PracticeUpdate Cardiology Best of 2018

TOP STORIES 2018 5

The Best of Sports Cardiology By Paul D. Thompson MD

D o you want a sure fire way to start an argument? Bring up the topic of sports pre-participation screening using an ECG in a group of cardiologists interested in the cardiac problems of young athletes. Approximately 40% of the group will insist that pre-participation screening with an ECG saves lives by detecting conditions associated with exercise-related sudden cardiac death (SCD) such as hypertrophic cardiomyopathy (HCM), right ventricular cardiomyopathy (RVCM), long QT syndrome (LQTS), and Wolff-Parkinson- White (WPW) syndrome. Another ~ 40% of the group will insist that pre-participation screening with an ECG puts athletes at risk for inappropriate implantable cardiac defibrillator (ICD) insertions, unnecessary ablations, exercise restriction, and general anxiety. The other 20% (all fellows or recent fellowship graduates), will be searching for the correct answer on their smart phones but to no avail because we do not know what approach is best. A central problem in determining the best approach to saving athletes’ lives is that no one knows for sure how big a problem SCD during sports participation is. The inci- dence for high school athletes has generally been estimated at 1 death per year for every 200,000 athletes. 1 The risk is much higher in men than in women, and some estimates of SCD death in young athletes have been as high as 1 death for every 3100 National Collegiate Athletic Association (NCAA) Divi- sion 1 basketball players. 2 So for my Best of Sports Cardiology article in 2018, I selected the article from Sanjay Sharma’s research group in London enti- tled, “ Outcomes of Cardiac Screening In Adolescent Soccer Players ” 3 (see page 12). I selected this article because it demonstrates

no symptoms, is always difficult because the decision can be affected by the ath- lete’s desire to compete and the clinician’s desire to take as little risk as possible. All of the surgical cases and 24 of the WPW pattern cases returned to soccer after their procedure. Most importantly, however, despite this extensive screening, the annual inci- dence of SCD was high at 1 SCD per 14,794 screened athletes. The reason for this high rate is unclear, but raises a troubling addi- tional question. Because SCD seems higher in Division 1 NCAA basketball players and in these elite soccer players, does intense exercise training increase the risk of SCD? This sounds like heresy; however, it is not questioning the widely recognized bene- fits of moderate physical activity, 4 but the benefits of the extreme training required for highly competitive endurance sports. This question has been asked before, 5 and perhaps, should be asked again. References 1. Lawless CE. Minnesota high school athletes 1993- 2012: evidence that American screening strategies and sideline preparedness are associated with very low rates of sudden cardiac deaths. J Am Coll Cardiol. 2013;62(14):1302-1303. 2. Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of sudden cardiac death in National Collegiate Athletic Association athletes. Circulation 2011;123(15):1594-1600. 3. Malhotra A, Dhutia H, Finocchiaro G, et al. Outcomes of cardiac screening in adolescent soccer players. N Engl J Med 2018;379(6):524-534. 4. Eijsvogels TM, Molossi S, Lee DC, Emery MS, Thompson PD. Exercise at the extremes: the amount of exercise to reduce cardiovascular events. J Am Coll Cardiol 2016;67(3):316-329. 5. Eijsvogels TM, Fernandez AB, Thompson PD. Are there deleterious cardiac effects of acute and chronic endurance exercise? Physiol Rev 2016;96(1):99-125. www.practiceupdate.com/c/76212

the complexity of the problem and raises an additional troubling question. These authors screened 11,168 adolescent, elite soccer players whose mean age was 14 ±1.2 years (mean ± SD), using medical history, physical examination, ECG, and echocardiography on all athletes. The stud- ies were reviewed by expert cardiologists. Consequently, the study does not directly address the benefit of adding only an ECG to the history and physical examination because they also underwent echocardi- ography. It also does not provide insight into how using non-expert cardiologists would affect the results. Even after this extensive screening and follow-up assessment by expert cardiol- ogists, 830 of the athletes (7%) required additional studies and 409 (4%) required cardiac magnetic resonance imaging. This demonstrates that the medical cost of ECG screening is not simply the cost of the ECG but the cost of subsequent testing. It also reminds us that elite athletes are different and their cardiac findings often mimic dan- gerous medical conditions. A total of 42 athletes (0.38%) were found to have cardiac disorders associated with SCD including HCM in 2 athletes, ARVC in 2, dilated cardiomyopathy in 1, LQTS in 3, anomalous coronary artery in 2, aortic valve disease in 2, and WPW ECG pat- tern in 26. The athletes with anomalous coronary artery and aortic valve disease and 24 of the athletes with WPW pattern underwent corrective surgery or ablation before returning to athletics. These 24 with WPW had evidence of dangerous accessory pathways on electrophysiol- ogy study. Only 2 of these 42 athletes had symptoms. Whether or not to operate on athletes with some of these disorders, and

VOL. 3 • NO. 4 • 2018