[PDF] - Byron K. Lee MD Professor of Medicine Director of EP Laboratory PDF Document

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Sudden Death in Athletes:

What is the role of ECG Screening?

Byron K. Lee MD Professor of Medicine Director of EP Laboratory leeb@medicine.ucsf.edu Division of Cardiology Cardiac Electrophysiology

Arrhythmias, Heart Failure, and Structural Heart Disease Honolulu, Hawaii October 8, 2015

Disclosures

Research

– Medtronic – Zoll – Boston Scientific – Apama

Consulting

– Cardionet – Biotronik – Janssen

Honorarium

– St. Jude – Biotronik

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Pheidippides Run: Marathon to Athens

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Background
Cause of SCD in athletes
ECG screening process
Cost effectiveness
Indeterminate findings
Saving lives

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450,000

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.

Magnitude of SCD in the US

Breast Cancer2

SCD 4 42,156 40,600 157,400 167,366

AIDS1 Lung Cancer2 Stroke3

SCD claims more lives each year than these

ther

diseases combined #1 Killer in the U.S.

SCD Landscape

Huikuri et. al. NEJM 2001 (adapted from Myerburg)

SCD-HeFT AVID MADIT

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Background
Cause of SCD in athletes
ECG screening process
Cost effectiveness
Indeterminate findings
Saving lives

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Causes of SCD (Age>35)

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Huikuri et al. NEJM 2001

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SCD due to CAD: Darryl Kile

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Causes of SCD (Age<35)

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Huikuri et al. NEJM 2001

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Maron NEJM 2003

Causes of SCD (age<35)

#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

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Maron NEJM 2003

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ECG in Hypertrophic CM

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Hypertrophic CM: Hank Gathers

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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

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Commotio Cordis

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Protection Against Commotio Cordis

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Causes of SCD (age<35)

#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

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Coronary-Artery Anomalies:Pete Maravich

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Background
Cause of SCD in athletes
ECG screening process
Cost effectiveness
Indeterminate findings
Saving lives

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Pre-participation Screening in Italy

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Corrado et al. JAMA 2006

Seattle Criteria: Normal Findings

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Seattle Criteria: Abnormal Findings

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Seattle Criteria: Abnormal Findings

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Cleared to play sports? Cleared to play sports?

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Torsade de Pointes

Background
Cause of SCD in athletes
ECG screening process
Cost effectiveness
Indeterminate findings
Saving lives

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Corrado et al. JAMA 2006

AHA Recommendation

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Maron et al. Circulation 2007

If age >35, add ETT if RF for CAD If age >65, add ETT

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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
$330,000 for every relevant disease diagnosed

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Other Cost Effectiveness Analysis

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HRS 2011 Annals of Internal Medicine 2010

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AHA Recommendation

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Maron et al. Circulation 2007

If age >35, add ETT if RF for CAD If age >65, add ETT

Background
Cause of SCD in athletes
ECG screening process
Cost effectiveness
Indeterminate findings
Saving lives

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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

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Pelliccia A, et al. Circulation 2000;102:278-284

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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

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17 year old Swimmer

Basavarajaiah et al. Br J of Sports Med 2006

17 year old Swimmer

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Basavarajaiah et al. Br J of Sports Med 2006

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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?

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17 year old Swimmer

Basavarajaiah et al. Br J of Sports Med 2006

After 8 week of Deconditioning

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Basavarajaiah et al. Br J of Sports Med 2006

LVH regressed from 14 mm to 11 mm

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Background
Cause of SCD in athletes
ECG screening process
Cost effectiveness
Indeterminate findings
Saving lives

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Conclusions

Most SCDs occur in otherwise healthy individuals
Main cause of SCD

– Over 35: CAD – Under 35: HCM, Commotio Cordis, Coronary Anomalies

Young athletes screening:

– H&P – ECG?

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

ICDs save lives without limiting physical activity

SECTION HEADING

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ICDs Do Save Lives Israel and Minnesota Data

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Steinvil et al. JACC 2011 Maron et al. Am J Cardiol 2009

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Detraining in 40 Elite Athletes

Pelliccia A, et al. Circulation 2002;105:944-949