EKG screening in athletics

Transcription

1 Use of PPE EKG screening in athletics Stefan Montgomery MD, ATC 4/27/18 The overall role of the preparticipation physical evaluation (PPE) is to evaluate the health of the athlete to optimize safe sports participation. Early detection of athletes at risk for sudden cardiac arrest and death (SCA/D) is an important objective of the PPE for athletes. CV screening in PPE The primary goal of cardiovascular screening of athletes is to identify underlying cardiac disorders predisposing to SCA/D Intent to reduce morbidity and mortality by mitigating risk through individualized, patientcentered, and disease-specific medical management. Disorders associated with sudden cardiac death HCM Idiopathic LVH ARVC/ARVD CAD Myocarditis Coronary artery anomalies Aortic dissection Dilated cardiomyopathy HCM Autosomal dominant but variable expressivity and age-related penetrance Diagnosis is clinical with ECHO standards Different mutations pose very different risks Mortality Risk with HCM Study of 312 patients showed 73% lived to age 75 Risk in young patients is low Cohort of 474 patients younger than 30 years of age at presentation (mean age 20.2 years), Annual HCM-related mortality rate was 0.54 percent per year over an average of 7.1 years of follow-up 13% of this group had aborted SCD using ICD, etc. 1

2 HCM is driving recommendations Relatively common-1 in 800 to 2600 adolescents Based on known mortality statistics and assuming 0% false positives Need to detect and disqualify 200 athletes to save one SCD in a year If every athlete got an ICD, 87% would not have needed it over a 7 year span EKG determination Likely abnormal in a high percentage of HCM, ARVC and Dilated CM Sometimes abnormal in some of the other conditions EKG would still miss coronary artery abnormalities, aortic dissection, CAD, commotio cordis Incidence of SCD College athletes ~ 1/50,000 High School athletes ~ 1/80,000 Female athletes ~ 1/300,000 High risk populations Male college basketball players ~ 1/9000 African-American college athletes ~ 1/16,000 Basketball and Football account for 50-60% of SCD in athletics Females in High School-low risk Intense exercise is a common trigger for SCD- 50% of cases occur during exercise Screening History- 20% sensitive, athlete tendency to minimize Physical Exam- few conditions have positive findings Pathologic versus benign murmurs are difficult EKG- 60% of conditions have abnormalities Requires diagnostic further workup after abnormal EKG False positive rate in past was as high as 10% but even with modern criteria still 2% 2 per 100 screened will need further workup with normal findings 2

3 Implementation of EKG screening Pre-screening planning and coordination Getting buy in from all involved Team Physicians, administrators, coaches, trainers, Cardiology consultants Decision must me made as to who to screen All athletes vs. Highest risk groups Must be agreed upon from the beginning ECG standards must be agreed on Avenues for prompt secondary testing Training --- lead placement and interpretation EKG interpretation Free modules on BMJ Learning Criteria specific ECG machines Refined criteria>seattle criteria> ESC criteria Commitment to evolve quality standards and continuous reassessment as improvements are made Cost Equipment ECG machine, leads, paper ECG overread Cardiology services and additional testing At this point should be considered preventative services Secondary Costs would be more diagnostic services Integrating ECG Screening Standardized history and physical examination + ECG Models ECG station during PPE ECG after examination ECG off-site Private Physician office ECG overread PCP/ Sports med point of care / cardiology remotely Secondary Testing For the athletes that have positive screen history, physical, or ECG must have adequate cardiology oversight Part of the planning should identify a predetermined avenue for efficient testing and consultation Echo or stress echo Cardiac MRI Cardiac Catheterization Sinus Bradycardia Due to increased vagal tone in a well-trained athlete, especially endurance athletes, in the absence of symptoms, a heart rate >30 should be considered normal Sinus Arrhythmia HR increases during inspiration and decreases during expiration First degree Atrioventricular Block 3

4 Normal findings Second degree AV block (Mobitz type 1 or Wenckebach phenomenon) Incomplete RBBB Junctional Escape Rhythm Ectopic Atrial Rhythm QRS voltage criteria for LVH and RVH Early Repolarization Normal findings Convex (domed) ST segment elevation combined with T wave inversion in leads V1-V4 in black/african athletes T wave inversion in V1-V3 in young adolescent athletes < 16 years old LVH and RVH by voltage criteria in isolation are considered part of the normal athlete heart 4

5 Normal vs. abnormal Normal vs. abnormal 5