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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

leeb@medicine.ucsf.edu

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

3

• 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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8

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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15

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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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22

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46

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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?