utility of a sports preutility of a sports pre ... bar cohen 10 00 am.pdf · january 14-15, 2011...

January 14-15, 2011 SCA Conference 1

Utility of a Sports PreUtility of a Sports Pre--Participation VisitParticipation Visit

Assistant Professor of PediatricsAssistant Professor of PediatricsDi i i f C di l / El t h i lDi i i f C di l / El t h i l

Yaniv BarYaniv Bar--Cohen, M.D.Cohen, M.D.

Division of Cardiology / ElectrophysiologyDivision of Cardiology / ElectrophysiologyChildrensChildrens Hospital Los AngelesHospital Los Angeles

Keck School of MedicineKeck School of Medicine

Utility of a Sports PreUtility of a Sports Pre--Participation VisitParticipation Visit

What is the appropriate What is the appropriate screening screening strategy for discovering patients at strategy for discovering patients at

risk for dying suddenly during risk for dying suddenly during athletic participation?athletic participation?


Screening = ControversyScreening = ControversyAffects a large number of patientsAffects a large number of patients

Affects a large number of physicians Affects a large number of physicians and other practitionersand other practitioners

Large amounts of funds and other Large amounts of funds and other ggresources requiredresources required

Blanket statements need to be madeBlanket statements need to be made

~0.5 ~0.5 -- 2 per 100,000 per year2 per 100,000 per yearsudden death rate in high schoolsudden death rate in high school--aged kidsaged kids

SCD in athletesSCD in athletesThe NumbersThe Numbers

–– sudden death rate in high schoolsudden death rate in high school--aged kidsaged kids

~10 million high school and college student ~10 million high school and college student athletes per yearathletes per year

»» ~50 ~50 -- 200 sudden deaths in athletes per year200 sudden deaths in athletes per yearp yp y


Arrhythmogenicity of SportsArrhythmogenicity of SportsHigh High catecholaminescatecholamines and surges of and surges of catecholaminescatecholaminesEmotional stressEmotional stressEmotional stressEmotional stressPossible myocardial ischemiaPossible myocardial ischemiaHemodynamic changesHemodynamic changesChanges in hydration and blood volumeChanges in hydration and blood volumeElectrolyte imbalanceElectrolyte imbalanceCardiac changes with trainingCardiac changes with training

Increased frequency of ventricular arrhythmiasIncreased frequency of ventricular arrhythmias

Arrhythmogenicity of SportsArrhythmogenicity of SportsRelative risk for sudden death in athletes (versus nonRelative risk for sudden death in athletes (versus non--athletes) in Italyathletes) in Italy19791979--1999 1999 –– 12 to 35 years of age12 to 35 years of agePopulation of 1,386,600Population of 1,386,600

–– 112,790 athletes112,790 athletes300 cases of SD (1 in 100,000 per year)300 cases of SD (1 in 100,000 per year)

–– 55 SD in athletes (2.3 in 100,000 per year)55 SD in athletes (2.3 in 100,000 per year)–– 245 SD in non245 SD in non--athletes (0.9 per 100,000 nonathletes (0.9 per 100,000 non--athletes)athletes)

Corrado et al. JACC 2003; 1: 1959Corrado et al. JACC 2003; 1: 1959--6363


SCD in athletes SCD in athletes -- etiologyetiology

MaronMaron et al. Circulation 2007;115;1643et al. Circulation 2007;115;1643--16551655.

ONLY History and physical examination for preparticipation screeningONLY History and physical examination for preparticipation screening–– ECG optionalECG optional

Same as 1996 guidelinesSame as 1996 guidelinesReleased due to recommendations of the European Society of CardiologyReleased due to recommendations of the European Society of Cardiology--Released due to recommendations of the European Society of Cardiology Released due to recommendations of the European Society of Cardiology

(ESC) and International Olympic Committee (IOC) that 12(ESC) and International Olympic Committee (IOC) that 12--lead ECG should be lead ECG should be included.included.

After thorough reAfter thorough re--evaluation of new considerations and data from the last decade, evaluation of new considerations and data from the last decade, AHA concluded that a routine AHA concluded that a routine preparticiaptionpreparticiaption ECG “is probably impractical.”ECG “is probably impractical.”


History and History and PhycialPhycial

Personal historyPersonal history1 Exertional1 Exertional chestchest pain /pain / discomfortdiscomfort

12 Elements12 Elements

–– 1. Exertional 1. Exertional chestchest pain / pain / discomfortdiscomfort–– 2. 2. Unexplained syncope / nearUnexplained syncope / near--syncope (judged not to be syncope (judged not to be neurocardiogenicneurocardiogenic / /

vasovagalvasovagal))–– 3. Excessive exertional and unexplained 3. Excessive exertional and unexplained dyspneadyspnea / fatigue, associated with / fatigue, associated with

exerciseexercise–– 4. Prior recognition of a heart murmur4. Prior recognition of a heart murmur–– 5. Elevated systemic blood pressure5. Elevated systemic blood pressure


Family HistoryFamily History66 Premature death (sudden and unexpected or otherwise) before 50 years ofPremature death (sudden and unexpected or otherwise) before 50 years of–– 6. 6. Premature death (sudden and unexpected, or otherwise) before 50 years of Premature death (sudden and unexpected, or otherwise) before 50 years of age and due to heart diseaseage and due to heart disease

–– 7. Disability from heart disease in a close relative <50 years of age7. Disability from heart disease in a close relative <50 years of age–– 8. Specific knowledge of certain cardiac conditions in family members 8. Specific knowledge of certain cardiac conditions in family members

(including hypertrophic or dilated (including hypertrophic or dilated cardiomyopathycardiomyopathy, long QT syndrome or , long QT syndrome or other ion other ion channelopathieschannelopathies, , MarfanMarfan syndrome or clinically important syndrome or clinically important arrhythmias)arrhythmias)



Physical ExaminationPhysical Examination9 Heart murmur9 Heart murmur auscultation should be performed in both supine andauscultation should be performed in both supine and–– 9. Heart murmur9. Heart murmur——auscultation should be performed in both supine and auscultation should be performed in both supine and standing position (or with standing position (or with ValsalvaValsalva maneuver), specifically to identify the maneuver), specifically to identify the murmur of dynamic left ventricular outflow tract obstruction in HCMmurmur of dynamic left ventricular outflow tract obstruction in HCM

–– 10. Femoral pulses to exclude aortic 10. Femoral pulses to exclude aortic coarctationcoarctation–– 11. Physical stigmata of 11. Physical stigmata of MarfanMarfan syndromesyndrome–– 12. Brachial artery blood pressure (sitting position)12. Brachial artery blood pressure (sitting position)

Screening H&P rulesScreening H&P rules

••Any positive finding is enough to trigger a cardiology Any positive finding is enough to trigger a cardiology referralreferral

••Screening should be performed before initial sports Screening should be performed before initial sports engagementengagement

••Middle and high school: parental verification requiredMiddle and high school: parental verification required••Repeat after two years for high school athletesRepeat after two years for high school athletes

••College: complete history and physical at matriculationCollege: complete history and physical at matriculation••Interim history (with blood pressure) each subsequent yearInterim history (with blood pressure) each subsequent year


Problems with Screening H & PProblems with Screening H & PLow sensitivity and specificity Low sensitivity and specificity

Of 115 athletes with SCD who had a standardOf 115 athletes with SCD who had a standardOf 115 athletes with SCD who had a standard Of 115 athletes with SCD who had a standard preparticipation medical evaluation, only 4 (3%) were preparticipation medical evaluation, only 4 (3%) were suspected of having cardiovascular diseasesuspected of having cardiovascular disease

Great variability in how the test is administeredGreat variability in how the test is administered

Chest pain and lightheadedness are commonChest pain and lightheadedness are common

HCM HCM –– difficult to detect by history and physical alonedifficult to detect by history and physical alone

Syncope is very important risk factor that may be ignoredSyncope is very important risk factor that may be ignored

MaronMaron, et al. JAMA 1996; 276:199, et al. JAMA 1996; 276:199--204. 204.

History of Syncope in SCDHistory of Syncope in SCDSweden: 42/162 (26%) of SCD with history of syncope / Sweden: 42/162 (26%) of SCD with history of syncope / presyncopepresyncope

1515 35 year olds35 year olds–– 1515--35 year olds35 year olds

Minnesota: 3/12 (25%) of SCD with history of syncope (2 of Minnesota: 3/12 (25%) of SCD with history of syncope (2 of 3 with syncope with exercise)3 with syncope with exercise)–– 11--22 year olds22 year olds

Israel (Soldiers): 15/83 (18%) with history of syncopeIsrael (Soldiers): 15/83 (18%) with history of syncopeIsrael (Soldiers): 15/83 (18%) with history of syncopeIsrael (Soldiers): 15/83 (18%) with history of syncope–– 1717--39 year olds39 year olds

WistenWisten et al. et al. ScandScand CardiovascCardiovasc J 2005; 39: 143J 2005; 39: 143--149149Driscoll et al. J Am Driscoll et al. J Am CollColl CardiolCardiol 1985 5:118B1985 5:118B--121B.121B.Kramer et al. Chest1988;93:345/7. Kramer et al. Chest1988;93:345/7.


Adherence to GuidelinesAdherence to Guidelines1997: 40% of states had no formal screening or inadequate (less than 4 of the 12 elements)

2005: 81% were deemed adequate (≥ 9 of the 12) 2% inadequate2005: 81% were deemed adequate (≥ 9 of the 12), 2% inadequate– California: 10 of the 12.

Increase in number of states allowing non-physicians (nurse practitioners, physician assistants and chiropractors and naturopathic clinicians) perform medical clearance of high school athletes

Recommended that H & P only be performed by physicians or healthcare workers with training, medical skills and background to reliably recognize or raise reasonable suspicion of heart disease

Glover DW et al. Glover DW et al. CardiolCardiol 2007;100:17092007;100:1709--1712.1712.

Screening ECG???Screening ECG???


Screening ECG in ItalyScreening ECG in ItalyItaly (Italy (VanetoVaneto region region –– high incidence of ARVC)high incidence of ARVC)19791979--2004 2004 ––implementation of a national screening programimplementation of a national screening programSCD in athletes fell from 3 6 per 100 000 toSCD in athletes fell from 3 6 per 100 000 to 0 4 per 100 0000 4 per 100 000SCD in athletes fell from 3.6 per 100,000 to SCD in athletes fell from 3.6 per 100,000 to 0.4 per 100,0000.4 per 100,000

89% reduction 89% reduction in mortalityin mortality

CorradoCorrado et al. JAMA. 2006;296:1593et al. JAMA. 2006;296:1593--16011601

Minnesota dataMinnesota data12 years experience 12 years experience -- inclusive of all sports inclusive of all sports participation in high schoolsparticipation in high schoolsparticipation in high schoolsparticipation in high schools

3 sudden deaths in 651,695 athletes3 sudden deaths in 651,695 athletes

Annual SCD rate: Annual SCD rate: 0.46 per 100,0000.46 per 100,000pp(compared to 0.4 per 100,000 in Italy after screening)(compared to 0.4 per 100,000 in Italy after screening)

MaronMaron et al. JACC 1998; 32: 1881et al. JACC 1998; 32: 1881--1884.1884.


Screening of athletes with and without ECGScreening of athletes with and without ECG510 college athletes (Harvard)510 college athletes (Harvard)H&P, ECG and echo on allH&P, ECG and echo on allDiscovered CV abnormalities in 11 of 510 (2.2%)Discovered CV abnormalities in 11 of 510 (2.2%)–– Bicuspid aortic valve in 2Bicuspid aortic valve in 2–– mitral valve prolapse in 3mitral valve prolapse in 3–– Pulmonary Pulmonary stenosisstenosis in 1in 1–– LV hypertrophy in 2LV hypertrophy in 2–– LV dilation in 2LV dilation in 2–– RV dilation in 1RV dilation in 1

H&P detected 5 (sensitivity 45.5%, specificity 94.4%)H&P detected 5 (sensitivity 45.5%, specificity 94.4%)ECG detected 5 additional (improving sensitivity to 90.9%, ECG detected 5 additional (improving sensitivity to 90.9%, but specificity to 82.7%but specificity to 82.7%False positive rate of 16.9% with ECG (vs. 5.5% False positive rate of 16.9% with ECG (vs. 5.5% -- H&P only)H&P only)

BaggishBaggish et al. Ann Intern Med 2010; 152: 269et al. Ann Intern Med 2010; 152: 269--275.275.

Is ECG screening a good idea?Is ECG screening a good idea?PROS of screeningPROS of screening–– Extremely tragic events Extremely tragic events -- may be able to prevent somemay be able to prevent some–– ECG Screening helped in Italy???ECG Screening helped in Italy???–– ECG can help identify HCM, LQT, ARVCECG can help identify HCM, LQT, ARVC–– Athletes at higher risk, so reasonable group to screen?Athletes at higher risk, so reasonable group to screen?–– Safe testSafe test–– Inexpensive test?Inexpensive test?


Is ECG screening a good idea?Is ECG screening a good idea?

CONS of screeningCONS of screening–– High false positive rateHigh false positive rateHigh false positive rateHigh false positive rate–– Still have false negativesStill have false negatives

»» Coronary artery abnormalities, some HCM, some LQT (1/3 Coronary artery abnormalities, some HCM, some LQT (1/3 with normal QTc), CPVTwith normal QTc), CPVT

–– Extremely low incidence of SCD in athletesExtremely low incidence of SCD in athletes–– Cost effectiveness?Cost effectiveness?–– Infrastructure / Who will do the testsInfrastructure / Who will do the tests–– Medical Legal issues Medical Legal issues –– Is it fair to only test athletes?Is it fair to only test athletes?

False Positive ECG’s in AthletesFalse Positive ECG’s in Athletes1005 athletes (785 clearance, 220 suspected problem)1005 athletes (785 clearance, 220 suspected problem)

–– 145 (14%) had distinctly abnormal ECGs145 (14%) had distinctly abnormal ECGs»» Male sex (n=125)Male sex (n=125)»» Younger age (<20)Younger age (<20)

E d t ( i liE d t ( i li t kii lt kii l di t i )di t i )»» Endurance sports (rowing, cycling, crossEndurance sports (rowing, cycling, cross--country skiing, longcountry skiing, long--distance running)distance running)

–– 247 (26%) mildly abnormal ECG 247 (26%) mildly abnormal ECG –– 603 (60%) normal or minor alteration603 (60%) normal or minor alteration

PellicciaPelliccia et al. et al. CirculationCirculation 2000;102;2782000;102;278--284284


ECG’s in athletesECG’s in athletes–– Of 145 with distinctly abnormal ECGs, 10% with CV diseaseOf 145 with distinctly abnormal ECGs, 10% with CV disease–– Of 247 with mildly abnormal ECG, 5% with CV diseaseOf 247 with mildly abnormal ECG, 5% with CV disease–– Of 603 with normal ECG or minor alteration, 4 % with CV diseaseOf 603 with normal ECG or minor alteration, 4 % with CV disease

–– 53 with CV Disease: 53 with CV Disease: »» MVP with mild regurgitation in 19MVP with mild regurgitation in 19»» Bicuspid aortic valve with regurgitation in 10Bicuspid aortic valve with regurgitation in 10»» ASD or VSD in 6ASD or VSD in 6»» Dilated cardiomyopathy in 4Dilated cardiomyopathy in 4»» WPW in 3WPW in 3»» Systemic Hypertension in 3Systemic Hypertension in 3»» Mild pulmonary artery Mild pulmonary artery stenosisstenosis in 2in 2»» MyocarditiisMyocarditiis in 2in 2»» HCM, HCM, prostethicprostethic aortic valve, aortic valve, pericarditispericarditis, coronary artery disease , coronary artery disease -- each in 1each in 1

27 had abnormal ECG 26 had normal ECG27 had abnormal ECG 26 had normal ECG–– 27 had abnormal ECG, 26 had normal ECG.27 had abnormal ECG, 26 had normal ECG.

–– ECG in athletes for identifying CV disease:ECG in athletes for identifying CV disease:»» Sensitivity 51%Sensitivity 51%»» Specificity 61%Specificity 61%»» Positive predictive value 7%Positive predictive value 7%»» Negative predictive value 96%Negative predictive value 96%

PellicciaPelliccia et al. et al. CirculationCirculation 2000;102;2782000;102;278--284284

False Positives and False Positives and DisqualificationDisqualification

10% who have ECG’s will require further testing (including echo)10% who have ECG’s will require further testing (including echo)2% will be disqualified based on enough suspicion of CV disease2% will be disqualified based on enough suspicion of CV disease–– Large number (~200,000) will be disqualified from sports (to possibly avoid Large number (~200,000) will be disqualified from sports (to possibly avoid

50 50 -- 200 deaths per year).200 deaths per year).»» Loss of identityLoss of identity»» Loss of role models for many individualsLoss of role models for many individuals»» Loss of possible future college educationLoss of possible future college education»» Loss of motivation to stay in schoolLoss of motivation to stay in school»» Loss of Health and Life???Loss of Health and Life???


Why sports are goodWhy sports are goodCardiovascular healthCardiovascular health

–– Improvement in aerobic power and maximum oxygen uptakeImprovement in aerobic power and maximum oxygen uptake–– Blood lipid levelsBlood lipid levelspp–– Glucose toleranceGlucose tolerance–– Reduces obesityReduces obesity

Prolongs life:Prolongs life:–– Framingham cohort (4121 patients) Framingham cohort (4121 patients) –– Exercise at age 50Exercise at age 50–– Adjusted for age, sex, smoking, any Adjusted for age, sex, smoking, any comorbiditycomorbidity (cancer, LVH, arthritis, diabetes, (cancer, LVH, arthritis, diabetes,

ankle edema or pulmonary disease)ankle edema or pulmonary disease)M d t A ti it (30 i t f lki 5 ti d )M d t A ti it (30 i t f lki 5 ti d ) 1 3 t 1 5 l1 3 t 1 5 l–– Moderate Activity (30 minutes of walking 5 times per day) Moderate Activity (30 minutes of walking 5 times per day) –– 1.3 to 1.5 years longer 1.3 to 1.5 years longer lifelife

–– High physical activity (30 minutes of running 5 times per week) High physical activity (30 minutes of running 5 times per week) –– 3.5 to 3.7 years 3.5 to 3.7 years longer lifelonger life

Fletcher et a., Statement of Exercise: Benefits and recommendations for Physical Fletcher et a., Statement of Exercise: Benefits and recommendations for Physical Activity Programs for all Americans (A statement for Health professionals by the Activity Programs for all Americans (A statement for Health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council of Clinical Cardiology, Committee on Exercise and Cardiac Rehabilitation of the Council of Clinical Cardiology, AHA. Circulation. 1996 Aug 15;94(4):857AHA. Circulation. 1996 Aug 15;94(4):857--62.62.

Franco et al. Arch Intern Med 2005;165:2355Franco et al. Arch Intern Med 2005;165:2355--2360.2360.

False Positives and False Positives and DisqualificationDisqualification

10% who have ECG’s will require further testing (including echo)10% who have ECG’s will require further testing (including echo)2% will be disqualified based on enough suspicion of CV disease2% will be disqualified based on enough suspicion of CV diseaseq g pq g p–– Large number (~200,000) will be disqualified from sports (to avoid 50 events per Large number (~200,000) will be disqualified from sports (to avoid 50 events per

year).year).»» Loss of identityLoss of identity»» Loss of role models for many individualsLoss of role models for many individuals»» Loss of possible future college educationLoss of possible future college education»» Loss of motivation to stay in schoolLoss of motivation to stay in school»» Loss of Health and Life???Loss of Health and Life???

Assume exercise can add 1 year of lifeAssume exercise can add 1 year of life200,000 years lost (divide by 10200,000 years lost (divide by 10--year range of athletes) = 20,000 years to save …year range of athletes) = 20,000 years to save …50 50 –– 200 lives per year x 70 years lost per person = 3,500 200 lives per year x 70 years lost per person = 3,500 –– 14,000 years14,000 years





–– Extremely low incidence of SCD in athletesExtremely low incidence of SCD in athletes–– Cost effectiveness?Cost effectiveness?–– Lack of InfrastructureLack of Infrastructure–– Medical Legal issues Medical Legal issues –– Is it fair to only test athletes?Is it fair to only test athletes?










Cost EffectivenessCost EffectivenessAHA 2007 Statement: $ 2 billion dollars per year AHA 2007 Statement: $ 2 billion dollars per year –– cost of preventing cost of preventing

each death is $3.4 million per life savedeach death is $3.4 million per life saved

Italian data: $1.3 million per life savedItalian data: $1.3 million per life saved

Wheeler et al: Adding ECG to preWheeler et al: Adding ECG to pre--participation screening participation screening $42,900 per life year saved (95% CI, $21,200$42,900 per life year saved (95% CI, $21,200––71,300) when 71,300) when

compared with H & P alonecompared with H & P alone

F ll t l $ 44 000 lif dF ll t l $ 44 000 lif d Addi ECG t H&PAddi ECG t H&P

ViskinViskin et al. Heart Rhythm 2007; 7: 525et al. Heart Rhythm 2007; 7: 525--528.528.MaronMaron et al. Circulation 2007;115: 1643et al. Circulation 2007;115: 1643--1655.1655.Wheeler et al. Ann Intern Med. 2010; 152: 276Wheeler et al. Ann Intern Med. 2010; 152: 276––286286Fuller et al. Fuller et al. Med Med SciSci Sports Sports ExercExerc. 2000; 32: 1809. 2000; 32: 1809--1811. 1811.

Fuller et al: $ 44,000 per life year saved Fuller et al: $ 44,000 per life year saved –– Adding ECG to H&PAdding ECG to H&P






InfrastructureInfrastructure

Who will do the ECG?Who will do the ECG?Who will interpret the ECG?Who will interpret the ECG?Who will pay for the ECG?Who will pay for the ECG?Who will pay for followWho will pay for follow--up (cardiologist visit, up (cardiologist visit, echo, echo, cathcath, MRI, genetic testing, etc.)?, MRI, genetic testing, etc.)?









–– Extremely low incidence of SCD in athletesExtremely low incidence of SCD in athletes–– Cost effectiveness?Cost effectiveness?–– Lack of InfrastructureLack of Infrastructure–– Medical Legal issues Medical Legal issues –– IS IT FAIR TO ONLY TEST ATHLETES???IS IT FAIR TO ONLY TEST ATHLETES???


ConclusionsConclusions

H&P currently recommended for preH&P currently recommended for pre--participation screeningparticipation screeningparticipation screeningparticipation screening

Attention to history of syncopeAttention to history of syncope

D t / i f t t / d t tD t / i f t t / d t tData / infrastructure / resources do not support Data / infrastructure / resources do not support widespread ECG screening of athletes in the US widespread ECG screening of athletes in the US at this time.at this time.

Thank You!Thank You!


10 Principles of a good screening test10 Principles of a good screening testWorld Health OrganizationWorld Health Organization

The condition should be an important health problem.The condition should be an important health problem.There should be an accepted treatment for patients with the disease.There should be an accepted treatment for patients with the disease.Facilities for diagnosis and treatment should be available.Facilities for diagnosis and treatment should be available.There should be a recognizable latent or early stage of the disease.There should be a recognizable latent or early stage of the disease.There should be a suitable test or examination for the condition.There should be a suitable test or examination for the condition.The test should be acceptable to the population.The test should be acceptable to the population.The natural history of the disease should be adequately understood.The natural history of the disease should be adequately understood.There should be an agreed policy on who to treat.There should be an agreed policy on who to treat.The total cost of finding a case (including diagnosis and treatment of patients diagnosed) The total cost of finding a case (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to medical expenditure as a whole.should be economically balanced in relation to medical expenditure as a whole.CaseCase--finding should be a continuous process, not just a "once and for all" project.finding should be a continuous process, not just a "once and for all" project.

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