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And the winner of best 2016 BJSM cover is..

28 May, 17 | by BJSM

SPORTS CARDIOLOGY: LOWERING RISK IN ATHLETES is the winning cover for 2016! Thank you to everyone that voted. The IOC Exercise & Pregnancy in Athletes Expert Group issue came in a close second.

January-50-2: Sports Cardiology: Lowering Risk in Athletes

We caught up with Dr. Jonathan Drezner, Editor of the Sports Cardiology issue, to ask him a few questions.

BJSM: Congratulations! How do you feel about winning “BJSM best cover” for 2016?

This is a great honor!  BJSM has a long history of unique and striking covers that draw attention to the important content of each issue.  To be selected as the 2016 best cover is an unexpected distinction.  But the real credit must be given to the brilliant work of Vicky Earle – BJSM graphics and cover specialist – who behind the scenes makes every cover special and a winner in its own right!

What important message does this cover illustrate?

The January 2016 BJSM issue was a special issue dedicated to sports cardiology and lowering athlete risk towards the prevention of sudden cardiac death (SCD).  This topic has captured the interest and efforts of the sports medicine community for many years.  Most recently, epidemiologic data has drawn attention to the differential risk of SCD in athletes – i.e. the concept that some athlete groups are at higher risk than others.  The cover depicts blindfolded people bumping into an elephant and imaging different risky outcomes.  One could interpret many things from this.  In the sports cardiology world, many have chosen to keep their head in the sand about athlete risk… unwilling to accept new science and robust data defining high risk groups and continuing to promote misinformation about incidence rates that depict a “rare” problem not worthy of our intervention.  We must open our eyes to the problem.  The very athletes we are charged of caring for and ensuring their safety on the playing field continue to die.  As a medical community, our response has been slow and clouded by debate, misperceptions, and faulty science.  For some, we must take off our blindfolds to see the true risk!  The solutions are not easy and many potential preventive strategies have their own challenges and limitations, but until we open our eyes as a discipline we cannot move forward.

This cover also carries a personal meaning for me.  In October 2015 I was honored to participate in the SASMA conference held in Johannesburg, South Africa.  The conference embodied collaboration and mentorship and inspired education at all levels.  It also featured a sports cardiology symposium.  After the conference the visiting faculty were treated to a safari experience with Dr. Jon Patricios and his family. It was an incredible experience with memories for a life-time. The elephant on the cover is a reminder of my experience in South Africa and also motivated the title and substance of my warm-up for this special issue: “ ‘Big Five’ of sports medicine: preparation, teamwork, passion, mentorship and collaboration. ”

 What in this issue, stands out for you as the ‘gold standard’ of SEM work?

This issue had many terrific articles.  The original research by Dhutia et al. represents a benchmark study that shed critical understanding on short QTc cut-offs in athletes.  It is one of many important contributions by Professor Sanjay Sharma and his research team from St. George’s University of London and the outstanding charity organization CRY (Cardiac Risk in the Young).  This study was used to help define QTc threshold values in the new International Criteria for Electrocardiographic Interpretation in Athletes: Consensus Statement (BJSM 2017 May;51(9):704-731).

In your opinion, where do we head from here?

First, Vicky must continue to guide the cover masterpieces of BJSM!  From a sports cardiology perspective, we must strive for better prevention, identification of athletes at risk, and safe participation in sports and exercise for all.

***

Stay tuned for the official announcement of the prize winners.

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.

*********************

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.

Sudden cardiac death in sport: time to simplify the guidelines to base them on mechanism and collapse – not breathing assessment.

7 Jun, 16 | by BJSM

By Dr Jonathan Hanson (@SportsDocSkye)

Another on field cardiac death in sport. Another debate about screening and medical care.

The successful resuscitation of Premier League football player Fabrice Muamba in 2012, in stark contrast to the tragic death of Marc Vivian Foe 9 years earlier, broadcast the role of basic life support and early defibrillation is to all with an interest in sport.

Media scrutiny of the recent on field death of Patrick Ekeng in Bucharest focused on the medical care provided during the incident. Professionals and the public expect high standards.

The majority of first responders in sport are either physiotherapists or from a primary care background – a population without frequent exposure to critically unwell patients. Although an accepted standard of training in sports pre-hospital care exists through a number of worldwide courses (including under the auspices of FIFA and UEFA), the ability to act appropriately still requires situation awareness, pattern recognition and appropraite decision making and excellent technical skills in a time of crisis.

Are we overcomplicating the challenge in the sport setting? 

By adhering to guidelines designed to treat a person on the street or in hospitals do we make it harder for those who assume the responsibility of first responder in sport?

Drills, checks, and sound clinical governance will help minimise the practical skill loss (often quoted at 90% skill loss at 1 year). But how can we assist in making the decision making easier?

As an emergency medicine doctor and sports physician I have seen quite a lot of cardiac arrests. I cannot recall any of the cases I have seen in hospital looking like the patient in the Mark Vivian Foe video, Fabrice Muamba, or this week’s Patrick Ekeng case.

The wide staring eyes, the very rapid but inefficient respiratory effort from arresting in a state of hyper adrenergic exercise and lactate debt, and the small degrees of twitching or movement do not make up what I typically see in my cardiac arrest experience in hospitals in the unwell, elderly or in patients who have arrested a few minutes before I arrive. My cardiac arrest experience does not cover folks like Patrick Ekeng either.

 

Current basic life support guidelines rely upon either a 10 second assessment for “normal” breathing (European guidelines) or simple “scan for breathing” (American Heart Association guidelines) as the decision making step to commence basic life support. We are advised not to confuse normal breathing with “agonal breathing” which is defined as slow, irregular and inefficient breaths of a dying patient. This description does match not the rapid regular agonal breathing initially witnessed in Muamba, Foe or Ekeng.

Is it any wonder that inexperienced but trained pitch side medical staff find it difficult to recognise the unusual rapid variant of agonal breathing of cardiac arrest in athletes? Our niche patient group and speed of response point toward the need for customised guidelines. It’s easy to mistake agonal breathing for normal breathing if it looks slightly atypical and you’ve never seen it before with the additional pressures of the stadium environment TV coverage.

Our aim should be to make it easier for the responder to recognise the diagnosis and commence CPR/AED. Thus increasing the chance of survival from 6% (no CPR) to 35% (CPR plus AED). A survival rate of 35% still sounds poor – but it is a six times increase as compared to the survival rate with no CPR/ AED.

 

Resuscitation guidelines do evolve. Concerns over disrupting a pelvic haematoma through “springing the pelvis” on examination in the primary survey of trauma patients led to a revision of the approach to pelvic fracture diagnosis. Now the decision is based on mechanism rather than the examination. If the mechanism is suspicious, the pelvis is treated as fractured and a binder applied without any springing until imaging suggests otherwise.
In spinal immobilisation in sport, although guidelines support minimal handling and the use of split devices to minimise logrolling, we often deal with much larger and wider body shapes than the general public body shape. More often than not we face a moving and handling safety issue in addition to concerns about spinal injury. Only a tiny minority of spinally packaged athletes need to go onto hospital and they are generally not multiply injured. The majority are removed from the device at the medical room and so don’t need to worry about pressure areas etc. Hence we work around the guidelines to fit our situation, sometimes using out of vogue long spine boards to accommodate the additional size and moving and handling challenge, rather than carrying directly on split devices designed for “normal” heights and widths.

 

Why can’t we adjust the resuscitation guidelines?

The morbidity from inappropriate CPR is very small and the AED will not give a shock to someone who does not need it.

The decision around whether to begin CPR could be made purely on the mechanism of off-the-ball collapse, thus simplifying the first responder’s decision, increasing the likelihood of high quality compressions with minimal interruptions and prompt use of a defibrillator.

It’s time to make the change and move to a mechanism based decision on commencing CPR.

A sudden off-the-ball collapse in sport should always be regarded as a cardiac arrest and receive a response with CPR and AED. We should adjust our training accordingly and educate on agonal breathing in the post exercise state.

This is in keeping with FIFA’s 11 steps to prevent cardiac death – but this needs to be adopted more widely.

“Performance of the emergency medical plan

  • Immediate recognition of collapsed player
    1. Assume SCA if collapsed and unresponsive
    2. Seizure activity and/or agonal respirations—SCA”

This would benefit of the rescuer and thus benefit the athlete.

******************

Dr Jonathan Hanson is a Sport and Emergency physician for the Sportscotland institute of sport and World Rugby Immediate care training management group.

Sudden cardiac death and ECG screening in athletes: what I think juniors need to know!

23 Oct, 15 | by BJSM

Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog series

By Daniel Taylor-Sweet (@dtaylorsweet)

Graphic_to_upload.24485429_stdProfessional athletes are among the most fit on the planet and a group you would not likely associate with sudden cardiac death (SCD). However, each year many professional and amateur athletes alike die from SCD. An athlete dying of SCD in front of the world’s media can have a devastating effect on both their families. Within the last few months the deaths of footballers: David Oniya [1], Gregory Mertens [2], Tim Nicot [3] and Cristian Gomez [4] have all been in the headlines.

SCD is essentially any non-traumatic and unexplained sudden death occurring from a cardiac arrest within 6 hours of participating in sport. [5] SCD occurs at a rate of between 0.9 and 1.21 cases per 100,000-athlete person-years. [6] Several different diseases such as hypertrophic cardiomyopathy (HoCM), congenital coronary anomalies and arrhythmogenic right ventricular dysplasia can cause SCD. [10]

HoCM is the most common cause of SCD in athletes, causing around 50% of cases. [11] It can be picked up by screening and exists in ~0.07% screened athletes. HoCM is fatal for athletes as a result of ventricular fibrillation. The main problem with HoCM is that the fatal episode is usually the first manifestation of the disease; so affected individuals are oblivious to the fact that they are at high risk of dropping dead. [12] HoCM can be easily diagnosed with a combination of ECG and echocardiography (however the gold standard investigation is Cardiac MRI). [13] [14] The ‘Seattle criteria’ is a recently published consensus that outlines a method of interpreting athletic ECGs and has led to improved outcomes of cardiac screening. [20]

Many governing bodies, such as the IOC, UEFA and the ICU alongside the European Society of Cardiology all recommend pre-competition ECG screening of athletes. But the situation becomes a little more confusing when organisations such as the British Heart Foundation and the American Society for Cardiology currently recommending against the ECG screening of athletes. Interestingly there is a difference in opinion between Europe and America, with the American sporting bodies having now almost fully adopted universal athlete ECG screening whereas sporting bodies in Europe have been slightly slower to launch ECG screening programs for their athletes. These differences in opinion beg the question should athletes be routinely screened for conditions that put them at risk of SCD?

The case for screening

In 1982 Italy was the first country in the world to make pre-competition cardiac screening for athletes part of the law. Their screening program involved a consultation and an ECG. In Italy prior to 1982 the rate of SCD sat at around 3.6 cases per 100,000 athlete person-years and after screening had been introduced the rate dropped down to 0.4 cases per 100,000 athlete person-years. A staggering 90% decrease in SCD in Italian athletes.

As the vast majority of athletes who die of SCD have no symptoms before their death screening is a very useful tool to identify these individuals. In athletes with HoCM there are clear, research derived treatment options that reduce their risk of death. These include lifestyle modification, competition restriction, drug treatment and implantable defibrillators. Diagnosed athletes are able to live long and healthy lives following their diagnosis. Anyone reading this article would happily attach himself or herself to an ECG machine right now – it’s this simplicity and safeness along with being both well validated and able to identify most causes of SCD that makes ECG such a very good tool for screening athletes.

The case against screening

One of the biggest problems with athlete screening at the moment revolves around the specificity of ECG when it’s used to look for HoCM. Several studies have found that when using ECG to screen for HoCM it gives 1 in 10 of screened athletes a false positive result (the number of athletes with HoCM should be around 1 in 1500). [15] This poses a big problem: as to get 1 true diagnosis you have to put 150 athletes through the psychological pressure of being told they may have a potentially fatal condition. On top of this any athlete identified will have to undergo potentially harmful further investigations, countless more consultations and would have to stop training or participating in sport – potentially hampering their careers.

Another major criticism of athlete ECG screening is that it potentially fails to be cost effective (one of the WHO’s major criteria for successful screening programs). [16] This is because of the very low numbers of athletes who have HoCM and the very large numbers of athletes who need to be screened. One study in America concluded that to prevent one case of SCD it would cost around £6.4 million [17] and when compared to the UK’s NHS Breast screening program that costs £68,500 per life saved it really begins to look very cost ineffective. [18]. One team estimated that within the USA a universal 20-year athlete ECG screening program could save over 4,800 lives but at a cost of £32 billion, which is an absolutely staggering amount of money.

Final thoughts

I believe after reviewing the literature that ECG screening should not be used by its self as a screening tool for identifying athletes at risk of SCD. It’s not specific enough to be used as a universal screening program due to the very high number of false positives it produces, this along with the exorbitant cost of screening makes it unsuitable. Excitingly a very recently published paper in the BJSM [Bessem et al, BJSM, Aug 2015] shows that when ECG is used as part as the Seattle ECG screening criteria that there is a huge reduction in the number of false positive results. [19] [20] This is very promising news as ECG screening used with the Seattle Criteria may prove more viable both economically and ethically and is definitely an area to watch in the future.  

Useful Links

BJSM Cardiology Podcast – http://bit.ly/J4IOoV

ECG Learning Module – http://bit.ly/1rPDOZT

BJSM Blog on SCD – http://bit.ly/1p26JZ9

BJSM Blog on FIFA’s view on Screening – http://bit.ly/1KMs0Bq

 

References

[1] http://www.independent.co.uk/news/people/news/nigerian-defender-david-oniya-collapses-on-pitch-and-pronounced-dead-30-minutes-later-10318790.html

[2]http://www.bbc.co.uk/sport/0/football/32537425

[3] http://www.dailymail.co.uk/sport/football/article-3076630/Tim-Nicot-dead-Second-Belgian-footballer-dies-cardiac-arrest-two-weeks-death-Gregory-Mertens.html

[4] http://www.mirror.co.uk/sport/football/news/argentine-footballer-cristian-gomez-dies-5757178

[5] Task Force 4: HCM and other cardiomyopathies, mitral valve prolapse, myocarditis, and Marfan syndrome. Maron BJ, Ackerman MJ, Nishimura RA, Pyeritz RE, Towbin JA, Udelson JE. J Am Coll Cardiol. 2005 Apr 19; 45(8):1340-5.

[6] Incidence and etiology of sports-related sudden cardiac death in Denmark–implications for preparticipation screening. Holst AG, Winkel BG, Theilade J, Kristensen IB, Thomsen JL, Ottesen GL, Svendsen JH, Haunsø S, Prescott E, Tfelt-Hansen J Heart Rhythm. 2010 Oct; 7(10):1365-71.

[10] Sudden Cardiac Death in Young Athletes; a Literature Review and Special Considerations in Asia. Farzin Halabchi, Tohid Seif-Barghi, and Reza Mazaheri. Asian J Sports Med. 2011 Mar; 2(1): 1–15.

[11] Sudden death in young athletes. Maron BJ, N Engl J Med. 2003 Sep 11; 349(11):1064-75.

[12] Incidence and aetiology of sudden cardiac death in young athletes: an international perspective. Borjesson M, Pelliccia A. Br J Sports Med. 2009 Sep; 43(9):644-8.

[13] Shirley KW, Adirim TA. Sudden Cardiac Death in Young Athletes. Clin Ped Emerg Med. 2005;6:194–9.

[14] Germans, Tjeerd; Wilde,Arthur A.M.; Dijkmans,Pieter A.; Chai,Wenxia; Kamp,Otto; Pinto,Yigal M.; van Rossum,Albert C. (2006). “Structural Abnormalities of the Inferoseptal Left Ventricular Wall Detected by Cardiac Magnetic Resonance Imaging in Carriers of Hypertrophic Cardiomyopathy Mutations”. Journal of the American College of Cardiology 48 (12): 2518–2523.

[15] Detection of hypertrophic cardiomyopathy is improved when using advanced rather than strictly conventional 12-lead electrocardiogram. Potter SL et al. J Electrocardiol. 2010 Nov-Dec;43(6):713-8. doi: 10.1016/j.jelectrocard. 2010.08.010.

[17] Halkin A, Steinvil A, Rosso, et al. Preventing sudden death of athletes with electrographic screening. J Am Coll Cardiol 2012; 60: 2271-2276.

[18] http://www.cancerscreening.nhs.uk/breastscreen/cost.html

[19] B Bessem et al, The ECG of high-level junior soccer players: comparing the ESC vs the Seattle criteria, Br J Sports Med 2015;49:1000-1006 doi:10.1136/bjsports-2013-093245.

[20] Drezner JA, Ackerman MJ, Anderson J, et al. Br J Sports Med 2013;47:122–124.

*****************************

Daniel Taylor-Sweet is fifth year medical student at Glasgow University. He is keen on all things Sports & Exercise Medicine related and is interested in pursuing a career within the field.

Dr. Liam West (@Liam_West) coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.

A risk of leaving players to lie on the ground without medical attention – death.

29 Aug, 15 | by Karim Khan

By Dr Efraim Kramer

PLDocsAs medical professionals, we have a duty to care for the sporting ill and/or injured. The health and welfare of those on the field of play is primary and paramount. What Mr Mourinho, as a commercially successful, highly motivated and acknowledged coach sometimes seems to deny is that sportsmen and women are not only injured on the football field, but may die and have indeed died. Seven football players died of Sudden Cardiac Arrest in the past three months alone — the youngest was an 11-year-old South African.

Enough noise, criticism and condemnation was make during the FIFA World Cup, Brazil 2014, concerning the various incidents of concussion and management of apparent back injuries for FIFA to update its regulations. Yet along comes Mr Mourinho, counters and criticizes his medical staff for doing exactly what they are meant to do and why they were employed in the first place and yet there is hardly any noise, muted criticism and no obvious condemnation.

I wonder if Mr Mourinho would like the medical staff to leave him lying on the ground in cardiac arrest under after the final whistle because it would not be in the interest of the game to try and resuscitate him whilst the game was in motion. The highly trained, very experienced and well-motivated medical staff who undertake duties during sports events have one primary goal – to care for, or save the patient who lies on the ground needing their assistance, skills and attention. No coach, manager or any other official is going to change that no matter the score, no matter the seeming importance of the match.

I am in full support of Dr Eva Caneiro’s management of Chelsea player Eden Hazard in the first round of the English Premier League (2015). Her work clearly met the expected and required scope of FIFA’s medical education and teaching philosophies and courses globally, as described by Prof Jiri Dvorak, FIFA Chief Medical Officer. We health professionals need to stand united and firm on this matter.

Dr Efraim Kramer is:

Head: Division of Emergency Medicine, Wits Medical School.

Extraordinary Professor: Section Sports Medicine. University of Pretoria.

Member: FIFA Medical Assessment + Research Center.

Netcare “Angels over Africa” Flight Physician.

Commentary on UK Faculty of Sport and Exercise Medicine Position Statement

18 Aug, 15 | by BJSM

”Heart Safe” communities – Why public AEDs are a good idea

By Steven Poon, MD, and Jonathan Drezner, MD, Center for Sports Cardiology, University of Washington

John Drez ECGRecently, the Faculty of Sport and Exercise Medicine (FSEM), an organization that promotes the specialist field of Sports and Exercise Medicine in the U.K., released a position statement in favor of Public Access Defibrillation programs (read it HERE).1 We applaud the FSEM’s efforts and strongly support public access to Automatic External Defibrillators (AEDs). Medical research clearly demonstrates that early use of AEDs in the treatment of sudden cardiac arrest (SCA) improves survival rates. A longitudinal, multi-center surveillance study (Cardiac Arrest Registry to Enhance Survival – CARES) in the U.S. has shown an overall survival rate of 7-10% after SCA without bystander intervention. However, studies evaluating Public Access Defibrillation in the U.S. and worldwide have shown a marked increase in survival rates, from 50-70%.2-3 In school athletic venues, survival rates to hospital discharge for young athletes with SCA reached 89% when on-site AEDs were available and used.4

We commend the statement for its concise, accurate and easily understood description of AED function, simplicity of use, portability and the vital role this device plays in increasing survival. Equipment manufacturers have emphasized the ability of bystanders to follow clearly marked application instructions and voice prompts to promote appropriate use. Furthermore, AED use has become a vital part of basic life-saving courses, such as that offered by the American Heart Association, with strong encouragement for lay person use of AEDs in emergency situations.

In addition to the excellent information presented in the FSEM position statement, other important elements for a successful Public Access Defibrillation program include AED location and placement, equipment maintenance, and an emphasis on recognizing SCA.  The success of Public Access Defibrillation programs is directly linked to ensuring that AEDs are readily available and accessible in public gathering locations. A study in Los Angeles showed increased survival rates by placing AEDs in areas with high pedestrian density such as airports and public swimming pools.5

What more can be done?

We would emphasize that proper planning to identify the optimal AED locations is crucial. Sports and fitness facilities are strategic venues to place AEDs because of their high population density and increased risk of SCA associated with exercise; survival rates are high when AEDs are available and used within exercise facilities.4 However, despite strong evidence that these are prime locations for AEDs, many exercise facilities still do not have AEDs in place.7 As a point of emphasis, AEDs should be accessible at all times to be most effective, with appropriate signage and public access – some studies have shown an unacceptable percentage of devices inaccessible or locked away at the time of need such as at night or on weekends.6

Equipment maintenance is another consideration for long-term success of a Public Access Defibrillation program. AED batteries and leads should be checked based on manufacturer guidelines (usually monthly). Within the sports medicine community, additional preparation and anticipation, including simple ‘readiness’ checks prior to sporting events, are important for emergency planning. The responsibility to properly maintain publicly located AEDs can be ill-defined, and this can lead to devices not being regularly serviced and checked. . Many AEDs now perform self-checks every 24 hours and will trigger an alarm if the battery is low or the leads need replacing. However, ensuring proper upkeep and designating the individuals responsible is essential to the program’s success.

Critical to survival and the prompt initiation of CPR and AED use is the rapid recognition of SCA. Proper management of SCA will only ensue if the emergency is recognized. The medical community can help educate the general public to understand that witnessed collapses are frequently SCA. In 2007, an inter-association task force released Guidelines for SCA recognition and management within the athletic setting.8 This document underscores that brief seizure-like activity can be a confusing hallmark of SCA in athletes, and SCA should be assumed in any (non-traumatic) collapsed and unresponsive athlete to eliminate delays in starting CPR or retrieving and applying an AED.8

The FSEM have taken a bold step to foster and improve heart safety within the U.K.  As sports medicine professionals, we should strongly support Public Access Defibrillation programs and ensure proper emergency planning and access to AEDs within our communities.

References:

  • Faculty of Sport and Exercise Medicine, “Position Statement: Automatic External Defibrillators in Public Places.” July 2015.
  • Culley LL, Rea TD, Murray JA, et al. Public access defibrillation in out-of-hospital cardiac arrest – a community based study. Circulation 2004;109:1859-1863.
  • Ringh M, Jonsson M, Nordberg P, et al. Survival after public access defibrillation in Stockholm, Sweden – a striking success. Resuscitation 2015;91:1-7.
  • Drezner JA, Toresdahl BG, Rao AL, et al. Outcomes from sudden cardiac arrest in US high schools: a 2-year prospective study from the National Registry for AED Use in Sports. Br J Sports Med 2013;47:1179-1183.
  • Eckstein M. The Los Angeles public access defibrillator (PAD) program: Ten years after. Resuscitation 2012;83:1411-1412.
  • Hansen CM, Wissenberg M, Weeke P, et al. Automated external defibrillators inaccessible to more than half of nearby cardiac arrests in public locations during evening, nighttime, and weekends. Circulation 2013;128:2224-2231.
  • Drezner JA, Asif IM, Harmon KG. Automated external defibrillators in health and fitness facilities. Phys Sportsmed 2011;39:114-118.
  • Drezner JA, Courson RW, Roberts WO, Mosesso VN, Link MS, Maron BJ. Inter-Association Task Force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement. Heart Rhythm. 2007;4:549-65

Automated External Defibrillators in Public Places: FSEM Position Statement

8 Aug, 15 | by BJSM

By Dr Zafar Iqbal & Prof John Somauroo 

@FSEM_UK Position statement

sealSudden Cardiac Arrest (SCA) is a major cause of death in developed Western countries with an estimated 60,000 cases annually in the UK. Every week in the UK 12 young people under 35 years of age die from SCA due to undiagnosed cardiac conditions. In addition, SCA occurring in those over the age of 35 is often due to coronary artery disease (the number one cause of death in the western world). In England, the ambulance service attempt resuscitation in approximately 25,000 cases per annum. However, only rarely are they able to provide defibrillation early enough for the patient to survive.

Most cases of SCA are due to Ventricular Fibrillation (VF), which is a shockable rhythm and could be returned to a normal sinus rhythm with the use of an Automated External Defibrillator (AED). The single most influential factor in improving survival is treatment with a life-saving defibrillation shock from an AED. Conditions for defibrillation are optimal for only a few minutes after the onset of VF and the best way of ensuring prompt defibrillation is having an AED nearby:

  • Using an AED is easy and can cause no harm; the Resuscitation Council (UK) states. “An AED [defibrillator] can be used safely and effectively without previous training” (RCUK Guidelines, 2010). AEDs are compact, portable, effective, require little maintenance and can be stored for long periods.
  • AEDs analyse the heart’s rhythm and will only deliver a shock if it is indicated. Once activated, the AED guides the user through each step of the defibrillation process by using voice and visual prompts.
  • Defibrillation is the use of a high-energy electric shock that stops the chaotic rhythm of VF and allows the normal, organised, electrical rhythm of the heart to re-start. This can allow the pumping action of the heart to return.
  • Standard AED pads are suitable for use in children older than 8 years. Special paediatric pads, that attenuate the current delivered during defibrillation, should be used in children aged between 1 and 8 years if they are available. If not available, standard adult-sized pads should be used. The use of an AED is not recommended in children aged less than 1 year. However, if an AED is the only defibrillator available its use should be considered (preferably with the paediatric pads described above).
  •  Following SCA, survival rates drop 7-10% every minute without defibrillation and therefore it is essential AEDs are publicly accessible. The majority of SCAs in the UK take place out of hospital where AEDs are not readily available.
  • In 2012, official figures reported that fewer than one in five people who suffer a cardiac arrest in the UK receive adequate care from bystanders. In some areas of the UK, just 1 in 14 people who suffered a cardiac arrest survived.
  • Survival rates in the UK are poor compared with international standards. For example, in Seattle in the United States and Stavanger in Norway, where many citizens are trained in cardiopulmonary resuscitation (CPR), survival from out of hospital SCA with a shockable rhythm is 52%.
  • Urgent defibrillation using an AED is the best way to re-establish the heart’s natural rhythm and CPR is also necessary to keep the patient alive. Evidence from the US shows that if an emergency ambulance is called and immediate bystander CPR is used, followed by early defibrillation and effective post-resuscitation care, survival rates following cardiac arrest can exceed 50 per cent.
    • CPR alone = 5% survival
    • CPR + early defibrillation = 50% survival
  • It is recommended that all school leavers are proficient in CPR and AED use.
  • All public AEDs should be registered with the local Ambulance Service Trust (AST) to confirm the AST is aware of the AED and can log it onto a local database. This will help ensure that an AED is accessed quickly if needed.

The survival rate from out of hospital SCA in the UK needs to improve to be comparable with other parts of the world. The major factor limiting the number of people who survive SCA is the ability to provide defibrillation within a critical time period. In countries with improved survival rates AEDs are more widely available and more of the public are trained in CPR. In the UK, as call-to-arrival times are usually greater than 10 minutes, ambulances often arrive too late to successfully resuscitate most people with out of hospital SCA. The best chance of survival for a casualty with SCA is prompt access to an AED, this could lead to a significant reduction in mortality in both children and adults.

**************************************

 

By Dr Zafar Iqbal (Sports and Exercise Medicine Physician – London) &

Prof John Somauroo (Consultant Cardiologist, Specialist in Heart Failure, Cardiomyopathies and Sports Cardiology – Chester and Liverpool)

References

1. A guide to Automated External Defibrillators (AEDs) By Resuscitation Council (UK) and British Heart Foundation. December 2013

2. Papadakis, M., Sharma, S., Cox, S., Sheppard, M.N., Panoulas, V.F. and Behr, E.R. “The magnitude of sudden cardiac death in the young: a death certificate-based review in England and Wales.” Europace 2009 Vol.11, No.10, p1353-1358

3. Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating effectiveness of

Fit to Live? Genotype-positive Phenotype-negative Hypertrophic Cardiomyopathy

3 Jul, 15 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective – A BJSM blog series

By Dr Christopher Speers

At a recent Cardiac Conditions Clinic with Dr William Bradlow (Consultant Cardiologist) at the Queen Elizabeth Hospital Birmingham, we reviewed a number of patients with Hypertrophic Cardiomyopathy (HCM) and Dilated Cardiomyopathy (DCM).

genesThese consultations produced numerous patient-centered exercise-related discussions, but one case in particular raised a challenging and novel exercise medicine dilemma; genotype positive-phenotype negative HCM.

This is seen in patients who have a family history of HCM, and have tested positive for a genetic mutation attributed to causing HCM.  However, they have normal ECGs and echocardiograms with no evidence of cardiac hypertrophy or left ventricular outflow tract obstruction. Therefore they are diagnosed as having ‘genotype positive-phenotype negative HCM’.

Are genotype positive-phenotype negative individuals at increased risk of Sudden Cardiac Death?

We know that HCM is phenotypically heterogeneous; with the age of onset, severity of symptoms, and relative risk of Sudden Cardiac Death (SCD) showing inter-patient variability even within family members with the same genetic mutation (1, 2).

Some studies have shown that particular genotype sub-groups, for example mutations of Troponin TNNT2 correlate with a higher risk of SCD.  There is also evidence that some genotype positive-phenotype negative individuals have impaired relaxation of myocardium, altered energy metabolism, and phenotypic changes such as crypts. This inherently abnormal cardiac tissue may predispose to adverse events (2, 4).

However there are only a very small number of cases of SCD in genotype positive-phenotype negative individuals described in the literature, making deductions challenging (2, 3, 4).

At present the clinical implications of these pre-hypertrophy cardiac changes are not known, and the real risk of SCD is thought to be significantly lower than that in clinical HCM (2, 4).

So what exercise advice should we give?

The governing bodies are clear on competitive sport exemption in individuals with clinical HCM. However the genotype positive-phenotype negative sub-group poses both an ethical and practical dilemma; it is not known if individuals will develop left ventricular hypertrophy or when this may occur. Developing clinical HCM would increase the risk of SCD, becoming particularly dangerous if undiagnosed in those engaged in competitive sport. At present there is no agreed international consensus on management.

The 36th Bethesda Conference 2005 states; ‘Although the clinical significance and natural history of genotype positive-phenotype negative individuals remains unresolved, no compelling data are available at present with which to preclude these patients from competitive sports, particularly in the absence of cardiac symptoms or a family history of sudden death.’ (5)

However the European Society of Cardiology (ESC) 2006 position paper states; Based on the level of present knowledge, the decision for participation in competitive sport should be individualized. However, prudent recommendation suggests restriction of these individuals from participation in competitive sports, especially those with high cardiac demand (i.e. high dynamic, high static sports), and to recommend prudently amateur and leisure time sport activities.’ (6)

2014 ESC guidelines on HCM management have since relaxed this approach to some degree; ‘In definite mutation carriers who have no evidence of disease expression, sports activity may be allowed after taking into account the underlying mutation and the type of sport activity, and the results of regular and repeated cardiac examinations.’ (4)

It is clear that this subgroup of genotype positive-phenotype negative individuals need long-term regular follow-up with 12-lead ECG, echocardiogram, exercise stress testing and cardiac MRI, particularly if engaging in regular sporting activity. The adjunct of genetic profiling may aid with risk stratification in the future.

The implications of this diagnosis and potential restriction from sporting activity are far reaching for the individual, having both negative psychological and physiological effects.

An individualised risk stratified exercise prescription with careful specialist follow-up must form the basis of current and future management. However further research is essential to enable us to understand the natural history of genotype-positive phenotype-negative HCM and the real risk of SCD in this sub-group.

What did we recommend?

In line with the ESC recommendations we worked with our patients, exploring the potential risks and current evidence, and together formulated an exercise prescription. We agreed upon maintaining a healthy level of fitness through regular exercise at an intensity level where one can still hold a conversation, with the stipulation of regular cardiology follow-up.

References

  • Ho CY. Genetics and clinical destiny: improving care in hypertrophic cardiomyopathy. Circulation. 2010; 122:2430Y40.
  • Sylvester, J. et al. The Dilemma of Genotype Positive-Phenotype Negative Hypertrophic Cardiomyopathy. Current Sports Medicine Reports. Volume 13 & Number 2 & March/April 2014.
  • Richard, P. et al. Advising a cardiac disease gene positive yet phenotype negative or borderline abnormal athlete: Is sporting disqualification really necessary? Br J Sports Med 2012;46(Suppl I):i59–i68.
  • 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy. European Heart Journal. (2014) 35, 2733–2779.
  • 36th Bethesda Conference. Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities. Journal of the American College of Cardiology. Vol. 45, No. 8, 2005
  • Pelliccia A, et al. Recommendations for participation in competitive sport and leisure-time physical activity in individuals with cardiomyopathies, myocarditis and pericarditis. European Journal of Cardiovascular Prevention and Rehabilitation 2006, 13:876–885.

Dr Christopher Speers BSc(Hons) MBChB MRCP(UK) is a ST3 Sport and Exercise Trainee in the West Midlands Deanery. He works with Bristol Rugby, British Universities and Colleges Sport, and is an Amateur Boxing Association Medical Officer. 

Dr Farrah Jawad is an ST4 Sport and Exercise Trainee and co-ordinates the BJSM Trainee Perspective blog.

Practical application of cardiac research: the way forward, for BOTH general medicine and sports medicine

11 May, 15 | by BJSM

Cardiology is a hot topic in sports medicine at the moment and also remains of major interest in the general medical field. As an example, Jessica Orchard received the Royal Australian College of General Practitioners (RACGP) National Best General Practice Research Article in Australian Family Physician (AFP) Award, 2015. Together with co-authors from The University of Sydney, Jessica was lead author on “iPhone ECG screening by practice nurses and receptionists for atrial fibrillation in general practice: the GP-SEARCH qualitative pilot study”, Open Access in Australian Family Physician, 2014 [1].

alive cor iECG

AliveCor iECG (Disclosures: AliveCor have provided free covers for study purposes. No author or associated institution has received any financial payment from AliveCor, nor owns any shares in AliveCor.)

The GP-SEARCH pilot study demonstrates a highly practical way to introduce modern technology (iPhone ECG screening) into general practice screening for atrial fibrillation, a common heart rhythm problem in older adults. The study highlights the approach’s feasibility both in terms of available technology, and practice nurses’ suitability for screening delivery. Obtaining a single lead ECG (usually lead I) rhythm trace on a smartphone screen (using an attached cover) takes less than a minute.

Screening application in Sports Medicine

iPhone cardiac

Athlete showing iECG reading

Jessica is currently investigating the utility of the same device (an iPhone single lead ECG App that can take a rhythm reading in under a minute) for diagnosis and screening in sports medicine settings. Cardiac conditions are very topical in sports medicine with the sad news of regular arrests and some sudden deaths in high level athletes around the world, the latest of which was Rugby League Welsh international Danny Jones 2 weeks ago. Jessica also blogged for BJSM on the advances in preventing sudden cardiac death at the IOC Prevention of Injury and Illness in Sport at Monaco in April 2014. Both rhythm disorders and outlet disorders can predispose to sudden death in sports and the single lead ECG is particularly useful at quickly assessing rhythm. Some arrhythmias that can lead to symptoms (including collapse) on the sporting field are very transient and obtaining a rhythm trace quickly is extremely valuable.

Related Research

With both a public health and law background Jessica has contributed two first author BJSM papers on the topics of:

  1. Reforming the bidding process for major sporting events to promote physical activity [2] and;
  2. Preventing radiation overexposure in sports medicine diagnostic investigations [3].

She was also a co-author on a recent cardiology paper protocol also using the iPhone ECG in BMJ Open [4].

References

  1. Orchard, J., Freedman, S., Lowres, N., Peiris, D., Neubeck, L. (2014). iPhone ECG screening by practice nurses and receptionists for atrial fibrillation in general practice: the GP-SEARCH qualitative pilot study. Australian Family Physician, 43(5), 315-319.
  2. Orchard, J., Orchard, J., Driscoll, T. (2010). Comparison of sports medicine, public health and exercise promotion between bidding countries for the FIFA World Cup in 2018. British Journal of Sports Medicine, 44(9), 631-636.
  3. Orchard, J., Orchard, J., Grenfell, T., Mitchell, A. (2014). Ionising radiation: three game-changing studies for imaging in sports medicine. British Journal of Sports Medicine, 48(8), 677-678.
  4. Lowres, N., Freedman, B., Gallagher, R., Kirkness, A., Marshman, D., Orchard, J., Neubeck, A. (2015). Identifying postoperative atrial fibrillation in cardiac surgical patients posthospital discharge, using iPhone ECG: A study protocol. BMJ Open, 5(1), 1-5.

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