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Sudden Death in Athletes: What is the role of ECG Screening?
Byron K. Lee MD
Professor of Medicine
Director of EP Laboratory
Division of Cardiology
Cardiac Electrophysiology
Arrhythmias, Heart Failure, and
Structural Heart Disease
Honolulu, Hawaii
October 8, 2015
Disclosures
• Research
– Medtronic
– Zoll
– Boston Scientific
– Apama
• Consulting
– Cardionet
– Biotronik
– Janssen
• Honorarium
– St. Jude
– Biotronik
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2
Pheidippides Run: Marathon to Athens
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• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
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3
450,000
1 U.S. Census Bureau, Statistical Abstract of the United States: 2001. 2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001. 3 2002 Heart and Stroke Statistical Update, American Heart Association. 4 Circulation. 2001;104:2158-2163.
Magnitude of SCD in the US
Breast Cancer2
SCD 4
42,156
40,600
157,400
167,366
AIDS1
Lung Cancer2
Stroke3 SCD claims
more lives
each year
than these
other
diseases
combined
#1 Killer
in the U.S.
SCD Landscape
Huikuri et. al. NEJM 2001 (adapted from Myerburg)
SCD-HeFT
AVID
MADIT
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• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
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Causes of SCD (Age>35)
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Huikuri et al. NEJM 2001
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SCD due to CAD: Darryl Kile
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Causes of SCD (Age<35)
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Huikuri et al. NEJM 2001
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Maron NEJM 2003
Causes of SCD (age<35) • #1: Hypertrophic CM
– 1 in 500
– Scarred and disordered myocardium
– Confirmed HCM in 26.4% of SCDs
– Probable HCM in 7.5% additional cases of SCD
– Diagnosis
• PE
• ECG
• Echo
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Maron NEJM 2003
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ECG in Hypertrophic CM
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Hypertrophic CM: Hank Gathers
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Causes of SCD (age<35)
• #2: Commotio Cordis
– Blunt blow to the chest 15-30ms before T-wave peak (vulnerable phase of repolarization)
– Mean age 13 years old
• Compliant chest wall
– 19.9% of SCDs
– Structural normal heart
– Normal ECG
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Commotio Cordis
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Protection Against Commotio Cordis
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Causes of SCD (age<35)
• #3: Congenital Coronary Artery Anomalies
– Artery arises from wrong aortic sinus
– Classic presentation: CP or syncope with exercise
– 13.7% of SCDs
– Diagnosis:
• Stress test
• Echo
• MRI
• CT
• Cath
– Normal ECG
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Coronary-Artery Anomalies:Pete Maravich
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• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
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Pre-participation Screening in Italy
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Corrado et al. JAMA 2006
Seattle Criteria: Normal Findings
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12
Seattle Criteria: Abnormal Findings
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Seattle Criteria: Abnormal Findings
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Cleared to play sports?
Cleared to play sports?
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Torsade de Pointes
• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
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Corrado et al. JAMA 2006
AHA Recommendation
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Maron et al. Circulation 2007
If age >35, add ETT if RF for CAD
If age >65, add ETT
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AHA Cost Analysis for U.S.
• 10M middle school and high school athletes
• Initial Screen
– $25 for H&P
– $50 for ECG
• Follow-up Screen
– $100 for H&P
– $400 for Echo
• Administrative Cost: 500M
• Total Cost: $2B
• $330,000 for every relevant disease diagnosed
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Other Cost Effectiveness Analysis
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HRS 2011
Annals of Internal Medicine 2010
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AHA Recommendation
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Maron et al. Circulation 2007
If age >35, add ETT if RF for CAD
If age >65, add ETT
• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
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Athlete’s Heart
• Triggers
– Endurance sports (rowing, cross country skiing, swimming)
– Isometric sports (weightlifting, wrestling)
• Cardiac changes
– Heart size and chamber enlargement
– Increased LV wall thickness
– Increased LA
– Preservation of systolic and diastolic function
• Associated with abnormal ECG patterns
• Considered a benign adaptation to training
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Pelliccia A, et al. Circulation 2000;102:278-284
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• Referred for Abnormal ECG
• Sees you for evaluation
– No syncope
– No symptoms of cardiac disease
– No FH of SCD
– Appears to be extremely physically fit
– Rest of exam benign except for a soft systolic murmur
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17 year old Swimmer
Basavarajaiah et al. Br J of Sports Med 2006
17 year old Swimmer
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Basavarajaiah et al. Br J of Sports Med 2006
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• Echo
– Significant concentric LVH with maximal wall thickness of 14 mm (normal <12 mm)
– Normal LV cavity of 48 mm
– Normal systolic and diastolic function
– Normal valves
• MRI normal except for wall thickening
• ETT normal
• 24 hour holter normal
• Now what?
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17 year old Swimmer
Basavarajaiah et al. Br J of Sports Med 2006
After 8 week of Deconditioning
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Basavarajaiah et al. Br J of Sports Med 2006
LVH regressed from 14 mm to 11 mm
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• Background
• Cause of SCD in athletes
• ECG screening process
• Cost effectiveness
• Indeterminate findings
• Saving lives
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Conclusions
• Most SCDs occur in otherwise healthy individuals
• Main cause of SCD
– Over 35: CAD
– Under 35: HCM, Commotio Cordis, Coronary Anomalies
• Young athletes screening:
– H&P
– ECG?
• Master athletes (age >35) screening:
– H&P
– ETT (if RFs for CAD or age>65)
• Community based programs can find new disease and save lives
• ICDs save lives without limiting physical activity
SECTION HEADING
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ICDs Do Save Lives
Israel and Minnesota Data
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Steinvil et al. JACC 2011
Maron et al. Am J Cardiol 2009
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Detraining in 40 Elite Athletes
• Pelliccia A, et al. Circulation 2002;105:944-949
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Detraining in 40 Elite Athletes
Pelliccia A, et al. Circulation 2002;105:944-949
Cleared to play sports?
