In the News: Cardiac Screening for Adult Recreational Athletes

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An important new study caught my eye.  In last week’s British Journal of Sports Medicine, Andrea Menafoglio and her colleagues from Bellinzona, Switzerland published (epublished ahead of print) a report entitled, “Cardiovascular evaluation of middle-aged individuals engaged in high-intensity sport activities:  implications for workload, yield and economic costs.”(1)

The study is important because it addresses the issue of cardiovascular screening in adult, recreational athletes, an area that’s received very little attention.

By comparison, the issue of cardiac screening for young, competitive athletes has received a great deal of attention over the past 25 years.  Many prominent medical scientific organizations have issued recommendations for pre-participation screening in young athletes, including the American Heart Association (1), American College of Cardiology (ACC), American Academy of Family Practice (AAFP), American Academy of Pediatrics (AAP), American College of Sports Medicine (ACSM), American Medical Society for Sports Medicine (AMSSM), just to name some of the American organizations.

These recommendations form the basis for the widespread use of mandatory pre-participation screening in secondary schools and colleges. The goal of such screening programs is to reduce the number of fatalities from sudden cardiac problems that arise during sporting activities.   The successes and pitfalls of such screening programs have been reported and the findings have engendered lively debate about what elements to include in screening programs, their effectiveness, and justification of their cost.

In this new study, the investigators report on a “real world” glimpse into cardiovascular screening in adult, recreational athletes.  Their aims were to evaluate the practicality of such a screening program, to measure the prevalence of previously unrecognized cardiovascular conditions in this group, and to determine the costs associated with initial screening and follow-up evaluation of athletes with an abnormal initial evaluation.

 

The Study

The investigators enrolled 785 athletes, aged 35-65 years (mean, 46.8 years), who engaged in “high-intensity sports” for at least 2 hours per week.  The athletes’ sports included running (in 33%) and cycling (in 24%), among others.  The majority of subjects (73%) were male.  The athletes were primarily “amateur” (69.7), but the group included some who competed in regional (23.7%), national (4.6%), or international competition (2.0%).

Athletes with a known history of cardiovascular disease, except for treated high blood pressure, as well as athletes who had previously undergone cardiac screening within the previous year were excluded.

Each athlete underwent a cardiac screening evaluation according to the current guidelines established by the European Association of Cardiovascular Prevention and Rehabilitation (EACPR).  The evaluation was free to each athlete and included:

  • Thorough personal and family medical history
  • Physical examination
  • ECG
  • Estimation of the individual’s cardiovascular risk using the Systemic Coronary Risk Evaluation (SCORE) chart for Switzerland
  • Blood testing for total cholesterol and serum glucose.

The SCORE chart was used to estimate the athlete’s 10-year risk of death due to atherosclerotic heart disease based on gender, age, total cholesterol level, systolic blood pressure, and smoking status.  Athletes were deemed at “high risk” if their predicted risk was >5% or if any single risk factor (eg, total cholesterol, blood pressure) was markedly abnormal.  The cost of this screening evaluation was reported to be $130 per athlete, or $102,050 total.

 

The Findings

The screening evaluation was abnormal in 112 athletes (14.3% of the total):

  • 5.1% due to abnormal, “pathologic” ECG findings
  • 4.7% because of abnormal physical examination
  • 1.6% due to a “positive” personal or family medical history
  • 4.1% because an athlete was at “high risk” for atherosclerotic heart disease

Each of these athletes then underwent subsequent, more detailed testing to shed more light on the athlete’s cardiac circumstance and to determine if a true cardiac problem was present.  These tests included, among others:  echocardiogram (an ultrasound examination of the heart’s structure and function); stress test; 24-hour blood pressure monitoring; 24-hour Holter monitoring (of the ECG, continuously, to evaluate for arrhythmias); cardiac MRI; coronary angiography; and tilt testing.  A total of 194 such tests were performed and these additional tests had a total cost of $54,556.

In the end, a new, previously unsuspected cardiovascular problem was identified in 22 (or 2.8% of the 785) athletes:

  • 8 with hypertension
  • 5 with mitral valve prolapse and at least moderate mitral regurgitation
  • 3 with biscuspid aortic valve (2 with moderate aortic regurgitation and 1 with mild aortic stenosis)
  • 1 with mild pulmonary valve stenosis
  • 1 with vaso-vagal syncope
  • 1 with Wolf-Parkinson-White syndrome
  • 1 with hypertrophic cardiomyopathy (HCM)*
  • 1 with significant coronary artery disease and “old” myocardial infarction*
  • 1 with abdominal aortic aneurysm*

This group included 19 men and 3 women.  Of these 22 athletes with newly diagnosed cardiac conditions, 3 were deemed ineligible to participate in their sports because of unacceptably high risk of cardiovascular events (indicated by an asterisk, above).  Each of the 3 athletes who were deemed ineligible for sports activities were identified by an abnormal ECG during the initial screening.

The other 90 athletes with an abnormal initial screening evaluation were “cleared” on the basis of their subsequent testing.  We might refer to these athletes as the “false-positives”–those with an abnormal initial screening evaluation, but no real cardiovascular problem.

Interestingly, no diagnosis of coronary artery disease (CAD) resulted from the 76 exercise stress tests that were performed.

 

The Investigators’ Conclusions

The authors reached 4 main conclusions:

  1. The screening program was effective in identifying a small, but significant, number of athletes with significant cardiovascular conditions that required treatment or monitoring.
  2. The screening program was effective in identifying a very small number of athletes in whom continued participation in sports activities was thought to be dangerous.
  3. Inclusion of the ECG in the initial screening evaluation was important.
  4. The screening program was practical and the costs were reasonable.

 

My Thoughts

This study provides some pertinent data to help frame our discussions about cardiovascular screening for adult, recreational athletes.  The study population here appears to be typical in many regards, and I suspect the study results can reasonably be generalized to athletic populations far beyond Switzerland.

Adult, recreational athletes are not typically bound by the mandatory pre-participation cardiac screening programs that are used for young, competitive athletes.  They have to make their own decisions in this regard.  They must decide whether “getting checked out” is worth the expense.  Athletes might have a variety of relevant questions.  How likely am I to discover a previously unrecognized cardiac problem–particularly if I don’t have any symptoms?  What are the chances that I could be a false-positive–with the burden of additional diagnostic testing to sort things out?  What will this all cost?

Each of these questions now has an answer.

With regard to the first question, there is an approximately 3% chance of identifying a previously unrecognized, unsuspected, and presumably asymptomatic, cardiovascular condition.  On t op of that, there is an approximately 4% chance of identifying a high risk profile, based on risk factors, that deserves close follow-up.  And finally, there is an approximately 0.4% chance (3 athletes among 785) of identifying a serious cardiovascular condition that places an athlete at undue risk of sudden cardiac death during exercise.  It’s not clear from the study whether these risks are similar for men and women.

The second question also has an answer.  The chance of a false-positive, using this particular screening evaluation, was approximately 11.5% (90 athletes among 785).  That is a fairly large number.  Recall that each of these athletes required additional diagnostic testing–at additional cost–to establish that they didn’t actually have a problem after all.

The third question has also been answered–at least in Switzerland.  The average cost of the screening program–initial evaluation plus the costs of additional testing that was needed–was $199 per athlete.  The cost for the 663 athletes who had a normal screening evaluation was only $130.  Obviously, the costs for the remaining 122 athletes, with an abnormal screening evaluation, and who required additional diagnostic testing, were greater.  All of these costs would be much higher in the United States, I suspect, and this issue is compounded by the fact that most health insurance policies don’t cover screening evaluations such as these.  For many American athletes, these expenses would be out-of-pocket.

At any rate, this new information will be helpful as athletes have discussions with their physicians about whether or not to pursue cardiac screening.

Those are my thoughts about the issue from the athlete perspective.

From the physician perspective, I think it’s important to note that all of the stress testing results were normal.  These are expensive tests.  We need to keep in mind that the pre-test probability of an abnormal finding in an asymptomatic population of exercisers is extraordinarily low.  Perhaps, it’s best to think twice before ordering a stress test in this situation.

And finally, from the perspective of the event organizer, the prevalence data here is enlightening.  Governing bodies and race directors should be aware that several percent of participating athletes will have unsuspected cardiovascular problems, including 0.4% who are at high risk of sudden cardiac death during exercise.  These numbers should inform safety planning efforts.  It shouldn’t be surprising that we have a small number of cardiac emergencies and even fatalities in recreational competitions involving adult athletes.

 

Reference:

1.  Menafoglio A, Di Valentino M, Porretta AP, et al.  Cardiovascular evaluation of middle-aged individuals engaged in high-intensity sport activities:  implications for workload, yield and economic costs.  Br J Sports Med 2014;01-6.  doi:10.1136/bjsports-2014-093857.

Mixed Emotions About The Medical Tent

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I’m fascinated by the medical tent at endurance sporting events.  Maybe that’s not surprising.  After all, I’m a doctor and an athlete.

I have mixed emotions about the medical tent, though.  Maybe you do, too.  Let me explain….

Dr. Laird and the Kona Medical Tent

I got to thinking about the medical tent this past month when I listened to a talk given by Dr. Robert Laird, the long-time (now retired) medical director for the Ironman World Championship race in Kona.  He gave a talk at a sports medicine symposium held in conjunction with this summer’s Challenge Atlantic City events.  He told the ~23-year history of medical support for the Ironman race, beginning with its first year in Kona in 1981.  That year, Dr. Laird stood on the pier watching the swimmers, dressed in running gear, stethoscope around his neck, cap on his head….and he alone was the extent of the medical support.

Of course, today it’s much different.  On race day, there is a 50- to 60-bed field hospital set up in a tented area across from the Kailua Pier.  It’s arranged in pods of 6 patient beds and staffed with many physicians, nurses, physical therapists, and non-medical volunteers as well.  On race day, it’s the 3rd largest “hospital” on the Big Island of Hawaii.  And on race day, up to several hundred athletes among the nearly 2,000 participants in the race receive medical care there.

The medical support team also has a fleet of makeshift “ambulances”–rented white vans with a temporary red cross affixed to the side.  Without these vehicles, the need to respond to athletes on the 112-mile bike course or 26.2-mile run course would overwhelm the resources of the local EMS system.

If you’re an athlete with medical needs on race day, the setup is awesome.  In truth, the Ironman event as we know it today would be impossible to stage without this elaborate medical support.

My Own Medical Tent Memories

Thankfully, I’ve avoided the medical tent as a patient.  I did take a break at a medical aid station along the run course at the 2012 Ironman New Zealand race when I was feeling poorly.  But after a cool refreshment, some much needed shade, and a short break, I was able to continue along my way.

I’ve waited near the doors of the medical tent on a couple occasions, though, while my athlete friends were receiving treatment.  I remember my buddy, George, losing 12 pounds during the Ironman New Zealand race in 2007 and needing rehydration.  I also recall my friend, John Pendergrast, an ophthalmologist, needing treatment for a couple hours after finishing the Ironman South Africa race.  Our small group of traveling partners waited anxiously to be sure that John was okay.

I volunteered once in a major medical tent–for the Ironman Florida race.  I worked the 6 pm to midnight shift.  My lasting memory will be of the athletes who arrived at the finish line and then collapsed.  On a day with high temperatures in the gentle 70’s I was surprised at how many athletes arrived at the medical tent at the finish line severely hypothermic and dehydrated.  It seemed that the athletes who were worst off were those who arrived after finishing the race in 10-11 hours or so.  Perhaps the later arrivals had gone too slowly to get “messed up.”  We treated a bunch of athletes that night.

I’ve enjoyed reading the accounts of others who’ve worked in the triathlon medical tent.  Check out the report by professional triathlete and physician, Tamsin Lewis.

Marathon Medical Tents

Of course, the medical tent today isn’t confined to triathlon.  There is elaborate medical safety planning for the major running races, too.  There is often a medical tent at the finish line of the big city marathons and these are often staffed, at least in part, by volunteers.

I recently attended a lunchtime lecture given by one of my cardiology colleagues who had volunteered at the medical tent for the Boston Marathon.  There’s a sports medicine symposium before the race and the attendees are offered the opportunity to volunteer in the medical tent.  This gives physicians a chance to put into practice what they’ve just learned.  Listening to his tale, I get the impression that virtually any medical problem can manifest during the marathon, but that dehydration and heat-related illnesses are the common medical ailments.  He shared (and I’ve heard from others as well) that ice baths for rapid cooling of victims with severe heat-related illness probably make the difference for survival–that the EMS system and local hospital emergency rooms might not have the available resources to get athlete patients cooled so quickly.  That’s an eye-opener.

Malpractice Insurance Issues

I’ve often wondered–and even worried–about the issue of malpractice insurance coverage for physician volunteers at medical tents.  It’s one thing if you’re an emergency physician or sports medicine physician.  But it’s another situation entirely if you’re volunteering in a capacity outside your specialty–and perhaps outside the state where you’re licensed.  The issue would seem to be relevant not only to physicians but also to nurses and other licensed healthcare professionals as well.

It would be interesting to know if there are instances of malpractice lawsuits brought by athlete-patients against medical tent volunteers.  I’m told by the folks at USA Triathlon (USAT) that they’re not (yet) aware of any instances.

In order to encourage volunteer participation by medical professionals at triathlon medical tents, USAT has organized a malpractice insurance coverage opportunity.  This opportunity hasn’t received much publicity.  For a very modest premium, any licensed medical professional can obtain insurance coverage in situations where their own policies wouldn’t be applicable.  I bet this would help put some potential volunteers’ minds at ease and encourage their involvement.

The Mixed Emotions

So, back to the mixed emotions.  No doubt, the medical tents at triathlon and major running events provide a useful and needed service.  In some cases, it would be impossible to hold events without an organized medical safety net that includes an on-site medical tent.  And no doubt, countless athletes have benefitted from care they’ve received by volunteers at these medical tents.  So, in the sense of providing a safety net for participants, the medical tent is great.

But on the other hand, I have to wonder if the very existence of the medical tent and ready availability of volunteer medical care doesn’t encourage unsafe behavior on the part of athletes or event organizers.  I also wonder how outsiders view this whole enterprise.  Surely, if intravenous hydration is required by large numbers of participants just to complete an event, there must be something wrong–either in the venue, the weather conditions, or the preparation of the athletes.  Yet I hear many athletes talk casually about how they’ll “just get an IV” after the race.

At any rate, this is all food for thought.  I’m intrigued by the medical tent.  I hope it’s there when I need it, staffed by capable healthcare professionals.  I’ll probably volunteer again, too.  But I’ll also have some nagging worries.

Some Great New Videos from WTC SwimSmart Initiative

Here’s a quick update from the World Triathlon Corporation (WTC) SwimSmart initiative.  They’ve put together a YouTube playlist called “SwimSmart Saturdays,” a 9-part series of short (~1-2 minute) video clips that illustrate their 9-point checklist for race day swim safety:

  1. Prepare Early
  2. Work Your Way Up
  3. Be in the Know
  4. Safety First
  5. Tried and True Gear
  6. Warm Up Right
  7. Assess the Situation
  8. Start Easy, Relax and Breathe
  9. Be Alert and Ask for Help

This is all great advice for triathletes looking to have a safe day at the race.

Related Posts:

1.  Swim safe in 2014

2.  USAT and race safety

3.  Triathlon fatalities:  2013 in review

A Weekend in Atlantic City

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AquabikeFinish

A couple weeks ago, I had the chance to spend the weekend in Atlantic City, New Jersey for the Challenge Atlantic City triathlon.  You may know that this was the inaugural edition of the race and the first iron distance triathlon by Challenge in the United States.  It was a terrific event and I had a great time.

I hadn’t visited Atlantic City for about 25 years.  Of course, there are new casinos now, both on and off the Boardwalk, but in many ways Atlantic City was very much like I remembered.  It’s a very unique combination of nostalgic Boardwalk beach town Americana and the business of towering casino hotel developments.  There’s new and old.  Shiny and dull.  Have and have not.  The differences are very striking.

It’s an unusual setting for a long-distance triathlon.  No doubt, it’s difficult to produce a 140.6-mile event in any urban setting, yet alone in the middle of the summer tourist season at a beach resort town!  I give the organizers a lot of credit for getting things together.

Thanks to a kind invitation from Brad Bernadini, MD, and the race director, Robert Vigorito, I had a chance to be involved with a 2-day Sports Medicine Symposium in the days before the race.  I gave talks on “Athlete’s Heart:  Good and Bad” and on “Triathlon Fatalities.”  The program included a variety of topics.  My favorite speaker was Robert Laird, MD, the long-time medical director of the Ironman World Championship.  He shared the fascinating tale of medical coverage at the event over the past 30 years.  My favorite slide was of Dr. Laird, stethoscope around his neck, standing on the Kona pier watching the first Kona edition of the race, in 1981.  That year, he was it.  Today, the event stages a 50- to 60-bed medical tent to take care of the athletes on race day.  I’ll devote my next blog post to some thoughts about medical tents at large endurance sports events.  I have mixed feelings.

As for the race, I chose to do the aquabike event.  This was a first.  I suppose there have been instances where I haven’t finished a triathlon, stopping on the run.  But this was the first time I’ve ever intentionally stopped the race at T2.  And I must say that race day has a very different feel when you don’t have to run a marathon after the long swim and bike!  Aquabike may be calling my name.

The swim portion of the race was deceptively challenging.  Held in the “back bay,” the venue was subject to a brisk incoming tide that produced a very strong current.  That, combined with a very unusual serpentine single-lap course made for a difficult swim.  As an interesting surprise on race morning, the water temperature was 80 degrees, so no wetsuits were allowed.  Most triathletes don’t have much opportunity to do 2.4-mile swims without a wetsuit.  It was a beautiful, sunny day, though, and the temperatures were mild.

The bike leg of the race took us away from the beach, up the Atlantic City Expressway (ACE), to the town of Hammonton.  There, we had two ~22-mile laps through the countryside which is apparently the U.S. capitol of blueberry farming.  There was a rewarding stretch through main street Hammonton on each lap where there were hundreds of cheering spectators, balloons, inflatable archway, and an announcer.  The race even provided shuttle buses for spectators who wanted to make the trip to Hammonton to watch the athletes.  This was a nice touch.  The ride back down the ACE to the beach was tough, into a ~15 mph headwind.  For me, at any rate, the ride didn’t seem “flat and fast,” as advertised!

I hope that Challenge is successful in getting this race established.  I understand there is a 5-year commitment at this point.  I appreciate the alternative to the series of World Triathlon Corporation (WTC) Ironman-branded events and I appreciate the choice of a venue in Atlantic City.  If you’re a triathlete, check out this race.  If you’re a medical or allied health professional, check out the pre-race sports medicine symposium.  And if you’re both….you can have a busy weekend next June!

Like I said, I was glad that my day was finished after the 112-mile bike ride.  After a shower–and a casino buffet meal–back at the hotel, I made my way to the finish line on the Boardwalk in front of historic Boardwalk Hall.  Most of the 26.2-mile run took place on the Boardwalk amongst the thousands of visitors.  It was really a sight.  And, as always, it was a thrill to see the athletes finishing late in the evening.  In Challenge style, children or family members were allowed to join athletes in the finishing chute.  The children seemed to draw the biggest cheers from the crowd.

 

 

Medical Toll at Obstacle Race

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A couple weeks ago I wrote about the medical toll at long-distance running events.  There was also a recent report on the medical toll at an obstacle course race that caught my eye.  On the face of it, the findings were surprising!

At the outset, let me issue a disclaimer.  I haven’t participated–or even spectated–at one of these obstacle course races, so I may not have the best perspective.  I’m talking, though, about races like the Tough Mudder, Warrior Dash, and Spartan Race, among others.  They’ve become very, very popular very, very quickly.  We’re talking 100’s of thousands of participants per year in the U.S.  One day, I’ll give it a try.  I’ll need to be brave!

 

The Study

A group of investigators headed by Marna Greenberg, DO, MPH, in the Department of Emergency Medicine at Lehigh Valley Hospital reported on a collection of patients who required hospital care stemming from their participation in an obstacle course race.  The event was the Tough Mudder Philadelphia race, held over the weekend of June 1, 2013.  As you may know, the Tough Mudder races are characterized by a 10- to 12-mile course with a series of 20-25 obstacles spread over the course.  By report, approximately 22,000 individuals participated in this particular race.

The investigators were the emergency room physicians at the hospital that was designated to care for participants who required hospital care for medical conditions or injuries that developed during the race.  In a report in the Annals of Emergency Medicine entitled “Unique Obstacle Race Injuries at an Extreme Sports Event:  A Case Series”, they share their first-hand experience which they characterized as surprising.

 

The Results

The report provides fair detail about 5 patients with “significant” injuries or diagnoses and compiles a list with pertinent findings in 43 total athletes who received care at the hospital. The 5 athletes with “significant” problems included:

  • 18 year old with myocarditis (inflammation of the heart muscle) caused by electrical shock during the event.  Required admission for 2 days.  Self-limited.
  • 28 year old with depressed level of consciousness and diagnoses of accelerated hypertension (high blood pressure) and pericarditis (inflammation of the sac that holds the heart).  Required admission for 2 days.  Self-limited.
  • 31 year old right-sided weakness who was found to have a stroke, seizure, and dehydration.  Required admission to the intensive care unit (ICU).  Was discharged to a rehab facility and at the time of writing, had persistent weakness due to the stroke.
  • 41 year old who experienced syncope (blacked out) after being shocked at an obstacle.  He fell, causing lacerations to the face.  He was discharged from the emergency room against medical advice to be hospitalized.
  • 25 year old woman with near syncope (nearly blacking out) because of electrical shock.  Required hospitalization for evaluation and was treated for dehydration and rhabdomyolosis (breakdown of muscle).

The 38 others had diagnoses that included:  heat injury, sunburn, ear barotrauma (pressure injury), shoulder dislocation, patella dislocation, heat exhaustion, vomiting, renal failure, various contusion injuries, rib fracture, dehydration, asthma, seizure, leg fracture, ankle sprain, and elbow sprain, among others.

 

The Takehome Messages

You never read about the medical toll at running races that are shorter than half marathon distance.  That’s not to say that athletes don’t have injuries or other medical problems manifest during those races.  It’s just that athletes are usually responsible for their own medical care or receive their care from the emergency medical system (EMS), rather than by race-supplied medical volunteers.  So nobody is keeping track of the “toll.”

This report is great peak into the issues with the obstacle races.  Kudos to the authors for sharing their experience.  Obviously, 43 victims among 22,000 participants is a small fraction.  We might reasonably expect, though, that additional athletes with minor injuries or medical conditions did not visit the hospital for care.

Some thoughts….

  • At an obstacle course race, the obstacles present a challenge and risk that is different from just running.  These events are certainly not risk-free.
  • There are typical medical issues like minor injuries, dehydration, and heat injury.  Some injuries and medical problems may be due very specifically to the obstacles themselves.
  • There will also be injuries that may not be expected–either by the athletes or by the nearby healthcare workers.  At this particular event, the myocarditis, pericarditis, stroke/seizure, and syncope diagnoses were examples.  Electrical shock was an unexpected causative factor.
  • Athletes should keep the potential risks in mind when they decide to participate and exercise great care while participating.

Like I said at the top, I’ll probably be a participant at some point.  But I’ll need to be brave!