Pre-participation screening for the prevention of sudden cardiac death in athletes

Pre-partecipation screening is the systematic practice of medically evaluating large populations of athletes before participation in sport activities for the purpose of identifying abnormalities that could cause disease progression or sudden death.In order to prevent sudden cardiac death(SCD),cardiovascular screening should include a strategy for excluding high-risk subjects from athletic and vigorous exercise.There are two major screening programmes in the world.In the United States competitive athletes are screened by means of family and personal history and physical examination.In Italy there is a mandatory screening for competitive athletes,which includes a resting electrocardiogram(ECG)for the detection of cardiac abnormalities.The most important issue to be addressed is whether a screened subject is really guaranteed that she/he is not suffering from any cardiac disease or at risk for SCD.Conceivably,the introduction of echocardiogram during the pre-participation screening,could be reasonable,despite the discrete sensitivity of ECG,in raising clinical suspicions of severe cardiac alterations predisposing to SCD.It is clear that the costbenefit ratio per saved lives of the ECG screening is abenchmark of the Public Health policy.On the contrary,the additional introduction of echocardiography in a large population screening programme seems to be too much expansive for the Public Health and for this reason not easily practicable,even if useful and not invasive.Even if we strongly believe that a saved life is more important than any cost-efficacy evaluation,the issue of the economical impact of this approach should be further assessed.

Early repolarization syndrome: A cause of sudden cardiac death

Early repolarization syndrome(ERS), demonstrated as J-point elevation on an electrocardiograph, was formerly thought to be a benign entity, but the recent studies have demonstrated that it can be linked to a considerable risk of life- threatening arrhythmias and sudden cardiac death(SCD). Early repolarization characteristics associated with SCD include high-amplitude J-point elevation, horizontal and/or downslopping ST segments, and inferior and/or lateral leads location. The prevalence of ERS varies between 3% and 24%, depending on age, sex and J-point elevation(0.05 m V vs 0.1 m V) being the main determinants.ERS patients are sporadic and they are at a higher risk of having recurrent cardiac events. Implantable cardioverter-defibrillator implantation and isoproterenol are the suggested therapies in this set of patients. On the other hand, asymptomatic patients with ERS are common and have a better prognosis. The risk stratification in asymptomatic patients with ERS still remains a grey area. This review provides an outline of the up-to-date evidence associated with ERS and the risk of life- threatening arrhythmias. Further prospective studies are required to elucidate the mechanisms of ventricular arrhythmogenesis in patients with ERS.

Risk factors for sudden cardiac death to determine high risk patients in specific patient populations that may benefit from a wearable defibrillator

BACKGROUND There is a high risk for sudden cardiac death(SCD) in certain patient groups that would not meet criteria for implantable cardioverter defibrillator(ICD) therapy.In conditions such as hypertrophic cardiomyopathy(HCM) there are clear risk scores that help define patients who are high risk for SCD and would benefit from ICD therapy. There are however many areas of uncertainty such as certain patients post myocardial infarction(MI). These patients are high risk for SCD but there is no clear tool for risk stratifying such patients.AIM To assess risk factors for sudden cardiac death in major cardiac disorders and to help select patients who might benefit from Wearable cardiac defibrillators(WCD).METHODS A literature search was performed looking for risk factors for SCD in patients post-MI, patients with left ventricular systolic dysfunction(LVSD), HCM, long QT syndrome(LQTS). There were 41 studies included and risk factors and the relative risks for SCD were compiled in table form.RESULTS We extracted data on relative risk for SCD of specific variables such as age,gender, ejection fraction. The greatest risk factors for SCD in post MI patients was the presence of diabetes [Hazard ratio(HR) 1.90-3.80], in patient with LVSD was ventricular tachycardia(Relative risk 3.50), in LQTS was a prolonged QTc(HR36.53) and in patients with HCM was LVH greater than 20 mm(HR 3.10). A proportion of patients currently not suitable for ICD might benefit from a WCDCONCLUSION There is a very high risk of SCD post MI, in patients with LVSD, HCM and LQTS even in those who do not meet criteria for ICD implantation. These patients may be candidates for a WCD. The development of more sensitive risk calculators to predict SCD is necessary in these patients to help guide treatment.

Hypertrophic cardiomyopathy and sudden cardiac death

Hypertrophic cardiomyopathy (HCM) is a common genetic cardiovascular disease that affects the left ventricle. HCM can appear at any age, with the majority of the patients remaining clinically stable. When patients complain of symptoms, these include: dyspnea, dizziness, syncope and angina. HCM can lead to sudden cardiac death (SCD), mainly due to ventricular tachyarrhythmia or ventricular tachycardia. High-risk patients benefit from implantable cardioverter-defibrillators. Left ventricular outflow tract obstruction is not a rare feature in HCM, especially in symptomatic patients, and procedures that abolish that obstruction provide positive and consistent results that can improve longterm survival. HCM is the most common cause of sudden death in young competitive athletes and preparticipation screening programs have to be implemented to avoid these tragic fatalities. The structure of these programs is a matter of large debate. Worldwide registries are necessary to identify the full extent of HCMrelated SCD.

Electrophysiologic testing guided risk stratification approach for sudden cardiac death beyond the left ventricular ejection fraction

Sudden cardiac death threats ischaemic and dilated cardiomyopathy patients. Anti- arrhythmic protection may be provided to these patients with implanted cardiac defibrillators(ICD), after an efficient risk stratification approach. The proposed risk stratifier of an impaired left ventricular ejection fraction has limited sensitivity meaning that a significant number of victims will remain undetectable by this risk stratification approach because they have a preserved left ventricular systolic function. Current risk stratification strategies focus on combinations of non invasive methods like T wave alternans, late potentials, heart rate turbulence, deceleration capacity and others, with invasive methods like the electrophysiologic study. In the presence of an electrically impaired substrate with formed post myocardial infarction fibrotic zones, programmed ventricular stimulation provides important prognostic information for the selection of the patients expected to benefit from an ICD implantation, while due to its high negative predictive value, patients at low risk level may also be detected. Clustering evidence from different research groups and electrophysiologic labs support an electrophysiologic testing guided risk stratification approach for sudden cardiac death.

Early detection of sudden cardiac death by using classical linear techniques and time-frequency methods on electrocardiogram signals

Early detection of sudden cardiac death may be used for surviving the life of cardiac patients. In this paper we have investigated an algorithm to detect and predict sudden cardiac death, by processing of heart rate variability signal through the classical and time-frequency methods. At first, one minute of ECG signals, just before the cardiac death event are extracted and used to compute heart rate variability (HRV) signal. Five features in time domain and four features in frequency domain are extracted from the HRV signal and used as classical linear features. Then the Wigner Ville transform is applied to the HRV signal, and 11 extra features in the time-frequency (TF) domain are obtained. In order to improve the performance of classification, the principal component analysis (PCA) is applied to the obtained features vector. Finally a neural network classifier is applied to the reduced features. The obtained results show that the TF method can classify normal and SCD subjects, more efficiently than the classical methods. A MIT-BIH ECG database was used to evaluate the proposed method. The proposed method was implemented using MLP classifier and had 74.36% and 99.16% correct detection rate (accuracy) for classical features and TF method, respectively. Also, the accuracy of the KNN classifier were 73.87% and 96.04%.

Ventricular Arrhythmia-Free Survival Following Therapeutic Hypothermia in Patients with Sudden Cardiac Death Due to Ventricular Tachycardia or Fibrillation

Background: The potential benefits of implantable cardioverter-defibrillator (ICD) therapy in patients with sudden cardiac death (SCD) treated with therapeutic hypothermia (TH) have not been well studied. Methods: Incidence of recurrent non-sustained ventricular arrhythmia, ICD therapy, and death were ascertained in 64 consecutive survivors of SCD due to ventricular fibrillation or tachycardia, who were treated with TH. Follow-up was 31.5 +/- 3.3 months in 41 ICD recipients and 36.3 +/- 3.9 months in 23 patients who did not receive an ICD due to the presence of a reversible cause of cardiac arrest, an acute myocardial infarction in 87%. Results: Combined incidence of ventricular arrhythmia, ICD therapy, or death in patients who underwent ICD placement (21.9%) were similar to overall mortality in the patients who did not receive an ICD (21.7%, p = 0.752). ICD placement was associated with a significant mortality benefit;95.1% survival in ICD recipients vs. 78.3% in the no-ICD group (p = 0.038). Electrocardiographic findings of ST segment elevation on admission were associated with increased event rate in ICD recipients (p = 0.039) and increased mortality in SCD patients who did not receive an ICD (p Conclusions: SCD survivors treated with TH are at increased risk for recurrent arrhythmic events and derive significant mortality benefit from ICD implantation. Increased mortality in revascularized SCD patients with acute coronary syndrome, thought to have a reversible cause of cardiac arrest, calls for prospective trials investigating utility of ICD in this vulnerable patient population.

Preventing Sudden Cardiac Death during Marathons with Pre-Race Aspirin

Objectives: Prevention of sudden cardiac death is the number one clinical priority in sports cardiology. While the overall cardiovascular risk of long distance running is acknowledged as low, the frequency of cardiac arrests and sudden death has increased in middle-aged males during marathons since the year 2000. An evidence-based strategy for protecting susceptible runners from these acute cardiac events during races is considered based on identification of the underlying cause. Method: Review of articles in Pub Med on adverse cardiac events during marathons. Findings: Recent epidemiological studies have identified an increasing frequency of cardiac arrest in middle-aged males during marathons since the year 2000 with atherosclerotic heart disease as the main cause of sudden cardiac death. Same-aged asymptomatic middle-aged male physician-runners showed a post-race polymorphonuclear leukocytosis with sequential increases in interleukin-6 and C-reactive protein as a likely consequence of rhabdomyolysis after “hitting the wall”. Increased fibrinogen, von Willebrand factor and D-dimer with in vivo platelet activation indicated a concurrent hemostatic imbalance with pro-coagulant effects. Cardiac troponins I and T and NT-pro-B-type natriuretic peptide were elevated after races as additionally predictive of acute cardiac events in asymptomatic persons. Conclusions: High short-term risk for acute cardiac events in asymptomatic middle-aged male runners is shown by stratification of validated biomarkers, which may render non-obstructive coronary atherosclerotic plaques vulnerable to rupture during marathons. Pre-race aspirin usage is prudent to reduce these events mediated by atherothrombosis based on conclusive evidence for prevention of first acute myocardial infarctions in same-aged healthy male physicians. Prospective studies are needed to determine the efficacy of pre-race low-dose aspirin for curtailing the increasing frequency of race-related cardiac arrest and sudden death in susceptible runners.

The Significance of Angiotensin Converting Enzyme Inhibitor or Angiotensin II Receptor Blocker Use in Sudden Cardiac Death

Objectives: To investigate the relationship between the use of angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) and hyperkalemia in patients diagnosed with sudden cardiac death. Methods: We examined oral ACE inhibitor or ARB use among cardiopulmonary arrest patients brought by ambulance to our emergency room during a 5-year period from January 2012 to December 2016. The cause of death was determined to be sudden cardiac death, despite temporary return of spontaneous circulation after starting cardiopulmonary resuscitation. Subjects were dichotomized into 2 groups, those taking and those not taking an ACE inhibitor or ARB. Variables determined retrospectively included serum potassium, estimated glomerular filtration rate as an index of kidney function and time from cardiopulmonary arrest to return of spontaneous circulation. The Mann-Whitney U-test was used to compare continuous data, and the chi-square test to compare categorical data between groups. The results are expressed as the median plus range. Statistical significance was assumed at p Results: Thirty-five patients met the inclusion criteria. The mean age was 77.1 years (range, 35 - 93 years), and there were 26 males and 9 females. Eleven subjects were ACE inhibitor or ARB users, and 24 were non-users. The serum potassium level was significantly higher in users than non-users (median, 6.2 mEq/L (range, 4.5 - 10.0) vs. 5.2 mEq/L (range, 3.6 - 8.3);p = 0.001). The estimated glomerular filtration rate was significantly lower in users than non-users (median, 25.1 mL/min/1.73 m2 (range, 4.6 - 60.3) vs. 46.9 mL/min/1.73 m2 (range, 19.8 - 97.1);p = 0.009). There was no significant difference in time from cardiopulmonary arrest to return of spontaneous circulation between the 2 groups (median, 24 minutes (range, 3 - 111) vs. 29 minutes (range, 10 - 54);p = 0.355). Conclusion: It is possible that hyperkalemia induced by ACE inhibitor or ARB use is a cause of sudden cardiac death, especially in patients with chronic kidney disease.

ECG is not a reliable predictor of sudden cardiac death in the general population

Objectives: To determine the predictive value of the ECG for sudden death in the general population. Design: In the Copenhagen City Heart Study, a randomly selected population sample in Copenhagen, Denmarkhas been followed prospectively since 1976. From this population sample, we analyzed ECGs of individuals who had suffered sudden cardiac death (SCD) before the age of 50 years and compared them with ECGs of a randomly selected control individuals from the same population sample. Specific ECG signs that could point toward a condition associated with a risk of SCD were noted. Results: From a total of 18,974 individuals in the cohort, 207 had died at an age younger than 50 years. Among these, 24 persons with SCD were identified. The most prevalent ECG abnormality was QRS fragmentation. We found no ECGs with long or short QTc, Brugada sign or WPW. The prevalence of signs of left ventricular hyper-trophy, early repolarization, or fragmentation was not different from the prevalence of these signs in the control group. Conclusion: In the Copenhagen City Heart Study, the ECG failed to predict SCD in persons who died before the age of 50 years.

Awareness of the Importance of Cardiopulmonary Resuscitation Skills Following the Sudden Cardiac Arrest of Damar Hamlin during a Buffalo Bills Game

Background: Cardiopulmonary resuscitation (CPR) is a life-saving skill that is often overlooked until a tragic event occurs. A popular NFL player, Damar Hamlin, safety for the Buffalo Bills, suffered a cardiac arrest on January 2, 2023. Due to prompt intervention and CPR, Hamlin survived the arrest and is playing again. This research sought to understand how people respond to this event on the internet. It also seeks to understand how this response can be used to raise CPR awareness. Design and Methods: Using Google Trends and Twitter data, we searched, downloaded, and retrospectively analyzed search interests relative to Hamlin’s cardiac arrest for a one-year duration. We searched for related keywords in the United States from March 2022 to March 2023, including “Damar Hamlin”, “sudden cardiac death”, “heart attack”, and “CPR”. Results: There was a significant rise in post-event Google searches that combined the terms “Damar Hamlin” and “SCD” (M = -28898.88, SE = 1537.66;t = 1.62, p Conclusion: Based on the analytics of these platforms, it can be concluded that there were active discussions and an awareness of life-saving skills such as CPR along with Hamlin’s cardiac event by his fans, as demonstrated by the data gathered from these platforms. This can provide us with valuable insight into human behavior and help us leverage this knowledge to promote health.

Sudden cardiac death in a case of Crohn's disease with COVID-19: A case report

Rationale:The mechanism of sudden cardiac death in COVID-19 can be multifactorial.Cardiac hypersensitivity to 5-ASA therapy leading to myocarditis has been reported in some cases.Cytokine storm syndrome and idiosyncratic reaction with mesalazine use may lead to sudden cardiac death in COVID-19.Use of immunosuppressants in hospitalized COVID-19 patients should be continued with caution,especially in patients with inflammatory bowel disease.Patient’s concern:A 75-year-old man who was tested positive for SARS-CoV-2 was admitted with a history of shortness of breath for the last two days.He was a known case of Crohn’s disease treated with mesalazine.Diagnosis:COVID-19 pneumonia with underlying Crohn’s disease leading to sudden cardiac death.Intervention:Remdesivir,antibiotics,steroids,low molecular weight heparin,tablet zinc,tab vitamin C,and other supportive treatment were started.Because of increased inflammatory markers,itolizumab was given to the patient on the 2nd day.Outcome:On the 5th day of the intensive care unit,the patient complained of sudden chest pain with respiratory distress leading to bradycardia and asystole and could not be resuscitated.Lessons:Causes for sudden cardiac death in COVID-19 pneumonia patients with Crohn’s disease is multifactorial.Although mesalazine may be a safe and effective drug in the management of inflammatory bowel disease,it can induce sytokine strom syndrome and idiosyncratic reactions that could be one of the reasons of sudden cardic death.Therefore,we should be aware of its serious and potentially life-threatening complications,especially in COVID-19 infected patients.

Sudden cardiac death in patients with rheumatoid arthritis

An increased cardiovascular morbidity and mortality, including the risk of sudden cardiac death(SCD), has been shown in patients with rheumatoid arthritis(RA). Abnormalities in autonomic markers such as heart rate variability and ventricular repolarization parameters, such as QTc interval and QT dispersion, have been associated with sudden death in patients with RA. The interplay between these parameters and inflammation that is known to exist with RA is of growing interest. In this article, we review the prevalence and predictors of SCD in patients with RA and describe the potential underlying mechanisms, which may contribute to this. We also review the impact of biologic agents on arrhythmic risk as well as cardiovascular morbidity and mortality.

Sudden Cardiac Death in Adult Patients with Stable Ischemic Heart Disease

There are approximately one half million patients with stable ischemic heart disease(SIHD)in the United States.Patients with stable ischemic heart disease who die suddenly do not maintain a Stable Ischemic profi le.Benchimol,et al.,reported 319 consecutive stable angina patients without clinical heart failure or a recent myocardial infarction but who had multiple risk factors and proven coronary disease which made them more prone to acute myocardial infarction or unstable angina.In the APSIS(angina prognosis in Stockholm)study,Hjemdahl reported that signs of ischemia or previous manifestations of coronary artery disease,i.e.,myocardial infarction or revascularization,were found in 69%of both male and female patients at baseline.Little,retrospectively reported that minor plaques may disrupt and result in unstable angina or occlusive coronary disease which then may result in acute myocardial infarction.Stable angina patients,by defi nition,are stable and are not high risk unless they have multiple factors or which may make them prone to evolve an acute coronary syndrome or develop a serious arrhythmia but sudden death does occur in some patients.

Sudden Cardiac Death: Clinical Perspectives from the University of Maiduguri Teaching Hospital, Nigeria

Despite tremendous advances in the management of cardiovascular diseases and cardiac arrest, there is paucity of information regarding sudden cardiac death in sub-Saharan Africa. We present a two-year review of sudden cardiac death cases among patients managed at a Nigerian tertiary hospital. Patients admitted from January 2012 to December 2013 were prospectively followed-up and cases of sudden cardiac death identified. Diagnosis was based on records of events preceding death, direct interview of attending physician/nurses, and family members/eye witnesses for out-of-hospital sudden cardiac death. Causes of death were obtained from the death certificates for cases of in-hospital events. Three hundred and eighty eight (M:F = 1:1.3) patients with a mean age of 42.22 ± 19.30 years were admitted into the cardiac unit during the period, out of whom 56 (14.4%) died. Twenty three (41.1%) were classified as sudden cardiac death. The predominant etiology was ischemic cardiomyopathy (39.1%), followed by peripartum cardiomyopathy (21.7%) and dilated cardiomyopathy (17.4%). Rheumatic heart disease was diagnosed in 17.4%, while 4.3% had pulmonary hypertension. Nineteen (82.6%) of the subjects had congestive cardiac failure. Hypokalemia and hypocalcaemia were recorded in 2 (8.7%) patients who developed prolongation of the QT interval following commencement of diuretics. Chest-compression-only cardiopulmonary resuscitation was attempted in 12 (52.1%) with a success rate of 8.3%. Sudden cardiac death is common among our patients admitted with cardiovascular diseases. The most common etiology is ischemic cardiomyopathy, followed by peripartum cardiomyopathy. Most of the victims were young, and there were no optimum resuscitative measures.

Sudden Cardiac Death in Dakar: Epidemiological and Anatomo-Pathological Characteristics

Sudden cardiac death (SCD) generally refers to sudden cardiovascular death of a person with or without pre-existing heart disease. This is a retrospective study conducted at the Department of Anatomy and Pathological Cytology at Aristide Le Dantec Hospital in Senegal. This study covers a period of 7 years from January 1st, 2000 to December 31st, 2006. During this 7-year period we collected 235 cases of sudden cardiovascular death out of a total of 3717 forensic autopsies, representing a frequency of 6.32%. Sudden cardiovascular deaths accounted for 75.3% of all 312 sudden deaths. 96.1% were black compared to 3.9% Caucasians. The average age of the patients was 46.86 years with extremes ranging from 17 to 86 years. The most affected age group was between 50 - 59 years old, representing 23.4% of the cases. The sex ratio was 4.3 in favour of men. Men aged 50 - 59 were the most affected, while women were more affected in the 20 - 29 age group. Cardiomyopathies constituted 54.9% with 90% of dilated cardiomyopathies of which 75% were male and 10% of hypertrophic cardiomyopathies more frequent also in men. Valvulopathies came in 3rd position with 3.4% of the cases and in 75% of the cases they were poly-valvulopathies. Atherosclerosis was incriminated in 2.5% of the cases and aortic localization was the most represented. Aortic dissection was implicated in 6 cases out of 235 or 2.5%. It was isolated in 4 cases (without other cardiac conditions), and in the other 2 cases it was accompanied by other cardiac lesions including hypertrophy, pericarditis and endocarditis. The other causes found were interauricular communication (n = 1) and pericarditis (n = 2). Sudden cardiovascular death is a major global public health problem. The lack of epidemiological data on sudden death in Africa motivated our work, which led us to note that 75.3% of all sudden deaths in adults were of cardiovascular origin.

Sudden Death as the Outcome of Cardiac Arrest,in a Portuguese Region:Where Do Resuscitation Manoeuvres Stand?

Cardiac Arrest (CA) is a major health problem, due to short and long-term sequel? and to associated mortality. Despite the improvement of out-of-hospital and in-hospital resuscitation manoeuvres, unexpected sudden fatal events occur. The authors reported the features of a series of sudden death (SD) cases where cardiopulmonary resuscitation (CPR) was performed. Files of 1053 medico-legal autopsies, from victims aged ≥18 years-old, were reviewed. Cardiac Arrest leading to Sudden Death were found in 477 cases (45.3%), but only 199 (42%) of these had been submitted to resuscitation manoeuvres. There was an elderly male predominance. Both non-cardiac and cardiac CA/SD causes were present, despite the higher coronary artery disease incidence. Both out-of-hospital and in-hospital events took place. Age, severity of the disease, comorbidities and predominance of out-of-hospital CA were obstacles to successful CPR, leading to SD. Knowing the population characteristics may help to improve Emergency Assistance.