PracticeUpdate Cardiology Best of 2018

EDITOR’S PICKS 13

By Jonathan A. Drezner MD M alhotra et al report the outcomes of cardiac screening in 11,168 adolescent soccer players (mean age, 16.4 years) from the English Football Association. This outstanding study is perhaps the most valuable contribution to date, which informs strategies aimed at the prevention of SCD in young athletes.

screening at levels other than elite athletes, and if early detection leads to reduced cardiovascular morbidity and mortality. This study found an annual incidence of SCD in competitive soc- cer players of 1 per 14,800 athletes, which approaches the SCD incidence reported in male college basketball players (1 per 9000). Cardiovascular screening methods should be guided by the risk of the athlete population and available sports cardiology resources. Male athletes engaged in basketball, soccer, and American foot- ball represent high-risk groups in which more intensive cardiac screening is warranted. Greater efforts and continued collabora- tion between sports medicine and cardiology specialties is needed to advance sports cardiology training and infrastructure. All athletes with cardiomyopathy in this study were advised against continued participation in competitive soccer. Of 5 athletes with HCM who withdrew from competitive sport, 3 athletes survived. Of the athletes with HCM, 2 who returned to play against medical advice died during exercise, supporting existing guidelines that disqualification from competitive sports for athletes with HCM is justified. In the US, a paradigm shift is emerging toward a model of shared decision-making for athletes identified with disorders at risk of SCD. This practice is supported by outcomes-based evidence in young athletes with ion channel disorders who are compliant with optimal medical management. However, no such evidence exists for athletes diagnosed with cardiomyopathy. A total of 26 athletes with WPW pattern underwent risk stratifi- cation, 24 underwent ablation, and all returned safely to sport. Perhaps the successful identification and treatment of athletes with WPW and LQTS explains why only 1 athlete with SCD was found to have sudden arrhythmic death syndrome, which is reported in US and UK studies using expert cardiovascular pathologists as a leading cause of SCD in young athletes. A total of 6 athletes with a negative screen suffered SCD nearly 7 years from initial evaluation (5 from a cardiomyopathy). This study highlights the need for serial ECG screening of adolescent athletes with a normal screening evaluation. It is well-established that indi- viduals with a genetic predisposition for a cardiomyopathy do not universally express their disease by adolescence. Although it is unknown if repeat evaluations would have detected the 6 athletes in this study who suffered SCD after a normal screen, screening every 2 years throughout an athlete’s competitive career is rec- ommended. It is uncertain if these cases represent false–negative screens or if, in several cases, the cardiomyopathy simply had not developed. In summary, this study highlights that a cardiac screening protocol in young athletes driven largely by the performance of ECG is effec- tive for the detection of conditions at risk for SCD, in which potential sudden death was avoided through medical management and/or activity modification in 40 of 42 (95%) athletes. However, a single screen in adolescence does not exclude the later development of genetic or acquired cardiac disease, and the high incidence of SCD found in this study warrants serial screening in elite soccer players. For athletes diagnosed with cardiomyopathy, continued competi- tive sports participation should be viewed with great caution.

Screening included a history questionnaire, physical examination, electrocardiogram (ECG), and echocardiogram. Overall, cardiac disorders associated with sudden cardiac death (SCD) were detected in 42 athletes (0.38%), including 5 with hypertrophic cardiomyopathy (HCM), 2 with arrhythmogenic right ventricular cardiomyopathy, 1 with dilated cardiomyopathy, 3 with long QT syndrome (LQTS), 2 with coronary artery anomalies, 3 with bicus- pid aortic valve with severe aortic regurgitation, or aortopathy, and 26 with Wolff-Parkinson-White (WPW) pattern. Of these 42 ath- letes, 4 (9%) had symptoms or an abnormal physical examination, 36 (86%) had an abnormal ECG, and 12 (29%) had an abnormal echocardiogram. During a mean follow-up period of 10.6 years, 8 athletes died from a cardiac disorder on average 6.8 years after their initial screening. Cardiovascular screening for the detection of disorders at potential risk of SCD is universally supported by major medical and sports governing societies. These data reinforce findings from other studies demonstrating the poor sensitivity of screening for cardi- ovascular conditions predisposing to SCD if using only history and physical examination (H&P). Indeed, two consensus statements in 2016 – one by the American Medical Society for Sports Medicine and one by an inter-association task force led by the NCAA – con- sider cardiovascular screening with H&P ineffective and history questionnaires unsupported by evidence. In this study, ECG was the most effective screening strategy. Early detection of cardiac conditions that predispose to SCD in young athletes is not effectively achieved by H&P alone, and its contin- ued promotion as the primary cardiovascular screening tool for young athletes in the US should be re-evaluated. The remaining questions are whether SCD occurs frequently enough to war- rant screening, if ECG screening can be performed with sufficient accuracy to limit unnecessary secondary testing and restriction from sport, if an infrastructure can be developed to accomplish

Dr. Drezner is Professor in the Department of Family Medicine and Director of the Center for Sports Cardiology at the University of Washington in Seattle, Washington.

VOL. 3 • NO. 4 • 2018