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Are elite athletes at higher risk of developing cardiovascular abnormalities than the average citizen?

6 Apr, 17 | by BJSM

By Javier S. Morales (MSc), Pedro L. Valenzuela (MSc), and Adrián Castillo García (MSc): @Fissac_es

High performance sport is a focal point for the media, and sadly, cases of sudden death in elite athletes appear in the news with relative frequency. These news added to findings such as those of Pellicia et al. (2016), who reported an unexpected and not negligible prevalence of cardiovascular (CV) abnormalities and pathological conditions among Olympic athletes (Pelliccia et al., 2016), have put exercise on the spotlight, with growing concern about the possible negative effects that regular strenuous exercise can provoke.

In light of the existing debate about the increased health risks of elite athletes, we consider that this information could lead people to misconceive the high volumes of exercise that these athletes perform during their sportive life as the cause of the aforementioned CV abnormalities. However, taking into account that nowadays sedentarism and its associated diseases are one of the greatest public health issues, we must avoid people from thinking of strenuous exercise per se as a source of increased morbidity or mortality.

Performing moderate physical activity has well-documented beneficial effects on CV morbidity, but there is controversy surrounding the effects of larger doses of physical activity (Eijsvogels, Fernandez, & Thompson, 2016). Concerning the CV maladaptation to strenuous exercise, Sanchis-Gomar et al. (2016) found in former elite and amateur athletes aged 40-70 years old that, although they presented an overall pattern of cardiac remodeling in comparison with control non-athletes participants (e.g. larger left and right ventricles and left auricle cavities), these changes were benign, with no differences in cardiac biomarkers (Sanchis-Gomar et al., 2016). Similarly, Bohm et al also reported these non-pathological morphological adaptations in elite master endurance athletes with a training history of 29±8 years, with no differences between these athletes and the control group neither for left or right ventricle volumes nor for cardiac biomarkers (Bohm et al., 2016). These results confirm that although the possibility of exercise-induced cardiac remodeling in elite athletes is high, these adaptations are very likely to be benign.

In fact, there is a large body of research supporting that the population that perform the highest levels of physical activity (i.e. elite athletes) seem to present a lower risk of CV diseases and mortality. Specifically, a meta-analysis including 42087 elite athletes reported a 27% lower risk of mortality associated to CV diseases in comparison with the general population (Garatachea et al., 2014). Furthermore, an epidemiological study that analyzed 15174 Olympic medalists found that these subjects lived a mean of 2.8 years more than the average population, independently of the country or the type of sport performed (Clarke et al., 2012).

On the other hand, it has been described a higher prevalence of sudden death in young athletes than in their non-athletes counterparts (Corrado, Basso, Rizzoli, Schiavon, & Thiene, 2003). However, it is important to highlight that physical exercise was not per se the cause of this enhanced mortality, but it triggered the event in those subjects who were already affected by an undiagnosed CV disease.

Therefore, very large doses of physical exercise such as those performed by elite athletes seem not to increase the prevalence of CV diseases during youth or even in later years, as the CV and mortality risk of elite athletes is the same or even lower than that of the average citizen. The dramatic occurrence of cardiac events in young athletes as well as the interesting results reported by Pelliccia et al. (2016) must raise consciousness about the necessity of an appropriate medical screening in the sportive context; strenuous physical exercise can trigger cardiac arrest in those subjects with a previous undiagnosed CV disease. However, they should not sharpen the discussion on the suitability of performing high-performance physical exercise from early ages.

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This post has been written by the FISSAC team (@Fissac_es):

Javier S. Morales is a researcher of the European University (Madrid). He also collaborates as a researcher at the Hospital Niño Jesús (Madrid) in childhood cancer and physical exercise.

Pedro L. Valenzuela is a pre-doctoral researcher in the Phisiology Unit of the University of Alcalá. He also serves as external collaborator in the Sports Medicine Centre of the Spanish Agency for Health Protection in Sport (AEPSAD).

Adrián Castillo García is a researcher at the Institute of Biomedical Research of Barcelona, research center that belongs to the Spanish National Research Council.”

References

Bohm, P., Schneider, G., Linneweber, L., Rentzsch, A., Krämer, N., Abdul-Khaliq, H., . . . Scharhag, J. (2016). Right and Left Ventricular Function and Mass in Male Elite Master Athletes: A Controlled Contrast-Enhanced Cardiovascular Magnetic Resonance Study. Circulation, 133(20), 1927-1935. doi:10.1161/CIRCULATIONAHA.115.020975

Clarke, P. M., Walter, S. J., Hayen, A., Mallon, W. J., Heijmans, J., & Studdert, D. M. (2012). Survival of the fittest: retrospective cohort study of the longevity of Olympic medallists in the modern era. BMJ, 345, e8308.

Corrado, D., Basso, C., Rizzoli, G., Schiavon, M., & Thiene, G. (2003). Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol, 42(11), 1959-1963.

Eijsvogels, T. M., Fernandez, A. B., & Thompson, P. D. (2016). Are There Deleterious Cardiac Effects of Acute and Chronic Endurance Exercise? Physiol Rev, 96(1), 99-125. doi:10.1152/physrev.00029.2014

Garatachea, N., Santos-Lozano, A., Sanchis-Gomar, F., Fiuza-Luces, C., Pareja-Galeano, H., Emanuele, E., & Lucia, A. (2014). Elite athletes live longer than the general population: a meta-analysis. Mayo Clin Proc, 89(9), 1195-1200. doi:10.1016/j.mayocp.2014.06.004

Pelliccia, A., Adami, P. E., Quattrini, F., Squeo, M. R., Caselli, S., Verdile, L., . . . Spataro, A. (2016). Are Olympic athletes free from cardiovascular diseases? Systematic investigation in 2352 participants from Athens 2004 to Sochi 2014. Br J Sports Med. doi:10.1136/bjsports-2016-096961

Sanchis-Gomar, F., López-Ramón, M., Alis, R., Garatachea, N., Pareja-Galeano, H., Santos-Lozano, A., . . . Lucia, A. (2016). No evidence of adverse cardiac remodeling in former elite endurance athletes. Int J Cardiol, 222, 171-177. doi:10.1016/j.ijcard.2016.07.197

 

International Criteria for ECG Interpretation in Athletes- Top Ranked Journals Publish Consensus Guidelines

9 Mar, 17 | by BJSM

The new “International Criteria for ECG Interpretation in Athletes” consensus guidelines have been published by the British Journal of Sports Medicine and co-published in two prestigious cardiology journals, the Journal of the American College of Cardiology and the European Heart Journal.

“This consensus guideline is a major milestone in the cardiovascular care of athletes,” said lead author and AMSSM past-president Jonathan Drezner, MD. The statement is the product of the 2nd Summit on ECG Interpretation in Athletes held in Seattle, WA, in February 2015. The event was made possible by support from AMSSM, FIFA and the NCAA. This unique collaboration among world leaders in sports cardiology provides updated standards for ECG interpretation in athletes and a clear guide to the secondary evaluation of ECG abnormalities.

The guideline is freely accessible at: http://bjsm.bmj.com/content/early/2017/03/03/bjsports-2016-097331

Sudden cardiac death remains the leading cause of mortality in athletes during sport. In the U.S. and most countries, a shortage of physician expertise limits wider application of the ECG in the care of the athlete. Thus, a critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology.

The statement is endorsed by 16 international sports medicine and cardiology societies including:

American Medical Society for Sports Medicine (AMSSM), Austrian Society of Sports Medicine and Prevention, Brazilian Society of Cardiology – Department of Exercise and Rehabilitation (SBC – DERC), British Association for Sports and Exercise Medicine (BASEM), Canadian Academy of Sport and Exercise Medicine (CASEM), European College of Sports and Exercise Physicians (ECOSEP), European Federation of Sports Medicine Associations (EFSMA), European Society of Cardiology (ESC) Section of Sports Cardiology, Fédération Internationale de Football Association (FIFA), German Society of Sports Medicine and Prevention, International Olympic Committee (IOC), Norwegian Association of Sports Medicine and Physical Activity (NIMF), South African Sports Medicine Association (SASMA), Spanish Society of Cardiology (SEC) Sports Cardiology Group, Sports Doctors Australia, and the Swedish Society of Exercise and Sports Medicine (SFAIM). The American College of Cardiology (ACC) affirms the value of this document (ACC supports the general principles in the document and believes it is of general benefit to its membership).

About the AMSSM: AMSSM is a multi-disciplinary organization of sports medicine physicians dedicated to education, research, advocacy and the care of athletes of all ages. The majority of AMSSM members are primary care physicians with fellowship training and added qualification in sports medicine who then combine their practice of sports medicine with their primary specialty. AMSSM includes members who specialize solely in non-surgical sports medicine and serve as team physicians at the youth level, NCAA, NFL, MLB, NBA, WNBA, MLS and NHL, as well as with Olympic teams. By nature of their training and experience, sports medicine physicians are ideally suited to provide comprehensive medical care for athletes, sports teams or active individuals who are simply looking to maintain a healthy lifestyle. www.amssm.org.

Cardiovascular screening in athletes: time to refocus!

3 Jan, 17 | by BJSM

By Dave Siebert, MD, @DaveMSiebert

focus

When medical students learn about hypertrophic cardiomyopathy (HCM), one fact often resonates as a shocking and tragic reality: it frequently first presents as sudden death. Yet HCM is just one of a heterogeneous list of pathologic structural and electrical cardiac disorders that can cause sudden death in athletes without prior warning. This troubling fact presents many challenges to clinicians striving to protect athletes from catastrophic incidents on the field of play.

The decision to screen an asymptomatic patient for disease is not always clear cut. The scientific literature is constantly in flux, requiring those that make medical recommendations to continually re-evaluate the best available evidence. When that evidence starts to conflict with historical practices, controversy often results.

Screening athletes for silent cardiovascular disease – such as HCM, long QT syndrome (LQTS), and arrhythmogenic right ventricular cardiomyopathy to name a few – is no different. However, the evidential landscape is in the midst of a dramatic shift.

In their recent BJSM manuscript1, Drs. Jonathan Drezner, Kimberly Harmon, Irfan Asif, and Joseph Marek present a critical review of cardiovascular screening in young athletes. They discuss a number of factors to consider when deciding whether or not to add an electrocardiogram (ECG) to the standard athlete pre-participation physical exam. Those factors include: (1) the consistent, strong evidence suggesting sudden cardiac arrest and death (SCA/D) are much more common in certain athlete subgroups2,3; (2) evidence-based methods to risk stratify and manage patients found to have a cardiovascular condition, such as Wolff-Parkinson-White4, HCM5, or LQTS6 exist; and (3) when implemented by physicians experienced in athlete ECG interpretation using modern criteria, many conditions associated with a higher risk of SCA/D can be detected with a false-positive rate of less than 2.5%7,8.

The authors also address the very concept of cardiovascular screening itself: “The premise of CV screening in athletes is that early detection of cardiac disorders associated with SCD can reduce morbidity and mortality through individualized and evidence-driven disease-specific management. Without believing in the benefit of early detection, then screening by any strategy is called into question. If one believes in early detection, screening by history and physical examination alone is inadequate.”

In September 2016, the American Medical Society for Sports Medicine (AMSSM) brought widespread attention to this dilemma with the publication of its Position Statement on Cardiovascular Preparticipation Screening in Athletes9. The consensus panel concludes that “the current (Preparticipation Physical Evaluation), while pragmatic and widely practiced, is limited in its ability to identify athletes with conditions at risk for SCA/D.” Moreover, the group discusses their concern that standardized symptom and family history questionnaires demonstrate a high false positive rate, sometimes surpassing 30%. Ironically, a high false positive rate is frequently cited as a potential pitfall of ECG screening, but the numbers aren’t comparable.

Where does the most recent evidence truly lie?

In two independent studies7,8, standard pre-participation history and physical exams failed to identify each of eight college athletes found to have potentially lethal cardiac disorders detected by screening ECG. At the same time, in one of these studies8, 37.2% of athletes reported one or more positive responses on a history questionnaire, and 3.5% had abnormal physical exam findings. The false-positive rate for an abnormal ECG, on the other hand, was just 2.2%.

Said another way, standard history or physical exam data were positive in over one-third of athletes but did not yield a single meaningful cardiac diagnosis. Conversely, each diagnosis that was made was done so solely by ECG during an otherwise negative screen.

Importantly, proponents for more intensive cardiovascular screening state that national mandates for ECG screening are not appropriate1,9. Rather, they call for the development of a trained physician infrastructure to conduct more effective screening for targeted athlete populations.

One of the most important characteristics of a screening tool is its ability to detect the disease in question in its pre-clinical state. However, many of the cardiovascular conditions relevant to young athletes often first present as sudden death in an otherwise asymptomatic patient. As such, the practice of relying on a symptom questionnaire is inherently called into question.

When deciding whether or not to add an ECG to the standard history and physical exam to screen for silent, potentially lethal cardiovascular diseases, a clinician must remember to ask themselves one simple question: What am I really looking for? After all, widespread agreement about the purpose of cardiovascular screening, achieving early detection of athletes with at-risk disorders, already exists. However, the standard history and physical exam just isn’t enough.

It’s time to refocus.

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Dave Siebert, MD, @DaveMSiebert is a Primary Care Sports Medicine Fellow, University of Washington. Contact: siebert@uw.edu

References

1Drezner JA, Harmon KG, Asif IM, Marek JC. Why cardiovascular screening in young athletes can save lives: a critical review. Br J Sports Med. 2016 Nov;50(22):1376-1378.

2Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, Zigman ML, Ellenbogen R, Rao AL, Ackerman MJ, Drezner JA. Incidence and etiology of sudden cardiac arrest and death in high school athletes in the United States. Mayo Clin Proc. 2016 Nov;91(11):1493-1502.

3Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, Zigman ML, Ellenbogen R, Rao AL, Ackerman MJ, Drezner JA. Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association athletes: a decade in review. Circulation. 2015 Jul 7;132(1):10-9.

4Rao AL, Salerno JC, Asif IM, Drezner JA. Evaluation and management of Wolff-Parkinson-White in athletes. Sports Health. 2014 Jul;6(4):326-32.

5Maron BJ, Rowin EJ, Casey SA, Lesser JR, Garberich RF, McGriff DM, Maron MS. Hypertrophic cardiomyopathy in children, adolescents, and young adults associated with low cardiovascular mortality with contemporary management strategies. Circulation. 2016 Jan 5;133(1):62-73.

6Johnson JN, Ackerman MJ. Return to play? Athletes with congenital long QT syndrome. Br J Sports Med. 2013 Jan;47(1):28-33.

7Fuller C, Scott C, Hug-English C, Yang W, Pasternak A. Five-year experience with screening electrocardiograms in National Collegiate Athletic Association Division I athletes. Clin J Sport Med. 2016 Sep;26(5):369-75.

8Drezner JA, Prutkin JM, Harmon KG, O’Kane JW, Pelto HF, Rao AL, Hassebrock JD, Petek BJ, Teteak C, Timonen M, Zigman M, Owens DS. Cardiovascular screening in college athletes. J Am Coll Cardiol. 2015 June 2;65(21):2353-5.

9Drezner JA, O’Connor FG, Harmon KG, Fields KB, Asplund CA, Asif IM, Price DE, Dimeff RJ, Bernhardt DT, Roberts WO. AMSSM position statement on cardiovascular preparticipation screening in athletes: current evidence, knowledge gaps, recommendations and future directions. Br J Sports Med. 2016 Sep 22.

Counseling athletes with hypertrophic cardiomyopathy; a difficult task for the sports physician.

7 Oct, 16 | by BJSM

By Dr. Tijmen van Assen, Wouter van Everdingen, and Prabath Lodewijks

Recently the combined American Heart Association / American College of Cardiology (AHA/ACC) taskforces defined eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities [1]. In this blog we discuss the recommendations of the task force concerning hypertrophic cardiomyopathy (HCM). HCM is the most common non-traumatic cause of sudden death in young competitive athletes [2]. HCM is also a common genetic heart disease, occurring in at least 1 in 500 people in the general population [3]. The diagnosis HCM is usually based on a typical and homogenic clinical phenotype; left ventricular (LV) hypertrophy without chamber dilatation in the absence of another cardiac or systemic disease capable of producing the magnitude of hypertrophy [4, 5]. The biggest challenge in counseling these patients may be the genetic heterogeneity of the disease. Over 1500 mutations from at least eleven major genes are described in HCM [6]. Potentially all unique genetic mutations behave different, leading to a rather complicated risk stratification strategy and counseling of athletes.

Sudden death risk

Recent risk stratification algorithms have effectively identified people at high risk for ventricular tachyarrhythmias (≥1 of the following risk factors; non-sustained VT on ambulatory (Holter) ECG, family history of HCM-related sudden death, unexplained syncope, massive LV hypertrophy ≥30mm on echocardiography or MRI [7]). Primary prevention of sudden cardiac death in these patients is effectuated by implantation of an ICD. ICD implantations have reduced HCM related sudden death to 0.5% per year [8]. In these HCM patients 4% receive appropriate ICD interventions per year. Nevertheless a subgroup of HCM patients without conventional risk factors, and thus without ICD, still die (0.6% per year in non ICD-populations) [8].

An additional risk factor for sudden cardiac death in HCM patients is high intensity competitive sports. High intensity activities cause physiological stress and have an unpredictable interaction with the underlying electrophysiological substrate. The interaction is possibly influenced by alternations in hydration, blood volume, electrolytes, as well as cathecholamine surge [1].

A new patient population is emerging, due to an increasing number of HCM family members which are diagnosed with documented disease causing mutations but without the clinical HCM phenotype [6]. Conversion to LV hypertrophy occurs most often in adolescence, but has also been observed in midlife and beyond [9, 10]. The difficulty is that the onset of hypertrophic growth is unpredictable and usually not accompanied by cardiac symptoms. But when LV hypertrophy is present, the patient may theoretically be subject to an unstable HCM electrophysiological substrate [1].

The abovementioned remarks and influencing factors indicate the difficulty to apply conventional risk-stratification strategies and to advise competitive athletes accordingly. Therefore, the AHA/ACC task force states that conservative and prudent recommendations regarding sports eligibility apply across the broad HCM disease spectrum and they come forward with four recommendations (table 1).

cardio-table-4-blg

 

Discussion

The recommendations stated in the table are rather black and white, while counseling of athletes is often more of a grey zone. According to recommendation 1, an asymptomatic, genotype-positive HCM patient without evidence of LV hypertrophy may be allowed to participate in competitive sports. An important addition however, is that the physician must agree with the athlete on the follow up frequency and modalities, as the physician should not miss an asymptomatic conversion to LV hypertrophy, because this could be subject to an unstable HCM electrophysiological substrate.

In these AHA/ACC statements the allowed sports intensity is limited to class 1A sports, corresponding with sports such as bowling, curling and golf. One may think that a slightly more liberal policy with appropriate follow up should be possible. Sports with a high static component cause high cardiac pressure load. This can result in cardiac hypertrophy and in that case may accelerate the HCM process in this patient group. Although it is not a dichotomous concept, sports with a predominant dynamic component cause pressure load in a lesser extent and therefore may be allowed in some HCM patients [11].

Statement 4 regarding the use of prophylactic ICD’s is quite clear. These devices should not be implanted for the primary purpose of permitting participation in high intensity competition. However, no statement is made for HCM patients who did receive an ICD because of a high risk profile. Again a more liberal policy on sports with a more dynamic component may be considered.

Conclusion

Key point in the counseling of athletes with HCM is to give advice tailored to the individual and to perform proper follow up in order to assess the myocardial consequences of the level of activity. In this way the patients’ policy can be adjusted in accordance to the progression of disease. A fully informed athlete who is at low risk on forehand should be enabled to play a role in shared decision making. However, final decision should always be in concert with all engaged parties, including the physician.

References

  1. Maron, B.J., et al., Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation, 2015. 132(22): p. e273-80.
  2. Maron, B.J., et al., Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation, 2009. 119(8): p. 1085-92.
  3. Maron, B.J., et al., Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Echocardiographic analysis of 4111 subjects in the CARDIA Study. Coronary Artery Risk Development in (Young) Adults. Circulation, 1995. 92(4): p. 785-9.
  4. Maron, B.J. and M.S. Maron, Hypertrophic cardiomyopathy. Lancet, 2013. 381(9862): p. 242-55.
  5. Maron, M.S., et al., Hypertrophic cardiomyopathy phenotype revisited after 50 years with cardiovascular magnetic resonance. J Am Coll Cardiol, 2009. 54(3): p. 220-8.
  6. Maron, B.J., M.S. Maron, and C. Semsarian, Genetics of hypertrophic cardiomyopathy after 20 years: clinical perspectives. J Am Coll Cardiol, 2012. 60(8): p. 705-15.
  7. Maron, B.J., et al., Implantable cardioverter-defibrillators and prevention of sudden cardiac death in hypertrophic cardiomyopathy. JAMA, 2007. 298(4): p. 405-12.
  8. Maron, B.J., et al., Hypertrophic Cardiomyopathy in Adulthood Associated With Low Cardiovascular Mortality With Contemporary Management Strategies. J Am Coll Cardiol, 2015. 65(18): p. 1915-28.
  9. Maron, B.J., et al., Onset of apical hypertrophic cardiomyopathy in adulthood. Am J Cardiol, 2011. 108(12): p. 1783-7.
  10. Maron, B.J., et al., Development of left ventricular hypertrophy in adults in hypertrophic cardiomyopathy caused by cardiac myosin-binding protein C gene mutations. J Am Coll Cardiol, 2001. 38(2): p. 315-21.
  11. Pluim, B.M., et al., The athlete’s heart. A meta-analysis of cardiac structure and function. Circulation, 2000. 101(3): p. 336-44.

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Tijmen van Assen, MD PhD is a resident in sports medicine at the University Medical Center (UMC) in Utrecht. Before the start of his residency, he conducted his PhD studies on the Anterior Cutaneous Nerve Entrapment Syndrome (ACNES), a frequently overlooked abdominal wall pain syndrome due to an entrapment of anterior cutaneous branche of the intercostal nerve (see for pdf: https://cris.maastrichtuniversity.nl/portal/files/1660458/guid-3f3497bc-c111-4c6a-be61-b9425761dc4c-ASSET1.0)

Wouter van Everdingen, MD is a PhD-student at the Cardiology Department of the University Medical Center (UMC) in Utrecht. He also works as a physician in the Sports Department of the UMC Utrecht.

Prabath Lodewijks, MD, is a sports physician in the University Medical Center (UMC) in Utrecht. He is also the team physician of FC Utrecht, a professional football team playing in the Dutch Eredivisie, the highest league of The Netherlands.

AMSSM and FIFA Hold 2nd Summit on ECG Interpretation in Athletes with top Worldwide Sports Cardiology Experts

27 Feb, 15 | by BJSM

Focus on scientifically driven ECG interpretation standards, developing clear guide to the proper evaluation of ECG abnormalities in athletes and updates to Free Online Training Program for Physicians.

vectorSEATTLE, Wash. – In a continued effort to help physicians more accurately interpret ECG results to improve cardiac safety in athletes and impact sudden cardiac death, the American Medical Society for Sports Medicine and the FIFA Medical Assessment and Research Center (FMARC) are bringing together top sports cardiology and sport medicine physicians from around the world for the 2nd Summit on ECG Interpretation in Athletes in Seattle Feb. 2627.

The Summit will focus on reaching agreement upon scientifically driven ECG interpretation standards, defining clear steps in the evaluation of ECG abnormalities and making updates to free online ECG learning modules that were designed as a result of the first ECG Summit. The 2012 Summit yielded four consensus papers and the launch of the educational modules available on the AMSSM and British Medical Journal learning site. To date, more than 13,000 modules have been completed by physicians from over 117 countries.

More than 30 of the world’s foremost authorities in sports cardiology and sports medicine will be part of the Summit, which is also being supported by the National Collegiate Athletic Association (NCAA) and includes representatives from the American College of Cardiology (ACC) Sports & Exercise Council, the European Society of Cardiology (ESC) Sports Cardiology Section and the Pediatric & Congenital Electrophysiology Society (PACES). The expert panel includes participants from 10 countries – Australia, Austria, Belgium, Brazil, Italy, Qatar, Sweden, Switzerland, the United Kingdom, and the United States.

“Whether an ECG is performed for screening or diagnostic purposes, physicians responsible for the cardiovascular care of athletes must be guided by ECG interpretation standards that distinguish normal ECG findings in athletes from ECG abnormalities requiring additional evaluation for conditions associated with sudden cardiac death,” said past AMSSM President Jonathan Drezner, MD, who is chair of the meeting. “Ideally, these standards, combined with greater physician education, will improve disease detection and limit false positive results.”

The 2012 meeting helped establish athlete specific ECG interpretation standards dubbed the “Seattle Criteria.” The 2015 Summit will update these standards based on new and emerging research to produce an international consensus to guide ECG interpretation in athletes. Dr. Drezner, who is also director of the UW Medicine Center for Sports Cardiology and a team physician for the University of Washington Huskies and Seattle Seahawks, added, “We all want athletes to be safe during sports participation. The summit represents a true scientific collaboration and commitment from the sports medicine and cardiology communities to protect the cardiovascular health and safety in athletes.”

The AMSSM is a multi disciplinary organization of sports medicine physicians whose members are dedicated to education, research, advocacy, and the care of athletes of all ages. Founded in 1991, the AMSSM is now comprised of more than 2,700 sports medicine physicians whose goal is to provide a link between the rapidly expanding core of knowledge related to sports medicine and its application to patients in a clinical setting.

Life saved in semi final of SAFF Championship 2013 by FIFA-supplied AED (FMEB – FIFA Medical Emergency Bag)

11 Sep, 13 | by Karim Khan

Preventing sudden cardiac death was a critical forum topic at the 2012 FIFA Medical Conference in Budapest.  Advocates argued that pitch-side automated external defibrillators (AED) be required at FIFA competitions all over the world. In the last 5 years, only 24 of 84 football players who suffered cardiac arrest survived. Tragically, there was no AED available at the stadium in 80% of cases. 

So what happened next – what ACTION was taken?

We are delighted to share this good news story, this GREAT news story forwarded via email to us by Jiří Dvořák (FIFA Chief Medical Officer, Chairman F-MARC, BJSM co-author of: Consensus statement: The FIFA medical emergency bag and FIFA 11 steps to prevent sudden cardiac death: setting a global standard and promoting consistent football field emergency care)     

Dear Dr. Jiri,

Wanted to inform you that in Kathmandu, Nepal during a semi final match of SAFF Championship 2013 between Nepal and Afghanistan on 8th September 2013 one player of the Afghanistan team, had a minor cardiac arrest. His life was saved due to timely intervention of competition doctor Dr. Binmra Bista. He used the FIFA-supplied AED to successfully revive the player and then quickly shifted to hospital within the span of 3-4 minutes. In hospital all tests were carried out and the tests reports were normal.

I spoke to Dr. Bista after the end of the match, he used the AED for the first time and he also thanked FIFA for supplying AEDs. It was a great experience for this doctor and he was very quick sense the real problem and thus he ended up using  the AED.

I think tomorrow you might be able to read some news stories on this.

Thanks and best regards,

shaji

Shaji Prabhakaran, Regional Development Officer at FIFA

Remember that BJSM has published theme issues on Sports Cardiology including screening and prevention of sudden cardiac death (November 2012 and February 2013). The AMSSM and FIFA collaborated on an ECG interpretation module hosted by BMJ Learning

AMSSM Module

 

Now the Wall Street Journal chimes in on athlete’s heart

24 Aug, 11 | by Karim Khan

Today a short link to the Wall Street Journal. [this link is to a free, shorter version of the paper – subscription version highlighted below].
BJSM Senior Associate Editor Jon Drezner is quoted liberally – all good stuff for sports medicine and for his University of Washington. Sports cardiology is a hot topic when it makes the mainstream media. We ran a sports cardiology blog yesterday — interpreting athletes’ ECG/EKG and now WSJ adds interesting new issues! Mandatory exclusion is clearly a tricky issue.

Next thing the editorial team will get accused for making this the BJSC – British Journal of Sports Cardiology!

See the links in yesterday’s guest blog (by Dr Babette Pluim – her PhD was in sports cardiology!). Also, Jon Drezner did a nice job explaining all this in his podcast!
There are key papers Online first and a couple of very interesting ones in the pipeline! Keep an eye out in the BJSC, oops, I mean BJSM for the latest in Sports Cardiology.

BJSM blogs are flagged for you on Twitter (@BJSM_BMJ). We also send other interesting links using that medium (one to two tweets per day).

Don’t forget our current home page – great IOC-supported theme issue on sport in young people and health.

New Guidelines to Improve ECG/EKG Interpretation in Athletes – Guest Blog by Dr Babette Pluim

22 Aug, 11 | by Karim Khan

Should 12-lead ECG be part of the pre-participation examination of athletes? Those in favor of ECG screening argue that it reduces the risk of sudden cardiovascular death;  those against screening point out the low cost-effectiveness, the low disease prevalence resulting in a low positive predictive value, the difficulties in distinguishing abnormal electrocardiographic changes indicative of cardiac pathology from normal, training-induced alterations and the inconsistencies in the definition of ECG abnormalities.

New perspective

In a recent edition of Circulation, Uberoi et al. tackled this obstacle of the varying definition of ECG abnormalities and have written a good, educational article that focuses on the interpretation of the electrocardiogram of athletes (Interpretation of the electrocardiogram of young athletes, Circulation 2011;124:746-757)

The European Society of Cardiology recently published new recommendations for the interpretation of the ECG in athletes. The strength of this current article by Uberoi et al. is that it builds on the guidelines of the European Society of Cardiology, but elaborates this even further, refines the recommendations, and includes excellent figures to illustrate the various examples.

Uberoi’s article discusses specific aspects of interpretation, presents the author’s commendations and then critiques the document of the European Society of Cardiology. The following aspects of the ECG are discussed: Increased QRS voltage, early repolarization, Q waves, conduction delay, QRS axis deviation, right ventricular hypertrophy, atrial abnormalities, T-wave inversion, ST depression, QT abnormalities (long and short), Brugada-like abnormalities and ARVD, ventricular preexitation, and ventricular extrasystoles and supraventricular arrhythmia.

The main conclusions and recommendations of the article are summarized in one clear table (Table 5 – split between two pages, 753-4).

A very useful and educational for anyone who is involved in the ECG screening of athletes! Read this great article in Circulation. And remember, sports cardiology is a major focus of BJSM – see the September 2009 issue (still highly topical), read the WarmUp for that issue, and listen to Senior Associate Editor Jon Drezner’s recent podcast of updates on sports cardiology. Previous blogs too!  Hot hot hot!!

Figure 5 (part 1, p. 753)

Figure 5. Summary of recommendations for screening PPE ECG. PPE indicates preparticipation examination; RAA, right atrial abnormality; LAA, left atrial abnormality; RVH, right ventricular hypertrophy; RAD, right axis deviation; RBBB, right bundle branch block; TWI, T-wave inversion; and QTc, heart-rate correction of the QT interval. (part 2, p. 754)

Guest Blog – Sports Cardiology by Dr Jon Drezner

12 Aug, 11 | by Karim Khan

This week in Circulation, Dr. Eloi Marijon and colleagues from France published their findings on sports-related sudden death.  This 5-year prospective observational study is an impressive achievement and also has a number of important findings.

How high is an athlete’s risk of SCD?

Notably, the relative risk of sports-related sudden death was 4.5 times higher in competitive young athletes (age 10-35) compared to noncompetitive sports participants of the same age.  Pre-participation cardiovascular screening is recommended for young competitive athletes, but little attention is given to cardiovascular screening in the general population of adolescents and young adults.

When considering ECG screening in athletes, many opponents suggest that athletes should not be selected out and receive more advanced screening at an additional cost when that same testing is not available to others.  This study supports that competitive young athletes are at higher risk then the general population of their peers participating in recreational sporting activities. The only other study to compare this was by Corrado (1999) who also found a higher risk of SCD in competitive athletes compared to age-matched controls (RR 2.5).  These population based studies support efforts for more intensive primary prevention of competitive athletes that are at a higher risk.

But…

I don’t think that athletes necessarily have a higher prevalence of cardiovascular disorders at risk for sudden death.  I believe the difference is in exposure time – with competitive athletes engaging in moderate or vigorous physical exertion more often than recreational athletes – and thus being exposed to the potential trigger (exercise) for SCA in the setting of their underlying heart condition.

The study found an annual incidence of sports-related sudden death of about 1 in 100,000 young competitive athletes in France.  This is consistent with population data from Norway (Solberg 2010) and about 2 times higher than prior estimates in the U.S.  Harmon et al. (2011) recently published a very high rate of SCD in U.S. college athletes (1:43,000), with some risk groups such as black male athletes with an alarming rate of SCD (1:13,000).

Early defib works!

As expected, the study confirms the critical impact of bystander CPR and early defibrillation after SCA.  It is interesting that both CPR (OR 3.73) and defibrillation (OR 3.71) had about the same influence on survival in the multiple logistic regression analysis.  Clearly both carry tremendous importance in improving survival after sports-related sudden death.  With a mean time from collapse to initiation of CPR of 4.8 minutes, and a mean time from collapse to first shock of 12.5 minutes, recommendations for improved bystander CPR training and access to AEDs in the sports setting is warranted. I suspect that if AEDs were more available and therefore defibrillation provided with less delay, that the odds ratio for use of defibrillation would be even higher.

The study breaks down the etiologies of SCD in young competitive athletes which are also very valuable.  The most common cause was unexplained, and many other studies also support that the leading cause of SCD in this age group is autopsy-negative sudden unexplained death, perhaps representing underlying ion channel disorders.  HCM or possible HCM represented only 14% of the cases in the study, which has been heavily suggested as the leading cause of SCD in U.S. athletes.  More research is needed to understand these differences, if they are real or influenced by methodology, ascertainment bias, and/or ethnicity.

Jonathan Drezner, MD – BJSM Senior Associate Editor (Sports Cardiology)

Associate Professor, Department of Family Medicine

Associate Director, Sports Medicine Fellowship

Team Physician, Seattle Seahawks & UW Huskies

University of Washington

4 more bonus features for you from BJSM (just a snippet of all the sports cardiology — BJSM is #1 in sports cardiology!)

1. You can listen to Jon Drezner’s podcast at http://tiny.cc/m5v38

2. Graphic (above) is the cover of the September 2009 IOC-supported special theme issue on sudden cardiac death – Table of contents herehttp://bjsm.bmj.com/content/43/9.toc

3. For a more recent paper, see Online First (not free) – Automated external defibrillator use at NCAA Division II and III universities by Drezner, Rogers and Horneff

4. To follow BJSM updates on Twitter @BJSM_BMJ

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