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ECG in screening strategies
Submit responseWe read with interest the work by Eckart et al (1) reporting the retrospective 25-year review of autopsies in military recruits. Authors state that study results may have been altered by preenlistment screening which, however, did not include electrocardiography (ECG) as a routinary tool. We (2) specifically addressed the effectiveness of pre-participation military evaluation in detecting hypertrophic cardiomyopaty (HCM) in a Italian population of 34,910 male conscripts, demonstrating that screening by 12-lead ECG (as well as history and physical examination) and subsequent referral to echocardiography when cardiovascular abnormalities were suspected, could effectively identify HCM. The power of ECG-based screening for HCM in that study was similar to that reported by Corrado et al. (3) in athletes. Similarly, our follow-up data were consistent with the hypothesis that withdrawal of such individuals from these activities might effectively blunt the occurrence of sudden cardiac death (3,4,5). Moreover, 12-lead ECG offers the potential to raise the clinical suspicion of clinically relevant (other than HCM) diseases, manifesting with ECG abnormalities, such as ARVC/D, dilated cardiomyopathy, long QT syndrome, Brugada syndrome, short QT syndrome, WPW syndrome, Lenègre syndrome (some of which are unidentifiable at autopsy) (6). The high number of unexplained sudden deaths (35%) could be otherwise properly interpreted if an ECG would have been performed. Sorbo et al. (7) reported the prevalence of WPW syndrome in 116,452 young male conscripts studied by the same ECG- based screening strategy. Both in the WPW and in the HCM study the vast majority of our conscripts were asymptomatic. Therefore, if pre- participation military screening had not been performed in these young men, it is probable that the diagnosis of HCM or WPW would have been delayed, or never accomplished. Recently, the employ of 12-lead ECG has been recommended in a consensus statement proposing a common European protocol to screen young athletes for prevention of sudden death (6). A study reporting the cardiological and genetic assessment of surviving relatives of sudden death victims, demonstrated the high diagnostic yield of ECG (at rest in 8, with exercise or flecainide in 5 subjects), with identification of the disease in 40% of families and 8.9 presymptomatic carriers for family (8).
Thus, we think that the study by Eckart et al. (1) prompts the need to implement 12-lead ECG in each screening policy (together with history and physical examination performed according to current recommendations (9,10)) of large populations (such as the military one). Such screening strategies of apparently healthy young people might be, however, encumbered by a high-frequency of false-positive test results: nonetheless, an early identification of clinically relevant pathological conditions in asymptomatic young people may permit both risk stratification and access to therapeutic interventions, potentially reducing the risk for sudden death.
Stefano Nistri, MD Cardiology Service, CMSR Veneto Medica, Altavilla Vicentina - Italy
Domenico Corrado, MD, PhD; Cristina Basso †, MD, PhD, Gaetano Thiene †, MD FRCP Department of †Pathology and Cardiology, University of Padua – Italy
REFERENCES
1. Eckart RE, Scoville SL, Campbell CL, Shry EA, Stajduhar KC, Potter RN, Pearse LA, Virmani R. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med. 2004 Dec 7;141:829-34.
2. Nistri S, Thiene G, Basso C, Corrado D, Vitolo A, Maron BJ. Screening for hypertrophic cardiomyopathy in a young male military population. Am J Cardiol. 2003 Apr 15;91:1021-3
3. Corrado C, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339:364-9
4. Maron BJ, Mitchell JH. 26th Bethesda Conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. J Am Coll Cardiol 1994;24;845-899
5. Maron BJ. The paradox of exercise (editorial). N Engl J Med 2000;343:1409
6. Pelliccia A, Fagard R, Bjornstad HH, Anastassakis A, Arbustini E, Assanelli D, Biffi A, Borjesson M, Carre F, Corrado D, Delise P, Dorwarth U, Hirth A, Heidbuchel H, Hoffmann E, Mellwig KP, Panhuyzen-Goedkoop N, Pisani A, Solberg EE, van-Buuren F, Vanhees L, Blomstrom-Lundqvist C, Deligiannis A, Dugmore D, Glikson M, Hoff PI, Hoffmann A, Hoffmann E, Horstkotte D, Nordrehaug JE, Oudhof J, McKenna WJ, Penco M, Priori S, Reybrouck T, Senden J, Spataro A, Thiene G; Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology; Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology.Eur Heart J. 2005;26:1422-45
7. Sorbo MD, Buja GF, Miorelli M, Nistri S, Perrone C, Manca S, Grasso F, Giordano GM, Nava A. The prevalence of the Wolff-Parkinson-White syndrome in a population of 116,542 young males G Ital Cardiol 1995;25:681 -7.
8. Tan HL, Hofman N, van Langen IM, van der Wal AC, Wilde AA. Sudden unexplained death: heritability and diagnostic yield of cardiological and genetic examination in surviving relatives. Circulation. 2005;112:207-13
9. Maron BJ, Pfister GC, Puffer JC. Preparticipation cardiovascular screening for young athletes. JAMA. 2000 Aug 23;284:957-8.
10. Glover DW, Maron BJ. Profile of preparticipation cardiovascular screening for high school athletes. JAMA. 1998 Jun 10;279:1817-9.
Conflict of Interest:
None declared
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Cardiac molecular defects might explain 'idiopathic' sudden cardiac death
Submit responseEckart and colleagues (1) consider slightly more than one third (44 of 126) of nontraumatic deaths in military recruits as idiopathic or unexplained. The authors base their findings on the gross anatomy exposed at autopsy, but advancement in cardiac molecular pathology has revealed several molecular level defects that can lead to sudden cardiac death. For example, familial polymorphic ventricular tachycardia is characterized by exercise-induced arrhythmias and sudden cardiac death due to missense mutations in the cardiac ryanodine receptor (RyR2), an intracellular Ca2+ release channel required for excitation-contraction coupling in the heart (2). Other possible cardiac causes of sudden death in this setting are inherited ventricular arrhythmias such as the long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, idiopathic ventricular fibrillation, and arrhythmogenic right ventricular cardiomyopathy. It is also interesting that a familial predisposition was noted in several cases of unexplained sudden cardiac death in the study.
1. Eckart RE, Scoville SL, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med. 2004;141:829-34.
2. Lehnart SE, Wehrens XH, Laitinen PJ, et al. Sudden death in familial polymorphic ventricular tachycardia associated with calcium release channel (ryanodine receptor) leak. Circulation. 2004;109:3208-14.
Conflict of Interest:
None declared
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Other Screening Possibilities
Submit responseAfter the initial history and physical which should on their form address the appropriate issues so they cannot be missed, the simplest screening test that comes readily to mind would be a timed 1 to 2 mile run, followed by a very basic assessment including a confidential self reporting form.
You mentioned the low sensitivity of ECG and stress ECG, and the more sensitive modalities of Ultrasound, CT, and MRI.
Another screening test would be stress Ultrasound, which in cost and availability should compare favorably with CT and MRI.
That would also apply to Thallium stress scintigraphy, planar or SPECT.
At the high tech end would be PET or PET / CT.
Your experience and thoughts would be appreciated. Thank you.
Conflict of Interest:
None declared