Pheidippides Run from Marathon to Athens ECG Screening and Risk Stratification in Competitive Athletes Byron K. Lee MD Associate Professor CA Heart Rhythm Symposium Director of EP Laboratory leeb@medicine.ucsf.edu September 7-8, 2012 Division of Cardiology Cardiac Electrophysiology 2 Pheidippides’ ECG? If Hippocrates Saw Pheidippides 3 4 1
SCD Landscape Magnitude of SCD in the US 167,366 SCD claims Stroke 3 more lives each year 450,000 than these other SCD 4 SCD-HeFT diseases Lung Cancer 2 157,400 combined AVID Breast Cancer 2 40,600 #1 Killer MADIT 42,156 in the U.S. AIDS 1 1 U.S. Census Bureau, Statistical Abstract of the United States : 2001 . 2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001 . 3 2002 Heart and Stroke Statistical Update , American Heart Association. 4 Circulation . 2001;104:2158-2163. Huikuri et. al. NEJM 2001 (adapted from Myerburg) Causes of SCD (Age>35) SCD due to CAD: Darryl Kile Huikuri et al. NEJM 2001 7 8 2
Causes of SCD (age<35) ECG in Hypertrophic CM • #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 2003 9 10 Hypertrophic CM: Hank Gathers 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 11 12 3
Commotio Cordis Protection Against Commotio Cordis 13 14 Causes of SCD (age<35) Coronary-Artery Anomalies:Pete Maravich • #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 15 16 4
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 Maron NEJM 2003 17 18 17 year old Swimmer 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 2006 Basavarajaiah et al. Br J of Sports Med 2006 19 20 5
After 8 week of Deconditioning 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? LVH regressed from 14 mm to 11 mm Basavarajaiah et al. Br J of Sports Med 2006 Basavarajaiah et al. Br J of Sports Med 2006 21 22 Pelliccia A, et al. Circulation 2000;102:278-284 6
Detraining in 40 Elite Athletes Detraining in 40 Elite Athletes Pelliccia A, et al. Circulation 2002;105:944-949 Pelliccia A, et al. Circulation 2002;105:944-949 • Automatic External Defibrillator ICD Size (AED) 7
ICDs and Exercise Pre-participation Screening in Italy Lempert et al. JCE 2006 Corrado et al. JAMA 2006 29 30 8
Israel and Minnesota Data Steinvil et al. JACC 2011 Corrado et al. JAMA 2006 Maron et al. Am J Cardiol 2009 33 34 AHA Recommendation 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 If age >35, add ETT if RF for CAD • $330,000 for every relevant disease diagnosed If age >65, add ETT Maron et al. Circulation 2007 35 36 9
Other Cost Effectiveness Analysis AHA Recommendation Annals of Internal Medicine 2010 If age >35, add ETT if RF for CAD If age >65, add ETT HRS 2011 Maron et al. Circulation 2007 37 38 39 40 10
41 42 Pre-participation Screening at UCSF ECG Screening at UCSF • 80 total volunteers • By the Numbers – 2009: 155 athletes – Half were RNs and MDs – 2010: 349 athletes • 40 volunteers for cardiac screening – 2011: 327 athletes – 7 ECG machines – 2012: 540 athletes • 10 ECGs per hour per machine • 1371 total screened – 2 Echo machines • 1216 unique athletes • 1.5 Echo’s per hour per machine • 52 (4.28%) with abnormal ECG leading to Echo • 8 (0.7%) not approved for sports and need further work-up by their own MDs 43 44 11
SECTION HEADING Conclusions Findings • Most SCDs occur in otherwise healthy individuals • Main cause of SCD • 8 non-approved athletes – Over 35: CAD – 2 WPW – Under 35: HCM, Commotio Cordis, Coronary Anomalies – 2 Long QT • ICDs can be life-saving but will limit physical activity – 1 RVE with ASD • Young athletes screening: – 1 LVH with syncope – H&P – 1 Bicuspid AV and PFO – ECG? – 1 Orthopedic injury • 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 45 46 Resuscitation Success vs. Time* 100 90 80 Chance of success reduced 70 7 - 10% each minute 60 % Success 50 *Non-linear 40 30 20 10 0 1 2 3 4 5 6 7 8 9 Time (minutes) Adapted from text: Cummins RO, Annals Emerg Med. 1989, 18:1269-1275. 47 12
Corrado et al. JAMA 2006 50 Anthony Van Loo 51 13
Recommend
More recommend