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1 Gerry Keenan MMS PA-C Associate Professor -Physician Assistant Studies Arizona School of Health Sciences A T Still University Event Medical Director-USA/Karate- Arizona Clinical Director-MEDfest/Healthy Athletes Special Olympics Arizona The copyrighted materials available in this class are for educational use only. One copy per student is permitted for educational purposes. Redistribution or duplication is prohibited Preventable deaths occur every year in the young population. Nick of Time Foundation states one high school athlete suffers a Sudden Cardiac Arrest every three days in US! 1

2 Athlete Screening may assist in preventing these deaths Preparation; Coaches training, Emergency Plan Appropriate equipment Advanced life support Education Preparation Screenings Research The Italian Study JAMA Oct 4;296(13): Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. Does preparticipation cardiovascular screening of athletes save lives? [Nat Clin Pract Cardiovasc Med. 2007] A preparticipation screening program can decrease the incidence of sudden cardiac death among young athletes. [J Pediatr. 2007] Protecting athletes from sudden cardiac death. [JAMA. 2006] 2

3 Cost: ECG, Echo, EXAM Certified testing Knowledgeable AND experienced Interpretation Using estimates from the Italian data, the authors of the new study created a computer simulation of how American athletes 14 to 22 years old would be affected by screening. They found that compared with no screening at all, screening with only a medical history and a physical examination saves just 0.56 life-years per 1,000 athletes, and costs about $111 per person. But adding an EKG would save 2.06 more life-years per 1,000 athletes at an additional cost of $89 per athlete, including all secondary examinations and treatment. This makes the cost of EKG screening $42,900 per life-year saved, on average, a number comparable to doing kidney dialysis ($20,000 to $80,000 per life-year saved). Other experts found the work impressive. It s as fair a statement as I ve ever seen on the cost-effectiveness of EKG screening, said Dr. Robert J. Myerburg, a cardiologist and professor of medicine at the University of Miami. 3

4 Seattle criteria Controversy Cost, Yield Testing..begets testing leads to testing causes testing. To the numbers: Rare diseases like HCM and Long-QT kill athletes at a frequency of about 0.01%. That s the left side of the equation. On the right side of the equation are the risks of all the cardiac caths, electrophysiology (EP) studies and dye-requiring CT scans ordered as a result of the screening tests. Though an individual cardiac cath, EP-study or CT are lowrisk, the cumulative risk of doing these on thousands of normal people surely approach the 0.01% chance of sudden death in an athlete. Said more simply, with made up numbers to make my point, if screening saves 50 of the 100 teens who die each year, but 50 die from complications that occur from chasing down incidentalomas, than it s an expensive statistical wash. John Mandrola, MD 4

5 Test or no do or not. Mandate vs Not to mandate- The man said Don t you realize that there are miles and miles of beach, with starfish all along it? There s too many, you can t possibly make a difference! The young girl bent down and picked up another starfish and threw it into the sea and said. made a difference to that one What is a PA to do??? One PA s view:.. MOM rule, me or mine. Do not test everyone. Offer referral IF there is concerning history or suspicion or if family or athlete request. Have a high index of suspicion. Prep at practice and competitions. Confront your BIA Remain informed. Seek consultation. 5

6 Age bias for Aortic Disection Tyler Kahle: i49s For a free online training module on ECG interpretation in athletes, please visit: For the November 2012 BJSM supplement on Advances in Sports Cardiology, please visit: Is the ECG Normal vs Abnormal long#sec-2 Understand the common normal findings Understand the abnormal findings Consultation with specialist WITH EXPERINCEIN ATHLETE S HEART,DISORDERS 6

7 Even when properly evaluated and interpreted ECG will NOT detect ALL conditions at risk. Br J Sports Med 2012;46:i6-i8 doi: /bjsports Professor Jonathan A Drezner, Department of Family Medicine, University of Washington, P.O. Box , Seattle, WA 98195, USA; jdrezner@uw.edu Br J Sports Med 2012;46:i6-i8 doi: /bjsports T wave inversion ST segment depression Pathological Q waves >1 mm in depth from baseline in two or more adjacent leads not including avr or V1 ( 1 note exception below figure 1) 1 mm in depth in two or more adjacent leads >3 mm in depth or >0.04 s in duration in two or more leads 7

8 Normal variant of T wave inversion in athletes of African-Caribbean descent. Jonathan A Drezner Br J Sports Med 2012;46:i6-i8 Copyright BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved. Complete left bundle branch block QRS >0.12 s, predominantly negative QRS complex in lead V1 (QS or rs), and upright monophasic R wave in leads I and V6 (figure 2) 8

9 Left bundle branch block: QRS >0.12 s, predominantly negative QRS complex in lead V1 (QS or rs), and upright monophasic R wave in leads I and V6. Jonathan A Drezner Br J Sports Med 2012;46:i6-i8 Copyright BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved. QRS >0.12 s, terminal R wave in lead V 1 (rsr ), and wide terminal S wave in leads I and V 6 (figure 3) Right bundle branch block: QRS >0.12 s, terminal R wave in lead V1 (rsr ), and wide terminal S wave in leads I and V6. Jonathan A Drezner Br J Sports Med 2012;46:i6-i8 Copyright BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved. 9

10 ntraventricular conduction delay Nonspecific, QRS >0.12 s Left atrial enlargement Prolonged P wave duration of >0.12 s in leads I or II with negative portion of the P wave 1 mm in depth and 0.04 s in duration in lead V1 Left axis deviation 30 to 90 Right atrial enlargement High/pointed P wave 2.5 mm in leads II and III or V1 Right ventricular hypertrophy Right axis deviation 120, tall R wave in V1+persistent precordial S waves (R-V1+S V5>10.5 mm) Mobitz type II 2 AV block Intermittently non-conducted P waves not preceded by PR prolongation and not followed by PR shortening 3 AV block Complete heart block PR interval <0.12 s with a delta wave (slurred upstroke in the QRS complex figure 4) 10

11 Delta wave: suggestive of ventricular pre-excitation; PR interval <0.12 s with or without a delta wave (slurred upstroke in the QRS complex). Jonathan A Drezner Br J Sports Med 2012;46:i6-i8 Copyright BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved. QTc 0.47 s (99% males) QTc 0.48 s (99% females) QTc 0.50 s (unequivocal LQTS; figure 5) QTc interval: LONG QT: QTc 0.47 s (99% males) or QTc 0.48 s (99% females). Jonathan A Drezner Br J Sports Med 2012;46:i6-i8 Copyright BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved. 11

12 QTc 0.34 s High take-off and downsloping ST segment elevation in V 1 V 3 (figure 6) Brugada ECG: high take-off and downsloping ST segment elevation in V1 V3. Jonathan A Drezner Br J Sports Med 2012;46:i6-i8 Copyright BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved. 12

13 Small negative deflection just beyond the QRS in V 1 or V 2 (figure 7) Epsilon wave: small negative deflection just beyond the QRS in V1 or V2. Jonathan A Drezner Br J Sports Med 2012;46:i6-i8 Copyright BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved. 13

14 Additional data are published online only. To view this file please visit the journal online ( /bjsports ) Harmon KG, Asif IM, Klossner D, et al. Incidence of sudden cardiac death in national collegiate athletic association athletes. Circulation 2011;123: [Abstract/FREE Full text] Drezner JA, Asif IM, Owens DS, et al. Accuracy of ECG interpretation in competitive athletes: the impact of using standardised ECG criteria. Br J Sports Med 2012;46: [Abstract/FREE Full text] Williams ES, Owens DS, Drezner JA, et al. Electrocardiogram interpretation in the athlete. Herzschrittmacherther Elektrophysiol 2012;23: [ Scholar Corrado D, Pelliccia A, Heidbuchel H, et al Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur Heart J 2010;31: [Abstract/FREE Full text] Uberoi A, Stein R, Perez MV, et al. Interpretation of the electrocardiogram of young athletes. Circulation 2011;124: [FREE Full text] 14