Implementation of the

preparticipation screening

and IOC Recommendation is

the goal for sport physicians

Antonio Pelliccia, MD

antonio.pelliccia@coni.it

The pre-participation screening

is efficient to reduce mortality in

young athletes

SD

per

100,0

00 a

thle

te-y

ears

Annual incidence of SCD in screened athletes vs. unscreened non-athletes

Corrado et al. JAMA 2006;296:1593-601

3.6

0.4

0.7 0.8

The PPS is efficient to reduce SCD in young athletes

Corrado et al JAMA 2006;296:1593-1601

Comparison of Italian and US sudden deaths rates

Corrado et al. JAMA 2006; 296: 1593-601

Maron et al. Am J Cardiol 2009; in press

Incidence of SCD in NCAA Athletes

Harmon et al. Circulation 2011

Case identification (2003-2008):

NCAA Resolutions List (87%)

Media Reports (56%)

Catastrophic insurance claims (20%)

VF/Asystole

EXERCISE:

Deydratation

Electrolyte

imbalance

Adrenergic

output

Ischemia

Unstable Electrophysiological Substrate

The mechanisms for reduced

mortality in athletes with CV diseases

disqualified from competitive sports

PEAK TRAINING AFTER DETRAINING

10,611

48

9

6

0,52,165

0

20

40

60

80

100

120

140

160

180

200

0

2000

4000

6000

8000

10000

12000

14000

16000

18000 NSVTPVBs

Detraining Re-trainingPeak-training

Impact of detraining and resumed training on VAs:

In athletes with structural CV disease

intensive training and competition increases

the incidence and severity of arrhythmias at

risk for SD.

On the contrary, detraning reduces the risk

and may have life-saving impact.

In conclusion, scientific evidence shows that:

The efficiency of PPS is mostly

due to inclusion of 12-lead ECG

ECG abnormalities in up to 95%:

ST-T wave changes

Deep Q waves

Left axis deviation

Exceedingly high QRS voltages

P wave changes

(LAenlargement)

ECG abnormalities in > 80%:

Inverted T waves in anterior

precordial leads (beyond V1)

RV conduction delay

Epsilon wave

PVBs with LBBB morphology

HCM

RVLV

RA

LA

ARVC

The rationale for including the 12-lead ECG:

Diagnosis of HCM in young athletes

Adolescence Adulthood

Genotype

anomaliesAbnormal ECG

LV Hypertrophy

Ab

norm

al

fin

din

gs

Sudden death can occur at any time !

Long-term follow-up of athletes with abnormal ECG (Pelliccia et al. New Engl J Med 2008; 358: 152-63)

5

70

6Cardiomyopathies

(HCM3; ARVC1; DCM1)Other CV disease (Hpt 3, CAD 1, myoc 1, SVT 1)

No symptoms,

no CV disease

1, sudden death

1, cardiac arrest

81Study group

9-year follow-up

Probability to identify cardiac diseases at risk for SCD

by ECG or by Hx+PE:

ECG Hx+PE

Hypertrophic cardiomyopathy up to 90% < 10%

Arrhythmogenic right ventricular

cardiomyopathy 60-80% < 10%

Dilated cardiomyopathy 30-60% < 10%

Myocarditis 30-60% < 10%

Marfan’s syndrome < 10% > 90%

Valvular Disease < 10% > 90%

Long QT and Short QT syndrome > 80% zero

Brugada syndrome > 90% zero

Pre-excitation syndrome (WPW) > 90% zero

Congenital Coronary Artery Anomalies < 10% < 10%

510Study

Population

Mean age: 19 years

White 67% (Black 10%)

Gender: Males 61%

College athletes

Matriculated Harvard Univ.

11

387

110

Echocardiography;

History, PE and 12-lead ECG

Relevant

Cardiac

Findings

Normal

Heart

Physiologic

Remodeling

(from A. Baggish et al. Ann Intern Med 2010; 152: 269)

CV Screening in 510 Bostonian College Athletes

by A. Baggish et al. Ann Int Med 2010; 152: 269

1, Bicuspid aortic valve Murmur None None

2, Bicuspid aortic valve Murmur/Click None None

3, MVP Murmur None None

4, MVP Murmur None None

5, MVP None None None

6, Pulm. stenosis Murmur None Pul. St.

7, LV hypertrophy None QRS volt/LAE None

8, LV hypertrophy None QRS volt/T neg HCM

9, LV dilation None LBBB None

10, LV dilation None LBBB Myocarditis

11, RV dilation None RBBB None

Cardiac morphology His. + PE ECG Diagnosis

The actual prevalence

of abnormal ECGs

31,864 athletes evaluated in 19 National Medical

Centers across all Italy

Normal ECGs

28.108

(88.2%)

Abnormal ECGs

3.756(11.8%)

Early repolarization;

incomplete RBBB; mildly

increased R/S wave voltages

(59%)

Inverted T waves

(20%)

LAFB

(4%)LVH

(7%)

WPW

(1%) Prolonged QT interval (0.03%)

RBBB

(9%)

ECG abnormalities found at PPS

42,386Athletes screened

in Padua,

1982-2004

38,472

(91%)

Normal findings

3,914 (9%)

“Positive” findings

From Corrado et al.

JAMA 2006

879

(2%)Cardiac

abnormalities

91

(0.2%)Cardiac

disease at risk

True

Positives

7% False

Positives

Witout CV diseases(i.e., true negatives)

4,438

(>99%)Structural CVAbnormalities

(i.e., false negatives)

12(<1%)

(Pelliccia et al. Eur Heart J. 2006)

4,450 athletes judged free of CV diseasesat CV preparticipation screening

ECHOCARDIOGRAPHY

Aortic valve

disease

MVP

Myocarditis

Marfan’s ARVC

(n = 2)

(n = 2) (n = 1)

(n = 3)

(n = 4)

Athletes with Structural CV Abnormalities

No HCM was found !

(Pelliccia et al. Eur Heart J. 2006)

Implementation of the

preparticipation screening:

educational activities

Novel ECG Interpretation in athletes:

“Normal”

Common and

Physiologic

Training-related

ECG alteration

“Abnormal”

Uncommon and

Pathologic

Training-unrelated

Need for further

work-up

510Study

Population

Mean age: 19 years

White 67% (Black 10%)

Gender: Males 61%

College athletes

Matriculated Harvard Univ.

Echocardiography;

History, PE and 12-lead ECG

(from A. Baggish et al. Personal communication)

Old ECG criteria New ECG criteria

16% ECG considered

abnormal

9% ECG considered

abnormal

Sensitivity 90%;

Specificity 83%

Sensitivity 91%;

Specificity 89%

Limitations

of the screening

Limitations of the PPS The Center for Coronary Artery

Anomalies (CCAA) at the Texas

Heart Institute launched in 2010 a

research program that involves

voluntary screenings of 10,000

middle school students for CCAA.

The study includes: 1) history

(personal and familial); 2) ECG

and, 3) a simplified program of

CMR.

1. The 12-lead ECG is efficient to identify (or raise

suspicion for) most CMPc and channelopathies, but

not for CCAA;

2. The prevalence of abnormal findings (ECG+PE+Hx) is

about 10% in large athlete populations; most are false

positive findings;

3. Routine echocardiography does not significantly

increase sensitivity of the ECG-screening for CMPs;

4. Disqualifying athletes with CV disease from competitive

sport may be life-saving;

In conclusion,

the Italian experience shows that:

Sudden Death in Athletes

“The fragility of life”

Dedicated to Marc-Vivien Foe

Antonio Pelliccia, MD

Institute of Sport Medicine and Science. Rome.

antonio.pelliccia@coni.it