Sports Cardiology: Matters of the Heart AMSSM Exchange Lecture AOSSM 2013 Annual Meeting Matthew Gammons, MD Vermont Orthopaedic Clinic Killington Medical Clinic Although sudden cardiac death is a relatively rare tragic event it can be devastating to families teams and communities Initial reports 1-200,000-300,000 Newer data 1-25,000-44,000 Even higher in some populations Background 1
Cardiac Screening 2013 American Heart Association and the American College of Sports Medicine do not recommend routine ECG screening The European Society of Cardiology and the International Olympic Committee Advocate ECG screening AHA/ACSM Qualified Examiner perform a full history and physical Personal History Exertional chest pain or discomfort Unexplained syncope or near syncope Excessive exertional or unexplained dyspnea or fatigue associated with exercise Previous recognition of a heart murmur Elevated systemic blood pressure Family History Premature sudden death in a relative < 50 years old because of heart disease Disability from heart disease in a close relative < 50 years old Relatives with hypertrophic or dilated cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan Syndrome or clinically important arrhythmias Physical Examination Heart murmur perform exam in both supine and standing positions( or with Valsalva) Femoral pulses to exclude aortic coarctation Physical Stigmata of Marfan Brachial artery blood pressure 2
History & Physical Challenges and Limitations Poor sensitivity and specificity Will miss the majority of athletes at risk Has no future predictive value No study exists that demonstrates a PPE based on hx and physical exam alone is effective in detecting or preventing athletes at risk for sudden death Limitations of the Pre-participation Evaluation Maron; JAMA 1996 134 athletes with SCD 115 had PPE Only 18% had CV symptoms in 36 months preceding death Only 4 (3%) suspected of CV disease and 1 (0.9%) diagnosed correctly on PPE 3
Should we add ECG to the PPE? No question that ECG increase the sensitivity of the PPE Significant concerns for false positive Resource allocation If we can refine the population it will improve the above Results Etiology of NCAA Deaths Harmon 2013 Aortic dissection 8% Myocarditis 8% Other 6% Possible HCM/SCT 3% HCM 3% Possible HCM/LVH 8% ARVC 3% Dilated CM 8% MI 6% SUD 33% Coronary Artery Abnormality 14% 4
Results Etiology of NCAA Deaths Harmon 2013 Sudden Unexplained Death - 33% Coronary Artery Abnormalities - 14% Myocarditis - 8% Dilated Cardiomyopathy - 8% Possible Hypertrophic Cardiomyopathy/LVH - 3% Aortic Dissection 8% Myocardial Infarction 6% Hypertrophic Cardiomyopathy 3% Arrhythmogenic right ventricular cardiomyopathy -3% Maron 2009 Traditionally used data Hypertrophic Cardiomyopathy 37% Coronary Artery Abnormalities - 17% Other 14% Myocarditis - 6% Arrhythmogenic right ventricular cardiomyopathy -3% 5
Aortic dissection 5% MI 20% Other 15% Corrado- 2003 SUD 28% HCM 7% ARVC 10% Dilated CM 5% Coronary Artery Abnormality 10% Eckart - 2004 Myocarditis 12% MI 9% Other 13% SUD 30% HCM 6% Possible HCM/LVH 1% ARVC 1% Dilated CM 1% Coronary Artery Abnormality 27% Possible HCM/LV/SCT 3% Aortic dissection 8% Myocarditis 8% MI 6% Other 6% NCAA SUD 33% HCM 3% Possible HCM/LVH 8% ARVC 3% Dilated CM 8% Coronary Artery Abnormality 14% Myocarditis 6% MI 3% SUD 6% Coronary Artery Abnormality 17% Aortic dissection 3% Maron - 2009 Other 14% Dilated CM 2% ARVC 4% HCM 37% Possible HCM/LVH 8% SCD Incidence: Understanding the Variables US Athletes Van Camp 1995 Age 13-25 Media reports 1:300,000 Maron 1998 Age 113-19 Insurance claims 1:200,000 Drezner 2005 Ages 18-13 Retrospective survey 1:67,000 Maron 2009 Ages 12-35 Media, Electronic Reports 1:166,000 Drezner 2009 Ages 14-17 Cross-sectional survey 1:23,000 Harmon 2011 Ages 17-24 NCAA Resolution list 1:44,000 Toresdahl 2013 Ages 14-18 Prospective high school 1:87,000 US Military Eckart 2004 Ages 18-35 Mandatory 1:9000 Eckart 2011 Ages 18-35 Mandatory 1:25,000 6
SCD Incidence: Understanding the Variables Population Age Methods & Reporting System Incidence US Athletes Van Camp (1995) Maron (1998) Drezner (2005) Maron (2009) Drezner (2009) Harmon (2011) Toresdahl (2013) US Military Eckart (2004) Eckart (2011) US Adolescents Chugh (2009) Meyer (2012) 13-24 13-19 18-23 12-35 14-17 17-24 14-18 10-14 14-24 Media reports Insurance claims Retrospective survey Media, electronic reports Cross-sectional survey NCAA Resolutions list Prospective, high school Must recognize the possibility that scientific limitations and/or misinterpretations have perpetuated an underestimate of SCD, and thus impeded progress 18-35 Mandatory towards the 18-35 Mandatory, DoD evaluation or implementation of more effective preventive programs. Prospective, EMS/hospitals Prospective, EMS 1:300,000 1:200,000 1:67,000 1:166,000 1:23,000 1:44,000 1:87,000 1:9,000 1:25,000 1:58,000 1:69,000 SCD in NCAA Athletes 45 cardiac-related deaths ( All had been screened) NCAA athletes (2003-2008) = 1,994,962 Incidence = 1:43,000 per year Male 1:33,000 / Female 1:76,000 Black 1:17,000 / White 1:58,000 Male/black 1:13,000 Male/basketball 1:7,000 7
SCD in NCAA Athletes 45 cardiac-related deaths NCAA athletes (2003-2008) = 1,994,962 Incidence = 1:43,000 per year Male 1:33,000 / Female 1:76,000 Black 1:17,000 / White 1:58,000 Male/black 1:13,000 Male/basketball 1:7,000 All these athletes were screened! ECG Interpretation A Call for Uniform Terminology Athlete s heart Common Physiologic Training-related ECG alteration irbbb Early Repolarization Voltage only LVH Longer QTc Epsilon wave Brugada-type Abnormal Uncommon Pathologic Circulation, 2011 Training-unrelated Indication for further work-up 8
ECG in Athletes Drezner et al Accuracy of ECG Interpretation in Athletes BJSM 2012 Seattle Criteria By applying this criteria ECG interpretations improved in 4 groups ( Cardiologist, Sports Medicine Physicians, Primary Care Attending and Primary Care Residents Decreases false positive rates BJSM 2012 9
ECG Interpretation Among Physician Groups 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 85% 78% 73% 73% Cardiologists SM Attendings PC Attendings PC Residents Before 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% ECG Interpretation Among Physician Groups 96% 85% 78% 91% 90% 92% 73% 73% Cardiologists SM Attendings PC Attendings PC Residents p < 0.001 p < 0.0001 p < 0.0001 p < 0.0001 Before After 10
Learning Module Learning.BMJ.com/ECGAthlete Free online training developed in association with FIFA 11
The ECG Debate Still many unknowns Size of athlete cohort False-positive results Unnecessary disqualification Undue anxiety Poor cost-effectiveness? Absence of physician infrastructure Low prevalence of disease ECG Screening in NCAA Athletes: A Multicenter Feasibility Trial in Division I Programs Drezner et al 2013 Prospective, multicenter trial involving 14 NCAA Division I universities Any athlete without prior ECG screening was eligible 12
History Early detection 14% False-positive 33.3% PPV 0.2% PE Early detection 14% False-positive 1.9% PPV 2.2% ECG Early detection 100% False-positive 2.9% PPV 8.9% Results Results Early Detection False- Positive PPV Hx 14% 33.3% 0.2% PE 14% 1.9% 2.2% ECG 100% 2.9% 8.9% 13
Where do we go from here? Real world screeing needs to be tested Prospective outcome studies need to clarify the role of different screening strategies Secondary Prevention Initial thought was the athlete were less likely to respond to ACLS and particularly defibrillation Structural disease Catecholamines Newer data suggests improved survival with early defibrillation times Probability of successful defibrillation for VF SCA diminishes rapidly over time. 14
Secondary Prevention Emergency Planning for SCA Survival trends in the U.S. following exerciserelated SCA in the youth: 2000-2006 [N=486; average survival 11%; range 4-21% per year] 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Low survival rate demands re-evaluation of emergency response planning for SCA in sport total 2000 2001 2002 2003 2004 2005 2006 Drezner; Heart Rhythm 2008 Total SCA p = 0.035 Confirmed SCA p = 0.018 15
Time to Defibrillation Every Second Counts Larsen; Ann Emerg Med 1993 Probability of successful defibrillation for VF SCA diminishes rapidly over time. Effectiveness of Emergency Response Planning for Sudden Cardiac Arrest in US High Schools with AED s 1,710 High Schools with onsite AED July 2006-2007 16
Circulation, 2009 Cross-sectional survey Comprehensive survey on emergency response planning and details of SCA cases 1,710 high schools with on-site AEDs (July 2006 July 2007) AED Use for SCA 36 cases (22 adults, 14 student-athletes) 35/36 (97%) SCA cases witnessed Brief seizure-like activity reported in 7/14 (50%) student-athletes after collapse 34/36 (94%) received bystander CPR AED deployed a shock in 30/36 (83%) cases 17
Survival to Hospital Discharge after SCA in U.S. High Schools with AEDs [N=36] Survival to hospital discharge 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 64% 64% 64% Student athletes (9/14) Non-students (14/22) Overall (23/36) Take Home SCA in Young Athletes Suspect SCA in any collapsed and unresponsive athlete Seizure = SCA until proven otherwise Must have AED programs in locations for youth sport 18
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