1 SCD Landscape Magnitude of SCD in the US 167,366 SCD claims - PowerPoint PPT Presentation

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