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EKG Abnormalities in Athletes. If you order it, what do you need to be on the lookout for.

Preparticipation Cardiovascular exam. EKG Abnormalities in Athletes. If you order it, what do you need to be on the lookout for. Shawn F. Kane, M.D. FAAFP MAJ(P). MC, SFS, DMO Regiment Flight Surgeon 160 th SOAR (A) Family Practice/Primary Care Sports Medicine. Outline.

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EKG Abnormalities in Athletes. If you order it, what do you need to be on the lookout for.

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  1. Preparticipation Cardiovascular exam EKG Abnormalities in Athletes.If you order it, what do you need to be on the lookout for. Shawn F. Kane, M.D. FAAFP MAJ(P). MC, SFS, DMO Regiment Flight Surgeon 160th SOAR (A) Family Practice/Primary Care Sports Medicine

  2. Outline • Statement of the problem • Preparticipation exam – yes/no, how much, how little, who, when and what? • Cardiovascular PPE • Prevention of Sudden Cardiac Death (SCD) • Controversies & Variations • Recommendations • If you get an EKG? • Normal Variants in an athletes heart • Abnormalities that CAN NOT be missed • Summary

  3. “Medical Clearanceis not a promise that the athlete or future military recruit, is free from potentially fatal cardiovascular disease. Thus, we need to acknowledge that, albeit potentially reduced, small risks remain for potentially fatal disease, even after a normal screening examination” Maron BJ. Cardiovascular risks to young athletes on the athletic field. Ann Intern Med 1998;129:379-86 • SCD during military basic training should raise concern as it implies • failure at many levels; • a potential fatal CV abnormality that fails to generate signs or symptoms • the patient’s failure to recognize and report unusual symptoms • the physician’s failure to recognize nonspecific symptoms that represent • a serious underlying CV condition • resuscitative efforts fail to restore spontaneous circulation. • Most of these failures do not invoke blame; rather, they present a • Challenge to the medical and scientific community to prolong life and • reduce the occurrence of SCD Balady GJ. Editorial – Sudden Cardiac Death in Young Military Recruits: Guarding the Heart of a Soldier. Ann Intern Med 2004; 141(11):882-83

  4. SCD Etiologies • Structural or Functional Abnormalities • Hypertrophic Cardiomyopathy • Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia • Coronary Artery Abnormalities • Marfan Syndrome with aortic dissection • Valvular Disease • Primary Electrical Abnormalities • Accessory pathway mediated tachycardia – Wolff-Parkinson-White • Long QT Syndrome • Short QT Syndrome • Brugada Syndrome • Primary/idiopathic ventricular tachycardia/fibrillation • Acquired • Commotio Cordis • Atherosclerotic Coronary Artery Disease • Drug Abuse

  5. SCD Causes Mason, PK and Mounsey JP Common Issues in Sports Cardiology Clin Sports Med 2005. 24, 463-476 Hosey RG and Armsey TD. Sudden Cardiac Death Clin Sports Med 2003. 22;51-66

  6. 25 yr review 126 nontraumatic sudden deaths 108(86%) related to exercise 64(51%) due to identifiable cardiac abnormality 44(35%) unexplained 64 Cardiac Cases 39(61%) Coronary Artery Anomalies. (LCA arising from right, anterior, sinus of valsalva. 13(20%) Myocarditis 8(13%) HCM Review of Military SCD Cases Eckart RE, Scoville, SL, Campbell CL, et al. Sudden Death in Young Adults: A 25-Year Review of Autopsies in Military Recruits. Ann Intern Med. 2004; 141:829-834

  7. Preparticipation Exam • Goal is to maintain the health and safety of the athlete in training and competition • Not to exclude participation, but to promote safe participation • Detect conditions that may be life threatening and predispose an athlete to sudden death. • GENERAL CONSENSUS – YES, athletes should undergo some type of PPE

  8. Preparticipation Exam - USA • 50/51 jurisdictions required a PPE • 8 states with no approved questionnaire • 40% of approved forms incorporated >9 of the 13 HX and PE items recommended by the AHA • 28% of approved forms has <4 items • 25 states authorized non-physician providers (NPs, PAs, chiropractors, naturopaths)

  9. Preparticipation Exam • AHA – pushing for a national standard for PPE to include cardiovascular screening. • Mandatory screening for all HS (9-12) and College athletes. • Repeated every 2 years with an interim history during intervening years • Include a history and physical designed to identify or raise suspicion of CV conditions know to increase risk of SCD • Conducted by healthcare worker (preferably physician) who as the appropriate training, skills and background to reliably obtain a CV history, perform a thorough CV physical and recognize heart disease.

  10. Preparticipation Exam • Preparticipation Examination Monograph 1992, 1997 and 2004 McGraw Hill • AHA • AAFP • AAP • ACC • ACSM • AMSSM • AOASM • AOSSM

  11. Preparticipation Exam – Italy (Europe) • Early 1970’s Italy passed law mandating that all athletes engaging in competitive sports will undergo a clinical evaluation and receive eligibility. • History, Physical and EKG

  12. Numbers and Money • 10-12 million athletes (HS/College Athletes in US) • 6 million athletes (all levels) Italy • Sudden Cardiac Death Rates: • 1:200-300,000 athletes/year US • 1:135,000 males • 1:769,000 females • 2.1:100,000 athletes/year Italy • Italy – twice as high with half the numbers

  13. 1 death 1000 at risk of sudden cardiac death 200,000 Athletes Numbers and Money HCM 1:500 incidence $500/ECHO $250,000 to detect 1 case

  14. Cardiovascular PPE • 12 Point History and Physical (AHA Consensus Panel for Preparticipation Athletic Screening, JACC 19 Apr 05 45(8): 1322-1326) • History: • Family Hx: • Premature SCD • Heart Disease in surviving relative less than 50 yo • Personal Hx: • Heart Murmur • Systemic Hypertension • Fatigue • Syncope/near-syncope • Excessive/unexplained exertional dyspnea • Exertional Chest Pain

  15. Cardiovascular PPE • Physical Exam • Heart Murmur • Supine(Sitting)/Standing & Dynamic/Static • Grade 3/6 or louder • Any diastolic murmur • Any murmur that gets louder with valsalva • Femoral Artery Pulses • Stigmata of Marfan Syndrome • Brachial Blood Pressure Measurement

  16. Marfan Syndrome

  17. May 2004 Pediatric BPshttp://www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.htm

  18. So you got the EKGNow what?

  19. The Athletes Heart • Recognized in the 19th century that the hearts of cross country skiers were bigger • CO=HR x SV • The trained athlete improves CO by increasing SV • Physiologic hypertrophy – an increase in LV mass due to repetitive exercise. • Heart dimensions rarely exceed the upper limits of normal if adjusted for body size • Detraining – physiologic v pathologic hypertrophy

  20. Sinus bradycardia Sinus arrhythmia 1st degree AV block 2nd degree, Type 1 AV block Incomplete RBBB RVH Repolarization Changes ST wave elevation Upward sloped ST wave T wave inversion LVH Upper limit of normal QT waves The Athletes EKG

  21. The Challenge

  22. Hypertrophic Cardiomyopathy • 1/3 of all SCD (US) • Incidence 1:500 general population • A primary familial disease with asymmetric hypertrophy without dilation of LV • Obstructive v Non-Obstructive • 95% of patients with HCM will have abnormal EKG • Unfortunately a much smaller percentage of patients will have abnormal PE

  23. Hypertrophic Cardiomyopathy • Murmur Characteristics: • Standing examination • Decrease venous return increases intensity of murmur • What do you hear? • Squat to stand the murmur will get louder • Stand to squat the murmur will get softer • Valsalva murmur will get louder

  24. HCM EKG

  25. Another HCM EKG

  26. ARVD • Characterized by regional or full thickness replacement of right free ventricular wall myocardium by fat and fibrous tissue. • Leads to electrical instability • Not identified until late 1970s • Incidence: 6/10,000 up to 44/10,000 • 3%-17% of SCDs

  27. ARVD Differential Diagnosis of ARVD Signs and Symptoms of ARVD Symptoms Abdominal pain Decreased exercise tolerance Dizziness Dyspnea (especially with exertion) Fatigue Mental confusion Palpitations Syncope or fainting Signs Cardiac arrest Peripheral edema Sudden death Tachycardia Anatomic Atrial septal defect Biventricular dysplasia Isolated myocarditis Naxos disease (ARVD associated with palmoplantar keratosis) Right ventricular infarct Right-sided valve insufficiency Uhl’s anomaly (congenital absence of right ventricular myocardium) Arrhythmias Benign extrasystoles Bundle branch reentry Dilated cardiomyopathy VT Idiopathic right ventricular arrhythmia Ischemic heart disease VT Right ventricular outflow tract VT Supraventricular tachycardia

  28. ARVD Figure 1. Postmortem heart in a patient with arrhythmogenic right ventricular dysplasia. Note how the right ventricular myocardium and endomyocardium have been replaced by fat. Triangle of dysplasia. Epsilon wave – a late positive deflection in the terminal QRS complex Anderson EL. Arrhythmogenic Right Ventricular Dysplasia Am Fam Physician. 2006;73:1391-8

  29. Global and/or regional dysfunction and structural alterations Major Severe dilatation and reduction of right ventricular ejection fraction with no (or only mild) left ventricular impairment Localized right ventricular aneurysms Severe segmental dilatation of the right ventricle Minor Mild global right ventricular dilatation and/or ejection fraction with a normal left ventricle Mild segmental dilatation of the right ventricle Regional right ventricular hypokinesis Tissue characterization of the walls Major Fibrofatty replacement of myocardium on endomyocardial biopsy ECG repolarization abnormalities Minor Inverted T waves in the right precordial leads (V2 and V3) in patients older than 12 years and in the absence of right bundle branch block ECG depolarization/conduction abnormalities Major Epsilon waves or localized prolongation (greater than 110 milliseconds) of the QRS complex in right precordial leads (V1 through V3) Minor Late potentials visible on signal-averaged ECG Arrhythmias Minor Sustained or nonsustained left bundle branch block type VT documented on ECG, Holter monitoring, or during exercise stress testing Frequent ventricular extrasystoles (more than 1,000 per 24 hours on Holter monitoring) Family history Major Familial disease confirmed at autopsy or surgery Minor Family history of premature sudden death (younger than 35 years) caused by suspected ARVD/C Family history (clinical diagnosis based on present criteria) Criteria for Dx of ARVD

  30. ARVD

  31. Another ARVD

  32. WPW • A cardiac conduction abnormality that is caused by an accessory (extranodal) electrical pathway. • 0.15%-0.30% of the general population • Symptomatic tachyarrhythmias • Occasionally (0.1%) the cause of SCD • Palpitations, lightheadedness and syncope plus EKG changes very worrysome

  33. WPW

  34. WPW

  35. WPW

  36. LONG QT • Infrequent 1/5000 • Defined as a corrected QT interval (QTc) of >450 msec in men and >460 in women. • Usually present with syncope after emotional or physical stress • “R on T Phenomenon” that can initiate a rapid polymorphic ventricular tachycardia (torsades de pointes) • Congenital v Acquired

  37. EKG Abnormality Summary

  38. Legal • Sudden death of an athlete is a high profile event – do you want to have been the one to “clear” them? • Physician reliance on consensus recommendations and guidelines based on the collective judgement of experts. • A physician must have and use the knowledge, skills and care ordinarily possessed and employed by members of the profession in good standing. • No successful litigations against physicians who followed consensus guidelines.

  39. EXTRA SLIDES

  40. Marfan Syndrome Stigmata

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