SUDDEN CARDIAC DEATH IN CHILDREN & ADOLESCENTS JANUARY 14-15, 2011 DISNEY S GRAND CALIFORNIAN

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1 JANUARY 14-15, 2011 DISNEY S GRAND CALIFORNIAN ECG SCREENING SHOULD BE MANDATORY IN ALL SCHOOL AGED CHILDREN- PRO A NTHONY C. CHANG, MD, MBA, MPH D IRECTOR, HEART I NSTITUTE, CHOC St. Camillus Best Child in Class January 14-15, 2011 SCA Conference 1

2 FBI St. Camillus No.EKG Best Child in Class Who would you trust more? Evidence-based Medicine - January 14-15, 2011 SCA Conference 2

3 Evidence-based Medicine A systematic - approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values. Reference Sackett DL (2000). Evidence-based medicine. London: Churchill-Livingstone. Evidence-based Medicine January 14-15, 2011 SCA Conference 3

4 Evidence-based Medicine Which h of the following does not have a systematic review? A. Fetal ECG monitoring B. ECG screening in athletes - C. QTc interval in medications D. ECG changes in strokes E. Accuracy of ECG for LVH Evidence-based Medicine/ ECG Screening - January 14-15, 2011 SCA Conference 4

5 ECG/ Diagnoses Hypertrophic cardiomyopathy (90%) Arrhythmogenic RV cardiomyopathy/dysplasia (70%) Short and long QT syndromes Brugada syndrome Marfan syndrome PRO: Rationale for ECG Screening of Athletes 1:28,000 1:250,000 Reference Corrado D et al (Italy)(2005). Eur Heart J; 26(5): January 14-15, 2011 SCA Conference 5

6 PRO: Rationale for ECG Screening of Athletes Rate of detection of ECG > history and physical. Reference Wingfield K et al (Stanford)(2004). Clin J Sport Med; 14(3): PRO: Rationale for ECG Screening of Athletes Olympic Committee (IOC) and ESC agree.. Reference Corrado D et al (Italy)(2005). Eur Heart J; 26(5): January 14-15, 2011 SCA Conference 6

7 PRO: Rationale for ECG Screening of Athletes Care and treatment options for detected diseases. PRO: Rationale for ECG Screening of Athletes Kinship relationships important if diagnosis made. January 14-15, 2011 SCA Conference 7

8 PRO: Rationale for ECG Screening of Athletes Screening test fulfills WHO criteria. 42,386 (100%) 3,914 (9%) Reference Corrado D et al (Italy)(2005). Eur Heart J; 26(5): (2%) PRO: Rationale for ECG Screening of Athletes Rate of detection of ECG > history and physical. Olympic Committee (IOC) and ESC agree. Care and treatment options for detected diseases. Kinship relationships important if diagnosis made. Screening test fulfills WHO criteria.. January 14-15, 2011 SCA Conference 8

9 JANUARY 14-15, 2011 DISNEY S GRAND CALIFORNIAN ECG SCREENING SHOULD BE MANDATORY IN ALL SCHOOL AGED CHILDREN- PRO A NTHONY C. CHANG, MD, MBA, MPH D IRECTOR, HEART I NSTITUTE, CHOC CON: The Fallacies January 14-15, 2011 SCA Conference 9

10 CON: The Fallacies Low incidence of sudden death in athletes. Reference Maron BJ and Zipes DP (2005). 36 th Bethesda Conference. JACC 45(8): CON: The Fallacies Allocation of resources deprive other diseases. Incidence Sudden Cardiac Death ~1:3,000 Cystic Fibrosis 1:3,500 PKU 1:15,000 Reference Drezner JA. Current Opinions in Cardiology 2008: 23: January 14-15, 2011 SCA Conference 10

11 CON: The Fallacies Money spent is not cost effective. Cost per QALY ($) History and Physical 84,000 or more ECG 8,800-43,000 Echocardiogram? AED 55, ,000 CPR 75,000 ICD 34,000-70,000 (50,000) Reference Wheeler MT et al. Ann Intern Med 2010; 152: CON: The Fallacies EKGs have low sensitivity and specificity. January 14-15, 2011 SCA Conference 11

12 CON: The Fallacies Low incidence of sudden death in athletes. Allocation of resources deprive other diseases. Money spent is not cost effective. EKGs have low sensitivity and specificity. Evidence-based Medicine/ The Parachute Study January 14-15, 2011 SCA Conference 12

13 Vision Orange County (California) will be the first county in the U.S. to have both a comprehensive preparticipation process (including EKG) for all school age children and a complete emergency preparedness program with 100% participation in CPR and AED training (starting with elementary/ middle schools). January 14-15, 2011 SCA Conference 13

14 Conclusion Appropriate screening, including a family history and a 12-lead electrocardiogram, increases the likelihood of confirming these diagnoses. The 12- lead electrocardiogram, albeit controversial, can be cost-effective as well as acceptable in its sensitivity, specificity, positive and negative predictive profiles with appropriate and innovative evidence-based medicine. Recommendations Process - Execution of Recommendations will be with fiscal accountability, innovative solutions, but relentless perseverance. January 14-15, 2011 SCA Conference 14

15 We must do what is right.. Not because it is easy, but because it is difficult. John F. Kennedy When you come to a fork in the road, take it Yogi Berra January 14-15, 2011 SCA Conference 15

16 Failure is not an option Gene Krantz As a parent 9/9 would obtain ECG As a cardiologist 6/9 would obtain ECG January 14-15, 2011 SCA Conference 16