Systematic echocardiography is not efficacious when screening an ethnically diverse cohort of athletes in West Asia

BACKGROUND

The clinical and economic value of including systematic echocardiography (ECHO) alongside the 12-lead electrocardiograpm (ECG) when undertaking pre-participation screening in athletes has not been examined, yet several sporting organistations recommend its inclusion.

DESIGN

To examine the efficacy of systematic ECHO alongside the ECG, to identify sudden cardiac death (SCD) disease and to provide a cost-analysis of a government-funded pre-participation screening programme.

METHODS

A total 1628 athletes presented for cardiological consultation, ECG, and ECHO as standard, with further cardiac examinations performed if necessary to confirm or exclude pathology. The efficacy of systematic ECHO was compared to an ECG-led programme, with ECHO reserved as a follow-up examination.

RESULTS

To screen 1628 athletes with ECG and ECHO cost US$743,996. There were 54 24-h-blood pressure/ECG Holter recordings, 62 exercise tests, 25 CMRs, two electrophysiological studies, and two genetic tests, which cost US$67,734: total US$811,730. Eight athletes (0.5%) were identified with hypertrophic cardiomyopathy (HCM) and two (0.1%) with Wolff-Parkinson-White syndrome. The cost per identifed athlete was US$81,173. All 10 athletes presented an abnormal ECG. No athlete diagnosed with HCM was identified by ECHO in isolation. When adopting a ECG-led screening protocol, 15% of athletes required ECHO as a follow-up examination, resulting in a US$380,600 cost reduction (47% saving), with the cost per diagnosis reduced to US$43,113.

CONCLUSIONS

Athletes diagnosed with a disease associated with SCD were identified via an abnormal ECG and/or physical examination, personal symptoms, or family history. Screening athletes with systematic ECHO is not economically or clinically effective.

Significance of deep T-wave inversions in asymptomatic athletes with normal cardiovascular examinations: practical solutions for managing the diagnostic conundrum

Preparticipation screening programmes for underlying cardiac pathologies are now commonplace for many international sporting organisations. However, providing medical clearance for an asymptomatic athlete without a family history of sudden cardiac death (SCD) is especially challenging when the athlete demonstrates particularly abnormal repolarisation patterns, highly suggestive of an inherited cardiomyopathy or channelopathy. Deep T-wave inversions of ≥ 2 contiguous anterior or lateral leads (but not aVR, and III) are of major concern for sports cardiologists who advise referring team physicians, as these ECG alterations are a recognised manifestation of hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC). Subsequently, inverted T-waves may represent the first and only sign of an inherited heart muscle disease, in the absence of any other features and before structural changes in the heart can be detected. However, to date, there remains little evidence that deep T-wave inversions are always pathognomonic of either a cardiomyopathy or an ion channel disorder in an asymptomatic athlete following long-term follow-up. This paper aims to provide a systematic review of the prevalence of T-wave inversion in athletes and examine T-wave inversion and its relationship to structural heart disease, notably HCM and ARVC with a view to identify young athletes at risk of SCD during sport. Finally, the review proposes clinical management pathways (including genetic testing) for asymptomatic athletes demonstrating significant T-wave inversion with structurally normal hearts.

Do big athletes have big hearts? Impact of extreme anthropometry upon cardiac hypertrophy in professional male athletes

AIM

Differentiating physiological cardiac hypertrophy from pathology is challenging when the athlete presents with extreme anthropometry. While upper normal limits exist for maximal left ventricular (LV) wall thickness (14 mm) and LV internal diameter in diastole (LVIDd, 65 mm), it is unknown if these limits are applicable to athletes with a body surface area (BSA) >2.3 m(2).

PURPOSE

To investigate cardiac structure in professional male athletes with a BSA>2.3 m(2), and to assess the validity of established upper normal limits for physiological cardiac hypertrophy.

METHODS

836 asymptomatic athletes without a family history of sudden death underwent ECG and echocardiographic screening. Athletes were grouped according to BSA (Group 1, BSA>2.3 m(2), n=100; Group 2, 2-2.29 m(2), n=244; Group 3, <1.99 m(2), n=492).

RESULTS

There was strong linear relationship between BSA and LV dimensions; yet no athlete with a normal ECG presented a maximal wall thickness and LVIDd greater than 13 and 65 mm, respectively. In Group 3 athletes, Black African ethnicity was associated with larger cardiac dimensions than either Caucasian or West Asian ethnicity. Three athletes were diagnosed with a cardiomyopathy (0.4% prevalence); with two athletes presenting a maximal wall thickness >13 mm, but in combination with an abnormal ECG suspicious of an inherited cardiac disease.

CONCLUSION

Regardless of extreme anthropometry, established upper limits for physiological cardiac hypertrophy of 14 mm for maximal wall thickness and 65 mm for LVIDd are clinically appropriate for all athletes. However, the abnormal ECG is key to diagnosis and guides follow-up, particularly when cardiac dimensions are within accepted limits.

[Sirolimus-eluting stent in the prevention of restenosis in small coronary arteries]

BACKGROUND

Angioplasty of coronary arteries with a small diameter (commonly defined as diameter inferior than 2.75 mm) is associated with a high rate of restenosis and revascularization. Since the use of Drug Eluting Stents (DES) and considering their good results on simple lesions compared to other techniques (balloon dilation and bare metal stents), many studies have also demonstrated the superiority of DES in reducing restenosis and revascularization of complex lesions in particular lesions on coronary arteries with small diameter.

AIM

Assessment of this revascularization procedure.

METHODS

Our study is a prospective one carried on between june 2002 and august 2006, involving a cohort of 299 patients. Patients are divided into 2 groups: group I: 175 patients with 220 lesions on coronary arteries with small diameter treated by 233 sirolimus DES (Cypher) and group II: 124 patients treated by 136 angioplasty of coronary arteries with diameter superior than 2.75 mm using 179 DES.

RESULTS

During hospitalisation, there was no significant difference in MACE between the 2 groups. Nevertheless, 2 patients among the first group had no angioplasty because of unsuccessful progression of the balloon through the lesion and the absence of atherectomy in our center. All patients having acute thrombosis during hospitalization and presenting with ST elevated acute coronary syndrome had successful urgent revascularization with TIMI 3 flow. The mid-term follow-up (12 months) concerned 157/174 patients in group I and 113/123 patients in group II. We observed a higher mortality and non fatal myocardial infarction in group I without statistically significant difference.

CONCLUSION

despite the complexity of the lesions on coronary arteries with small diameter and despite the association with several risk factors in particular diabetes, the use of DES reduces the MACE specially secondary revascularisations thus improving early and midterm prognosis.

[Endo arterial investigation: suspicious for the cholesterol crystal embolism disease]

BACKGROUND

Cholesterol crystal embolism (CCE) is a rare disorder which can complicate cardiac catheterization, angiographic studies and cardiovascular surgery. The CCE exposes to a great risk of renal failure and it can even threaten life by means of a multi visceral failing syndrome.

AIM

Report a new case of CCE following cardiac catheterization.

CASE

We report the observation of a 63-year-old patient who had a coronary angiography via the right femoral artery after a myocardial infarction. This examination has showed a multi-vessel coronary disease. 15 days later, the patient presented purplish and painful discoloration of his toes. The laboratory findings showed a mild inflammatory syndrome and eosinophilia at 700 / microL. There was not a renal dysfunction nor proteinuria nor hematuria. We performed a skin biopsy and made the diagnosis of CCE. Trans oesophageal echography objectified an irregular atherosclerotic plaque in the isthmic aorta. The CT scan revealed a spindle-shaped aneurysm in the end of the abdominal aorta. This aneurysm contains a marginal surrounding thrombosis with high embolic risk. The patient was put under clopidogrel, enoxaparin, simvastatin, colchicine and atenolol and operated successfully.

CONCLUSION

The two particularities of this observation are, on one hand, the absence of a renal involvement, which represents the main prognostic factor of the CCE. On the other hand, the CCE has revealed a very unstable aneurysm of the aorta which could be complicated during the cardiac catheterisation. The CCE is a difficult diagnosis that must be remembered before any cardiac catheterisation, because it often reflects unstable aortic atherosclerotic lesions.

[Chronic heart failure: role of Doppler echocardiography in the evaluation of mortality risk]

BACKGROUND

Chronic heart failure (CHF) is a major cause of morbidity and mortality. Despite recent improvements in the management of this condition, the overall prognosis remains poor. Echocardiography is the most useful test in the evaluation of systolic and diastolic function and has also a prognostic value.

AIM

The aim of this study is to determine echocardiographic predictors of mortality in patients with CHF.

METHODS

We followed 100 patients with a diagnosis of CHF over an average period of 44+/-40.5 months. We compared echocardiographic parameters in survivors and non survivors.

RESULTS

Four variables predicted death: LVEF <35% (p=0.001), TDE <150ms (p=0.001), E/A ratio >2 (p=0.05) and E/Ea ratio >10 (p=0.008).

CONCLUSION

Doppler echocardiography has a central role in the evaluation of patients with CHF. It provides valuable prognostic information by combination of several parameters.

[Influence of sex on immediate and late results of percutaneous coronary angioplasty]

Prior studies have reported worse results after percutaneous transluminal coronary angioplasty (PTCA) in women than in men. However, recent data suggest that this difference is less marked. The aim of our study is to evaluate whether the procedural outcome is equal in the two genders. Six hundred and eighty-eight PTCA were studied in 96 consecutive women and 509 men who underwent the procedure in our catheterization laboratory between 1998 and 2004. Women undergoing PTCA were older than men and had a higher incidence of diabetes, hypercholesterolemia and hypertension. Multivessel disease and severe coronary lesions were more frequent in women. The stenting rates, the use of drug eluting stents and of glycoprotein IIbIIIa inhibitors were similar in the two sexes. Procedural success rate was similar in the two groups. No significant differences were found in in-hospital mortality and in the resort to emergency coronary artery bypass grafting (CABG). 14 month after the procedure there were similar rates of death, repeated revascularisation and restenosis have been shown in the two sexes. Even if the baseline characteristics remain worse in women, increased experience of the operators, introduction of new stents and use of glycoprotein IIIbIIa inhibitors have improved the results in patients undergoing PTCA. This improvement has been higher in women than in men leading to the equalization of the outcome in the two sexes.

[Asymptomatic cor triatriatum sinister in adulthood]

Cor triatrium sinister is a rare congenital disease (0,1% of cases of congenital heart disease). Cor triatrium is recognized by the finding of an abnormal fibromuscular membrane that subdivise the left atrium into posterosuperior and anteroinferor chambers. This anomaly creates an obstacle to the venous pulmonary flow. Depending on the severity of obstruction, cor triatrium may be symptomatic in childhood but it can be symtom free even in adulthood. Diagnosis of this abnormality has been easy supported by transthoracic and transoesophageal echocardiography.Treatment is easy to perform and consists in surgical defenitive correction in symptomatic patients. We report a case of a 31-year-old man in whom a non obstructive cor triatrium was discovered while evaluation for an atrial fibrillation secondary to a hyperthyroidism. According to this rare case we try to evaluate the severity and the outcome of this disease relating the literature data.