1. Screening Athletes to Prevent Sudden Cardiac Death
Christopher Davis, MD, PhD
Pediatric Grand Rounds
August 20, 2010
Rady Children’s Hospital San Diego
UCSD

2. Disclosures
None

3. Sudden Cardiac Death
How many athletes die suddenly each year from cardiovascular causes?
What conditions do they have?
How can they be screened to prevent as many deaths as possible in a reasonably efficient manner?

4. Miklos Feher

5. SCD in Athletes

6. SCD in Young Athletes
SCD defined: death within 1-2 hours of the onset of symptoms/sudden arrest directly attributable to the cardiovascular system

7. Age-related and disease-specific risk for SCD
Myerburg, R. J. et al. Circulation 2007;116:
Copyright ©2007 American Heart Association

8. Sudden Cardiac Death in young people is a RARE event

9. Number of cardiovascular (CV), trauma-related, and other sudden death events in 1866 young competitive athletes, tabulated by year
Maron, B. J. et al. Circulation 2009;119:
Copyright ©2009 American Heart Association

10. Flow diagram summarizing causes of death in 1866 young competitive athletes
Maron, B. J. et al. Circulation 2009;119:
Copyright ©2009 American Heart Association

12. Causes of SCD
ARVC
Marfan Syndrome
HCM

13. Anomalous origin of the coronary arteries

14. Cardiovascular deaths according to race, with respect to the number of white and nonwhite athletes with each disease
Maron, B. J. et al. Circulation 2009;119:
Copyright ©2009 American Heart Association

16. SCD may be the first manifestation of many of these diseases
Thus, routine screening must be carried out in an attempt to diagnose them

17. Screening Athletes: Standard of Care in U.S.

19. Does this work?
One analysis of 134 young athletes who died suddenly, only 3% of examined athletes had abnormalities on the standard H&P (Maron et al, JAMA, 1996)
H&Ps are either being done improperly/incompletely, or they are insufficient for screening for these diseases…

20. Should we add something to the standard screening protocol?
12-lead ECG
Echocardiogram
Exercise Testing

21. Should we add something to the standard screening protocol?
12-lead ECG
Echocardiogram
Exercise Testing

22. Other Expert Panels European Society of Cardiology
H&P + 12-lead ECG
International Olympic Committee
Professional Athletes: > 90% get ECGs; 17% get echocardiograms (more elite athletes = more screening)
Harris et al, Arch Int Med, 2006

24. Italian Law
A law, first passed in 1971 and amended in 1982, requires any athlete of organized competitive sports (age 12-35) to undergo medical screening including an ECG and a 3-minute exercise step test.

26. Cardiovascular Conditions Causing Disqualification From Competitive Sports in 879 Athletes Over 2 Consecutive Screening Periods ( and ) at the Center for Sports Medicine in Padua, Italy
Corrado, D. et al. JAMA 2006;296:
Copyright restrictions may apply.

27. Italian Experience ~42,000 athletes screened (1979-2004)
9% required more testing due to an abnormal ECG
2% were ultimately disqualified from competition
55 sudden deaths occurred (only 4 women) throughout the study period

28. Annual Incidence Rates of Sudden Cardiovascular Death in Screened Competitive Athletes and Unscreened Nonathletes Aged 12 to 35 Years in the Veneto Region of Italy ( )
Corrado, D. et al. JAMA 2006;296:
Copyright restrictions may apply.

29. Important Caveats Observational study only
Not controlled trial of ECG vs. no ECG
Italy has a specific system set up to perform these screenings
In the 2% that were disqualified, none subsequently died (i.e. were they really at risk?; problem of screening asymptomatic pts)
High rate of death in the early era

30. U.S. data, (0.6 per 100,000 person-years)
Annual Incidence Rates of Sudden Cardiovascular Death in Screened Competitive Athletes and Unscreened Nonathletes Aged 12 to 35 Years in the Veneto Region of Italy ( )
U.S. data, (0.6 per 100,000 person-years)
Corrado, D. et al. JAMA 2006;296:
Copyright restrictions may apply.

32. Nevada High School Screening
5,615 HS athletes screened ( )
H&P + 12-lead ECG  echo if abnormal
22 athletes had CV disease that disqualified them from sports
Detection Rate of Tests:
0 by history
1/1000 by BP
1/6000 by physical exam
1/350 by ECG

33. Study of Harvard Athletes (Baggish, 2010):

34. 510 athletes screened 1. standard of care (H&P)
2. athletes then had ECGs and echocardiograms
The H&P’s were done by MDs blinded to the ECG/Echo results and results were determined for the efficacy of H&P vs. addition of ECG

35. Harvard Athletes
11 of 510 athletes had abnormal echocardiograms (2.2%)

36. Study flow diagram.LV = left ventricular; LVH = left ventricular hypertrophy; RV = right ventricular.
Study flow diagram.LV = left ventricular; LVH = left ventricular hypertrophy; RV = right ventricular.
Baggish A L et al. Ann Intern Med 2010;152:
©2010 by American College of Physicians

37. Harvard Athletes
Standard H&P detected 5 of 11 patients with underlying CV disease
Sensitivity = 45%
Specificity = 94%
Thus, as a screening test, H&Ps are significantly lacking in sensitivity
What about the addition of ECGs?

38. Harvard Study
Of the 11 athletes with CV disease, the addition of ECGs detected 10
Sensitivity = 91%
Specificity = 83%
False + rate = 17%
Many athletes required further testing
Financial cost
Emotional stress
Inappropriate exclusion from sports?

39. Cost of screening all U.S. athletes
Average cost per year of life saved = $42,000 - $200,000.
AHA estimate = ~$2 billion per year to screen adolescent athletes in the U.S. (~10,000,000 H.S. and college athletes)
Based on $50 per ECG

40. So, ECGs will detect diseases that H&Ps will not
Is the “cost” of doing this worth the benefit?

41. One last problem… Athlete’s Heart Different normal values
Overlap of physiologic changes and pathologic changes

43. Causes of Death in U.S. Children (ages 15-19)
1. Unintentional injury (MVC, drowning, fire, etc): ~14,000 deaths per year
2. Homicide: ~1,900/year
3. Suicide: 1,500/year
4. Cancer: 700/year

44. Worldwide causes of death

46. Pro-ECG ECGs detect diseases that H&Ps do not
In the U.S., HCM is the leading cause of SCD in athletes and likely will produce an abnormal ECG (~90%)
Identification of an athlete with a genetic CV condition can lead to diagnoses of family members
The cost-benefit ratio is comparable to many other initiatives with similar benefit

47. Anti-ECG
There remains no good data from a controlled trial proving ECGs are effective
The cost of implementation is between $1 and $2 billion per year. Resources are scarce.
The current U.S. system (H&P only) achieves a death rate similar to Italy
There will be children excluded from sports whose ultimate risk of SCD is been low and the exclusion was unnecessary

48. Back to Pro-ECG
“…support for preventive medicine and research into individual risk profiling in the U.S. is far below what a country of its wealth should be placing into such efforts. It is not for the scientific, clinical, and organizational communities to prioritize health dollars but rather to indicate what is needed and provide the supporting arguments. The decision to spend money on preventing some finite number of potentially avoidable deaths in adolescents and young adults is a priority determination that belongs in the hands of the public. Ask any parent.” – R. Myerburg & V. Vetter

49. Vote
□ Include ECGs in screening athletes
□ Do not include ECGs

50. Conclusions Screening athletes for SCD is needed
The appropriate method of screening remains debatable
The easiest solution would be a better screening test

51. THANK YOU

53. The Japanese Experience
Since 1973, national system for screening cardiovascular disease
All students in 1st, 7th, and 10th grade get questionnaires and ECGs
Results of screening (n = 37,000)
2.7% failed screening  further w/u
3 sudden deaths

54. ECG cost-effectiveness
Myerburg, R. J. et al. Circulation 2007;116:
Copyright ©2007 American Heart Association

55. Figure 1
Prospective screening of 5,615 high school athletes for risk of sudden cardiac death.
FULLER, COLIN; McNULTY, CANDACE; SPRING, DONALD; ARGER, KOSTA; BRUCE, STEPHEN; CHRYSSOS, BASIL; DRUMMER, ERIC; KELLEY, FRANK; NEWMARK, MICHAEL; WHIPPLE, GERALD
Medicine & Science in Sports & Exercise. 29(9): , September 1997.
Figure 1 -Overall results of cardiac preparticipation screening in 5,615 high school athletes.
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