artery narrow which can cause the heart to receive less blood. If a complete blockage occurs if can lead to a heart attack. Studies done on HCM patients have indicated that this disease can actually be inherited by a mutated gene and is seen as the leading genetic cause of SCD in competitive athletes in the U.S. Both diseases in fact have the ability to be genetic and be passed down to the offspring from the infected parent(s). SCD seems to be more prevalent in start-stop sports such as football and basketball. In said sports, aside from being competitive, the athlete is required to use a large amount of energy at one given time to propel themselves forward sometimes into another player during a given play. Although rare, SCD is most likely to occur during exercise or immediately after. Adrenaline, which can be created in the body during any exercise or sport, such as a stop-start sport and in addition to that can be seen in competitive swimming, can in fact trigger an arrhythmia which in the end may lead to SCD. If we take a closer look into football we find out that SCD is the leading cause of death among the National Collegiate Athletic Association (NCAA). Since linemen need to exhibit an increased amount of energy and is combined with the player often holding their breath with increases the electrical defect within the heart. If an athlete conditions and exercises extensively, their heart often remodels itself and thickens the

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ventricular walls so that the athlete has more endurance since sports require more strength, stamina and energy which puts the athlete at a higher risk for SCD. SCD also can be seen more among African American (black) males who are involved in playing sports. During autopsies of the deceased, reports were collected that indicated that HCM as previously mentioned was present among black with approximately 20% while 10% in whites. Scientists estimate that SCD under some extreme cases may be genetic and a phenotype amongst black males. (Chandra, et al. 1028) Since SCD is commonly seen in basketball or football, we see the comparison that it is prevalent among men rather than females. However, if the conditions are right, females may exhibit SCD similar to males since I previously mentioned that it can genetic and be passed down to offspring. Studies conducted show a prevalence of early repolarization pattern in black males that have a lower heart rate and increased QRS wave. A QRS wave is ventricular depolarization, when it is increased this means that the heart is exerting more energy to push the blood out of the left and right ventricles. Some studies have been conducted in which resulted in the findings that perhaps Sudden cardiac death can be prevented by a 12-lead electrocardiogram (EKG). Unfortunately, guidelines constructed by the American Heart Association (AHA) state that an EKG is optional and is often not required. Usually, in an individual wishes to participate in a sport they are required to receive a physical before they can begin training or participation. During the physical if an abnormality is detected then further tests such as an EKG should be conducted. To determine a diagnosis, the doctor will execute an EKG which records the electrical activity of the athletes heart and translates the recordings onto a line on paper that signifies the PQRST complex. Findings from such tests show that approximately 90% of the affected athletes exhibit an abnormal resting EKG. Since an EKG is not mandatory physicians usually rely on the patients family history. The

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reason why the AHA does not make the use of an EKG in athletes or even society mandatory is due to the cost of it which estimates to be about $2.5 to $3.4 billion per year. If an EKG is conducted early enough and a defect can be caught early, there are a few treatment methods the doctors can utilize. Upon diagnosis of a defect, doctors may disqualify athletes from participating in competitive sports. If the athlete is diagnosed with HCM then the doctor will most likely restrict the athlete from participating in competitive sports which can lead to SCD. Recently, studies have shown due to the lack of evidence and data for a specific disease, doctors often are incorrect about the type of activities that they restrict. (Roston, et al. 1375) However, due to the controversy of todays increasing risk of obesity, doctors often allow low to moderate exercise by individuals who are diagnosed with a cardiac defect. If an athletes EKG screen comes back positive for a cardiac defect, the athlete must undergo a follow up test and would most likely be disqualified from any physical activity including sports. Athletes are disqualifies from participating in competitive sports or often prescribed to be deconditioned, which means to decrease exercise, due to the discovery of an abnormality which can increase the athletes or individuals risk for SCD. In addition to the findings made after the EKG is done, doctors may instead deduce to treat the problem with surgery depending on the severity of the defect. Doctors may decide to perform a surgical procedure which consists of the implantation of a cardiodefibrillator which sends electrical impulses to the heart when it indicates an arrhythmia. A study was conducted and outlined by Roston et al. which consisted of a survey to determine the pattern of maximum exercise involvement that should be allowed for patients with heart disease. The study resulted that some cardiac care providers only partially implement the guidelines for

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physical activity by either over or under restricting exercise for patients with a known cardiac defect. (Roston, et al. 1377)

Whats missing? What Im interested in investigating is the prevention of death among athletes as well as in the general population. The gap that is continuous throughout the articles I have researched is the cost of one EKG to be preformed and the lack of funding for them. Although sudden cardiac death (SCD) is rare, some ideas that can help with the prevention of such deaths is making EKGs more affordable, which can in turn be achieved by finding funding to pay for the use of this procedure. In making EKGs more affordable, many cardiac defects can be caught early and be dealt with accordingly. If a defect can be detected early on in an individuals life then the doctors can find a cure or come to a plausible outcome than can decrease the risk of cardiac failure. If more funding can be found, the cost of an EKG will decrease and more people will be able to receive the procedure earlier in life. This may in the end increase prevention and allow doctors to diagnosis a defect at the onset instead of catching it later in life when it has the potential to become fatal.

Proposal: I am interested in looking into the prevention of deaths among athletes who may die of sudden cardiac death (SCD) due to a heart defect or disease through making and EKG, a medical procedure, more affordable for patients. One type of prevention I think would be helpful to take a further look into and research is finding more appropriate funding so that more EKGs can be performed on more people. Research estimates that it costs approximately $2.5 to $3.4 billion per year for an EKG. Although sudden cardiac death is rare, it is still an occurrence that takes the

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community by surprise. Scientists have deduced that perhaps more cases of SCD can be prevented with more EKGs that are preformed earlier in life. However, due to the amount of money it takes to perform one makes that goal nearly economically impossible. My proposal is for finding more funding in order to perhaps make these EKGs affordable for the average individual. Id like to model my proposal to that of the Susan G. Komen fundraisers for breast cancer. This organization holds many different events and benefits in which people can participate in and raise money to fund further research efforts. The same can be said about SCD. If a whole organization can be established then many races and events towards the cause which many people can participate in and others can donate money to fund further research efforts. Such events being held would not only raise funds but would also serve as an educational purpose for the public and raise awareness world-wide to promote the dangers of such a disease. Perhaps this can also enhance the knowledge on someone and encourage them to donate and fund the cause as well as take the necessary precautions to seek diagnosis as early as possible if they exhibit any type of cardiac defect.

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Bibliography: Angelini, Paolo, Mladen Vidovich, Christine Lawless, Macarthur Elayda, J. Alberto Lopez, Dwayne Wolf, and James Willerson. "Preventing Sudden Cardiac Death in Athletes. "Forthcoming Clinical Investigation 2nd ser. 40 (2013): 148-55. Print. Balady, G. J., and J. A. Drezner. "Tackling Cardiovascular Health Risks in College Football Players." Circulation 128.5 (2013): 477-80. Print. Bar-Cohen, Yaniv, and Michael J. Silka. "The Pre-Sports Cardiovascular Evaluation: Should It Depend on the Level of Competition, the Sport, or the State?" Pediatric Cardiology 33.3 (2012): 417-27. Print. Batra, Anjan S., and Seshadri Balaji. "Prevalence and Spectrum Diseases Predisposing to Sudden Cardiac Death: Are They the Same for Both the Athlete and the Nonathlete?" Pediatric Cardiology 33.3 (2012): 379-86. Print. Chandra, Navin, Rachel Bastiaenen, Michael Papadakis, and Sanjay Sharma. "Sudden Cardiac Death in Young Athletes." Journal of the American College of Cardiology61.10 (2013): 1027-040. Print. Choi, Kristal, Yann Ping Pan, Michelle Pock, and Ruey-Kang R. Chang. "Active Surveillance of Sudden Cardiac Death in Young Athletes by Periodic Internet Searches." Pediatric Cardiology 34.8 (2013): 1816-822. Print. Halkin, Amir, Arie Steinvil, Raphael Rosso, Arnon Adler, Uri Rozovski, and Sami Viskin. "Preventing Sudden Death of Athletes With Electrocardiographic Screening." Journal of the American College of Cardiology 60.22 (2012): 2271-276. Print. Law, Ian H., and Kevin Shannon. "Implantable Cardioverter-Defibrillators and the Young Athlete: Can the Two Coexist?" Pediatric Cardiology 33.3 (2012): 387-93. Print.

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McClaskey, David, Daniel Lee, and Eric Buch. "Outcomes among Athletes with Arrhythmias and Electrocardiographic Abnormalities: Implications for ECG Interpretation." Sports Medicine 43.10 (2013): 979-91. Print. Morse, Emily, and Marjorie Funk. "Preparticipation Screening and Prevention of Sudden Cardiac Death in Athletes: Implications for Primary Care." Journal of the American Academy of Nurse Practitioners 24.2 (2012): 63-69. Print. Roston, Thomas M., Astrid M. Souza, George G. S. Sandor, Shubhayan Sanatani, and James E. Potts. "Physical Activity Recommendations for Patients With Electrophysiologic and Structural Congenital Heart Disease: A Survey of Canadian Health Care Providers."Pediatric Cardiology 34.6 (2013): 1374-381. Print. Sarquella-Brugada, Georgia, Oscar Campuzano, Anna Iglesias, Josep Snchez-Malagn, Myriam Guerra-Balic, Josep Brugada, and Ramon Brugada. "Genetics of Sudden Cardiac Death in Children and Young Athletes." Cardiology in the Young 23.02 (2013): 159-73. Print. Tanguturi, Varsha Keelara, Peter A. Noseworthy, Christopher Newton-Cheh, and Aaron L. Baggish. "The Electrocardiographic Early Repolarization Pattern in Athletes." Sports Medicine 42.5 (2012): 359-66. Print. Vaseghi, Marmar, Michael J. Ackerman, and Ravi Mandapati. "Restricting Sports for Athletes With Heart Disease: Are We Saving Lives, Avoiding Lawsuits, or Just Promoting Obesity and Sedentary Living?" Pediatric Cardiology 33.3 (2012): 407-16. Print. "Hypertrophic Cardiomyopathy: MedlinePlus Medical Encyclopedia." U.S National Library of Medicine. U.S. National Library of Medicine, n.d. Web. 31 Mar. 2014.