Transcript Slide 1

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.
Famous athletes who
have died of sudden
cardiac death
Alexei Cherepanov
Marc-Vivien Foe
Jesse
Marunde
Anthony
Bates
Ryan Shay
Gaines Adams
Pete Maravich
Hank Gathers
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
‘93-’04 death rate
(per 100,000)
12
11
.87
.93
• 2001-2004 deaths
2001-2004 death rate
(not statistically significant)
2
.38
4
.90
Maron et al. Am J of Card. 2009.
Conclusions of Maron et al
• “…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.”
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
Minnesota
23 +/- 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.
ECG identifies disease: H+P does not
Wilson et al. Brit J Sports Med. 2007.
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.
Dutch
screening
program
(cont’d)
Bessem et al. Br J Sports Med. 2009.
Additional testing for athletes with positive ECG screen
Bessem et al. Brit J Spts. Med. 2009.
ECG together with H&P:
sensitive but not specific
• Prospective cross-sectional comparison
• 510 college athletes
• All had H&P, ECG and echocardiogram
Test
Echo
H/PE
ECG
# abnormal
11
5
5
% false positive
N/A
5.5
16.9
Baggish AL et al. Annals Int Med. 2010.
Flow chart for cardiac screening
LV = left ventricular; LVH = left ventricular
hypertrophy; RV = right ventricular.
Baggish et al. Ann Int. Med. 2010.
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
CV = cardiovascular
ECG = 12-lead
electrocardiography
H & P = history and
physical
examination
M = Markov node
Wheeler et al. Ann Int Med. 2010.
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)
Greater
increases in the
years of life
saved are
associated with
higher
incremental
costs.
Wheeler et al. Ann Intern Med. 2010.
• “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):26975.
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, PanhuyzenGoedkoopN, 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