Protecting The Heart of The American Athlete...and 63o/c> -91o/c> of black athletes • A dynamic process in some athletes directly affected by training • No data to support an association

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ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.

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Colin M. Fuller M.D., F.A.C.C., F.A.C.P., F.S.C.A.I.Northern Nevada Cardiology

Northern Nevada Medical CenterSports Cardiologist UNR Sports Teams and Reno Big Hors Basketball Team

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Benefits of Exercise

Improved Self esteem Pleasure / endorphins Comradery Recognition Scholarships Income Weight Loss

Stress Management Better sleep Better sex Decreased cardiovascular

risk

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Non cardiovascular risks of exercising athletes: Injury / trauma Lightning Drowning Heat Stroke Sick cell crisis Other

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Sudden Cardiac Arrest

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Faces of SCA (2012)

PIERMARIO MOROSINI – age 25, died after on-field SCA

FABRICE MUAMBA – AGE 23 survived on-field cardiac arrest, retired from soccer

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Protecting The Heart of The American Athlete

Athlete: any individual who engages in routine vigorous physical exercise in the setting of competition, recreation or occupation

Causes of SCA/ SCD Prevalence of conditions placing athlete at risk of SCA/SCD Incidence of SCA/SCD in young athletes Screening young athletes for risk of SCA/SCD Limitations Challenges

New International criteria for interpreting athlete’s EKG’s Screening Older Athletes for Risk of SCA/SCD

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1991

Gardnerville Primary Care M.D.

Performed State of Nevada mandated pre-participation history and physical on this young man.

Asked “should I have done an EKG?”

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Sudden Cardiac Death in Young Athletes – Causes (in Order of Frequency)

Hypertrophic cardiomyopathy Anomalous coronary artery Ruptured aorta Myocarditis Aortic stenosis Dilated cardiomyopathy Right ventricular dysplasia Primary conduction abnormalities

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Hypertrophic Cardiomyopathy

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Anomalous Coronary Artery

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Cystic Medial Necrosis of AortaMarfan’s Syndrome

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Flo Hyman1984 VolleyballOlympic Silver Medalist

SportsIllustrated Feb 17, 1984

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Suddenly Died 1986

After leaving a game in Japanfor a substitution

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Myocarditis - Microscopic

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Congenital Aortic Valve Stenosis

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Greatly dilated and moderately hypertrophied heart

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Arrythmogenic Right Ventricular Dysplasia (ARVD)

Partial or total replacement of a portion of RV myocardium with adipose and/or fibrous tissue

Males > females; familial predisposition Exam: normal EKG: usually abnormal: PVCs, T↓V1 –V4 Echo: dilated RV; often normal MRI very helpful

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Primary Conduction Abnormalities Long QT syndrome 1/2000 WPW syndrome 1/1000 Brugada’s Syndrome 1/3000 ECG’s Abnormal 99% of the time

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Sudden Cardiac Death in Young Athletes –Causes (in Order of Frequency)

*Hypertrophic cardiomyopathy Anomalous coronary artery Ruptured aorta *Myocarditis *Aortic stenosis *Dilated cardiomyopathy *Right ventricular dysplasia *Primary conduction abnormalities

*typically have abnormal ECG

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1995

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SensitivitySpecificity

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1996

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1996

AHA recommends that both a cardiac history and physical examination be performed before participating in organized high school (grade 9-12) and collegiate sports. Screening should be repeated every two years.”

Evidence - ZERO

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2016

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1/250 young athletes have a previous undetected cardiac condition placing them

at risk of SCA/SCD during sports.

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Risk of SCA/SCD: Situation for Athlete # Involved In Risk

Sports/per year of CV Death

High School 5 million 1-3/100,000

NCAA 450,000 2-3/100,000

Male NCAA Div. 1 3000 30/100,000Basketball Players

Marathons 14 million road race 1/100,000finishers Competing in a

(55% female) marathon550,000 marathon

finishers(1/2 >40 years)

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2017

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2016

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Through 2016 at UNR

1500 athletes screened by ECG42 Abnormal EKG 6 found after cardiac

testing to have disease• 3 HCM• 2 WPW• 1 Dilated Cardiomyopathy

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Green, Yellow, Red: Understanding the Updated “International Recommendations for

Electrocardiographic Interpretation in Athletes”

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• International standard for ECG interpretation in athletes

• Endorsed by 17 international sports medicine and cardiology societies

• Clear guide to the evaluation of ECG abnormalities

• Sports medicine and cardiology looking through same lens

Freely available at: http://bjsm.bmj.com/content/early/2017/03/03/bjsports-2016-097331

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http://bjsm.bmj.com/content/early/2017/03/03/bjsports-2016-097331

Does modifying the criteria come with a cost?

Do we sacrifice sensitivity to improve specificity?

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False-PositiveRate

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Chart1

Brosnan 2013Brosnan 2013Brosnan 2013Brosnan 2013

Pickham 2014Pickham 2014Pickham 2014Pickham 2014

Sheikh 2014Sheikh 2014Sheikh 2014Sheikh 2014

Riding 2014Riding 2014Riding 2014Riding 2014

Fuller 2016Fuller 2016Fuller 2016Fuller 2016

ESC 2010

Stanford

Seattle

Revised

Performance of ECG Standards

17

4.2

0

26

8.1

5.7

21.5

9.6

6.6

22.3

11.6

5.3

10.7

6.6

2.8

2.8

Sheet1

ESC 2010StanfordSeattleRevised

Brosnan 2013174.2

Pickham 2014268.15.7

Sheikh 201421.59.66.6

Riding 201422.311.65.3

Fuller 201610.76.62.82.8

"no change in sensitivity"

"100% sensitivity for SCD-associated conditions"

"all three criteria identified 98.1% of athletes with established HCM"

"all with 100% sensitivity for the pathological conditions detected"

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QRS voltage criteria for LVH

• Increased QRS voltage is associated withn1ale sex, athletic activity and younger age

• All existing ECG criteria for LVH correlatepoorly with increased LV wall thicknessand LV mass on imaging studies

• Up to 64% of athletes fulfill the SokolowLyon index for LVH

• Isolated QRS voltage criteria for LVH ispresent in fewer than 2% of patients withHCM

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Sohaib, J Cardiov Mag Res, 2009

Pelliccia, Circ, 2000Papadakis, Eur Heart J, 2009, 2011

ECG from a 19 year old asymptomatic soccer player demonstrating voltage criteriaforLVH (S-V1 + R-V5 > 35

mm).

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Voltage Criteria for RVH

• Voltage criteria for RVH occur in up to 13% of athletes fulfilling the SokolowLyon index

• Correlates poorly vvith increased RV wall thickness on echocardiography

• Isolated voltage for RVH does not correlate with underlying pathology inathletes particularly ARVC or pulmonary hypertension

Zahdi, Eur Heart J, 2013

Papadakis, Eur Heart J, 2011

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Incomplete Right Bundle Branch Block

• Mildly delayed RV conduction in athletes iscaused by RV remodeling with increased cavity size and resultant increased conduction time

• No evidence of intrinsic delay within theHis-Purkinje system

• Represents a phenotype of cardiacadaptation

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ECG demonstrates incomplete right bundle branch block (RBBB) with rSR'

pattern in V1 and QRS duration of< 120 ms. Incomplete RBBB is a common

and normal finding in athletes and

does not require additional evaluation. Kim, Am J Card, 2011

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Early Re polarization

• A common finding in healthypopulations (2% - 44%)

• Present in up to 45% Caucasian athletesand 63o/c> - 91o/c> of black athletes

• A dynamic process in some athletesdirectly affected by training

• No data to support an associationbetween inferior early re polarization andSCD in athletes

• All patterns of isolated earlyrepolarization should be consideredbenign

Quattrini, Heart Rhythm, 2014 Tikkanen, NEJM, 2009

Noseworthy, JACC, CircArrhy, 2011 Papadakis,Eur Heart J, 2009, 2011

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Repolarization in black athletes

• 2/3 of black athletes exhibit ST seg1nent elevation and 25% demonstrateTWI

• Black athletes also co1n1nonly demonstrate a repolarization variantconsisting of }-point elevation and convex ST segment elevation in theanterior leads (V1-V 4) followed by TWI

• 13% of 904 black male athletes had isolated TWI in leads V1-V 4 comparedto 4 % of black sedentary controls - none had cardio1nyopathy

Di Paolo, JACC, 2012 Sheikh, BJSM, 2013

Rawlins, Circ, 2010 Papadakis, Eur Heart J, 2011

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Normal Variant: Repolarization Changes in Black/African Athletes

ECG from a 24 year old asymptomatic black/African soccer player demonstrating J-point elevation, convex (‘domed’) ST elevation followed by

T-wave inversion in leads V1-V4 (circles). This is a normal repolarization pattern in black/African athletes.

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''Juvenile'' ECG Pattern

• Juvenile ECG pattern= TWI or biphasic T wave beyond lead V2 inadolescents who have not reached physical maturity

• Anterior TWI that extends beyond lead V2 is rare (0.1%) in "'rhite athletes> 16

• TWI in anterior leads (V1 - V3) should not pro1npt further evaluation

Calo, Heart 2015

Migliore, Circ, 2012

Papadakis, Eur Heart J, 2009

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Juvenile ECG Pattern in Athletes < 16

Anterior TWI in V1-V3 in a 12 y.o. asymptomatic athlete

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Bradycardia

• Defined as HR < 60 bpm and is present in up to 80% of highly trainedathletes

• Due to increased vagal tone and possible structural atrial remodeling

• In the absence of symptoms such as fatigue, dizziness, or syncope HR> 30bp1n are considered normal

Stein, JACC, 2002

Sharma, BJSM, 1999

Papadakis, Eur Heart J, 2009

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Others Common Findings in Athletes

• Due to high vagal tone and/or intrinsic AV node changes

• Sinus arrhythmia

• J unctional escape rhythm Present • Ectopic atrial rhythm or "wandering atrial pacemaker" in 8% of

st • 1 degree AV block- present in 7.5% of athletes athletes

• Mobitz Type I (Wenkebach) second degree AV block

• Resolves vvith onset of exercise

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• 2533 athletes (14-35) and 9997 controls

• Isolated R/LAD or R/LAE was present in 5.5% of athletes

• Athletes had slightly higher prevalence of LAD and LAE• More common in athletes who trained over 20 hours/week

• Athletes with LAD or LAE exhibited larger left atrial and ventricular dimensions compared to athletes without

• No difference in cardiac dimensions in athletes with RAD/RAE compared to athletes without

Gati, Eur Heart J, 2013

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• Present in 1% of population and 0.5%-3% in athletes

• In study of 510 athletes 13 had RBBB, none had pathology

• Appear to be related to exercise induced cardiac remodeling

• RV Enlargement• Diminished RV systolic function at rest• Interventricular dyssynchrony

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Right Bundle Branch Block

19 yo Caucasian male athlete with complete RBBB. When found in isolation without other borderline or abnormal ECG findings, RBBB

does not require more investigation when there are no clinical markers of concern.

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ECG from an asymptomatic 22 year old black male athlete demonstrating complete right bundle branch block (QRS ≥ 120 ms), left axis deviation (-57°), and right atrial enlargement (P wave ≥ 2.5 mm in II and aVF). The presence of two or more borderline ECG findings warrants additional investigation to exclude pathologic cardiac disease.

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Though 50% of athletes with sudden cardiac arrest / death during sports have prior cardiovascular symptoms…

Athletes minimize/ ignore symptoms

Pay attention to chest pain/ shortness of breath/ fainting!

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Cardiovascular benefits of exercise (isotonic) for the older athlete (>35 years) athlete:

WeightBlood sugarBlood pressureBad (LDL) cholesterolRisk of heart attackMortality – average life expectancy increased

7 years behind sedentary counterparts

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• OLDER (>35 years) ATHLETE

• Think coronary artery disease

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History• 55 year old male long-time endurance athlete

without known medical history presenting with reduced exercise capacity.

• Active with daily endurance runs since his 30s, most recently completing two marathons per year. ~7:30-8 min/mile pace.

• First noted shortness of breath, generalized exertional fatigue, and slowing in his typical pace about 6 months prior to evaluation.

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Prevention of SCA/SCD During Exercise in the Older Athlete

•Control Modifiable Risk Factors for CAD•Blood sugar•Blood pressure•LDL cholesterol•Smoking

•Maintain or achieve ideal body weight

•No cocaine or meth

•No performance supplements purchased at the “gym”

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Assess your health needs by marking all true statements:

History you have had: A heart attack Heart surgery Cardiac catheterization Coronary angioplasty (PCTA) Pacemaker / implantable cardiac defibrillator / rhythm disturbance Heart valve disease Heart failure Heart transplantation Congenital heart disease

If ≥ 1, there is a need to see a cardiologist before starting, resuming or increasing exercise.

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Symptoms

DYou experience chest discomfort with exertion D You experience unreasonable breathlessness D You experience dizziness, fainting, blacl

Cardiovascular risl< factors

D You are a man older than 45 years D You are a woman older than 55 years or you have had a

hysterectomy or you are postmenopausal D You smoke D Your blood pressure is > 140 / 90 D You don't know your blood pressure D Your blood cholesterol level is >240 mg/dl D You don't know your cholesterol level D You have a close blood relative who had a heart attack before

age 55 (father or brother) or age 65 (mother or sister) D You are diabetic or take medicine to control you blood sugar D You are physically inactive (i.e., you get 20 pounds overweight

If> 1, there is a need to see a cardiologist before starting, resuming

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Protecting The Heart of The American AthleteSlide Number 2Slide Number 3Slide Number 4Slide Number 5Slide Number 6Slide Number 7Slide Number 8Protecting The Heart of The American AthleteSlide Number 10Sudden Cardiac Death in Young Athletes – Causes �(in Order of Frequency)Slide Number 12Anomalous Coronary ArterySlide Number 14Slide Number 15Slide Number 16Slide Number 17Slide Number 18Slide Number 19Arrythmogenic Right Ventricular Dysplasia (ARVD)Primary Conduction AbnormalitiesSlide Number 22Slide Number 23Slide Number 24Slide Number 25Slide Number 26Slide Number 27Slide Number 28Slide Number 29Slide Number 30Slide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36Does modifying the criteria come with a cost?Slide Number 38Slide Number 39Slide Number 40Slide Number 41Slide Number 42Slide Number 43Slide Number 44Slide Number 45Slide Number 46Slide Number 47Slide Number 48Slide Number 49Slide Number 50Slide Number 51Slide Number 52Slide Number 53Slide Number 54Slide Number 55Slide Number 56Slide Number 57Slide Number 58Slide Number 59Slide Number 60Slide Number 61Slide Number 62Slide Number 63Slide Number 64Slide Number 65Slide Number 66Slide Number 67Slide Number 68Slide Number 69Slide Number 70Slide Number 71Slide Number 72Slide Number 73Slide Number 74Slide Number 75Slide Number 76Video Release Statement.pdf�Video will be taken at this clinic and potentially used in�Project ECHO promotional materials. By attending this �clinic, you consent to have your photo taken and allow �Project ECHO to use this photo and/or video. If you don’t want your photo taken, please let us know. Thank you!