Dilemma of Cardiac Screening & Sudden Cardiac Death in Athletes: The UAE Experience

Dr. Abdulhameed Alattar MBBCh, MRCGP, ABFM, MSc SEM Sports Physician, Dubai Health Authority Chairman, Sports Medicine Committee UAE National Olympic Committee

 Review the epidemiology and common causes of sudden death in young competitive athletes  Discuss the validity of adding ECG to athletes Cardiac Screening  Outline the UAE Experience

 ‘ Sudden Cardiac Death (SCD) is defined as an event that is non-traumatic, non-violant, unexpected, and resulting from sudden cardiac arrest within six hours of previously witnessed normal health’. (Sharma et al, 1997. Br J Sports Med)

 More common in males than females (9:1)  More common in black athletes  Most reported cases in football and basketball  90% deaths during or immediately after exertion  75% athletes are asymptomatic  Sport increases risk of SCD by 2.5-3%

 In people aged >35 years, most common cause of SCD is Coronary Artery Disease  In young individuals/athletes (<35 years), the most common causes of SCD is Inherited / Congenital cardiac disorders

 Structural:  Hypertrophic cardiomyopathy (HCM)  Arrythmogenic right ventricular cardiomyopathy (ARVC)  Dilated cardiomyopathy (DCM)  Valvular heart disease (e.g. aortic stenosis, mitral valve prolapse etc.)  Coronary artery anomalies  Marfan’s syndrome  Premature coronary artery disease  Electrical:  Long QT syndrome  Wolff-Parkinson-White syndrome  Brugada syndrome  Catecholaminergic polymorphic ventricular tachycardia (CPVT)  Short QT syndrome  Acquired causes:  Drugs  Myocarditis  Commotio cordis  Heat stroke / electrolyte imbalance

USA ITALY

Study Population Reporting method Incidence Van Camp (1995) High school & college athletes; age 13-24 (US) Public media reports 1:300,000 Maron (1998) High school athletes in Minnesota; age 13-19 (US) Catastrophic insurance claims 1:200,000 Eckart (2004) Military recruits; age 18-35 (US) Mandatory, autopsy based 1:9,000 Corrado (2006) Competitive athletes; age 12-35 (Italy) Mandatory registry for SCD 1:25,000 Drezner (2009) Competitive athletes; age 14-17 (US) Cross Sectional survey 1:23,000 Harmon (2011) College athletes; age 17-24 (US) NCAA Resolution database 1:44,000

 “The ultimate objective of the pre-participation screening of athletes is the detection of ‘silent’ cardiovascular abnormalities that can lead to SCD.”  ACC 36th Bethesda Conference, 2005  “The main purpose of the consensus document is to reinforce the need for PPE medical clearance of all young athletes involved in organized sports programs to prevent athletic field fatalities”  ESC Consensus Statement, 2005

FOR  Highly visible events  Loss of numerous years of life  Association between exercise and sudden death  Acceptable interventions to prevent fatalities AGAINST  Sudden deaths in athletes uncommon; 1 in 50,000  Rare disorders; diverse pathology  Elaborate screening programmes not cost effective  Risk of false positives

 American model  History +  Examination  Italian model  History +  Examination +  ECG

 Corrado et al 2006

European Heart Journal 2005

 Comparison of history and physical examinationVs ECG in screening young athletes   Positive results requiring  further test Sensitivity to Detect  Lethal CVD Study H&P ECG Total No. of cases H&P ECG Wilson et al (2008) 2.5% 1.5% 4% 9 0 100% Bessem et al (2009) 8% 8% 13% 3% 33% 67% Hevia et al (2011) 1.2% 6.1% 7.4% 2 0 100% Baggish et al (2010) 6% 16% 20% 3 33% 67% Total 4.4% 7.9% 11.1% 17 12% 88%

 Coronary artery disease  Coronary artery anomalies  Valve diseases  Cost implications / false positives / expertise

 Most sudden cardiac arrests start withVF.  Most important factor is interval between cardiac arrest and defibrillation.  Public access defibrillators have improved survival rates.  Survival of 50-64% if shocked within 2-3 minutes; <10% after 10 minutes.  Emergency response planning is required to ensure efficient response to SCA. Time chain for SurvivalTime chain for Survival

http://www.whri.qmul.ac.uk/ Section II Cross Sectional Study on Pre-Participation Musculoskeletal and Cardiac Screening of Male Athletes in UAE A Alattar, N Maffulli, S Ghani William Harvey Research Institute, Barts and the London School of Medicine and Dentistry Queen Mary University of London

ECG interpretation using the 2010 ESC recommendations (Corrado et al 2010) Stage One Stage Two

Total (n = 230) Yes, n (%) GENERAL MEDICAL Have you ever had a preparticipation evaluation? 34 (14.8%) CARDIOVASCULAR SYSTEM Have you ever fainted or passed out during / after exertion? 6 (2.6%) Have you ever been dizzy during / after exertion? 9 (3.9%) Have you ever had chest pain or tightness during / after exertion? 3 (1.3%) Do you get tired more quickly than your friends during exercise? 5 (2.2%) Have you ever had shortness of breath that made it difficult to perform sport? 2 (0.9%) Have you ever had racing heart or skipped heartbeats? 3 (1.3%) Have you even been told you have a heart condition? 2 (0.9%) Has anyone in your family with less than 35 years of age died suddenly from a heart condition ? 2 (0.9%)

Stage 1 screening: History, physical examination (PE), ECG 230 (100%) Abnormalities: 56 (24%) History & PE alone 8 (3%) ECG alone 40 (17%) History/PE/ECG 8 (3%) No abnormalities: Eligible for sports 174 (76%) Stage 2 screening: additional testing preformed in 54 (23%) No abnormalities: Eligible for sports 47 (20%) Abnormalities: Confirmed cardiovascular disease 7 (3%) No sports restriction 3(1%) Sports restriction 4 (2%) Stage 1 False Positive rate 20.4% ECG False positive rate 18.3%

ELECTROCARDIOGRAPHIC FINDINGS IN ATHLETES (n=230) N (%) GROUP 1 (training-related) ECG findings Sinus Bradycardia (HR < 60) 124(53.9%) 1st Degree AV Block (PR > 120ms) 35(15.2%) Partial Right Bundle Branch Block (pRBBB) 28(12.1%) Voltage criteria for Left Ventricular Hypertrophy (LVH) 81(35.2%) Early Repolarization (ER) – overall prevalence 84(36.5%) ER in anterior leads (in isolation or combination) 72(31.3%) ER isolated to inferior and/or lateral leads 47(20.4%)

GROUP 2 (training-unrelated) ECG findings n (%) Left Bundle Branch Block (LBBB) 1 (0.4%) Right Atrial Enlargement (RAE) 2 (0.8%) Left Atrial Enlargement (LAE) 7 (3.0%) Right Axis Deviation (axis ≥ 120°) 1 (0.4%) Left Axis Deviation (axis ≤ 30°) 10 (4.3%) Right Ventricular Hypertrophy (RVH) 3 (1.3%) Prolonged QT interval (QTc>470ms) 1 (0.4%) Abnormal T-wave inversions (TWI) – overall prevalence 24 (10.4%) TWI in anterior leads 7 (3.0%) TWI in inferior leads 18 (7.8%) TWI in lateral leads 7 (3.0%) Ventricular Ectopics (≥2 per ECG strip) 2 (0.8%) ST segment depression 1 (0.4%) Atrial Fibrillation 1 (0.4%) Wolff-Parkinson-White (WPW) pattern 2 (0.8%)

Diagnosis History / Exam Positive ECG Positive No. additional tests N (%) Sports Restriction Hypertension Y N 0 2 (0.87%) No WPW N Y 4 2 (0.87%) No Long QT Syndrome Y Y 3 1 (0.43%) Yes ARVC Y Y 4 1 (0.43%) Yes Atrial Fibrillation Y Y 3 1 (0.43%) Temporary Myocardial Ischemia Y Y 4 1 (0.43%) Yes Insufficient Mitral Valve Y N 1 1 (0.43%) No

 Only 14.8% had previous PPE  44 athletes (23%) underwent additional testing  47 athletes (20.4%) had false positive screening (similar to Baggish et al 2010)  7 athletes (3%) had a positive screening result and 4 athletes (2%) were restricted from sport  Number needed to screen was 33

 Sudden cardiac death in young individuals is not rare  Most common conditions are inherited of congenital cardiac disorders  Screening can identify cases and reduce risk of SCD  Emergency response planning is required to ensure efficient response to SCA.