-ICASM 2013-1 -ICASM 2013-1

Pre-participation ECG Pre-participation ECG screening in military screening in military

recruits- the IDF recruits- the IDF experienceexperience

Alon Grossman M.D MHAAlon Grossman M.D MHA11,, 22,, 33, Alex Prokupetz MHA, Alex Prokupetz MHA11,, 22, Igor Lipchenca MD , Igor Lipchenca MD 44

1.1. IAF aero medical center, Tel Hashomer, IsraelIAF aero medical center, Tel Hashomer, Israel

2.2. IDF medical corpsIDF medical corps

3.3. Department of Internal Medicine E, Rabin Medical Center Beilinson Campus affiliated to Tel Aviv Department of Internal Medicine E, Rabin Medical Center Beilinson Campus affiliated to Tel Aviv

University Sackler Medical School, Israel University Sackler Medical School, Israel

4.4. Leviev Heart Center, Sheba Medical Center and Tel Aviv University, Tel Hashomer, IsraelLeviev Heart Center, Sheba Medical Center and Tel Aviv University, Tel Hashomer, Israel

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IntroductionIntroduction

Despite the large numbers of athletes Despite the large numbers of athletes

undergoing pre-participation screening, there undergoing pre-participation screening, there

is a continuing debate regarding the optimal is a continuing debate regarding the optimal

method of screeningmethod of screening

The main concern in performing mass ECG The main concern in performing mass ECG

screening in athletes is the costly additional screening in athletes is the costly additional

work up required based on resting ECG work up required based on resting ECG

findingsfindings

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IntroductionIntroduction

Professional guidelines in the US do not recommend use of either ECG or Professional guidelines in the US do not recommend use of either ECG or

echocardiography for screening of college athletesechocardiography for screening of college athletes11

On the other hand, 12-lead ECG has been supported for screening purposes On the other hand, 12-lead ECG has been supported for screening purposes

among athletes by the Sport Cardiology section of the European society of among athletes by the Sport Cardiology section of the European society of

Cardiology and Medical Commission of the International Olympic Committee Cardiology and Medical Commission of the International Olympic Committee

and has been shown to reduce mortality in this populationand has been shown to reduce mortality in this population22

1. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to pre participation screening for cardiovascular 1. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to pre participation screening for cardiovascular

abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity,

and Metabolism: endorsed by the American College of Cardiology Foundation. Circulationand Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. . 2007; 115:1643-16552007; 115:1643-1655

2. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after 2. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after

implementation of a pre-participation screening program. JAMA 2006; 296:1593–1601implementation of a pre-participation screening program. JAMA 2006; 296:1593–1601

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BackgroundBackground

Recruits to elite units in the IDF undergo pre-participation ECG prior their Recruits to elite units in the IDF undergo pre-participation ECG prior their

enlistmentenlistment

This process has been performed sporadically in the last years but all ECGS This process has been performed sporadically in the last years but all ECGS

are performed at the IAF aero medical Center since January 2010are performed at the IAF aero medical Center since January 2010

All elite units candidates undergo a preliminary medical selection process All elite units candidates undergo a preliminary medical selection process

at the IDF recruitment center (History & PE)at the IDF recruitment center (History & PE)

Only those who are physically healthy are allowed to enlist to elite units Only those who are physically healthy are allowed to enlist to elite units

and only they undergo pre-participation ECGand only they undergo pre-participation ECG

This population consists of 17-19 years old male subjectsThis population consists of 17-19 years old male subjects

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BackgroundBackground

All ECGS are evaluated by a single All ECGS are evaluated by a single

cardiologistcardiologist Those requiring further evaluation, Those requiring further evaluation,

complete the evaluation prior to enlistmentcomplete the evaluation prior to enlistment A military physician from the IAF aero A military physician from the IAF aero

medical center summarizes the medical medical center summarizes the medical

evaluation and decides whether the evaluation and decides whether the

candidate is eligible to enlist to a special candidate is eligible to enlist to a special

unitunit

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AimsAims

To characterize causes of referral to continued To characterize causes of referral to continued

investigation based on resting ECG findingsinvestigation based on resting ECG findings

To summarize the additional work-up performedTo summarize the additional work-up performed

To summarize the rate of significant findings To summarize the rate of significant findings

resulting in disqualification of military resulting in disqualification of military

candidates in this populationcandidates in this population

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ResultsResults

1,455 subjects underwent pre-1,455 subjects underwent pre-

participation ECG in the year 2010participation ECG in the year 2010

1,388 studies (95.39%) interpreted as 1,388 studies (95.39%) interpreted as

normalnormal

67 referred to further evaluation 67 referred to further evaluation

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Causes for referralCauses for referralCause of referralDefinitionNumber of cases (% of

total findings)T wave changesNon specific16( 23.9%)

Pre-excitation patternPR segment shorter than 120 milliseconds) with or without a delta

wave

14( 20.9%)

LVHS1+R5,6 wave voltage greater than 35 mm in precordial leads and/or R-wave greater than 15 mm in peripheral lead

I and/or 12 mm in aVL

11( 16.4%)

Sinus bradycardiaRates slower than 50 BPM9( 13.4%)

BlocksAV blocks of various degree, LBBB or RBBB, LAHB or LPHB

6( 8.9%)

Atrial or ventricular premature beats5(7.5%)

Early repolarization patternupward ST-segment elevation in 2 or more peripheral or precordial leads,

beginning from an elevated J point and continuing with an upsloping shape

into the T-wave

3( 4.5%)

Long QT intervalcorrected QT interval (QTc) greater than 440 milliseconds

3( 4.5%)

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Additional Additional investigationsinvestigations

ECG findingEchoStress testHolterAdenosine test

T wave changes17810

Early repolarization

2210

Long QT1220

Pre excitation pattern

17711

Atrial or ventricular

premature beats

2320

LVH16100

Blocks7730

Sinus bradycardia0860

Total46382211

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Clinical DiagnosisClinical Diagnosis

ECG findingFinal diagnosis (#)

T wave changesBAV (1)VSD (1)LVH (1)

Early repolarizationLVH (1)

Atrial or ventricular premature beats

Dilated left ventricle (1)

LVHLVH (1)Non compacted apex (1)

Long QT, pre-excitation pattern, sinus bradycardia, blocks

None

Total number7

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example 1example 1

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Example 2Example 2

ICRBBB with non-specific T wave changes in inferior leadsICRBBB with non-specific T wave changes in inferior leads

Echocardiography interpreted as normalEchocardiography interpreted as normal

No further w/u required No further w/u required

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Example 3Example 3

Early repolarization pattern particularly in V2Early repolarization pattern particularly in V2

Echocardiography-normalEchocardiography-normal

No further w/u requiredNo further w/u required

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DiscussionDiscussion

Screening for cardiovascular disease among athletes and military Screening for cardiovascular disease among athletes and military

candidates is imperative as sudden death is obviously tragic and candidates is imperative as sudden death is obviously tragic and

potentially preventablepotentially preventable

Debate continues regarding the optimal method of screening, this Debate continues regarding the optimal method of screening, this

ranging from reliance solely on history and physical examination ranging from reliance solely on history and physical examination

to performance of 12-lead ECG and echocardiographyto performance of 12-lead ECG and echocardiography

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DiscussionDiscussion

The total rate of ECGS defined as abnormal in this cohort The total rate of ECGS defined as abnormal in this cohort

was 4.6%, a percentage much lower than previously reported was 4.6%, a percentage much lower than previously reported

Yet, even in a previous report by Pellicia et al (8) in which Yet, even in a previous report by Pellicia et al (8) in which

11.8% of ECGs were interpreted as abnormal, additional 11.8% of ECGs were interpreted as abnormal, additional

evaluation was requested in only 4.8% of ECGs, disregarding evaluation was requested in only 4.8% of ECGs, disregarding

some of the findings noted on routine ECG some of the findings noted on routine ECG

This rate is similar to that reported in this study and This rate is similar to that reported in this study and

probably represents the true rate of ECG findings requiring probably represents the true rate of ECG findings requiring

further evaluation in young athletes further evaluation in young athletes

Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339: 364–369Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339: 364–369

Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R, Castagna W, Ciacciarelli A, Costini G, Cuffari B, Drago E, Federici V, Gribaudo Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R, Castagna W, Ciacciarelli A, Costini G, Cuffari B, Drago E, Federici V, Gribaudo

CG, Iacovelli G, Landolfi L, Menichetti G, Atzeni UO, Parisi A, Pizzi1 AR, Rosa M, Santelli F, Santilio F, Vagnini A, Casasco M, and Di Luigi L. CG, Iacovelli G, Landolfi L, Menichetti G, Atzeni UO, Parisi A, Pizzi1 AR, Rosa M, Santelli F, Santilio F, Vagnini A, Casasco M, and Di Luigi L.

Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur

Heart J 2007; 28(16): 2006-2010.Heart J 2007; 28(16): 2006-2010.

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T wavesT waves

T wave changes was the most common cause for T wave changes was the most common cause for

continued investigation in the cohortcontinued investigation in the cohort

This is probably due to the non specific nature of This is probably due to the non specific nature of

this findingthis finding

Disqualifying findings were identified in 18.75% of Disqualifying findings were identified in 18.75% of

evaluations in these subjects evaluations in these subjects

Whether these clinical findings were associated Whether these clinical findings were associated

with the ECG findings or were incidental is unclearwith the ECG findings or were incidental is unclear

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PRE EXCITATION PATTERNPRE EXCITATION PATTERN

Signs of pre-excitation were identified in 14 subjects who Signs of pre-excitation were identified in 14 subjects who

comprised 0.96% of the study populationcomprised 0.96% of the study population

This is a higher percentage than previously reported (0.2%)This is a higher percentage than previously reported (0.2%)

Probably resulted from the high awareness to this condition Probably resulted from the high awareness to this condition

among interpreting cardiologistsamong interpreting cardiologists

No cases of pre-excitation syndrome identifiedNo cases of pre-excitation syndrome identified

This is similar to a previous report from the Israeli air forceThis is similar to a previous report from the Israeli air force

Ferrer MF. Electrocardiographic variations, arrhythmias, pacemakers. In: Lew EA, Gajewski J. Medical Risks: Trends Ferrer MF. Electrocardiographic variations, arrhythmias, pacemakers. In: Lew EA, Gajewski J. Medical Risks: Trends

in Mortality by age and time elapsed. New York, NY: Praeger 1990. in Mortality by age and time elapsed. New York, NY: Praeger 1990.

Grossman A et al Use of adenosine test for the exclusion of pre-excitation syndrome in asymptomatic individuals. Grossman A et al Use of adenosine test for the exclusion of pre-excitation syndrome in asymptomatic individuals.

Ann Noninvasive Electrocardiol 2011 Apr 16 (2); 180-183.Ann Noninvasive Electrocardiol 2011 Apr 16 (2); 180-183.

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LVH criteriaLVH criteria

Signs of LVH were identified in only 7.56% of the study Signs of LVH were identified in only 7.56% of the study

populationpopulation

This is significantly lower than reported in previous This is significantly lower than reported in previous

studies (up to 45%)studies (up to 45%)

This is surprising given the young age of the population This is surprising given the young age of the population

and the fact that the subjects were all very physically and the fact that the subjects were all very physically

activeactive

Disqualifying findings were identified in 18.2% of these Disqualifying findings were identified in 18.2% of these

subjectssubjects

Pelliccia A et al Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-Pelliccia A et al Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-

participation cardiovascular screening. Eur Heart J 2007; 28(16): 2006-2010participation cardiovascular screening. Eur Heart J 2007; 28(16): 2006-2010

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LIMITATIONSLIMITATIONS

A selective cohort (healthy, physically A selective cohort (healthy, physically

active underwent ECG during screening active underwent ECG during screening

for athletic activity)for athletic activity)

Single physician interpreting all ECGS Single physician interpreting all ECGS

(high inter-observer variability reported in (high inter-observer variability reported in

the literature) the literature)

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ConclusionsConclusions

T wave changes, although non-specific, T wave changes, although non-specific,

may be a sign of cardiac diseasemay be a sign of cardiac disease

Pre-excitation pattern is of low Pre-excitation pattern is of low

specificity for the diagnosis of PES, but specificity for the diagnosis of PES, but

because of the lethal potential of this because of the lethal potential of this

condition, adenosine should be condition, adenosine should be

performed in subjects with a suspicious performed in subjects with a suspicious

patternpattern

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ConclusionsConclusions

ECG-LVH criteria have a low sensitivity in young ECG-LVH criteria have a low sensitivity in young

subjects, but because of the fatal potential of subjects, but because of the fatal potential of

HOCM and because the specificity of the ECG is HOCM and because the specificity of the ECG is

very high, echocardiography should be very high, echocardiography should be

performed to all those with ECG criteriaperformed to all those with ECG criteria

Policy makers should take into account the large Policy makers should take into account the large

number of echocardiographies that will be number of echocardiographies that will be

performed in order to identify subjects with true performed in order to identify subjects with true

LVHLVH

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ConclusionsConclusions

Sinus bradycardia and Sinus bradycardia and

conduction disturbances (low conduction disturbances (low

degree AVB and hemiblocks) degree AVB and hemiblocks)

probably result from increased probably result from increased

vagal tone and require no vagal tone and require no

additional work-upadditional work-up

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