Return to play with hypertrophic cardiomyopathy: are we moving too fast? A critical review.

The diagnosis of a potentially lethal cardiovascular disease in a young athlete presents a complex dilemma regarding athlete safety, patient autonomy, team or institutional risk tolerance and medical decision-making. Consensus cardiology recommendations previously supported the 'blanket' disqualification of athletes with hypertrophic cardiomyopathy (HCM) from competitive sport. More recently, epidemiological studies examining the relative contribution of HCM as a cause of sudden cardiac death (SCD) in young athletes and reports from small cohorts of older athletes with HCM that continue to exercise have fueled debate whether it is safe to play with HCM. Shared decision-making is endorsed within the sports cardiology community in which athletes can make an informed decision about treatment options and potentially elect to continue competitive sports participation. This review critically examines the available evidence relevant to sports eligibility decisions in young athletes diagnosed with HCM. Histopathologically, HCM presents an unstable myocardial substrate that is vulnerable to ventricular tachyarrhythmias during exercise. Studies support that young age and intense competitive sports are risk factors for SCD in patients with HCM. We provide an estimate of annual mortality based on our understanding of disease prevalence and the incidence of HCM-related SCD in different athlete populations. Adolescent and young adult male athletes and athletes participating in a higher risk sport such as basketball, soccer and American football exhibit a greater risk. This review explores the potential harms and benefits of sports disqualification in athletes with HCM and details the challenges and limitations of shared decision-making when all parties may not agree.

International recommendations for electrocardiographic interpretation in athletes.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

International criteria for electrocardiographic interpretation in athletes: Consensus statement.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

International Recommendations for Electrocardiographic Interpretation in Athletes.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On February 26-27, 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

Why cardiovascular screening in young athletes can save lives: a critical review.

Cardiovascular (CV) screening in young athletes remains challenging and a topic of considerable debate. Recent criticisms of ECG screening have perpetuated arguments that ECG screening is neither indicated nor effective by applying outdated incidence data and flawed methodology. In response, this article provides a critical review of the arguments in favour of ECG screening in athletes and the early detection of CV disorders at elevated risk of sudden cardiac death (SCD). Importantly, no study to date has demonstrated that screening by history and physical examination alone is effective in detecting athletes at risk or in preventing SCD. ECG screening using current athlete-specific interpretation standards provides a low false-positive rate and improves detection of potentially lethal CV conditions. Further, risk reduction in athletes identified with CV disorders can be effectively achieved through modern strategies for risk stratification and disease-specific management. By every definition of the purpose of CV screening, ECG-inclusive programmes will better meet the stated objective of early detection when proper ECG interpretation and adequate cardiology resources are available. Less debate on screening protocols and more emphasis on advancing physician skills and infrastructure in sports cardiology is needed to more effectively screen targeted athlete populations.

ECG screening for SCD in young adults: community volunteers can acquire higher quality ECGs than health professionals.

BACKGROUND AND PURPOSE: ECG screening of young athletes for risk of sudden cardiac death has grown in popularity throughout the world. The purpose of this study is to assess the technical error rate of ECGs acquired by appropriately trained community volunteers compared to that reported in the literature utilizing trained medical personnel. METHODS: This is a retrospective study analyzing consecutive ECGs acquired during 5 successive high school screenings at 3 separate schools in 2011. RESULTS: A total of 4477 consecutive ECGs were acquired and assessed for technical quality. The total rate of technically inadequate tracings was 0.34%. This is lower than that reported in outpatient clinics acquired by medically trained technicians (0.4%) and in ICUs acquired by nurses (4.8%). CONCLUSIONS: This study demonstrates that the ECG training program utilized by the YH4L program for community volunteers results in a technical error rate that is lower than reported in the literature.

Effectiveness of the electronic medical record in improving the management of hypertension.

Clinical studies suggest that hypertension is often undiagnosed, undertreated, and poorly controlled. In 1997, the authors developed a comprehensive electronic medical record that interfaces with physicians during each outpatient visit and provides real-time feedback about patient care management, including the management of hypertension. The purpose of this study was to determine whether this interactive electronic medical record results in better detection and control of hypertension. During a 12-month study period, consecutive outpatients (n=1076) were seen for routine follow-up; patient care documentation relied solely on the electronic medical record. Quality indicators for hypertension included: 1) documentation of the diagnosis of hypertension; 2) use of blood pressure-lowering drugs; and 3) successful blood pressure lowering to < or =140/90 mm Hg. The authors compared the hypertension management of these patients to a control group of similar patients (n=723) with medical records consisting solely of traditional pen and paper charts. Baseline characteristics were similar between the two groups, including the prevalence of hypertension (73% vs. 70%; p=NS). However, the electronic medical record resulted in higher documentation rates of hypertension (90% vs. 77%; p<0.001), greater use of antihypertensive therapy (94% vs. 90%; p<0.01), and more successful blood pressure lowering to < or =140/90 mm Hg (54% vs. 28%; p<0.001). In conclusion, the electronic medical record with real-time feedback improves the physicians ability to detect, treat, and control hypertension.