Comparative evaluation of an electrocardiogram workflow model for athletic cardiovascular screening: Primary care network versus sports cardiology interpretation.

BACKGROUND: Electrocardiogram (ECG) testing in pre-participation screening (PPS) remains controversial due to its cost, resource dependency, and the potential for inaccurate interpretations. At most centres, ECGs are conducted internally by providers trained in athletic ECG interpretation. Outsourcing ECG requisitions to an athlete's primary care network (PCN) may reduce institutional demands. This study compared PCN-conducted athletic ECG interpretation to expert sports cardiology interpretation. METHODS: This was a retrospective, single-centre chart-review study of all athletes who underwent cardiovascular PPS between 2017 and 2021. All athletes submitted an ECG with their screening package, which was conducted and interpreted within their PCN. All ECGs were reinterpreted by a sports cardiologist using the International Criteria (IC) for electrocardiographic interpretation in athletes. Overall, positive, and negative percent agreement were used to compare PCN-conducted ECG interpretation with IC interpretation. RESULTS: A total of 740 athletes submitted a screening package with a valid ECG (mean age: 18.5 years, 39.6% female). PCN-conducted ECGs were interpreted by 181 unique physicians. Among 41 (5.5%) PCN-conducted ECGs that were initially interpreted as abnormal, only 5 (0.7%) were classified as abnormal according to the IC. All PCN-conducted ECGs reported as normal were also classified as normal according to the IC. The overall agreement between PCN-conducted and IC ECG interpretation was 95.1% (positive percent agreement: 100%, negative percent agreement: 95.1%). CONCLUSIONS: Normal PCN-conducted athletic ECGs are interpreted with high agreement to the IC. Majority of PCN-conducted ECGs interpreted as abnormal are indeed normal as per the IC. These findings suggest that a PPS workflow model that outsources ECG requisitions to a PCN may be a reliable approach to PPS, all while reducing screening-related institutional costs and resource requirements.

Non-COVID-19 cardiovascular pathology from return-to-play screening in college athletes after COVID-19.

OBJECTIVE: Concerns for cardiac involvement after SARS-CoV-2 infection led to widespread cardiac testing in athletes. We examined incidental non-COVID-19 cardiovascular pathology in college athletes undergoing postinfection return-to-play screening. METHODS: The Outcomes Registry for Cardiac Conditions in Athletes was a nationwide prospective multicentre observational cohort study that captured testing and outcomes data from 45 institutions (September 2020-June 2021). Athletes with an ECG and transthoracic echocardiogram (TTE) and no pre-existing conditions were included. Findings were defined as major (associated with sudden cardiac death or requiring intervention), minor (warrants surveillance), incidental (no follow-up needed) or uncertain significance (abnormal with subsequent normal testing). RESULTS: Athletes with both ECG and TTE (n=2900, mean age 20±1, 32% female, 27% black) were included. 35 (1.2%) had ECG abnormalities. Of these, 2 (5.7%) had TTE abnormalities indicating cardiomyopathy (hypertrophic-1, dilated-1), and 1 with normal TTE had atrial fibrillation. Of 2865 (98.8%) athletes with a normal ECG, 54 (1.9%) had TTE abnormalities: 3 (5.6%) with aortic root dilatation ≥40 mm, 15 (27.8%) with minor abnormalities, 25 (46.3%) with incidental findings and 11 (20.4%) with findings of uncertain significance. Overall, 6 (0.2%) athletes had major conditions; however, coronary anatomy and aortic dimensions were inconsistently reported and pathology may have been missed. CONCLUSION: Major non-COVID-19 cardiovascular pathology was identified in 1/500 college athletes undergoing return-to-play screening. In athletes without ECG abnormalities, TTE's added value was limited to pathological aortic root dilatation in 1/1000 athletes and minor abnormalities warranting surveillance in 1/160 athletes. Two-thirds of findings were incidental or of uncertain significance.

Cardiac point-of-care to cart-based ultrasound translation using constrained CycleGAN.

PURPOSE:  The emerging market of cardiac handheld ultrasound (US) is on the rise. Despite the advantages in ease of access and the lower cost, a gap in image quality can still be observed between the echocardiography (echo) data captured by point-of-care ultrasound (POCUS) compared to conventional cart-based US, which limits the further adaptation of POCUS. In this work, we aim to present a machine learning solution based on recent advances in adversarial training to investigate the feasibility of translating POCUS echo images to the quality level of high-end cart-based US systems. METHODS:  We propose a constrained cycle-consistent generative adversarial architecture for unpaired translation of cardiac POCUS to cart-based US data. We impose a structured shape-wise regularization via a critic segmentation network to preserve the underlying shape of the heart during quality translation. The proposed deep transfer model is constrained to the anatomy of the left ventricle (LV) in apical two-chamber (AP2) echo views. RESULTS:  A total of 1089 echo studies from 841 patients are used in this study. The AP2 frames are captured by POCUS (Philips Lumify and Clarius) and cart-based (Philips iE33 and Vivid E9) US machines. The dataset of quality translation comprises a total of 441 echo studies from 395 patients. Data from both POCUS and cart-based systems of the same patient were available in 122 cases. The deep-quality transfer model is integrated into a pipeline for an automated cardiac evaluation task, namely segmentation of LV in AP2 view. By transferring the low-quality POCUS data to the cart-based US, a significant average improvement of 30% and 34 mm is obtained in the LV segmentation Dice score and Hausdorff distance metrics, respectively. CONCLUSION:  This paper presents the feasibility of a machine learning solution to transform the image quality of POCUS data to that of high-quality high-end cart-based systems. The experiments show that by leveraging the quality translation through the proposed constrained adversarial training, the accuracy of automatic segmentation with POCUS data could be improved.

Canadian Cardiovascular Society Cardiovascular Screening of Competitive Athletes: The Utility of the Screening Electrocardiogram to Predict Sudden Cardiac Death.

Prevention of sudden cardiac arrest/death (SCA/D) among athletes is a universal goal, although the optimal strategy for its achievement is controversial, with the inclusion of the 12-lead electrocardiogram (ECG) at the center of the debate. The ECG exhibits superior sensitivity over history and physical examination to detect conditions associated with SCA/D. However, the identification of disease does not necessarily lead to a significant reduction in SCA/D. The "Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes" recommended against the routine performance of an ECG for the initial cardiovascular screening of competitive athletes. The incidence of SCA/D among athletes (<35 years of age), the risk of SCA/D during sport participation among individuals with abnormalities found on screening ECG, the efficacy of the ECG to identify conditions associated with SCA/D, and the positive predictive value of an abnormal ECG to predict SCA/D are critically examined. This review presents the evidence informing the panel's recommendation.

Translation of the Canadian Cardiovascular Society/Canadian Heart Rhythm Society Cardiovascular Screening and Care of Athletes Program Into Practice.

In the absence of systematic cardiovascular preparticipation screening (PPS) practices in Canada, the Canadian Cardiovascular Society and Canadian Heart Rhythm Society published a joint position statement outlining PPS recommendations for competitive athletes in an effort to standardize screening. The Queen's University Cardiovascular Screening and Care of Athletes Program aimed to translate these recommendations into practice. Screening packages were administered to athletes in 2017 and 2018. Each package required completion of a medical/history questionnaire, a physician's examination, and 12-lead electrocardiogram performed by the athlete's primary care physician. A tiered approach to screening, as recommended by the position statement, was implemented. A multidisciplinary team flagged at-risk athletes and determined the need for follow-up testing and participation eligibility. Over a 2-year period, 517 varsity athletes were screened, with 438 (84.7%) completing all recommended screening components. Analysis of completed packages resulted in 114 (26.0%) athletes flagged for initial review. After subsequent review by an emergency care physician, only 12 (2.7%) athletes required further referral to cardiology for assessment or further testing. All athletes referred for cardiology assessment were cleared for participation, except for one, who was eventually cleared after a shared decision-making process and cardiovascular intervention. The Queen's University Cardiovascular Screening and Care of Athletes Program shows the successful implementation of a cardiovascular PPS program that used shared decision-making and a multidisciplinary approach to screening, allowing for efficiency and effective resource utilization.

Point-of-Care Ultrasound as a Component of Preparticipation Screening of Athletes: A Systematic Review.

This review examined whether the addition of point-of-care ultrasound (POCUS) to electrocardiography (ECG)-inclusive preparticipation screening strategies has the potential to reduce false-positive results and detect diseases associated with sudden cardiac death that may not be identified through current modalities. Five studies, representing 2646 athletes, demonstrated that ECG-inclusive preparticipation screening strategies resulted in positive results in 19.9% of the cohort. With the addition of POCUS, positive results were reduced to 4.9%, and 1 additional condition potentially associated with sudden cardiac death was identified. The magnitude of positive results with POCUS may be reduced if current ECG criteria were applied.

Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes.

Sudden cardiac death (SCD), especially in a young seemingly healthy individual, is a tragic and highly publicized event, which is often followed by a strong emotional reaction from the public and medical community." Although rare, SCD in the young is devastating to families and communities, underpinning our society's desire to avoid any circumstances predisposing to the loss of human life during exertion. The Canadian Cardiovascular Society Position Statement on the cardiovascular screening of athletes provides evidence-based recommendations for Canadian sporting organizations and institutions with a focus on the role of routine electrocardiogram (ECG) screening in preventing SCD. We recommend that the cardiac screening and care of athletes within the Canadian health care model comprise a sequential (tiered) approach to the identification of cardiac risk, emphasizing the limitations of screening, the importance of shared decision-making when cardiac conditions are diagnosed, and the creation of policies and procedures for the management of emergencies in sport settings. Thus, we recommend against the routine (first-line or blanket mass performance of ECG) performance of a 12-lead ECG for the initial cardiovascular screening of competitive athletes. Organization/athlete-centred cardiovascular screening and care of athletes program is recommended. Such screening should occur in the context of a consistent, systematic approach to cardiovascular screening and care that provides: assessment, appropriate investigations, interpretation, management, counselling, and follow-up. The recommendations presented comprise a tiered framework that allows institutions some choice as to program creation.

Feasibility and Reliability of Nonexpert POCUS for Cardiovascular Preparticipation Screening of Varsity Athletes: The SHARP Protocol.

BACKGROUND: Point of care ultrasound (POCUS) is a potential adjunctive cardiovascular preparticipation screening modality for young competitive athletes. A novel cardiac POCUS screening protocol, Screening the Heart of the Athlete Research Program (SHARP), was developed for nonexpert examiners to assess common structural etiologies associated with sudden cardiac arrest/death (SCA/D). METHODS: Assessment of primary outcomes of feasibility, and reliability of obtained measurements, performed by comparison to formal transthoracic echocardiogram was undertaken. Inter-rater reliability was based on Intraclass correlation coefficients (ICC) defined as moderate for 0.40 to 0.59, good for 0.60 to 0.79, and excellent for 0.80 or greater. Electrocardiograms (ECGs) were also obtained. Identification of disease or other abnormalities was a secondary outcome. RESULTS: Fifty varsity athletes at our institution underwent the SHARP protocol, with 19 undergoing formal transthoracic echocardiogram and ECG for comparison. POCUS image quality was good to excellent. Feasibility of assessing for hypertrophic cardiomyopathy, aortic root dilatation, and left-ventricular function was deemed highly possible but limited in 20% for right-ventricular assessment. Reliability was good for measurements of interventricular septal thickness (0.67), end diastolic left-ventricular diameter (0.61), aortic root diameter (0.63), and moderate for left-ventricular posterior wall thickness (0.42). No cardiovascular abnormalities were detected. CONCLUSIONS: A novel, comprehensive SHARP POCUS protocol performed by nonexpert practitioners demonstrated feasibility and reliability to assess varsity level athletes for common structural etiologies associated with SCA/D. Further large athlete screening cohort studies are required to validate the SHARP protocol and the role of cardiac POCUS as a screening modality.

Variation in Preparticipation Screening Medical Questionnaires and Physical Examinations Across Canadian Universities.

Pre-participation screening of athletes to prevent sudden cardiac arrest or death is endorsed by international guidelines. Standardized histories and physical examinations are recommended to optimize effectiveness. To assess current screening practices across Canada in the university athlete population, we sought to analyze the preparticipation screening form of all universities. A comparative analysis to recommendations from the American Heart Association (AHA), European Society of Cardiology (ESC), and the Preparticipation Physical Evaluation (PPE-4) was conducted. Pre-participation forms from 30 of 56 U Sports universities were obtained. Adherence to published guidelines was highly variable. Ten percent strictly followed any of the 3 guideline recommendations, and only 43% contained at least 75% of the recommended items. Average percentage adherence to AHA and ESC guidelines was statistically significantly higher than adherence to the PPE-4 (62.2% and 66.1%, respectively, vs 52.7%, P < 0.001). Family history of common cardiac conditions predisposing athletes to sudden cardiac death and family history of sudden or unexpected death was omitted in 80% and 30% of forms, respectively. Recommendations for examining for stigmata of Marfan syndrome and assessment of femoral pulses was absent on more than 70% of forms. Although there is great controversy regarding the benefits and impact of screening, our results suggest that Canadian universities are conducting pre-participation screening although in a highly variable manner. Incomplete and variable screening questionnaires employed by Canadian universities may negatively affect the potential to identify athletes with underlying disease. We recommend that, if pre-participation screening is performed, a guideline-based questionnaire be used to optimize accuracy.

Current Practices and Attitudes of Canadian Team Physicians Toward Cardiovascular Preparticipation Screening.

To determine the current cardiovascular preparticipation screening practices and attitudes of team physicians for Canadian University and Major Junior Hockey Athletes, a 13-question survey was distributed to lead physicians of each organization. The response rate was 47% (48% [27 of 56] for the Canadian Interuniversity Sport and 55% [11 of 20] for the Ontario Hockey League). Ninety-two percent of physicians reported some form of preparticipation screening, with 22% currently using 12-lead electrocardiogram. Substantial inter- and intraorganization variability existed. Physicians not performing electrocardiogram screening reported lack of evidence (45%) and lack of cost-effectiveness (28%) as their rationale. To our knowledge, this is the first study to investigate Canadian athletic screening practices, and highlights the need for national guidelines.