Author + information
- Paolo Angelini, MD∗ (, )
- Benjamin Y. Cheong, MD,
- Veronica V. Lenge De Rosen, MD,
- J. Alberto Lopez, MD,
- Carlo Uribe, MD,
- Anthony H. Masso, PhD,
- Syed W. Ali, BSc,
- Barry R. Davis, MD, PhD,
- Raja Muthupillai, PhD and
- James T. Willerson, MD
- ↵∗Department of Cardiology, Texas Heart Institute, 6624 Fannin Street, Suite 2780, Houston, Texas 77030
Improving screening of candidates for participation in sports requires accurate methods of identifying high-risk cardiovascular conditions (hr-CVCs) that predispose young people to sudden cardiac death (SCD). Most sports-related SCDs are potentially preventable if recognized before an adverse occurrence. However, most experts agree that history and physical examination capture no more than 5% of the hr-CVCs capable of causing SCD (1,2). In contrast, electrocardiography (ECG) can capture some hr-CVCs, but it cannot accurately identify coronary anomalies (3,4) or some cardiomyopathies (CMPs). Therefore, in a pilot study of a potentially more accurate screening method, we attempted to estimate the prevalence of hr-CVCs in young people by using a screening protocol that involved a questionnaire, resting electrocardiogram, and cardiac magnetic resonance imaging (MRI). Specific clinical markers for possible high-risk CMP in this population (which are different from those in adults’ hearts) are not currently available.
The study was approved by an institutional review board. Volunteers (n = 5,255, mean 13.1 years of age, range 11 to 18 years of age, 54% male) from a general population of middle and high school students were screened to identify primarily 3 types of hr-CVC: ECG abnormalities, CMPs, and anomalous coronary artery origin from the opposite sinus with intramural coronary course (ACAOS) (the only coronary anomalies recognized as a cause of SCD in military recruits ). The MRI data, obtained with a mobile 1.5-T scanner without sedation or contrast agents, were used to determine left ventricular structure and to locate precisely the coronary ostia and proximal course. We aimed to establish normal ranges for left ventricular dimensions and mass according to sex, age, race, and body surface area, to identify quantitative markers for normality (i.e., mean ± 1 or 2 SD) and of probable “high-risk” dilated and hypertrophic CMPs. The data were systematically reviewed by 1 electrophysiologist and 2 cardio-radiologists and evaluated by experienced cardiologists to determine whether the findings indicated the need for expert secondary evaluation for probable hr-CVC.
Means and percentages for participants’ baseline characteristics were computed. The prevalences (with 95% confidence intervals) of the various hr-CVCs were calculated as the number of participants with the condition divided by the net study sample size. Associations of symptoms and ECG abnormalities with demographic characteristics and with MRI findings of hr-CVCs were tested with chi-square tests or the Fisher exact test; Student's t-tests were used to compare means.
From 5,243 completed, diagnostic-quality studies, screening identified 70 (1.34%) cases of hr-CVC (Table 1): 11 (16% of all hr-CVCs) dilated CMPs, 3 (4%) hypertrophic CMPs (all nonobstructive), 23 (33%) cases of ACAOS-IM (6 [9%] left ACAOS; 17 [24%] right ACAOS), 3 (4%) Wolff-Parkinson-White patterns, 29 (41%) cases of prolonged QT interval (>470 ms), and 1 (1%) Brugada pattern. Surprisingly, 982 cases of left ventricular noncompaction (in 18.7% of the total cohort) were identified by their distinctive double-layer architecture and >2.3 ratio of noncompact-to-compact myocardial thickness (the Petersen criteria). Currently, this anomaly is not considered by itself to be an hr-CVC.
The rate of self-reported symptoms did not differ significantly between participants identified as having hr-CVC (16 of 70; 22.9%) and participants without hr-CVC (926 of 5,173, or 17.9%; p = 0.28). In addition, among 1,486 (28.3%) participants found to have (mild) ECG abnormalities (chiefly left and right ventricular hypertrophy, identified by voltage), none was identified as having structural hr-CVC at MRI screening.
Our findings suggest that approximately 1.3% of young people (10 to 18 years of age) have hr-CVCs that may pose a risk of SCD during sports. In this study of adolescents, ECG did not detect any abnormalities (including changes in the T waves) in participants found by MRI to have coronary artery anomalies or CMPs, suggesting a significant potential for false negative findings with ECG alone.
If sports and exercise are to be promoted for good health, reliable screening should be recognized as a condition of endorsing and safely engaging in them. Among young candidates for athletic activity, an MRI-based screening protocol could accurately identify potentially deadly abnormalities, allowing pre-selected selective secondary evaluation by appropriate subspecialists.
Please note: Portions of the data described in this article were presented at the Annual Scientific Session of the American College of Cardiology, Washington, DC, March 17–19, 2017. Funding for this study (also called “Screen to Prevent,” S2P) was generously supplied by the Kinder Foundation, the Brown Foundation, and the Texas Heart Institute’s general funds). All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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