EP Lab Digest - September 2007 - (Page 9)

SEPTEMBER COVER STORY den death: Proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2005;26:516-524. International Olympic Committee Medical Commission, International Olympic Committee. Sudden Cardiovascular Death in Sport. Lausanne Recommendations. http://multimedia.olympic.org/pdf/en_report_88 6.pdf Corrado D, Basso C, Pavei A, et al.Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 2006;296:1593-1601. Tasaki H, Hamasaki Y, Ichimaru T. Mass screening for heart disease of school children in Saga city: 7year follow up study. Jpn Circ J 1987;51:14151420. Haneda N, Mori C, Nishio T, et al. Heart diseases discovered by mass screening in the schools of Shimane Prefecture over a period of 5 years. Jpn Circ J 1986;50:1325-1329. Fuller CM, McNulty CM, Spring DA, et al. Prospective screening of 5,615 high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc 1997;29:1131-1138. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: Endorsed by the American College of Cardiology Foundation. Circulation 2007;115:1643-1655. Pelliccia A, Culasso F, Di Paolo FM, et al. Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J 2007;28:2006-2010. The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program – Center for Medicaid Services. Maron BJ, Shirani J, Poliac LC, et al. Sudden death in young competitive athletes: Clinical, demographic, and pathological profiles. JAMA 1996;276:199-204. interpretation of recordings from areas lacking manpower. Readings and information directed to a central database could be available for study to increase efficiency and effectiveness of the ECG screening process. • Medical-legal implications of false negative results: concern stems from reality that the ECG is not 100% predictive of all conditions that may cause sudden cardiac death. However, as mentioned previously, the ECG is far more sensitive at identifying those at risk than medical history and physical exam alone. Examining physicians may be concerned about potential litigation if they clear an athlete who later manifests symptoms or suffers sudden cardiac death. It is unrealistic to expect 100% sensitivity from any diagnostic test.The high sensitivity of the ECG to diagnose most cardiac conditions has been demonstrated, and its utility should not be dismissed. Examiners have a duty to inform their patients of the risks and benefits of any testing they plan to perform, and the patient has the responsibility to consent or decline testing based on this information. The medical informed consent process is well-defined and should be applied to the preparticipation exam just as it is to other testing and therapeutic options. • Impact of false positive results: the panelists are primarily concerned with the financial burden of additional testing that may in the end reveal the good news that no cardiac abnormalities are present. They also express concern for the patient and their family who may be overwhelmed by the possibility of a life-threatening disorder that could unfairly restrict their participation in organized sports. Of particular note is the burden this additional testing might place on those with low socioeconomic status.9 Recent Italian data indicates that the incidence of false positives is far less than reported by the panel.10 Regarding the emotional impact of an overly conservative result that may or may not indicate a problem on advanced testing, most patients and parents surveyed would rather accept the temporary inconvenience and psychological strain than be forced to cope with the tragic consequences of a missed diagnosis, which could result in death or disability. To answer the real economic problems faced by those without the financial means to seek additional testing and treatment, there are already federal and state programs in place to screen and provide therapy for low-income children from birth to age 21.11 Not only are these existing programs available to assist those in true need, but the models of these programs may also provide insights on how we might approach funding and implementation to the broader population of all school-aged children. It is important to also mention that screening efforts focused primarily on student athletes miss the other 25 million U.S. school children who do not participate in organized sports. It is estimated that sudden cardiac death takes the lives of 7,000 children and adolescents each year in this country. Because the majority of these deaths typically occur outside public venues and there is no central registry for these events, the actual numbers are difficult to determine. Many experts believe that the number of deaths due to sudden cardiac arrest in children, adolescents and young adults is vastly underestimated. As compassionate citizens, we are horrified when avoidable mass casualties take innocent lives, and we vow to commit whatever resources are necessary to prevent similar tragedies in the future. Why then would we not demand a program to prevent the unnecessary deaths of thousands of children and young adults each year due to undiagnosed heart disorders? Are these events any less shocking because they occur incrementally and often privately without major media coverage? Reliable diagnostic tools and effective treatment options exist to prevent SCD due to undiagnosed heart abnormalities. However, some experts believe it is more cost-effective to reserve advanced testing for only those with a strong family history or who have exhibited obvious symptoms of a possible heart disorder. Considering that cardiac arrest is the sentinel event in more than 55% of sudden deaths, does it make sense to wait and see who manifests symptoms sufficient to justify additional testing?12 Furthermore, the genetic basis for many rhythm disorders multiplies the risk of SCD to as many as 50% of the index patient’s family. Patient organizations like the C.A.R.E. Foundation hear countless stories of children and young adults dying suddenly, with no small number of these deaths occurring even after prescient episodes of syncope, chest pain or shortness of breath were unfortunately attributed to more benign conditions such as anxiety, growing pains or asthma. Sadly, there are also far too many missed opportunities to prevent sudden death in young athletes who had in fact affirmed episodes of shortness of breath, dizziness or chest pain on their pre-participation questionnaire, though further cardiac evaluations were not performed. Admittedly, these reports are anecdotal, lacking scientific validation to support evidence-based medicine. Nonetheless, one at a time these deaths add up to significant numbers and are devastating to those who have lost loved ones for no fault other than they were unaware that their symptoms might be warning of a serious underlying heart problem. Advocates for universal ECG screening to prevent sudden death in the young appreciate the enormous challenges to be faced in implementing such a program in the United States.We also believe that the time is right to build on lessons learned by our European and Japanese colleagues to assess what qualities can be emulated in a U.S. program and where inconsistencies require additional investigation. To that end, a next logical step would be to begin screening programs while simultaneously initiating a prospective nationwide ECG screening study to better understand issues regarding methods, costs, effectiveness, and infrastructure requirements. 4. 5. 6. 7. 8. 9. 10. References 1. Gemayel C, Pelliccia A, Thompson PD. Arrhythmogenic right ventricular cardiomyopathy. J Am Coll Cardiol 2001;38:1773-1781. 2. Maron BJ. Risk stratification and prevention of sudden death in hypertrophic cardiomyopathy. Cardiol Rev 2002;10:173-181. 3. Corrado D, Pelliccia A, Bjornstad HH, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sud- 11. 12. Deadline for AHA Issue: Readers, time is running out to get your article included in our November 2007 issue of EP Lab Digest! Remember, this issue will be distributed at the American Heart Association meeting. To have your submission considered for publication, please email your article to “jelrod@hmpcommunications.com”. We’d love to hear from you! http://multimedia.olympic.org/pdf/en_report_886.pdf

Table of Contents Feed for the Digital Edition of EP Lab Digest - September 2007

The ICD Shock and Stress Management Program: Interview with Samuel F. Sears Jr., PhD Universal ECG Screening: The Advocate’s Perspective Contents Letter from the Editor Spotlight Interview: Morristown Memorial Hospital 10-Minute Interview: About the Mended Hearts and Mended Little Hearts Organizations ICD Patient Support Groups Email Discussion Group: September 2007 Technology: Only As Good As the Attitude Behind It! Electrophysiologic Management and Treatment of Chronic and Acute Cardiac Device Infection First Annual EP Lab Digest Salary Survey Events Calendar Industry News and Products

EP Lab Digest - September 2007

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