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ECG Screening: Published Experience

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Publié le

Christopher Kontos, MD
Duke University Medical Center

Publié dans : Santé & Médecine
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ECG Screening: Published Experience

  1. 1. ECG Screening of Athletes: Published Experience Christopher D. Kontos, MD Associate Professor of Medicine Division of Cardiology Duke University Medical Center March 28, 2015
  2. 2. Rationale for Preparticipation Screening of Athletes •  HCM and cardiac dysrhythmias account for ~50% of SCD in athletes •  ECG is an efficient means to identify these abnormalities •  Mortality reduction with screening has been demonstrated (Corrado et al, JAMA 2006;296:1593-1601) •  Subsequent studies have failed to corroborate this reduction –  Maron et al, Am J Cardiol 2009;104:276-80 –  Steinvil et al, J Am Coll Cardiol 2011;57:1291-6
  3. 3. Rationale for Preparticipation Screening of Athletes Corrado et al, JAMA 2006;296:1593-1601 Implementation of screening program
  4. 4. First Line Preparticipation Screening in Italy since 1982 •  Personal history •  Family history •  Physical examination •  12-lead ECG Corrado et al, JAMA 2006;296:1593-1601
  5. 5. The Challenge of ECG Screening in Athletes •  Distinguish normal physiological adaptation in athletes (athlete’s heart) from abnormal findings suggestive of pathology •  Common causes of SCD (HCM, ARVC) have characteristic ECG findings •  Up to 90% with HCM have abnormal ECG •  Only 50-60% with ARVC have abnormal ECG •  Many abnormal ECG findings in CM are normal variants in athletes or in certain ethnic groups (e.g., TWI)
  6. 6. •  Assessed the prevalence of ECG abnormalities among a cohort of elite Australian athletes •  Assessed the impact of Seattle Criteria in reducing false positive screening ECGs •  1078 elite Australian athletes, age 16-35 Br J Sports Med 2014;48:1144-50
  7. 7. Sports Participation and Training-Related ECG Abnormalities among Elite Australian Athletes Brosnan et al, Br J Sports Med 2014;48:1144-50 Total: 86.7%
  8. 8. Brosnan et al, Br J Sports Med 2014;48:1144-50 Training-Unrelated ECG Abnormalities in Australian Athletes
  9. 9. Scheme for Screening Athletes with Training- Unrelated ECG Abnormalities Brosnan et al, Br J Sports Med 2014;48:1144-50
  10. 10. Seattle Criteria Increase Specificity of Preparticipation Screening Brosnan et al, Br J Sports Med 2014;48:1144-50
  11. 11. Seattle Criteria Increase Specificity of Preparticipation Screening Brosnan et al, Br J Sports Med 2014;48:1144-50 0.3% of screened athletes with abnormal ECG and cardiac pathology
  12. 12. •  Seattle criteria reduced the number of “abnormal” ECGs by 74% - from 17.3% to 4.5% •  Prevalence of Group 2 abnormalities higher than in studies of University athletes in US and Netherlands (17.3% vs. 7-10%) •  Identification of cardiac pathology similarly low (0.3%) •  Impact on specificity – reduction in additional unnecessary testing •  No impact on sensitivity Brosnan et al, Br J Sports Med 2014;48:1144-50 Seattle Criteria Increase Specificity of Preparticipation Screening
  13. 13. Refined Criteria from ESC and Seattle for the Detection of Cardiac Abnormalities in Elite Athletes •  Several isolated ECG patterns have low diagnostic yield for cardiac abnormalities •  Consensus-based guidelines often do not incorporate scientific observations into recommendations •  Recommendations have been based almost exclusively on data from white athletes •  Study was designed to: –  assess performance of ESC and Seattle compared to refined criteria in cohorts of elite white (n=4297) and black (n=1208) athletes –  determine their sensitivity in a cohort of young, asymptomatic athletes with HCM (n=103) Sheikh et al, Circulation 2014;129:1637-49
  14. 14. The Refined ECG Criteria Sheikh et al, Circulation 2014;129:1637-49 Previously in ESC Group 2 or in association with recognized training-related ECG changes
  15. 15. Positive ECGs Based on the 3 Screening Criteria Sheikh et al, Circulation 2014;129:1637-49 40 16 18 7 12 5 98 98 98
  16. 16. Sheikh et al, Circulation 2014;129:1637-49 Refined Criteria Improve Specificity for Detecting Major Cardiac Abnormalities - Primarily in Black Athletes
  17. 17. Refined Criteria Improve Specificity for Detecting Major Cardiac Abnormalities - Primarily in Black Athletes Sheikh et al, Circulation 2014;129:1637-49
  18. 18. Efficacy of Screening Using Refined Criteria Sheikh et al, Circulation 2014;129:1637-49 5505 athletes screened ECG-identified disease 0.3% Screening-identified disease 0.7% Disease among abnormal ECGs 0.45%
  19. 19. Refined ECG Screening Criteria •  Persistent high false positive rate, particularly in black athletes, mainly due to TWI •  Low incidence of disease among abnormal ECGs •  Implications of some identified disease for sports participation is unclear (Bicuspid AoV, ASD, MVP) •  Clear need for prospective clinical trial of ECG screening Sheikh et al, Circulation 2014;129:1637-49
  20. 20. The Problem of Pathological T-Wave Inversion in Athletes •  Pathological T-wave inversion is rare in healthy athletes, common in cardiac disease •  Prospective analysis of prevalence of cardiac pathology in athletes with PTWI •  Analysis of effectiveness of cardiac MRI for evaluation of cardiac pathology in athletes Schnell et al, Circulation 2015;131:165-73
  21. 21. Recognition and Significance of Pathological T-Wave Inversion in Athletes Pathological T-wave inversion Physiological T-wave inversion Schnell et al, Circulation 2015;131:165-73
  22. 22. Recognition and Significance of Pathological T-Wave Inversion in Athletes 6372 athletes screened with PTWI Schnell et al, Circulation 2015;131:165-73 1% of screened athletes 45% of abnormal ECGs 2.4% with PTWI
  23. 23. Significance of PTWI in Athletes •  PTWI indicates high likelihood of cardiac pathology •  Cardiac MRI significantly increases cardiac disease identification with PTWI •  PTWI most frequently indicates HCM (81%) •  Annual follow-up is important, accounting for up to 7% of positive cases •  Cost of screening: –  $1839 per athlete to identify cardiac pathology –  $2620 per athlete, including annual follow-up Schnell et al, Circulation 2015;131:165-73
  24. 24. Summary •  ECG remains the first-line tool for preparticipation screening of athletes •  Revision of guidelines has continued to improve specificity •  Additional studies are needed (with appropriate clinical correlates) to optimize sensitivity and specificity •  High false positive rates result in high cost of additional testing that does not necessarily justify broad screening •  Important to remember that use of ECG criteria must always be considered in the context of the history and exam

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