Professor Sanjay Sharma St George s University of London
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1 How to Evaluate an Athlete of Afro- Caribbean Origin. Professor Sanjay Sharma St George s University of London
2 Background: Causes of SCD in Sport
3 Young competitive athlete Personal and family history Physical examination 12-lead rest ECG Negative findings Positive findings Eligibility for competition No cardiovascular disease Further examination Cardiovascular disease Management according to established protocols
4 TIME-TREND OF SUDDEN CARDIAC DEATH INCIDENCE IN ATHLETES VS NON-ATHLETES Veneto Region of Italy
5 Young competitive athlete Italian Model Personal and family history Physical examination Endorsed 12-lead rest ECG by Negative findings Eligibility for competition - ESC No cardiovascular disease - IOC Positive findings Further examination Cardiovascular disease - FIFA Management according to established protocols
6 Results of athletes screened in Veneto Corrado; JAMA 2006 Athletes screened: 42,386 Abnormal ECG: 3,914 (9%) Cardiac disorder: 879 (2%) All disqualified False Positive 7% Potentially lethal disorder: 91 (0.2%)
7 Age Size Ethnicity Gender Anabolic Drugs Type of sport Cardiac Dimensions Inherited Cardiomyopathy or ion channel disorder
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9
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11 The Challenge Left ventricular hypertrophy Repolarisation anomalies
12 Determinants of Left Ventricular Hypertrophy in Caucasian Athletes Large BSA Male sex High Dynamic Sports Adult athletes LVH Underlying hypertrophic cardiomyopathy
13 Determinants of Left Ventricular Hypertrophy in Caucasian Athletes Male sex Female sex Adolescent athletes Adult athletes LVH Any sport involving dynamic activity
14 Distribution of Left Ventricular Wall Thickness (%) in 300 Black Athletes and 300 White Athletes Basavarajaiah S et al JACC 2008
15 Distribution of Left Ventricular Wall Thickness in Black Athletes and White Athletes 18% 3% Basavarajaiah S et al JACC 2008
16 Black Athletes with LVH and Repolarisation Abnormalities Echocardiography Symmetric LVH Normal or enlarged LV cavity > mm LA < 50 mm Normal E/A > 1.5 E /A > 2.5 E/E < 6 Exercise test No ischaemic changes, or arrhythmias Normal BP responses 24 hour Holter No evidence of NSVT CMR No evidence of myocardial fibrosis
17 Left Ventricular Wall Thickness in 240 Black Female and 200 White Female Elite Athletes No of Athletes (%) % Maximal Left ventricular Wall Thickness (mm) Rawlins J et al Circulation 2010 Black White
18 Left Ventricular Wall Thickness Measurements in 199 Black and 597 White Adolescent Athletes % Maximal LV Wall Thickness (mm) 8% Black Athletes <18 White Athletes <18
19 Subjects 1819 asymptomatic white and 911 black male athletes. No obvious FH of cardiomyopathy West African (70%), East African (20%), North African (10% Participating at regional or National level 22 different sporting disciplines Mean age 22.8 (range 14-35) BSA 1.91 ± 0.16 m -2 (range )
20 Sports football Athletics martial arts basketball boxing rugby Athletics - jump tennis Netball swimming handball athletics combi fencing gymnastics weightlifting cycling skating athletics - throw canoeing windsurfing badminton rowing 7,9 1,8 4,4 7,8 1,6 1,5 1,5 1,2 1,0 0,9 0,8 0,6 0,5 0,3 0,3 0,2 0,1 0,1 0,1 16,3 15,6 35, %
21 ECG Comparison in Black versus Caucasian Athletes Parameter Black athletes White athletes p N = 911 N = 1819 LVH (%) < LA Enlargement < RA Enlargement < ST elevation (%) < T inversions (%) 23 4 <0.001 Deep T inversions (%) 12 1 <0.001
22 Kenyan Marathon Runner
23 Kenyan Marathon Runner
24 Distribution of T-Wave Inversion in Black and Caucasian Athletes , % 6 Black athletes 6 White Athletes 4, ,9 1,6 0,3 V1-V4 II, III, avf V5,V6
25 ECG of a 24 Year old Black Soccer Player
26 ECG of a Nationally Ranked Black Rugby Player
27 Anterior Precordial ECG Changes in black athletes V1 V2 V3
28 Anterior Precordial ECG Changes in black athletes V4 V5 V6
29 Early Repolarisation Pattern
30 Associations 6-fold increase in T wave inversions Black Ethnicity 4-fold increase in ST segment elevation
31 ECG During and After Detraining During peak season Off season
32 . ECG Changes in a Black Football Player 12-year follow up
33 16-Year old Professional Soccer Player
34 ECG in an African Soccer Player with an Aborted Sudden Cardiac Death
35 ECG of a black athlete with HCM
36 4,2% 3,8% 6,0% 2,5% 1,9% 4,1% 3,4% 12,7% 76,9% Distribution of T wave Inversions in Black Athletes (n= 206), Black Controls (n=115) and Black Individuals with HCM (n=52) 100% 80% 60% 40% p=0.006 p=0.212 Black Athletes Black Controls 20% Black HCM 0% Confined in V1-V4 Inferior leads Lateral leads
37 ECG Changes in Black Female Athletes Inv T 14% Rawlins J et al Circ 2010 LAE 13% RAE 5% Normal 49% ST Elev 11% LVH Volt 8%
38 ECG of a Black Female Athlete
39 ECG Changes in Black Adolescent Athletes Parameter African Caucasian R5/S1 (mm) 48.6 ± ± 8.8 Sokolow/Lyon LVH (%) ST- elevation (%) Deep T-wave inv (%) 14 9 Diffusely flat/biphasic T (%) 25 8 J waves/slurred ST seg (%) 18 1 ST pattern: Concave (%) Convex (%) 38 1
40
41 0.8% 0.2%
42 Personal Opinion Physiology Pathology
43 Personal Opinion Physiology Pathology
44 More Homework Required!!
45 Conclusions Repolarisation changes comprising of ST segment elevation and T wave inversion are common in adult black male athletes. These qualitative changes are also observed to a lesser extent in adolescent and female black athletes. Adolescent black male athletes may exhibit a LV wall thickness up to 15 mm T wave inversion in V1-V4 may be normal variants
46 Black Athletes with LVH and Repolarisation Abnormalities Demographics Mean BSA m 2 Age 16 years All West African or Caribbean in origin Echocardiography Symmetric LVH Normal or enlarged LV cavity > mm LA < 50 mm Normal E/A > 1.5 E /A > 2.5 E/E < 6 Exercise test No ischaemic changes, or arrhythmias Normal BP responses 24 hour Holter No evidence of NSVT CMR No evidence of myocardial fibrosis
Dr Navin Chandra Clinical Research Fellow in Cardiology St George s University of London
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