Pre-Participation Physicals & ECG Interpretation:

New Advances in Sports Cardiology

Irfan M. Asif, MD Vice Chair, Academic Affairs & Research

Director, Sports Medicine Fellowship Associate Professor, Department of Family Medicine

Greenville Health System, University of South Carolina- Greenville SOM Clemson University School of Health Research

G H S C l i n i c a l U n i v e r s i t y P a r t n e r s

Hank Gathers

February 11, 1967 – March 4, 1990 26 Year Anniversary

Leading cause of death during exercise

Sudden Cardiac Death (SCD)

10 Year NCAA Study: Objective

1. Overall risk compared to death from any cause

2. Better define SCD in NCAA athletes

- Incidence

- Etiology

- Comparison of Reporting Mechanisms

3. Risk among subgroups

10 school years of forensically-based data

Methods & Study Design

• A database of deaths (2003 – 2013) was developed

– Internal NCAA database

– Parent Heart Watch

– NCAA Catastrophic Insurance Claims

• Additional information was acquired through internet searches,

media reports, emails and telephone calls to athletic trainers,

coroners and next of kin

• Autopsy reports were obtained and cause of death was

adjudicated by an expert panel using standard definitions

Accident50%

Suicide8%

Homicide8%

Cardiac15%

Cardiac/SCT0%

SCT2%

Headinjury1%

HeatStroke1%

Drug/EtohOverdose

3%

Cancer7%

Medical-other3%

Meningi s1%

Unknown1%

CausesofDeathinNCAAAthletes2003-2013

4,242,519 Athlete-Years

537 Deaths

79 Cardiac Deaths

Results

Group Incidence

Overall 1in53,703

Males 1in38,390

Females 1in121,593

African-American 1in20,147

Caucasian 1in59,153

High Risk: Males & African Americans

Sport Incidence

Men’sBasketball 1in8,978

Men’sSoccer 1in23,689

Football 1in35,951

Cross-Country 1in44,973

Baseball 1in50,023

Swimming 1in50,197

Volleyball 1in53,685

Lacrosse 1in54,401

Women’sBasketball 1in77,061

High Risk: Basketball

Volleyball4%

Soccer11%

Swimming5% Wrestling

2%

Crew1%

Golf1%Lacrosse

4%Football23%

Basketball27%

Crosscountry8%

Baseball8%

Track4%

So ball1%

Tennis1%

Sports

Sudden Cardiac Death by Sport

Football and Men’s Basketball account for 23% of NCAA

athletes, but ½ of SCD’s

Paradigm #1

The incidence of sudden cardiac death in

young athletes is remarkably higher than

previously recognized, especially in high

risk sub-groups

AHA Scientific Statement: 2007

Leading Causes of SCD

Maron et al, Circulation 2007; 115: 2358-2368

Circulation, 2009

SuddenUnexplainedDeath25%

Anomalouscoronary11%

Myocardi s9%CAD

9%

CardiomyopathyNOS8%

idiopathicLVH/possiblecardiomyopathy

8%

Aor cdissec on5%

HCM6%

ARVC5%

WPW3%

DCM3%

LongQT2%

Commo o2%

IdiopathicLVH/SCT2%

KawasakiDisease2%

Etiology

Sudden Unexplained

Death is the leading

finding associated with

SCD in NCAA athletes

Harmon, Asif, et al, Circ, 2015

Autopsy-Negative Sudden Unexplained Death

• Post-mortem examination fails to identify structural cause of death

• Inherited arrhythmia syndromes and ion-channel disorders

?

Average HCM = 10% Average SUD = 30%

Paradigm #2

Hypertrophic cardiomyopathy may not be

the leading cause of death in young

athletes…Autopsy negative sudden

unexplained death seems to be the most

common finding in this cohort during post-

mortem examination

Goal of Screening

“…the main purpose of the periodic health exam is to screen for injuries or medical conditions that may

place an athlete at risk for safe participation.”

Ljungqvist; BJSM 2009

IOC Identify potentially life-threatening or disabling conditions so that they can be treated or risk factors modified and screen for conditions that may pre-dispose to injury.

Identify potentially life-threatening or disabling conditions so that they can be treated or risk factors modified and screen for conditions that may pre-dispose to injury.

“The ultimate objective of pre-participation screening of athletes is the

detection of ‘silent’ cardiovascular abnormalities that can lead to SCD.”

ACC, 36th Bethesda Conference; 2005

“The ultimate objective of pre-participation screening of athletes is the

detection of ‘silent’ cardiovascular abnormalities that can lead to SCD.”

ACC, 36th Bethesda Conference; 2005

“The principal objective of screening is to reduce the cardiovascular risks associated with organized sports and

enhance the safety of athletic participation.”

Maron; Circulation 2007

AHA

Cardiovascular Screening: There is No Debate!

The question is not: “Should we screen?”

The question is: “How should we screen?”

What is the best screen?

History?

What is the best screen?

Physical Exam ?

What is the best screen?

ECG?

September 17, 2014

1996 / 2007 2014

Pre-participation Physical Evaluation (PPE) 4th Edition

http://ppesportsevaluation.org/

AAFP

AAP

ACSM

AMSSM

AOASM

AOSSM

History

PPE-4 AHA 2014

Collaboration between Sports Medicine and Cardiology • Personal History • Family History • Physical Examination

FREELY AVAILABLE

Maron et al. JAMA, 1996-Vol 276, No. 3

Traditional Protocol: Evidence?

The standard pre-participation screening

process appears to be limited in its power

to identify those cardiovascular lesions

ultimately responsible for death.

Maron, JAMA, 1996

The ECG Debate

Challenges: False Positive Rates

• Prior studies show FP

rates of 15-40%

• FP & TP rates are driven

by the criteria chosen to

define “abnormal”

Maron et al, JACC, 1987; 10: 1214-1221

Pelliccia et al, Circulation, 2000; 102:278-284

Frame of “Reference”

Reference

Everydayhealth.com SIkids.com

70 Year Old with Active Chest Pain 20 Year Old Asymptomatic Athlete

VS.

Challenge: False Positive Rates?

Normal Training related changes

Abnormal Training unrelated changes

Physiologic

Pathologic

• FP rates are improved with the use of athlete-specific ECG interpretation standards

• Emerging data of higher prevalence of ECG abnormalities in males, African Americans, basketball players, and endurance athletes

• Evidence to exclude axis deviation, atrial enlargement and RBBB as being abnormal criteria in isolation

The Effectiveness of Screening History, Physical Exam

and ECG to Detect Potentially Lethal Cardiac Disorders

in Athletes: A Systematic Review/Meta-Analysis

Harmon, J ECG, 2015

ECG History Physical

Sensitivity 94% 20% 9%

Specificity 93% 94% 97%

Positive

Likelihood Ratio* 14.8 3.22 2.93

Negative

Likelihood Ratio* 0.055 0.85 0.93

Sensitivity, Specificity, and Positive and Negative Likelihood Ratios (Meta-analysis

of pooled data)

Test False Positive Rate

Range

History 8% 1% - 31%

Physical 10% 0% - 15%

ECG 6% 1% - 19%

False Positive Rates from Pooled Data

Electrocardiographic Screening in NCAA Athletes: A 2-year Multicenter

Feasibility Trial

Results

• 35 institutions participated

– Year 1: 13 Div I programs

– Year 2: 12 Div I programs 13 Div II/III programs

• Total athletes screened: N = 5,258

– Year 1: 2,465

– Year 2: 2,793

5,258 athletes

55% male; 45% female

17 intercollegiate sports

73% Caucasian 16 % Afro-American

Mean Age: 20.1

PE 108 (2.1%)

ECG 192 (3.7%)

Hx 1,750 (33.3%)

SOB 13% Syncope 11% CP 7% Serious cardiac disorder: 13 (0.25%)

WPW (11) Large ASD with RV dilatation

requiring surgery (1) Hypertrophic Cardiomyopathy (1)

() screen

No unjustified disqualification from sport

False-Positives

33%

2.0% 3.4%

0%

5%

10%

15%

20%

25%

30%

35%

Hx PE ECG

False-Positive Rate

10 X

Males have significantly more ECG abnormalities compared to females (p<0.0001)

Afro-American 4.8% vs. Caucasian 3.4% (p=0.069)

2.5%

4.5%

Rate of Abnormal ECGs by Gender and Race

Male Female

Statistical Performance Measures

Sensitivity Specificity PPV

Hx 15.4% 73% 0.1%

PE 7.6% 98% 1.8%

ECG 100% 96.6% 6.8%

1000

55

15

Paradigm #3

The ECG out-performs the history and

physical examination as a screening test

for diseases associated with sudden

cardiac death

85%

78% 73% 73%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cardiologists SM Attendings PC Attendings PC Residents

ECG Interpretation Among Physician Groups

Before

p < 0.024 p < 0.0011 p < 0.0013

BJSM 2012

85%

78% 73% 73%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cardiologists SM Attendings PC Attendings PC Residents

ECG Interpretation Among Physician Groups

Before

85%78%

73% 73%

96%91% 90% 92%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cardiologists SM Attendings PC Attendings PC Residents

ECG Interpretation Among Physician Groups

Before

After

p < 0.001 p < 0.0001 p < 0.0001 p < 0.0001

Seattle Criteria

ECG demonstrates sinus bradycardia, early repolarization with ST elevation (arrows) and peaked T-waves, and voltage criteria for left ventricular hypertrophy. These are common findings related to regular training.

>35mm

Common ECG Findings in Athlete’s Heart

>35mm

This ECG demonstrates a markedly abnormal pattern with T-wave inversion and ST depression in the inferolateral leads. Additional

testing is required to evaluate for cardiomyopathy.

Hypertrophic Cardiomyopathy

Need Help?

Refined ECG Interpretation Criteria

Seattle ECG Summit February 26-27, 2015

Paradigm #4

Physician education is the major hurdle in

implementing ECG screening in athletes.

However, tremendous resources are

available

AEDs in Sport

• Provide a means of early defibrillation and the potential for effective secondary prevention of SCD

– Athletes

– Students

– Staff

– Spectators

– Coaches

– Officials

– Visitors

– AEDs in high risk locations

It’s NOT just about AEDs…

EMERGENCY

PREPAREDNESS

Written Emergency Action Plan for SCA

All staff awareness

Emergency communication

Trained responders in CPR/AED

Access to early defibrillation (<3-5 min collapse to shock)

Practice and review of the EAP at least annually

Integration of AED into local EMS system

Screening Is Not Perfect…

Emergency Response Planning, CPR Training, & AED Programs are critical

Paradigm #5

Screening is not perfect…An Emergency

Action Plan must be in place for all

sporting venues and event coverage

Paradigms

1. Sudden cardiac death appears to be more common than

previously recognized

2. HCM may not be the leading cause of death in young

athletes

3. As a screening tool, the ECG outperforms the history &

physical, especially with the appropriate criteria

4. Physician education of ECG interpretation seems to be

the most practical hurdle for broad scale implementation

5. Screening is not perfect…Have an EAP and an AED

available

Thank You

G H S C l i n i c a l U n i v e r s i t y P a r t n e r s