Warrior Medics San Antonio Medical BRAC Integration Office, 916-1000 Incidence of Sudden Cardiac Death Associated with Physical Exertion in the United States Military Samuel O. Jones, MD, MPH, FACC, FHRS Colonel, US Air Force Associate Professor, USUHS Arrhythmia Service, Cardiology Division
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San Antonio Medical BRAC Integration Office, 916-1000 Incidence of Sudden Cardiac Death Associated with Physical Exertion in the United States Military.
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Warrior Medics
San Antonio Medical BRAC Integration Office, 916-1000
Incidence of Sudden Cardiac Death Associated with Physical Exertion in
the United States Military
Samuel O. Jones, MD, MPH, FACC, FHRSColonel, US Air Force
Associate Professor, USUHSArrhythmia Service, Cardiology Division
San Antonio Military Medical Center
Warrior Medics
San Antonio Medical BRAC Integration Office, 916-1000
• Conflicts: None
• The information and opinions expressed in this document are solely those of the authors and do not represent an endorsement by or the views of the Uniformed Services University of the Health Sciences, the United States Air Force, the Department of Defense, or the United States Government.
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San Antonio Medical BRAC Integration Office, 916-1000 3
Background
• Sudden Cardiac Death (SCD) is a tragic and devastating event– SCD which occurs to an athlete during sports or
physical exertion generates immense public attention• Increasingly recognized, a significant percentage
of cases occur during physical exertion, due to the inherent elevated risk.
• Incidence rates vary and precise data may be difficult– Varying definitions, incomplete ability to identify
cases, and different populations studied.
Warrior Medics
San Antonio Medical BRAC Integration Office, 916-1000 4
Background• Relative risk of SCD is elevated during or
immediately post exertion– Physicians Health Study 16.9 x RR– Police officers 40.6 x (during restraints)– Firefighters 12.1 to 136 times greater during fire
suppression as compared to non-emergency duty • Pathophysiology
Albert CM. NEJM 2000;343:1355Varvarigou V. BMJ 2014;349: 6534Kales SN. NEJM 2007;235:1207
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San Antonio Medical BRAC Integration Office, 916-1000 5
Incidence of SCD w/ Exertion
• Young patients 12-35 in Denmark 1.2 per 100,000• General population of sports related deaths in
France 0.46 per 100,000 (? as high as 1.7 ?)• Marathon runners 2005-2010 rate of 1.25 per
100,000• Triathlon 1.5 per 100,000
Marijon E. Circ 2011;124:672Holst AG.. Heart Rhythm.2010; 7: 1365Kim JH. NEJM 2012; 366:130Harris K JAMA 2010;303:1255
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San Antonio Medical BRAC Integration Office, 916-1000 6
Background
• U.S. military records provide excellent data for analysis given – complete capture of all deaths– well-defined population– comprehensive electronic medical record– accessible surveillance systems
• Study aimed to calculate the incidence rate of SCD related to exertion in the U.S. military– Secondarily, determine etiologies, classify according to
activities, and characterize demographic and risk profiles of decedents.
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SCD in the Athlete
• Earliest case report of SCD in the athlete?
• Pheidippides (530 BC- 490 BC)• Ran from battlefield near
Marathon to Athens to announce Greek victory over Persians
• Upon giving the message, he collapsed and died
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San Antonio Medical BRAC Integration Office, 916-1000 8
Warrior Medics
San Antonio Medical BRAC Integration Office, 916-1000
The Problem
• Definition of “athlete” may be broad– In total, there are estimated 5 million HS athletes– 500,000 collegiate– 5,000 professional– Extend to firefighters? 1.2 million AD military?
• Young, vigorous, represent healthy lifestyle– Sudden death does not fit our beliefs
• Each event is a high profile case, generating public outcry to prevent these conditions
Warrior Medics
San Antonio Medical BRAC Integration Office, 916-1000
San Antonio Medical BRAC Integration Office, 916-1000
Results
• In age ≥35 years, cardiac risk factors present– 80% had BMI > 25, 32% hyperlipidemia,
24% hypertension, 15% smoking• No deaths occurred at extremes of temperature
– WBGT<85 degrees or indoors• Predominant activity was running or elliptical use
in 60%. • 20% of all events occurred during mandatory run
of physical fitness test– Of these, 2/3 occurred after the test completed
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San Antonio Medical BRAC Integration Office, 916-1000 27
Limitations
• Information was obtained retrospectively and from case materials that were not collected systematically
• Missing data points • Population of predominantly young males who
voluntarily joined the service may not translate to other populations
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San Antonio Medical BRAC Integration Office, 916-1000 28
Conclusions
• From 2005-2010, the overall incidence in U.S. military members (1.63 per 100,000) was similar to most reported corresponding civilian SCD rates.
• Compared within groups, higher incidence rates were present in age ≥35 years, African-Americans, and males.
• The most common diagnosis depended on age– Age ≥35 years CAD– Age <35 years idiopathic and anomalous coronary
arteries
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San Antonio Medical BRAC Integration Office, 916-1000 29
Thank You
Physical Activity Preceding SCD
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All Cases
Cases By Age Group
n = 200 % <35 years ≥35 years
n = 75 % n =125 %
Running/Elliptical 119 59.5 54 72.0 65 52.0
Other* 20 10.0 4 5.3 16 12.8
PT†/Unit PT
17 8.5 1 1.3 16 12.8
Walking‡ 13 6.5 4 5.3 9 7.2
Swimming 8 4.0 6 8.0 2 1.6
Basketball 7 3.5 3 4.0 4 3.2
Weight Lifting, etc§ 7 3.5 2 2.7 5 4.0
Bicycling 4 2.0 1 1.3 3 2.4
Football 1 0.5 0 0.0 1 0.8
Soccer 1 0.5 0 0.0 1 0.8
Tennis 1 0.5 0 0.0 1 0.8
Unknown 2 1.0 0 0.0 2 1.6*Generalized exercise, returning from gym, furniture moving, construction, mowing lawn, dancing †PT, physical training ‡Includes road marches and marching with body armor in formation §Includes Pull ups, Sit-ups, Combatives
Cardiac Risk Factors
All CasesCases By Age Group
n =200 %
<35 years ≥35 years
n =75 % n =125 %Hyperlipidemia 42 21.0 2 2.7 40 32.0
Smoker 33 16.5 14 18.7 19 15.2
Hypertension 31 15.5 1 1.3 30 24.0
Family Hx of CAD 25 12.5 6 8.0 19 15.2
Family Hx of SCD 7 3.5 4 5.3 3 2.4
Previous Hx CAD 4 2.0 0 0.0 4 15.2
Diabetes 2 1.0 0 0.0 2 2.0
*Prevalence values represent the minimum burden of these factors, due to missing data.
Warrior Medics
San Antonio Medical BRAC Integration Office, 916-1000
SCD- US military
• DoD registry 1998-2008– AD members, 15 million pt-yrs (~1.5 million/yr)– Over 14,000 sudden deaths
• 902 due to likely SCD with full records (~90/yr)– Mean age 38, predominantly males – 79% definitely cardiac– 21% sudden unexplained death (autopsy did not
clearly reveal a cause• Significant percentage occurred during exertion
Warrior Medics
San Antonio Medical BRAC Integration Office, 916-1000
JACC 2011
Incidence of SCD in Athletes
Warrior Medics
San Antonio Medical BRAC Integration Office, 916-1000
Maron BJ, et al. J Am Coll Cardiol 2003;41:974–80 Corrado D, et al. J Am Coll Cardiol 2003;42:1959–63 Eckart RE, et al. Ann Int Med 2004;141:829– 834
Warrior Medics
San Antonio Medical BRAC Integration Office, 916-1000
Screening- US perspective
• Multiple issues with Italian data – Association does not prove causality
• US different than Italy– Population 5 x as great, different disease prevalence
• ECG is an imperfect test – 5-20% chance of abnormal ECG with many false pos
• Follow-up testing more of an issue in US • Cost prohibitive (estimated over $2 Billion annual
costs for US)
Warrior Medics
San Antonio Medical BRAC Integration Office, 916-1000
Legal / Ethical Issues
• Nay-sayers of screening:– Inherent risk is understood and accepted– Impossible to achieve zero-risk– In the big public health picture- low prevalence
• Assuming a limited pot of money, should we spend this on other items?
– Societal double standard for competitive athletes• Who is responsible?