La valutazione dell atleta: è una strategia salva-vita e costo-efficace?

Transcription

1 La valutazione dell atleta: è una strategia salva-vita e costo-efficace?

2

3

4 Primo trattato di Medicina

5

6 Wilson and Jungner s criteria In the 1960s the World Health Organization adopted the Wilson and Jungner s criteria for evaluating public health screening measures Public health screening program justifiable when: 1) the condition to be detected is of public health importance 2) there is an effective test for detecting the condition at a sufficiently early stage to permit intervention 3) There are available effective preventive measures/treatments for the condition when it is detected at an early stage 4) there is evidence that early treatment, before onset of symptoms, leads to better outcomes.

7 Cardiovascular causes of sudden death associated with sports Adults (age > 35 years): Atherosclerotic coronary artery disease Young competitive athletes (age 35 years): Hypertrophic cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy Congenital anomalies of coronary arteries Myocarditis Aortic rupture Valvular disease Preexcitation syndromes and conduction diseases Ion channel diseases Congenital heart disease, operated or unoperated

8 Leading causes of sudden cardiovascular death in young competitive athletes HCM ARVC/D

9 Sensitivity of 12-lead ECG in SD victims of HCM 78 SD victims of HCM 53 Prior 12-lead ECG 51/53 (96%) Positive ECG (LVH, ST-T changes, q waves) Maron et al. Circulation 1982; 65:

10 Sensitivity of 12-lead ECG in sport-related SD victims with ARVC 21 Sport-related SD victims with ARVC 17 Prior 12-lead ECG 15/17 (88%) Positive ECG (negative T-waves beyond V1, QRS widening) Corrado et al PACE 2002; 25 (abstr) :544

11 Corrado et al. Eur Heart J 2005

12 LENEGRE BRUGADA LQT1 LQT2 LQT3 SQT Syndrome

13

14 Preparticipation Athletic Screening (Padua: ) Athletes screened: 33,735 Athletes disqualified: 1,058 (3%) Cardiovascular causes of disqualification: 621 (59%) Hypertrophic Cardiomyopathy: 22 (0.07% of 33,735) Corrado et al. N Engl J Med 1998; 339: 364-9

15 Clinical Characteristics of Athletes Disqualified for HCM (Padua: ) N.: 22 Age: 20±4 yrs Sex (% male): 90 Reason for echo: ECG changes (80%) LV wall Thickness: 19±3 mm LV cavity: 43±2 mm LVH after detraining: unchanged Corrado et al N Engl J Med 1998; 339:

16 Prevalence of HCM in young white people ECG ECG: 0.07% (22 of 33,735) Corrado et al NEJM, 1998 ECHO: 0.10% (2 of 2,030) Maron et al Circulation, 1995

17 Clinical Outcome of Athletes Disqualified for HCM (Padua: ) Follow up duration: 7.8±2.8 yrs Deaths: none Paroxysmal A F: 2 (Beta-blockers, amio) Nonsustained VT: 1 (amio) Corrado et al N Engl J Med 1998; 339:

18 Analysis of efficacy of the Italian preparticipation screening compared to that recommended by the American Heart Association (that is essentially based on history and physical examination, without 12-lead ECG) for identification of cardiovascular diseases at risk of SD during sports History Physical examination ECG Italy vs U.S. History, Physical examination Corrado et al. Circulation (abstr.) 2004

19 Identification of Cardiovascular Diseases at risk for SD in the Athlete (Center for sports Medicine; Padua ) 12-lead ECG makes the difference *Number of athletes that would have been identified on the basis of Hx and physical exam only

20 Corrado et al JAMA 2006;296:

21 Annual Incidence Rates of Sudden Cardiovascular Death in Screened Competitive Athletes and Unscreened Nonathletes Aged 12 to 35 Years in the Veneto Region of Italy ( ) Sudden death per person-years 5,00 3,75 2,50 1, P for trend <0.001 Years Athletes Nonathletes Corrado et al JAMA 2006;296:

22 Mortality trend for sudden death from Cardiomyopathies RR=0.10 1,50 Sudden death per athlete-years 1,13 0,75 0,38 P for trend = Pre-screening ( ) Early-screening ( ) Late-screening ( ) Corrado et al JAMA 2006;296:

23 Cardiovascular conditions causing disqualification from competitive sports in 879 athletes over 2 consecutive screening periods ( and ) at the Center for Sports Medicine in Padua, Italy NUMBER OF DISQUALIFIED ATHETES* CARDIOVASCULAR CAUSES OF DISQUALIFICATION Total Study Period ( ) N=879 (%) Early screening Period ( ) N=455 (%) Late screening Period ( ) N=424 (%) P-value Rhythm and conduction abnormalities 345 (39) 166 (36) 179 (42.2) ventricular arrhythmias 173 (19.6) 81 (18) 92 (21.6) supraventricular arrhythmias 73 (8.3) 39 (8.6) 34 (8.0) WPW Syndrome 55 (6.3) 29 (6.3) 26 (6.1) LBBB or RBBB & LAD 26 (3.0) 8 (1.7) 18 (4.2) second Degree AV Block 13 (1.5) 7 (1.5) 6 (1.4) long QT Syndrome 5 (0.6) 2 (0.4) 3 (0.7) 0.93 Systemic hypertension: 205 (23) 118 (25.9) 87 (20.5) 0.96 Valvular disease (including MVP): 184 (21) 106 (23.3) 78 (18.4) 0.09 Cardiomyopathies 60 (6.8) 20 (4.4) 40 (9.4) hypertrophic 30 (3.4) 14 (3.0) 16 (3.8) arrhythmogenic right ventricular 16 (1.8) 2 (0.4) 14 (3.3) dilated 14 (1.6) 4 (0.9) 10 (2.4) 0.21 Coronary artery disease 11 (1.3) 2 (0.4) 9 (2.1) 0.05 Other 74 (8.4) 43 (9.5) 31 (7.3) 0.42

24 A 21 years old basket player with HCM identified at PPS Corrado et al. Circulation (Abstr) 2004

25 A 20 years-old soccer player with ARVC/D identified at PPS Corrado et al. Circulation (Abstr) 2004

26 A 20 years-old soccer player with ARVC/D identified at PPS Corrado et al. Circulation (Abstr) 2004

27

28 Screening of young athletes for Cardiovascular diseases (Center for Sports Medicine, Padua ) Athletes screened 42,386 Positive findings 3,914 (9%) Heart diseases 879 (2%) False positive 7-9% Potentially lethal heart diseases 91 (0.2%) Corrado et al JAMA 2006; 296:

29 Clinical significance of abnormal ECG patterns in trained athletes Pelliccia et al. Circulation. 2000;102:278-84

30 ECG Abnormalities in the Athlete Common ECG patterns (up to 80%)* Sinus bradycardia; First degree AV block; Notched QRS in V1 or incomplete RBBB; Early repolarization; Isolated QRS voltage criteria for left ventricular hypertrophy Uncommon ECG patterns (<5%) T-wave inversion; ST-segment depression; Pathological Q waves; Left atrial enlargement; Left axis deviation/left anterior hemiblock; Right axis deviation/left posterior hemiblock; Right ventricular hypertrophy; Complete LBBB or /RBBB; Long or short QT interval; Brugada-like early repolarization; Ventricular arrhythmias

31 Marginal Overlap between ECG Abnormalities In HCM patients and Trained Athletes ECG pattern Athletes N=1005 (%) HCM N=260 (%) P value Isolated increase of QRS voltages Nonvoltage criteria of LVH 403 (40) 5 (1.9) < ( 1.3) 155 (59.6) < ST/T repolarization abnormalities 27 (2.7) 209 (80) < Pathologic Q waves 17(1.7) 103 (39.6) < AHA Scientific Sessions 2007

32

33 ECG Abnormalities in the Athlete Common ECG patterns (up to 80%)* Sinus bradycardia; First degree AV block; Notched QRS in V1 or incomplete RBBB; Early repolarization; Isolated QRS voltage criteria for left ventricular hypertrophy Uncommon ECG patterns (<5%) T-wave inversion; ST-segment depression; Pathological Q waves; Left atrial enlargement; Left axis deviation/left anterior hemiblock; Right axis deviation/left posterior hemiblock; Right ventricular hypertrophy; Complete LBBB or /RBBB; Long or short QT interval; Brugada-like early repolarization; Ventricular arrhythmias

34 ! from Basso et al Circulation 1996;94:

35

36 Prevalence of right precordial T-wave inversion at preparticipation ECG screening: Study population: 3086 consecutive athletes Gender: 2138 M, 948 F Age: mean 15.4±9 yrs; range 7-35 yrs T-wave inversion beyond V1(overall): 127 athl. (4.1%) 70 (2.3%) in leads V1 and V2 57 (1.8%) in leads V1 to V3 or beyond T-wave inversion (ath. 14 years ): 1.4% (p<0.001) T-wave inversion (ath.<14 years ): 9,3% ARVC/D diagnosis (Echo/cardiac MR): 3 of 127 (2.3%) ARVC/D prevalence in this population: 0.1%

37 National health system In Italy screening is made feasible because of its limited costs in the setting of a mass-program. National health system developed in terms of health care and prevention services Infrastructure Sports physicians

38 Years of life saved Unlike older patients with coronary artery diseases or heart failure, young individuals diagnosed with a genetic disease at risk of arrhythmic cardiac arrest will survive for many decades with normal or nearly normal life expectancy This large amount of life-years saved influences costeffectiveness analysis and explains why all reports on ECG screening of young individuals have provided cost estimates per year of life saved well below $ 50,000.

39 Screening cascade The benefit of preparticipation evaluation goes beyond the detection of index athletes with an inherited heart disease because it enables cascade screening of relatives and results in a multiplier effect for identifying other affected family members and saving additional lives.

40 CONCLUSIONS Italian ECG screening has met the Wilson and Jungner s criteria: 1) safe sports activity is a important health problem; 2) affected, but still asymptomatic, athletes are accurately identified by ECG screening; 3) an effective management strategy exists based on restriction of training/competition and subsequent clinical treatment; 4) early identification and management of asymptomatic athletes favourably modify the outcome of the underlying diseases leading to substantial reduction of SCD.

41 The end He who saves a single life saves the whole world -Talmud Sanhedrin 4:5

42 Maurizio Schiavon, MD Sports Medicine & Physical Activities Unit National Health Service ULSS 16 of Padova, Italy ai Colli Social Health Department Domenico Corrado, MD, PhD Department of Cardiac, Thoracic and Vascular Sciences University of Padova, Italy