Screening athletes for cardiac disease © Copyright 2010

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. 2009.

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

Ryan Shay Gaines Adams Hank Gathers Pete Maravich

What causes SCD? Distribution of cardiovascular causes of sudden death in 1435 young competitive athletes Maron BJ et al. Circ. 2007.

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

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)

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

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

SCD rate in athletes and non-athletes, Veneto, Italy, 1979-2004 Corrado D. JAMA. 2006.

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

Italy and Minnesota comparable in population and ethnicity Maron et al. Am J Card. 2009.

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. 2009.

Side by side comparison Veneto Minnesota 1993-2004 death 12 11 ‘93-’04 death rate (per 100,000) .87 .93 2001-2004 deaths 2 4 2001-2004 death rate .38 .90 (not statistically significant) Maron et al. Am J of Card. 2009.

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. 2009.

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

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. 2010.

Age at death: Italy vs. Minnesota Mean age at death: Italy Minnesota 23 +/- 2 yrs 17+/- 4 yrs Corrado et al. Am J Card. 2010.

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. 2010.

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

Baggish et al. Ann Int Med. 2010.

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. 2005.

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

How do H&P and ECG compare? 1074 athletes ages 10-27 1646 schoolchildren age 14-20 (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. 2007.

ECG identifies disease: H+P does not Wilson et al. Brit J Sports Med. 2007.

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. 2009.

Outcomes from a Dutch screening program Bessem et al. Br J Sports Med. 2009.

Dutch screening program (cont’d) Bessem et al. Br J Sports Med. 2009.

Additional testing for athletes with positive ECG screen Bessem et al. Brit J Spts. Med. 2009.

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 11 N/A H/PE 5 5.5 ECG 5 16.9 Baggish AL et al. Annals Int Med. 2010.

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. 2010.

Baggish et al. Ann Int Med. 2010.

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

Differences between NIH recommendations (BC#36) and European Society of Cardiology (ESC) recommendations for sports restrictions Pelliccia et al. J Am Coll Card. 2008.

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

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. 2000.

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. 2007.

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. 2010.

Wheeler et al. Ann Int Med. 2010.

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

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 1000 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. 2010.

“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. 2007.

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. 2009.

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

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.

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. 2008.

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

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. 2010 Mar 2;152(5):269-75. Corrado D. An Electrocardiogram Should Not Be Included in Routine Preparticipation Screening of Young Athletes. Circulation. 2007 Nov 7;116(22):2610-14. 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. 2005 Mar;26:516–524.

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. 2007 Mar 27;115(12):1643-455. Myerburg RJ Vetter VL. Electrocardiograms Should Be Included in Preparticipation Screening of Athletes. Circulation. 2007;116:2616-2626. 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. 2010 Mar 2;152(5):276-86. Last updated 3/19/10