Echocardiography as a screen to prevent SCD in athletes — 5 Questions with CJSM
January 8, 2017
For our first “5 Questions with CJSM” of 2017, we have a special guest: Dr. Gianmichel Corrado, of Boston Children’s Hospital and Northeastern University.
Dr. Gian Corrado is a doubly special guest for me: he is the lead author of a ‘published-ahead-of-print’ CJSM study and is someone who trained me in sports medicine at Boston Children’s Hospital.
I have fond memories of working alongside him, the head team physician for Northeastern University in Boston, as we cared for hockey and football athletes. And I remember the work he was just beginning to do in his now-blossoming area of research.
The new study reports the findings of a novel ‘take’ on a controversial aspect of sports medicine: how might we screen for underlying disorders that predispose our athletes to sudden cardiac death (SCD)?
By the way, don’t let Dr. Gian Corrado’s name fool you — this is not that Dr. Corrado, (Domenico Corrado), who also has published on screening for SCD; but both Drs. Corrado share a similar concern: the primary prevention of this catastrophic event.
Dr. Gian Corrado’s approach is to use ‘screening echocardiography in front-line providers,’ and his findings can be found here: ‘Early Screening for Cardiovascular Abnormalities with Pre-Participation Echocardiography: Feasibility Study.’
Dr. Corrado has this to say about his important work:
1. CJSM: What was the principal outcome measure you were looking at in this study? What were the secondary outcome measures?
GC: Central in the debate as to how to best identify athletes at risk for sudden death (SD) is cost-effectiveness. The American Heart Association continues to recommend a history and physical (H&P) as the sole method for screening young athletes for the cardiac conditions that can cause SD. The H&P has been shown to be a poor test to apply to the above dilemma as it misses athletes whom have potentially deadly cardiac conditions and falsely identifies those that do not. Many feel that, given this reality, an electrocardiogram (ECG) screening program should be implemented. This approach has been shown to have significant limitations as it too yields high false positive rates. The Northeastern Group has suggested and demonstrated that with advances in portable ultrasound frontline providers (FLP) can obtain limited echocardiographic images pertinent to the structural conditions that dominate in culpability with SD. Given the possibility of portable echocardiogram by FLP (PEFP) as part of the process of screening athletes, we felt it was appropriate to analyze the cost-effectiveness of these three screening methods. Time-Driven Activity-Based Costing is a well-established business model that allows us to quantify and potentially give a dollar number to the time spent by health care practitioners as it relates to screening for cardiac abnormalities that can cause sudden death. As such, we set up three stations (H&P, ECG, and PEFP) during our pre-participation physical examination (PPE) day and we timed how long it took for the athlete to complete each station and this time measurement was our primary outcome measure. We found PEFP was significantly faster than H&P or ECG. Our secondary outcome measure related to how PEFP might affect interpretation of positive H&P or ECG. We found PEFP has the potential to decrease false positive ECG rates. Given the flawed nature of the H&P and ECG and the preliminary findings that PEFP may be faster and more accurate lends credence to the notion that PEFP may be the future for screening young athletes for the conditions that cause sudden death.
GC: The downside to screening in the US is partially addressed in (I). We have no method to date that does not cost hundreds of millions and fails to do the job it was tasked to do. Imagine if you were trying to sell a new screening process for acute myocardial infarction (MI) in patients presenting with suspicious symptoms to a hospital system and you had to divulge that it will cost a fortune and fail to identify those patients who are having an MI and falsely identify those who were not. No one in their right mind would buy this product, and yet, it’s what we are trying to sell the medical community for PPE screening. The AHA has a position statement that does an excellent job explaining some of the many obstacles to screening, and they aren’t only cost efficiency; they also include issues of social justice and legal issues. As it stands, there are those that believe the practice of cardiac screening should be abandoned altogether. Our hope is that through a combination of the best elements of the H&P, ECG, and PEFP, we can devise a screening process which breathes new life into what has become a rubber stamp for many practitioners.
3. CJSM: What do you think are the potential benefits of incorporating “portable echocardiography by a frontline physician (PEFP)” into screening for SCD in athletes?
GC: See above, but also consider this: The ceiling for what can be learned by the FLP wielding a portable ultrasound is very high. We discovered that by merely swinging our probe north we could obtain images of the aortic root and ascending aorta, and FLP measurements matched the cardiologists. This data is published in the CJSM. Once an FLP gets comfortable with the probe, he or she will want to discover more. They will look at the body of literature in emergency medicine, obstetrics, intensive care, and trauma surgery, and they will want to learn how to visualize an intrauterine pregnancy, evaluate for free fluid in the abdomen, etc. It is just this sort of medical advance, where the sky is the limit, which breathes new life into an often stagnant practice for our FLPs. I doubt there will be much in the way of innovation with the H&P or ECG where the ceiling is quite low despite continued efforts to tweak them.
4. CJSM: If you had to compose a 140 character tweet to underscore the benefits of PEFP, what would it be?
GC: I would tweet something like this: The H&P remains essentially unchanged. We are still trying to capture the morphology of our patient’s hearts by measuring electrical currents, and all the while, portable ultrasound is within our reach and will allow for direct visualization of the heart. What are we waiting for? [We like the message, Dr. Corrado, but perhaps you can take an on-line tutorial from Trump University to learn how to compress that information into 140 characters!]
5. CJSM: What directions do you see taking your future research on PEFP?
GC: The next step is a multi-center trial. The seeds have been planted and we are beginning to get interest. Interest is especially mounting in the New England area where ESCAPE has been in the media – newspapers, TV, radio – but we are also seeing interest in other parts of the country. Physicians and academics are becoming interested in ESCAPE’s potential to supplement the pre-participation physical exam and in studying and learning the technique. We are also making progress with our efforts to perform PEFP in school systems which will improve upon current screening practices, and will also be an additional opportunity for us to collect data that will help us understand the strengths and weaknesses of PEFP.
Thanks so much Dr. Corrado. And for the readers, again, click on this link and check out the original research article itself and learn more about screening echocardiography as performed at point-of-care by primary care sports medicine physicians.
If you want to learn more about other approaches to screening for SCD that have appeared in the pages of CJSM, take the chance to listen to our podcast with Dr. Jonathan Drezner. Or if you want to learn more about other uses of ultrasound in primary-care sports medicine, listen to our podcast with Dr. Jonathan Finnoff.
We hope your 2017 has started well, and that this year is one of good fortune for you and yours.