Screening athletes for cardiac disease

© Copyright 2010

Incidence of sudden cardiac death (SCD) in the young:

estimates vary

• Corrado et al: 1.0/105 (<35 yo, Italy)• Maron et al: 0.46/105 (high school, USA)• Van Camp et al 0.4/105 (HS/college, USA)

Wren: 0.4/105 (normal children & teens, meta-analysis)• Overall: probably about 1 death for every 250,000 young

athletes per year

Wren. Heart. 2009.

Marc-Vivien Foe

Anthony Bates

Jesse Marunde

Alexei Cherepanov

Famous athletes who have died of sudden

cardiac death

Gaines Adams

Hank Gathers Pete Maravich

Ryan Shay

What causes SCD?

Distribution of cardiovascular causes of sudden death in 1435 young competitive athletes

Maron BJ et al. Circ. 2007.

Is SCD preventable?

• The $2 billion question!

• Some conditions that predispose to SCD can be picked up on sports screening, others cannot

• Screening programs are expensive

• Experts advocate different approaches

Two approaches to screening

• Focused history and physical exam, further work-up only if risk-factors identified (U.S. approach)

• H&P, plus ECG, with further work-up if abnormalities on either (Italian approach)

The Italian experience

• Pioneers of ECG screening for athletes

• They provide annual ECGs for all athletes ages 12-35

• They report dramatic reduction in SCD

The Italian Experience, 1979-2004

• 42,386 athletes 12 to 35 years old• Controls: non-athletes, same ages• Results

– 55 athletes and 265 non-athletes died of SCD– After screening, athlete deaths fell 89 percent from

3.6 to .4 per 100,000 people per year– No change in SCD among non-athletes

SCD rate in athletes and non-athletes, Veneto, Italy, 1979-2004

Corrado D. JAMA. 2006.

What about the USA?

• Maron et al compared SCD death rates in Minnesota with those reported in Veneto

• They found that, without ECG screening, SCD rates in MN were comparable to those in Italy with ECG screening

Italy and Minnesota comparable in population and

ethnicity

Maron et al. Am J Card. 2009.

Trends in rates of SCD in MN and Veneto, 1979-2004

Since 1995, there has been no statistical difference in SCD

Maron et al. Am J Card. 2009.

Side by side comparison

Veneto Minnesota

• 1993-2004 death 12 11 ‘93-’04 death rate (per 100,000) .87 .93 • 2001-2004 deaths 2 4 2001-2004 death rate .38 .90 (not statistically significant)

Maron et al. Am J of Card. 2009.

• “…athlete sudden-death rates in these demographically similar regions of the U.S. and Italy have not differed significantly in recent years. These data do not support a lower mortality rate associated with preparticipation screening programs involving routine ECG and examinations by specially trained personnel.”

Conclusions of Maron et al

Maron et al. Am J Card. 2009.

Possible explanations of differences between US and

Italy

• Age: SCD death rates are higher in older athletes than in younger

• Sex: SCD rates are higher in males than in females

Age

• Italy screens all athletes 12 to 35 years of age

• MN screens mostly HS and college athletes

• If one considers the SCD rate in the general population of 20 to 40-yr-olds in Olmsted County, MN, it is similar to that in the pre-screening Italian population (4.5/100,000)

Corrado et al. Am J Card. 2010.

Age at death: Italy vs. Minnesota

Mean age at death:

Italy Minnesota23 +/- 2 yrs 17+/- 4 yrs

Corrado et al. Am J Card. 2010.

Sex

• Male athletes die at 5 -10X rate of female athletes

• In Italy, 82% of athletes are male• In MN, 65% of athletes are male

• This would contribute to higher death rates in Italy

Corrado et al. Am J Card. 2010.

American Heart Association (AHA) versus European Society of

Cardiology (ESC)

• AHA recommends focused, 12 item H&P

• European Society of Cardiology and International Olympic Committee recommend routine ECG

Baggish et al. Ann Int Med. 2010.

European Society of Cardiology proposed screening protocol for young competitive athletes

Corrado et al. Eur Heart J. 2005.

Studies comparing H&P with ECG

• Three studies– Wilson et al 2007 (UK)– Bessem et al 2009 (Holland)– Baggish et al 2010 (US)

How do H&P and ECG compare?

• 1074 athletes ages 10-27• 1646 schoolchildren age 14-20 (Total N = 2720)

– Personal and family history questionnaires– Physical exam by cardiologists– 12-lead ECG

• 9 diagnosed with a disease associated with SCD • 0/9 diagnosed with H&P alone

• 9/2720 (0.3% kept out of sports)

Wilson et al. Brit J Sports Med. 2007.

Wilson et al. Brit J Sports Med. 2007.

ECG identifies disease: H+P does not

H&P plus ECG

• 1/06 – 4/08• 428 cardiovascular screenings • Outcome measures:

– (false) positive screening result– Negative screening result– Further testing per Lausanne protocol– Number needed to screen

Bessem et al. Br J Sports Med. 2009.

Outcomes from a Dutch

screening program

Bessem et al. Br J Sports Med. 2009.

Bessem et al. Br J Sports Med. 2009.

Dutch screening

program (cont’d)

Bessem et al. Brit J Spts. Med. 2009.

Additional testing for athletes with positive ECG screen

ECG together with H&P: sensitive but not specific

• Prospective cross-sectional comparison• 510 college athletes• All had H&P, ECG and echocardiogram

Test # abnormal % false positive

Echo 11 N/A

H/PE 5 5.5

ECG 5 16.9

Baggish AL et al. Annals Int Med. 2010.

Flow chart for cardiac screening

Baggish et al. Ann Int. Med. 2010.

LV = left ventricular; LVH = left ventricular hypertrophy; RV = right ventricular.

Baggish et al. Ann Int Med. 2010.

Exclusion from sports

• Disagreement among experts about what diagnoses should lead to exclusion from competitive sports

• Again, US and Europe have different approaches

Differences between NIH recommendations (BC#36) and European Society of Cardiology (ESC) recommendations for sports restrictions

Pelliccia et al. J Am Coll Card. 2008.

What about cost?

• Two recent studies of the cost effectiveness of screening

– Fuller– Maron– Wheeler

Cost of universal screening

• A study of cost per year of life saved among high-school athletes by using ECG versus H/PE versus echocardiogram

– $44,000 per year for 12-lead ECG– $84,000 for specific cardiovascular H/PE– $200,000 for echocardiogram

(Note: Study assumes 1 death per 100,000 athletes. May be high)

Fuller CM. Med Sci Sports Exerc. 2000.

Another cost estimate

• Assumptions:– 10 million US. athletes require ECG screen– 10,000 have a cardiac condition identifiable by ECG– 9,000 have an irregular ECG that hints at cardiac disease

• Result: $330,000 to identify each athlete with cardiac disease. 10% of those would actually die.

• Result: $3.3 million to prevent each death

Maron BJ et al. Circ. 2007.

Decision analysis model for a screening program

Wheeler et al. Ann Int Med. 2010.

CV = cardiovascular

ECG = 12-lead electrocardiography

H & P = history and physical examination

M = Markov node

Wheeler et al. Ann Int Med. 2010.

Cost-effectiveness varies with cost of testing and thresholds for sensitivity and specificity

Cost-effectiveness of screening athletes to prevent sudden cardiac death. Data reported with each symbol are the estimated sensitivity and

specificity, as well as criteria (reference)

Wheeler et al. Ann Intern Med. 2010.

Greater increases in the years of life saved are associated with higher incremental costs.

• “We recognize that some may not regard these estimated costs per athlete as excessive for detecting potentially lethal cardiovascular disease in young people; however, the fundamental issue defined by these calculations concerns the practicality and feasibility of establishing a continuous annual national program for many years at a cost of approximately $2 billion per year.”

Maron BJ et al. Circ. 2007.

To save one life…

• About 1,700 athletes would have to be prohibited from sports, and their families warned that sudden cardiac death could kill their child

Bessem et al. Br J Sports Med. 2009.

Difficulties with screening

• Many false positives and false negatives– Cannot prevent all deaths

– Prevents sports participation in many people at low risk of SCD • Anxiety for athletes with positive screen • Cost• Demands on medical personnel• Freedom vs. paternalism

Freedom vs. paternalism

• The Italian approach to ECG screening gives the state the authority not only to require an ECG, but to decide who will play sports and who will not

• This approach may not work in the U.S.

U.S. vs. Europe

• “It would seem that many of the distinctions can be explained on the basis of differences in Europe and the U.S. with regard to cultural background, societal attitudes, and also perceived exposure to liability.”

Pelliccia. J Am Coll Card. 2008.

So what is a pediatrician to do?

• AHA recommends H&P, without routine ECG

• Present parents the facts

• Acknowledge uncertainty

• Ultimately, must be a shared, well-informed, and individualized decision

Resources

Baggish AL, Hutter AM Jr, Wang F, Yared K, Weiner RB, Kupperman E, Picard MH, Wood MJ. Cardiovascular Screening in College Athletes With and Without Electrocardiography: A Cross-sectional Study. Ann Intern Med. 2010 Mar 2;152(5):269-75.

Corrado D. An Electrocardiogram Should Not Be Included in Routine Preparticipation Screening of Young Athletes. Circulation. 2007 Nov 7;116(22):2610-14.

Corrado D, Pelliccia A, Biornstad HH, Vanhees L, Biffi A, Boriesson M, Panhuyzen-GoedkoopN, Deligiannis A, Solberg E, Dugmore D, Mellwig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Heidbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E, Blomstrom-Lundqvist C, McKenna WJFagard R, Thiene G; Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005 Mar;26:516–524.

Resources (cont’d)

Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, Dimeff R, Douglas PS, Glover DW, Hutter AM Jr, Krauss MD, Maron MS, Mitten MJ, Roberts WO, Puffer JC; American Heart Association Council on Nutrition, Physical Activity, and Metabolism. Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007 Update: A Scientific Statement From the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: Endorsed by the American College of Cardiology Foundation. Circulation. 2007 Mar 27;115(12):1643-455.

Myerburg RJ Vetter VL. Electrocardiograms Should Be Included in Preparticipation Screening of Athletes. Circulation. 2007;116:2616-2626.

Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA. Cost-effectiveness of Preparticipation Screening for Preventing Sudden Cardiac Death in Young. Ann Intern Med. 2010 Mar 2;152(5):276-86.

Last updated 3/19/10