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Screening Athletes to Prevent Sudden Cardiac Death Christopher Davis, MD, PhD Pediatric Grand Rounds August 20, 2010 Rady Childrens Hospital San Diego.

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Presentation on theme: "Screening Athletes to Prevent Sudden Cardiac Death Christopher Davis, MD, PhD Pediatric Grand Rounds August 20, 2010 Rady Childrens Hospital San Diego."— Presentation transcript:

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

2 Disclosures None None

3 Sudden Cardiac Death How many athletes die suddenly each year from cardiovascular causes? How many athletes die suddenly each year from cardiovascular causes? What conditions do they have? What conditions do they have? How can they be screened to prevent as many deaths as possible in a reasonably efficient manner? 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 SCD defined: death within 1-2 hours of the onset of symptoms/sudden arrest directly attributable to the cardiovascular system

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

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

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

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

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12 Causes of SCD HCM ARVC Marfan Syndrome

13 Anomalous origin of the coronary arteries

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

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

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

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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) 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… 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 12-lead ECG Echocardiogram Echocardiogram Exercise Testing Exercise Testing

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

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

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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. 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.

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26 Copyright restrictions may apply. Corrado, D. et al. JAMA 2006;296: 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

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

28 Copyright restrictions may apply. Corrado, D. et al. JAMA 2006;296: 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 ( )

29 Important Caveats Observational study only Observational study only Not controlled trial of ECG vs. no ECG Not controlled trial of ECG vs. no ECG Italy has a specific system set up to perform these screenings 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) 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 High rate of death in the early era

30 Copyright restrictions may apply. Corrado, D. et al. JAMA 2006;296: 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)

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

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

34 510 athletes screened 510 athletes screened 1. standard of care (H&P) 1. standard of care (H&P) 2. athletes then had ECGs and echocardiograms 2. athletes then had ECGs and echocardiograms The H&Ps were done by MDs blinded to the ECG/Echo results and results were determined for the efficacy of H&P vs. addition of ECG The H&Ps 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%) 11 of 510 athletes had abnormal echocardiograms (2.2%)

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

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

39 Cost of screening all U.S. athletes Average cost per year of life saved = $42,000 - $200,000. 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) 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 Based on $50 per ECG

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

41 One last problem… Athletes Heart Athletes Heart Different normal values Different normal values Overlap of physiologic changes and pathologic changes Overlap of physiologic changes and pathologic changes

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

44 Worldwide causes of death

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46 Pro-ECG ECGs detect diseases that H&Ps do not 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%) 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 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 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 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 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 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 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 …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 Include ECGs in screening athletes Do not include ECGs Do not include ECGs

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

51 THANK YOU

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

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

55 © Williams & Wilkins All Rights Reserved. Published by Lippincott Williams & Wilkins, Inc.2 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 Figure 1 -Overall results of cardiac preparticipation screening in 5,615 high school athletes.


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