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Screening athletes for cardiac disease © Copyright 2010.

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Presentation on theme: "Screening athletes for cardiac disease © Copyright 2010."— Presentation transcript:

1 Screening athletes for cardiac disease © Copyright 2010

2 Incidence of sudden cardiac death (SCD) in the young: estimates vary Corrado et al: 1.0/10 5 (<35 yo, Italy) Maron et al: 0.46/10 5 (high school, USA) Van Camp et al 0.4/10 5 (HS/college, USA) Wren: 0.4/10 5 (normal children & teens, meta-analysis) Overall: probably about 1 death for every 250,000 young athletes per year Wren. Heart

3 Marc-Vivien Foe Anthony Bates Jesse Marunde Alexei Cherepanov Famous athletes who have died of sudden cardiac death

4 Gaines Adams Hank Gathers Pete Maravich Ryan Shay

5 What causes SCD? Distribution of cardiovascular causes of sudden death in 1435 young competitive athletes Maron BJ et al. Circ

6 Is SCD preventable? The $2 billion question! Some conditions that predispose to SCD can be picked up on sports screening, others cannot Screening programs are expensive Experts advocate different approaches

7 Two approaches to screening Focused history and physical exam, further work-up only if risk-factors identified (U.S. approach) H&P, plus ECG, with further work-up if abnormalities on either (Italian approach)

8 The Italian experience Pioneers of ECG screening for athletes They provide annual ECGs for all athletes ages They report dramatic reduction in SCD

9 The Italian Experience, ,386 athletes 12 to 35 years old Controls: non-athletes, same ages Results –55 athletes and 265 non-athletes died of SCD –After screening, athlete deaths fell 89 percent from 3.6 to.4 per 100,000 people per year –No change in SCD among non-athletes

10 SCD rate in athletes and non-athletes, Veneto, Italy, Corrado D. JAMA

11 What about the USA? Maron et al compared SCD death rates in Minnesota with those reported in Veneto They found that, without ECG screening, SCD rates in MN were comparable to those in Italy with ECG screening

12 Italy and Minnesota comparable in population and ethnicity Maron et al. Am J Card

13 Trends in rates of SCD in MN and Veneto, Since 1995, there has been no statistical difference in SCD Maron et al. Am J Card

14 Side by side comparison Veneto Minnesota death ‘93-’04 death rate (per 100,000) deaths death rate (not statistically significant) Maron et al. Am J of Card

15 “…athlete sudden-death rates in these demographically similar regions of the U.S. and Italy have not differed significantly in recent years. These data do not support a lower mortality rate associated with preparticipation screening programs involving routine ECG and examinations by specially trained personnel.” Conclusions of Maron et al Maron et al. Am J Card

16 Possible explanations of differences between US and Italy Age: SCD death rates are higher in older athletes than in younger Sex: SCD rates are higher in males than in females

17 Age Italy screens all athletes 12 to 35 years of age MN screens mostly HS and college athletes If one considers the SCD rate in the general population of 20 to 40-yr-olds in Olmsted County, MN, it is similar to that in the pre-screening Italian population (4.5/100,000) Corrado et al. Am J Card

18 Age at death: Italy vs. Minnesota Mean age at death: Italy Minnesota 23 +/- 2 yrs 17+/- 4 yrs Corrado et al. Am J Card

19 Sex Male athletes die at 5 -10X rate of female athletes In Italy, 82% of athletes are male In MN, 65% of athletes are male This would contribute to higher death rates in Italy Corrado et al. Am J Card

20 American Heart Association (AHA) versus European Society of Cardiology (ESC) AHA recommends focused, 12 item H&P European Society of Cardiology and International Olympic Committee recommend routine ECG

21 Baggish et al. Ann Int Med

22 European Society of Cardiology proposed screening protocol for young competitive athletes Corrado et al. Eur Heart J

23 Studies comparing H&P with ECG Three studies –Wilson et al 2007 (UK) –Bessem et al 2009 (Holland) –Baggish et al 2010 (US)

24 How do H&P and ECG compare? 1074 athletes ages schoolchildren age (Total N = 2720) –Personal and family history questionnaires –Physical exam by cardiologists –12-lead ECG 9 diagnosed with a disease associated with SCD 0/9 diagnosed with H&P alone 9/2720 (0.3% kept out of sports ) Wilson et al. Brit J Sports Med

25 ECG identifies disease: H+P does not

26 H&P plus ECG 1/06 – 4/ cardiovascular screenings Outcome measures: –(false) positive screening result –Negative screening result –Further testing per Lausanne protocol –Number needed to screen Bessem et al. Br J Sports Med

27 Outcomes from a Dutch screening program Bessem et al. Br J Sports Med

28 Dutch screening program (cont’d)

29 Bessem et al. Brit J Spts. Med Additional testing for athletes with positive ECG screen

30 ECG together with H&P : sensitive but not specific Prospective cross-sectional comparison 510 college athletes All had H&P, ECG and echocardiogram Test# abnormal% false positive Echo11 N/A H/PE ECG Baggish AL et al. Annals Int Med

31 Flow chart for cardiac screening Baggish et al. Ann Int. Med LV = left ventricular; LVH = left ventricular hypertrophy; RV = right ventricular.

32 Baggish et al. Ann Int Med

33 Exclusion from sports Disagreement among experts about what diagnoses should lead to exclusion from competitive sports Again, US and Europe have different approaches

34 Differences between NIH recommendations (BC#36) and European Society of Cardiology (ESC) recommendations for sports restrictions Pelliccia et al. J Am Coll Card

35 What about cost? Two recent studies of the cost effectiveness of screening –Fuller –Maron –Wheeler

36 Cost of universal screening A study of cost per year of life saved among high-school athletes by using ECG versus H/PE versus echocardiogram –$44,000 per year for 12-lead ECG –$84,000 for specific cardiovascular H/PE –$200,000 for echocardiogram (Note: Study assumes 1 death per 100,000 athletes. May be high) Fuller CM. Med Sci Sports Exerc

37 Another cost estimate Assumptions: –10 million US. athletes require ECG screen –10,000 have a cardiac condition identifiable by ECG –9,000 have an irregular ECG that hints at cardiac disease Result: $330,000 to identify each athlete with cardiac disease. 10% of those would actually die. Result: $3.3 million to prevent each death Maron BJ et al. Circ

38 Decision analysis model for a screening program Wheeler et al. Ann Int Med CV = cardiovascular ECG = 12-lead electrocardiography H & P = history and physical examination M = Markov node

39 Wheeler et al. Ann Int Med

40 Cost-effectiveness varies with cost of testing and thresholds for sensitivity and specificity

41 Cost-effectiveness of screening athletes to prevent sudden cardiac death. Data reported with each symbol are the estimated sensitivity and specificity, as well as criteria (reference) Wheeler et al. Ann Intern Med Greater increases in the years of life saved are associated with higher incremental costs.

42 “We recognize that some may not regard these estimated costs per athlete as excessive for detecting potentially lethal cardiovascular disease in young people; however, the fundamental issue defined by these calculations concerns the practicality and feasibility of establishing a continuous annual national program for many years at a cost of approximately $2 billion per year.” Maron BJ et al. Circ

43 To save one life… About 1,700 athletes would have to be prohibited from sports, and their families warned that sudden cardiac death could kill their child Bessem et al. Br J Sports Med

44 Difficulties with screening Many false positives and false negatives –Cannot prevent all deaths –Prevents sports participation in many people at low risk of SCD Anxiety for athletes with positive screen Cost Demands on medical personnel Freedom vs. paternalism

45 The Italian approach to ECG screening gives the state the authority not only to require an ECG, but to decide who will play sports and who will not This approach may not work in the U.S.

46 U.S. vs. Europe “It would seem that many of the distinctions can be explained on the basis of differences in Europe and the U.S. with regard to cultural background, societal attitudes, and also perceived exposure to liability.” Pelliccia. J Am Coll Card

47 So what is a pediatrician to do? AHA recommends H&P, without routine ECG Present parents the facts Acknowledge uncertainty Ultimately, must be a shared, well-informed, and individualized decision

48 Resources Baggish AL, Hutter AM Jr, Wang F, Yared K, Weiner RB, Kupperman E, Picard MH, Wood MJ. Cardiovascular Screening in College Athletes With and Without Electrocardiography: A Cross-sectional Study. Ann Intern Med Mar 2;152(5): Cardiovascular Screening in College Athletes With and Without Electrocardiography: A Cross-sectional Study. Corrado D. An Electrocardiogram Should Not Be Included in Routine Preparticipation Screening of Young Athletes. Circulation Nov 7;116(22): An Electrocardiogram Should Not Be Included in Routine Preparticipation Screening of Young Athletes Corrado D, Pelliccia A, Biornstad HH, Vanhees L, Biffi A, Boriesson M, Panhuyzen- GoedkoopN, Deligiannis A, Solberg E, Dugmore D, Mellwig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Heidbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E, Blomstrom-Lundqvist C, McKenna WJFagard R, Thiene G; Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J Mar;26:516–524.Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology

49 Resources (cont’d) Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, Dimeff R, Douglas PS, Glover DW, Hutter AM Jr, Krauss MD, Maron MS, Mitten MJ, Roberts WO, Puffer JC; American Heart Association Council on Nutrition, Physical Activity, and Metabolism. Recommendations and Considerations Related to Preparticipation 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 Mar 27;115(12): Recommendations and Considerations Related to Preparticipation 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 Myerburg RJ Vetter VL. Electrocardiograms Should Be Included in Preparticipation Screening of Athletes. Circulation. 2007;116: Electrocardiograms Should Be Included in Preparticipation Screening of Athletes Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA. Cost-effectiveness of Preparticipation Screening for Preventing Sudden Cardiac Death in Young. Ann Intern Med Mar 2;152(5): Cost-effectiveness of Preparticipation Screening for Preventing Sudden Cardiac Death in Young Last updated 3/19/10


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