Guest blog by Dr Steven Cox (from CRY – Cardiac Risk in the Young

The UK’s National Health Service (NHS)  policy – that “screening should not be offered*”  is currently discouraging young people who may be at risk of sudden cardiac death from having simple, non-invasive and potentially life-saving tests.

The National Screening Committee need to review its position which is out of date

It is the view of the charity Cardiac Risk in the Young (CRY) that:

• All young people (14-35 years old) should be offered the option to have cardiac screening
• Cardiac testing should only be conducted by specialist cardiologists with the necessary skills and expertise to ensure accurate interpretation of the investigations.
• The National Screening Committee policy should widen the remit to consider all cardiac conditions that can cause young sudden cardiac death
• The National Screening Committee policy directly contradicts with the general NHS policy of “prevention”

Can anyone do these tests?

Cardiac screening needs to be overseen by a cardiologist with expertise in this specialist area of cardiology, including; athletes heart, ethnic differences in cardiac adaptation to exercise, and structural/electrical cardiac conditions. Professor Sanjay Sharma is a leading sports cardiologist and CRY’s consultant cardiologist who gives his time to oversee the CRY screening programme.

When a specialist cardiologist conducts the tests the number of false positives and false negatives significantly decrease (i.e. fewer people are told they may have a problem and are subjected to further investigations when they do not have a problem, and fewer people with a problem are given an all clear).

Could the NHS handle so many people wanting testing?

In the current economic era the answer is probably not. Moreover the NHS does not have the infrastructure, including the facilities or the expertise, to immediately implement a national screening programme for ALL young people.

However, CRY is leading the way in training specialist doctors, conducting research and providing educational resources so this will be possible in the future.

Although the implementation of nationwide screening is hampered at this point due to the economic constrains and lack of infrastructure and expertise that does not mean that screening should not be recommended. On the contrary, these limitations should prompt the development of a collaborative scheme between the Government, NHS, charity organisations such as CRY and sporting bodies to provide an initiative to offer cost effective screening.

Is there any evidence from other countries that screening is worthwhile?

In Italy where screening prior to participation in organised sport is mandatory they have reduced the incidence of young sudden cardiac death by 90%. This research has informed international policies that either mandate or recommend cardiac screening prior to participation in organised sport.

Incorrect interpretation of ECG leading to death is every clinician’s nightmare. Rare but frightening. But what is ‘correct’ interpretation in some settings? What do certain variations in ECG tracings mean? Sinister or sublime?

To address the controversies in ECG interpretation in athletes, leaders in the field held an ECG Summit in Seattle. The goal –  to improve the cardiac care of athletes and better identify those at risk of sudden cardiac death.

An historic occasion 2012 ECG Summit Participants - Photo by Dr. Ashwin Rao

BJSM congratulates the multidisciplinary collaboration – such shared initiatives are all too rare in medicine. Representatives from the American Medical Society for Sports Medicine (AMSSM) partnered with the European Society of Cardiology (ESC) Sports Cardiology Section, the Pediatric & Congenital Electrophysiology Society (PACES), other leading U.S. cardiologists, and the FIFA Medical Assessment and Research Center (F-MARC). The explicit goal –  “to define ECG interpretation standards in athletes and develop a comprehensive online training module for physicians around the world to gain expertise in ECG interpretation and the proper evaluation of ECG abnormalities suggestive of a pathologic cardiovascular disorder.”

The clinical community waits with bated breath for the conclusions so they can be implemented to help patients. BJSM is pleased to facilitate as an information channel – in print, digital media, video and podcasts.

Read more on the ECG summit here.

Among the many practical, effective, and groundbreaking ideas discussed at the Summit, one with global impact will the online training module. Collaborators will translate the ECG interpretation standards consensus recommendations into a comprehensive online training module hosted by British Medical Journal (BMJ) Learning. BMJ Learning is an international leader in e-learning so adds great expertise in translating the Summit lessons to the clinicians who will implement the new practice.

The American Medical Society for Sports Medicine reports : “the E-learning resource will be freely accessible to any physician world-wide and help create a larger physician infrastructure that is skilled and capable of accurate ECG interpretation in athletes. Improved ECG interpretation may identify athletes with at-risk disorders and help prevent sudden death in sport. “

Watch this space for updates on the release of this material – it is tentatively scheduled for late 2012.

For more on this topic…

Related Publications:

• Drezner, J, Harmon, K, and Borjesson, M. 2011. Incidence of sudden cardiac death in athletes: where did the science go? BJSM, 45: 947-948.

• J A Drezner JA, Rogers KJ, and Horneff JG. 2010. Automated external defibrillator use at NCAA Division II and III universities. BJSM, Published online first: 16 November 2010.

• September 2009 BJSM – deals specifically with cardiac issues and the athlete

Podcast:

• Preventing sudden cardiac death with Jon Drezner

Blogs:

• Authoritative resource for sudden cardiac death – finally! Guest blog by Jon Drezner
• New Guidelines to Improve ECG/EKG Interpretation in Athletes – Guest Blog by Dr Babette Pluim
• Sports Cardiology by Dr Jon Drezner
• Debating Strategies to Reduce Sudden Cardiac Death in Athletes: Dr. Drezner Responds to Sports Cardiology Editorial

At the 2011 IOC conferences held in Corsica and Monaco significant session times were dedicated to cardiac screening and the role of ECG screening in prevention of sudden cardiac death (SCD). I attended as deputy Medical Director for the Australian Olympic Committee (AOC), and also as the Medical Director for the New South Wales Institute of Sport (NSWIS). I had also recently been part of a medical subcommittee for NESC (National Elite Sports Council) reviewing elite athlete medical screens to get some standardisation across Australia’s many state sports institutes and academies.

As part of this screening, we had already included a strong recommendation for including ECG screening as part of the process. At that stage, (early 2011), mandatory ECG screens had already started at the Australian Institute of Sport in 2010,  and the AFL draft recruits (mostly around 18 years old) were also undergoing ECG screening in addition to their medical questionnaire and examination. Hence I was delighted with the excellent wealth of knowledge presented on the subject by such experts as John Drezner (USA) and Antonio Pelliccia (Italy), and came home to Australia with renewed enthusiasm to argue the cause.

With some help and support from John Drezner, I argued the case for mandatory ECG screening in athletes, to the NSWIS Board in May 2011. This would involve organising, financing and implementing  ECG screening for over 600 scholarship holders, including policies for repeat screens and the issue of what to do with abnormal findings. Around the same time, there had been some media attention to the subject with both electronic media and newspaper articles highlighting young, sudden cardiac deaths.

I am pleased to report that the NSWIS board and CEO supported the policy for mandatory ECG screening, and this became reality on July the 1^st 2011. The process also includes education of physicians involved in the screening process, coaches, parents and athletes, and this has been done via a series of newsletters, and coach seminars. We intend to perform an ECG screen annually up to age 20. The Victorian Institute of Sport (VIS) has also followed suit with mandatory ECG screens upon entry fo new scholarship holders.

Similarly, I put forward a summary paper to the AOC Medical Commission, and with the AOC Medical Director Dr Peter Bacquie, submitted a more detailed paper to the AOC board. For the 2012 London Olympics, ECGs have been “strongly recommended”, but are not mandatory. Further changes will no doubt be implemented, with a seminar session to be held in November at the Australasian College of Sports Physician’s Annual Conference on this topic, with presentations by Dr Dan Exeter, myself and Dr Chris Milne who attended the IOC course in Lausanne in September 2011 on ECGs in athletes. There has also been an ethics approved study run by Associate Professor Keiran Fallon from the AIS to document the ECG changes in Australian athletes. This is a very important study due to the very different population base in Australia, particularly with respect to Aborigines, Torres Strait Islanders, NZ Maoris and other athletes of Polynesian origin. Clearly more to come on this topic in future.

Related Publications:

• Drezner, J, Harmon, K, and Borjesson, M. 2011. Incidence of sudden cardiac death in athletes: where did the science go? BJSM, 45: 947-948.

• J A Drezner JA, Rogers KJ, and Horneff JG. 2010. Automated external defibrillator use at NCAA Division II and III universities. BJSM, Published online first: 16 November 2010.

• September 2009 BJSM – deals specifically with cardiac issues and the athlete

Podcast:

• Preventing sudden cardiac death with Jon Drezner

Blogs:

• Authoritative resource for sudden cardiac death – finally! Guest blog by Jon Drezner
• New Guidelines to Improve ECG/EKG Interpretation in Athletes – Guest Blog by Dr Babette Pluim
• Sports Cardiology by Dr Jon Drezner
• Debating Strategies to Reduce Sudden Cardiac Death in Athletes: Dr. Drezner Responds to Sports Cardiology Editorial

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

Dr Donald Kuah, MBBS FACSP, is an experienced sports physician specialist and one of the founding practitioners at Sydney Sports Medicine Centre in Olympic Park. He has been the NSW Institute of Sport Medical Director since the year 2000, being responsible for the state’s top 750 elite athletes.

iStockphoto.com/soupstock

Sudden Death in Young Adults (JACC 2011, 58:12),  has a wealth of information and will be an article  to reference for a long time.  Finally a large, systematic incidence and etiology study on sudden death in young adults with sound methodology, a defined population (military), mandatory reporting, and post-mortem protocols.

The authors openly question the ascertainment and referral bias of studies with ‘passive surveillance’ methods.  Almost all of the information on the etiology of SCD in young athletes in the U.S. comes from a single registry reporting that hypertrophic cardiomyopathy (HCM) is the leading cause of SCD.  Although competitive athletes may represent a different population, there is potential for ascertainment bias in any study without a systematic and/or mandatory identification of cases.

All other studies find autopsy-negative sudden unexplained death as the leading cause of SCD in young adults, and a proportion of HCM similar to this study (10-15%).  It is striking that sudden unexplained death represented 41% of the cases in this study.

The incidence of SCD in those <20 yo is alarming (3.25/100,000 or 1 in 30,000) and actually higher than we found in NCAA athletes (Circulation, 2011).  This increases to nearly 1 in 25,000 for <35 yo (exactly the incidence found in Italy in the same age range before more rigorous screening).  The authors also found a higher risk in African Americans who represented 15% of the study population but 33% of the SCD cases <35 yo (although the exact risk is not reported).  They include Wolff Parkinson White (WPW)  in the list of possibilities for sudden unexplained death — something I think may represent a higher proportion than we think – in addition to the ion channel disorders.  It is a little surprising to me they report no cases of aortic root dissection.  Also, only 7.5% of deaths due to sudden unexplained death had prodromal symptoms (within a week) of syncope or palpitations, and only 4.3% had chest pain or dyspnea. This provides powerful support of screening with more than just a history questionnaire if the intention is truly to identify those at risk.

Related Publications

Drezner, J, Harmon, K, and Borjesson, M. 2011. Incidence of sudden cardiac death in athletes: where did the science go? BJSM, 45: 947-948.

September 2009 BJSM – deals specifically with cardiac issues and the athlete

Blogs:

• New Guidelines to Improve ECG/EKG Interpretation in Athletes – Guest Blog by Dr Babette Pluim
• Sports Cardiology by Dr Jon Drezner
• Debating Strategies to Reduce Sudden Cardiac Death in Athletes: Dr. Drezner Responds to Sports Cardiology Editorial

Dr. Jonathan Drezner is an Associate Professor of the Department of Family Medicine, Associate Director of the Sports Medicine Fellowship , and Team Physician for the Seattle Seahawks & UW Huskies.

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.

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 here – http://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

BJSM aims to be relevant to clinicians and to influence practice. It has been pleasing to see BJSM quoted in the New York Times, the Financial Post, and other major international news outlets. Our September issue (PDF), in partnership with the IOC continues to have an impact the world over. This link is to the widely read US News. To read the editorial about sudden cardiac death for athletes in the September issue click here.