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Why Are Athletes Experiencing Cardiac Arrest and Can We Prevent It? (with Jon Drezner, MD)
Episode 6215th August 2023 • Your Doctor Friends • Dr. Jeremy Alland and Dr. Julie Bruene
00:00:00 01:03:41

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Does you feel like you've been seeing more and more stories about young athletes collapsing from sudden cardiac arrest?

Damar Hamlin of the Buffalo Bills collapsed after a collision in sudden cardiac arrest last year during Monday Night Football. A few weeks ago, Bronny James, the son of LeBron James, suffered cardiac arrest at a USC basketball practice. 

Is there a trend we should be aware of? Is this new?

What's the deal? Is cardiac arrest common? Can it be prevented?

What better way to find answers than to grab OUR DOCTOR FRIEND, maybe one that happens to be nationally recognized in the area of Sports Cardiology and screening for cardiac conditions in athletes, and ask him these great questions! 

Welcome, Jon Drezner, MD!

Dr. Jon Drezner is a Professor in the Department of Family Medicine and Director of the UW Medicine Center for Sports Cardiology at the University of Washington.

  • He serves as Editor-in-Chief of the British Journal of Sports Medicine
  • He is Team Physician for the Seattle Seahawks (NFL), OL Reign (NWSL), and the University of Washington.
  • Dr. Drezner is past-President of the American Medical Society for Sports Medicine (AMSSM, 2012-13) and has dedicated his career to the prevention of sudden cardiac arrest and death (SCA/D) in young athletes and the development of effective models for prevention.

This is a great episode, friends! Give it a listen and perhaps we can figure out how to STOP THE HEART-STOPPING!

Key highlights in this episode include:

Why do these elite athletes, the picture of peak performance, experience cardiac arrest?

How common is sudden cardiac arrest in athletes? Does the prevalence change when looking at different types of athletes/sports?

Who is at risk? How do we know?

Are there warning signs for sudden cardiac arrest? What are they?

Why do some people (like Bronny and Damar) have better outcomes than other people who suffer cardiac arrest?

How can we screen for conditions that can cause sudden cardiac arrest?

What about people out of high school and college age who are athletic, what are their risks of sudden cardiac arrest?

Dr. Drezner recommends the following resources to learn more about sudden cardiac arrest in athletes:

Parent Heart Watch website.

The American Heart Association website.

Take a lifesaving CPR class through the American Red Cross!

The University of Washington Center for Sports Cardiology E-Academy, learn about ECG interpretation in athletes!

You can find Dr. Drezner via his UWashington profile HERE, and on Twitter at @DreznerJon.


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[00:00:06] Julie Bruene: Yeah, I mean, we're in that world, like that's the type of physicianing we do for the most part as sports medicine docs. And I still feel like there's, there's, there's more being talked about than, than there has been in the past several years, for sure.


And, and both of these are high profile cases. They have led to a lot of news coverage. There's been plenty of buzz about it. Um, but what really kind of. Pushed us to this episode or pushed me to this episode was, you know, on the day of Bronnie's collapse, I hadn't heard of it at that point, but I had a number of patients come in and ask me, had I heard about it?

And then they just kept asking me a bunch of questions and I was like, this is great. I should just remember all these questions people are asking me and we should just do an episode. So they kept saying like, why did, why do you think it happened? Is it common? Is he going to be okay? Could it? Have been prevented.

I mean, these are all good questions and ones that obviously I couldn't answer at the time, but, but certainly ones that I'm sure more than just my patients were thinking. Um, so what better way to get the answers to this than you and me not answering them, but to go grab a doctor friend, maybe one that happens to be nationally recognized in the area of sports, cardiology and screening for cardiac conditions and athletes.

Bring them on the show and ask them these great questions. What do you think?


[00:01:32] Jeremy Alland: Yeah, we happen to be networked here So we're gonna be doing a pretty good job with that. So today your doctor friends will be answering Why do athletes get cardiac arrest and can we prevent it

Welcome to your doctor Friends, the show that teaches you to sniff out the garbage and answers all the questions that you wish you could call or text your doctor friend. My name's Julie Bruny. And I'm Jeremy Allen. And we are two physicians who work at a nationally ranked practice and take care of some of the world's greatest athletes.

We know that you have questions and we want to help. We wanna be your doctor friends.


It's incredibly jaw dropping to think about these people who we look at and we're like, you're the fittest person I know. And then they collapse of cardiac arrest and you say, how can that happen? So the cases above have fortunately have had good outcomes to date. The, um, the, the both athletes, as far as I know, are doing very well, um, but their notoriety has certainly allowed us to expand the conversation about preventing these situations in the future.

So with that, I'm going to be super excited to bring on our expert today. I want to introduce everybody to Dr. John Drezner. John is a professor in the department of family medicine and director of the UW medicine center for sports cardiology at the university of Washington.

He serves as the editor in chief of the British journal of sports medicine. And he's a team physician for the Seattle Seahawks, the OL rain of the NWSL and the university of Washington, the newest member of the big 10. Dr. Dresner is a past president of the American Medical Society of Sports Medicine, AMSSM, which is our big organization, and he's dedicated his career to the prevention of sudden cardiac arrest and death, S C A slash D, in young athletes and the development of effective models for prevention. So he fits this. I mean, I couldn't think of anybody better to be on for this. So John, can't thank you enough for coming on and joining us. Welcome to the show. Thank you.


[00:03:40] Jeremy Alland: Yeah, this is, uh, an awesome topic and I know that, uh, when these big stories came out, I mean, you, I, you were quoted in big publications. I, people want your time and we're so, we're so grateful to have it. So before we dive in we'd love to hear about your journey to your current role. Sports cardiology is. I think a relatively young field and maybe people didn't even know that there was sports cardiology. You're a family doctor. You paved the way for a lot of this. Maybe give us your story, your biopic. Who is John Dresner? It


[00:04:09] Julie Bruene: As long as you want, man.


You know, for me, um, I was first exposed to athletic heart changes and sudden cardiac death and athletes through a medical school rotation in my fourth year at U C L A. And it just struck a chord with me. I, I was a, I was a college basketball player. I played at Brown University. And during my era, um, was when Hank gathers died and that was an incredibly tragic event, you know, public view, um, really no on court resuscitation, just an incredible tragedy followed, um, soon thereafter by Reggie Lewis limb bias and sort of other, um, basketball players who had cardiac arrest.

And then in medical school was interested in everything. My favorite rotation was the cardiac intensive care unit. Um, and this rotation in sports medicine. And then I did a family medicine residency and it all just sort of stayed with me. Um, and eventually my, my first publication was on screening and prevention of sudden cardiac death.

iate setting that was back in:

But then I realized that even with AEDs, there were still a lot of young athletes who were dying and it made me turn towards the other side of prevention. You know, how can we screen these athletes and prevent these tragedies from happening? And I think it, it required that I look closely at Common practices within the U.

S. Sort of this history and physical based, you know, sports physical that really we learn is like the foundation of sports medicine. We hang our hat on it. And unfortunately, it really has no evidence that it works. And our European colleagues who have for decades now done something different using an electric cardiogram or an E.

K. G. To help us sort of look under the hood for those heart conditions that are silent but can be can be killers. And, and that sort of just sparked a fire, you know, to, to. Help our discipline sports medicine physicians do what we're supposed to do, but do it better You know, we all have to do sports physicals.

No one wants to do a bad job So if we're going to do screening, let's do it. Well


[00:07:20] Jon Drezner: Thank you


So should I just tell them, it's all horseshit, don't bother? What do you think?


Um, you know, it's true. And unfortunately, it's true. I mean, we're taught these history questionnaires that kids have to fill out. I've got three Children. They've all filled them out through their years. Um, We see them over and over again. All our states require them. And when people fill out these questionnaires, there's a high false positive response.

t health questions, you know,:

Like they're just poorly written. The physical exam we do with the stethoscope is, is really old school. Um, we've published research that really none of us are good at distinguishing. a pathologic heart murmur from a physiologic heart murmur. And so, which is really the main, like, sort of focus of how we've learned PPEs or sports physicals in medical school was we have to listen a certain way to the athlete.

We're going to listen to you standing and laying down and holding your breath and listen for this heart murmur. Where most of the time with the disease we're looking for, hypertrophic cardiomyopathy, that heart murmur doesn't exist. And if we do hear a heart murmur, we're not very good at distinguishing if it's normal or abnormal.

And so no one's getting the right workup anyway. And if we just did an EKG, we'd understand if they have cardiomyopathy or not. And so, I think what people forget here is that the single primary objective of doing a sports physical is the identification of heart conditions that put kids at risk for sudden death.

And we've chosen for decades now to use a tool, a questionnaire and a stethoscope that don't work, that don't identify those kids. And so why not use a different tool for the exact same purpose that actually statistically performs much better, but only if you know what you're doing. And so, as you know, within the sports medicine community, we've spent...

You know, a lot of time and effort to try to train our sports medicine colleagues that EKG interpretation and accurate interpretation is really a fundamental skill. It's, it's not like only the people who are interested in sports cardiology should be able to do this. I think if you're a sports medicine physician, this is absolutely a fundamental skill.

You should be good at it and you should be doing it frequently. It should distinguish you. from just a primary care provider has a lot of other things to focus on and maybe hasn't spent the time to learn ECG interpretation and athletes. So for your lecture tomorrow, I hope it's good. I'm sure it will be great.

We've got lots of resources we can share with you about how to learn ECG interpretation for your fellows. Boy, I hope they do our training modules. We know all about the international criteria. Um, but I think if you want to make a difference for them, preparing them long term to hopefully help identify the conditions at risk.

I think it has to include an EKG.


One, because it's required. So you have to, you have to get this thing done or else you can't play. And so I think that it becomes a very perfunctory thing that some primary care providers and sports medicine physicians do to check off a box so that this kid can go do the thing. And I don't think that that's doing our duty and our service to our patients sometimes.

And if it's just like, yeah, yeah, yeah, yeah, yeah, you're fine. I think you've lost an opportunity for one fulfilling that duty. I mean, I would certainly say that there's other parts of the Exam that are helpful just for like, general health things, great, but if our, if our goal, like you're saying, John, is to prevent, or to screen for conditions and prevent sudden cardiac death, I agree with you wholeheartedly that it ain't cutting it.


I'm gonna do mental health screen. I'm gonna tell you not to smoke, wear a helmet, use a condom. And there's some preventive things there that you can do that may be of value. But when you look at the literature of why kids are getting sports physicals, the primary objective is the identification of conditions that put them at risk of catastrophic injury or sudden death.

That's, and, and for many kids who don't have access to care, the creation of a required Sports physical has been a barrier to sports participation, and it unfortunately, you know, disproportionately affects those who don't have good access to care, who don't have the financial resources, who may not have insurance, you know, on TV.

At the end of this month, our sports medicine group is volunteering our time to perform sports physicals at a school district within the state of Washington that has the most socioeconomic deprivation than anyone else.


[00:13:29] Jon Drezner: Yeah, that's what happens when you sit too long at my desk and the lights


[00:13:33] Jon Drezner: Or you're just trying to quiet me, or you're just trying to quiet me in the middle of the podcast, which is also possible and has probably happened to me before. So


[00:13:43] Jon Drezner: yeah, so, but anyway, so at the end of the month, we're doing these sports physicals in a, in a student population with, with very low, you know, resources and access to care. For really the sole purpose of allowing the opportunity to play sports. And I know that the creators of the, of the sports physical and the pre participation evaluation, you know, that the goal was not to create barriers.

Right. And, but, but in reality, we have. We've created a mandatory evaluation that actually cost a ton of resources and money that has really no proven benefit outside of just a normal, well, childcare check, but that's not really the main purpose and we're not using the right tools. And so, you know, if we're really going to step back, the right thing to do, which we'll never be able to do at this point is to either rewind or just dismantle the way we do sports physicals and recreate it.

but we don't. And I think it's a little different when you are a team physician, maybe at a college setting or a professional setting where you're now acquiring a new patient into your practice. And that sports physical is that opportunity to get to know their health history and their health concerns, current injuries, as well as that heart screen.

Um, but for our adolescents, our middle school and high school athletes who are required to get the sports physicals, you know, they're, they're, they're getting the sports physical to check the box and not necessarily for that general health screen.


[00:15:31] Jon Drezner: I think we can, I think we can prevent it. I think we can do a much better job than we are. But I think everyone has to recognize that no matter what we do from a screening standpoint, it's not perfect. It's not perfect. We're always going to hear about cases of sudden cardiac arrest in young athletes because no matter how we screen them We will never identify all of the potential disorders that can lead to sudden cardiac arrest And there are some disorders that can be acquired over time.

And so, a single time point in screen doesn't necessarily protect you forever. And you have to have the other side of prevention and be prepared to respond to sudden cardiac arrest in the case of an emergency. And I, I know we'll talk about what that means and the availability of AEDs and how we've seen that, you know, save Damar Hamlin and how, you know, we've heard that that's exactly what happened to save Bronny.

And so... Um, I do think that we can do better. I think when we use an EKG, an EKG should suggest or identify about two thirds of the heart conditions that place a young person at risk for sudden cardiac arrest. And so that's pretty good. Um, and what comes next is really important because there's lots of evidence.

disease specific evidence that when you have early detection and intervene, when you do risk stratification, where you treat certain diseases with medications or certain diseases with heart ablations or certain patients that are really high risk at an internal defibrillator, that these interventions save lives.

And so I really believe that as screening has You know, as this, um, pendulum has swung more and more to better screening use of an EKG, more early detection of those heart illnesses that we are going to, um, have this opportunity. for better management of these disorders before they're ever a problem. And management doesn't always mean disqualification from sports.

The whole goal is to hopefully keep kids playing sports, but safer than they are knowing what they have. if they have a heart condition.


Like, these are the picture of peak performance. Why is he having cardiac arrest?


And these heart conditions, um, have a variety, uh, of, um, uh, structural or electrical problems with the heart. They can be heart muscle diseases, what's called cardiomyopathy. They can be electrical disorders of the heart, things like Long QT syndrome or Wolff Parkinson White. They can be structural or abnormalities of the heart, like an anomalous coronary artery.

They can be acquired disorders like myocarditis or early coronary disease. So there's a real spectrum and that's also what makes screening so difficult. You're not looking for a single disease. You're looking for a variety of different diseases. So it makes it challenging as a clinician to identify what it is and, and also to follow up with the right testing if one of your screening tests is, is abnormal.

And most of these individuals who harbor one of these conditions usually don't know it. And I think that's what people don't understand. You can have one of these conditions and feel totally healthy. You can perform like an elite athlete. You can still do wonderful things in sports until you have that lethal arrhythmia and you have sudden cardiac arrest.

And so there is evidence that probably about 80% of young athletes who suffer sudden cardiac arrest. never had any warning symptoms that they had a heart problem and the cardiac arrest was actually the first presentation of their heart disease. And so, if you just stop for a second right there and think for a moment that we've based our screening evaluation on asking about prior symptoms, well, out of the gates, we've missed most of the people at risk.

Right? If only maybe 20% have any warning symptoms before they end up having sudden cardiac arrest and just didn't know it. Um, so most of them can have these sort of silent conditions. Why all of a sudden on that day at that moment? They have cardiac arrest when they've been playing sports for years and years with no problem.

That's a really good question and I don't think we have the answer for it. Um, so so This can be out of the blue, it can be somewhat random, and that's why we need to be prepared for it as well.


[00:21:08] Jon Drezner: Most of them are, um, so some are congenital, they're born with it, like anomalous coronary arteries, some of these structural conditions. Some of them are genetic heart conditions, like cardiomyopathy. If you look at cardiomyopathies, um, the majority of them are inherited, so there's a family history of cardiomyopathy, but some are sporadic, meaning that you're the first person in your family to have the, the actual gene mutation that causes the heart disease.

Um, and, and then our, our, our electrical conditions of the heart, the ion channel disorders like long QT are genetic, um, but things like Wolff Parkinson White are not. And so I think most I would say are inherited or genetic, but many conditions are not.


[00:22:09] Jon Drezner: Yeah, so, so, so let's, let's divide this question into two things. So, so one is like, how common are these heart conditions? you know, uh, in other words, the prevalence of these heart conditions overall. And then the second question, well, how common is cardiac arrest in athletes? Cause those are two different questions because a lot of kids, a lot of people can have these heart conditions and thankfully not everyone goes on to have cardiac arrest.

So, so the first question, like how common are heart conditions in young athletes? You know, the research shows that about one in 300 young athletes has a heart condition at potential risk for sudden cardiac arrest. Again, that doesn't mean that they all go on to have a tragic event, but they are at higher risk because of their heart condition.

So combine all those diseases I talked about, the heart muscle diseases, the electrical problems, about one in 300 kids would have one of those problems. And majority of which are identifiable by an EKG. You know, thankfully they don't go on to have problems. When we look at the research about how common cardiac arrest is, you know, that is research that.

Um, has improved over the last couple decades and now we have better and better numbers. So if we look at college athletes, you know, the risks of sudden cardiac arrest overall is about one in 45, 000. So that doesn't sound that high, but that's, that's about five times higher than I learned in medical 250, 000.

And that's because we have better research now and better reporting strategies and case identification strategies. But some athlete groups are higher risk. And so we know that male athletes are higher risk than female athletes, probably 3 to 1 if not higher. Um, for reasons that, um, we don't understand, black athletes tend to be at higher risk than white athletes.

There are some sporting groups that stand out as well. Male basketball players are the single highest risk group. And if you look at NCA Division 1 male basketball players, the risk of sudden cardiac arrest is about 1 in 5, 000. And in one research study that we did, in male Division 1 black basketball players, the risk of sudden cardiac arrest was 1 in 2, 000 per year.

So, so 1 in 2, 000 per year, 1 in 5, 000 per year, is, is so different than one in 250, 000 a year. You know what I mean? Like, so as a, as a sports medicine physician tasks, with making sure that your kid is safe to play sports. This really is our responsibility. And this is where I don't understand like our colleagues who take care of men's basketball in college and who aren't doing a robust screen.

I don't get it. I just don't get it. I don't understand it. Um, there's sort of no position to fall back on if there was a tragedy and you didn't look harder before it ever happened. Um, so, so it seems like Research over time has allowed us to have more information about, um, perhaps which risk groups stand out.

And if we're thinking about screening, you know, at minimum, these highest risk groups warrant better screening.


So they don't all do the same thing. And what are they not required to do all the same thing?


Um, we did a, uh, Chris Myers from Baylor led, uh, a survey, um, of Power 5 conferences. It was about five years ago. So you take the biggest conferences, the wealthiest, um, athletic institutions in the country, and about 75% were screening their athletes with EKG. And so even in the Power 5 conferences, with all the resources, it still wasn't universal.

And you can, you know, for sure guess that If you are a lower level, let's say Division 1 or certainly Division 2 or Division 3 school, the likelihood that you're doing universal EKG screening of your athletes is, is much lower. And so you have to have a very committed, honestly, team physician who knows what they're doing and has made it happen.

Um, and so unfortunately, I would say the majority of our college athletes are not getting EKG screens. And then at the high school level, it's, I mean, it's almost nobody.


[00:28:12] Jon Drezner: absolutely. And, and this is where policymakers have to, you know, think carefully about, about what they do. I think from the medical stand aside, a couple of comments, you know, male basketball is the highest risk group. If you combine, if you take male basketball and American football, you have over 50% of all sudden cardiac arrest in young athletes in two sports alone.

And if you add soccer to that, you have about two thirds of all cases in just those three sports add in track and field and you're at 75%. And so you have some risk groups to sort of, you know, think about, um, You know, it's also hard, I think, only to screen male athletes and not female athletes, too, because female athletes can be at risk as well.

And so, these decisions become difficult, and the way I, um, suggest to my colleagues who are just starting to, like, dip their toe in the water to do EKG screening is I think you need to gain experience. And I think there's, there's good justification. To pick a couple teams, probably your high risk teams like basketball and football, or maybe just men's and women's basketball or men's and women's soccer and do EKG screening.

So you can gain experience so you can work out your referral pathways. You can get your cardiologist some experience and then next year, expand it to all your athletes. And once you're doing it in all your college athletes, when you're in your clinic and you're seeing your high school athlete, I guarantee you, you'll be doing your, your EKG screen as well.

Cause now you feel more confident. You've got the experience. So like any other skill you sort of need to develop that experience, train and, and, and, um, implement it, you know, more broadly in medicine, we don't always treat every person the same, meaning there's good precedent that people with high risk family histories will get screening earlier.

So for instance, if we think about colon cancer, breast cancer, things like that, strong family histories, you may be getting your colonoscopy earlier. You may be getting your mammogram. earlier. If you're in a higher risk group. So there's sort of precedent to look at high risk groups and intervene differently.

And this needs to be worked out more so in our athlete groups. But, but I, but I actually don't think it's too far fetched that there could be targeted screening for high risk groups, at least as a starting point. to develop better infrastructure to do it in everyone.


So why those four sports?


Other mechanisms come from, you know, reporting from the high school associations, you know, or an athletic trainer or something like that to the National Center for Catastrophic Sports Injury Research. So we have different mechanisms, but the majority are media reports. And I do think that the high profile sports are more likely to generate a media report.

And so, there is some, some evidence of this with data from one of Kim Harmon's studies, one of my colleagues here at the University of Washington, looking at sudden cardiac death in NCAA athletes. So looking at all the databases that we could find, all the cases, you know, if you were a Division I athlete with a cardiac arrest, Only about 88% of those cases had a media report that we could find in those cases.

And in the Division 2 athlete, it was like 65%. In the Division 3 athlete, it was like 44%. So you can just see that the profile of the athlete and the setting drove the likelihood of having media attention to it. Which then sort of carries over to the likelihood that we find it and include it in our research on incidents.

So, I think we just have to acknowledge that there could be some bias in what we're finding and that these cases may be occurring in, in lower profile sports at rates that we just don't understand.


Do you feel like there's any amount of these folks that get missed because, I don't know, do people sometimes just have sudden cardiac death in the shower or while they're swimming or while driving a car and then we call it something else? Like, do you feel like we're pretty accurately catching? Young people that are having these conditions.

What if nobody's around? You know, are you catching this on autopsy? That kind of stuff. I don't know if there's that many people falling through the cracks or not.


It can also occur... at rest or during sleep. The type of heart condition also dictates some of that risk as well. So, um, if you look at things like anomalous coronary artery, um, arrhythmogenic cardiomyopathy, um, these are very much exercise related events in our young athletes. When you look at something like hypertrophic cardiomyopathy, about half of the cases occur at rest or sleep.

So that's not a, it's not a pure split 50 50 when you think that an athlete only exercises about two hours a day and is at rest or sleep maybe 22 hours a day, but still it's not always during exercise. And so prevention for us, it's not just making people heart safe for what they do in sport is it's for life, right?

It's, it's outside of sport as well. Once we find a heart condition, we want to make them safe, you know, all around.


[00:35:35] Jon Drezner: Well, you've heard that. I mean, you know, as a, as a medical professional, when you, when you learn about something called long QT syndrome, that some of the triggers can be emotional stress. Some of the triggers can be loud noises. And, and so Things that happen when you're driving, whether it's emotional stress, honking horns, something like that, every, you know, can be triggered when that person goes into cardiac arrest and gets in a car accident, you may never know, and that is not something you would find on autopsy.

And there you have it, right? You have an unknown. reason why that person had a cardiac arrest or why they got in a fatal car accident. Now, same thing with some of our drownings, you know, um, cold water immersion can be a trigger for cardiac arrest and can be a trigger specifically in long QT syndrome.

And again, not going to show up on autopsy. postmortem genetic testing could find it, but, but, you know, it doesn't always go that distance. So yeah, lots, lots of unknowns.


[00:36:53] Jon Drezner: You know, good, good question, Jeremy. Um, you know, some of the disorders are certainly present when you're younger. Um, things like long QT, Wolf Parker's white, et cetera. Other disorders develop phenotypically, meaning the expression of the heart disease happens later. Usually. through adolescence and puberty, things like hypertrophic cardiomyopathy.

So you could not have it when you're 14 and have it when you're 18, so to speak. Um, and so when we look at the numbers specifically, the numbers of on sudden cardiac arrest in the young and young athletes starts to go up around age 12. With a, with a spike like 14 to 16 and, and then from there, because that's the development of some of those genetic conditions that are finally expressing themselves.

Um, for purposes of, of athletic screening, I, I don't necessarily think we need to be screening younger than age 12 or younger than, than middle school. And I think for, for certain we want to be screening when, when people are in, in high school.


That kind of thing.


Um, and the amount of advocacy for CPR training and availability of AEDs within the sports cardiology space. This is the one thing that we have actually done really well in terms of improving survival outcomes and young athletes who suffer a sudden cardiac arrest. And if you go back to early research that we did, Looking at exercise related, sudden cardiac arrest in the youth between 2001 to 2006, the overall survival was only 11%.

Fast forward in data between:

[00:39:38] Jeremy Alland: Wow.


That's a 250% increase in survival. And so, this is, this is directly related to better recognition of sudden cardiac arrest in athletes, more availability of automated external defibrillators or AEDs on site, and hopefully more athletic trainers who are medical professionals in the high school setting.

And thankfully, you know, we can look at sudden cardiac arrest in a young person during exercise. This is a survivable event, largely a survivable event, with prompt recognition, prompt CPR, and, and use of an AED. And so if you're a parent listening, and you're wondering, wow, you know, I want to make sure my, my kids are safe, my school is safe, you know, etc.

What do I do? I think that's the first thing I would do. I'd look around the school, where are the AEDs? I'd, I'd ask myself after hours, is an AED accessible? When it's a weekend game, is there an AED at the field? Do we have an athletic trainer in my, in my school? Um, can I help the school raise funds for more AEDs or to support an athletic trainer?

These are the things that will make the, the environment that your kids are playing in. Uh, more safe.


[00:41:33] Jon Drezner: Yeah, good, good point. There are some warning symptoms that I think are important. So, um, passing out with exercise is one of the red flag warning symptoms and you should be evaluated by a physician. And I think in a young person, true passing out with exercise deserves both an EKG and an echocardiogram.

The EKG looking for all the things we talked about and the echocardiogram looking specifically for anomalous coronary arteries. Thank Um, another warning symptom is chest pain with exercise, and I want to qualify what this chest pain feels like. So the chest pain is usually center of the chest or left sided, um, probably squeezing, increasing, and happens at peak exertion, and then quickly goes away when you stop exercising.

It's the type of chest pain that makes you stop. If you were an older person with this type of chest pain, we would call it angina. or ischemic type chest pain. And that's sort of the chest pain that I think is the warning symptom. You know, chest pain that's bilateral, that's right sided where your heart isn't, just a tightness feeling.

It's so hard to qualify. Chest pain that you, you run your mile through and you never stop. I just don't know, you know, yeah, you can get it checked out, but I don't know just how sensitive that type of symptom is. So, exertional chest pain that makes you stop exercising, if you're, if that's happening to your kid, also get, get evaluated.

I think to me, those are the two biggest warning symptoms. The third feature that I would throw out there is if you have a family history of heart problems, specifically heart problems that have caused sudden cardiac arrest or death in a family member before the age of 40 or 50, you should get screened for those, you should have your child screened for one of those genetic heart conditions.


[00:43:38] Jon Drezner: Absolutely. So, so, so those are the three questions on the questionnaire that I do think matter, except they're not worded perfectly.


[00:43:47] Jon Drezner: We can


[00:43:53] Jon Drezner: Yeah, we, we, we, we, we reworded our history questions, so we use them differently. We have some data on that, we'll publish it soon, I hope, which shows that it reduces the false positive rate. Um, whether or not it, it helps with sensitivity is to be determined.


[00:44:14] Jeremy Alland: Yeah, we do we spend a lot of time on that communication is everything that's the whole reason we even exist to be honest this podcast It's communicating better. I want to get back into prevention a little bit I think we have a pretty good idea of where you stand on screening through this conversation, but maybe just to summarize real quick You know, like, should we screen to everyone?

Should everybody be screened once? Should everybody be screened a bunch of times? Like, where do you, what's your blanket statement for screening? And I guess what the screening consists of.


Um, and that they have, you know, a high quality heart screen with someone who knows how to interpret the EKG. You know, in primary care, you're not going to refer someone for their colonoscopy. If that person doesn't know how to do the colonoscopy, right? And so we shouldn't just start doing EKGs on kids if we don't know how to interpret it.

I saw one of those people today. They had to get an EKG for playing college athletics. They saw their primary care provider. They had a totally normal looking EKG that was called, quote, borderline. And now they have to have yet a second visit with someone just to sort of sign off and say, your EKG is actually normal.

You didn't really need to be here. Um, so we could sign that medical clearance. Um, you guys are lucky in Chicago. You have an incredible foundation in Chicago called Young Hearts for Life, led by Joe Merrick and his wife, Kathy. Um, you know, that foundation has screened probably close, if not over a half million adolescents.

They go into local schools and they screen a couple thousand kids in a day. It's incredible. Joe is one of my mentors, and that would be a great place to go and get a heart screen, quite honestly, in the Chicago area, because Young Hearts for Life does it super well. I think your sports medicine group could be another place.

I mean, there are places that they could seek out. They could see a cardiologist, hopefully, that has interest in sports cardiology. And get their heart screen. So as we develop this infrastructure becomes more broadly available. So this shouldn't invoke panic as a parent, you know, you want what you want your kid to be safe.

It's a good conversation to have with your, with your kid's physician about how they should be screened. I think it certainly makes sense to, to seek out some, um, higher quality and, and more, um, uh, robust screening. Uh, if your kid is really a competitive athlete, cause exercise can be one of those triggers.

for, for cardiac arrest if they have a silent heart condition.


[00:47:31] Jon Drezner: Yeah, so, so across the country they have to have a, a, a sports physical or what's called a pre participation physical evaluation, a PPE. It's usually beginning in middle school and every two years. Um, some school districts or states will require it every year or every three years, depending. Um, and that.

That evaluation is a history questionnaire and a physical exam and someone and a medical provider to sign off that the kid is cleared to play sports. And that's essentially what's happening. The EKG is, is not required. Um, it's just unfortunate that we're requiring evaluation that, that isn't very effective at identifying kids at risk.

So if we're serious about it. We're going to invest on the infrastructure to do this better.


[00:48:26] Jon Drezner: Oh yeah, absolutely. Um, Italy. Would be the country that is doing it probably the best because of the way they train their sports medicine physicians. They're all highly trained and EKG screening is by law in, in Italy. So starting at age 12, if you're, if you're involved in sports, you're mandated to have a heart screen that includes an EKG.

ve data that was published in:

There's been critics of that study and whatnot, but it should open everyone's eyes to the fact that we can do this better than we are in the United States.


[00:49:31] Jeremy Alland: It makes me think that like, you could do this, like somebody who is in Washington can review someone in Chicago's EKGs. So like we could access these people could review these EKGs remotely. Right.


We review them and then send back recommendations if they're, if they're abnormal. Um, so there is a way certainly to do this type of remote, you know, ECG interpretation. I used to think that the ticket to really broad EKG screening in our young athletic population was physician infrastructure. And while I think that is really important, the real ticket to broad Implementation of EKG is technology and you know, there's one EKG system on the market.

eening athletes called Cardea:

to look at ECGs in in young athletes and I know some of that work is happening. It's certainly not ready for prime time. It's in its early phases of research, but there's really no reason that technology can't do this better than we can looking at an EKG. And once we get to that point where a machine can read it was super accuracy, super low, low, you know, false positive rate, very low unnecessary testing afterwards.

And a lot of accuracy now becomes broadly applicable and we can, we can do that. And, and again, the goal of that early detection, the same goal that we have right now, we're just using tools that don't do it very well. So better early detection. And then I think we can intervene and hopefully make these, these athletes safer.


Let's get this I mean, I feel like it's a very American capitalist thing to be like Let's wait for someone to want to profit off of it so that we can


[00:52:35] Julie Bruene: mass screen


And ultrasound machines are getting, you know, better and even smaller and more portable and less expensive, et cetera. So technology has helped. I think in the, in the cardiac space, it will be the same, and this will allow more people to do it. We'll never be able to replace, thankfully, you know, the human side of it.

Um, which has to think through difficult... Treatment algorithms and management strategies and shared decision making with with an athlete who is diagnosed with a potential heart condition or a confirmed heart condition, you know, the study that we're doing now that's called Orca outcomes registry for cardiac conditions and athletes is intended to do just that is to monitor young athletes who are identified with a heart condition and really see what happens over time, whether or not they continue to play sports, monitor their cardiovascular outcomes, quality of life outcomes, health, you know, mental health outcomes.

And we have really the, the sports cardiology community around the nation as part of that study. So, um, that to me is sort of the human side of it, meaning understanding how to counsel, taking in all the facts, disease management, et cetera. But the, the diagnostic testing, hopefully we'll just get better and better and we'll be able to use it.


[00:54:29] Jon Drezner: Yeah, you know, there's, there's some, there's some peak times, right? So that sort of, um, you know, late high school period, early college period is probably our peak time. So 16 to, you know, age 20, it would be my, my high risk sort of timeframe. Um, with certain heart conditions, the longer you've lived, you've sort of You've sort of proven your, your lower risk to have an event and, and, you know, if you take a young adolescent with the same disease as let's say a 30 year old, the young adolescent is sort of higher risk until proven otherwise.

When you've lived longer, you've, you've lived out of some of that risk, you know, thankfully, um, I don't think necessarily the screening has to occur. you know, forever as a competitive athlete. You know, if you've had a normal screen and you're just playing pickup hoops and stuff like that later on, I don't necessarily think you need to continue with, with, uh, you know, uh, a yearly screen or something like that, the turning point becomes when.

New diseases have the potential to develop. And so I know that's not the focus of this podcast, perhaps another time, but how do we screen our, our, our aging athletes, our masters athletes, our 45 and up group. You know, when you turn, once you hit 35, the leading cause of sudden cardiac arrest is just typical atherosclerosis and coronary artery disease and just the people who have it really prematurely.

But when you're 45 and older, that's clearly what's, what might get you. And there are some ways to screen for that well, um, that aren't in the EKG. And that's a different talk using like a coronary artery calcium score. And so, yeah, so I think, you know, people play hoops for, for a long time. I still try to get on the court here and there just to get embarrassed by my son who can beat me really easily now.


[00:56:17] Jon Drezner: but that's okay. Um, but I think about the group around me of my peers who are playing and who may have medical conditions or maybe who has been screened. And, you know, there is a way to screen that group better than we are. Um, and of course, you know, we always got to have those defibrillators around and make sure that people are playing in safe environments.


[00:56:46] Jon Drezner: I don't think so. The wearables, um, you know, monitor your heart rate that maybe can detect something like atrial fibrillation, which is a nonlethal arrhythmia. Um, and they can certainly have some value to help you with your training regimen and stuff like that. I don't think that they are necessarily detecting conditions at risk for sudden death in young athletes at this point.


[00:57:22] Jeremy Alland: No, well,


[00:57:28] Jeremy Alland: there, there's no videotape of me playing, but I do know that my strain score would probably equal that of a college basketball player without the amount of strain that the college basketball player is put in.


[00:57:46] Jeremy Alland: You heard it here first, aging is normal from Dr. John Dresner. Um, I have one more question before we wrap up here. You've, you've painted a really good picture on screening. this point, it kind of feels like a no brainer. Like it seems like we should be doing this. So what's the argument not to be doing it?

Who, who's standing up and arguing against this and say, what are they saying?


So it led to unnecessary and costly tests while holding the athlete out to play. Well, that has completely changed now that our false positive rate is so much lower, right? So we're like in that 1% range for high school athletes and maybe 2% range for college athletes compared to 20, 25%, you know, when you look back two decades ago.

So the cost effectiveness piece of this has completely changed. Um, and. I think that, um, we have unfortunately been impacted by national organizations that have not changed with the evidence, meaning that as new evidence emerged that the standard history and physical didn't work, that EKG could detect conditions at risk better, you know, using the same goal of the, of the evaluation, um, that they didn't change their ways.

They were stuck to say, Nope, don't do EKG, just do history and physical. If those same organizations, would have stood up and say, we want to set a five year goal. We want to, we know this is a better protocol, a better screen. We want everyone to be able to do it well. So we're going to sort of progressively get ourselves there by investing in infrastructure training and education.

You know, if the American Heart Association, if the American Academy of Pediatrics would have stood up and said, we need to learn EKG so we can do this well, I guarantee that this would have come true by now, but instead they have continued to put their foot down and say, we shouldn't use it. And I totally disagree.

And the, and I don't think there'll be, they're providing an evidence based recommendation.


[01:00:11] Jeremy Alland: Uh, anything you want to, uh, ask Julie before I wrap up here?


[01:00:18] Jeremy Alland: Awesome. Uh, one of the things we always ask, uh, guests on the show, John is if you have any resources you recommend for people to either learn more or refer to this topic, they finished, they're really interested to learn more. We're like, where do you point people?


Um, and so parent heart watch, I think is honestly a wonderful resource. Um, American Heart Association, America Red Cross, if you're not CPR trained, you should be CPR trained. Your school should have defibrillators. Make sure you raise some money and put those AEDs both inside and outside. Um, and if you're a clinician and you want to know more, want to know more about EKG screening and interpretation, then come to our website, um, for the, the, the UW sports cardiology, what we call the eAcademy and they can find the training modules, which are free.


[01:01:44] Julie Bruene: I'm gonna, I'm just gonna can my whole PPE lecture for tomorrow and just link to that and then just, just coast.


So we coupled the episodes for everybody. So please check out next week. Good preview.


[01:02:15] Jeremy Alland: Well, my, uh, my call to action will wrap, um, will. Tie in the episode from last week and really come into play next week. And that is, we are really giving some information on how people can save lives and that's not doctors and that's not clinicians and that's not nurses who do this for a living. That is somebody walking down the street.

That is a friend that is a family member who recognizes something and takes action and saves a life. Um, so with the heat illness, and again, talking about sudden cardiac death this week. And then, uh, CPR and stroke and such. We'll talk about next week.

Thank you. Everybody can be a lifesaver. So that's my call to action.


the amazing music is credited to Skill Cell with Bay Licensure The podcast is meant for educational and entertainment purposes only The contents of this podcast should not be taken as medical advice to treat any medical condition in either yourself or others Please consult a medical professional for any medical issues that you may be having The contents of this podcast are the opinions of the host only and do not reflect the opinions of their employers or affiliations This entire disclaimer also applies to any guess or contributors to the podcast Under no circumstances shall Dr Julie Bruny or Dr.

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