HYPERTROPHIC CARDIOMYOPATHY, SUDDEN ATHLETE DEATH

 Hypertrophic Cardiomyopathy is passed through generations as autosomal dominant and genetic testing is available to rule in or out the inherited form of HCM. (Affordable Genetic Test as www.genedx.com/hcm)

What Is HCM and What Causes It? HCM is a form of heart muscle disease in which the muscular walls of the ventricles (lower chambers of the heart) become abnormally thickened.

The thickening of the heart muscle causes the muscle itself to function abnormally. The thickening also can cause the ventricles to become distorted, which can interfere with the function of the aortic valve and the mitral valve, which regulate blood flow.

HCM is caused by a genetic abnormality that produces a disorder in the growth of the heart muscle fibers. In some families, HCM is passed on as an “autosomal dominant” trait, which means that if the gene for HCM is inherited from a single parent, the child will have the disease.

However, in almost half the patients with HCM, the genetic problem is not inherited at all, but occurs as a spontaneous mutation – in which case, parents and siblings of the patient will not be at risk for this condition (but children of the patient can be.) [It is acquired and not inherited.]

What Does HCM Cause? There are 4 kinds of cardiac problems caused by HCM:

• 1) HCM can cause diastolic dysfunction. “Diastolic dysfunction” refers to the fact that thickened ventricles become stiff, making it more difficult for the ventricles to fill with blood. This stiffness causes the blood to “back up” into the lungs, causing shortness of breath – usually with exertion. The diastolic dysfunction also makes it more difficult for patients with HCM to have arrhythmias, especially atrial fibrillation.
• 2) HCM can cause systolic dysfunction. “Systolic dysfunction” means that the heart’s pumping action is not normal – that is, when the heart beats, an insufficient volume of blood is ejected. In HCM, systolic dysfunction is usually caused by abnormal functioning of the mitral or aortic valves, which, in turn, is caused by distortion of the ventricles resulting from the abnormal thickening of muscle.
• [An abnormally low ejection fraction.]
• 3) HCM can cause dilated cardiomyopathy. This condition leads to heart failure, and is caused by an eventual “burning out” of the thickened heart muscle. Dilated cardiomyopathy occurs late in the course of the disease.
• 4) Finally, HCM can cause sudden death. The sudden death in HCM is usually due to ventricular tachycardia or ventricular fibrillation – severe heart flutters. While many of these sudden deaths occur during vigorous exertion, it can also occur during minimal exertion or at rest, with no warning whatsoever. The risk of sudden death has been estimated being as high as 5% per year in patients in their teens and 20s, though it drops off somewhat after that.

 Sudden Youth Athlete Death can result from the onset of ventricular tachycardia or another heart arrhythmia or left ventricular insufficiency 2° to Hypertrophic Cardiomyopathy.

• The only symptoms might occur during exercise and/or at rest and include:
• Shortness of breath
• Chest pain or tightness
• Fainting or dizziness
• Heart palpitations: heart beating rapidly or irregularly
• Sudden drop in blood pressure

When athletes voluntarily complain or answer when questioned during Sports, Recreation and Exercise (SRE) Participation Physical Examination with any of the above symptoms, they must undergo screening with an Electrocardiogram and an Electrocardiogram. These are essential diagnostic tests to rule in or out HCM. 

How Is HCM Diagnosed? In general, the electrocardiogram is the best method of diagnosing HCM. The echocardiogram allows accurate measurement of the thickness of the ventricular walls, and can detect abnormal heart valve function as well. The electrocardiogram (ECG) also can give important clues as to the presence of HCM.

Both an ECG and echocardiogram should be performed in close relatives of a patient diagnosed with HCM, and an echocardiogram should be performed in any person in whom the ECG or the physical examination suggests ventricular hypertrophy.

How Is HCM Treated? HCM cannot be cured, but it can be managed. Beta blockers and calcium blockers can help reduce the “stiffness” in the thickened heart muscle. In some patients – especially those who have significant heart valve dysfunction – surgery to remove portions of the thickened heart muscle is necessary. Atrial fibrillation, if it occurs, often causes severe symptoms and needs to be managed more aggressively in patients with HCM than in the general population.

How Can Sudden Death Be Prevented? Sudden death in HCM is often seen in younger patients – often before symptoms have occurred, or even before a diagnosis has been made. While sudden death is always a devastating problem, it is particularly so when it occurs in young people.

Many methods have been tried for reducing the risk of sudden death in patients with HCM – including avoiding exercise, using beta blockers and calcium blockers, and using antiarrhythmic drugs – these methods unfortunately met with mixed results. In recent years it has become apparent that in patients whose risk of sudden death appears high, an implantable defibrillator should be used. 

The implantable defibrillator is a pacemaker-like device that is implanted under the skin, monitors the heart rhythm continuously, and automatically delivers a shock to the heart to restore a normal rhythm should a dangerous ventricular arrhythmia occur. While it sometimes seems a drastic step, it is much less drastic than allowing a young individual to die suddenly.  [Hypertrophic Cardiomyopathy – HCM, A Common Heart Disorder By Richard N. Fogoros, M.D.]

 “Being diagnosed with a disease that can cause sudden cardiac death is NOT a death sentence. If an individual is predisposed to SCD, then it is actually good to have a diagnosis so that appropriate therapy can be initiated.

Unfortunately, many people do not know they are at increased risk for SCD and thus do not have the treatments in place that can prolong their lives indefinitely.

“Sudden cardiac arrest is the leading cause of death in young athletes. The purpose of this review is to summarize the role of automated external defibrillators and emergency planning for sudden cardiac arrest in the athletic setting.

Sudden cardiac arrest (SCA) is the most common cause of death in the United States resulting in more than 300 000 deaths annually. 32 Sudden cardiac arrest is also the leading cause of sudden death in young athletes 20, 35 accounting for approximately 75% of all cases. 21 

The death of an athlete is a catastrophic event that has devastating effects on a family, teammates school/university, and the local community. Athletes are regarded as the healthiest members of society, and their sudden death during practice or competition often sparks debate regarding the adequacy of emergency planning for athletic events.

Early defibrillation programs involving access to automated external defibrillators by targeted local responders have demonstrated a survival benefit for sudden cardiac arrest in many public and athletic settings.

Conclusion: Schools and organizations sponsoring athletic programs should implement automated external defibrillators as part of a comprehensive emergency action plan for sudden cardiac arrest. 

In a collapsed and unresponsive athlete, sudden cardiac arrest should be suspected and an automated external defibrillator applied as soon as possible, as decreasing the time interval to defibrillation is the most important priority to improve survival in sudden cardiac arrest. [Please see the complete article about the following report:  [Rothmier JD, Drezner JA. The Role of Automated External Defibrillators in Athletics. Sports Health. 2009;1(1):16-20. doi:10.1177/1941738108326979.]

The information below lists some of the common measures used to prevent SCD. It is by no means complete, and anyone who is at risk for SCD, should see a physician for optimal care of their particular risk factor.”

1. Implantable Cardioverter-Defibrillator (ICD)
2. Automated External Defibrillator (AED)
3. Radio-Frequency Ablation (RFA)
4. Anti-Arrhythmic Medications
5. Lifestyle Modification [Prevention of Sudden Cardiac Death, Johns Hopkins Pathology Home]