1. 1. Cardiac Screening in High School Athletes SportsMedicinePodcast.com
2. 2. DISCLOSURES No relevant financial relationships Meets California AB1195 requirements for Cultural And Linguistic Compentency
3. 3. Agenda Why talk about cardiac screening in high school athletes? How common is sudden cardiac death? What can (and should) we change ? How effective is our current cardiac screening? How do we screen currently?
4. 4. Why talk about cardiac screening?
5. 5. Why talk about cardiac screening?
6. 6. Why talk about cardiac screening?
7. 7. 39 | 2011 Kaiser Foundation Health Plan, Inc. For internal use only.June 12, 2013 Why talk about cardiac screening?
8. 8. Why talk about cardiac screening?
9. 9. How common is SCD?
10. 10. How common is SCD? Organized High School/College Athletes Males - 1:133,333 per year or 7.5 per million Females -1:769,230 per year or 1.3 deaths per million
11. 11. How common is SCD? Military Boot Camp 13 deaths per 100,000 recruit-year thats about 120 deaths over 25 years
12. 12. How common is SCD? Marathon Runners 1:50,000 Race Finishers (Mean Age 37yo) Marion 1986 1:184,000 cardiac event/ runners (Baggish 2012) Triathlons 1:75,000 deaths/ triathletes
13. 13. How common is SCD? Total Deaths per year from SCD in athletes? about 300
14. 14. How common is SCD? Ryan Shay Hank Gathers Fabrice Muamba
15. 15. How common is SCD? Rich Peverley Dallas Stars
16. 16. Causes of SCD?
17. 17. Causes of SCD? HCM 36% Coronary Anomalies 17% Increased Cardiac Mass (possible HCM) 10% Ruptured Aorta/Dissect 5% Tunneled LAD 5% Aortic Stenosis 5% Myocarditis 3% Dilated CM 3% Idiopathic Myocdardial scarring 3% Arrhythmogenic RV dysplasia 3%
18. 18. Current Recommendations
19. 19. 2007 - AHA and Six Sports Medicine Organizations Current Recommendations - U.S. 12 Point Cardiac Screening added to PPE Personal Medical History Family History Physical Exam
20. 20. 2007 - AHA and Six Sports Medicine Organizations Current Recommendations - U.S. Personal Medical History - Exertional chest pain or discomfort - Unexplained syncope/near-syncope - Excessive exertional fatigue/dyspnea - Prior diagnosis of heart murmur - Elevated blood pressure
21. 21. 2007 - AHA and Six Sports Medicine Organizations Current Recommendations - U.S. Family History - Premature sudden death (< age 50) - Disability from heart disease (< age 50) - History of HCM, LQTS, Marfan Syndrome
22. 22. 2007 - AHA and Six Sports Medicine Organizations Current Recommendations - U.S. Physical Exam - Heart murmur - Femoral pulses (aortic coartation) - Marfan-like appearance - Brachial artery blood pressure
23. 23. Effectiveness
24. 24. Overall AHA Compliance Score 0-4 5-8 9-11 12 PEDIATRICS 0.8% 11.2% 83.0% 5.3% FAMILY MEDICINE 0.5% 13.3% 80% 5% TOTAL 0.7% 12.2% 81.4% 5.7% Source: Madsen NL, et al, Br J Sports Med 2013; 47:172-177
25. 25. 41 AHA vs EKG Positive Results Needed W/U H&P EKG Total Wilson - UK 2720 athletes 2.5% 1.5% 4% Bessem Netherlands 428 athletes 8% 8% 13% Hevia Spain 1220 athletes 1.2% 6.1% 7.4% Baggish US 510 athletes 6% 16% 20% Total 4878 athletes 4.4% 7.9% 11.1% Source: Asif IM, Drezner JA, Prg in Cardio Disease, 54 (2012) 445-450
26. 26. Why not an EKG on every athlete?
27. 27. To EKG or Not? Europe requires a resting EKG Italy (Venuto) 1982 - SCD 4.2/ 100,000 athletes 2004 - SCD 0.9/ 100,000 athletes Most common cause in Italy? Arrhythmogenic RV dysplasia.
28. 28. Whats a normal EKG? EKG Findings in Athletes considered WNL Sinus Bradycardia as low as 30-40 bpm Various A/V blocks occur in up to 33% of athletes First Degree (PR>0.2) Most Common Second Degree (Mobitz-1 or Wenkeback) Increased R or S wave voltage without Left axis deviation, QRS prolongation, or LAE Incomplete RBBB U-waves with up-sloping ST segments and normal T waves
29. 29. Causes of SCD Hypertrophic Cardiomyopathy********************** Sporatic or inherited (autosomal-dominant) Can predispose to malignant ventricular arrhythmias leading to syncope or sudden death S/S: Dyspnea (initially exertional in onset), Angina, Exertional syncope, exertional presyncope, fatigue, palpitations Exam: Systolic murmur that increases with valsalva Testing: CXR: cardiomegaly EKG: LVH Echo: confirmation of HCM Tx: B-Blockers ICD Septal artery ethanol ablation
30. 30. Causes of SCD Coronary Artery Anomalies In one review of 78 cases of CAA who died of sudden death, 62% of those were asymptomatic S/S: Only ~ 1/3 of pts have any symptoms of exertional syncope (