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Pre-participation ECG screening in military recruits- the IDF experience

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Pre-participation ECG screening in military recruits- the IDF experience Alon Grossman M.D MHA1, 2, 3, Alex Prokupetz MHA1, 2, Igor Lipchenca MD 4 – PowerPoint PPT presentation

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Title: Pre-participation ECG screening in military recruits- the IDF experience


1
Pre-participation ECG screening in military
recruits- the IDF experience
  • Alon Grossman M.D MHA1, 2, 3, Alex Prokupetz
    MHA1, 2, Igor Lipchenca MD 4
  • IAF aero medical center, Tel Hashomer, Israel
  • IDF medical corps
  • Department of Internal Medicine E, Rabin Medical
    Center Beilinson Campus affiliated to Tel Aviv
    University Sackler Medical School, Israel
  • Leviev Heart Center, Sheba Medical Center and Tel
    Aviv University, Tel Hashomer, Israel

2
Introduction
  • Despite the large numbers of athletes undergoing
    pre-participation screening, there is a
    continuing debate regarding the optimal method of
    screening
  • The main concern in performing mass ECG screening
    in athletes is the costly additional work up
    required based on resting ECG findings

3
Introduction
  • Professional guidelines in the US do not
    recommend use of either ECG or echocardiography
    for screening of college athletes1
  • On the other hand, 12-lead ECG has been supported
    for screening purposes among athletes by the
    Sport Cardiology section of the European society
    of Cardiology and Medical Commission of the
    International Olympic Committee and has been
    shown to reduce mortality in this population2
  • 1. Maron BJ, Thompson PD, Ackerman MJ, et al.
    Recommendations and considerations related to pre
    participation screening for cardiovascular
    abnormalities in competitive athletes 2007
    update a scientific statement from the American
    Heart Association Council on Nutrition, Physical
    Activity, and Metabolism endorsed by the
    American College of Cardiology Foundation.
    Circulation. 2007 1151643-1655
  • 2. Corrado D, Basso C, Pavei A, Michieli P,
    Schiavon M, Thiene G. Trends in sudden
    cardiovascular death in young competitive
    athletes after implementation of a
    pre-participation screening program. JAMA 2006
    29615931601

4
Background
  • Recruits to elite units in the IDF undergo
    pre-participation ECG prior their enlistment
  • This process has been performed sporadically in
    the last years but all ECGS are performed at the
    IAF aero medical Center since January 2010
  • All elite units candidates undergo a preliminary
    medical selection process at the IDF recruitment
    center (History PE)
  • Only those who are physically healthy are allowed
    to enlist to elite units and only they undergo
    pre-participation ECG
  • This population consists of 17-19 years old male
    subjects

5
Background
  • All ECGS are evaluated by a single cardiologist
  • Those requiring further evaluation, complete the
    evaluation prior to enlistment
  • A military physician from the IAF aero medical
    center summarizes the medical evaluation and
    decides whether the candidate is eligible to
    enlist to a special unit

6
Aims
  • To characterize causes of referral to continued
    investigation based on resting ECG findings
  • To summarize the additional work-up performed
  • To summarize the rate of significant findings
    resulting in disqualification of military
    candidates in this population

7
Results
  • 1,455 subjects underwent pre-participation ECG in
    the year 2010
  • 1,388 studies (95.39) interpreted as normal
  • 67 referred to further evaluation

8
Causes for referral
Number of cases ( of total findings) Definition Cause of referral
16 (23.9) Non specific T wave changes
14 (20.9) PR segment shorter than 120 milliseconds) with or without a delta wave Pre-excitation pattern
11 (16.4) S1R5,6 wave voltage greater than 35 mm in precordial leads and/or R-wave greater than 15 mm in peripheral lead I and/or 12 mm in aVL LVH
9 (13.4) Rates slower than 50 BPM Sinus bradycardia
6 (8.9) AV blocks of various degree, LBBB or RBBB, LAHB or LPHB Blocks
5(7.5) Atrial or ventricular premature beats
3 (4.5) upward ST-segment elevation in 2 or more peripheral or precordial leads, beginning from an elevated J point and continuing with an upsloping shape into the T-wave Early repolarization pattern
3 (4.5) corrected QT interval (QTc) greater than 440 milliseconds Long QT interval
9
Additional investigations
Adenosine test Holter Stress test Echo ECG finding
0 1 8 17 T wave changes
0 1 2 2 Early repolarization
0 2 2 1 Long QT
11 7 7 1 Pre excitation pattern
0 2 3 2 Atrial or ventricular premature beats
0 0 1 16 LVH
0 3 7 7 Blocks
0 6 8 0 Sinus bradycardia
11 22 38 46 Total
10
Clinical Diagnosis
Final diagnosis () ECG finding
BAV (1) VSD (1) LVH (1) T wave changes
LVH (1) Early repolarization
Dilated left ventricle (1) Atrial or ventricular premature beats
LVH (1) Non compacted apex (1) LVH
None Long QT, pre-excitation pattern, sinus bradycardia, blocks
7 Total number
11
example 1
12
Example 2
  • ICRBBB with non-specific T wave changes in
    inferior leads
  • Echocardiography interpreted as normal
  • No further w/u required

13
Example 3
  • Early repolarization pattern particularly in V2
  • Echocardiography-normal
  • No further w/u required

14
Discussion
  • Screening for cardiovascular disease among
    athletes and military candidates is imperative as
    sudden death is obviously tragic and potentially
    preventable
  • Debate continues regarding the optimal method of
    screening, this ranging from reliance solely on
    history and physical examination to performance
    of 12-lead ECG and echocardiography

15
Discussion
  • The total rate of ECGS defined as abnormal in
    this cohort was 4.6, a percentage much lower
    than previously reported
  • Yet, even in a previous report by Pellicia et al
    (8) in which 11.8 of ECGs were interpreted as
    abnormal, additional evaluation was requested in
    only 4.8 of ECGs, disregarding some of the
    findings noted on routine ECG
  • This rate is similar to that reported in this
    study and probably represents the true rate of
    ECG findings requiring further evaluation in
    young athletes
  • Corrado D, Basso C, Schiavon M, Thiene G.
    Screening for hypertrophic cardiomyopathy in
    young athletes. N Engl J Med 1998339 364369
  • Pelliccia A, Culasso F, Di Paolo FM, Accettura D,
    Cantore R, Castagna W, Ciacciarelli A, Costini G,
    Cuffari B, Drago E, Federici V, Gribaudo CG,
    Iacovelli G, Landolfi L, Menichetti G, Atzeni UO,
    Parisi A, Pizzi1 AR, Rosa M, Santelli F, Santilio
    F, Vagnini A, Casasco M, and Di Luigi L.
    Prevalence of abnormal electrocardiograms in a
    large, unselected population undergoing
    pre-participation cardiovascular screening. Eur
    Heart J 2007 28(16) 2006-2010.

16
T waves
  • T wave changes was the most common cause for
    continued investigation in the cohort
  • This is probably due to the non specific nature
    of this finding
  • Disqualifying findings were identified in 18.75
    of evaluations in these subjects
  • Whether these clinical findings were associated
    with the ECG findings or were incidental is
    unclear

17
PRE EXCITATION PATTERN
  • Signs of pre-excitation were identified in 14
    subjects who comprised 0.96 of the study
    population
  • This is a higher percentage than previously
    reported (0.2)
  • Probably resulted from the high awareness to this
    condition among interpreting cardiologists
  • No cases of pre-excitation syndrome identified
  • This is similar to a previous report from the
    Israeli air force
  • Ferrer MF. Electrocardiographic variations,
    arrhythmias, pacemakers. In Lew EA, Gajewski J.
    Medical Risks Trends in Mortality by age and
    time elapsed. New York, NY Praeger 1990.
  • Grossman A et al Use of adenosine test for the
    exclusion of pre-excitation syndrome in
    asymptomatic individuals. Ann Noninvasive
    Electrocardiol 2011 Apr 16 (2) 180-183.

18
LVH criteria
  • Signs of LVH were identified in only 7.56 of the
    study population
  • This is significantly lower than reported in
    previous studies (up to 45)
  • This is surprising given the young age of the
    population and the fact that the subjects were
    all very physically active
  • Disqualifying findings were identified in 18.2
    of these subjects
  • Pelliccia A et al Prevalence of abnormal
    electrocardiograms in a large, unselected
    population undergoing pre-participation
    cardiovascular screening. Eur Heart J 2007
    28(16) 2006-2010

19
LIMITATIONS
  • A selective cohort (healthy, physically active
    underwent ECG during screening for athletic
    activity)
  • Single physician interpreting all ECGS (high
    inter-observer variability reported in the
    literature)

20
Conclusions
  • T wave changes, although non-specific, may be a
    sign of cardiac disease
  • Pre-excitation pattern is of low specificity for
    the diagnosis of PES, but because of the lethal
    potential of this condition, adenosine should be
    performed in subjects with a suspicious pattern

21
Conclusions
  • ECG-LVH criteria have a low sensitivity in young
    subjects, but because of the fatal potential of
    HOCM and because the specificity of the ECG is
    very high, echocardiography should be performed
    to all those with ECG criteria
  • Policy makers should take into account the large
    number of echocardiographies that will be
    performed in order to identify subjects with true
    LVH

22
Conclusions
  • Sinus bradycardia and conduction disturbances
    (low degree AVB and hemiblocks) probably result
    from increased vagal tone and require no
    additional work-up

23
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