- ICASM 2013 - 1 - ICASM 2013 - 1 Pre-participation ECG Pre-participation ECG screening in military screening in military recruits- the IDF recruits- the IDF experience experience Alon Grossman M.D MHA Alon Grossman M.D MHA 1, 2, 3 , Alex Prokupetz MHA , Alex Prokupetz MHA 1, 2 , Igor Lipchenca , Igor Lipchenca MD MD 4 1. 1. IAF aero medical center, Tel Hashomer, Israel IAF aero medical center, Tel Hashomer, Israel 2. 2. IDF medical corps IDF medical corps 3. 3. Department of Internal Medicine E, Rabin Medical Center Beilinson Campus affiliated Department of Internal Medicine E, Rabin Medical Center Beilinson Campus affiliated to Tel Aviv University Sackler Medical School, Israel to Tel Aviv University Sackler Medical School, Israel 4. 4. Leviev Heart Center, Sheba Medical Center and Tel Aviv University, Tel Hashomer, Leviev Heart Center, Sheba Medical Center and Tel Aviv University, Tel Hashomer, Israel Israel
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-ICASM 2013- 1 1 Pre-participation ECG screening in military recruits- the IDF experience Alon Grossman M.D MHA 1, 2, 3, Alex Prokupetz MHA 1, 2, Igor.
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-ICASM 2013-1 -ICASM 2013-1
Pre-participation ECG Pre-participation ECG screening in military screening in military
recruits- the IDF recruits- the IDF experienceexperience
Alon Grossman M.D MHAAlon Grossman M.D MHA11,, 22,, 33, Alex Prokupetz MHA, Alex Prokupetz MHA11,, 22, Igor Lipchenca MD , Igor Lipchenca MD 44
1.1. IAF aero medical center, Tel Hashomer, IsraelIAF aero medical center, Tel Hashomer, Israel
2.2. IDF medical corpsIDF medical corps
3.3. Department of Internal Medicine E, Rabin Medical Center Beilinson Campus affiliated to Tel Aviv Department of Internal Medicine E, Rabin Medical Center Beilinson Campus affiliated to Tel Aviv
University Sackler Medical School, Israel University Sackler Medical School, Israel
4.4. Leviev Heart Center, Sheba Medical Center and Tel Aviv University, Tel Hashomer, IsraelLeviev Heart Center, Sheba Medical Center and Tel Aviv University, Tel Hashomer, Israel
-ICASM 2013-2
IntroductionIntroduction
Despite the large numbers of athletes Despite the large numbers of athletes
undergoing pre-participation screening, there undergoing pre-participation screening, there
is a continuing debate regarding the optimal is a continuing debate regarding the optimal
method of screeningmethod of screening
The main concern in performing mass ECG The main concern in performing mass ECG
screening in athletes is the costly additional screening in athletes is the costly additional
work up required based on resting ECG work up required based on resting ECG
findingsfindings
-ICASM 2013-3
IntroductionIntroduction
Professional guidelines in the US do not recommend use of either ECG or Professional guidelines in the US do not recommend use of either ECG or
echocardiography for screening of college athletesechocardiography for screening of college athletes11
On the other hand, 12-lead ECG has been supported for screening purposes On the other hand, 12-lead ECG has been supported for screening purposes
among athletes by the Sport Cardiology section of the European society of among athletes by the Sport Cardiology section of the European society of
Cardiology and Medical Commission of the International Olympic Committee Cardiology and Medical Commission of the International Olympic Committee
and has been shown to reduce mortality in this populationand has been shown to reduce mortality in this population22
1. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to pre participation screening for cardiovascular 1. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to pre participation screening for cardiovascular
abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, 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. Circulationand Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. . 2007; 115:1643-16552007; 115:1643-1655
2. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after 2. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after
implementation of a pre-participation screening program. JAMA 2006; 296:1593–1601implementation of a pre-participation screening program. JAMA 2006; 296:1593–1601
-ICASM 2013-4
BackgroundBackground
Recruits to elite units in the IDF undergo pre-participation ECG prior their Recruits to elite units in the IDF undergo pre-participation ECG prior their
enlistmentenlistment
This process has been performed sporadically in the last years but all ECGS This process has been performed sporadically in the last years but all ECGS
are performed at the IAF aero medical Center since January 2010are performed at the IAF aero medical Center since January 2010
All elite units candidates undergo a preliminary medical selection process All elite units candidates undergo a preliminary medical selection process
at the IDF recruitment center (History & PE)at the IDF recruitment center (History & PE)
Only those who are physically healthy are allowed to enlist to elite units Only those who are physically healthy are allowed to enlist to elite units
and only they undergo pre-participation ECGand only they undergo pre-participation ECG
This population consists of 17-19 years old male subjectsThis population consists of 17-19 years old male subjects
-ICASM 2013-5
BackgroundBackground
All ECGS are evaluated by a single All ECGS are evaluated by a single
cardiologistcardiologist Those requiring further evaluation, Those requiring further evaluation,
complete the evaluation prior to enlistmentcomplete the evaluation prior to enlistment A military physician from the IAF aero A military physician from the IAF aero
medical center summarizes the medical medical center summarizes the medical
evaluation and decides whether the evaluation and decides whether the
candidate is eligible to enlist to a special candidate is eligible to enlist to a special
unitunit
-ICASM 2013-6
AimsAims
To characterize causes of referral to continued To characterize causes of referral to continued
investigation based on resting ECG findingsinvestigation based on resting ECG findings
To summarize the additional work-up performedTo summarize the additional work-up performed
To summarize the rate of significant findings To summarize the rate of significant findings
resulting in disqualification of military resulting in disqualification of military
candidates in this populationcandidates in this population
Long QT, pre-excitation pattern, sinus bradycardia, blocks
None
Total number7
-ICASM 2013-11
example 1example 1
-ICASM 2013-12
Example 2Example 2
ICRBBB with non-specific T wave changes in inferior leadsICRBBB with non-specific T wave changes in inferior leads
Echocardiography interpreted as normalEchocardiography interpreted as normal
No further w/u required No further w/u required
-ICASM 2013-13
Example 3Example 3
Early repolarization pattern particularly in V2Early repolarization pattern particularly in V2
Echocardiography-normalEchocardiography-normal
No further w/u requiredNo further w/u required
-ICASM 2013-14
DiscussionDiscussion
Screening for cardiovascular disease among athletes and military Screening for cardiovascular disease among athletes and military
candidates is imperative as sudden death is obviously tragic and candidates is imperative as sudden death is obviously tragic and
potentially preventablepotentially preventable
Debate continues regarding the optimal method of screening, this Debate continues regarding the optimal method of screening, this
ranging from reliance solely on history and physical examination ranging from reliance solely on history and physical examination
to performance of 12-lead ECG and echocardiographyto performance of 12-lead ECG and echocardiography
-ICASM 2013-15
DiscussionDiscussion
The total rate of ECGS defined as abnormal in this cohort The total rate of ECGS defined as abnormal in this cohort
was 4.6%, a percentage much lower than previously reported was 4.6%, a percentage much lower than previously reported
Yet, even in a previous report by Pellicia et al (8) in which Yet, even in a previous report by Pellicia et al (8) in which
11.8% of ECGs were interpreted as abnormal, additional 11.8% of ECGs were interpreted as abnormal, additional
evaluation was requested in only 4.8% of ECGs, disregarding evaluation was requested in only 4.8% of ECGs, disregarding
some of the findings noted on routine ECG some of the findings noted on routine ECG
This rate is similar to that reported in this study and This rate is similar to that reported in this study and
probably represents the true rate of ECG findings requiring probably represents the true rate of ECG findings requiring
further evaluation in young athletes further evaluation in young athletes
Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339: 364–369Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339: 364–369
Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R, Castagna W, Ciacciarelli A, Costini G, Cuffari B, Drago E, Federici V, Gribaudo Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R, Castagna W, Ciacciarelli A, Costini G, Cuffari B, Drago E, Federici V, Gribaudo
CG, Iacovelli G, Landolfi L, Menichetti G, Atzeni UO, Parisi A, Pizzi1 AR, Rosa M, Santelli F, Santilio F, Vagnini A, Casasco M, and Di Luigi L. CG, Iacovelli G, Landolfi L, Menichetti G, Atzeni UO, Parisi A, Pizzi1 AR, Rosa M, Santelli F, Santilio F, Vagnini A, Casasco M, and Di Luigi L.
Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur
T wave changes was the most common cause for T wave changes was the most common cause for
continued investigation in the cohortcontinued investigation in the cohort
This is probably due to the non specific nature of This is probably due to the non specific nature of
this findingthis finding
Disqualifying findings were identified in 18.75% of Disqualifying findings were identified in 18.75% of
evaluations in these subjects evaluations in these subjects
Whether these clinical findings were associated Whether these clinical findings were associated
with the ECG findings or were incidental is unclearwith the ECG findings or were incidental is unclear
-ICASM 2013-17
PRE EXCITATION PATTERNPRE EXCITATION PATTERN
Signs of pre-excitation were identified in 14 subjects who Signs of pre-excitation were identified in 14 subjects who
comprised 0.96% of the study populationcomprised 0.96% of the study population
This is a higher percentage than previously reported (0.2%)This is a higher percentage than previously reported (0.2%)
Probably resulted from the high awareness to this condition Probably resulted from the high awareness to this condition
among interpreting cardiologistsamong interpreting cardiologists
No cases of pre-excitation syndrome identifiedNo cases of pre-excitation syndrome identified
This is similar to a previous report from the Israeli air forceThis is similar to a previous report from the Israeli air force
Ferrer MF. Electrocardiographic variations, arrhythmias, pacemakers. In: Lew EA, Gajewski J. Medical Risks: Trends Ferrer MF. Electrocardiographic variations, arrhythmias, pacemakers. In: Lew EA, Gajewski J. Medical Risks: Trends
in Mortality by age and time elapsed. New York, NY: Praeger 1990. in Mortality by age and time elapsed. New York, NY: Praeger 1990.
Grossman A et al Use of adenosine test for the exclusion of pre-excitation syndrome in asymptomatic individuals. Grossman A et al Use of adenosine test for the exclusion of pre-excitation syndrome in asymptomatic individuals.
Signs of LVH were identified in only 7.56% of the study Signs of LVH were identified in only 7.56% of the study
populationpopulation
This is significantly lower than reported in previous This is significantly lower than reported in previous
studies (up to 45%)studies (up to 45%)
This is surprising given the young age of the population This is surprising given the young age of the population
and the fact that the subjects were all very physically and the fact that the subjects were all very physically
activeactive
Disqualifying findings were identified in 18.2% of these Disqualifying findings were identified in 18.2% of these
subjectssubjects
Pelliccia A et al Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-Pelliccia A et al Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-