Outcome of pre-participation screening of novice middle-aged long-distance runners
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1 Outcome of preparticipation screening of novice middleaged longdistance runners Philip Aagaard 1 A Sahlén 1, L Bergfeldt 2, F Braunschweig 1 1 Karolinska University Hospital, Dept. of Cardiology, Stockholm Sweden 2 Sahlgrenska Academy, Dept. of Molecular & Clinical Medicine, Gothenburg Sweden
2 SCD incidence after preparticipation screening of young athletes (<35 years) Corrado; JACC, 2008
3 deaths (n) SCD is more common in athletes >35 years Exercise related SCD in Sweden < Age (years) Folksam Insurance Report, 2005
4 EACPR screening recommendations Based on: 1. Habitual level of physical activity 2. Intensity of planned activity 3. Cardiovascular risk profile
5 EACPR screening recommendations Based on: 1. Habitual level of physical activity 2. Intensity of planned activity 3. Cardiovascular risk profile All highintensity ysical activity are subject to detailed evaluation by a qualified physician even in the absence of symptoms or risk factors for CAD.
6 Objectives 1. To characterise the cardiovascular risk profile of male, first time endurance race participants y. 2. To evaluate the potential diagnostic yield of the EACPR screening recommendations.
7 Materials and methods Inclusion criteria: Male years Participating for the first time in the 2010 Lidingöloppet (30km, 15km or 10km) Living near Stockholm Exclusion criteria: >2 participations in a race >10km in the last 2 y
8 Materials and methods Questionnaires History, phys exam 12lead ECG Blood tests Dopplerecho Further workup e.g. Revised PARQ, training questionnaires Standardized after AHAguidelines for preparticipation evaluation 1 According to ESC guidelines for ECG interpretation in athletes 2 Lipid profile, CBC, electrolytes, NTproBNP Dimensions, syst/diast function, TVI On individual basis 1 Maron, Circulation, 2007; 2 Corrado, Eur Hear J, 2010
9 Results Baseline characteristics Parameter Median Range Participants (n) 153 Age (ys) 51 BMI (kg / m 2 ) 25 Resting heart rate (bpm) 58 Systolic BP (mmhg) 134 Diastolic P (mmhg) 81 Left ventricular mass index (g / m 2 ) 119 NTproBNP (ng / L) 38 Training background (hours / week) 2.8 Smoking history (%)
10 Results Further work up in 13 / 153 subjects Age Screening modality (finding) Workup Questionnaire (exertional dyspnoea) Questionnaire (exertional CP) Physical exam (BP= 180/110) ECG (QTc = 4ms) ECG (QTc = MVP) ECG (TWI beyond V3) ECG (QTc> 500ms) ECG (QTc> 500ms) ECG (AV block I + syncope) Echo (mild AI) Echo (cardiac tumor) ET + 24h BP +CMR CT + surgery Finding AFib AFib AFib HTN MVP LQTS (?) LQTS (?) AV block III Grade 1+ AI Cardiac tumor
11 Results Further work up in 13 / 153 subjects Age Screening modality (finding) Workup Questionnaire (exertional dyspnoea) Questionnaire (exertional CP) Physical exam (BP= 180/110) ECG (QTc = 4ms) ECG (QTc = MVP) ECG (TWI beyond V3) ECG (QTc> 500ms) ECG (QTc> 500ms) ECG (AV block I + syncope) Echo (mild AI) Echo (cardiac tumor) ET + 24h BP +CMR CT + surgery Finding AFib AFib AFib HTN MVP LQTS (?) LQTS (?) AV block III Grade 1+ AI Cardiac tumor
12 Results Further work up in 13 / 153 subjects Age Screening modality (finding) Workup Questionnaire (exertional dyspnoea) Questionnaire (exertional CP) Physical exam (BP= 180/110) ECG (QTc = 4ms) ECG (QTc = MVP) ECG (TWI beyond V3) ECG (QTc> 500ms) ECG (QTc> 500ms) ECG (AV block I + syncope) Echo (mild AI) Echo (cardiac tumor) ET + 24h BP +CMR CT + surgery Finding AFib AFib AFib HTN MVP LQTS (?) LQTS (?) AV block III Grade 1+ AI Cardiac tumor
13 Results Further work up in 13 / 153 subjects Age Screening modality (finding) Workup Questionnaire (exertio dyspnoea) Questionnaire (exertional CP) Physical exam (BP= 180/110) ECG (TWI beyond V3) ECG (QTc = 4) ECG (QTc = MVP) ECG (QTc > 500ms) ECG (QTc > 500ms) ECG (AV block I + syncope) Echo (mild AI) Echo (cardiac tumor) ET + 24h BP + CMR CT + surgery Finding AFib AFib AFib HTN MVP LQTS (?) LQTS (?) AV block III Grade 1+ AI Cardiac tumor
14 Results Further work up in 13 / 153 subjects Age Screening modality (finding) Workup Questionnaire (exertio dyspnoea) Questionnaire (exertional CP) Physical exam (BP= 180/110) ECG (TWI beyond V3) ECG (QTc = 4) ECG (QTc = MVP) ECG (QTc > 500ms) ECG (QTc > 500ms) ECG (AV block I + syncope) Echo (mild AI) Echo (cardiac tumor) ET + 24h BP + CMR CT + surgery Finding AFib AFib AFib Mild HTN MVP LQTS (?) LQTS (?) AV block III Grade 1+ AI Cardiac tumor
15 Results Further work up in 13 / 153 subjects Age Screening modality (finding) Workup Finding Questionnaire (exert. dyspnoea) Questionnaire (exertional CP) Physical exam (BP= 180/110 ECG ECG (QTc=464 + MVP) ECG (TWI beyond V3) ECG (QTc > 500ms) ECG (QTc > 500ms) ECG (AV block I + syncope) Echo (mild AI) Echo (cardiac tumor) ET + 24h BP +CMR CT + surgery AFib AFib AFib HTN MVP LQTS (?)* LQTS (?)* AV block III Grade 1+ AI Cardiac tumor *disqualified
16 Results Further work up in 13 / 153 subjects Age Screening modality (finding) Workup Finding Questionnaire (exert. dyspnoea) Questionnaire (exertional CP) Physical exam (BP= 180/110) ECG (QTc = 4ms) ECG (QTc = MVP) ECG (TWI beyond V3) ECG (QTc > 500ms) ECG (QTc > 500ms) ECG (AV block I + syncope) Echo (mild AI) Echo (cardiac tumor) ET + 24h BP +CMR CT + surgery AFib AFib AFib HTN MVP LQTS (?)* LQTS (?)* AV block III* Grade 1+ AI Cardiac tumor *disqualified
17 Results Further work up in 13 / 153 subjects Age Screening modality (finding) Workup Finding Questionnaire (exert. Dyspnea) Questionnaire (exertional CP) Physical exam (BP= 180/110 ECG (QTc= 4ms) ECG (QTc=464 + MVP) ECG (TWI beyond V3) ECG (QTc> 500ms) ECG (QTc> 500ms) ECG (AV block I + syncope) Echo (mild AI) Echo (cardiac tumor) ET + 24h BP +CMR CT + surgery AFib AFib AFib HTN MVP LQTS (?)* LQTS (?)* AV block III* Grade 1+ AI Cardiac tumor *disqualified
18 Results Further work up in 13 / 153 subjects Age Screening modality (finding) Workup Finding Questionnaire (exert. dyspnea) Questionnaire (exertional CP) Physical exam (BP= 180/110) ECG (QTc = 4ms) ECG (QTc = MVP) ECG (TWI beyond V3) ECG (QTc> 500ms) ECG (QTc> 500ms) ECG (AV block I + syncope) Echo (mild AI) Echo (cardiac tumor) ET + 24h BP +CMR CT + surgery AFib AFib AFib HTN MVP LQTS (?)* LQTS (?)* AV block III* Grade 1+ AI Cardiac tumor* *disqualified
19 Results Screening process flow chart: n= 13 further workup n= 4 disqualified n=153 screened Screening according to EACPR recommendations n= 11 further workup n= 3 disqualified
20 Conclusions I Screening with EACPR recommendations led to further work up of 7 % and to disqualification of 2 % of firsttime male endurance race participants y. We found no runner with coronary artery disease. The 12lead ECG reveals important information and should be part of the preparticipation evaluation.
21 Conclusions II Preparticipation evaluation of middleaged and older athletes may find athletes in whom sports could have a negative effect on health. However, screening may also lead to findings and workup of conditions not related to the risk of exercise induced adverse cardiac events.
22 2 subjects with QTc >500ms Workup: h holter monitoring >> maximum exercise test >> genetic analysis
23 1 subject with atrial tumor Figur som visar sinuspaus Figur som visar complete AV block Workup: TEE >> CT >> surgery
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