Screening athletes for cardiovascular disease in Africa: a challenging experience

Cardiomyopathy and Sudden Cardiac Death Among the Athletes in Developing Countries: Incidence and Their Prevention Strategies

The incidence of cardiomyopathy in athletes contributes significantly to the public health burden in developing countries. Most effective management strategies primarily rely on the modification of risk factors, and it is less expensive compared to other advanced investigations. Moreover, limited data is available concerning the incidence of adverse events including cardiac arrest and the strategies to prevent them, especially in this population subset. Therefore, devising preventative strategies that can easily be implemented in athletes and provide a cost-effective approach is warranted. We aim to discuss the incidence of major adverse cardiac events in athletes with cardiomyopathies and their associated risk factors and to evaluate the various strategies proposed to prevent the progression of cardiomyopathy in this population, with the initial hypothesis that the treatment of these pathologies poses a substantial challenge in this population. With regard to methodology, this is a narrative review. Search terms were described using the Population, Exposure, and Outcome (PEO) framework. A comprehensive search strategy was used to screen and identify any relevant literature in the PubMed and Google Scholar databases. This was done in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocol. Four studies were identified in the final analysis. The incidence of sudden cardiac arrest varied between 0.3% and 0.33% among the athletes affected with cardiomyopathies. Routine and pre-participation screening has shown success in reducing the incidence of sudden cardiac death in athletes as a result of undiagnosed cardiomyopathies. Supervised exercise regimes have been proposed to reduce the incidence of cardiomyopathy in athletes. Beyond identification strategies, the prevention of cardiomyopathies revolves around the modification of risk factors. To conclude, the challenges athletes face, suffering from cardiomyopathy, have been an ongoing issue with unexpected cardiac arrest as the end result. Despite the decreased incidence of cardiomyopathies observed in athletes, the challenge in diagnosis can result in catastrophic outcomes, especially in developing countries. Therefore, adopting prevention strategies can have a profound impact on the identification and management of these pathologies.

The Impact of Ethnicity on Athlete ECG Interpretation: A Systematic Review

Athlete ECG interpretation criteria have been developed and refined from research in athlete populations; however, current guidelines are based on available data primarily from Caucasian and Black athletes. This study aimed to assess the impact of ethnicity on ECG interpretation in athletes. A systematic review was conducted of the MEDLINE, EMBASE, Scopus, SPORTDiscus, and Web of Science databases, for papers that assessed athlete screening ECGs and compared findings on the basis of ethnicity. Fifty-one papers which compared ECGs from various ethnicities were included. Most studies assessed Black athletes against Caucasian athletes and found a greater prevalence of T-wave inversion (TWI) (2.6–22.8% vs. 0–5.0%) and anterior TWI (3.7–14.3% vs. 0.6–2.0%). Black athlete subgroups in Africa had TWI (20–40%) and anterior TWI (4.3–18.7%) at a higher prevalence than other Black athletes. Athletes who were defined as mixed-race, Asian, and Pacific Islander are potentially more like Black athletes than Caucasian athletes. Black ethnicity is known to have an impact on the accurate interpretation of athlete ECGs; however, there is nuance related to origin of both parents. Asian and Pacific Islander origin also may impact athlete ECG interpretation. Further research is required to assist in distinguishing abnormal and normal athlete ECGs in different ethnic populations.

Cardiac Screening to Mitigate the Risk of Sudden Cardiac Death in Middle Eastern and African Competitive Athletes. A Systematic Review

OBJECTIVE

The study aims to review the literature regarding abnormalities predisposing to Sudden Cardiac Death (SCD) in young Middle Eastern and African competitive athletes between the years 2009-2019 and aims to assess cardiac pre-participation screening methods.

METHODS

A PubMed search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search targeted articles that reported the prevalence of cardiac abnormalities found in Middle Eastern and African athletes, and it also focused on comparing cardiac screening methods for assessment of athletes.

RESULTS

our studies fell within the inclusion criteria and were included in the study. Results identified a shortage in the literature regarding prevalence rates of SCD in the Middle East and Africa. Additionally, there seems to be a lack of ethnicity-specific cardiac pre-participation screening programs in the region. Nevertheless, the prevalence of SCD-related abnormalities (HCM, ARVC, etc …) ranged from 0.47 to 4.29%. Included studies conveyed only male athletes with no reports on the female athletic population.

CONCLUSION

The present study highlights a need to develop an efficient cardiac pre-participation screening program specific to Arab and African athletes due to their high false-positive rates in contrast to Caucasian athletes. Significant evidence proves that an adequate cardiac screening program can prevent SCD in young competitive athletes. Therefore, it is imperative that future studies highlight the prevalence of abnormalities directly related to SCD in order to create a valid screening program that can be implemented in the region to mitigate the risk of shocking events.

Genetics of inherited cardiomyopathies in Africa

In sub-Saharan Africa (SSA), the burden of noncommunicable diseases (NCDs) is rising disproportionately in comparison to the rest of the world, affecting urban, semi-urban and rural dwellers alike. NCDs are predicted to surpass infections like human immunodeficiency virus, tuberculosis and malaria as the leading cause of mortality in SSA over the next decade. Heart failure (HF) is the dominant form of cardiovascular disease (CVD), and a leading cause of NCD in SSA. The main causes of HF in SSA are hypertension, cardiomyopathies, rheumatic heart disease, pericardial disease, and to a lesser extent, coronary heart disease. Of these, the cardiomyopathies deserve greater attention because of the relatively poor understanding of mechanisms of disease, poor outcomes and the disproportionate impact they have on young, economically active individuals. Morphofunctionally, cardiomyopathies are classified as dilated, hypertrophic, restrictive and arrhythmogenic; regardless of classification, at least half of these are inherited forms of CVD. In this review, we summarise all studies that have investigated the incidence of cardiomyopathy across Africa, with a focus on the inherited cardiomyopathies. We also review data on the molecular genetic underpinnings of cardiomyopathy in Africa, where there is a striking lack of studies reporting on the genetics of cardiomyopathy. We highlight the impact that genetic testing, through candidate gene screening, association studies and next generation sequencing technologies such as whole exome sequencing and targeted resequencing has had on the understanding of cardiomyopathy in Africa. Finally, we emphasise the need for future studies to fill large gaps in our knowledge in relation to the genetics of inherited cardiomyopathies in Africa.

Technically Adequate Images for Preparticipation Screening Echocardiography Can Be Obtained by Novices After a Single Day of Training

OBJECTIVES

Echocardiography-naïve physicians were trained in a 1-day course to determine whether they could obtain images adequate for preparticipation screening in athletes.

METHODS

Twenty-six physicians with no previous experience in echocardiography were trained to perform preparticipation screening echocardiography during a 6-hour course. Each image was rated for its technical quality on a diagnostic adequacy score. The time taken to perform the images was also evaluated.

RESULTS

The images obtained a median score of 3 (interquartile range, 2-4), which was considered adequate for preparticipation screening. Video clips achieved a higher rating than the still images, with a median score of 4 (interquartile range, 3-4). The best-performing 50% of the participants obtained adequate images for screening 95% of the time after the initial training. Considering the group overall, 79.2% of all video clips were adequate. The median time to perform the scans was 39 seconds. The correlation between the time and adequacy score showed that the quickest novices were also able to obtain the best images.

CONCLUSIONS

It is feasible to use novice sonographers to perform preparticipation screening echocardiography provided that the skill of the candidates is assessed after training, and competent individuals are selected. Video images should be used rather than still images.

Efficacy of pre-participation cardiac evaluation recommendations among athletes participating in World Athletics Championships

Background

Athletes competing in athletics (track and field) at international level may be participating with underlying undiagnosed life-threatening cardiovascular conditions. Our objective was to analyse variations in pre-participation cardiac evaluation prevalence among athletes participating in two International Association of Athletics Federations (IAAF) World Athletics Championships, with regard to the human developmental level and global region of their home countries, as well as athletes' age category, gender, event group and medical insurance type.

Design

Cross-sectional web-based survey.

Methods

A total of 1785 athletes competing in the IAAF World Under 18 Championships Nairobi 2017 and World Championships London 2017 were invited to complete a pre-participation health questionnaire investigating the experience of a pre-participation cardiac examination.

Results

A total of 704 (39%) of the athletes participated. Among these, 59% (60% of women; 58% of men) reported that they had been provided at least one type of pre-participation cardiac evaluation. Athletes from very high income countries, Europe and Asia, showed a higher prevalence of at least one pre-participation cardiac evaluation.

Conclusions

The prevalence of pre-participation cardiac evaluation in low to middle income countries, and the African continent in particular, needs urgent attention. Furthermore, increases in evaluation prevalence should be accompanied by the development of cost-effective methods that can be adopted in all global regions.

Cost-effectiveness of pre-participation screening of athletes with ECG in Europe and Algeria

The aim of this study is to evaluate the cost-effectiveness of ECG in combination with family and personal history and physical examination in order to detect cardiovascular diseases that might cause sudden death in athletes. The study was conducted on a cohort of 6,634, mainly young professional and recreational athletes, 1,071 from Algeria and 5,563 from Europe (France, Germany and Greece). Each athlete underwent medical history, physical examination, and resting 12-lead ECG. 293 athletes (4.4 %), 149 in Europe (2.7 %) and 144 in Algeria (13.4 %) required further tests, and 56 were diagnosed with cardiovascular disease and thus disqualified. The cost-effectiveness ratio (CER) was calculated as the ratio between the cost of screening and the number of statistical life-years saved by the intervention. The estimated reduced risk of death deriving from treatment or disqualification resulted in the saving of 79.1 statistical life-years in Europe and 136.3 in Algeria. CER of screening was 4,071 purchasing-power-parity-adjusted US dollars ($PPP) in Europe and 582 $PPP in Algeria. The results of this study strongly support the utilisation of 12-lead ECG in the pre-participation screening of young athletes, especially in countries where secondary preventive care is not highly developed.

Modern standards of ECG interpretation in young athletes: yield and effectiveness

Although cardiovascular screening is recommended before participating in competitive sports, the role of the 12-lead electrocardiogram (ECG) has been debated. When added to the medical history and physical examination, an ECG used during the pre-participation screening (PPS) of young athletes can greatly enhance the ability to detect underlying cardiovascular pathology. Concerns over false positive rates, however, have posed an obstacle to large-scale implementation. The recent development of modern athlete-specific ECG interpretation criteria has dramatically reduced false positive rates to levels below other commonly used screening tests (e.g. breast cancer, prostate cancer) and subsequently improved cost effectiveness. There are also emerging data that certain sub-groups have a higher prevalence of ECG abnormalities, including males, athletes of Afro-Caribbean descent, basketball players, and endurance athletes. While false positive rates from a number of studies are reduced with the improved standards, there may be room for continued improvements. Future efforts should focus on refining criteria based on age, race, gender, ethnicity, and sport, while also clearly delineating the appropriate work-up strategies for those with abnormal findings, as this can lead to improved resource utilization.