All right, good evening and welcome to the first AMSSM National Fellow Online Lecture of the Academic Year. This national lecture is brought to you by the AMSSM Online Fellows Education Subcommittee, which is also under the AMSSM Education and Fellowship Committee. Kind of our goals, you can see, is to serve as an adjunct to your individual program's educational programming, provide fellows with direct access to educational experiences with experienced AMSSM members, and at times, invited guests in a variety of formats, and also is to assist in CAQ exam preparation. A couple of rules that you might notice change in today's lectures, there will be no chat function, and unfortunately, we cannot take submitted questions. But I will ask you, as this goes live, please mute your devices' microphones and turn off your video. After the program, please complete the evaluation, which will be sent at the end of the lecture. So without further ado, I'd like to introduce you to the speaker for tonight, Dr. Brett Torsdall. Dr. Torsdall is a sports and family medicine physician at the Hospital for Special Surgery in New York City. He serves as an assistant attending physician and research director for the HSS Primary Care Sports Medicine Service. He is also a team physician for US Biathlon. He will give us a lecture on sudden cardiac arrest in athletes. Welcome, Dr. Torsdall. Thank you, thanks for having me. Appreciate the invite, and great job to everybody on that committee for putting these lectures together. I've enjoyed them so far, and I'm excited to be a part of this. I'm sorry I can't join you all live and do some Q&A with you. I'll be back in Montana, hopefully outside of cell phone and internet signal for a little while. But I appreciate the flexibility that we can record this ahead of time. Well, I can jump into it. So again, my name's Brett Torsdall. I'm originally from Montana, now out in New York at Hospital for Special Surgery, and have a clinical academic research interest in sports cardiology from my time at University of Washington, and I'm able to carry that forward and continue some of the work out here in New York. So what I'm gonna share with you is just an overview of sudden cardiac arrest in terms of identification, treatment, emergency planning, prevention. And I'll try to put this in context of what you've seen so far through the National Fellow Lecture Series. So back in August this past year, you heard from Jonathan Kim and Chad Asplund about cardiovascular screening, collapsed athletes, and then in September, John Dresner and Aaron Baggish spoke or presented on, Dr. Dresner described the international criteria for interpretation of ECG, and Aaron Baggish described structural heart diseases seen in athletes. So what I'm gonna be going through is more of when everything kind of coalesces into that event that we hope that none of us end up seeing, but if we recover enough events, there will be a day where somebody on the field, on the sideline will have a cardiac arrest, and you wanna make sure that it's not the first time that you've seen it in terms of videos and knowing what signs and symptoms to look out for and making sure that you've thought through time and again what you're gonna do in that event. So this goes back to the exercise paradox and how we think about exercise and sports having so many benefits for overall health, but in the short term, why is there this transient increase risk of arrhythmias and sudden cardiac arrest? And so the questions are how much exercise is too much and who's at risk? And the thing that's really underlying who's at risk is the questions about the relative and absolute increased risk of cardiac arrest with athletes with the various heart conditions. And unfortunately, a lot of that is just unknown. So this is the framework that I think about when thinking about sudden cardiac arrest and athletes who may be identified as having risk factors for sudden cardiac arrest. So when we're seeing an athlete as part of their screening or covering a game, everyone more or less looks like a healthy athlete in quotes, but underlying that could be some pretty serious heart conditions. So how do we get from a so-called healthy athlete to an athlete who's collapsed and unresponsive on the field? So this can go one of two ways. So one, this healthy athlete could in fact have a normal heart or they could have an abnormal heart just without any sort of symptoms or potentially symptoms that have not been recognized. Add in the stress of exercise and sport, this leads to an arrhythmia and sudden cardiac can occur. Following sudden cardiac arrest, the athlete either survives, should be a SCA survivor or sudden cardiac death. And so when we're thinking about how often sudden cardiac arrest and cardiac death occurs, we can look at the different instances based on different levels of play. So in high school athletes, often reports describe about one in 80,000 athletes per year will experience sudden cardiac arrest. In NCAA athletes, there have been some pretty robust studies with sudden cardiac death that have estimated one in 40,000 to one in 60,000 cases per year. However, it's very different between men and women and between different sports or contexts. So among male basketball players in the NCAA, the risk of sudden cardiac death is approximately one in 5,000. This counts for about 75% of fatalities during training or competition. Other circumstances where folks and fellows will be on the sidelines or covering an event where we need to be thinking about this is often with the mass event, mass events like a marathon. So with the marathon, it's estimated that one in 50,000 race participants will experience a sudden cardiac death. As I mentioned before, there's an increased risk among males compared to females. And when we think about these numbers, it's sometimes hard to know like what's the big picture here how important are these, what's the relative risk of sudden cardiac death versus other causes of death in young people. So the CDC has reports on various causes of death in folks age 15 to 24. This is some older data from 2013, but just in all comers, not specifically athletes, cardiac conditions represent only 4% of causes of sudden death or causes of death in young folks. But when it cardiac conditions for NCAA athletes, it's 15%. So quite a bit higher when we're looking at just athletes specifically. Thinking then again, what are the causes of death in athletes and how do heart conditions compare? There's a study from Mary Bowden who describes just a prevalence of fatalities among high school and college football players. And we're seeing that cardiac makes up a big portion of that supply. Corey Stringer Institute describes the four H's for cause of death during sports, heart, heat, head, hemoglobin, heart being one of the most common. So now that we've gone through a bit of the incidents and the context of what's going on, let's jump into just a brief review of some of the pathophysiology. And this goes back to, wanna make sure people reference back some of the prior lectures from Aaron Vegas, John Dresner describing the arrhythmias, the structural heart conditions, but just as a brief review. For a normal heart, these are the ways that you could potentially end up with a cardiac arrest. So commotio cortis, that's where there's the direct impact to the chest wall that can cause an arrhythmia if it occurs at a specific point in the heart cycle. So it's in this repolarization phase of the cycle that seems to be the time at which there is just the right kind of impact in just the wrong place. Cardiac arrest can occur. Typically it occurs in younger athletes who have a more pliable chest wall, most often in boys more than girls. The other thing that can happen in older age and is definitely on the minds of a lot of team physicians is myocarditis. That's even pre-COVID was known to be a cause of sudden cardiac arrest in some cases. Substance use is one of the other ways that an athlete can go from having a perfectly normal heart at the time of their PPE to subsequently having a sudden cardiac arrest during sport. In terms of the different causes of an abnormal heart, it varies by age. So we're talking about older athletes, those over age 35. The majority of these cases are coronary artery disease. Much of the discussion is looking at high school, college aged athletes and the types of underlying conditions that can predispose athletes to having a cardiac arrest are quite varied. There's a lot of debate. Folks may have seen this figure before, but it's looking at different populations of athletes, different registries that are used to try to determine what are the main causes of structural electrical heart disease that could predispose an athlete to a cardiac arrest. So this upper left is in the U.S. where we're seeing hypertrophic cardiomyopathy is commonly reported as the most common cause of most common underlying cause for an athlete experiencing a sudden cardiac arrest. Whereas in Italy, the upper right, we're looking at ARVC as seen more commonly there. Again, there's some debate whether some of these populations are looking for it more and finding it more, or if there's differences in screening strategies that are seen in the distributions of these different pathophysiologies. But at the end of the day, it's important to be aware of the different causes and we can dive deeper into that at another time, but it's important just to recognize the different symptoms and the other screening data points that you'll be looking for to identify athletes at risk, and then collaborating with some of the cardiologists that may be on your medical support team to identify exactly what's the cause of these underlying conditions. So certainly not expected at the end of fellowship to be able to kind of know all the ins and outs of every different condition known to cause sudden cardiac arrest, but important to know the big categories of electrical and structural, and some of the signs and symptoms that you would be looking for on a screening exam. What I wanna focus a lot of the discussion on today is what to do in the case of a sudden cardiac arrest, the recognition, the treatment, and how to plan for it. So all of the treatment for a sudden cardiac arrest is really dependent on being able to recognize that this collapsed athlete is experiencing a sudden cardiac arrest and not something else. So many times, talking with schools, athletic directors, coaches, as part of some prior research, the challenges that people would run into in terms of not providing that early treatment was that it was not quickly recognized as a sudden cardiac arrest. Folks would think it was seizure. Maybe they are just passed out from heat or strenuous exercise, but often the symptoms and the signs, the signs that an athlete experiencing a cardiac arrest will exhibit don't necessarily look like the textbook collapse of an athlete falling down and remaining motionless and completely unresponsive. There's often times where folks will experience different moments of looking like they're regaining consciousness then becoming unconscious again or having some movements of their arms or legs that make you think that they're awake. They may be breathing these agonal breaths that may seem to give you a sense that they are experiencing some other cause of being collapsed rather than a cardiac arrest. So when it comes to treating sudden cardiac arrest, it really requires having that high level of suspicion for any sort of non-contact collapse that even if you go out onto the field or wherever you're assessing an athlete, making sure that it's high in your differential of what's going on and not being coming to a reassured or crossing out off too quickly. If you're feeling like you may be feeling a pulse or they may be breathing or they may be somewhat responsive, they're making some noise. They may be vocalizing a little bit, but it's not necessarily something that there's a way that you can clearly rule out a sudden cardiac arrest. So agonal breathing, seizure-like activity, feeling like there might be a pulse, don't too quickly get off your sudden cardiac arrest pathway that should be always what you're initiating as your emergency action plan for treatment of sudden cardiac arrest if there is that collapsed athlete. So that's step one. So once you recognize the problem, then from there, it should be pretty straightforward that you want to start with the early CPR and emphasis on chest compressions, and then you want to get your AED available. So when you have an AED, oftentimes that will be on the sideline for certain events. Other times it may be installed on the wall. It's important wherever you're at during your fellowship year, folks who aren't in fellowship, if they're covering an event, you want to make sure that when you arrive at the venue, you know where that AED is, or who's carrying the AED and how to communicate to them so that you can get the AED to the athlete's side as soon as possible. The goal is within three to five minutes, really the sooner the better. And as soon as it's there, apply that AED and you can discontinue CPR as soon as you get that AED going. Once it's charging, as you're learning, as you learn the BLS, your CPR classes that you can resume CPR while the AED is charging, hands off for delivering the shock and then resuming CPR soon afterwards. The part of this chain of survival from American Heart Association is getting the athlete then to the ER as soon as possible. So sometimes kind of seen is the way that you can absorb the information better. There's a couple of great resources that I want to direct people to. So one is U.S. Soccer Recognized to Recover. So it goes through a simulation of a class athlete and how to do that on-field assessment, how to initiate CPR, apply the AED and what in a perfect scenario it would look like. The other one, as I mentioned a minute, is from NFL or from USA Football. This is one of the things that FIFA describes in there. Recognized to Recover is this sudden cardiac arrest signs and symptoms. So first observing that there's a non-contact collapse. If the player's unconscious, unresponsive breathing, they simply say here, ignore breathing. Ignore breathing signs, whether normal or abnormal or absent because a cardiac arrest could be occurring even if they appear to be breathing normal and then seizure, as we had talked about before. One of those things that arms and legs can move during a cardiac arrest, but again, that you don't want to too quickly assume that an athlete's having a seizure. The other one here is from USA Football, a familiar face for a lot of folks as John Dresner describing. Again, going through another scenario of what a cardiac looks like, what things to identify, what to recognize so that you can quickly start your emergency response and get the AED to the athlete as soon as possible. So those are just a couple of things to kind of write down. Remember to check out on YouTube so you can see it as well as just hear it, read it, make sure that when it happens, you know what to do. It becomes second nature. The other thing that I'd want to make sure every fellow has seen is the video of Hank Gowther's collapse obviously a tragic video and hard to watch knowing the outcome of Hank Gowther's collapse on the court when he was playing basketball in college. But it's a really kind of an iconic way of seeing how sudden cardiac arrest can look where he gets up and then collapses again. There's seizure-like movements in his arms and legs. So just really important that you take a look at this. And if you see something like this, it's not the first time seeing it in real life because if that were to happen today, we don't want to have another tragedy just because an athlete is presumed to have a seizure and only later is recognized that something else, something more serious is going on. And we're talking about timeframe to getting the defibrillator and how that affects outcome. We're looking at this figure that if you've gone through primary care training, residency training, you're probably gonna be familiar with it that the success for a resuscitation is time dependent on the delivery of defibrillation. So when it comes to AED effectiveness in the athletic setting, very similar in terms of what we're seeing so that if a school has an AED on site, the school is often able to provide, that AED is able to get to the athlete within the three to five minute timeframe. And one of our prior studies was able to show. However, if the school is dependent on calling 911, having the ambulance bring in the AED, that's where the EMS is often over 10 minutes away in terms of being able to get that AED to the athlete side. So really important in that case that if you are a team physician for a school or organization to just be an advocate to make sure that the correct supplies are available and that an AED is available at all times when whether it's a practice or a game that it's not locked in a nurse's cabinet somewhere in the school and is inaccessible after hours when practices are happening. It's important that these things are all figured out so that the AED is available to get there quickly. So talking about AEDs, let's do a little quiz of, is an AED available here or there? That's kind of like green eggs and ham. Would you like it here or there? So can you use an AED in the snow? I think because Mario you're the only one on the call today, I'm gonna have you unmute and see if you can guess how well you do with these. So- Yes, you can use it in the snow. Okay, good. Ice? Yes. Metal surface? Yes. Wet grass after rain? So again, you can, you just need to make sure you wipe off their chest. Good. Wet grass while raining? And again, you want them covered and wipe off the chest. Okay, yep. You can cover them or protect them from the rain, that's best. Standing water, I gave you that. Move them. Move them, yep. Pacemaker? Use an alternate site. Yeah, but you can still use it. An implantable defibrillator that apparently has not functioned. And then that should be yes as well, right? Medication patch? Less likely. Yeah, just don't put it over the patch. Yep, there you go. All right. All right, 100%, A plus. All right, that's the only quiz I'll give you today. So return to play. This is often a bigger discussion and it's more condition dependent. So this is once you get through the treatment, the recognition, the treatment phase, what do you then do with your athletes that are now recovered from a cardiac arrest and getting them back to play? So again, it really just goes back into each of the underlying condition for the cause of their cardiac arrest. This also parallels a lot of the discussion of when you identify an athlete who has an underlying heart condition associated with cardiac arrest, what's your clearance protocol and can they be cleared? So there are some expert guidelines that you can reference from AHA, ACC. The most recent ones are the 2015 ones that you can pull up and read about for those specific diagnoses that you can probably not be navigating these things as an independent primary care sports medicine physician, but it's good to know the literature when you're working with a cardiologist or working with your larger medical network for caring for these teams. So just to make sure that you have this referenced. But in terms of some specific conditions, folks with Wolf-Parkinson-White syndrome, there are high versus low-risk pathways that often are important for determining who would be eligible for an ablation and potential return to play after an ablation or who with a low-risk pathway can simply return to play without needing an ablation depending on symptoms. Long QT syndrome, there are sports that are possible with beta blocker use and there are registries of athletes with long QT syndrome that have shown good outcomes with compliance with beta blocker use in terms of not having episodes or subsequent episodes of cardiac arrest. And then with implanted defibrillators, there are recommendations against certain sports with playing with the defibrillator, specifically those with contact sports who may risk injury to the limbs. However, there are some athletes who despite these recommendations may opt to continue playing in their preferred sport. And there are ongoing studies to look at the outcomes. And there have been so far, last I looked, no reported deaths. There could be some updated information there, but as far as implanted defibrillators, many athletes are able to return to some level of competition. Terms of prevention, so we talked about treatment, but when we're thinking about preventing a sudden cardiac death, there's really two ways to do that. The first step is to prepare for sudden cardiac arrest. So you're not necessarily preventing the cardiac arrest itself, but you're preventing a cardiac death. So that's your emergency action plan. Step two is identifying athletes at risk for sudden cardiac arrest, and that's done through screening. So of these two steps, I think a lot of us kind of gravitate towards step two because that seems like the more standard way of preventing, if you could prevent an athlete from ever experiencing a cardiac arrest, that is wonderful. But in terms of just the order of importance, because as identifying all athletes at risk for sudden cardiac arrest is not possible, the first step that you always wanna do as a team physician, an event or a medical director of an event, you wanna make sure that you have step one clearly planned for so you have your emergency action plan in place, and then you can then focus on what can you do to identify athletes that are potentially at risk for cardiac arrest. So emergency planning, this is important for every school, competition venue, practice facility that you are affiliated with. So you wanna have an emergency action plan that outlines exactly what's gonna be done in the event of a possible cardiac arrest, and also what needs to be done to make sure that the right equipment is available and people know how to run an emergency response. So these are the different elements that are important for your emergency action plan. So you wanna have it coordinated within your local emergency medical system. So that means that you share your emergency action plan with the local EMS, that if you're having EMS on site, that they know what resources you have available. So say you're covering a game and you have an ambulance there, you wanna make sure that you know what they're bringing and they know what you have in the training and making sure that those two things are integrated. It also can be helpful that if you have the AED available, may not necessarily be known to everybody on site, but if you could say a visitor or spectator who's there and witnesses a cardiac arrest occurring outside of the venue or the field of play, if they call 911, if the 911 operator's aware of a defibrillator on site, they would be able to help get that, an onsite defibrillator there sooner. So there are different ways to help coordinate that with EMS. And so that's an important aspect of an emergency action plan. Communication system is critical. You wanna be able to make sure that key personnel for any event are able to stay in close contact, close communication. So if there's, this is things from people who are on the field to the people who are on the sidelines. So if somebody runs out to evaluate a player who's down, that there's a way to communicate to the people on the sidelines or the EMS, who may be in a parked vehicle somewhere outside that their assistance is needed. So to be able to bring more people onto the field in the event of a collapsed athlete. Also being able to communicate to security or other venue personnel so that they can make sure that if ambulance, if more medical services are being sent, like another ambulance is coming, that they are able to meet the ambulance at a specific site or a driveway or a gate to help usher the ambulance in and ensure that it's cleared. So having communication in place ahead of time ensures that you can get the right kind of help when you need it. In terms of personnel, I wanna make sure you know ahead of time who's gonna be the point person for just maintaining the equipment. So who's responsible for an AED and who's checking to make sure it has a battery that works and pads that are still haven't expired and who's gonna be the person that coordinates the rehearsals of the emergency action plan, your emergency response, who needs to be trained in CPR in AED use. So that could be the coaches, that could be teachers, different support for a different staff for the team. And then when it comes to if an event occurs, who is that chain of command to help respond to it. In terms of the equipment, we've mentioned this many times, the AED is just the most critical part of your cardiac arrest treatment. So you wanna have it in place, figure out what's gonna be most effective for an installed versus portable device. So certainly an installed one makes it easy to find because people know where it's at at any time. A portable device can be really good to have if you have say a school with an offsite field where the logistics of getting back to the installed device and then taking it to the field would create an unreasonable delay. Then you would wanna make sure that you have both something installed in the school and then another defibrillator on the field or that the athletic trainers could take with them. Oftentimes at races, especially the big ones, you'll see that there'll be defibrillators in the AED stations, but also defibrillators with folks on bikes so that in between places where there's aid stations or ambulances along the course, there's somebody with a portable defibrillator that can get there quickly, potentially easier than any ambulance could. So figuring out how many AEDs you need and where to install them, which ones to have portable, all depends on the logistics, the layout of whatever event or venue you're working within. You wanna make sure that these are accessible at all times. You hear of situations where a school may spend a lot of money to get an AED. They're a couple of thousand dollars, they're not cheap. So they may want to try to make sure that it's, they don't lose that, that it doesn't get stolen. But in those cases, if it's locked up, you might as well not even have it because it's inaccessible and doesn't help in the case of a cardiac arrest. Always good to have extra pads, towels, scissors, razor, those kinds of equipments in the emergency response bag or supply kit with the AED. So those are the kind of equipment that you'll wanna have. So once you have your personnel that are identified, making sure somebody is responsible for that and checking in to make sure everything's working and in order. Transportation route, one other piece of the emergency action plan that you want to have laid out ahead of time. So this is often like a Google Earth type picture or can be just a diagram of where the athletes will be so that whether they are on the field of play or on the bench or in the locker room that at any point along there, you've thought of how an athlete could be, could go down and how would you get the equipment to the athlete so that you could respond to the athlete there, then in there. And then how are you gonna get the athlete to the hospital in an ambulance? So you don't wanna be having routes of transporting an athlete through spectators or things that are potentially gonna be blocked by media vehicles or other parking lots that get full. So having a very clear transportation route is going to save you the problems that can come where somebody may have gotten through the initial response and the treatment up to the point of getting into the ambulance. But as you saw in one of those chains of survival, one of them is immediate access to post to cardiac care in the hospital. And so that can get interrupted if you're now having to wait for gates to be opened or cars to be moved to get the athlete back to the hospital. And then all of this is important but it's pretty much worthless if nobody knows about it and nobody's practiced it. So what you need to do is make sure that everybody on the medical team and those other key personnel know what to do, know what the plan will be, and then rehearse that plan so that they can carry it out in the event of a cardiac arrest. Going to the other side of sudden cardiac arrest prevention now. So we're talking about screening. So you've put in place your emergency action plan. You have everything you need so that in the event of a cardiac arrest, you can respond quickly and effectively. So then what's the other part? So here we're talking about screening. So we're trying to identify athletes who may have underlying heart conditions that could put them at increased risk of cardiac arrest. Much of the conversation has gone back to this paper from Corrado in 2006 where it's describing the decrease in sudden cardiac death after implementing an ECG screening protocol. So we're seeing in these early years of this figure here where there is a screened athletes and unscreened athletes, sorry, unscreened non-athletes. So the solid line is the athletes in the population in Northern Italy where there was a higher risk of sudden cardiac death among the athletes and a lower risk among non-athletes, which is kind of what we expect anywhere. But they showed that after implementing this ECG program that the risk of cardiac death decreased over time and they attributed that to the implementation of the ECG screening program. And this study hasn't been replicated and there's some limitations to it, but it's something that does suggest that there's potential value in screening athletes with ECG beyond simply history and physical. So we'll go into a bit of the discussion about how to screen athletes and what are some of the challenges with screening athletes or the different elements of a screening program. So we're thinking about the screening or diagnostic tools. We should really kind of think about them all independent history and physical exam are just been more or less the standard for as long as people have been doing pre-participation evaluations. So finding out if there's any symptoms of cardiac conditions, family history of cardiac conditions, and this has been modified in various forms as people learn more about the underlying heart conditions, learn more about some of the symptoms that are more specific to those heart conditions. So trying to narrow the history taking a bit. So that is improving, but still limited in what you can learn from a history and an exam. For the exam that includes measuring blood pressure, rate rhythm, pulses, murmurs, MARF and stigmata. And with those two elements, that is what the American Heart Association recommends for screening athletes in the US. Beyond that, we're talking to resting electrocardiogram or ECG, and that's recommended by and utilized by other organizations. So FIFA, NFL, IOC, many others are incorporating resting ECG as part of their screening program. We can talk about why in a minute. Echocardiogram, exercise stress test, stress echo. The stress echoes are done in the NBA and WNBA and a few other leagues as well, but that is just taking it to one further level in a bit dependent on the resources available and the risk of the population as a whole. In general, the challenges for any sort of screening program for conditions like the cardiac conditions that predispose athletes to sudden cardiac arrest is in general, the low prevalence of the conditions. Some estimate one in 300 athletes will be carrying a diagnosis or having an underlying condition that could put them at risk for cardiac arrest. There's psychological impact of screening. What, how does it, what's the experience or what's the stress that an athlete experiences if they're told that they have some abnormality for which they need to undergo additional testing or maybe they have to undergo not only just additional testing in the moment, but also serial testing over years. How does that affect them mentally? And then there's still in many cases an unknown absolute risk of sudden cardiac arrest. So for every person with this one condition on an annual basis, what is their risk of cardiac arrest and how does that compare to other heart conditions or other medical conditions that may be putting them at risk with sports participation? Some conditions, they still are at risk of experiencing a cardiac arrest even without the external stress of sports or exercise. So we have to think about what's the added stress, what's the added risk of sports and exercise onto what would otherwise just be an elevator risk because they have this underlying condition. Sometimes it's difficult to really assess the effect of these screening interventions. In Italy, they had this kind of a closed population, a more universal ECG program that got implemented. But in reality, especially in the US, it's not so straightforward because we don't have necessarily a closed population of high school athletes or in colleges, it's a little bit different, but every school, every league is a little bit different in their screening strategies. And it's not always possible to be able to assess the effect of each separate screening protocol in terms of how does it affect the overall risk of cardiac arrest. And so it's challenging to then prove the effectiveness of these more advanced screening compared to PPE, but just because we're not necessarily able to see, to measure all those outcomes over the course of decades, there still is times where we can make a strong argument for using advanced screening in certain populations when resources and expertise allow. There's also issues of cost and access to some of these secondary tests. So whether you're screening with history and physical or ECG, there's gonna be abnormals that you're gonna find and those will all require additional testing to really determine if they are true abnormals. And so we think about these secondary tests or it's often discussed when we're talking about the advanced cardiac screening, but it's something that is really a part of any of the screening tests that we need to understand that when we do a screening test, additional tests may be needed for which a lot of those will end up being normal, reassuring, and not necessarily change the long-term prognosis for our athletes. With genetic testing, it can sometimes become quite complicated that all screening with various genetic testing is not the norm. There are situations where an athlete may have a family history where they have a genetic, a known genetic or a confirmed genetic cardiovascular condition. And if we test an athlete for that condition, what is known about them? What's the increased risk of cardiac arrest for them if they don't have any of the phenotype changes? So if their ECG is normal, if their echo is normal, what does it mean to have a positive genetic test? So that's one of these questions that's still not clear for some of the cardiac conditions. And thankfully, there's some very smart sports cardiology experts out there that can help us navigate those situations. Ultimately, that goes back to what's our role as team physicians? How much are we able to determine what is an acceptable or unacceptable risk to the athlete? So there's been a move generally to the role in medicine, not necessarily in sports medicine or team physician, as a team physician, but just as a shared decision-making that our role is to help educate patients, to let them know what their risks are, let them know what their treatment options are, and then in a shared decision-making model, allow the athletes to, or allow a patient to decide what's best for them in their life goals. It's a little bit different in the context of caring for a team, whether that's at a school or at a professional level, that there is a bit of liability that comes back to the organization if athletes with these underlying heart conditions are known and how much risk is an organization or a school willing to accept to allow these athletes to continue to play with what's known of their underlying heart condition. So certainly ethical challenges play a role when we're talking about screening. Breaking it down, some of the specific challenges for each of the different screening strategies for history. The problem here is that the majority of people who, majority of athletes who have underlying heart conditions don't actually have symptoms that can be directly attributed to those underlying heart conditions. Chest pain, palpitations, things like lightheadedness could be from asthma, could be from stress, anxiety. There's many other things that could contribute to what they perceive as cardiac symptoms. Family history sometimes is unknown. You may say like, you'll hear from an athlete that they have an uncle that died at a young age. You're not really sure, the athlete's not sure about their circumstances, or maybe they were told it was a heart problem. Maybe they were told that they just had a big heart, but you don't really know what that means. And so it's hard to necessarily know how much of that history affects the risk to the athlete that you're working with. In terms of the physical exam, there's been some interesting studies on murmur grade and quality that doesn't necessarily correlate with pathology. So I remember learning in pediatrics rotations that here's, these are the things that identify a pathologic murmur versus a benign murmur. And when it comes to screening an athlete, there's not necessarily black and white murmurs where these are all bad and these are all good. There's a lot of sounds that a heart can make that don't necessarily match up or don't necessarily indicate an underlying heart condition. And there's a lot of underlying heart conditions that don't make any murmurs. So we can't be too reassured or certain one way or the other simply based on what a heart sounds like. With ECG, this is an active debate. There's a lot of discussion points on either side of whether or not to use ECG when screening an athlete. So the challenge here is often differentiating it from athletic heart syndrome. So there's normal changes that can happen with a heart as it adapts to the stresses of sport and exercise. So you'll see different AV blocks. You'll see early repolarization, an incomplete right bundle. You'll see LVH, RVH, bivoltage criteria. All of these things are normal in athletes. And so some of the first criteria didn't do as well differentiating these athletic heart, these normal adaptations to exercise and stress from what's actually a true abnormal. So the false positive rate has changed over time and it's where each iteration is coming down. It does add an extra cost and there's requires not only the physical infrastructure of the equipment, but also the personnel infrastructure of having people who are trained at being able to interpret ECGs because although there are some devices that do a pretty good job at using the international consensus criteria to provide a computer interpretation to it, it does require a physician ovarian before a final determination of normal or abnormal ECG. Echo challenges here often involve differentiating from an athletic heart syndrome. So there's different changes that can happen that may be pathologic or may be borderline you don't really know until you either watch it over time or get additional information such as with a cardiac MRI. There are circumstances where an athlete may need to rest from training for a few months to allow the heart to detrain so that you can get a better sense of what's pathologic and what's physiologic in terms of changes in the heart shape and size. And that can become, can throw a big wrench into somebody's season or their career goals in sport. So that is certainly a risk or a challenge when it comes to screening with Echo. I mentioned previously the different false positive rates for the iterations of ECG criterion seen going back to 2010 with the European Society of Cardiology that was one of the first that reported that was used pretty high false positive rate 17 to 27%. And then each subsequent time that new criteria has been published seeing that false positive rate go down. And so with this international recommendations or consensus criteria, that's going to be the one from 2017 the false positive rate and some of the studies using that have been in the one to 2% range. So a really low false positive rate compared to things such as history and physical where the false positive rates quite a bit higher. At the end of the day, you have to make a decision if you are a team physician on how you're going to screen your athletes for cardiac conditions. So the AMSSM position statement on cardiovascular screening concluded this that it really should be a individual determination that when you're considering what to do for screening you have to consider the risk of sudden cardiac arrest or sudden cardiac death within that population. And what's your available infrastructure and cardiology resources. So for example, for what I'm working with the US Biathlon we've had an ECG machine that's just a Bluetooth machine that I use when screening the athletes. It costs nothing more than for me just to add in ECG tabs. I feel comfortable with the ECG criteria. I have folks I can lean on if I have any questions. It really requires a pretty low investment after that initial investment of the device to be able to maintain that type of screening program. So for me, looking at the risk of cardiac arrest even though there's not much published on Nordic skiing on biathlon and sudden cardiac arrest it is something that there is the available infrastructure and cardiology resources. So that regardless of that risk, I feel comfortable. I find that the risk benefit ratio is favors using an ECG in that setting. So that's the protocol that we've been using for the past seven years that I've been working with the team but it's different for different levels of play and different athletes. And so there are, this is just something that you can work through individually. You can lean on your fellowship faculty, other mentors to help you decide what's gonna be best for that team that you're working with or the athletes that you're working with. And then if you do end up going through the process of ECG screening program or any sort of screening program what you need to know is how are you going? Do you have the training to carry it forward? And then what's your plan? What's your plan if something is found to be abnormal? So even with the history and physical if that's how you plan to screen your athletes you wanna know what are you gonna do if you have a positive history or a positive physical exam do the athletes, how are you gonna get that testing set up quickly so that there's not a delay in getting the care that they need giving them the additional testing because the last thing you want to do is have something found that's abnormal at the start of the season. The expectation is that the athletes are supposed to be jumping right into a training camp. And if you are saying you're not clearing them for participation until you have these additional tests set up you wanna know how to get those set up quickly so that you can make sure that there's minimal time in terms of the stress and anxiety of getting the additional tests and then just their time out of play if you do end up finding that the whatever potential positive outcome from your screening is warrants that short-term restriction from athletics so that you can get more information. So things that you wanna kind of plan for steps one, two and three and make sure that you have a support team in place to get these athletes in quickly if needed. This was shared in one of the prior fellow lecture series. So definitely tune into the one from John Rosner where he described this in depth but just showing you here how these are the various characteristics of ECGs where you could be reassured if you see only findings in the green. If you have any of the borderline findings in the yellow, that middle box if you have two or more further workup is needed in one a single borderline ECG finding requires no additional testing and then the abnormal ECG findings on the right in red. So all of these require further workup. So that is the latest of the ECG interpretation. Going through a little bit of the more detailed definitions of each of these criterias in this slide here this is the borderline criterias left axis deviation, left atrial enlargement right axis deviation, atrial enlargement complete right bundle branch block would be in this one. And then this table here goes through the detailed definitions of all of the findings that are in the abnormal block where these all need to undergo additional testing. So lots of information out there. You can read about it. You can tune into the lecture from last fall or you can also do this the online eAcademy for this program. So this would, if you have more time especially if you're starting to work with the team and you may be the point person for interpreting ECGs definitely check this out. In the few minutes that we have remaining I just wanted to go through just a few of the kind of hot topic items with COVID-19 as that's always of interest when it comes to sports cardiology, sudden cardiac arrest and COVID-19. So just jumping into a few items here. This is what we're talking about with COVID-19 that there is myocarditis and seen in these cardiac MRI images. So when I, after reading a few, some of these papers and staring at these for a while to me it kind of looks like an Andy Warhol picture. And so thankfully we don't as primary care sports medicine physicians we don't have to be the ones that have to identify how much myocardial uptake on these cardiac MRIs is too much but it is important just to know what's out there. What's the discussion been over the past year in case you're as a fellow now if you were in the middle of a busy second and third year of residency this may be something where you weren't able to keep up with. So in terms of COVID-19 in general and the general population, not just in athletes it's known to be associated with a few different cardiac sequelae. So with myocardial injury, myocarditis hypoxic ischemic injury has been seen as well as stress cardiomyopathy has been seen following COVID. Typically these would be in more of the more severe cases of COVID where somebody is in the ICU. Arrhythmias are also seen associated with not only the structural, the myocardial injury but also electrolyte disturbances. And for a time when folks were being treated with azithromycin, hydroxychloroquine, antivirals sometimes those can cause arrhythmias. But when it comes to the prevalence of the myocardial injury, the arrhythmias these are most of the studies are coming the early studies were coming out of inpatients. So 20% of hospitalized patients were reported to have a myocardial injury, 17% with an arrhythmia. Those are both from early to mid 2020. So early on in the pandemic, but then in college athletes so this is the study that came out in September, 2020. So this was right at the start of the football season. And some of the folks who were involved in decision-making for college football were made aware of some of these results ahead of time. But in this study from Ohio State showed that in 26 athletes that they had that underwent cardiac MRI that some had mild symptoms of COVID, 15% had findings on cardiac MRI consistent with myocarditis, which two were symptomatic. And none of the other screening tests were abnormal that could identify athletes with possible myocarditis. So this was a little bit alarming at first that you couldn't use necessarily symptoms, ECG or lab tests to identify athletes with possible myocarditis. So there was a lot of headlines that came from this football seasons that were canceled, a lot of sports season that were canceled. I thought this was a good commentary from Sanjay Sharma in response to that article said, there was no control population, no normative data in athletes. Because there are some of these findings that were used to identify or define used for the diagnosis of myocarditis that could just be present in athletes in general, such as insert RV insertion point fibrosis. And what would we see with a cardiac MRI after a cold? So we don't want to jump to conclusions was his interpretation. And I think that was spot on. Now with a little bit more time in the pandemic, there's been this follow-up study. It was from the big 10. So they set up a COVID-19 cardiac registry. And over the past year, they tested nearly 1,600 COVID positive athletes with cardiac MRI and determined that with their criteria, 2.3% were diagnosed with myocarditis. Again, not necessarily able to use much for other findings to identify those with or without myocarditis. We had, they reported nine of the 37 athletes had symptoms. Seven had elevated troponins, five with abnormal ECG, five with abnormal echo. So as a result, there've been a number of protocols published on how to return to sport after having a COVID-19 diagnosis and when further testing is needed because it's not practical to have all athletes with COVID-19 tested with troponin, ECG, echo, cardiac MRI. So how do we differentiate who needs the further workup when it's not so clear, when these symptoms are not necessarily always predictive of underlying pathology? So this one is from Emory in May of 2020. This one is from Kim in JAMA of October of 2020. And then most recent, this one here is from Matt Wilson in BGSM later in 2020. And is probably the most comprehensive of the different protocols that are out there. Thankfully, we're now kind of in the realm of vaccines where many athletes are vaccinated. So the amount of symptoms that athletes will have is much less than before. So hopefully able to keep many of the athletes on the left side of this figure. And so we're seeing that if an athlete here has no signs or symptoms of COVID-19 and was just diagnosed based on the routine screening for COVID that some schools or some leagues are doing, that there's no further cardiac testing that's needed based on these recommendations. If an athlete has symptoms and is symptom-free for seven days or no sooner than 10 days, sorry, symptom-free at rest for seven days and no sooner than 10 days from symptom onset, that's where you can undergo the ECG echo, but no additional testing. And then if those are normal, then an athlete's able to be returned to play gradually. The BGSM put together a couple infographics to go along with this. So just the return to play has started again here, 10 days from symptom onset, at least seven days symptom-free, not taking any medications to manage the symptoms and then going through the graduated return to play. And then here's an example of a graduated return to play protocol over the course of two and a half weeks. So with that, I would love to be able to answer questions for in-person, but like I said, I will be out of town. So you're gonna be hearing from me just recorded, but I would encourage you all to email me. I'm happy to answer any questions or continue the discussion offline through email. So thanks again for letting me join you all for this online lecture series and speaking to you today. So hopefully you learned something new. Thanks. Brett, thank you again for that talk with lots of good information and even that sudden pop quiz for me. So that was nice and fun, but I do have just a couple of questions as kind of a follow-up. I know you talked about the emergency planning and mentioned locating AED as one of the things you should do once you're in a venue, as well as knowing the emergency action plan. For those who are visiting team positions, how would fellows best coordinate with other team positions and what kind of role they should play in the emergency action plan? In an ideal world, if it was some sort of, say you're a visiting team position on the road with the team, that there would be some standard for the league or sport that you're working within so that the hand signals, the communication is all determined at a larger scale. So it's not that each place you go, you have to learn something new, but the things that you do wanna know is where you're gonna find the AEDs, how you're going with the transportation route and the communication if there's a specific communication plan for that venue. And so that's often posted. One of the recommendations for emergency action plan is to have it posted. So it's available for visiting teams. So if you are on the road, best to introduce yourself to the host team medical staff, see who's gonna be on the sidelines, meet who your paramedics are, if they are our paramedics and then find out from them what they want your role to be in the event of a cardiac event or any sort of medical emergency because cardiac arrest is just one of several medical emergencies that you need to be prepared for when you're covering an event. So in terms of you wanna meet the host team physicians, the medical staff, and then if you are hosting other medical staff as a home team, making sure that you have kind of copies of the emergency action plan to share with them. And if you can do that, even ahead of time, email it to whoever's coming to town, that would get you bonus points so that people who are coming in already know what to expect. Thank you. And again, I guess my last question would just be, I guess, more of a personal one, right? Cause I like to think of myself as an athlete over the age of 35. I know you mentioned that the majority of sudden cardiac arrest in this age group are more due to coronary artery disease. So have we looked into doing anything extra for cardiac screening for those who are greater than 35? I know like, is it something that we're looking at like either ASCVD risk scores or even coronary calcium scoring? Yeah, as far as I know, there's some considerations and some guidelines on that. I don't think it's become any, there's not a standard at this point in terms of what needs to be done just because the, just a resting ECG often is not able to pick up some of those early signs of coronary disease. So it's working with your primary care doc, your cardiologist. If you do have a family history of early coronary disease, that may be something that you and your primary care doc decide to be more aggressive with treating any sort of dyslipidemia. Probably it seems like at this point, there's fewer and fewer indications for primary prevention using aspirin and then undergoing the advanced screening as indicated, probably more symptom driven than anything else. No, thank you for that. So, but I think I don't have any further questions and thank you for this conversation, kind of a one-on-one type of a lecture here. I think we'll wrap up for today, but I did want to thank you, Dr. Torsdal, for your time giving us this great lecture and sharing your expertise. I wish we could have more time to kind of talk a little bit more sports cardiology, but again, think of this as, again, as an adjunct to what the fellows are going to be learning throughout their time in fellowship. I thank you, the viewer, for tuning in today at the normal scheduled time. Don't forget to fill out your evaluations and please tune in next week, which will be August 11th, 2020 or 2021 at 8.30 p.m. Eastern. We will discuss ankle sprains with an update on diagnosis and management. Thank you.

3rd Edition, CASE 06

3rd Edition

Cardiac

sudden cardiac arrest

athletes

emergency action plan

CPR

AED defibrillation

sports cardiology

screening processes

COVID-19 impact

cardiac health

Dr. Brett Torsdall