Jonathan Kim MD, FACC

Transcription

1 Jonathan Kim MD, FACC Assistant Professor, Division of Cardiology, Emory University Adjunct Assistant Professor, School of Applied Physiology, Georgia Tech Team Cardiologist, Sports Medicine, Emory University and Georgia Tech Team Cardiologist Atlanta Falcons and Atlanta Hawks Medical Director, Peachtree Road Race (Atlanta Track Club) Emory Sports Medicine Symposium 2016 April 23, 2016

2 No conflicts Athletic Affiliations: Funding Sources: NIH K23

3 1. Sudden Cardiac Death in Athletes 2. Athletic Pre-Participation CV Screening 3. Red Flags What to Watch For in the Training Room

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5 Controversial, source of debate 3.6/100,000 athlete-years in the pre-screening Italian era Corrado D et al. JAMA 2006;296: /100,000 athlete-years in NCAA athletes Harmon KG et al. Circulation 2011;123: /100,000 athlete-years in NCAA athletes Maron BJ et al. J Am Coll Cardiol 2014;63:

6 Kim JH et al. N Engl J Med 2012;366:132-42

7 Chandra N et al. J Am Coll Cardiol 2013;61:

8 Autosomal dominant with variable penetrance LVH in absence of of elevated loading conditions, and with myocardial disarray on pathology Sudden death often first clinical manifestation of the disease Prevalence 1:500 (0.2%)-> % in athletes Overall risk of SCD = 1% per year

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10 Most common anomalies implicated include the left coronary arising from the right sinus of Valsava and the right coronary arising from the left sinus of Valsava Coronary blood flow impaired by abnormal ostia, compression of anomalous artery as it courses between MPA and ascending aorta, and possibly vasospasm Diagnosis by ECG and echo is LIMITED, need high index of suspicion Gold standard for diagnosis: MRA/CTA

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12 Fibro-fatty replacement of myocardium in the inflow tract, outflow tract, and/or apex of the RV Right ventricular dilatation, dysfunction, aneurysms Prevalence 1:1,000 in the general population Mutations in genes encoding cardiac desmosomal proteins 5-fold higher risk of SCD during competitive sports Corrado D et al. J Am Coll Cardiol 2003;24:

13 James CA et al. J Am Coll Cardiol 2013;62:

14 Pre-participation screening (PPS) is recommended by the American Heart Association AND the European Society of Cardiology Difference lies in the recommendation for a pre-participation ECG ECG improves the ability to diagnose WPW, LQTS, Brugada, HCM, ARVC In Italy, use of ECG decreased incidence of SCD from 3.6/100,000 -> 0.4/100,000 (90% reduction)

15 Maron BJ et al. Circulation 2014;130:

16 History & Physical Psychology Efficacy SCREENING Cost False Positives Legal Issues

17 Drezner JA et al. Br J Sports Med 2013;47:122-24

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20 510 collegiate athletes screened with ECG and TTE, false positive rate 16.9% (2005 ESC criteria) Baggish AL et al. Ann Intern Med 2010;152: Same cohort, false positive rate decreased to 10% (preserved sensitivity) using 2010 ESC criteria Weiner RB et al. Heart 2011;97: athletes (16-35 years old), Seattle criteria decreased false positive rate from 17% to 4.2% compared to 2010 ESC criteria Drezner JA et al. Br J Sports Med 2013;47: Further refined criteria recently published- accounts for large number of abnormal ECG findings in African-American athletes CA and 1200 AA; false positives decreased using new criteria in both CA and AA compared with 2010 ESC and Seattle criteria - Improved specificity Sheikh N et al. Circulation 2014;129:

21 Kim JH. Can J Cardiol. 2016

22 Kim JH. Can J Cardiol. 2016

23 Be VERY cautious of the athlete complaining of EXERTIONAL symptoms chest pain, shortness of breath, dizziness, syncope, palpitations Loss of exercise tolerance The lack of the exertional component lowers the degree of concern Family history HTN in football players

24 1. 18 y/o football player with chest pain Preparticipation CV evaluation y/o marathon runner with syncope The evaluation of the athlete with symptoms

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32 Prospective, longitudinal study evaluating 113 collegiate freshmen ASF players over 6 years SBP increase from 116 ± 8 to 125 ± 13 mm Hg, P <0.001 Predictors of post-season SBP included player position, intraseason weight gain, family history of hypertension Among linemen, increase in LV mass correlated with the change in SBP Weiner RB et al. Circulation 2013;128:524-31

33 Kim JH et al. Am J Cardiol 2015;115:262-67

34 Sports Cardiology is an extension of Sports Medicine and a part of the athlete health care team Sudden cardiac death is rare in all athletic populations ECG is NOT in the pre-participation US guidelines, but can be helpful if appropriate logistics in place In the evaluation of athletic patients, there are substantial (though sometimes subtle) clues in the history (HPI and Family) Diagnostic approach requires a systematic and integrative approach

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