Sudden Cardiac Death: The Israeli Experience

dr jose garza

Dr. Jose Garza, conducting a stress test on an athlete, Monterrey, Mexico

Screening for sudden cardiac death (SCD) remains one of the more contentious debates in the world of sports medicine.  As a matter of public policy, consensus medical opinion in the United States still argues against universal, mandatory  screening with electrocardiograms (ECGs); whereas in Europe, specifically in Italy, ECG screening is more of a routine practice.

The debate over this screening is carried on at many conferences and in many medical journals, including ours.  We’ve previously looked at the question of whether it makes sense to screen North American athletes with ECGs, for instance.  Earlier this year, we published a review of the different approaches American universities are currently using regarding the issue of athletic cardiovascular screening.  Recently, the topic came up in the podcast discussion I had with Dr. William Roberts on new directions for the pre-participation evaluation (PPE).  American and European sport medicine bodies can find a lot of common ground in where the PPE can be improved, according to Dr. Roberts, with the principal exception of this one issue.

Recently, Dr. Sami Viskin, from the Department of Cardiology, Tel Aviv Medical Center, spoke at my home institution about how athletes are screened for SCD in Israel.  He has written extensively on the issue of screening athletes for SCD, including a study arguing that it is not a cost-effective strategy in the United States.  The title of his recent talk: “Mandatory ECG screening of athletes saves lives: proven fact or wishful thinking?”

Our Division of Sports Medicine has been hosting another international guest this past month: Dr. Jose Angel Garza, a sports medicine physician from the University Hospital of the Universidad Autonoma de Nuevo Leon (UANL) in Monterrey, Mexico. He was also present at Dr. Viskin’s talk, and I asked him for his reflections on the subject of mandatory ECG screening in athletes.

Thanks Joe!

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Among the sports medical community, there is an ongoing and often heated debate on whether mandatory ECG screening should be performed on athletes. Several countries such as Italy and Israel have implemented such measures. The European Society of Cardiology has issued recommendations about mandatory screening of athletes with ECG. So this begs the question: Does ECG screening save lives in athletes? Read more of this post

Motor Vehicle Accidents: The Leading Cause of Death in Collegiate Athletes

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Motor Vehicle Accidents: the number one
killer of NCAA athletes

The title of today’s post is striking.

In sports medicine we focus–rightly–on entities such as sudden cardiac death, cervical spine injuries, second impact syndrome, exertional heat illness, hyponatremia……There  is a long list of conditions that can befall athletes which can cause serious mortality and morbidity.

But from a public health perspective, our priorities are possibly misplaced. At the very least I wonder sometimes if we may ‘strain at a gnat and swallow the camel‘ when we focus intensely on chest protectors and commotio cordis and say nothing about the use of seat belts in our athletes.

In August CJSM published ‘ahead of print’  “Motor Vehicle Accidents:  the Leading Cause of Death in Collegiate Athletes,” a study authored by I Asif, K Harmon, and D Klossner, authors who have published other epidemiologic work on sudden death in young athletes.  The data presented gave me pause. For all our concern about sudden death from hypertrophic cardiomyopathy,  to name one example, the data show that far and away the greatest threat to the young athletes under our care are accidents or unintentional injury.

The authors conducted a 5 year retrospective analysis using two data bases:  an NCAA database, and the “Parent Heart Watch” database.  This second database has an interesting history: a non profit group which began tracking sudden cardiac death in American athletes in 2000.   Various death rates were calculated, notably: 1) an overall death rate for athletes was found to be 13.86/100,000 athlete-years; 2) a death rate from accidents of 7.36/100,000 athlete-years; 3) a death rate from cardiac causes of 2.28/100,000 athlete-years; 4) a death rate due to accidents found highest in the sport of division I wrestlers, with a rate of 28.2/100,000 athlete-years.   Deaths from unintentional injuries occur at “….nearly twice the rate of all medical causes of death combined,” the authors note. Read more of this post

Cardiac screening of athletes with ECG – is it time to focus on the older athletic population?

Roy Shephard’s article in the May edition of CJSM , ‘Is Electrocardiogram Screening of North American Athletes Now Warranted?’ discusses the ongoing controversy of the appropriateness of the use of ECGs in screening College athletes for causes of sudden cardiac death. I’m wondering if it is now the time for us to focus our thoughts on ECG screening of the older athletic population.

My own awareness of the issues around ECG screening of athletes started some 20 years ago when I presented a session on ‘The Athlete’s Heart’ as part of my Physiology degree studies at University College, London. I remember being quizzed at the end of my presentation by the Course Tutor on the effects of detraining, and wishing that I had done a little more reading to back up my claims when I gave my answer stating that, as the adaptations to the normal heart were the result of normal physiological mechanisms, detraining should always result in changes to pre-training baseline on the ECG reflecting the anatomical and physiological detraining effects. His face at the time told me the story that he wasn’t entirely convinced, but I think I got away with it!

I have continued to revisit the issues and re-evaluate the evidence as my career in Sport and Exercise Medicine (SEM) has progressed. My first clinical experience of preparticipation screening came almost a decade ago whilst working in New Zealand when I was involved in providing care for New Zealand Academy of Sport athletes. Since then, another essay on the subject during my MSc SEM studies, teaching MSc and BSc students on an annual basis on ‘The Athlete’s Heart and Sudden Cardiac Death,’ and most recently conducting screening as part of the Football Association’s mandatory screening programme of young footballers, has kept me in touch with emerging research and clinical practice.

One thought has remained with me over the years – that of the importance of fundamental epidemiological principles such as Wilson’s criteria in screening, and linked to those, the need to consider what we are trying to achieve by screening . Essentially, the cardiac screening process seeks to identify individuals at an increased risk of sudden cardiac death. What we do not wish to do is to prevent healthy individuals from enjoying all of the benefits of sport and exercise. Sudden Cardiac Death in the young is still a rare event, mainly due to the underlying age-related population prevalence of associated conditions such as hypertrophic cardiomyopathy, but what about the older population?

The emerging importance of physical activity as an important, under-recognised independent risk factor for morbidity and mortality, often associated with lifestyle diseases such as type II diabetes mellitus, has led to an increasing global effort to engage the population in regular exercise as part of both primary and secondary disease prevention strategies. Whilst it is indisputable that the population benefits of exercise far outweigh the associated risks, it is nevertheless true that the risk of sudden cardiac death during exercise in the over 35’s is considerably higher than in the younger population due to the higher prevalence of associated conditions, mainly coronary heart disease.

ACSM guidelines and AHA risk stratification criteria for exercise testing and prescription offer clinicians guidance in the risk stratification of individuals who engage with healthcare professionals prior to becoming physically active, and point towards the appropriate use of ECG and Exercise Stress Testing as part of the preparticipation evaluation process. However, many individuals, including the older population who regularly exercise or those who may be about to commence regular exercise having been sedentary, will not come under the care of a healthcare professional. These individuals are therefore unlikely to participate in cardiac screening programmes.

Many questions about population cardiac screening prior to participation in sport and exercise come to mind, including :

1) What is the risk / benefit ratio and cost effectiveness of the adoption of ECG screening and exercise stress testing as per ACSM and AHA guidelines on a population basis for those wishing to engage in exercise?

2) How regularly should ECG screening and cardiac stress testing as part of preparticipation evaluation on an ongoing basis be conducted in the older athletic population?

3) What is the best and most appropriate way to engage older individuals involved in exercising, or about to become physically active, in order to conduct screening?

4) Should we be adopting targeted screening including ECG and cardiac stress testing in the older population who are involved in regular exercise?

My greatest concern is for the safety of the older, sedentary individual who decides to take up the sport they previously played perhaps 20 years ago at College, or perhaps who wishes to participate in a 10K run for a local charity, and who does not seek appropriate healthcare advice prior to increasing their physical activity levels.

Should we be focussing our efforts more at population level on screening these older individuals when attempting to prevent sudden cardiac death related to exercise?

IOC Injury Prevention Conference, Monaco

The setting for IOC Injury Prevention Conference, photo Osman Ahmed

Where do I begin?

The IOC World Conference on Prevention of Injury and Illness in Sport took place in Monaco a couple of weeks ago (16 – 18 March).

It was one of the best conferences I have ever attended.

Drawing from clinicians across the globe, the conference packed in ‘not-to-be-missed’ sessions over the course of the three days.  The issues ranged from prevention of ACL injuries to the best treatment of tendinopathies; preventing sudden cardiac death to addressing the scourge of physical and sexual abuse in sports.

South African friends (L to R): Jon Patricios, Ross Tucker, Wayne Viljoen, Phatho Zondi

The lecturers were an impressive array of clinicians, many of whose names will be familiar to readers of this CJSM blog or the journal itself: Roald Bahr organized the proceedings and talked about the challenges of screening for athletes at risk of injury; past AMSSM presidents Jonathan Drezner and Cindy Chang gave keynote addresses, as did the esteemed Willem van Mechelen; Osman Ahmed and a panel of others gave a very informative presentation on the uses of social media in sports medicine.  The list goes on.

I can’t do justice to the full conference, if only because of the necessary limitation of ‘concurrent sessions’ — with so much content to cover, the organizers understandably needed to schedule sessions aside from the keynote speeches concurrently.  How to choose when there may be two or three talks one wants to see at the same time? Read more of this post

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