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Chowdhury D, Elliott PA, Asaki SY, Amdani S, Nguyen Q, Ronai C, Tierney S, Levy VY, Puri K, Altman CA, Johnson JN, Glickstein JS. Addressing Disparities in Pediatric Congenital Heart Disease: A Call for Equitable Health Care. J Am Heart Assoc 2024; 13:e032415. [PMID: 38934870 PMCID: PMC11255720 DOI: 10.1161/jaha.123.032415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
While significant progress has been made in reducing disparities within the US health care system, notable gaps remain. This article explores existing disparities within pediatric congenital heart disease care. Congenital heart disease, the most common birth defect and a leading cause of infant death, has garnered substantial attention, revealing certain disparities within the US health care system. Factors such as race, ethnicity, insurance coverage, socioeconomic status, and geographic location are all commonalities that significantly affect health disparities in pediatric congenital heart disease. This comprehensive review sheds light on disparities from diverse perspectives in pediatric care, demonstrates the inequities and inequalities leading to these disparities, presents effective solutions, and issues a call to action for providers, institutions, and the health care system. Recognizing and addressing these disparities is imperative for ensuring equitable care and enhancing the long-term well-being of children affected by congenital heart disease. Implementing robust, evidence-based frameworks that promote responsible and safe interventions is fundamental to enduring change.
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Affiliation(s)
- Devyani Chowdhury
- Cardiology Care for ChildrenLancasterPAUSA
- Nemours Cardiac CenterWilmingtonDEUSA
| | | | - S. Yukiko Asaki
- Department of Pediatric CardiologyUniversity of Utah, and Primary Children’s HospitalSalt LakeUTUSA
| | - Shahnawaz Amdani
- Division of Cardiology & Cardiovascular Medicine, Children’s Institute Department of HeartVascular & ThoracicClevelandOHUSA
| | - Quang‐Tuyen Nguyen
- Division of General Pediatrics, Department of PediatricsPrimary Children’s Hospital, University of UtahSalt Lake CityUTUSA
| | - Christina Ronai
- Department of Pediatrics, Division of Pediatric CardiologyOregon Health and Sciences UniversityPortlandORUSA
- Department of Cardiology, Boston Children’s Hospital, Department of PediatricsHarvard Medical SchoolBostonMAUSA
| | - Seda Tierney
- Department of Pediatrics, Division of Cardiology, Lucile Packard Children’s HospitalStanford University Medical CenterPalo AltoCAUSA
| | - Victor Y. Levy
- Division of Pediatric Cardiology and NeonatologyLogan Health Children’s HospitalKalispellMTUSA
| | - Kriti Puri
- Section of Pediatric Cardiology, Department of PediatricsBaylor College of MedicineHoustonTXUSA
| | | | - Jonathan N. Johnson
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric CardiologyMayo ClinicRochesterMNUSA
| | - Julie S. Glickstein
- Division of Cardiology, Department of PediatricsColumbia University Irving Medical CenterNew YorkNYUSA
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McHugh C, Petek B, Grant AJ, Gustus S, van Dyk N, Hind K, Wilson F, Wasfy M. ECG findings in professional rugby players using international screening recommendations. BMJ Open Sport Exerc Med 2024; 10:e001813. [PMID: 38562152 PMCID: PMC10982795 DOI: 10.1136/bmjsem-2023-001813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 04/04/2024] Open
Abstract
Background While World Rugby guidelines do not mandate the inclusion of an electrocardiogram (ECG) for all players, this is required for entry into international rugby competitions. We, therefore, sought to describe sport-specific normative ECG values and evaluate the performance of contemporary athlete ECG guidelines in male and female professional rugby players. Methods We retrospectively analysed professional rugby players' ECGs (n=356, male 79%) obtained during preparticipation screening (2010-2022), comparing by sex and playing position (forwards vs backs). ECGs were categorised as normal 'training-related', borderline and abnormal findings, as defined by the 2017 International Recommendations. Results 84% of players had one or more normal, 'training-related' findings, with males having a higher prevalence than females (91% vs 60%, p<0.001). Most ECG findings did not vary by position. No female player had borderline or abnormal ECG findings. Borderline findings were present in 3% (n=12/356) of players. Abnormal findings were present in 2% (n=7/356) of players. Overall, 2.2% of ECGs were 'positive' (n=8/356, including n=1 ECG with two borderline findings). Conclusions The application of contemporary ECG interpretation criteria resulted in a low positivity rate isolated to male players. These results help inform the logistic feasibility of ECG-inclusive screening, which is already required to enter major tournaments.
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Affiliation(s)
- Clíodhna McHugh
- Department of Physiotherapy, Trinity College Dublin, Dublin, Ireland
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bradley Petek
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Sports Cardiology Program, Oregon Health & Science University Knight Cardiovascular Institute, Portland, Oregon, USA
| | - Aubrey J Grant
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Sport & Performance, MedStar Health, Columbia, Maryland, USA
| | - Sarah Gustus
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nicol van Dyk
- High Performance Unit, Irish Rugby Football Union, Dublin, Ireland
- Section Sports Medicine, Faculty of Health Science, University of Pretoria, Pretoria, South Africa
| | - Karen Hind
- Department of Sport and Exercise Science, Durham University, Durham, UK
| | - Fiona Wilson
- Department of Physiotherapy, Trinity College Dublin, Dublin, Ireland
| | - Meagan Wasfy
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Football Player Health Study, Harvard Medical School, Boston, Massachusetts, USA
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Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Card Electrophysiol Clin 2024; 16:35-49. [PMID: 38280813 PMCID: PMC11207195 DOI: 10.1016/j.ccep.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
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Zapata Martínez M, Pardo Ríos M, García Alberola A, López-Picazo Ferrer J, Banacloche Cano C, Iglesias Gómez C, Pérez Gálvez MD, Fernández Redondo C, Gimeno Blanes JR. [Screening for heart disease in kids and adolescents (Prevencar Program)]. Aten Primaria 2024; 56:102782. [PMID: 37924621 PMCID: PMC10654544 DOI: 10.1016/j.aprim.2023.102782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/13/2023] [Accepted: 09/18/2023] [Indexed: 11/06/2023] Open
Abstract
OBJECTIVE The objective was to develop a screening for heart disease detection in primary care, to identify pathological electrocardiographic changes and underlying heart disease in adolescents. DESIGN The study was carried out for one year using multistage sampling. SITE: Primary care centers in a health area that had digital ECG equipment (12 centers) were selected. PARTICIPANTS Initially, 718 (16.6%) 14-year-old adolescents were recruited and those with a previous diagnosis of heart disease were excluded. INTERVENTIONS Screening consisted of including a health questionnaire in the mandatory 14-year-old check-up. MAIN MEASUREMENTS Screening included a questionnaire, cardiac auscultation, ECG and echocardiography. Abnormality criteria were established to refer for a second evaluation by a cardiologist. RESULTS Finally, the sample was made up of 698 adolescents, with a mean age of 13.7±0.5 years, and 354 (50.7%) were boys. A total of 149 (21.3%) were selected for a second review by cardiology: 88 (12.6%) due to a positive questionnaire, 11 (2.2%) due to abnormal cardiac auscultation, and 66 (9.5%) due to ECG findings. Adolescents with evidence of heart disease were 24 (3.4%). Of these, 14 (2.0%) had suggestive alterations and follow-up was recommended, 6 (0.9%) had a definitive diagnosis of heart disease, and 4 (0.6%) had other pathological findings related to the cardiovascular system. CONCLUSIONS The screening allowed us to identify 1% of adolescents with heart disease and another 2% will remain in follow-up. The ECG detected more pathological cases than the questionnaire.
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Affiliation(s)
- Marta Zapata Martínez
- Centro de Salud de Aljucer, Aljucer, Murcia, España; Universidad de Murcia, Murcia, España; Instituto Murciano de la Investigación Biosanitaria (IMIB), Murcia, España.
| | - Manuel Pardo Ríos
- Gerencia de Urgencias y Emergencias 061 de la Región de Murcia, Murcia, España; UCAM Universidad Católica de Murcia, Guadalupe, Murcia, España
| | - Arcadio García Alberola
- Universidad de Murcia, Murcia, España; Instituto Murciano de la Investigación Biosanitaria (IMIB), Murcia, España; Unidad Arrítmias y Electrofisiología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - Julio López-Picazo Ferrer
- Universidad de Murcia, Murcia, España; Instituto Murciano de la Investigación Biosanitaria (IMIB), Murcia, España; Unidad de Calidad, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | | | | | - M Dolores Pérez Gálvez
- Dirección y Gerencia, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | | | - Juan Ramón Gimeno Blanes
- Universidad de Murcia, Murcia, España; Instituto Murciano de la Investigación Biosanitaria (IMIB), Murcia, España; Unidad de Cardiopatías Familiares (CSUR- ERN Guard-Heart), Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España; CIBERCV CB16/11/00385 (ISCIII)
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Orchard JJ, Orchard JW, Davis AJ, Puranik R, Isbister JC, La Gerche A, Driscoll T, Doughty RN, Hamilton B. Clinical outcomes of 10 years of cardiac screening in elite New Zealand athletes. J Sci Med Sport 2023; 26:659-666. [PMID: 37932202 DOI: 10.1016/j.jsams.2023.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 10/10/2023] [Accepted: 10/16/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVES To report findings from the High Performance Sport New Zealand cardiac screening programme, including comparisons between sexes and ethnicities. DESIGN Retrospective cohort study. METHODS Elite Olympic-sport athletes were screened (2012-2022) with personal/family history, physical examination, resting 12-lead ECG and followed from the date of first screening until July 2022. An audit reviewed screening records, including demographic data, ECGs, follow-up and diagnoses. Flagged/equivocal ECGs were re-reviewed (International Criteria). RESULTS 2075 ECGs from 1189 athletes (53 % female, mean age 21 years; 83 % European, 9 % Māori, 5 % Pacific Islander, 3 % other) were included. No athletes retired for cardiac reasons; there were no cardiac deaths or major cardiac incidents (mean follow-up from first screening: 6.1 years (range: 0.6-10.9 years)). Diagnoses included Wolff-Parkinson-White (WPW) syndrome (0.7 %) and cardiomyopathies (0.3 %). Overall, 3.5 % of ECGs were abnormal, with ECGs of females more commonly abnormal (4.4 % vs 2.5 %, p = 0.02) and with a higher proportion of ECGs with abnormal T-wave inversion (TWI) (3.1 % vs 0.9 %, p < 0.001) compared to males. Of the abnormal TWI in females (all aged ≥16 years), 47 % was limited to V1-V3 with no other abnormalities. Abnormality rates were similar between Māori, Pacific Islander and European athlete ECGs. CONCLUSIONS WPW was the most frequent diagnosis, with very little cardiomyopathy found. The proportion of abnormal ECGs was low overall, but higher in females. This was driven by anterior TWI in V1-V3 which was not associated with diagnoses of conditions associated with sudden cardiac death (SCD). There was no difference in the proportion of abnormal ECGs of Māori or Pacific Island athletes compared to European athletes.
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Affiliation(s)
- Jessica J Orchard
- Sydney School of Public Health, Faculty of Medicine & Health, The University of Sydney, Australia. https://twitter.com/jessicajorchard
| | - John W Orchard
- Sydney School of Public Health, Faculty of Medicine & Health, The University of Sydney, Australia. https://twitter.com/DrJohnOrchard
| | - Angus J Davis
- Sydney School of Public Health, Faculty of Medicine & Health, The University of Sydney, Australia. https://twitter.com/AngusDavis6
| | - Rajesh Puranik
- Faculty of Medicine & Health, The University of Sydney, Australia
| | - Julia C Isbister
- Sydney School of Public Health, Faculty of Medicine & Health, The University of Sydney, Australia. https://twitter.com/JuliaIsbister
| | - Andre La Gerche
- Baker Heart & Diabetes Institute, Australia; National Centre for Sports Cardiology, Australia. https://twitter.com/ALaGerche
| | - Tim Driscoll
- Sydney School of Public Health, Faculty of Medicine & Health, The University of Sydney, Australia
| | - Robert N Doughty
- University of Auckland, New Zealand; The Heart Group, New Zealand
| | - Bruce Hamilton
- High Performance Sport New Zealand, New Zealand; Sport Research Institute of New Zealand, Auckland University of Technology, New Zealand.
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Kırık ABT, Yüksel O, Dursun H, Çöllüoğlu İT, Kocahan T, Kaya D. Visual or computer-based measurements: Which is important for the interpretation of an athlete's electrocardiography? REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20230476. [PMID: 37909616 PMCID: PMC10610756 DOI: 10.1590/1806-9282.20230476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/22/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE Preparticipation screening of athletes by electrocardiography is the most crucial step in determining sudden cardiac death risk factors. Several electrocardiography interpretation software programs have been developed for physicians practicing in this field. Our study aimed to assess cardiopoint sudden death screening module by comparing its findings with two cardiologists using Seattle and International criteria. METHODS A total of 303 licensed national athletes (37% females) were enrolled. electrocardiographies were examined by the cardiopoint sudden death screening module using Seattle criteria and cardiologists. The consistency between cardiologists and software was compared, and the confidence assessment of the module was tested. RESULTS With regard to Seattle criteria, moderate consistency was found between the cardiopoint sudden death screening module and the 1st (κ=0.41) and 2nd cardiologist (κ=0.59). Consistency between two cardiologists was moderate (κ=0.55). When we applied International criteria, there was moderate consistency between the module and the 1st cardiologist (κ=0.42), and good consistency between the module and the 2nd cardiologist (κ=0.63). Consistency between the two cardiologists was good (κ=0.62). CONCLUSION The cardiopoint sudden death screening module had similar agreement with cardiologists based on both criteria. However, the software needs to be updated according to International criteria. Using computer-based measurements for preparticipation screening will help to save time and provide standardization of electrocardiography interpretation.
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Affiliation(s)
| | - Oğuz Yüksel
- Dokuz Eylül University, Faculty of Medicine, Department of Sports Medicine – İzmir, Turkey
| | - Hüseyin Dursun
- Dokuz Eylül University, Faculty of Medicine, Department of Cardiology – İzmir, Turkey
| | - İnci Tuğçe Çöllüoğlu
- Karabük University Education and Research Hospital, Department of Cardiology – Karabük, Turkey
| | - Tuğba Kocahan
- University of Health Sciences Gülhane Training and Research Hospital, Department of Sports Medicine – Ankara, Turkey
| | - Dayimi Kaya
- Dokuz Eylül University, Faculty of Medicine, Department of Cardiology – İzmir, Turkey
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Marshall M, Malik A, Shah M, Fish FA, Etheridge SP, Aziz PF, Russell MW, Tisma S, Pflaumer A, Sreeram N, Kubus P, Law IH, Kantoch MJ, Kertesz NJ, Strieper M, Erickson CC, Moore JP, Nakano SJ, Singh HR, Chang P, Cohen M, Fournier A, Ilina MV, Zimmermann F, Horndasch M, Li W, Batra AS, Liberman L, Hamilton R, Janson CM, Sanatani S, Zeltser I, McDaniel G, Blaufox AD, Garnreiter JM, Balaji S. Patterns of Electrocardiographic Abnormalities in Children with Hypertrophic Cardiomyopathy. Pediatr Cardiol 2023:10.1007/s00246-023-03252-4. [PMID: 37684488 DOI: 10.1007/s00246-023-03252-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/25/2023] [Indexed: 09/10/2023]
Abstract
Hypertrophic cardiomyopathy (HCM), a common cardiomyopathy in children, is an important cause of morbidity and mortality. Early recognition and appropriate management are important. An electrocardiogram (ECG) is often used as a screening tool in children to detect heart disease. The ECG patterns in children with HCM are not well described.ECGs collected from an international cohort of children, and adolescents (≤ 21 years) with HCM were reviewed. 482 ECGs met inclusion criteria. Age ranged from 1 day to 21 years, median 13 years. Of the 482 ECGs, 57 (12%) were normal. The most common abnormalities noted were left ventricular hypertrophy (LVH) in 108/482 (22%) and biventricular hypertrophy (BVH) in 116/482 (24%) Of the patients with LVH/BVH (n = 224), 135 (60%) also had a strain pattern (LVH in 83, BVH in 52). Isolated strain pattern (in the absence of criteria for hypertrophy) was seen in 43/482 (9%). Isolated pathologic Q waves were seen in 71/482 (15%). Pediatric HCM, 88% have an abnormal ECG. The most common ECG abnormalities were LVH or BVH with or without strain. Strain pattern without hypertrophy and a pathologic Q wave were present in a significant proportion (24%) of patients. Thus, a significant number of children with HCM have ECG abnormalities that are not typical for "hypertrophy". The presence of the ECG abnormalities described above in a child should prompt further examination with an echocardiogram to rule out HCM.
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Affiliation(s)
- Mayme Marshall
- Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Aneeq Malik
- University of Los Angeles Olive View, Los Angeles, CA, USA
| | - Maully Shah
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Peter F Aziz
- Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | | | | | - Andreas Pflaumer
- Royal Children's Hospital, University of Melbourne, Parkville, VIC, Australia
| | | | | | - Ian H Law
- University of Iowa, Iowa City, IA, USA
| | | | | | - Margaret Strieper
- Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | | | | | | | - Harinder R Singh
- Children's Hospital of San Antonio, Baylor College of Medicine, San Antonio, TX, USA
| | | | - Mitchell Cohen
- Inova LJ Murphy Children's Hospital, Falls Church, VA, USA
| | | | | | | | | | - Walter Li
- University of California, San Francisco, CA, USA
| | | | | | | | | | | | | | | | - Andrew D Blaufox
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | | | - Seshadri Balaji
- Oregon Health and Science University, 707 SW Gaines Street, Portland, OR, 97239, USA.
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Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Cardiol Clin 2023; 41:35-49. [PMID: 36368810 PMCID: PMC10292923 DOI: 10.1016/j.ccl.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
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Hill B, Grubic N, Williamson M, Phelan DM, Baggish AL, Dorian P, Drezner JA, Johri AM. Does cardiovascular preparticipation screening cause psychological distress in athletes? A systematic review. Br J Sports Med 2023; 57:172-178. [PMID: 36418151 DOI: 10.1136/bjsports-2022-105918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the psychological implications of cardiovascular preparticipation screening (PPS) in athletes. DESIGN Systematic review. DATA SOURCES MEDLINE, EMBASE, PubMed, CINAHL, SPORTDiscus, APA PsycInfo, Cochrane Library and grey literature sources. STUDY ELIGIBILITY CRITERIA Observational and experimental studies assessing a population of athletes who participated in a cardiovascular PPS protocol, where psychological outcomes before, during and/or after PPS were reported. METHODS Results of included studies were synthesised by consolidating similar study-reported measures for key psychological outcomes before, during and/or after screening. Summary measures (medians, ranges) were computed across studies for each psychological outcome. RESULTS A total of eight studies were included in this review (median sample size: 479). Study cohorts consisted of high school, collegiate, professional and recreational athletes (medians: 59% male, 20.5 years). Most athletes reported positive reactions to screening and would recommend it to others (range 88%-100%, five studies). Increased psychological distress was mainly reported among athletes detected with pathological cardiac conditions and true-positive screening results. In comparison, athletes with false-positive screening results still reported an increased feeling of safety while participating in sport and were satisfied with PPS. A universal conclusion across all studies was that most athletes did not experience psychological distress before, during or after PPS, regardless of the screening modality used or accuracy of results. CONCLUSION Psychological distress associated with PPS in athletes is rare and limited to athletes with true-positive findings. To mitigate downstream consequences in athletes who experience psychological distress, appropriate interventions and resources should be accessible prior to the screening procedure. PROSPERO REGISTRATION NUMBER CRD42021272887.
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Affiliation(s)
- Braeden Hill
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nicholas Grubic
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Dermot M Phelan
- Sports Cardiology Center, Atrium Health Sanger Heart and Vascular Institute, Charlotte, North Carolina, USA
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul Dorian
- Department of Medicine, Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan A Drezner
- Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
| | - Amer M Johri
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Ujeyl A, Niederseer D. [The athlete's ECG : What is normal or abnormal?]. Herzschrittmacherther Elektrophysiol 2023; 34:10-18. [PMID: 36670183 PMCID: PMC9950162 DOI: 10.1007/s00399-022-00917-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/12/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND The electrocardiogram (ECG) has become a mobile and cost-effective routine assessment tool to risk stratify leisure-time and professional athletes during preparticipation screening. A central goal is the reduction of sudden cardiac death in sports through early recognition of the most prevalent underlying cardiac pathologies, e.g., hereditary cardiomyopathies or primary arrhythmias. METHODS Continuous evolution of the first ECG criteria for athletes, presented in 2010 by the European Society of Cardiology (ESC), has helped to improve the specificity of the criteria to both detect cardiac pathologies in early stages and differentiate from physiologic adaptation of the athlete's heart. Thus, the risk of false-positive findings and erroneous stigmatizations of athletes has been successfully reduced. CONCLUSION This review article intends to trace back the changes of the ECG criteria in the light of a growing body of scientific evidence over the last 15 years, to present the key messages of the current International ECG criteria from 2017 and to identify some of the remaining challenges that wait to be answered by physicians in the field of sports medicine and sports cardiology.
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Affiliation(s)
- Amaar Ujeyl
- Praxis LANS Cardio, Hamburg, Deutschland ,grid.264200.20000 0000 8546 682XMSc Sports Cardiology, St. George’s University of London, London, Großbritannien
| | - David Niederseer
- Klinik für Kardiologie, Universitäres Herzzentrum Zürich, Universitätsspital Zürich, Universität Zürich, Rämistrasse 100, Zürich, 8091, Schweiz.
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11
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Evaluation of a Preparticipation Cardiovascular Screening Program Among 1,686 National Collegiate Athletic Association Division I Athletes: Comparison of the Seattle, Refined, and International Electrocardiogram Screening Criteria. Clin J Sport Med 2022; 32:306-312. [PMID: 32487874 DOI: 10.1097/jsm.0000000000000858] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 04/06/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To: (1) analyze the results of 5 years of preparticipation cardiac screening including 12-lead electrocardiogram (ECG) of National Collegiate Athletic Association (NCAA) Division I athletes; and (2) assess the rates of ECG screening abnormalities and false-positive rates among 3 ECG screening criteria. DESIGN Retrospective chart review. SETTING National Collegiate Athletic Association Division I University. PARTICIPANTS One thousand six hundred eighty-six first-year athletes presenting for their preparticipation examination including 12-lead resting ECG. INTERVENTIONS At the completion of the study period, all ECGs were retrospectively reviewed using the Seattle, Refined, and International Criteria. MAIN OUTCOME MEASURES (1) Prevalence of pathologic cardiac conditions identified by screening; and (2) number of ECG screening abnormalities by criteria. RESULTS Three athletes (0.2%) were found to have conditions that are associated with sudden cardiac death. Retrospective review of ECGs using Seattle, Refined, and International criteria revealed an abnormal ECG rate of 3.0%, 2.1%, and 1.8%, respectively. International criteria [odds ratios (OR), 0.58; P = 0.02] demonstrated a lower false-positive rate compared with the Seattle criteria. There was no significant difference in false-positive rates between the Seattle and Refined (OR, 0.68; P = 0.09) or the International and Refined criteria (OR, 0.85; P = 0.5). CONCLUSIONS There was a low rate of significant cardiac pathology in this population, and no athletes were permanently restricted from play as a result of screening. Our results suggest that the International criteria have the lowest false-positive rate of athlete-specific ECG criteria, and thus, it is the preferred method for preparticipation ECG screening in NCAA athletes.
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12
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Dimitriadis K, Bletsa E, Lazarou E, Leontsinis I, Stampouloglou P, Dri E, Sakalidis A, Pyrpyris N, Tsioufis P, Siasos G, Tsiachris D, Tsioufis K. A Narrative Review on Exercise and Cardiovascular Events: “Primum Non Nocere”. HEART AND MIND 2022. [DOI: 10.4103/hm.hm_25_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Albiński M, Saubade M, Benaim C, Menafoglio A, Meyer P, Capelli B, Perrin T, Trachsel L, Hagemeyer D, Casagrande D, Wilhelm M, Pirrello T, Albrecht S, Schmied C, Mivelaz Y, Tercier S, Baggish A, Gabus V. Impact of early sports specialisation on paediatric ECG. Scand J Med Sci Sports 2021; 31:1335-1341. [PMID: 33619756 DOI: 10.1111/sms.13942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
Athletes of pediatric age are growing in number. They are subject to a number of risks, among them sudden cardiac death (SCD). This study aimed to characterize the pediatric athlete population in Switzerland, to evaluate electrocardiographic findings based on the International Criteria for electrocardiography (ECG) Interpretation in Athletes, and to analyze the association between demographic data, sport type, and ECG changes. Retrospective, observational study of pediatric athletes (less than 18 years old) including medical history, physical examination, and a 12-lead resting ECG. The primary focus was on identification of normal, borderline, and abnormal ECG findings. The secondary observation was the relation between ECG and demographic, anthropometric, sport-related, and clinical data. The 891 athletes (mean 14.8 years, 35% girls) practiced 45 different sports on three different levels, representing all types of static and dynamic composition of the Classification of Sports by Mitchell. There were 75.4% of normal ECG findings, among them most commonly early repolarization, sinus bradycardia, and left ventricular hypertrophy; 4.3% had a borderline finding; 2.1% were abnormal and required further investigations, without SCD-related diagnosis. While the normal ECG findings were related to sex, age, and endurance sports, no such observation was found for borderline or abnormal criteria. Our results in an entirely pediatric population of athletes demonstrate that sex, age, and type of sports correlate with normal ECG findings. Abnormal ECG findings in pediatric athletes are rare. The International Criteria for ECG Interpretation in Athletes are appropriate for this age group.
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Affiliation(s)
- Maciej Albiński
- Department of Woman-Mother-Child, Division of Paediatrics, Lausanne University Hospital, Lausanne, Switzerland
| | - Mathieu Saubade
- Center of Sports Medicine, Division of Physical and Rehabilitation Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,Department of Woman-Mother-Child, Interdisciplinary Division for Adolescent Health, Lausanne University Hospital, Lausanne, Switzerland
| | - Charles Benaim
- Center of Sports Medicine, Division of Physical and Rehabilitation Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrea Menafoglio
- Department of Cardiology, San Giovanni Hospital Bellinzona, Bellinzona, Switzerland
| | - Philippe Meyer
- Service of Cardiology, University Hospital Geneva, Geneva, Switzerland
| | - Bruno Capelli
- Department of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Tilman Perrin
- Department of Cardiology, Inselspital, University Hospital Bern, Bern University, Bern, Switzerland
| | - Lukas Trachsel
- Department of Cardiology, Inselspital, University Hospital Bern, Bern University, Bern, Switzerland
| | - Daniel Hagemeyer
- Department of Cardiology, Inselspital, University Hospital Bern, Bern University, Bern, Switzerland
| | - Damien Casagrande
- Department of Cardiology, Inselspital, University Hospital Bern, Bern University, Bern, Switzerland
| | - Matthias Wilhelm
- Department of Cardiology, Inselspital, University Hospital Bern, Bern University, Bern, Switzerland
| | - Tony Pirrello
- Swiss Federal Institute of Sports, Magglingen, Switzerland
| | | | - Christian Schmied
- Department of Cardiology, University Heart Center Zurich, University of Zurich, Zurich, Switzerland
| | - Yvan Mivelaz
- Department of Woman-Mother-Child, Paediatric Cardiology Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Stéphane Tercier
- Department of Woman-Mother-Child, Interdisciplinary Division for Adolescent Health, Lausanne University Hospital, Lausanne, Switzerland
| | - Aaron Baggish
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Vincent Gabus
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
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14
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Churchill TW, Petek BJ, Wasfy MM, Guseh JS, Weiner RB, Singh TK, Schmied C, O'Malley H, Chiampas G, Baggish AL. Cardiac Structure and Function in Elite Female and Male Soccer Players. JAMA Cardiol 2021; 6:316-325. [PMID: 33263734 DOI: 10.1001/jamacardio.2020.6088] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Population-specific normative data are essential for the evaluation of competitive athletes. At present, there are limited data defining normal electrocardiographic (ECG) and echocardiographic values among elite US soccer players. Objective To describe ECG and echocardiographic findings in healthy elite US soccer players. Design, Setting, and Participants This cross-sectional study analyzed Fédération Internationale de Football Association-mandated screening sessions performed at US Soccer National Team training locations from January 2015 to December 2019. US women's and men's national team soccer players undergoing mandated cardiovascular screening were included. Main Outcomes and Measures Normal training-related and abnormal ECG findings were reported using the International Recommendations for Electrocardiographic Interpretation in Athletes. Echocardiographic measurements of structural and functional parameters relevant to cardiovascular remodeling were assessed relative to American Society of Echocardiography guideline-defined normal ranges. Results A total of 238 athletes (122 [51%] female; mean [SD] age, 20 [4] years; age range, 15-40 years) were included. Male athletes demonstrated a higher prevalence of normal training-related ECG findings, while female athletes were more likely to have abnormal ECG patterns (14 [11%] vs 0 in male cohort), largely accounted for by abnormal T-wave inversions. Echocardiography revealed no pathologic findings meeting criteria for sport restriction, but athletes frequently exceeded normal ranges for structural cardiac parameters responsive to exercise-induced remodeling including body surface area-indexed left ventricular (LV) mass (58 of 113 female athletes [51%] and 67 of 114 male athletes [59%]), indexed LV volume (89 of 115 female athletes [77%] and 76 of 111 male athletes [68%]), and LV wall thickness (37 of 122 female athletes [30%] and 47 of 116 male athletes [41%]). Age-stratified analysis revealed age-dependent increases in LV wall thickness, mass, and volumes among female athletes and LV wall thickness and mass among male athletes. Conclusions and Relevance These data represent the first set of comprehensive normative values for elite US soccer players and one of the largest sport-specific echocardiographic remodeling studies in female athletes. Abnormal ECG findings were more common in female athletes, while both female and male athletes frequently exceeded clinical normality cut points for remodeling-associated echocardiographic parameters.
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Affiliation(s)
- Timothy W Churchill
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston
| | - Bradley J Petek
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston
| | - Meagan M Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston
| | - James S Guseh
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston
| | - Rory B Weiner
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston
| | | | | | | | - George Chiampas
- United States Soccer Federation, Chicago, Illinois.,Feinberg School of Medicine, Department of Emergency Medicine, Northwestern University, Evanston, Illinois
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston.,Echocardiography Laboratory, Massachusetts General Hospital, Boston.,United States Soccer Federation, Chicago, Illinois
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15
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Petek BJ, Baggish AL. Pre-participation Cardiovascular Screening in Young Competitive Athletes. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2021; 8:77-89. [PMID: 33552703 DOI: 10.1007/s40138-020-00214-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose of Review The purpose of this review was to highlight the current recommendations, data, and limitations for methods of cardiovascular screening in athletes. Recent Findings While the history and physical (H&P) alone remains the cornerstone for preparticipation cardiovascular screening (PPCS) in athletes, the advent of modern electrocardiographic (ECG) screening criteria has drastically increased sensitivity and decreased false positive rates for screening. Advanced imaging techniques remain an important component of secondary testing after an athlete has an abnormal initial screening exam, however, the use of imaging for universal screening has not been rigorously tested to date. Current disqualification guidelines have now begun to emphasize shared decision making between the provider and athlete in situations of clinical equipoise. Summary All major medical and sporting societies recommend PPCS using a focused medical history and physical examination for all competitive athletes, but there remains controversy about the role of ECG and advanced imaging in PPCS. Future research should focus on the creation of a randomized trial that is powered for mortality that can truly assess the utility of PPCS in athletes.
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Affiliation(s)
| | - Aaron L Baggish
- Massachusetts General Hospital Cardiovascular Performance Program
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16
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Jones JC, Sugimoto D, Kobelski GP, Rao P, Miller S, Koilor C, Corrado GD, Shipon DM. Parameters of cardiac symptoms in young athletes using the Heartbytes database. PHYSICIAN SPORTSMED 2021; 49:37-44. [PMID: 32281468 DOI: 10.1080/00913847.2020.1755908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: To determine clinical parameters that are related to abnormal cardiac symptoms in physically active youth. Methods: We used Simon's Heart Heartbytes National Youth Cardiac Registry to collect data from adolescent athletes in southeastern Pennsylvania. We collected age, race/ethnicity, abnormal cardiac symptoms, medical history, medication use, caffeine intake, and family history. We obtained height, weight, blood pressure, cardiac murmur findings, and ECGs. Echocardiogram was obtained if necessary. Binary logistic regression analysis was performed to identify independent associations between abnormal cardiac symptoms and collected variables. The odds ratio (OR), 95% confidence interval (95% CI), and p-values were used as statistical values. Results: Of the 887 athletes (543 males and 344 females, age = 16.9 ± 2.1 years, height = 166.9 ± 11.4 cm, weight = 62.0 ± 16.0 kg), 186 (21%) had abnormal cardiac symptoms including chest pain, passing out, difficulty breathing, extreme fatigue, and heart race. There was an independent association between abnormal symptoms and a past medical history (OR: 4.77, 95%CI: 3.18, 7.17, p = 0.001) and medication use (OR: 1.74, 95%CI: 1.08, 2.79, p = 0.022). In medical history, young athletes with asthma showed a greater propensity of abnormal cardiac symptoms (48.9%) compared to young athletes without (14.0%, p = 0.001). Additionally, young athletes with anxiety or depression demonstrated a higher proportion of abnormal cardiac symptoms (48.9%) than those without (19.5%, p = 0.001). Although the association between the presence of abnormal symptoms and African-American race (OR: 2.04, 95%CI: 0.96, 4.35, p = 0.065) and average daily consumption of at least 2 caffeine drinks (OR: 2.08, 95%CI: 0.86, 5.02, p = 0.103) were not significant, there was a trend to reach the a priori significance level. Conclusions: This study identified several clinical parameters that are associated with symptoms suggestive of abnormal cardiac conditions. Larger studies need to be done to better sort out the clinical history that may contribute to false positives to further reduce false positives at heart screenings.
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Affiliation(s)
- Jacob C Jones
- The Micheli Center for Sports Injury Prevention , Waltham, MA, USA.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital , Waltham, MA, USA.,Department of Orthopaedic Surgery, Harvard Medical School , Boston, MA, USA
| | - Dai Sugimoto
- The Micheli Center for Sports Injury Prevention , Waltham, MA, USA.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital , Waltham, MA, USA.,Department of Orthopaedic Surgery, Harvard Medical School , Boston, MA, USA
| | - Greggory P Kobelski
- The Micheli Center for Sports Injury Prevention , Waltham, MA, USA.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital , Waltham, MA, USA
| | - Prashant Rao
- Division of Cardiovascular Medicine, Department of Medicine, Thomas Jefferson University Hospitals , Philadelphia, PA, USA
| | - Stanton Miller
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University , Philadelphia, PA, USA
| | - Chris Koilor
- Division of Cardiovascular Medicine, Department of Medicine, Thomas Jefferson University Hospitals , Philadelphia, PA, USA
| | - Gianmichel D Corrado
- The Micheli Center for Sports Injury Prevention , Waltham, MA, USA.,Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital , Waltham, MA, USA.,Department of Orthopaedic Surgery, Harvard Medical School , Boston, MA, USA
| | - David M Shipon
- Division of Cardiovascular Medicine, Department of Medicine, Thomas Jefferson University Hospitals , Philadelphia, PA, USA
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17
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Abela M, Sharma S. Electrocardiographic interpretation in athletes. Minerva Cardiol Angiol 2020; 69:533-556. [PMID: 33059398 DOI: 10.23736/s2724-5683.20.05331-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Participation in regular exercise of moderate intensity is associated with a plethora of systemic benefits, including a reduction in risk factors for coronary atherosclerosis; however, intensive exercise may paradoxically culminate in sudden cardiac arrest among individuals harboring arrhythmogenic substrates. The precise mechanism for arrhythmogenesis is likely multifactorial, however, surges in catecholamines, electrolyte shifts, acid-base disturbances, increased core temperature and demand myocardial ischemia are potential contributors. Although most deaths occur in middle aged and older males with atherosclerotic coronary artery disease, a significant proportion also affect young athletes with inherited or congenital cardiac abnormalities. The impact of such catastrophes on society, particularly when a young high-profile athlete is affected could be considered a justified reason for identifying individuals who may be at risk. Given the rarity of deaths in young athletes, only the simplest screening test, such as the 12-lead electrocardiography (ECG) may be considered to be cost effective. The ECG is effective for detecting serious electrical diseases in young athletes such as congenital electrical accessory pathways and ion channel diseases but can also identify athletes with potential life-threatening structural diseases such as hypertrophic and arrhythmogenic cardiomyopathy. One of the concerns about ECG screening is that regular intensive exercise results in several physiological alterations in cardiac structure and function that are reflected on the athlete's ECG. Sinus bradycardia, first-degree atrioventricular block, incomplete right bundle branch block, minor J-point elevation and large QRS voltages are common. Conversely, some repolarization anomalies affecting the ST segment, T waves and QT interval may overlap with patterns observed in patients with serious cardiac diseases. The situation is complicated further because age, sex and ethnicity of the athletes also influence the ECG and there is a risk that erroneous interpretation could have serious consequences. This review will describe the normal electrical patterns of the "athlete's heart" and provide insights into differentiation physiological electrical patterns from those observed in serious cardiac disease.
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Affiliation(s)
- Mark Abela
- Department of Cardiology, Mater Dei Hospital, Msida, Malta - .,Malta Medical School, University of Malta, Msida, Malta - .,St. George's University Hospitals, NHS Foundation Trust, St George's University, London, UK -
| | - Sanjay Sharma
- St. George's University Hospitals, NHS Foundation Trust, St George's University, London, UK
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18
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Electrocardiogram interpretation in college athletes: Local institution versus sports cardiology center interpretation. J Electrocardiol 2020; 62:49-56. [DOI: 10.1016/j.jelectrocard.2020.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 02/04/2023]
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19
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Ozo U, Sharma S. The Impact of Ethnicity on Cardiac Adaptation. Eur Cardiol 2020; 15:e61. [PMID: 32944090 DOI: 10.15420/ecr.2020.01] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/22/2020] [Indexed: 01/15/2023] Open
Abstract
Regular intensive exercise is associated with a plethora of electrical, structural and functional adaptations within the heart to promote a prolonged and sustained increase in cardiac output. Bradycardia, increased cardiac dimensions, enhanced ventricular filling, augmentation of stroke volume and high peak oxygen consumption are recognised features of the athlete's heart. The type and magnitude of these adaptations to physical exercise are governed by age, sex, ethnicity, sporting discipline and intensity of sport. Some athletes, particularly those of African or Afro-Caribbean (black) origin reveal changes that overlap with diseases implicated in sudden cardiac death. In such instances, erroneous interpretation has potentially serious consequences ranging from unfair disqualification to false reassurance. This article focuses on ethnic variation in the physiological cardiac adaption to exercise.
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20
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Zorzi A, Vio R, Bettella N, Corrado D. Criteria for interpretation of the athlete's ECG: A critical appraisal. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:882-890. [PMID: 32602144 DOI: 10.1111/pace.14001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/18/2020] [Accepted: 06/28/2020] [Indexed: 01/27/2023]
Abstract
The electrocardiogram (ECG) is cheap and widely available but its use as a screening tool for early identification of athletes with a cardiac disease at risk of sudden cardiac death is controversial because of presumed low specificity. In the last decade, several efforts have been made to improve the distinction between physiological and pathological ECG findings in the athlete, leading to continuous evolution of the interpretation criteria. The most recent 2017 International criteria grouped ECG changes into three categories: normal, borderline, and abnormal. Borderline findings warrant further investigations only when two or more are present while abnormal changes should always be considered as the sign of a possible underlying disease. This review encompasses the evolution of the athlete's ECG interpretation criteria and highlights areas of uncertainty that will need to be addressed by further studies.
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Affiliation(s)
- Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Riccardo Vio
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Natascia Bettella
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
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21
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Petek BJ, Baggish AL. Current controversies in pre-participation cardiovascular screening for young competitive athletes. Expert Rev Cardiovasc Ther 2020; 18:435-442. [PMID: 32594825 DOI: 10.1080/14779072.2020.1787154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Pre-participation cardiovascular screening (PPCS) in athletes is recommended by numerous medical and sporting societies. While there is consensus that young athletes should be screened prior to participation in competitive sports, there are on-going debates regarding the true incidence of sudden cardiac death (SCD), the most frequent causes of SCD, and the optimal methods for PPCS. AREAS COVERED This review focuses on the current evidence for the incidence of SCD, causes of SCD, and the pros and cons of a history and physical exam (H&P) and electrocardiogram (ECG) in PPCS of young competitive athletes. EXPERT OPINION With significant controversy surrounding PPCS in athletes, a large-randomized trial powered for mortality is needed to assess the utility of PPCS and to define the optimal screening methods to detect cardiovascular diseases that may lead to SCD in competitive athletes. Until a trial of this caliber is created, controversy will remain and heterogeneity in care will exist. Future research should also define the optimal timing and frequency of PPCS given age-related penetrance of certain diseases, create evidence-based history questionnaires, continue to optimize ECG screening criteria, and create more learning modules for ECG interpretation in athletes.
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Affiliation(s)
- Bradley J Petek
- Department of Medicine, Massachusetts General Hospital , Boston, MA, USA
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital , Boston, MA, USA
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22
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Weiss M, Rao P, Johnson D, Billups T, Taing C, LaNoue M, Koilor C, Miller S, Langstaff R, Shipon D. Physician adherence to 'Seattle' and 'International' ECG criteria in adolescent athletes: An analysis of compliance by specialty, experience, and practice environment. J Electrocardiol 2020; 60:98-101. [PMID: 32339816 DOI: 10.1016/j.jelectrocard.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/06/2020] [Accepted: 04/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Screening electrocardiography (ECG) for athletes is both controversial and rapidly evolving. While identifying an abnormal ECG could detect a serious cardiovascular disease, falsely interpreting a benign ECG pattern as abnormal can lead to unnecessary testing, cost, and anxiety. Though recent refinements of athlete screening ECG criteria have significantly improved its accuracy, in clinical practice physician adherence to these criteria may vary. METHODS We analyzed physician adherence to contemporary athlete ECG criteria in a large, national athlete screening registry. 1577 consecutive screening ECGs were independently re- interpreted to assess for physician adherence to Seattle Criteria or International Criteria, respective to the criteria in place when the screening was performed. We further determined the most common ECG interpretations that deviated from these criteria, and analyzed physician characteristics for independent predictors of adherence to published ECG criteria. RESULTS Though overall adherence to contemporary criteria was high, 60.4% of ECGs interpreted as abnormal did not meet athlete ECG criteria for pathology when independently re- read. The most common ECG patterns misinterpreted as abnormal were isolated left ventricular hypertrophy (LVH) and non-pathologic T-wave inversions (TWI). Multivariate regression identified three independent predictors of adherence to athlete ECG criteria: participating in a screening overseen by the organization's medical leadership, electrophysiology specialists and adult cardiologists. CONCLUSION This study highlights the need for quality control measures and continued clinician education in a controversial and rapidly evolving field. Clinician education for athlete screening ECG criteria should emphasize the recent changes in how TWI and LVH voltage criteria should be interpreted in this patient population.
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Affiliation(s)
- Max Weiss
- Thomas Jefferson University Hospital, Philadelphia, PA, United States of America.
| | - Prashant Rao
- Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
| | - Drew Johnson
- Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
| | - Taiwanna Billups
- Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
| | - Chou Taing
- Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
| | - Marianna LaNoue
- Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
| | - Chris Koilor
- Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
| | - Stanton Miller
- Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
| | - Renee Langstaff
- Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
| | - David Shipon
- Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
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MacLachlan H, Drezner JA. Cardiac evaluation of young athletes: Time for a risk-based approach? Clin Cardiol 2020; 43:906-914. [PMID: 32242971 PMCID: PMC7403680 DOI: 10.1002/clc.23364] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 03/06/2020] [Accepted: 03/13/2020] [Indexed: 12/13/2022] Open
Abstract
Pre‐participation cardiovascular screening (PPCS) is recommended by several scientific and sporting organizations on the premise that early detection of cardiac disease provides a platform for individualized risk assessment and management; which has been proven to lower mortality rates for certain conditions associated with sudden cardiac arrest (SCA) and sudden cardiac death (SCD). What constitutes the most effective strategy for PPCS of young athletes remains a topic of considerable debate. The addition of the electrocardiogram (ECG) to the medical history and physical examination undoubtedly enhances early detection of disease, which meets the primary objective of PPCS. The benefit of enhanced sensitivity must be carefully balanced against the risk of potential harm through increased false‐positive findings, costly downstream investigations, and unnecessary restriction/disqualification from competitive sports. To mitigate this risk, it is essential that ECG‐based PPCS programs are implemented by institutions with a strong infrastructure and by physicians appropriately trained in modern ECG standards with adequate cardiology resources to guide downstream investigations. While PPCS is compulsory for most competitive athletes, the current debate surrounding ECG‐based programs exists in a binary form; whereby ECG screening is mandated for all competitive athletes or none at all. This polarized approach fails to consider individualized patient risk and the available sports cardiology resources. The limitations of a uniform approach are highlighted by evolving data, which suggest that athletes display a differential risk profile for SCA/SCD, which is influenced by age, sex, ethnicity, sporting discipline, and standard of play. Evaluation of the etiology of SCA/SCD within high‐risk populations reveals a disproportionately higher prevalence of ECG‐detectable conditions. Selective ECG screening using a risk‐based approach may, therefore, offer a more cost‐effective and feasible approach to PPCS in the setting of limited sports cardiology resources, although this approach is not without important ethical considerations.
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Affiliation(s)
- Hamish MacLachlan
- Cardiovascular Sciences Research Centre, St Georges University of London, London, UK
| | - Jonathan A Drezner
- Department of Family Medicine and the Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
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24
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Drezner JA. 18 highlights from the International Criteria for ECG interpretation in athletes. Br J Sports Med 2020; 54:197-199. [PMID: 31704696 DOI: 10.1136/bjsports-2019-101537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Jonathan A Drezner
- Center for Sports Cardiology, University of Washington, Seattle, WA 98195, USA
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25
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Audit of a cardiac screening policy for elite Australian cricketers. J Sci Med Sport 2019; 23:541-547. [PMID: 31956043 DOI: 10.1016/j.jsams.2019.12.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/24/2019] [Accepted: 12/18/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To report the compliance and results of an electrocardiogram (ECG) cardiac screening program in male and female elite Australian cricketers. DESIGN cross-sectional study. METHODS Elite cricketers were offered screening in accordance with Cricket Australia policy. Players who consented provided a personal and family history, physical examination and resting 12-lead ECG. An audit (1 February 2019) examined all cardiac screening records for male and female players in all Australian Cricket state squads from 16 years upwards. Data extracted from the Cricket Australia database included the number of players who underwent screening; signed waivers opting out; and had follow-up tests. ECGs were re-reviewed according to the International Criteria. RESULTS 710 players were included in the cohort (mean age 20.4±4.9 years, 62% male). 692 (97.5%) players underwent recommended cardiac screening or signed a waiver opting out (1.1%). 173 (24.4%) players were screened (or signed a waiver) more than once. Follow-up testing was conducted for 59 (6.9%) cases. No players were excluded from sport due to a cardiac problem and no major cardiac incidents occurred to any player in the audit cohort. Review of 830 ECGs showed benign athlete heart changes, including sinus bradycardia (33.5%), left ventricular hypertrophy (16.3%), and incomplete/partial right bundle branch block (8.4%), were common but abnormal screening ECGs were uncommon (2.0%). CONCLUSIONS An audit of a cardiac screening program in elite Australian cricketers found excellent compliance. A small proportion required follow-up testing and no player was excluded from sport due to a cardiac problem. ECG analysis suggested cricket is a sport of moderate cardiac demands, with benign athlete heart changes common.
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