new advances in sports cardiology - health sciences...
TRANSCRIPT
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Pre-Participation Physicals & ECG Interpretation:
New Advances in Sports Cardiology
Irfan M. Asif, MD Vice Chair, Academic Affairs & Research
Director, Sports Medicine Fellowship Associate Professor, Department of Family Medicine
Greenville Health System, University of South Carolina- Greenville SOM Clemson University School of Health Research
G H S C l i n i c a l U n i v e r s i t y P a r t n e r s
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Hank Gathers
February 11, 1967 – March 4, 1990 26 Year Anniversary
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Leading cause of death during exercise
Sudden Cardiac Death (SCD)
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10 Year NCAA Study: Objective
1. Overall risk compared to death from any cause
2. Better define SCD in NCAA athletes
- Incidence
- Etiology
- Comparison of Reporting Mechanisms
3. Risk among subgroups
10 school years of forensically-based data
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Methods & Study Design
• A database of deaths (2003 – 2013) was developed
– Internal NCAA database
– Parent Heart Watch
– NCAA Catastrophic Insurance Claims
• Additional information was acquired through internet searches,
media reports, emails and telephone calls to athletic trainers,
coroners and next of kin
• Autopsy reports were obtained and cause of death was
adjudicated by an expert panel using standard definitions
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Accident50%
Suicide8%
Homicide8%
Cardiac15%
Cardiac/SCT0%
SCT2%
Headinjury1%
HeatStroke1%
Drug/EtohOverdose
3%
Cancer7%
Medical-other3%
Meningi s1%
Unknown1%
CausesofDeathinNCAAAthletes2003-2013
4,242,519 Athlete-Years
537 Deaths
79 Cardiac Deaths
Results
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Group Incidence
Overall 1in53,703
Males 1in38,390
Females 1in121,593
African-American 1in20,147
Caucasian 1in59,153
High Risk: Males & African Americans
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Sport Incidence
Men’sBasketball 1in8,978
Men’sSoccer 1in23,689
Football 1in35,951
Cross-Country 1in44,973
Baseball 1in50,023
Swimming 1in50,197
Volleyball 1in53,685
Lacrosse 1in54,401
Women’sBasketball 1in77,061
High Risk: Basketball
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Volleyball4%
Soccer11%
Swimming5% Wrestling
2%
Crew1%
Golf1%Lacrosse
4%Football23%
Basketball27%
Crosscountry8%
Baseball8%
Track4%
So ball1%
Tennis1%
Sports
Sudden Cardiac Death by Sport
Football and Men’s Basketball account for 23% of NCAA
athletes, but ½ of SCD’s
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Paradigm #1
The incidence of sudden cardiac death in
young athletes is remarkably higher than
previously recognized, especially in high
risk sub-groups
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AHA Scientific Statement: 2007
Leading Causes of SCD
Maron et al, Circulation 2007; 115: 2358-2368
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Circulation, 2009
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SuddenUnexplainedDeath25%
Anomalouscoronary11%
Myocardi s9%CAD
9%
CardiomyopathyNOS8%
idiopathicLVH/possiblecardiomyopathy
8%
Aor cdissec on5%
HCM6%
ARVC5%
WPW3%
DCM3%
LongQT2%
Commo o2%
IdiopathicLVH/SCT2%
KawasakiDisease2%
Etiology
Sudden Unexplained
Death is the leading
finding associated with
SCD in NCAA athletes
Harmon, Asif, et al, Circ, 2015
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Autopsy-Negative Sudden Unexplained Death
• Post-mortem examination fails to identify structural cause of death
• Inherited arrhythmia syndromes and ion-channel disorders
?
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Average HCM = 10% Average SUD = 30%
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Paradigm #2
Hypertrophic cardiomyopathy may not be
the leading cause of death in young
athletes…Autopsy negative sudden
unexplained death seems to be the most
common finding in this cohort during post-
mortem examination
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Goal of Screening
“…the main purpose of the periodic health exam is to screen for injuries or medical conditions that may
place an athlete at risk for safe participation.”
Ljungqvist; BJSM 2009
IOC Identify potentially life-threatening or disabling conditions so that they can be treated or risk factors modified and screen for conditions that may pre-dispose to injury.
Identify potentially life-threatening or disabling conditions so that they can be treated or risk factors modified and screen for conditions that may pre-dispose to injury.
“The ultimate objective of pre-participation screening of athletes is the
detection of ‘silent’ cardiovascular abnormalities that can lead to SCD.”
ACC, 36th Bethesda Conference; 2005
“The ultimate objective of pre-participation screening of athletes is the
detection of ‘silent’ cardiovascular abnormalities that can lead to SCD.”
ACC, 36th Bethesda Conference; 2005
“The principal objective of screening is to reduce the cardiovascular risks associated with organized sports and
enhance the safety of athletic participation.”
Maron; Circulation 2007
AHA
Cardiovascular Screening: There is No Debate!
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The question is not: “Should we screen?”
The question is: “How should we screen?”
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What is the best screen?
History?
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What is the best screen?
Physical Exam ?
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What is the best screen?
ECG?
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September 17, 2014
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1996 / 2007 2014
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Pre-participation Physical Evaluation (PPE) 4th Edition
http://ppesportsevaluation.org/
AAFP
AAP
ACSM
AMSSM
AOASM
AOSSM
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History
PPE-4 AHA 2014
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Collaboration between Sports Medicine and Cardiology • Personal History • Family History • Physical Examination
FREELY AVAILABLE
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Maron et al. JAMA, 1996-Vol 276, No. 3
Traditional Protocol: Evidence?
The standard pre-participation screening
process appears to be limited in its power
to identify those cardiovascular lesions
ultimately responsible for death.
Maron, JAMA, 1996
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The ECG Debate
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Challenges: False Positive Rates
• Prior studies show FP
rates of 15-40%
• FP & TP rates are driven
by the criteria chosen to
define “abnormal”
Maron et al, JACC, 1987; 10: 1214-1221
Pelliccia et al, Circulation, 2000; 102:278-284
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Frame of “Reference”
Reference
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Everydayhealth.com SIkids.com
70 Year Old with Active Chest Pain 20 Year Old Asymptomatic Athlete
VS.
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Challenge: False Positive Rates?
Normal Training related changes
Abnormal Training unrelated changes
Physiologic
Pathologic
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• FP rates are improved with the use of athlete-specific ECG interpretation standards
• Emerging data of higher prevalence of ECG abnormalities in males, African Americans, basketball players, and endurance athletes
• Evidence to exclude axis deviation, atrial enlargement and RBBB as being abnormal criteria in isolation
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The Effectiveness of Screening History, Physical Exam
and ECG to Detect Potentially Lethal Cardiac Disorders
in Athletes: A Systematic Review/Meta-Analysis
Harmon, J ECG, 2015
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ECG History Physical
Sensitivity 94% 20% 9%
Specificity 93% 94% 97%
Positive
Likelihood Ratio* 14.8 3.22 2.93
Negative
Likelihood Ratio* 0.055 0.85 0.93
Sensitivity, Specificity, and Positive and Negative Likelihood Ratios (Meta-analysis
of pooled data)
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Test False Positive Rate
Range
History 8% 1% - 31%
Physical 10% 0% - 15%
ECG 6% 1% - 19%
False Positive Rates from Pooled Data
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Electrocardiographic Screening in NCAA Athletes: A 2-year Multicenter
Feasibility Trial
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Results
• 35 institutions participated
– Year 1: 13 Div I programs
– Year 2: 12 Div I programs 13 Div II/III programs
• Total athletes screened: N = 5,258
– Year 1: 2,465
– Year 2: 2,793
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5,258 athletes
55% male; 45% female
17 intercollegiate sports
73% Caucasian 16 % Afro-American
Mean Age: 20.1
PE 108 (2.1%)
ECG 192 (3.7%)
Hx 1,750 (33.3%)
SOB 13% Syncope 11% CP 7% Serious cardiac disorder: 13 (0.25%)
WPW (11) Large ASD with RV dilatation
requiring surgery (1) Hypertrophic Cardiomyopathy (1)
() screen
No unjustified disqualification from sport
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False-Positives
33%
2.0% 3.4%
0%
5%
10%
15%
20%
25%
30%
35%
Hx PE ECG
False-Positive Rate
10 X
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Males have significantly more ECG abnormalities compared to females (p<0.0001)
Afro-American 4.8% vs. Caucasian 3.4% (p=0.069)
2.5%
4.5%
Rate of Abnormal ECGs by Gender and Race
Male Female
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Statistical Performance Measures
Sensitivity Specificity PPV
Hx 15.4% 73% 0.1%
PE 7.6% 98% 1.8%
ECG 100% 96.6% 6.8%
1000
55
15
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Paradigm #3
The ECG out-performs the history and
physical examination as a screening test
for diseases associated with sudden
cardiac death
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85%
78% 73% 73%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cardiologists SM Attendings PC Attendings PC Residents
ECG Interpretation Among Physician Groups
Before
p < 0.024 p < 0.0011 p < 0.0013
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BJSM 2012
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85%
78% 73% 73%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cardiologists SM Attendings PC Attendings PC Residents
ECG Interpretation Among Physician Groups
Before
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85%78%
73% 73%
96%91% 90% 92%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cardiologists SM Attendings PC Attendings PC Residents
ECG Interpretation Among Physician Groups
Before
After
p < 0.001 p < 0.0001 p < 0.0001 p < 0.0001
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Seattle Criteria
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ECG demonstrates sinus bradycardia, early repolarization with ST elevation (arrows) and peaked T-waves, and voltage criteria for left ventricular hypertrophy. These are common findings related to regular training.
>35mm
Common ECG Findings in Athlete’s Heart
>35mm
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This ECG demonstrates a markedly abnormal pattern with T-wave inversion and ST depression in the inferolateral leads. Additional
testing is required to evaluate for cardiomyopathy.
Hypertrophic Cardiomyopathy
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Need Help?
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Refined ECG Interpretation Criteria
Seattle ECG Summit February 26-27, 2015
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Paradigm #4
Physician education is the major hurdle in
implementing ECG screening in athletes.
However, tremendous resources are
available
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AEDs in Sport
• Provide a means of early defibrillation and the potential for effective secondary prevention of SCD
– Athletes
– Students
– Staff
– Spectators
– Coaches
– Officials
– Visitors
– AEDs in high risk locations
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It’s NOT just about AEDs…
EMERGENCY
PREPAREDNESS
Written Emergency Action Plan for SCA
All staff awareness
Emergency communication
Trained responders in CPR/AED
Access to early defibrillation (<3-5 min collapse to shock)
Practice and review of the EAP at least annually
Integration of AED into local EMS system
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Screening Is Not Perfect…
Emergency Response Planning, CPR Training, & AED Programs are critical
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Paradigm #5
Screening is not perfect…An Emergency
Action Plan must be in place for all
sporting venues and event coverage
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Paradigms
1. Sudden cardiac death appears to be more common than
previously recognized
2. HCM may not be the leading cause of death in young
athletes
3. As a screening tool, the ECG outperforms the history &
physical, especially with the appropriate criteria
4. Physician education of ECG interpretation seems to be
the most practical hurdle for broad scale implementation
5. Screening is not perfect…Have an EAP and an AED
available
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Thank You
G H S C l i n i c a l U n i v e r s i t y P a r t n e r s