Cardiovascular evaluation, including resting and exercise electrocardiography, before participation in competitive sports: cross sectional study

Cardiovascular risk and its influencing factors during exercise in apparently healthy Chinese adult population

BACKGROUND

There are few studies on the safety of sub-maximal exercise testing of aerobic exercise in apparently healthy Chinese populations. The purpose of this study was to explore the frequency of exercise electrocardiography (ECG) abnormalities and the corresponding exercise intensities, as well as the associated influencing factors, during a symptom-limited stepwise incremental cardiopulmonary exercise test (CPET) in an apparently healthy Chinese population.

METHODS

A cross-sectional study was done in four communities, one urban and one rural in the North (Beijing) and in the South (Hezhou, Guangxi) of China from 1 January 2017 to 31 December 2018, respectively. Total of 1642 participants was recruited, 918 were eligible and completed demographic indicators, routine blood indicators, physical activity status, symptom-limited CPET and exercise ECG were included in the analysis.

RESULTS

Of the exercise ECG outcomes, 10 (1.1%) were positive and occurred at exercise intensities ≥ 62.50% heart rate reserve (HRR); 44 (4.8%) were equivocal and 864 (94.1%) were normal. Individuals with Cardiovascular Disease Risk Factor (CVDRF) = 3-4 were 2.6 times more likely to have a equivocal and abnormal exercise ECG than those with CVDRF = 0-2. Exercise ECGs of individuals with CVDRF = 5-7 were 5.4 times more likely to be positive and abnormal than exercise ECGs of individuals with CVDRF = 0-2.

CONCLUSIONS

The exercise intensity of 62.5% HRR can be used as a safe upper limit for safe participation in exercise in apparently healthy Chinese population; the greater the number of CVDRFs, the greater the likelihood of cardiovascular risk during exercise.

Screening Sportsmen and Sportswomen Over Age 35: The Relevance of an Exercise Electrocardiogram. Data From the SEEPRED Study

INTRODUCTION

The importance of exercise electrocardiogram (ECG) is still controversial in the prevention of cardiovascular events among sportsmen and sportswomen. The aim of this study was to assess the relevance of exercise ECG as a screening tool to prevent cardiovascular events when any cardiovascular disease (CVD) risk factors are present.

METHODS

The study included leisure time asymptomatic sportsmen and sportswomen over age 35 evaluated from 2011 to 2016 at the University Hospital of Saint-Etienne (France). Major adverse cardiovascular events (MACE) and atrial fibrillation were collected at 3 years.

RESULTS

Of the cohort of 2457 sportsmen and sportswomen (mean age 50.2 ± 9.4 years), 50 (2%) had a high-risk SCORE2. A total of 256 exercise ECGs (10%) were defined as positive, most of them due to silent myocardial ischemia (SMI) (n = 196; 8%). These 196 SMI cases led to 33 coronary angiograms (1%), which revealed 23 significant coronary stenoses requiring revascularization. In multivariate logistic regression analysis, having at least two CVD risk factors was independently associated with (1) positive exercise ECG (OR = 1.80 [95% CI: 1.29-2.52], p = 0.0006), with (2) suspected SMI (OR = 2.57 [95% CI: 1.10-6.02], p = 0.0304), with (3) confirmed SMI (OR = 8.20 [95% CI: 3.46-19.46], p < 0.0001) and with (4) cardiovascular events (MACE or atrial fibrillation) (OR = 6.95 [95% CI: 3.49-13.81], p < 0.0001) at 3 years (median).

CONCLUSIONS

The study supports the European recommendations for the use of exercise ECG in evaluation of asymptomatic leisure time sportsmen over age 35. Having at least two CVD risk factors was the best predictor for presence of coronary artery stenosis that may increase the risk for adverse events.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06024863.

Characteristics of Second-Line Investigations of Middle-Aged Athletes Who Failed Preparticipation Examinations

OBJECTIVE

The role of exercise testing during preparticipation examinations (PPEs) of middle-aged athletes is uncertain. This study examined the characteristics of disqualifications after an initial PPE that includes an exercise test in competitive athletes older than 30 years. We investigated disqualification rates and reasons, second-line investigations performed, and final decisions regarding competitive sports participation.

DESIGN

Chart review.

SETTING

Sports medicine clinic.

PARTICIPANTS

Athletes aged >30 years that performed an exercise test as part of their annual PPE at our sports medicine clinic (n = 866).

INDEPENDENT VARIABLES

Age, sex, height, weight, sport type, cardiovascular risk factors, and abnormal PPE findings.

MAIN OUTCOME MEASURES

Additional investigations performed, approval/disqualification regarding competitive sports participation.

RESULTS

The initial disqualification rate of athletes was 9.8%. Three (3.6%) athletes were disqualified following questionnaire and physical examination, 19 (22.4%) because of resting electrocardiogram findings, and 65 (76.5%) following the exercise test. After additional work-up, only 5 athletes (0.4%) were ultimately found ineligible for competitive sports. From those, only 2 athletes (0.2%) were disqualified because of exercise test findings, which were episodes of supraventricular tachycardia and not ischemia-related.

CONCLUSIONS

The addition of an exercise test to the PPE of middle-aged athletes is of limited value. If exercise testing of older athletes is performed, arrhythmias are probably of higher significance than ST-T changes.

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators

This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.

Screening young athletes for diseases at risk of sudden cardiac death: role of stress testing for ventricular arrhythmias

Aims

The athletic preparticipation evaluation (PPE) protocol proposed by the European Society of Cardiology includes history, physical examination and resting electrocardiogram (ECG). The aim of this study was to assess the results of adding constant-load ECG stress testing (EST) to the protocol for the evaluation of ventricular arrhythmias (VA) inducibility.

Methods

We evaluated a consecutive cohort of young athletes with history, physical examination, resting ECG and EST. Athletes with VA induced by EST underwent 24-hour 12-lead Holter monitoring and echocardiography. Cardiac magnetic resonance (CMR) was reserved for those with frequent, repetitive or exercise-worsened VA, and for athletes with echocardiographic abnormalities.

Results

Of 10,985 athletes (median age 15 years, 66% males), 451 (4.1%) had an abnormal history, physical examination or resting ECG and 31 (0.28%) were diagnosed with a cardiac disease and were at risk of sudden cardiac death. Among the remaining 10,534 athletes, VA at EST occurred in 524 (5.0%) and a previously missed at-risk condition was identified in 23 (0.22%); the most common (N = 10) was an echocardiographically silent non-ischaemic left-ventricular fibrosis evidenced by CMR. The addition of EST increased the diagnostic yield of PPE by 75% (from 0.28% to 0.49%) and decreased the positive predictive value by 20% (from 6.9% to 5.5%). During a 32 ± 21 months follow-up, no cardiac arrests occurred among either eligible athletes or non-eligible athletes with cardiovascular disease.

Conclusions

The addition of exercise testing for the evaluation of VA inducibility to history, physical examination and ECG resulted in an increase of the diagnostic yield of PPE at the expense of an increase in false-positive findings.

The importance of ST elevation in V2-4 ECG leads in athletes

BACKGROUND

Early repolarization in the anterior ECG leads (ERV_2-4) is considered to be a sign of right ventricular (RV) remodeling, but its etiology and importance are unclear.

METHODS

A total of 243 top-level endurance-trained athletes (ETA; 183 men and 60 women, weekly training hours: 15-20) and 120 leisure-time athletes (LTA; 71 men and 49 women, weekly training hours: 5-6) were investigated. The ERV_2-4 sign was evaluated concerning type of sport, gender, transthoracic echocardiographic parameters, and ECG changes, which can indicate elevated RV systolic pressure [left atrium enlargement (LAE), right atrium enlargement (RAE), RV conduction defect (RVcd)].

RESULTS

Stroke volume and left ventricular mass were higher in ETAs vs. LTAs in both genders (p < 0.01). Prevalence of the ERV_2-4 sign was significantly higher in men than in women [p = 0.000, odds ratio (OR) = 36.4] and in ETAs than in LTAs (p = 0.000). The highest ERV_2-4 prevalence appeared in the most highly trained triathlonists and canoe and kayak paddlers (OR = 13.8 and 5.2, respectively). Within the ETA group, the post-exercise LAE, RAE, and RVcd changes developed more frequently in cases with than without ERV_2-4 (LAE: men: p < 0.05, females: p < 0.005; RAE: men: p < 0.05, females: p < 0.005; RVcd: N.S.). These post-exercise appearing LAE, RAE, and RVcd are associated with the ERV_2-4 sign (OR = 4.0, 3.7, and 3.8, respectively).

CONCLUSIONS

According to these results, ERV_2-4 develops mainly in male ETAs due to long-lasting and repeated endurance training. The ERV_2-4 sign indicates RV's adaptation to maintain higher compensatory pulmonary pressure and flow during exercise but its danger regarding malignant arrhythmias is unclear.

How to evaluate premature ventricular beats in the athlete: critical review and proposal of a diagnostic algorithm

Although premature ventricular beats (PVBs) in young people and athletes are usually benign, they may rarely mark underlying heart disease and risk of sudden cardiac death during sport. This review addresses the prevalence, clinical meaning and diagnostic/prognostic assessment of PVBs in the athlete. The article focuses on the characteristics of PVBs, such as the morphological pattern of the ectopic QRS and the response to exercise, which accurately stratify risk. We propose an algorithm to help the sport and exercise physician manage the athlete with PVBs. We also address (1) which athletes need more indepth investigation, including cardiac MRI to exclude an underlying pathological myocardial substrate, and (2) which athletes can remain eligible to competitive sports and who needs to be excluded.

[Place of the exercise stress test at the sportsman]

Is the stress test still part of the useful examinations in the detection of risk heart disease in sports subjects? Should we continue to use it as a surveillance examination in coronary sports patients? Meta-analysis, considering a ST subshift of more than 1mm as a criterion for positivity, underline the low prevalence of abnormal examinations and a significant rate of false-positives. But for the diagnosis of coronary artery disease, it is mainly the evolution of the ST segment to effort or recovery and the occurrence of stress arrhythmias that detect true positivity. When coronary risk is more important (presence of risk factors, resumption of sport, intense and prolonged efforts), it seems lawful to recommend such a review on a regular basis among men over 40 years of age with two risk factors but Also among veterans taking up sport after a period of prolonged inactivity. For the asymptomatic coronary athlete the stress test remains at the centre of the final decision for the resumption of a sport in competition irrespective of the method of revascularization. Of course the stress test, even inevitable, remains flawed in the detection of coronary artery disease in the asymptomatic athlete. However, it provides additional information on the condition of being maximal, and attaching importance to arrhythmias, the tensional profile and the maximum power developed in addition to the ST segment's only study.

Assessment of cardiovascular risk and preparticipation screening protocols in masters athletes: the Masters Athlete Screening Study (MASS): a cross-sectional study

Background

Underlying coronary artery disease (CAD) is the primary cause of sudden cardiac death in masters athletes (>35 years). Preparticipation screening may detect cardiovascular disease; however, the optimal screening method is undefined in this population. The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and the American Heart Association (AHA) Preparticipation Screening Questionnaire are often currently used; however, a more comprehensive risk assessment may be required. We sought to ascertain the cardiovascular risk and to assess the effectiveness of screening tools in masters athletes.

Methods

This cross-sectional study performed preparticipation screening on masters athletes, which included an ECG, the AHA 14-element recommendations and Framingham Risk Score (FRS). If the preparticipation screening was abnormal, further evaluations were performed. The effectiveness of the screening tools was determined by their positive predictive value (PPV).

Results

798 athletes were included in the preparticipation screening analysis (62.7% male, 54.6±9.5 years, range 35–81). The metabolic equivalent task hours per week was 80.8±44.0, and the average physical activity experience was 35.1±14.8 years. Sixty-four per cent underwent additional evaluations. Cardiovascular disease was detected in 11.4%, with CAD (7.9%) being the most common diagnosis. High FRS (>20%) was seen in 8.5% of the study population. Ten athletes were diagnosed with significant CAD; 90% were asymptomatic. A high FRS was most indicative of underlying CAD (PPV 38.2%).

Conclusion

Masters athletes are not immune to elevated cardiovascular risk and cardiovascular disease. Comprehensive preparticipation screening including an ECG and FRS can detect cardiovascular disease. An exercise stress test should be considered in those with risk factors, regardless of fitness level.

Diagnostic Evaluation of Nontraumatic Chest Pain in Athletes

This article is a clinically relevant review of the existing medical literature relating to the assessment and diagnostic evaluation for athletes complaining of nontraumatic chest pain. The literature was searched using the following databases for the years 1975 forward: Cochrane Database of Systematic Reviews; CINAHL; PubMed (MEDLINE); and SportDiscus. The general search used the keywords chest pain and athletes. The search was revised to include subject headings and subheadings, including chest pain and prevalence and athletes. Cross-referencing published articles from the databases searched discovered additional articles. No dissertations, theses, or meeting proceedings were reviewed. The authors discuss the scope of this complex problem and the diagnostic dilemma chest pain in athletes can provide. Next, the authors delve into the vast differential and attempt to simplify this process for the sports medicine physician by dividing potential etiologies into cardiac and noncardiac conditions. Life-threatening causes of chest pain in athletes may be cardiac or noncardiac in origin, which highlights the need for the sports medicine physician to consider pathology in multiple organ systems simultaneously. This article emphasizes the importance of ruling out immediately life threatening diagnoses, while acknowledging the most common causes of noncardiac chest pain in young athletes are benign. The authors propose a practical algorithm the sports medicine physician can use as a guide for the assessment and diagnostic work-up of the athlete with chest pain designed to help the physician arrive at the correct diagnosis in a clinically efficient and cost-effective manner.

The Validity of Adding ECG to the Preparticipation Screening of Athletes An Evidence Based Literature Review

OBJECTIVE

To review the available evidence establishing the validity of adding electrocardiogram to the preparticipation cardiac screening in athletes.

DATA SOURCES

MEDLINE and CINAHL databases were searched. Additional references from the bibliographies of retrieved articles were also reviewed and experts in the area were contacted.

SELECTION CRITERIA

Only original research articles seeking to establish the use of electrocardiography followed by second line investigations in athletes under 36 years of age were reviewed.

SEARCH RESULT AND QUALITY ASSESSMENT

The initial literature search identified 226 papers. Of these, 16 original articles (all type II evidence-population-based clinical studies) met the selection criteria and directly related to the use of electrocardiography in athletes cardiac screening. The methodological qualities of included studies were assessed using the Downs and Black checklist.

CONCLUSION

Screening with electrocardiography represents best clinical practice to prevent or reduce the risk of sudden cardiac death in athletes. It significantly improves the sensitivity of history and physical examination alone; it has reasonable specificity and excellent negative predictive value; and it is cost-effective. Future studies must be large, multicentre, multination, prospective trials powered to determine how different screening options affect the incidence of sudden cardiac death. Efforts should also be targeted toward secondary prevention of sudden cardiac death with pitch side cardiac resuscitation and the immediate use of defibrillator.

Standardised pre-competitive screening of athletes in some European and African countries: the SMILE study

Most of the available data on the cardiovascular screening of athletes come from Italy, with fewer records being available outside of Italy and for non-Caucasian populations. The goals of the SMILE project (Sport Medicine Intervention to save Lives through ECG) are to evaluate the usefulness of 12-lead ECGs for the detection of cardiac diseases in athletes from three European countries and one African country and to estimate how many second-level examinations are needed subsequent to the initial screening in order to classify athletes with abnormal characteristics. A digital network consisting of Sport Centres and second and third opinion centres was set up in Greece, Germany, France and Algeria. Standard digital data input was carried out through the application of 12-lead ECGs, Bethesda questionnaires and physical examinations. Two hundred ninety-three of the 6,634 consecutive athletes required further evaluation, mostly (88.4 %) as a consequence of abnormal ECGs. After careful evaluation, 237 were determined to be healthy or apparently healthy, while 56 athletes were found to have cardiac disorders and were thus disqualified from active participation in sports. There was a large difference in the prevalence of diseases detected in Europe as compared with Algeria (0.23 and 4.01 %, respectively). Our data confirmed the noteworthy value of 12-lead resting ECGs as compared with other first-level evaluations, especially in athletes with asymptomatic cardiac diseases. Its value seems to have been even higher in Algeria than in the European countries. The establishment of a digital network of Sport Centres for second/third opinions in conjunction with the use of standard digital data input seems to be a valuable means for increasing the effectiveness of screening.

Pre-participation musculoskeletal and cardiac screening of male athletes in the United arab emirates

This study presents the results of pre-participation musculoskeletal and cardiac screening using the Lausanne recommendations, which include a personal and family history, physical examination and electrocardiography. Cross sectional study using the Lausanne screenings and the European Society of Cardiology (ESC) recommendations carried out at Al-Ahli club in Dubai, United Arab Emirates. 230 male athletes participating in organised sports were included. Exclusion criteria were those under 14 or over 35 years old, females and athletes with established cardiovascular disease. Primary outcome are the results of Lausanne screening with outline of the negative, positive and false positive results and number needed to screen. Secondary outcomes include the results of musculoskeletal and neurological screening. A total of 174 (76%) athletes had a negative screening result. Fifty-four athletes (23%) underwent additional testing. Forty-seven athletes (20.4%) had false positive screening results. Seven athletes (3%) had a positive screening result and four athletes (2%) were restricted from sport. The number of athletes needed to screen to detect one lethal cardiovascular condition was 33 athletes. The Lausanne recommendations are well suited for the United Arab Emirates. The number needed to screen to detect one athlete with serious cardiovascular disease is acceptable at 33.

Quality of care for intimate partner violence in South African primary care: a qualitative study

Intimate partner violence (IPV) makes a substantial contribution to the burden of disease in South Africa. This article explores the current quality of care for IPV in public sector primary care facilities within the Western Cape. Only 10% of women attending primary care, while suffering from IPV, were recognized. Case studies, based on in-depth interviews and medical records, were used to reflect on the quality of care received among the women who were recognized. Care tended to be superficial, fragmented, poorly coordinated, and lacking in continuity. The recognition, management, and appropriate documentation of IPV should be prioritized within the training of primary care providers. It may be necessary to appoint IPV champions within primary care to ensure comprehensive care for survivors of IPV.

Noninvasive cardiac screening in young athletes with ventricular arrhythmias

The aim of this study was to analyze using noninvasive cardiac examinations a series of young athletes discovered to have ventricular arrhythmias (VAs) during the preparticipation screening program for competitive sports. One hundred forty-five athletes (mean age 17 ± 5 years) were evaluated. The study protocol included electrocardiography (ECG), exercise testing, 2-dimensional and Doppler echocardiography, 24-hour Holter monitoring, signal-averaged ECG, and in selected cases contrast-enhanced cardiac magnetic resonance imaging. Results of ECG were normal in most athletes (85%). VAs were initially detected prevalently during exercise testing (85%) and in the remaining cases on ECG and Holter monitoring. Premature ventricular complexes disappeared during exercise in 56% of subjects. Premature ventricular complexes during Holter monitoring averaged 4,700 per day, predominantly monomorphic (88%), single, and/or in couplets (79%). The most important echocardiographic findings were mitral valve prolapse in 29 patients (20%), congenital heart disease in 4 (3%), and right ventricular regional kinetic abnormalities in 5 (3.5%). On cardiac magnetic resonance imaging, right ventricular regional kinetic abnormalities were detected in 9 of 30 athletes and were diagnostic of arrhythmogenic right ventricular cardiomyopathy in only 1 athlete. Overall, 30% of athletes were judged to have potentially dangerous VAs. In asymptomatic athletes with prevalently normal ECG, most VAs can be identified by adding an exercise test during preparticipation screening. In conclusion, cardiac screening with noninvasive examinations remains a fundamental tool for the identification of a possible pathologic substrate and for the characterization of electrical instability.

The fittest person in the morgue?

The cardiovascular benefits of regular physical activity are well established (J. Sci. Med. Sport,7, 2004, 6). James Fixx wrote the best-selling book on running entitled The Complete Book of Running (1977), which led to an increase in popularity. However, when Fixx collapsed and died suddenly while running in 1984, people began to consider the adverse effects of sport on cardiac conditions. Going back in time, in 490 bc Phidippides, a young Greek messenger, ran 26.2 miles from Marathon to Athens delivering the news of the Greek victory over the Persians, and immediately collapsed and died. This is probably the first recorded incident of sudden death of an athlete running a marathon. According to Noakes (Med. Sci. Sports Exerc.,19, 1987, 187), one of the earliest reports on the association between running and cardiac risk was published in 1909, which claimed that school cross-country races over one mile for boys below the age of 19 years were totally inappropriate, and that the associated stress will cause damage in the heart and other organs. Death in athletes is highly publicized and has a substantial emotional impact on the community at large, given that athletes are perceived as the healthiest segment of society.

The pre-participation examination for leisure time physical activity: general medical and cardiological issues

BACKGROUND

There is current debate on the appropriate type and extent of medical testing for amateur and hobby athletes before they engage in sports. In particular, views diverge on the value of an ECG at rest.

METHODS

We selectively searched the Medline and Embase databases for relevant publications that appeared from 1990 to 2008. The most pertinent ones are discussed here along with current reviews and guidelines that give recommendations on pre-participation testing for amateur athletes.

RESULTS

History-taking and physical examination are standard around the world. The American guidelines on pre-participation examination do not recommend an ECG at rest, yet the guidelines for most European countries explicitly recommend it. No prospective cohort studies have been performed to date that might provide high-grade evidence (class and level) to support this practice. We discuss the pros and cons of an ECG at rest and also present the guideline recommendations on exercise-ECG testing for amateur athletes over age 40.

CONCLUSION

In accordance with the current European recommendations, and in consideration of the risks of athletic activity, we recommend that all persons participating in sports should undergo a pre-participation examination that includes an ECG at rest. Although primary-prevention campaigns advise physically inactive persons to get regular exercise, prospective studies are still lacking as a basis for recommendations in this group.

Return-to-play in sport: a decision-based model

OBJECTIVE

Return-to-play (RTP) decisions are fundamental to the practice of sports medicine but vary greatly for the same medical condition and circumstance. Although there are published articles that identify individual components that go into these decisions, there exists neither quantitative criteria nor a model for the sequence or weighting of these components within the medical decision-making process. Our objective was to develop a decision-based model for clinical use by sports medicine practitioners.

DATA SOURCES

English literature related to RTP decision making.

MAIN RESULTS

We developed a 3-step decision-based RTP model for an injury or illness that is specific to the individual practitioner making the RTP decision: health status, participation risk, and decision modification. In Step 1, the Health Status of the athlete is assessed through the evaluation of Medical Factors related to how much healing has occurred. In Step 2, the clinician evaluates the Participation Risk associated with participation, which is informed by not only the current health status but also by the Sport Risk Modifiers (eg, ability to protect the injury with padding, athlete position). Different individuals are expected to have different thresholds for "acceptable level of risk," and these thresholds will change based on context. In Step 3, Decision Modifiers are considered and the decision to RTP or not is made.

CONCLUSIONS

Our model helps clarify the processes that clinicians use consciously and subconsciously when making RTP decisions. Providing such a structure should decrease controversy, assist physicians, and identify important gaps in practice areas where research evidence is lacking.

Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes

BACKGROUND

Inclusion of 12-lead electrocardiography (ECG) in preparticipation screening of young athletes is controversial because of concerns about cost-effectiveness.

OBJECTIVE

To evaluate the cost-effectiveness of ECG plus cardiovascular-focused history and physical examination compared with cardiovascular-focused history and physical examination alone for preparticipation screening.

DESIGN

Decision-analysis, cost-effectiveness model.

DATA SOURCES

Published epidemiologic and preparticipation screening data, vital statistics, and other publicly available data.

TARGET POPULATION

Competitive athletes in high school and college aged 14 to 22 years.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

Nonparticipation in competitive athletic activity and disease-specific treatment for identified athletes with heart disease.

OUTCOME MEASURE

Incremental health care cost per life-year gained.

RESULTS OF BASE-CASE ANALYSIS

Addition of ECG to preparticipation screening saves 2.06 life-years per 1000 athletes at an incremental total cost of $89 per athlete and yields a cost-effectiveness ratio of $42 900 per life-year saved (95% CI, $21 200 to $71 300 per life-year saved) compared with cardiovascular-focused history and physical examination alone. Compared with no screening, ECG plus cardiovascular-focused history and physical examination saves 2.6 life-years per 1000 athletes screened and costs $199 per athlete, yielding a cost-effectiveness ratio of $76 100 per life-year saved ($62 400 to $130 000).

RESULTS OF SENSITIVITY ANALYSIS

Results are sensitive to the relative risk reduction associated with nonparticipation and the cost of initial screening.

LIMITATIONS

Effectiveness data are derived from 1 major European study. Patterns of causes of sudden death may vary among countries.

CONCLUSION

Screening young athletes with 12-lead ECG plus cardiovascular-focused history and physical examination may be cost-effective.

PRIMARY FUNDING SOURCE

Stanford Cardiovascular Institute and the Breetwor Foundation.

Reproducibility of axial force and manometric recordings in the oesophagus during wet and dry swallows

BACKGROUND

Manometry is the golden standard to diagnose oesophageal motility disorders but it gives an indirect picture of the peristalsis by measuring radial force only. A novel probe design using electrical impedance recordings enabled axial force and manometry to be recorded simultaneously. Using this method the aims were to study the amplitude and duration of peristaltic contractions, to test the correlation between axial force and manometry, and the reproducibility of the method.

METHODS

Ten healthy men were included twice. The probe was positioned 5 cm proximal to the lower oesophageal sphincter after which five dry swallows and five wet swallows were done. This was repeated with 0, 2, 4 and 6 mL of water in a bag mounted distal to the axial force recording site.

KEY RESULTS

Duration and amplitude of contractions were measured by axial force and manometry. Both increased with the bag volume (P < 0.05), with force measurements having approximately twice the dynamic range than manometry (P < 0.05). Contraction duration and amplitude showed good reproducibility for both axial force and manometry (interclass correlation coefficients >0.6). The best association between axial force and manometry was found during wet swallows with an empty bag (r = 0.72, P < 0.001), otherwise these measurements were not associated.

CONCLUSIONS & INFERENCES

The system provided a more complete description of primary oesophageal peristalsis. Axial force and manometry were both reproducible but force measurements had increased dynamic range. As manometry and axial force generally are not associated, they each provide different information, and in combination they may be useful to better characterize oesophageal motor function.

Axial force measurement for esophageal function testing

The esophagus serves to transport food and fluid from the pharynx to the stomach. Manometry has been the “golden standard” for the diagnosis of esophageal motility diseases for many decades. Hence, esophageal function is normally evaluated by means of manometry even though it reflects the squeeze force (force in radial direction) whereas the bolus moves along the length of esophagus in a distal direction. Force measurements in the longitudinal (axial) direction provide a more direct measure of esophageal transport function. The technique used to record axial force has developed from external force transducers over in-vivo strain gauges of various sizes to electrical impedance based measurements. The amplitude and duration of the axial force has been shown to be as reliable as manometry. Normal, as well as abnormal, manometric recordings occur with normal bolus transit, which have been documented using imaging modalities such as radiography and scintigraphy. This inconsistency using manometry has also been documented by axial force recordings. This underlines the lack of information when diagnostics are based on manometry alone. Increasing the volume of a bag mounted on a probe with combined axial force and manometry recordings showed that axial force amplitude increased by 130% in contrast to an increase of 30% using manometry. Using axial force in combination with manometry provides a more complete picture of esophageal motility, and the current paper outlines the advantages of using this method.

Sudden cardiac death in young athletes

Evidence supports a systematic screening programme before participation