368 Serial vs. single cardiovascular screening of adolescent athletes

Abstract The primary objective of preparticipation cardiovascular evaluation (PPCE) in young athletes is to detect asymptomatic individuals with cardiovascular disease (CVD) at risk of sudden cardiac death (SCD). The study population included a consecutive series of competitive athletes age 12–18 years who underwent PPCE, which according to Italian law is mandatory and based on yearly evaluations, at the Center for Sports Medicine of Treviso (Veneto region of Italy), from 2009 to 2019. The screening protocol included personal and family history questionnaire, physical examination, resting 12-lead ECG, and limited stress testing for evaluation of exertional ventricular arrhythmias. 2,3 This latter test was performed using a bicycle with constant-load increases (i.e. 2 W/kg in female participants and 3 W/kg in male participants) for 3 min for at least 85% or more of maximal heart rate was achieved, plus 3 min of postexercise monitoring. 3 Athletes with a positive medical history and abnormal physical examination, ECG, or stress test underwent further investigations. The diagnostic yield of the initial screening session was compared with that of repeat PPCEs. Athletes with a definitive diagnosis of CVD at risk of SCD were considered ineligible for competitive sports, although they received a tailored programme for leisure physical activity and were enrolled in a yearly follow-up programme. Outcome data of screened athletes, either eligible or ineligible to play competitive sports, were obtained from office visits, hospital records, or interrogation of the Registry of Juvenile SCD of the Veneto region. The study population included 15 127 consecutive athletes (64% male, 96% White) who underwent a total of 53 396 annual PPCEs (mean 3.7 per athlete) over the 11-year study period. The median age at first screening was 13 years [interquartile range (IQR): 12–14]. Sixty-three athletes (65% male) were diagnosed with a CVD at risk of SCD such as congenital heart disease (n = 17), ion channel disease (n = 11), inherited cardiomyopathy (n = 13), isolated nonischaemic left ventricular scar (NLVS) with ventricular arrhythmias (n = 18), or other (n = 4); 266 athletes had cardiac conditions not associated with SCD. Seventeen of the 63 athletes (27%) with atrisk CVD had a positive family history, symptoms, or abnormal physical examination, 38 (60%) had ECG abnormalities, and 32 (51%) developed arrhythmias on limited exercise testing. CVDs more frequently identified on repeat evaluation included inherited cardiomyopathies [7/11 (64%)], NLVS with ventricular arrhythmias [15/18 (83%)], and long QT syndrome [7/11 (64%)]. During a mean follow-up of 6.7 ± 3.5 years, 1 athlete with a negative PPCE experienced an episode of aborted SCD attributable to ventricular fibrillation that remained unexplained after a comprehensive diagnostic workup (event rate, 0.98/100 000 athletes per year). These results show that annual cardiovascular screening of adolescent athletes increased by three times the diagnostic yield of CVD at risk of SCD compared with a once-only (initial) evaluation. Inherited cardiomyopathies and isolated NLVS with ventricular arrhythmias were the CVDs more frequently identified on repeat evaluation.

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

European Journal of Preventive Cardiology ◽

10.1177/2047487319890973 ◽

2019 ◽

Vol 27 (3) ◽

pp. 311-320 ◽

Cited By ~ 9

Author(s):

Alessandro Zorzi ◽

Teresina Vessella ◽

Manuel De Lazzari ◽

Alberto Cipriani ◽

Vittoria Menegon ◽

...

Keyword(s):

At Risk ◽

Sudden Cardiac Death ◽

Physical Examination ◽

Cardiac Death ◽

Ventricular Arrhythmias ◽

Stress Testing ◽

Diagnostic Yield ◽

Holter Monitoring ◽

Left Ventricular ◽

Young Athletes

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.

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P1110Role of an extensive diagnostic work-up in the detection of concealed cardiomyopathies in athletes with complex ventricular arrhythmias and implications for sports" eligibility assessment

EP Europace ◽

10.1093/europace/euaa162.163 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

A Dello Russo ◽

M Casella ◽

F Guerra ◽

P Compagnucci ◽

A Gasperetti ◽

...

Keyword(s):

Risk Score ◽

Ventricular Arrhythmias ◽

Heart Diseases ◽

Risk Scores ◽

Competitive Sports ◽

Non Invasive ◽

Structural Heart Diseases ◽

Eligibility Assessment ◽

Work Up

Abstract Background ventricular Arrhythmias (VAs) are a common clinical problem and a critical issue with regards to sports" eligibility in athletes. Although VAs can be considered a benign feature of the athlete’s heart adaptive phenotype, they may also be the only clinical manifestation of a concealed cardiomyopathy, potentially heralding sudden cardiac death (SCD) during sports activity. Purpose to evaluate the diagnostic contribution and the implications for sports eligibility assessment of a thorough non-invasive and invasive work-up including electrophysiology study (EPS), electroanatomical mapping (EAM) and endomyocardial biopsy (EMB) in athletes with complex VAs and to derive a multiparametric risk score in order to easily predict structural heart diseases’ diagnosis. Methods we conducted a prospective, single-arm, open-label single center, observational study. All consecutive athletes presenting for evaluation at our institution after being disqualified from participating in sports due to complex VAs were enrolled. The athletes underwent a baseline non-invasive diagnostic protocol with transthoracic echocardiogram and gadolinium enhanced cardiac magnetic resonance imaging (cMRI). Subsequently EPS, EAM and EAM-guided EMB were performed if deemed necessary. Sports eligibility status was re-assessed at 6 months’ follow-up. A multivariable logistic regression model was built, considering cMRI as the gold standard exam. Results after diagnostic evaluation, 55 subjects (26.4%) had a diagnosis of heart disease, most commonly myocarditis (n = 27) and arrhythmogenic right ventricular cardiomyopathy (ARVC, n = 16). After 6 months, 100 athletes (48.1%) were judged eligible to participate in competitive sports and 46 subjects (22.1%) were deemed eligible to participate in non-competitive sports. On multivariable logistic-regression analysis, abnormalities on ECG (OR 5.3) or on echocardiogram (OR 3.7), sustained VA inducibility on EPS (OR 17.7) and low-voltage areas on EAM (OR 7.7) proved all predictive of concealed structural heart diseases’ diagnosis. We derived two simple risk scores: a 40-points risk score and an 8-points risk score (obtained by weighing each variable according to the regression model’s ORs). Both these risk scores’ performance proved very good (AUC = 0.856 for the 40-points score and AUC = 0.852 for the 8-points score, figure 1). Conclusions approximately 1/4 of athletes presenting with complex VAs have a concealed heart disease, most commonly myocarditis or ARVC. ECG, echocardiogram and EAM abnormalities and sustained VAs inducibility on EPS are predictive of structural heart diseases’ detection. Therefore, these diagnostic tests should be routinely included in the evaluation of athletes with complex VAs. A risk score including the results of these tests can greatly help in the prediction of concealed structural heart diseases’ diagnosis. More than 2/3 of subjects were judged eligible to participate in sports at 6 months’ follow-up. Abstract Figure 1. ROC curves for diagnosis

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OP0217 IS METACARPOPHALANGEAL-JOINT PAIN AS AN EARLY SYMPTOM OF PATIENTS AT RISK FOR PROGRESSION TO INFLAMMATORY ARTHRITIS EXPLAINED BY MRI-DETECTED SUBCLINICAL INFLAMMATION? – A LARGE OBSERVATIONAL STUDY

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2021-eular.1597 ◽

2021 ◽

Vol 80 (Suppl 1) ◽

pp. 130.2-130

Author(s):

Q. Dumoulin ◽

X. Matthijssen ◽

F. Wouters ◽

A. Van der Helm - van Mil ◽

E. Niemantsverdriet

Keyword(s):

At Risk ◽

Physical Examination ◽

Joint Pain ◽

Inflammatory Arthritis ◽

Multivariable Analysis ◽

Metacarpophalangeal Joint ◽

Subclinical Inflammation ◽

Joint Tenderness ◽

Definition Of

Background:Pain in metacarpophalangeal (MCP)-joints in patients presenting with clinically suspect arthralgia (CSA) is one of the clinical features by which patients are considered at risk for progression to inflammatory arthritis (IA). As such this symptom is characteristic for CSA and therefore part of a list of clinical parameters determined by an EULAR-taskforce to identify a more homogeneous group of patients within CSA (the EULAR definition of arthralgia suspicious for progression to RA). MRI-detected subclinical inflammation is known to be present in patients with CSA. In general, arthralgia in CSA can be explained by this subclinical inflammation, however to date, the association of subclinical inflammation with pain in MCP-joints specifically is not clear. Subsequently, it is unknown whether this association differs pertinently when investigated with self-reported pain, or with pain in the form of tenderness at physical examination.Objectives:This study will investigate whether MCP-pain and MCP-joint tenderness are associated with MRI-detected subclinical inflammation in patients with CSA, and more specifically those who have progressed to IA.Methods:Between April 2012- February 2019, 602 patients were consecutively included in the Leiden clinically suspect arthralgia (CSA)-cohort. Follow-up ended when patients developed clinically apparent IA (determined at physical examination), or else after 2-years (median follow-up time 25 months). MCP-joints were assessed for self-reported joint pain by the patient using a mannequin and subsequently for joint tenderness by physical examination. Baseline unilateral MRIs of the MCP (2-5)-joints were scored by two readers, blinded for clinical data, on subclinical inflammation (synovitis, tenosynovitis, osteitis). Associations between MCP-pain or MCP-joint tenderness and MRI-detected subclinical inflammation were studied at patient level by logistic regression analyses, entering the mentioned MRI-detected features separately (univariable) and together (multivariable).Results:33% of 227 patients with self-reported MCP-pain had MRI-detected subclinical inflammation and 38% of 226 patients with MCP-joint tenderness had MRI-detected subclinical inflammation. Self-reported MCP-joint pain was univariable associated with subclinical inflammation and synovitis in particular (OR 2.00, 95% CI: 1.21-3.30, OR 2.87, 95% CI: 1.29-6.39). In multivariable analysis this MCP-pain was associated with synovitis (OR 2.54, 95% CI: 1.12-5.77). MCP-joint tenderness was univariable associated with subclinical inflammation, and synovitis and tenosynovitis in particular (OR 1.84, 95% CI: 1.29-2.63, OR 1.76, 95% CI: 1.10-2.81, OR 1.69, 95% CI: 1.12-2.55, respectively). In multivariable analysis, tenosynovitis remained significant (OR 1.54, 95% CI: 1.00-2.36). Of all patients with self-reported MCP-joint pain who developed IA, 50% had MRI-detected subclinical inflammation. For MCP-joint tenderness this was 61%. Patients with MCP-joint tenderness without subclinical inflammation who developed IA, developed clinical arthritis at a joint that was not scanned (85%), hence they may have had subclinical inflammation that was not imaged. The other 15% did develop arthritis in an MCP-joint, suggesting that subclinical inflammation developed after CSA-onset.Conclusion:Arthralgia in the MCP-joints is associated with subclinical inflammation in CSA, in particular with synovitis and tenosynovitis. The prevalence of subclinical inflammation is highest for tender joints at physical examination; this can be acknowledged when applying the EULAR definition of arthralgia suspicious for progression to RA.Disclosure of Interests:None declared

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Abstract WP224: Should Carotid Bruit Be Abandoned as a Marker of Carotid Stenosis and Cardiovascular Disease in Older Persons? The Cardiovascular Health Study

Stroke ◽

10.1161/str.51.suppl_1.wp224 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Adnan I Qureshi ◽

Omer Saeed ◽

Hunain Aslam

Keyword(s):

Cardiovascular Disease ◽

At Risk ◽

Ischemic Stroke ◽

Physical Examination ◽

Carotid Stenosis ◽

Cardiovascular Health ◽

Health Study ◽

Cardiovascular Health Study ◽

Elderly Persons

Importance: Auscultation for carotid bruit has been considered part of physical examination for over five decades. Objective: To test whether a carotid bruit (CB) can identify patients with internal carotid artery stenosis (50% or greater) and those at risk of myocardial infarction (MI), ischemic stroke and/or death among elderly persons. Methods: We analyzed data from the Cardiovascular Health Study a population-based, prospective observational cohort study of risk factors for cardiovascular disease in adults 65 years or older. CB was auscultated and maximum percent stenosis was assessed using duplex ultrasound at baseline visit. Longitudinal follow-up was conducted for a mean (SD) of 13 (6.2) years to identify incidence of ischemic stroke, MI and death using annual extensive clinical examinations and 6 monthly clinic visits, and contact by phone to ascertain occurrence of cardiovascular events. We performed Cox proportional hazards analysis to determine the effect of CB on incidence of MI, stroke and death during follow up after adjusting for potential confounders. Results: The mean (SD) age of the entire cohort (n = 5888) was 72.8 (5.6) years; 2466 (41.9%) were men. CB was identified in 361 (6.1%) of 5888 persons. Carotid stenosis (50% or greater) was identified in 79 of 361 person with CB (sensitivity of 28.6%). No CB was auscultated in 197 out of 276 patients with carotid stenosis (specificity of 94%). During follow-up, higher proportion of persons with CB experienced ischemic stroke (10.8% versus 7.2%, p=.01), MI (15.0% versus 8.9%,p=<.0001) and death (36.3% versus 21.7%,p=<.0001). There were no differences in the risk of stroke (HR 1.2, 95% CI 0.9-1.5) between persons with CB compared with those without CB in the multivariate analysis after adjusting for age, gender, race hypertension, diabetes and smoking. There was a significantly higher rate of death among persons with CB (HR 1.3, 95% CI (1.1-1.5; p-<.01) and MI (HR 1.4, 95% CI 1.0-1.8; p-.03) compared with those who did not after adjusting for potential confounders. Conclusions: In this study, CB was a not a reliable marker for identification of carotid stenosis and those at risk for ischemic stroke. The current analysis does not support continued use of carotid bruit as part of physical examination.

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Pre-participation cardiovascular screening: is community screening using hand-held cardiac ultrasound feasible?

Echo Research and Practice ◽

10.1530/erp-15-0010 ◽

2015 ◽

Vol 2 (2) ◽

pp. 49-55 ◽

Cited By ~ 5

Author(s):

A R J Mitchell ◽

R Hurry ◽

P Le Page ◽

H MacLachlan

Keyword(s):

Physical Examination ◽

Marginal Cost ◽

Screening Programme ◽

Personal History ◽

Cardiac Ultrasound ◽

Community Based ◽

Community Screening ◽

Cardiovascular Screening ◽

Electrocardiogram Ecg

We evaluated the feasibility and costs of utilising hand-held cardiac ultrasound (HHCU) as part of a community-based pre-participation cardiovascular screening programme. Ninety-seven school children were screened using a personal history, a physical examination, a resting 12-lead electrocardiogram (ECG) and a HHCU. A consultant cardiologist independently reviewed and reported the data. Previously undiagnosed cardiovascular abnormalities were identified in nine participants (9%). An additional three participants (3%) were diagnosed with hypertension. The nine abnormalities were identified at a cost of £460 per finding, with a cost of £43 per participant screened. The marginal cost of adding a HHCU to the personal history, physical examination and ECG was £16 per participant. Pre-participation screening in the community using hand-held echocardiography is practical and inexpensive. The additional sensitivity and specificity provided by the ultrasound may enhance screening programmes, thereby reducing false positives and the need for expensive follow-up testing.

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P2281Inadequate heart rate control begets sustained ventricular arrhythmias in a large cohort of women

European Heart Journal ◽

10.1093/eurheartj/ehz748.0758 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

J W Erath ◽

V Kutyifa ◽

B Assmus ◽

A Burch ◽

D Bondermann ◽

...

Keyword(s):

At Risk ◽

Heart Rate ◽

Older Women ◽

Rate Control ◽

Ventricular Arrhythmias ◽

Shock Therapy ◽

Heart Rate Control ◽

Younger Women ◽

Risk Patients

Abstract Background The Wearable Cardioverter Defibrillator (WCD) is an effective therapy for treating ventricular arrhythmias (VT/VF) in at-risk patients, while providing continuous heart rate (HR) monitoring. Because women are under-represented in defibrillator trials, we chose to specifically focus on HR control in women prior to VT/VF events. Purpose To evaluate HR profiles preceding sustained VT/VF in women fitted with a WCD. Methods Data from women fitted with WCD (≥30 days use) from 2015 to 2018 were obtained from the manufacturer's database. HR is expressed as a weekly resting nighttime median (midnight to 7 am). Men (random sample) with the same inclusion criteria served as a control. Results A total of 21,440 women, age 67±15 years, were included for analysis. Over a median WCD use of 90 days (59–116 days), 118 women (0.6%) and 133 men (0.8%) received shocks for VT/VF (p=0.01). Resting HR one-week preceding VT/VF was above the target of 70bpm in 55% of shocked women (65 of 118) versus 44% of non-shocked women (9,272 of 21,322, p=0.01) (figure). HR one week before WCD shock was similar in women and men (71 bpm vs. 72 bpm; p=0.60). Younger women (≤50 years) had higher HR prior to shock than older women (HR 80 bpm vs. 70 bpm p=0.003). Among shocked patients, 24-hour-survival was 89% in women and 88% in men. During three-month follow-up, the same percentage of men and women died after receiving adequate WCD shock therapy (18%). Heart rate profiles Conclusions Women with adequate heart rate control experienced significantly less spontaneous VT/VF than those with higher heart rates. The WCD can be utilized as a diagnostic tool to monitor HR in at-risk women in addition to treating sustained VT/VF.

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Continuous Electrical Monitoring in Patients with Arrhythmic Myocarditis: Insights from a Referral Center

Journal of Clinical Medicine ◽

10.3390/jcm10215142 ◽

2021 ◽

Vol 10 (21) ◽

pp. 5142

Author(s):

Giovanni Peretto ◽

Patrizio Mazzone ◽

Gabriele Paglino ◽

Alessandra Marzi ◽

Georgios Tsitsinakis ◽

...

Keyword(s):

Ventricular Arrhythmias ◽

De Novo ◽

Diagnostic Yield ◽

Clinical Impact ◽

Gadolinium Enhancement ◽

Icd Implantation ◽

Loop Recorder ◽

Arrhythmia Detection ◽

Prospective Monitoring

Background. The incidence and burden of arrhythmias in myocarditis are under-reported. Objective. We aimed to assess the diagnostic yield and clinical impact of continuous arrhythmia monitoring (CAM) in patients with arrhythmic myocarditis. Methods. We enrolled consecutive adult patients (n = 104; 71% males, age 47 ± 11 year, mean LVEF 50 ± 13%) with biopsy-proven active myocarditis and de novo ventricular arrhythmias (VAs). All patients underwent prospective monitoring by both sequential 24-h Holter ECGs and CAM, including either ICD (n = 62; 60%) or loop recorder (n = 42; 40%). Results. By 3.7 ± 1.6 year follow up, 45 patients (43%) had VT, 67 (64%) NSVT and 102 (98%) premature ventricular complexes (PVC). As compared to the Holter ECG (average 9.5 exams per patient), CAM identified more patients with VA (VT: 45 vs. 4; NSVT: 64 vs. 45; both p < 0.001), more VA episodes (VT: 100 vs. 4%; NSVT: 91 vs. 12%) and earlier NSVT timing (median 6 vs. 24 months, p < 0.001). The extensive ICD implantation strategy was proven beneficial in 80% of the population. Histological signs of chronically active myocarditis (n = 73, 70%) and anteroseptal late gadolinium enhancement (n = 26, 25%) were significantly associated with the occurrence of VTs during follow up, even in the primary prevention subgroup. Conclusion. In patients with arrhythmic myocarditis, CAM allowed accurate arrhythmia detection and showed a considerable clinical impact.

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