4/30/2013. Sports Medicine Highlights from the first ACC Symposium on Sports Cardiology. Disclosures
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1 Sports Medicine Highlights from the first ACC Symposium on Sports Cardiology Disclosures Biomedical Systems (Consultant) Biotie (Consultant) Cook MED Institute (CEC) Eli Lilly (DSMB Consultant) Eli Lilly (DSMB, Consultant) Euthymics (Consultant) Intercept (Consultant) NFL Scouting Combine (Cardiac Testing) Synosia (Consultant) Xenoport (Consultant) 1
2 Sports Section launched in signed up for complimentary membership Sports Section grew to 3,900 members in ,700 paid section members 2,200 complimentary (fellows in training) Sports Cardiology Topics Defining the athlete and cardiovascular adaptation Causes, epidemiology and prevention of sudden death in athletes Interpretation of cardiac diagnostic tests in athletes Return to play decisions Defining the American Athlete Size of the population 4,000,000 5,000,000 High School / Youth 500,000 NCAA Countless Masters to weekend warriors 2
3 Defining the American Athlete Diversity of the population Age 5-?? Gender Title IX Activity Extremes of competition Athletes Have Changed in Shape 20% of the 2013 NFL Scouting Combine Players > 300 lbs. Cardiovascular Adaptation to Exercise Training Aaron Baggish Harvard Ben Levine - Texas 3
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7 Causes, Epidemiology, and Prevention of Sudden Cardiac Death in Athletes Mark Link - Tufts Paul Thompson - Hartford Hospital Mary Jo Gordon Faces of SCA Pistol Pete Maravich (age 40, died during pickup basketball game of previously undetected coronary artery anomaly) Reggie Lewis (age 27, died during off season practice with cardiomyopathy) Hank Gathers (age 23, died during basketball game, autopsy demonstrated HOCM) 7
8 Faces of SCA Piermario Morosini (age 25, died after on-field SCA) Fabrice Muamba (age 23, survived on-field cardiac arrest, retired from soccer) Annual Incidence of SCD in Athletes Per 100K/Yr Deaths CHD (40 year old man) Breast / prostate cancer Auto Accident Lightning Harmon KG et al, Circ 2011;123:1594; Maron BJ et al, Ann Intern Med 1998;129:379; Vogel R (personal data) Causes of Sudden Death in 387 Young Athletes HOCM ( 27%) Commot io Cordis Coronary Artery Anomalies LVH (Idiopathic) Myocarditis Ruptured aortic aneurysm Bridged coronary artery Aort ic st enosis Atherosclerotic CAD Dilat ed CM Myxomatous mitral valve degenerat ion Ast hma Heat st roke Drug abuse Other CV Cause Maron, Data from registry of Minneapolis Heart Institute Foundation Long- QT syndrome 8
9 Patient Presentation June,1993: 36 y/o female runner, weight lifter, volunteer FF/EMT presents with palpitations and near-syncope Family History Family of eight (8) children: 2 sisters w/ LQTS and aborted SCA; one at age 17 (proband), other at age 22 1 sister, 1 brother asymptomatic w/ LQTS per ECG Father w/ multiple syncopal episodes Nephew w/ LQTS; 2 aborted SCAs at age 11 Maternal grandfather had SCD at age 37 Paternal great aunt had SCD at age 15 Paternal 1 st cousin w/ TdP at age 35 9
10 ECG at age 36 years Patient Clinical Course Placed on β-blocker; ICD not implanted Physician advised no running; patient complied Patient did well from age Inferior MI at age 49 (Jan. 07); peak troponin = 24.9; Cardiac rehab (Feb. June 07) Syncope (Oct. 07) following cerebral angiogram; CPR ICD implanted (Nov. 07) Patient Presentation Post-MI: Total cholesterol = 266 BMI = 30.1 Cath report: OM branch occlusion; 30-40% proximal vessel narrowing; discrete LV akinesis; EF = 65 Nuclear stress: Moderately severe inferolateral wall defect, reversible w/ rest 10
11 Outcome Post-MI Cardiac Rehab Genetic testing results (Oct. 11): KCNH2/LQTS-2, G5845 mutation ICD Sports Registry: Fourteen (14) 5k races (Aug. 11-Oct. 12) 12) National Weight Control Registry: BMI = 21.4 Total cholesterol = 200 (w/o Rx) ECG Kovacs Lawless ECHO Baggish MRI Martinez Interpretation of Cardiac Tests in Athletes 11
12 Interpretation of Cardiac Tests in Athletes ECG Corrado - EHJ (2010) 31: Recommendations for Interpretation of 12 lead ECG in the Athlete t Drezner - British Journal of Sports Medicine (2013) 47: Seattle Criteria Summit on ECG Interpretation in Athletes February 2012, Seattle WA Summit on ECG Interpretation in Athletes February 2012, Seattle WA Drezner,
13 Sensitivity and specificity of ECG DISEASE Likely to be detected w/ ECG Long QT syndrome Brugada syndrome Coronary anomalies ECG Findings High Q-T c 440 msec males Q-T c 460 in females Low Low RBBB, and coved ST elevation in V1 and V2 None characteristic Sensitivity Specificity % Intermediate At least 20% Low High Low Lawless and Best: Electrocardiograms in athletes: MSSE 40: (5) 787, 2008 Interpreting Athlete ECGs QT Measurement and Correction Richard J MD FACC Krannert Institute of Cardiology Indiana University School of Medicine Indianapolis, IN 13
14 Challenges to QT Measurement "there are difficulties in the exact determination of the points which are to be used for the measurement of the QT interval in a given complex" "there are difficulties when the actual QT duration is corrected for heart rate" Challenges to QT Measurement "there are difficulties in the exact determination of the points which are to be used for the measurement of the QT interval in a given complex" "there are difficulties when the actual QT duration is corrected for heart rate" Lepeschkin and Surawicz: Circulation 6, , 1952 Factors known to effect QT interval Heart Rate Meals Autonomic system Posture Electrolyte balance Time of day Emotional State Interaction with Staff or other Subjects 14
15 4/30/2013 File name/location Company Confidential Copyright 2000 Eli Lilly and Company 43 4/30/2013 File name/location Company Confidential Copyright 2000 Eli Lilly and Company 44 4/30/2013 File name/location Company Confidential Copyright 2000 Eli Lilly and Company 45 15
16 On Screen Calipers 4/30/2013 File name/location Company Confidential Copyright 2000 Eli Lilly and Company 46 QTc Interval by Age and Gender nterval (msec) QTcL in Age (years) Gender Females Males Dmitrienko et al DIJ, 2005 Relative Performance of QT Correction Formulas Bazett correction Fridericia correction QTcB interval (m msec) QTcF interval (m msec) RR interval (sec) RR interval (sec) RR interval=60/heart rate 16
17 Accuracy of QT Interval Correction Methods for Prediction of Drug-Induced Torsades de Pointes QT uncorrected QT Fridericia R QT Bazett s Area under the ROC curve RR interval Circulation 2004;110:III-580. Results Receiver Operating Characteristics Curve Uncorrected QT Interval 1.0 vity Sensitiv Specificity Circulation 2004;110:III-580. Results Receiver Operating Characteristics Curve Bazett s-corrected QT Interval y Sensitivity Specificity Circulation 2004;110:III
18 Results Receiver Operating Characteristics Curve Fridericia-Corrected QT Interval y Sensitivity Specificity Circulation 2004;110:III /30/2013 NFL Combine Echo Data, (N=985) 18
19 Red Flags LVEF < 50% IVS thickness > 1.6cm Concentric LVH > 2.0 cm. Any regional wall motion abnormality Aortic diameter > 4.0 cm. Greater than moderate valvular regurgitation Any valvular stenosis Aberrant coronary artery Pericardial effusion > normal variant ASD / VSD Dextrocardia Congenital structural abnormality Red Flags (revised) LVEF < 50% IVS thickness > 1.6cm Concentric LVH > 2.0 cm. Any regional wall motion abnormality Aortic diameter > 4.0 cm. Aberrant coronary artery ASD / VSD NFL Scouting Combine Facts/Figures 342 players 3 days available for screening, with concentration on 2 days C di t d ith CV i Coordinated with non-cv screenings Volumes 342 resting 12 lead ECGs 342 resting echo / doppler / strain studies Anticipate stress echos 19
20 Ages NFL Scouting Combine Facts/Figures Height Weight lbs Screening Flow ECG Resting 12 lead Cardiologist Read ECHO Stress Echo Resting Echo/Doppler Cardiologist Read Modified Bruce Cardiologist Read Franchise Medical Teams Establishing Reference Ranges 3 years data approximately 1,000 players Quantitative data on chamber size, wall thickness, systolic and diastolic function Exploratory analyses e.g. global LV strain 20
21 4/30/2013 4/30/2013 Return to Play Decisions Challenge I Genetics Multiple new channelopathies identified since 2005 Readily available genetic testingti Heart Rhythm Society 2011 Guidelines re: Genetic testing in suspected channelopathies 21
22 Return to Play Decisions Challenge II Athletes Have Changed in Other Characteristics >1,000,000 adults with congenital defects External Environment Has Changed 22
23 External Environment Has Changed Requires that the student athlete who is suspected of experiencing a symptom of sudden cardiac arrest be removed from play Google search on Athlete heart sceeen = 2,670,000 hits External Environment Has Changed 23
24 Summary and Conclusions Millions of athletes of all shapes and sizes are in need of expert cardiac care Thousands of ACC members have expressed an interest in the topic and have come together in the ACC Sports Cardiology Section Bethesda 36 will be updated soon (Joint AHA/ACC document on participation) 24
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