Sudden cardiac death in athletes is more common that you might think. Many of us can remember the tragic death on the court of the great college basketball player Hank Gathers of Loyola. Common causes of death in athletes include Hypertrophic Cardiomyopathy (HCM) and Long QT syndrome (LQTS). Screening of high school and college athletes has been a hot topic of debate lately. How do we screen, who do we screen and when do we screen? Certainly, in today’s healthcare environment, economics play a role–we must be cost effective with our screening techniques while at the same time effectively identifying at risk young athletes.
When athletes are identified as having a condition that puts them at risk for sudden death, it often results in the end of a career. In certain cases of HCM or LQTS patients must be implanted with an Implantable Cardioverter Defibrillator (ICD) in order to protect them from sudden death. In other cases medical therapy is prescribed. Certainly, this type of diagnosis can be a devastating, life-changing event for a young person.
In recent days, many of us have been glued to our televisions watching the Olympic games. Many of these athletes have trained their entire lives for one competition, one event, one lap in the pool. One competitor in particular has defied the odds and has stirred debate about how electrophysiologists deal with young athletes at risk for sudden cardiac death. Swimmer Dana Vollmer won the Gold medal in the 100 meter butterfly in London. An article published this week in the New York Times
highlighted her Olympic journey. Ms Vollmer has LQTS and as a 15 year old high school athlete was told that the only way she could continue to compete was to have an ICD implanted. She was diagnosed after experiencing dizzy spells while in the pool during training sessions. After a thorough evaluation by a local cardiologist she was found to have LQTS. Ms Vollmer chose not to have an ICD implanted. However, her mother agreed to sit in at each and every workout and competition with an external automated defibrillator (AED) sitting at her feet.LQTS accounts for nearly 2000 deaths annually and the risk is three times higher in competitive athletes. There are guidelines and criteria for management that have been developed in both Europe and the US (known as 36th Bethesda conference criteria and the European Society of Cardiology guidelines). Both sets of guidelines rely on expert opinion–there are very little data available on sports participation in LQTS patients to guide our decision making.A study done at Mayo Clinic recently published in the Journal of the American Medical Association (JAMA)
reviewed records of patients with LQTS (age 6-40 years) from 2000 to 2010. Of the 353 patients, 63% were not involved in sports and 88% chose to stop competitive sports once initially diagnosed. 130 patients remained in competitive sports and 20 of these patients had ICDs implanted. Only one of the patients who continued to compete in sports had an event–an aborted cardiac arrest while warming up for a game–twice. He received two life saving shocks for ventricular fibrillation. Both episodes occurred in the setting of medical non compliance–he failed to take his beta blocker prior to competition. In this particular retrospective review of LQTS athletes, only one patient had an event. This certainly brings up much controversy in how we treat these young competitive athlete patients.
One of my colleagues, Dr Wes Fisher has blogged about this controversy in the past. (Please see his blog here http://drwes.blogspot.com/2012/05/dark-side-of-ekg-screening-in-athletes.html). Dr Wes eloquently gives us a glimpse into the negative repercussions of EKG screening in athletes. However, we must remember that screening athletes is a tricky business. On the one hand we must make sure that young people are safe when competing in sports. On the other hand, we must be careful not to ruin a potential Gold medal career with speculation.
Ms Vollmer is an inspiration to all of us–both doctor and patient. She was given a potential life-threatening diagnosis at the age of 15. Still a teenager, she had to make an adult level decision that would affect the rest of her life. She has very supportive parents who helped her make the choice and ensured that she would be safe while competing and training. A two-time Olympic champion, Ms Vollmer was able to overcome great challenges and continued to believe in herself and in her abilities. Even though she had a potential life threatening heart condition, she continued to live and enjoy life to its fullest.
There remains much controversy on how best to screen athletes and how best to treat disorders such as LQTS. Not every competitive athlete patient with LQTS needs an ICD. Clearly, from the Mayo review, not every athlete with LQTS has an event. As physicians treating heart rhythm disorders, we must carefully review each case and partner with our patients to make good decisions. Together we can follow Dana Vollmer’s example and continue to “Go for the Gold”.
(Photo: Doug Mills, The New York Times)