Gleason, Kerkhof, Cilia, Lanya, Finnoff, Sugimoto, Corrado
Clin J Sport Medicine 2016; 0: 1-7
Sudden Cardiac Death (SCD) is estimated to occur between 1/40000 – 1/80000 of our young athletes. Although the incidence is uncommon, it remains a concern because the consequences are so tragic. So how should we screen our young athletes? This article aims to address this.
The traditional H&P often leads to a significant number of false positives and false negatives. The ECG has been mandated by the European Society of Cardiology and the IOC. This has led to a reduction of SCD in Italy by 90% however this effect has not been duplicated in North America. This is likely due to the fact that the etiology of SCD in Europe is arrhythmogenic RV cardiomyopathy whereas in North America the most common cause is structure cardiomyopathy (eg. HOCM). This is not picked up by the standard ECG. There has been an attempt to increase the sensitivity of ECG findings by using the ‘Seattle criteria’, however, there still appears to be some deficits with this method.
The American Heart Association has encouraged the investigation of a feasible and clinically relevant method to meet the shortcomings of the traditional H&P and ECG.
The ESCAPE protocol (Early Screening for Cardiac Abnormality with Pre-participation Echocardiography) attempts to meet this need. Essentially a front-line physician (non-cardiologist) performs an Echo of the heart using a portable ECHO to look for structural abnormalities in their athletes. Three measurements are taken: septal to free wall ratio <1.3; a septal thickness of >15mm, and/or a hypertrophied LV. It has been shown that there is no significant difference between a cardiologist and a non-cardiologist in gathering these measurements with accuracy.
This study chose to compare the time it takes to perform H&P vs ECG vs Echo as the primary outcome regarding feasibility. They found on average the H+P and ECG took approximately 4 min each and the ECHO averaged approximately 2min 17 sec which is statistically significant. The goal of the ECHO screen is to determine who needs a formal CV workup, not to diagnose HOCM. One of the limitations of this study was its small sample size of n=35. Some barriers to successful implementation of ECHO screening would be physician training, and accessibility to portable ECHOs. However, access to improved diagnostic modalities may improve in the future allowing our screens to be more cost effective, as well as more reliable and accurate.
In summary, the writers felt that the portable ECHO is feasible and accurate if used for CV screening in our athletes. Primary outcome of ‘physician time’ needed to screen is significantly less than that required of an H&P and/or ECG. Secondary outcomes are also encouraging. This included a reduction of false positive and false negative rates of ECG’s and H&P’s that led to unnecessary testing and costs. They conclude that a directed physical exam, a rhythm strip, and a portable ECHO screen may be the answer to the question, “How do we as healthcare providers best screen athletes at risk for Sudden Cardiac Death?”
View original research (PDF): Early_screening_for_cardiovascular_abnormalities-99503
Article summarized and presented by:
Keith Morgan BSc, MD, CCFP
Sport and Exercise Medicine Fellow
University of Ottawa.
Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (CAC SEM), Dip Sport & Exercise Medicine