1. -ICASM 2013- 1 1 Pre-participation ECG screening in military recruits- the IDF experience Alon Grossman M.D MHA 1, 2, 3, Alex Prokupetz MHA 1, 2, Igor Lipchenca MD 4 1. IAF aero medical center, Tel Hashomer, Israel 2. IDF medical corps 3. Department of Internal Medicine E, Rabin Medical Center Beilinson Campus affiliated to Tel Aviv University Sackler Medical School, Israel 4. Leviev Heart Center, Sheba Medical Center and Tel Aviv University, Tel Hashomer, Israel

2. -ICASM 2013- 2 Introduction  Despite the large numbers of athletes undergoing pre-participation screening, there is a continuing debate regarding the optimal method of screening  The main concern in performing mass ECG screening in athletes is the costly additional work up required based on resting ECG findings

3. -ICASM 2013- 3 Introduction  Professional guidelines in the US do not recommend use of either ECG or echocardiography for screening of college athletes 1  On the other hand, 12-lead ECG has been supported for screening purposes among athletes by the Sport Cardiology section of the European society of Cardiology and Medical Commission of the International Olympic Committee and has been shown to reduce mortality in this population 2 1. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to pre participation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007; 115:1643-1655 2. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a pre-participation screening program. JAMA 2006; 296:1593–1601

4. -ICASM 2013- 4 Background  Recruits to elite units in the IDF undergo pre-participation ECG prior their enlistment  This process has been performed sporadically in the last years but all ECGS are performed at the IAF aero medical Center since January 2010  All elite units candidates undergo a preliminary medical selection process at the IDF recruitment center (History & PE)  Only those who are physically healthy are allowed to enlist to elite units and only they undergo pre-participation ECG  This population consists of 17-19 years old male subjects

5. -ICASM 2013- 5 Background  All ECGS are evaluated by a single cardiologist  Those requiring further evaluation, complete the evaluation prior to enlistment  A military physician from the IAF aero medical center summarizes the medical evaluation and decides whether the candidate is eligible to enlist to a special unit

6. -ICASM 2013- 6 Aims  To characterize causes of referral to continued investigation based on resting ECG findings  To summarize the additional work-up performed  To summarize the rate of significant findings resulting in disqualification of military candidates in this population

7. -ICASM 2013- 7 Results  1,455 subjects underwent pre- participation ECG in the year 2010  1,388 studies (95.39%) interpreted as normal  67 referred to further evaluation

8. -ICASM 2013- 8 Causes for referral Number of cases (% of total findings) DefinitionCause of referral 16 (23.9%)Non specificT wave changes 14 (20.9%)PR segment shorter than 120 milliseconds) with or without a delta wave Pre-excitation pattern 11 (16.4%)S1+R5,6 wave voltage greater than 35 mm in precordial leads and/or R-wave greater than 15 mm in peripheral lead I and/or 12 mm in aVL LVH 9 (13.4%)Rates slower than 50 BPMSinus bradycardia 6 (8.9%)AV blocks of various degree, LBBB or RBBB, LAHB or LPHB Blocks 5(7.5%)Atrial or ventricular premature beats 3 (4.5%)upward ST-segment elevation in 2 or more peripheral or precordial leads, beginning from an elevated J point and continuing with an upsloping shape into the T-wave Early repolarization pattern 3 (4.5%)corrected QT interval (QTc) greater than 440 milliseconds Long QT interval

9. -ICASM 2013- 9 Additional investigations Adenosine testHolterStress testEchoECG finding 01817T wave changes 0122Early repolarization 0221Long QT 11771Pre excitation pattern 0232Atrial or ventricular premature beats 00116LVH 0377Blocks 0680Sinus bradycardia 11223846Total

10. -ICASM 2013- 10 Clinical Diagnosis Final diagnosis (#)ECG finding BAV (1) VSD (1) LVH (1) T wave changes LVH (1)Early repolarization Dilated left ventricle (1)Atrial or ventricular premature beats LVH (1) Non compacted apex (1) LVH NoneLong QT, pre-excitation pattern, sinus bradycardia, blocks 7Total number

11. -ICASM 2013- 11 example 1

12. -ICASM 2013- 12 Example 2  ICRBBB with non-specific T wave changes in inferior leads  Echocardiography interpreted as normal  No further w/u required

13. -ICASM 2013- 13 Example 3  Early repolarization pattern particularly in V2  Echocardiography-normal  No further w/u required

14. -ICASM 2013- 14 Discussion  Screening for cardiovascular disease among athletes and military candidates is imperative as sudden death is obviously tragic and potentially preventable  Debate continues regarding the optimal method of screening, this ranging from reliance solely on history and physical examination to performance of 12-lead ECG and echocardiography 

15. -ICASM 2013- 15 Discussion  The total rate of ECGS defined as abnormal in this cohort was 4.6%, a percentage much lower than previously reported  Yet, even in a previous report by Pellicia et al (8) in which 11.8% of ECGs were interpreted as abnormal, additional evaluation was requested in only 4.8% of ECGs, disregarding some of the findings noted on routine ECG  This rate is similar to that reported in this study and probably represents the true rate of ECG findings requiring further evaluation in young athletes Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339: 364–369 Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R, Castagna W, Ciacciarelli A, Costini G, Cuffari B, Drago E, Federici V, Gribaudo CG, Iacovelli G, Landolfi L, Menichetti G, Atzeni UO, Parisi A, Pizzi1 AR, Rosa M, Santelli F, Santilio F, Vagnini A, Casasco M, and Di Luigi L. Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J 2007; 28(16): 2006-2010.

16. -ICASM 2013- 16 T waves  T wave changes was the most common cause for continued investigation in the cohort  This is probably due to the non specific nature of this finding  Disqualifying findings were identified in 18.75% of evaluations in these subjects  Whether these clinical findings were associated with the ECG findings or were incidental is unclear

17. -ICASM 2013- 17 PRE EXCITATION PATTERN  Signs of pre-excitation were identified in 14 subjects who comprised 0.96% of the study population  This is a higher percentage than previously reported (0.2%)  Probably resulted from the high awareness to this condition among interpreting cardiologists  No cases of pre-excitation syndrome identified  This is similar to a previous report from the Israeli air force Ferrer MF. Electrocardiographic variations, arrhythmias, pacemakers. In: Lew EA, Gajewski J. Medical Risks: Trends in Mortality by age and time elapsed. New York, NY: Praeger 1990. Grossman A et al Use of adenosine test for the exclusion of pre-excitation syndrome in asymptomatic individuals. Ann Noninvasive Electrocardiol 2011 Apr 16 (2); 180-183.

18. -ICASM 2013- 18 LVH criteria  Signs of LVH were identified in only 7.56% of the study population  This is significantly lower than reported in previous studies (up to 45%)  This is surprising given the young age of the population and the fact that the subjects were all very physically active  Disqualifying findings were identified in 18.2% of these subjects Pelliccia A et al Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J 2007; 28(16): 2006-2010

19. -ICASM 2013- 19 LIMITATIONS  A selective cohort (healthy, physically active underwent ECG during screening for athletic activity)  Single physician interpreting all ECGS (high inter-observer variability reported in the literature)

20. -ICASM 2013- 20 Conclusions  T wave changes, although non-specific, may be a sign of cardiac disease  Pre-excitation pattern is of low specificity for the diagnosis of PES, but because of the lethal potential of this condition, adenosine should be performed in subjects with a suspicious pattern

21. -ICASM 2013- 21 Conclusions  ECG-LVH criteria have a low sensitivity in young subjects, but because of the fatal potential of HOCM and because the specificity of the ECG is very high, echocardiography should be performed to all those with ECG criteria  Policy makers should take into account the large number of echocardiographies that will be performed in order to identify subjects with true LVH

22. -ICASM 2013- 22 Conclusions  Sinus bradycardia and conduction disturbances (low degree AVB and hemiblocks) probably result from increased vagal tone and require no additional work-up

23. -ICASM 2013- 23