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The Athlete’s Heart

Article: The Seattle Criteria increase the specificity of pre-participation ECG screening among elite athletes, Brosnan et al., Br J Sports Med 2014 48: 1144-1150

Written by: Jody Murray, Bsc/BPhe, MD, CCFP and current Sport Medicine Fellow

Pre-participation ECG’s have been long debated for athletes.  The European Society of Cardiology (ESC) and other groups such as the International Olympic Committee are now recommending that elite athletes have a pre-participation ECG testing.  This has come as a result of lower sudden cardiac death in Italy’s Veneto region where there has been mandatory ECG screening for the last 30 yrs.

The athletic heart will undergo normal adaptations in response to exercise, which in and of itself, cause electrical changes on ECG.  False positive ECG testing leads to further cardiac investigations for the athlete and unnecessary costs to the health care system which has called into question the significance of ecg testing for athletes.

Recently a set of 3 papers categorizing ECG changes has come out helping to sort out what are normal adaptations versus changes associated with cardiac pathology.  These papers are known as the Seattle Criteria and can be accessed through the British Journal of Sport Medicine.

In 2014, Brosnan et al., decided to look at the Seattle Criteria compared with the ESC criteria in identifying elite Australian athletes with significant cardiac disease which would put them at risk of sudden cardiac death.  As a result of this study they concluded that the use of the Seattle Criteria during ECG interpretation of the elite athlete reduced further screening in individuals from 1 out of 5 athletes to 1 out of 20.  Using the Seattle criteria, they were still able to identify the 3 individuals with significant cardiac abnormalities.  This study suggests that using this new criteria might be as sensitive as using the 2010 ESC guidelines for detection of athletes at risk but with significantly lower the false positive rates and therefore marked cost reduction to our health care system.

 

Athletes with implantable cardioverter defibrillators: can they return to competitive sports?

Written by: Jody Murray, Bsc/BPhe, MD, CCFP and current Sport Medicine Fellow

Article: Athletes with implantable cardioverter defibrillators: can they return to competitive sports? Prutkin JM, et al. Br J Sports Med January 2016 Vol 50 No 2.

As a sport medicine physician, sudden cardiac death is at the top of the list of worst case scenarios for event coverage.  Sudden Cardiac Death (SCD) represents 75% of fatalities during exertion and is most commonly due to an undiagnosed either electrical or structural cardiovascular condition.

Pre-participation screening involves taking a thorough history of cardiac symptoms and family history in order to identify an athlete at risk.  On history one should ask about chest pain, dyspnea, palpitations, dizziness or syncope during exertion.  Upon family history one should ask about any deaths that occurred to relatives that were at a young age and unexplained.  This may also include unexplained drowning in individuals that were strong swimmers.

If you have identified an athlete at risk for SCD, they should undergo further cardiovascular investigations including an ECG, echo and be referred for evaluation by a specialist.

The most common conditions identified include premature coronary artery disease, cardiomyopathies (such as hypertrophic cardiomyopathy), congential coronary anomalies, congenital valvular heart disease and ion channelopathies (such as brugada syndome).  Some of these conditions are managed by inserting implantable cardioverter defibrillators (ICD).

The above article recently published by the BJSM looked at what do with these athletes following ICD insertion.  Can they return to competitive sports?  Previous recommendations from the American College of Cardiology and the European Society of Cardiology stated they could return to low-intensity sports only.  These guidelines were based on expert opinion with limited data.

Recent data looking at ICD failures and the number of shocks delivered (either appropriate and inappropriate) has led to the new conclusion that athletes with ICDs can play sports safely.  The 2015 American College of Cardiology and American Heart Association guidelines state now that sports partification with an ICD may be allowed if there have been no shocks for 3 months.  A discussion should be had with the family and the athlete about the risks involved in returning to competitive sport such that the athlete and their family can make an informed decision about future participation.