Pre-Participation Evaluation: Scope of History & Physical Adding ECG, Echo and Other Imaging

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Tamanna Singh, MD:

I'm going to go ahead and talk about the incorporation, the history and a physical from a cardiac lens, and incorporating things like an ECG and other imaging modalities, predominantly echo, coronary CT and MRI moving forward.

Tamanna Singh, MD:

The goal for this session today is just to discuss what cardiac risk assessment is in athletes, and we typically do hear that language of screening. We really try to steer away from that terminology and really try to push more of a risk assessment vocabulary. We'll talk a little bit about the role of the EKG in addition to the H and P as well as what supports that with respect to incorporating that in screening or not. And then, we'll dive into some multi-modality imaging in athletes and when that is appropriate.

Tamanna Singh, MD:

I always like to start by defining what a competitive athlete is, and we use the definition by the Bethesda Conference. It's one who participates in an organized team or individual sport that requires regular competition against others as a central component, places a high premium on excellence and achievement and requires some form of systemic, usually intense training. It's really a distinctive activity and a lifestyle versus something that you may dabble in, not so much on the day-to-day.

So why do we assess risk in these individuals? And based upon the Interassociation Consensus Statement on Cardiovascular Care of College Athletes, it's really to identify conditions that may put these individuals at unreasonable risk of death or catastrophic injury with the potential to modify and reduce risk through individualized management. Dr. Figler touched on this already with respect to what our at-risk populations are, and this is based upon registry data from about 2003 to 2013 looking at high risk populations for sudden cardiac deaths, specifically among our NCAA athletes. They're predominantly male, African American and typically basketball players. And about a quarter percent of screened athletes do have potentially dangerous cardiac conditions that can be identified.

Tamanna Singh, MD:

Again, just remembering what our target cohort really is, we really try to make sure that we're looking at our male genders. Our female athletes, typically, from both an electric perspective as well as a cardiomyopathy perspective, are less at risk of sudden cardiac death compared to their male counterparts. But male basketball players definitely, one in about 9,000 typically can have that risk of sudden death. Causes of sudden cardiac death run the gamut. We typically, as you know, like to think about the heart as a pump, an electrical circuit, and then, we, of course, want to take a look at the coronary vasculature. Just from a congenital perspective, we always want to make sure we're taking into account familial cardiomyopathies, congenital abnormalities, anything that can be acquired, whether it be atherosclerosis in our masters athletes, myocarditis, particularly, that's been a big topic with this pandemic, at least early on. And then, some of the electrical derangement, including long QT syndrome, catecholaminergic polymorphic VT as well as WPW, Brugada and whatnot. And then, we can always have a structurally normal heart and have situations where sudden cardiac death can be precipitated. That can be with toxins, that can be with environmental factors, anything related to temperature, hypo/hyperthermia, acquired long QT, perhaps drug related, and then commotio cordis.

Tamanna Singh, MD:

How does the NCAA support cardiac assessment? It supports the concept. We do incorporate the American Heart Association 14-point recommendation as well as the pre-participation physical evaluation questioning tools, or the PPE4. And when we think about cardiac assessments, there's really no consensus as to whether or not there is a long-term benefit or is there a risk of using EKGs for cardiac risk assessment, but if they are used, one of the most important things is that we actually have cardiovascular specialists who are able to interpret those EKGs with the lens of an athlete. You'll notice, as we go through our sessions today, and we'll talk a lot about how EKGs that may be abnormal in our sedentary population may not be abnormal in our athlete population. It's important to make sure that we can implement these screening strategies for all of our athletes and really make sure we're incorporating those high-risk groups. And then, it's also important to tell our athletes what we're doing. We want to make sure that they understand what the rationale is behind the ECG tool as a cardiac risk assessment strategy and what the risks and benefits of using that tool, if it's not used appropriately, can be.

Tamanna Singh, MD:

When we think about how we begin with our assessment, it's with any athlete, we make sure that we have a very comprehensive history and physical and we really try to probe these athletes. A lot of them can understand that whatever information they do provide to us is going to determine what we do downstream. And many of them do need the help of their families to understand what their family history is, and that can also be very important to determine if certain symptoms are worthy of further evaluation. We're always keeping our ears out for listening for common symptoms like chest discomfort, difficulty breathing, if they're syncopating with exertion, if they're noticing a decline in their performance, any family history of sudden death or premature coronary disease or any sort of familial cardiomyopathy is going to be relevant. And this will lead to a very focused cardiovascular exam, oftentimes may lead to an EKG, but that's also just very dependent on the institution that's doing the risk assessment.

Tamanna Singh, MD:

I just wanted to give you an example of what the 14 points AHA tool versus the PPE4 looks like. The PPE4 is probably a little more specific in the questions, but when it comes to personal history, we're asking about those types of symptoms. We're asking if they ever were seen by a cardiologist before, did they ever or were they ever told they had a heart murmur? That's quite a common one. Or were they ever told they had high blood pressure? That's oftentimes something that can easily be missed. The PPE4 is going to be, obviously, a little more specific, so sometimes, we'll use that. It can be a little challenging for athletes if they don't necessarily know the answers to these questions. And then, with respect to family history, again, we want to make sure that really ensuring that we got down to whether or not there is some heightened risk for sudden cardiac death that we want to make sure we don't miss. Their exams are always going to be inclusive of getting blood pressure, making sure we do a full cardiac exam, femoral pulses, whatnot. And then, of course, looking for any sort of stigma to connective tissue disease like Marfan's or Ehlers-Danlos and whatnot.

Tamanna Singh, MD:

ECG interpretation, this is typically what we use as sports cardiologists and we're trying to determine, with our ECG tools, what is normal, what is abnormal and what requires additional investigation. And you can see here already that there are a couple of things that are normal for athletes that perhaps may not be normal for non-athletes, particularly when we're looking at TUA changes in specific populations.

Some things to think about with respect to whether or not we should include EKG in our discussions with cardiac risk assessment programs, there can be benefits of mass screening. We can identify small numbers of athletes who may have this increased risk of death or perhaps have not had a diagnosed cardiomyopathy or whatnot. But the caveat is there's still limited evidence of pouring the effectiveness of this type of screening tool to achieve actual prevention of sports related death. They still tend to happen. It is currently practiced and mandated in three countries, in Italy and Israel. We do practice it here in the US, but it is not mandated. And for the athlete, again, we always have to make sure that we're justifying what we are doing and that they understand why our approach is such with respect to risk assessment because, oftentimes, they've never really had an EKG before they've come to see us. It can be very stress-provoking. And of course, they're always wondering, well, is this going to be something that's going to keep me off the team or off the court or whatnot.

Tamanna Singh, MD:

Let's dive in a little bit to the efficacy of cardiovascular assessments with the EKG versus just the H and P alone. There is some outcome data in athlete screening and mortality, and it's been primarily driven by the single database out of Italy where a ARVC or arrhythmogenic right ventricular cardiomyopathy, or now just AC, is endemic in this area. They were able to demonstrate a very sharp decrease in mortality rate over a 30-year period, which the investigators think is related to the EKG, but you can see, particularly when you have one cardiomyopathy that's endemic, how an EKG with specific findings for AC should be able to catch that. I bring that up just to show that it has been demonstrated to reduce mortality, but again, not without its caveats.

Tamanna Singh, MD:

This type or degree of reduction in cardiovascular mortality with ECG as a tool hasn't really been replicated anywhere else. There is some evidence from the US and Israel that diminishes the value of EKG with respect to reducing athlete mortality, so that predisposes to how ECGs have been incorporated nationwide. And what we're noticing is that the mortality directly attributed to routine EKG is really more of an observation that's primarily driven by low event rates in competitive athletes with cardiovascular disease. What are some cons of just an isolated H&P, since we talked a little bit about the limitations of utilizing an EKG? Well, the questions, as you can see, can be very broad and non-specific and if someone's not really using one of these recommended tools, they can be very non-specific, and we can miss things. It can lead to a lot of false positives or false negatives. In fact, 24 percent to 43 percent of college athletes reported at least one positive cardiovascular symptom or family history when the AHA or PPE tools were used, and 68% of high school athletes reported a positive history. Those positive historical findings are going to predicate what we want to do, and that's where an EKG can be very helpful to determine whether or not those symptoms are something that we need to investigate further. The addition of a resting EKG for screening protocols hasn't really been shown in an adequately designed study to prevent sudden cardiac deaths, but it does improve sensitivity to many cardiac conditions such as, perhaps, hypertrophic cardiomyopathy, perhaps some ion channel disorders, perhaps some pre-excitation pathways.

Tamanna Singh, MD:

Unfortunately, an EKG is not helpful when we have other causes of sudden cardiac death that can't be seen on a rhythm strip such as anomalous coronaries or acropathies. And there is, again, a physician-to-physician variability and interpretation, so it is extremely important to pay heed to some of those EKG tools that we use to determine what is normal for an athlete and what is not. This was a really nice study talking about the efficacy of pre-participation cardiovascular evaluation, and she specifically looked at the sensitivity specificity and the positive predictive value of just a history and physical compared to adding an EKG. And you can clearly see that both sensitivity and specificity increased quite markedly with the incorporation of an EKG and the false positive rates really went down about 6 percent with an EKG versus 10 percent with just a physical. They were able to identify about 160 lethal conditions, which is about 0.3 percent. Most of them were WPW, about 42 percent. And then, that was followed by long QT and hypertrophic cardiomyopathy. Now, this is also an evaluation of about 47,000 athletes, so it was a really, really large database. The majority of athletes who experience sudden cardiac death really don't have any recognized warning signs or symptoms, so they can go undetected when they are screened by just an H&P. Again, this is where the EKG can be helpful. And then, just to follow up with that 2015 study, she, then in 2019 took a look at the history of physical versus an H&P plus the inclusion of an EKG in the PAC 12. And here, there was no specific cardiovascular risk assessment program for these schools, no required screening method, but they looked at a number of cardiovascular conditions that were identified associated with sudden cardiac death with and without EKGs. And what they found is that schools that did use an EKG were actually eight times more likely to find conditions associated with sudden cardiac death than those using just an H&P alone. And 75 percent of athletes who were diagnosed with the condition were actually allowed to return to play. That's probably one of the biggest benefits of utilizing an EKG strategy. Oftentimes, these guys may see someone who doesn't really understand how to interpret their history, their physical and what to do from that point forward. These athletes are relegated to being told they've got to stay off the court, but if we can at least identify whether or not that risk or that symptom is something that we need to be concerned about, that's super helpful.

Tamanna Singh, MD:

And then, in terms of what our AHA consensus is currently, currently, our consensus ruled against any mandated screening. That's because we have a large number of athletes to screen and a very low incidence of events and there can be a lot of costs associated with this as well as liability. And then, of course, we need to have the right people involved, people who know how to interpret these tests, how to perform an EKG risk assessment strategy at institutions, and there's a lot of variability in that at this point. How do we appropriately implement the EKG and cardiovascular risk assessments? We have to make sure that we disclose that it has some limitation in its predictive accuracy for sudden cardiac death, make sure the interpretation is highest quality, make sure we have cardiology oversight. And then, of course, if this program is really implemented in the best way possible, then, the addition of an EKG will really improve our cardiovascular screening and ability to detect any sort of silent conditions that put those athletes at heightened risk. And this is just a nice schematic about what an emergency action plan looks like, which really should be thought of rehearsed and put into practice whenever you are incorporating some sort of cardiac tool in your PPE screening.

Tamanna Singh, MD:

Getting back to our algorithm, we talked a little bit about the H&P, the inclusion of the EKG, but now, I want to dive into some of that more cardiac specific testing that we do as predominantly starting with echo and then going into our more expansive imaging modalities. The reasoning behind actually going to look at structure and function outside of just what an EKG shows is because there's a lot of changes that can happen to the actual heart with respect to exercise and that's what we call exercise induced cardiac remodeling. This is a schematic from our 2015 competitive athlete's guidelines that tries to characterize certain sports with certain findings that we would expect when it comes to left ventricular thickness, biventricular dilatation and any other sort of remodeling that is physiologic versus pathologic. This three-by-three plot is not expensive, to say the least. We do try to hit some of the more common sports, but I also like this diagram that talks a little bit more about sport disciplines, talking about what's more static, what's dynamic, so what's more endurance related and what's more weightlifting related, just because that allows for us to think, as cardiologists, about what impacts would we expect to see with respect to remodeling in the heart that's not pathophysiologic.

Tamanna Singh, MD:

That brings us into this gray zone, and this is why it's really important to understand what changes to expect versus what changes are going to be something that you need to further investigate that can be related to sudden cardiac death. What I'm getting at here is that the way we really think about this process is, when we see abnormalities on imaging, or I really shouldn't use that term, abnormalities, but when we see findings that may be abnormal in a specific population on imaging modalities, we want to make sure that we're thinking through, what sport does that individual play? What is their gender? What is their hemodynamics? What are their vitals? What's their family history? That's going to lead us down a diagnostic pathway in terms of, is this something that is physiologic? Is this something that's pathologic? And do we need additional imaging to define what we're looking at?

Tamanna Singh, MD:

Some of the common things that we see, left ventricular hypertrophy, sometimes, that can be flagged as abnormal, but really, it's sport related, sometimes dilated left ventricular size or right ventricular size. Really, with endurance part, we see four chamber dilatations, which is not abnormal, particularly when the diastolic function is normal. And then, we're also seeing a lot of hypertrabeculation, which you can see with extensive sport participation, which is not left ventricular noncompaction, but sometimes can be flagged that way. And so, it's our job to make sure that we can differentiate ourselves from the two because they determine whether an athlete's going to be able to play a sport or not.

Tamanna Singh, MD:

What are some benefits of echo? We use the echo all day every day. It's a really cheap tool. It's very easy to implement. We can easily do it with respect to bringing it with us to a screening site. It's very portable. And we can easily characterize a lot of these findings, particularly related to cardiomyopathies or valve disease, and oftentimes, even looking at the origins of coronary arteries on short axis imaging. In terms of echo versus alternative imaging modalities, this was a nice schematic just showing you what it looks like when we compare echo to some more expensive imaging tools that have high variability in either access, quality or readership. Cost, accessibility, portability, are very simplistic for echo versus the other two modalities. And like I mentioned, we can easily characterize a lot of the findings that we need to say, is this athlete someone who needs additional testing or is this an athlete who can return to sport participation?

Tamanna Singh, MD:

While I really pumped up the echo, it does have some limitations. You can see the origins of the coronaries most of the time, but they can be quite limited and oftentimes will need additional imaging to further delineate anatomy. We can't see the entire aorta. So, if you're worried about acropathies you want additional imaging. Sometimes, we see a lot of acoustic shadowing from ribs. We can't see the ventricular morphology. Sometimes, we get some limited cross-sectional imaging of the apex. And we can't actually characterize the quality of the myocardium, so we can't identify fibrosis, edema, inflammation, which is super important in things like myocarditis.

Tamanna Singh, MD:

Should all PPE include an echo? It's really not recommended as first line. We're going from HNP to probable EKG, and then to our imaging strategies, but it can be advantageous in terms of improving the sensitivity of identifying a lot of these cardiovascular disorders, though, again, you want to make sure you've got the right reader reading the study who understands what to expect for athletes versus not.

Tamanna Singh, MD:

We're going to quickly finish up with a couple of our other imaging tools. Cardiac CT angiography is something that many of us use, particularly when we're concerned about anomalous coronaries, or we need to further define the coronary anatomy in our master's athletes without doing any functional testing. If we want to characterize the aorta, if we're looking to do coronary artery calcium scoring, the big risk with CT angiography, and you can expect this if you're putting a younger athlete under the scanner, is radiation exposure. Oftentimes, we have athletes who we're trying to look at their aortas, perhaps their valves, and we're doing surveillance imaging and over decades and decades, that's a lot of radiation exposure.

Tamanna Singh, MD:

That's where I think cardiac MRI can be very helpful, though. I think MRI has so many big benefits and it is really our gold standard for defining the characteristics of myocardium, looking at the pericardium, being able to look at valve morphology regurgitant volumes, looking at coronary artery anatomy, it's the prime tool. I love MRI. It's obviously not going to be something that we go to immediately. Limitations, high cost. Sometimes, we have individuals, athletes with MRI onsite devices who can't get those images, and limited access. And again, it's super important that whoever is reading the image understands what they're reading and is able to interpret it within the context of an athlete. And then, renal functional claustrophobia is some of the things that we also encounter.

Tamanna Singh, MD:

There are a lot of roles for multimodality imaging as a supplement, typically, to the H&P, and most oftentimes, an EKG that follows. This is just a nice schematic that tells you what our thought process is whenever we see an athlete in our clinic or at a screening event: always starts with the H&P, probe, probe, probe. Probe the family history, make sure you're doing a thorough physical exam, and then, make sure you're interpreting the EKG with the lens of a sports cardiologist. Oftentimes, we'll go towards an echo, and that will help us determine if we need any other imaging tools to further define anatomy, structure, all, again, to make sure that we can get an athlete back to playing the sport that they love in a very efficient manner.

Tamanna Singh, MD:

Just to summarize, pre-participation cardiac screening in athletes is super valuable in identifying a lot of conditions that can be associated with sudden cardiac death, and I already said that including an EKG can really be helpful in improving sensitivity and specificity. Echo is a super easy imaging tool that you can utilize, it often leads to downstream testing as necessary to further define anatomy, again, going back to whether an athlete can play, but it's just super important to understand what the limitations are with all of these tools, making sure you're looking through a sports cardiology lens to ensure that an athlete is getting treated appropriately, fairly, and can get back to what they love doing.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts or listen at clevelandclinic.org/cardiacconsultpodcast.