Sudden Death in Athletes: What is the role of ECG Screening?

Transcription

1 Sudden Death in Athletes: What is the role of ECG Screening? Byron K. Lee MD Professor of Medicine Director of EP Laboratory Division of Cardiology Cardiac Electrophysiology Arrhythmias, Heart Failure, and Structural Heart Disease Honolulu, Hawaii October 8, 2015 Disclosures Research Medtronic Zoll Boston Scientific Apama Consulting Cardionet Biotronik Janssen Honorarium St. Jude Biotronik 2 1

2 Pheidippides Run: Marathon to Athens 3 Background Cause of SCD in athletes ECG screening process Cost effectiveness Indeterminate findings Saving lives 4 2

3 Magnitude of SCD in the US Stroke 3 Lung Cancer 2 167, ,400 SCD claims more lives each year than these other diseases combined 450,000 SCD 4 Breast Cancer 2 AIDS 1 40,600 42,156 #1 Killer in the U.S. 1 U.S. Census Bureau, Statistical Abstract of the United States: American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures Heart and Stroke Statistical Update, American Heart Association. 4 Circulation. 2001;104: SCD Landscape SCD-HeFT AVID MADIT Huikuri et. al. NEJM 2001 (adapted from Myerburg) 3

4 Background Cause of SCD in athletes ECG screening process Cost effectiveness Indeterminate findings Saving lives 7 Causes of SCD (Age>35) Huikuri et al. NEJM

5 SCD due to CAD: Darryl Kile 9 Causes of SCD (Age<35) Huikuri et al. NEJM

6 Maron NEJM Causes of SCD (age<35) #1: Hypertrophic CM 1 in 500 Scarred and disordered myocardium Confirmed HCM in 26.4% of SCDs Probable HCM in 7.5% additional cases of SCD Diagnosis PE ECG Echo Maron NEJM

7 ECG in Hypertrophic CM 13 Hypertrophic CM: Hank Gathers 14 7

8 Causes of SCD (age<35) #2: Commotio Cordis Blunt blow to the chest 15-30ms before T-wave peak (vulnerable phase of repolarization) Mean age 13 years old Compliant chest wall 19.9% of SCDs Structural normal heart Normal ECG 15 Commotio Cordis 16 8

9 Protection Against Commotio Cordis 17 Causes of SCD (age<35) #3: Congenital Coronary Artery Anomalies Artery arises from wrong aortic sinus Classic presentation: CP or syncope with exercise 13.7% of SCDs Diagnosis: Stress test Echo MRI CT Cath Normal ECG 18 9

10 Coronary-Artery Anomalies:Pete Maravich 19 Background Cause of SCD in athletes ECG screening process Cost effectiveness Indeterminate findings Saving lives 20 10

11 Pre-participation Screening in Italy Corrado et al. JAMA Seattle Criteria: Normal Findings 22 11

12 Seattle Criteria: Abnormal Findings 23 Seattle Criteria: Abnormal Findings 24 12

13 Cleared to play sports? Cleared to play sports? 13

14 Torsade de Pointes Background Cause of SCD in athletes ECG screening process Cost effectiveness Indeterminate findings Saving lives 28 14

15 Corrado et al. JAMA AHA Recommendation If age >35, add ETT if RF for CAD If age >65, add ETT Maron et al. Circulation

16 AHA Cost Analysis for U.S. 10M middle school and high school athletes Initial Screen $25 for H&P $50 for ECG Follow-up Screen $100 for H&P $400 for Echo Administrative Cost: 500M Total Cost: $2B $330,000 for every relevant disease diagnosed 31 Other Cost Effectiveness Analysis Annals of Internal Medicine 2010 HRS

17 AHA Recommendation If age >35, add ETT if RF for CAD If age >65, add ETT Maron et al. Circulation Background Cause of SCD in athletes ECG screening process Cost effectiveness Indeterminate findings Saving lives 34 17

18 Athlete s Heart Triggers Endurance sports (rowing, cross country skiing, swimming) Isometric sports (weightlifting, wrestling) Cardiac changes Heart size and chamber enlargement Increased LV wall thickness Increased LA Preservation of systolic and diastolic function Associated with abnormal ECG patterns Considered a benign adaptation to training 35 Pelliccia A, et al. Circulation 2000;102:

19 17 year old Swimmer Referred for Abnormal ECG Sees you for evaluation No syncope No symptoms of cardiac disease No FH of SCD Appears to be extremely physically fit Rest of exam benign except for a soft systolic murmur Basavarajaiah et al. Br J of Sports Med year old Swimmer Basavarajaiah et al. Br J of Sports Med

20 17 year old Swimmer Echo Significant concentric LVH with maximal wall thickness of 14 mm (normal <12 mm) Normal LV cavity of 48 mm Normal systolic and diastolic function Normal valves MRI normal except for wall thickening ETT normal 24 hour holter normal Now what? Basavarajaiah et al. Br J of Sports Med After 8 week of Deconditioning LVH regressed from 14 mm to 11 mm Basavarajaiah et al. Br J of Sports Med

21 Background Cause of SCD in athletes ECG screening process Cost effectiveness Indeterminate findings Saving lives 42 21

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24 47 SECTION HEADING Conclusions Most SCDs occur in otherwise healthy individuals Main cause of SCD Over 35: CAD Under 35: HCM, Commotio Cordis, Coronary Anomalies Young athletes screening: H&P ECG? Master athletes (age >35) screening: H&P ETT (if RFs for CAD or age>65) Community based programs can find new disease and save lives ICDs save lives without limiting physical activity 48 24

25 ICDs Do Save Lives Israel and Minnesota Data Steinvil et al. JACC 2011 Maron et al. Am J Cardiol

26 51 Detraining in 40 Elite Athletes Pelliccia A, et al. Circulation 2002;105:

27 Detraining in 40 Elite Athletes Pelliccia A, et al. Circulation 2002;105: Cleared to play sports? 27