Screening Athletes to Screening Athletes to Prevent Sudden Cardiac Prevent Sudden Cardiac

DeathDeath

Christopher Davis, MD, PhDChristopher Davis, MD, PhDPediatric Grand Rounds Pediatric Grand Rounds

August 20, 2010August 20, 2010Rady Children’s Hospital San DiegoRady Children’s Hospital San Diego

UCSDUCSD

DisclosuresDisclosures

None None

Sudden Cardiac DeathSudden Cardiac Death

How many athletes die suddenly each How many athletes die suddenly each year from cardiovascular causes?year from cardiovascular causes?

What conditions do they have?What conditions do they have? How can they be screened to prevent as How can they be screened to prevent as

many deaths as possible in a reasonably many deaths as possible in a reasonably efficient manner? efficient manner?

Miklos FeherMiklos Feher

SCD in AthletesSCD in Athletes

SCD in Young AthletesSCD in Young Athletes

SCD defined: death within 1-2 hours of SCD defined: death within 1-2 hours of the onset of symptoms/sudden arrest the onset of symptoms/sudden arrest directly attributable to the cardiovascular directly attributable to the cardiovascular systemsystem

Copyright ©2007 American Heart Association

Myerburg, R. J. et al. Circulation 2007;116:2616-2626

Age-related and disease-specific risk for SCD

Sudden Cardiac Death in young people is Sudden Cardiac Death in young people is a a RARERARE event event

Copyright ©2009 American Heart Association

Maron, B. J. et al. Circulation 2009;119:1085-1092

Number of cardiovascular (CV), trauma-related, and other sudden death events in 1866 young competitive athletes, tabulated by year

Copyright ©2009 American Heart Association

Maron, B. J. et al. Circulation 2009;119:1085-1092

Flow diagram summarizing causes of death in 1866 young competitive athletes

Causes of SCDCauses of SCD

HCM

ARVC

Marfan Syndrome

Anomalous origin of the coronary Anomalous origin of the coronary arteriesarteries

Copyright ©2009 American Heart Association

Maron, B. J. et al. Circulation 2009;119:1085-1092

Cardiovascular deaths according to race, with respect to the number of white and nonwhite athletes with each disease

SCD may be the first manifestation of SCD may be the first manifestation of many of these diseasesmany of these diseases

Thus, routine screening must be carried Thus, routine screening must be carried out in an attempt to diagnose themout in an attempt to diagnose them

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

Does this work?Does this work?

One analysis of 134 young athletes who One analysis of 134 young athletes who died suddenly, only 3% of examined died suddenly, only 3% of examined athletes had abnormalities on the standard athletes had abnormalities on the standard H&P H&P (Maron et al, JAMA, 1996)(Maron et al, JAMA, 1996)

H&Ps are either H&Ps are either being done being done improperly/incompletelyimproperly/incompletely, or they are , or they are insufficient for screening for these insufficient for screening for these diseases…diseases…

Should we add something to the Should we add something to the standard screening protocol?standard screening protocol?

12-lead ECG12-lead ECG EchocardiogramEchocardiogram Exercise TestingExercise Testing

Should we add something to the Should we add something to the standard screening protocol?standard screening protocol?

12-lead ECG12-lead ECG EchocardiogramEchocardiogram Exercise TestingExercise Testing

Other Expert PanelsOther Expert Panels

European Society of CardiologyEuropean Society of Cardiology H&P H&P + 12-lead ECG+ 12-lead ECG

International Olympic CommitteeInternational Olympic Committee H&P H&P + 12-lead ECG + 12-lead ECG

Professional Athletes: > 90% get ECGs; Professional Athletes: > 90% get ECGs; 17% get echocardiograms (more elite 17% get echocardiograms (more elite athletes = more screening)athletes = more screening)

Harris et al, Arch Int Med, 2006Harris et al, Arch Int Med, 2006

Italian LawItalian Law

A law, first passed in 1971 and amended A law, first passed in 1971 and amended in 1982, requires any athlete of organized in 1982, requires any athlete of organized competitive sports (age 12-35) to undergo competitive sports (age 12-35) to undergo medical screening medical screening including an ECGincluding an ECG and a and a 3-minute exercise step test.3-minute exercise step test.

Copyright restrictions may apply.

Corrado, D. et al. JAMA 2006;296:1593-1601.

Cardiovascular Conditions Causing Disqualification From Competitive Sports in 879 Athletes Over 2 Consecutive Screening Periods (1982-1992 and 1993-2004) at the Center for Sports

Medicine in Padua, Italy

Italian ExperienceItalian Experience

~42,000 athletes screened (1979-2004)~42,000 athletes screened (1979-2004) 9% required more testing due to an 9% required more testing due to an

abnormal ECGabnormal ECG 2% were ultimately disqualified from 2% were ultimately disqualified from

competitioncompetition 55 sudden deaths occurred (only 4 55 sudden deaths occurred (only 4

women) throughout the study periodwomen) throughout the study period

Copyright restrictions may apply.

Corrado, D. et al. JAMA 2006;296:1593-1601.

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 (1979-2004)

Important CaveatsImportant Caveats

Observational study onlyObservational study only Not controlled trial of ECG vs. no ECGNot controlled trial of ECG vs. no ECG

Italy has a specific system set up to Italy has a specific system set up to perform these screeningsperform these screenings

In the 2% that were disqualified, none In the 2% that were disqualified, none subsequently died (i.e. were they really at subsequently died (i.e. were they really at risk?; problem of screening asymptomatic risk?; problem of screening asymptomatic pts)pts)

High rate of death in the early eraHigh rate of death in the early era

Copyright restrictions may apply.

Corrado, D. et al. JAMA 2006;296:1593-1601.

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 (1979-2004)

U.S. data, (0.6 per 100,000 person-years)

Nevada High School ScreeningNevada High School Screening

5,615 HS athletes screened (1994-96)5,615 HS athletes screened (1994-96) H&P + 12-lead ECG H&P + 12-lead ECG echo if abnormal echo if abnormal

22 athletes had CV disease that 22 athletes had CV disease that disqualified them from sportsdisqualified them from sports

Detection Rate of Tests:Detection Rate of Tests: 0 by history0 by history 1/1000 by BP1/1000 by BP 1/6000 by physical exam1/6000 by physical exam 1/350 by ECG1/350 by ECG

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

510 athletes screened510 athletes screened 1. standard of care (H&P)1. standard of care (H&P) 2. athletes then had ECGs and 2. athletes then had ECGs and

echocardiogramsechocardiograms

The H&P’s were done by MDs blinded to the The H&P’s were done by MDs blinded to the ECG/Echo results and results were ECG/Echo results and results were determined for the efficacy of H&P vs. determined for the efficacy of H&P vs. addition of ECGaddition of ECG

Harvard AthletesHarvard Athletes

11 of 510 athletes had abnormal 11 of 510 athletes had abnormal echocardiograms (2.2%)echocardiograms (2.2%)

Study flow diagram.LV = left ventricular; LVH = left ventricular hypertrophy; RV = right ventricular.

Baggish A L et al. Ann Intern Med 2010;152:269-275

©2010 by American College of Physicians

Harvard AthletesHarvard Athletes

Standard H&P detected 5 of 11 patients Standard H&P detected 5 of 11 patients with underlying CV diseasewith underlying CV disease Sensitivity = 45%Sensitivity = 45% Specificity = 94%Specificity = 94%

Thus, as a screening test, H&Ps are Thus, as a screening test, H&Ps are significantly lacking in sensitivitysignificantly lacking in sensitivity

What about the addition of ECGs?What about the addition of ECGs?

Harvard StudyHarvard Study

Of the 11 athletes with CV disease, the Of the 11 athletes with CV disease, the addition of ECGs detected 10 addition of ECGs detected 10 Sensitivity = 91%Sensitivity = 91% Specificity = 83%Specificity = 83% False + rate = 17%False + rate = 17%

Many athletes required further testingMany athletes required further testing Financial costFinancial cost Emotional stressEmotional stress Inappropriate exclusion from sports?Inappropriate exclusion from sports?

Cost of screening all U.S. athletesCost of screening all U.S. athletes

Average cost per year of life saved = Average cost per year of life saved = $42,000$42,000 - $200,000. - $200,000.

AHA estimate = ~$2 billion per year to AHA estimate = ~$2 billion per year to screen adolescent athletes in the U.S. screen adolescent athletes in the U.S. (~10,000,000 H.S. and college athletes)(~10,000,000 H.S. and college athletes) Based on $50 per ECGBased on $50 per ECG

So,So, ECGs will detect diseases that H&Ps will notECGs 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?

One last problem…One last problem…

Athlete’s HeartAthlete’s Heart Different normal Different normal

valuesvalues Overlap of physiologic Overlap of physiologic

changes and changes and pathologic changespathologic changes

Causes of Death in U.S. Children Causes of Death in U.S. Children (ages 15-19)(ages 15-19)

1. Unintentional injury (MVC, drowning, 1. Unintentional injury (MVC, drowning, fire, etc): ~14,000 deaths per yearfire, etc): ~14,000 deaths per year

2. Homicide: ~1,900/year2. Homicide: ~1,900/year 3. Suicide: 1,500/year3. Suicide: 1,500/year 4. Cancer: 700/year4. Cancer: 700/year

Worldwide causes of deathWorldwide causes of death

Pro-ECGPro-ECG

ECGs detect diseases that H&Ps do notECGs detect diseases that H&Ps do not In the U.S., HCM is the leading cause of In the U.S., HCM is the leading cause of

SCD in athletes and likely will produce an SCD in athletes and likely will produce an abnormal ECG (~90%)abnormal ECG (~90%)

Identification of an athlete with a genetic Identification of an athlete with a genetic CV condition can lead to diagnoses of CV condition can lead to diagnoses of family membersfamily members

The cost-benefit ratio is comparable to The cost-benefit ratio is comparable to many other initiatives with similar benefitmany other initiatives with similar benefit

Anti-ECGAnti-ECG

There remains no good data from a controlled There remains no good data from a controlled trial proving ECGs are effectivetrial proving ECGs are effective

The cost of implementation is between $1 and The cost of implementation is between $1 and $2 billion per year. Resources are scarce.$2 billion per year. Resources are scarce.

The current U.S. system (H&P only) achieves a The current U.S. system (H&P only) achieves a death rate similar to Italydeath rate similar to Italy

There will be children excluded from sports There will be children excluded from sports whose ultimate risk of SCD is been low and the whose ultimate risk of SCD is been low and the exclusion was unnecessary exclusion was unnecessary

Back to Pro-ECGBack to Pro-ECG

“…“…support for preventive medicine and support for preventive medicine and research research into individual risk profiling in the U.S. is far into individual risk profiling in the U.S. is far below what a country of its wealth should be placing into below what a country of its wealth should be placing into such efforts. It is not for the scientific, clinical, and such efforts. It is not for the scientific, clinical, and organizational communities to prioritize health dollars but organizational communities to prioritize health dollars but rather to indicate what is needed and provide the rather to indicate what is needed and provide the supporting arguments. The decision to spend money on supporting arguments. The decision to spend money on preventing some finite number of potentially avoidable preventing some finite number of potentially avoidable deaths in adolescents and young adults is a priority deaths in adolescents and young adults is a priority determination that belongs in the hands of the public. determination that belongs in the hands of the public. Ask any parent.” – R. Myerburg & V. VetterAsk any parent.” – R. Myerburg & V. Vetter

VoteVote

□ □ Include ECGs in screening athletesInclude ECGs in screening athletes □ □ Do not include ECGsDo not include ECGs

ConclusionsConclusions

Screening athletes for SCD is neededScreening athletes for SCD is needed The appropriate method of screening The appropriate method of screening

remains debatableremains debatable The easiest solution would be a better The easiest solution would be a better

screening testscreening test

THANK YOU

The Japanese ExperienceThe Japanese Experience

Since 1973, national system for screening Since 1973, national system for screening cardiovascular diseasecardiovascular disease

All studentsAll students in 1 in 1stst, 7, 7thth, and 10, and 10thth grade get grade get questionnaires and ECGsquestionnaires and ECGs

Results of screening (n = 37,000)Results of screening (n = 37,000) 2.7% failed screening 2.7% failed screening further w/u further w/u 3 sudden deaths 3 sudden deaths

Copyright ©2007 American Heart Association

Myerburg, R. J. et al. Circulation 2007;116:2616-2626

ECG cost-effectiveness

© Williams & Wilkins 1997. 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):1131-1138, September 1997.

Figure 1 -Overall results of cardiac preparticipation screening in 5,615 high school athletes.