Is Early Repolarization in the Aviator truly...

Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2095, 3 May 2013 1

Robert Sarlay, Jr., MD, MPH, FACEP

Lt Col, USAF, MC, FS

USAF School of Aerospace Medicine

WPAFB, OH

RAM 2013

Early Repolarization in the Early Repolarization in the Aviator Aviator


Disclosure InformationDisclosure Information8484thth Annual Scientific Meeting Annual Scientific Meeting

Dr. Robert Sarlay, Jr.Dr. Robert Sarlay, Jr.

I have no financial relationships to disclose.

I will not discuss off-label use and/or investigational use in my presentation


• Principal Investigator• Lt Col Robert Sarlay, Jr.

• Preceptor• Maj Eddie Davenport

• Secondary Investigators• Mr. Jared Haynes• Ms. Rosa Alvarado

Preceptor/InvestigatorsPreceptor/Investigators


• Early repolarization pattern (ERP) more common:• Young• Athletes

• ERP tends to resolve over time• Prior research often based on single ECG

prevalence studies• ERP is considered benign• Recent literature contradicts this consensus

• Pro-arrhythmic trait?• Increased incidence sudden cardiac death

Background / Literature Background / Literature ReviewReview


• Prevalence General Population• 1-5% prevalence depending on the study• Eastaugh (1989) – Review article first described 1936

young military recruits, 1-2% had ERP• Lanza et al. (2012) – Prospective study of 4176 subjects

presenting to hospital without heart disease found 84 (2.0%) had ERP

• Tikkanen et al. (2009) – 10,864 patients from general population, 630 had ERP (5.8%)

• Noseworthy et al. (2011) – ERP 243 of 3,955 (6.1%) Framingham Heart Study and 180 of 5,489 (3.3%) Health 2000 Survey



• Prevalence in Athletes• Tanguturi et al. (2012) – ERP in athletes range from 20 to 90%• Noseworthy et al. (2011) – Cross-sectional cohort of 879

college athletes, 25.1% had ERP; exercise training led to increases in prevalence

• Prevalence in Aircrew• Boos et al. (2012) – Reported 11.8% of 868 healthy aircrew had

ERP [average age 39.6, 95.4% male]

• Natural History• Adhikarla (2011) – 29,281 patients found 479 with ERP,

analyzed 244 found that 10 years later 68% no longer had ERP on ECG, at time largest serial comparison

• Other studies have reported decreasing prevalence with age



• USAF ECG Library• All cardiac data• 281,737 aviators• 1950-2011 inclusive (60+ years)• Age 17 to 65• 1.2 million ECG studies

• Inclusion Criteria for ERP• >0.1 mv J-point elevation in >2 inferior or

lateral leads (II, III, AVF; I, AVL, V4-6)

MethodsMethods


• Queried database for all ERP ECGs• Queried any ERP subject for any normal

ECG• Divided results into categories

• Group 1 – Always had ERP• Group 2 – ERP then normal • Group 3 – Normal then ERP• Group 4 – Variable

MethodsMethods


• SAS software used• Descriptive statistics • Bonferroni test used to compare:

• Group 2 – ERP to normal• Group 3 – Normal to ERP

MethodsMethods


• 85,642 ECGs either normal or ERP pattern• Total 41,327 ECGs with ERP pattern• Unique 27,797 with ERP pattern • Groups:

1) Always ERP = 1570 / 952 complete

2) ERP Normal = 12,432 / 5,636 complete

3) Normal ERP = 15,562 / 6,697 complete

4) Variable = 56,078 / 14,516 complete

ResultsResults


ResultsResults


• Prevalence• 9.9% aviators had ERP

• Natural History• 20.3% lost ERP over time• 27.5% retained ERP over time• 52.2% variable

ResultsResults


Mean Standard Deviation

Skewness Range Min/Max

Age (yr) 28.34 7.7 0.71 42 17 / 59

Height (in) 70.73 2.6 -0.02 19 60 / 79

Weight (lb) 169.9 20.2 0.31 149 106 / 255

Systolic 116.4 10.3 0.05 80 80 / 160

Diastolic 73.3 8.5 -0.04 56 40 / 96

ResultsResultsGroup 1 – Always ERPGroup 1 – Always ERP




Age (yr) 34.2 6.7 -0.03 46 17 / 63

Height (in) 70.7 2.6 -0.15 20 58 / 78

Weight (lb) 178 22.6 0.46 209 86 / 295

Systolic 118.8 11.4 0.50 92 88 / 180

Diastolic 74.9 8.7 0.07 110 40 / 150

Time Between

6.9 5.3 0.78 28.4 0 / 28.4

ResultsResultsGroup 2 – ERP then Normal Group 2 – ERP then Normal




Age (yr) 37 7.6 -0.35 46 19 / 65

Height (in) 70.5 2.6 -0.53 37 43 / 80

Weight (lb) 174.6 20.5 0.26 165 99 / 264

Systolic 116.9 10.7 0.43 98 82 / 180

Diastolic 74.7 8.2 -0.06 61 49 / 110

Time Between

10.0 6.9 0.63 87.9 0 / 87.9

ResultsResultsGroup 3 – Normal then ERPGroup 3 – Normal then ERP


• Statistical difference between groups• Age• Weight• Systolic BP• Time to change

• No statistical difference between groups• Height• Diastolic BP

ResultsResultsCompare Group 2 to 3Compare Group 2 to 3


• USAF aviators have higher prevalence of ERP than general population

• ? Healthy heart as with athletes

• Prevalence similar to prior aviation studies 9.9% vs. 11.8%

• Retention of ERP similar to prior studies 27.5% vs. 32%

DiscussionDiscussion


• Not all ECGs reviewed• Only 51 females identified• Sampling bias because of required ECGs

for initial flying physical and at age 35

LimitationsLimitations


• Analysis of large database with serial ECGs over time was consistent with prior research in regard to the natural history and prevalence of ERP

ConclusionConclusion


• Correlate ERP with outcome data to determine if aviators are at increased risk of cardiovascular events or increased mortality

• Further analyze the variable group with regard to consistency of diagnosis

• Prospectively follow ERP diagnosis over time

Future ResearchFuture Research


• Adhikarla C, Boga M, Wood AD, et al. Natural history of the electrocardiographic pattern of early repolarization in ambulatory patients. Am J Cardiol 2011;108:1831-5.

• Boineau J P. The early repolarization variant --normal or marker of heart disease in certain subjects. J Electrocardiol 2007;40:3.e11-6.

• Boos CJ, Jamil Y, Park M, et al. Electrocardiographic abnormalities in medically screened military aircrew. Aviat Space Environ Med 2012;83:1055-9.

• Eastaugh JA. The early repolarization syndrome. J Emerg Med 1989;7:257-62.• Haïssaguerre M, Derval N, Sacher F, et al. Sudden cardiac arrest associated with early

repolarization. N Engl J Med 2008;358:2016-23.• Haruta D, Matsuo K, Tsuneto A, et al. Incidence and prognostic value of early repolarization

pattern in the 12-lead electrocardiogram. Circulation 2011;123:2931-7.• Junttila MJ, Sager S, Tikkanen J, et al. Clinical significance of variants of J-points and J-waves:

early repolarization patterns and risk. Eur Heart J 2012;33:2639-44.• Lanza GA, Mollo R, Cosenza A, et al. Prevalence and clinical correlates of early repolarization

and J wave in a large cohort of subjects without overt heart disease. J Electrocardiol 2012;45:404-10.

BibliographyBibliography


• Noseworthy PA, Tikkanen JT, Porthan K, et al. The early repolarization pattern in the general population: clinical correlates and heritability. J Am Coll Cardiol 2011;57:2284-9.

• Noseworthy PA, Weiner R, Kim J, et al. Early repolarization pattern in competitive athletes: clinical correlates and the effects of exercise training. Circ Arrhythm Electrophysiol 2011;4:432-40.

• Nunn LM, Bhar-Amato J, Lowe MD, et al. Prevalence of J-point elevation in sudden arrhythmic death syndrome families. J Am Coll Cardiol 2011;58:286-90.

• Rollin A, Maury P, Bongard V, et al. Prevalence, prognosis, and identification of the malignant form of early repolarization pattern in a population-based study. Am J Cardiol 2012;110:1302-8.

• Stern S. Clinical aspects of the early repolarization syndrome: a 2011 update. Ann Noninvasive Electrocardiol 2011;16:192-5.

• Tanguturi, VK, Noseworthy PA, Newton-Cheh C, et al. The electrocardiographic early repolarization pattern in athletes: normal variant or sudden death risk factor? Sports Med 2012;42:359-66.

• Tikkanen JT, Anttonen O, Junttila MJ, et al. Long-term outcome associated with early repolarization on electrocardiography. N Engl J Med 2009;361:2529-37.

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Is Early Repolarization in the Aviator truly...

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