How to Evaluate an Athlete of Afro- Caribbean Origin. Professor Sanjay Sharma St George s University of London
Background: Causes of SCD in Sport
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
TIME-TREND OF SUDDEN CARDIAC DEATH INCIDENCE IN ATHLETES VS NON-ATHLETES Veneto Region of Italy 1979-2002
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
Results of athletes screened in Veneto 1979-2004- 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%)
Age Size Ethnicity Gender Anabolic Drugs Type of sport Cardiac Dimensions Inherited Cardiomyopathy or ion channel disorder
The Challenge Left ventricular hypertrophy Repolarisation anomalies
Determinants of Left Ventricular Hypertrophy in Caucasian Athletes Large BSA Male sex High Dynamic Sports Adult athletes LVH Underlying hypertrophic cardiomyopathy
Determinants of Left Ventricular Hypertrophy in Caucasian Athletes Male sex Female sex Adolescent athletes Adult athletes LVH Any sport involving dynamic activity
Distribution of Left Ventricular Wall Thickness (%) in 300 Black Athletes and 300 White Athletes Basavarajaiah S et al JACC 2008
Distribution of Left Ventricular Wall Thickness in Black Athletes and White Athletes 18% 3% Basavarajaiah S et al JACC 2008
Black Athletes with LVH and Repolarisation Abnormalities Echocardiography Symmetric LVH Normal or enlarged LV cavity > 52-64 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
Left Ventricular Wall Thickness in 240 Black Female and 200 White Female Elite Athletes No of Athletes (%) 40 35 30 25 20 15 10 5 0 3% 6 7 8 9 10 11 12 13 Maximal Left ventricular Wall Thickness (mm) Rawlins J et al Circulation 2010 Black White
Left Ventricular Wall Thickness Measurements in 199 Black and 597 White Adolescent Athletes % 35 30 25 20 15 10 5 0 6 7 8 9 10 11 12 13 14 15 Maximal LV Wall Thickness (mm) 8% Black Athletes <18 White Athletes <18
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 1.36-2.29)
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 35,8 0 10 20 30 40 %
ECG Comparison in Black versus Caucasian Athletes Parameter Black athletes White athletes p N = 911 N = 1819 LVH (%) 37 26 < 000.1 LA Enlargement 8.6 2.8 < 0.001 RA Enlargement 6.3 0.3 < 0.001 ST elevation (%) 63.2 26.5 < 0.001 T inversions (%) 23 4 <0.001 Deep T inversions (%) 12 1 <0.001
Kenyan Marathon Runner
Kenyan Marathon Runner
Distribution of T-Wave Inversion in Black and Caucasian Athletes 14 12 12,7 10 8 % 6 Black athletes 6 White Athletes 4,1 4 2 0 1,9 1,6 0,3 V1-V4 II, III, avf V5,V6
ECG of a 24 Year old Black Soccer Player
ECG of a Nationally Ranked Black Rugby Player
Anterior Precordial ECG Changes in black athletes V1 V2 V3
Anterior Precordial ECG Changes in black athletes V4 V5 V6
Early Repolarisation Pattern
Associations 6-fold increase in T wave inversions Black Ethnicity 4-fold increase in ST segment elevation
ECG During and After Detraining During peak season Off season
. ECG Changes in a Black Football Player 12-year follow up 1996 2008
16-Year old Professional Soccer Player
ECG in an African Soccer Player with an Aborted Sudden Cardiac Death
ECG of a black athlete with HCM
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
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%
ECG of a Black Female Athlete
ECG Changes in Black Adolescent Athletes Parameter African Caucasian R5/S1 (mm) 48.6 ± 12 34.1 ± 8.8 Sokolow/Lyon LVH (%) 89 42 ST- elevation (%) 91 56 Deep T-wave inv (%) 14 9 Diffusely flat/biphasic T (%) 25 8 J waves/slurred ST seg (%) 18 1 ST pattern: Concave (%) 57 55 Convex (%) 38 1
0.8% 0.2%
Personal Opinion Physiology Pathology
Personal Opinion Physiology Pathology
More Homework Required!!
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
Black Athletes with LVH and Repolarisation Abnormalities Demographics Mean BSA 2 0.2 m 2 Age 16 years All West African or Caribbean in origin Echocardiography Symmetric LVH Normal or enlarged LV cavity > 52-64 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