Heart Rhythm. 2012 Dec 13. pii: S1547-5271(12)01448-8. doi: 10.1016/j.hrthm.2012.12.014. [Epub ahead of print]
Sudden death in the young - Did sensationalism trump science?
Source
San Antonio Military Medical Center, San Antonio, Texas. Electronic address: robert.eckart@us.army.mil.
Based upon our findings, the context of sudden cardiac death is at odds with popular media depiction in high profile publicized deaths in athletes during vigorous exercise 18,19,22-24. In those 19 years of age and older, only 9% of the cases of sudden cardiac death occurred during physical activity. This is comparable to the Danish sudden death registry, where only 11% of deaths before age 35 occurred during sports or vigorous activity 25. However, given that the time spent exercising represents a very small proportion of the total day, this 9% supports previous observations that exertion represents a state of higher risk in adults 26,27. Despite this, a population perspective reflecting previous studies in older adults strongly supports the overall protective effect of regular exercise, and suggest that interventions such as automatic external defibrillators (AEDs) will have a modest effect if targeting younger athletes during participation 28. While this does not negate the efficiency of placing AEDs in public areas, it does suggest that it will have a modest impact in this population. By comparison, 33% of deaths in those 2-18 years occurred during moderate activity, which has a lower risk than intensive exercise24. As well, although 27% of pediatric deaths were classified as occurring during low intensity activities (not sleep), retrospectively determining the intensity of play that may have been associated with adrenergic stimulation (such as video games) is difficult.
The presence of premonitory symptoms as a sentinel sign preceding sudden cardiac death raises the prospect that targeting these may unmask those at risk and identify those who are eligible for prevention strategies. This is certainly an appealing interpretation, although it is hampered by the low specificity of symptoms such as presyncope or palpitations, and the obvious recall bias of the remaining friends and family who were interviewed during the death investigation. Limited data suggest that clear sentinel symptoms such as worrisome syncope are present in as few as 13-30% of cardiac arrest survivors with latent causes of arrest such as primary arrhythmia syndromes and familial cardiomyopathies 29. The current study was clearly limited by the scope of historical detail contained in the coroner’s narrative, but does suggest that a potential symptom was present in half of the patients, and significantly more so in females.
The frequency of unrecognized heart disease is strong rationale for early screening. Early onset coronary artery disease may present as sudden cardiac death because of plaque rupture without ischemic reconditioning, leading to ventricular fibrillation 30. The frequent absence of sufficient warning symptoms suggests that age 30 may be a reasonable time to consider screening for coronary artery disease. Nonetheless, a prevention strategy and public education of warning symptoms are clearly established mandates that have reduced the burden of both atherosclerotic heart disease, and recognition of other mechanisms. Of interest, congenital heart disease was rare in the current series, in part because death in the context of manifest and severe congenital heart disease was not likely to be reported as sudden or unexpected.
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