3 Sudden Cardiac DeathHow 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?
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 ECGEchocardiogramExercise Testing
21 Should we add something to the standard screening protocol? 12-lead ECGEchocardiogramExercise Testing
22 Other Expert Panels European Society of Cardiology H&P + 12-lead ECGInternational Olympic CommitteeProfessional Athletes: > 90% get ECGs; 17% get echocardiograms (more elite athletes = more screening)Harris et al, Arch Int Med, 2006
24 Italian LawA 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, ItalyCorrado, 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 ECG2% were ultimately disqualified from competition55 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 ECGItaly has a specific system set up to perform these screeningsIn 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 abnormal22 athletes had CV disease that disqualified them from sportsDetection Rate of Tests:0 by history1/1000 by BP1/6000 by physical exam1/350 by ECG
34 510 athletes screened 1. standard of care (H&P) 2. athletes then had ECGs and echocardiogramsThe 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 Athletes11 of 510 athletes had abnormal echocardiograms (2.2%)
37 Harvard AthletesStandard H&P detected 5 of 11 patients with underlying CV diseaseSensitivity = 45%Specificity = 94%Thus, as a screening test, H&Ps are significantly lacking in sensitivityWhat about the addition of ECGs?
38 Harvard StudyOf the 11 athletes with CV disease, the addition of ECGs detected 10Sensitivity = 91%Specificity = 83%False + rate = 17%Many athletes required further testingFinancial costEmotional stressInappropriate 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
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 membersThe cost-benefit ratio is comparable to many other initiatives with similar benefit
47 Anti-ECGThere remains no good data from a controlled trial proving ECGs are effectiveThe 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 ItalyThere 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 debatableThe easiest solution would be a better screening test
53 The Japanese Experience Since 1973, national system for screening cardiovascular diseaseAll students in 1st, 7th, and 10th grade get questionnaires and ECGsResults of screening (n = 37,000)2.7% failed screening further w/u3 sudden deaths