1. Screening athletes for cardiac disease
© Copyright 2010

2. Incidence of sudden cardiac death (SCD) in the young: estimates vary
Corrado et al: 1.0/105 (<35 yo, Italy)
Maron et al: 0.46/105 (high school, USA)
Van Camp et al 0.4/105 (HS/college, USA) Wren: 0.4/105 (normal children & teens, meta-analysis)
Overall: probably about 1 death for every 250,000 young athletes per year
Wren. Heart

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

4. Ryan Shay
Gaines Adams
Hank Gathers
Pete Maravich

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 12-35
They report dramatic reduction in SCD

9. The Italian Experience, 1979-2004
42,386 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, 1979-2004
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, 1979-2004
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. Conclusions of Maron et al
“…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.”
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 /- 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. 2010.

22. European Society of Cardiology proposed screening protocol for young competitive athletes
Figure 1 Flow diagram illustrating the proposed screening protocol for young competitive athletes. The initial cardiovascular protocol includes family and personal history, physical examination with determination of blood pressure, and basal 12-lead ECG. Additional tests, such as echocardiography, 24-h Holter monitoring, or stress testing, SAECG, and cardiac MRI are requested only for subjects who had positive findings at the initial evaluation. In uncertain cases, invasive tests such as contrast ventriculography (both right and left), coronary angiography, endomyocardial biopsy, and electrophysiological study may be necessary in order to confirm (or rule out) the diagnosis of cardiovascular disease. Athletes diagnosed with clinically relevant cardiovascular abnormalities are managed according to available guidelines for assessing athletic risk. EMB, endomyocardial biopsy; EPS, electrophysiological study; MRI, magnetic resonance imaging; SAECG, signal-averaged ECG.
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 10-27
1646 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
Wilson et al. Brit J Sports Med

26. H&P plus ECG 1/06 – 4/08 428 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)
Bessem et al. Br J Sports Med

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

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
Echo N/A
H/PE
ECG
Baggish AL et al. Annals Int Med

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

32. Baggish et al. Ann Int Med. 2010.

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

39. Wheeler et al. Ann Int Med. 2010.

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)
Greater increases in the years of life saved are associated with higher incremental costs.
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). Evaluation of different screening methods and test characteristics derived from the athlete- screening literature. Test methods and reported test results were used as inputs in the model and compared with a strategy of no screening. The discounted incremental life-years gained per athletes screened are plotted against the cost per athlete screened for each method. The incremental cost-effectiveness ratio, screening method, and threshold for a positive test result are shown together with the reference from which test characteristic estimates were derived. Because of significant heterogeneity between the populations studied and methods used in the studies compared, the test characteristics derived from each study may not be entirely applicable to the screened population described for the base case. In addition, the methods of FH, H, and H & P are not uniform across the studies referenced. References from which input estimates have been derived are shown in parentheses. Details of incremental cost- effectiveness ratio versus no screening for each study and comparison with a baseline of H & P for those including history can be found in Appendix Table 4. Estimated test sensitivity and specificity for each graphed incremental cost-effectiveness ratio is shown and is derived from references in parentheses. Incremental cost-effectiveness ratios versus no screening and test sensitivity and specificity are as follows: cost-effectiveness ratio, $51 400 (sensitivity 40%, specificity 98%), $63 400 (45%, 95.2%), $64 000 (25%, 98.8%), $76 100 (68%, 95%), $78 800 (73%, 93.1%), $81 000 (55%, 89.7%), $81 600 (90%, 84.9%), $153 900 (25%, 97.5%), $174 000 (75%, 61.5%), $199 200 (15%, 97%), $232 500 (34%, 84.7%), $264 000 (85%, 35%), and $275 000 (5%, 97.1%); life costing (5%, 70.1%). ECG = 12-lead electrocardiography; FH = family history; H & P = cardiovascular-focused history and physical examination; LVH = left ventricular hypertrophy.
Wheeler et al. Ann Intern Med

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. Freedom vs. paternalism
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):
Corrado D. An Electrocardiogram Should Not Be Included in Routine Preparticipation Screening of Young Athletes. Circulation Nov 7;116(22):
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.

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):
Myerburg RJ Vetter VL. Electrocardiograms Should Be Included in Preparticipation Screening of Athletes. Circulation. 2007;116:
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):
Last updated 3/19/10