In the Pediatric Cardiology session of Pediatric Clinical Connections, Marjorie Gayanilo, MD , presents on the topic of Cardiac Screening for Young Adults. She reviews the epidemiology of sudden death in young athletes younger than 35 years old. She then discusses the pathophysiology and clinical features of some of the main diseases that are responsible for sudden cardiac death. Finally, Dr. Gayanilo shares the current thinking on cardiac screening and prevention of sudden death.
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Uh, we hit 25 and it's 6:02, so I think I'm gonna get us started. Again, always trying to respect everybody's time. Um, thanks for joining everybody back to Clinical Connections. Glad to see you all, uh, Mike Jaker here. I think most of you know me at this point, um, but hopefully we have some new people, um, on as well, um, and it is very nice. Is that my friend Doctor Arnon, who I see on there. Um, good. Good to see her face. So, um, as well as others, nice to see you Eureka, um. Welcome, and I'm gonna introduce our speaker for tonight. So, um, just housekeeping, everybody, if you can throw your name in the chat, just, uh, for attendance purposes, that would be terrific. Uh, #1, 2, if you have questions during the talk, please throw them in the chat as well. Um, and we'll address them all, um, at the end, um, if there's something, um, that I feel the need to interrupt, um, during the talk, I'll do that with a. Question, but otherwise we'll say most questions to the end. But if everybody can please, uh, just throw your name into the chat, that would be, uh, terrific. Uh, so Allie can keep track attendance wise. Um, I'm gonna introduce, uh, Marjorie Galanillo, our speaker for tonight. Um, sometimes on these talks, we have old friends in our department who I've known for a very long time, um, and some Sometimes we have new friends, and, um, tonight I'm happy to have a new friend, um, joining us. So, um, Marjorie, it's very nice to see you here, um, and looking forward to hearing your talk and hearing about you a little bit. Uh, Marjorie's gonna be speaking as you can see about, uh, cardiac screening for young athletes, and, um, I'm gonna let her take it away, um, say hello to us, and, um, I'm looking forward to a good talk. So welcome, Marjorie. Thank you, thank you. Um, thank you for the organizers for inviting me to talk, and thank you everyone who showed up, um, to hear me talk today. I know everybody's busy after work. Um, I'm Marjorie. I'm a pediatric cardiologist, um I'm at Sinai. Um, I, my interests are in fetal cardiology, preventative cardiology, and of course, general pediatric cardiology. Um, I go to Mount Sinai, but I also have offices in New Jersey in Paramus at the Valley location, as well as uh in Teaneck. Um, so going forward, we're gonna be talking about cardiac screening for young athletes and basically can we prevent sudden cardiac death. I have no disclosures. So the objectives of today's topic is uh to review the epidemiology of sudden death in young athletes, and I say less than 35 years of age just because in Europe that's the data that they collected, um, briefly discussed the pathophysiology and clinical features of um some of the culprits and main diseases that are responsible for sudden cardiac death. Um, talk about athlete's heart and how it can overlap with a significant cardiac conditions, and then discuss the current thinking and the debate on cardiac screening and prevention of sudden death. So what is sudden cardiac death? It's defined as an unexpected death from the cardiac causes that occurs within 1 hour or within 24 hours in unwitness cases, from the onset of an acute change in cardiovascular status in the absence of external causal factors. Now when we think of sudden cardiac death in young athletes, it's pretty devastating, especially this is the population that is supposed to be the healthiest. And so when we hear about sudden death, especially in young athletes in the news, uh, we're shocked. I don't know if some of you remember these athletes, um, there's Pistol Pete Maravich, um, he was a famous basketball player, and he died suddenly in his 40s, um, after he retired, just playing recreational basketball. Um, he had a single coronary arising from the right sinus. Um, there's also, uh, Reggie Lewis, who died suddenly after he collapsed on on the basketball court, and he had hypertrophic cardiomyopathy. There's Hank gathers. He had exercise induced VT, um, and that was related to idiopathic cardiomyopathy, and actually at the time of his death, he had, he had been on beta blockers and he asked to reduce his dosage because it was making him feel fatigued. And I don't know if any of you know Flo Harman. She was a volleyball player, and when she died, they saw an autopsy that she had aortic dissection and undiagnosed Marfan syndrome. So the incidence varies. Um, in the US it can be anywhere from 1 in 100,000 to 200,000, and this is likely underestimated because there's really no systemic national registry for sudden death in sports, and some of the data is derived from high profile events or deaths of prolific athletes. And some studies um include sudden deaths while others report sudden cardiac arrest, so then the denominator changes. Also, an expert cardiac pathologist is rarely responsible for conducting a postmortem exam, and so therefore, a rare conditions like a mogenic right ventricular cardiomyopathy or atypical forms of cardiomyopathy may not be identified. And deaths from ion channelopathies or accessory electrical pathways are not identified during a postmortem exam. Most deaths occur in adolescent males with the mean age of 17, with a high preponderance in black athletes, and it's more common in men. Um, women have less than a tenfold number of sudden death events. Now, if you take a look at this figure, um, in the early 2000s, there were two studies, one out of Italy by Colorado at all, and they noted that the um causes of sudden cardiac death in their population, and the most common was ARVC and that was followed by atherosclerotic coronary artery disease, and then coronary artery anomalies, followed by myocarditis, and then a sprinkle of other cardiac diseases. And their population that they studied were less than 35 years of age. And then you have a study based at um in the US by Maron at all, and they showed that the majority were hypertrophic cardiomyopathy and 36%, and that was followed by coronary artery anomalies, and then myocarditis, and then other cardiomyopathies like ARBC and dilated cardiomyopathy. But then you look at like um further out in the timeline and you see that the percentage of sudden unexplained death goes up. Um, in one study it's 25%, and then another study it's as high as 42%. There has been a recent review that was seen in Europe, which highlighted that up to 40% of sudden cardiac deaths in young individuals didn't actually have an autopsy. So this may account for the increased rate of unexplained sudden deaths. Now we'll go over the causes of sudden cardiac death. We'll first start with structural abnormalities. So the first is I approach for cardiomyopathy. This is the most common inherited cardiac disease and um the EKG remains the crucial in the diagnosis, and it's found to be abnormal in more than 90% of cases. It's the cause of sudden cardiac death, anywhere from 2 to 36% of athletes, and the prevention of sudden cardiac death relies on the use of ICD in primary and secondary prevention. After accurate prognostic stratification, of course. So here's an example. This is a 12 year old with a symmetric septal hypertrophy. Notice the very pathological deep Q waves in the inferior leads of 23, and AVF, and you can also see it in V5 and V6. And of course there's um prominent voltages in the in the precordial leads. Here's another example. This one is an 8 year old with severe obstructive HCM, um, and you can see here T wave inversions in V4, V5 and V6, as well as ST segment abnormalities that is noted in like lead 1 and AVL. Echo is diagnostic in most cases. Um, cardiac MRI can also be helpful when echo is inconclusive. It can show some fibrosis or some scarring, and it can also reveal if there's a ventricular outflow tract obstruction. It can be reported at rest and with stress in up to 2/3 of patients. Next is a rhythmogenic cardiomyopathy, ARVC. This is an inherited condition that is characterized by progressive fibro fatty replacement of the myocardium, and it has a high propensity for fatal arrhythmias. Um, as I showed in the previous figure, it's the most common cause of sudden cardiac death in young athletes in um Northeast Italy. Um, the diagnosis of ARVC is complex, um, and traditionally based on the task force criteria, we won't go over that just because of the sake of time, but it includes a series of clinical, EKG, structural and functional traits. The majority of patients should be excluded from most competitive sports, and the ones that are at risk should be implanted with an ICD. Now, here's a postmortem evaluation of a 33 year old footballer in Europe. Um, you can see already in his baseline EKG there's a PVC in the middle of the EKG, but there's diffuse T wave inversions as well as low voltages. And on MRI you can see in the red arrow, there's an aneurysm noted right below the tricuspid valve. And you notice also streaks of fibrosis, um, noted in along the septum as well as in the RV free wall. And here um microscopically, you can see the streaks of fibrosis, and on microscopy, you can also see streaks of fat and fibrosis. Dilate cardiomyopathy is the presence of left ventricular or bi-ventricular dilation, along with systolic dysfunction, uh, and in the absence of abnormal loading conditions or coronary artery disease. This is a rare cause of sudden cardiac death in athletes, mostly because those with dilated cardiomyopathy have impaired functional capacity, so they're unable to engage in real vigorous exercise for a prolonged amount of time. Myocarditis is an inflammatory disease of the myocardium, and it's a most common cause is a viral infection. Now, the thing with myocarditis is that the natural history is quite variable. Um, the majority of patients recover, but then a small minority developed dilated cardiomyopathy and then have symptoms of heart failure. The, this makes up 2 to 9% of cases of sudden cardiac death in athletes. And the MRI is the gold standard noninvasively, um, and biopsy helps to confirm the diagnosis because it can show lymphocytic infiltration and myocyte necrosis. Athletes that have myocarditis should refrain from intense exercise for at least 3 months just because it's shown that they have a high propensity for ventricular arrhythmias, especially in the acute phase. And finally, coronary artery anomalies. This is the 2nd most frequent cause of sudden cardiac death in young athletes in the US, um, making up up to 17% of sudden cardiac deaths. Uh, we worry about anomalous origin of the left coronary artery arising from the right coronary sinus. There's also an entity called myocardial bridging. Um, this is when there's a presence of band of cardiac muscle. That overlies the segment of the coronary artery where the LAD is most frequently affected, and you can imagine when the heart squeezes that muscle squeezes and can compress the coronary and cause low perfusion. Here are some figures showing the anomalous left main coronary artery arising from the right sinus, um, on the left end. Basically, it takes a course between the aorta and the pulmonary artery, um, and the theory is that during exercise, um, this area of the coronary can get pinched down and stretched, and so then that will cause low coronary perfusion. Um, and the most worrisome is when the coronary artery takes an intramural course, and that's when it goes along the through the aortic wall. So then that is uh more at risk of compression, um, causing um ischemia. And a lot of times we also see uh anomalous right coronary artery from the left sinus, and of course, usually we see that in asymptomatic patients and so um sometimes we don't know what to do because um they have no symptoms and And with this um anomalous right from the left, they don't always um present with sudden cardiac death. Unlike the opposite side with anomalous left coronary from the right sinus, um, this is more worrisome and so if you ask pediatric cardiologists, patients that have symptoms and anomalous left coronary artery from the right, they're more likely to recommend surgical repair. So, now talking about electrical abnormalities, the first we'll talk about long QT syndrome. This is an autosomal dominant but rarely autosomal recessive pattern. Um, the, the prevalence is up to 1 in 2000 cases, um. Pathogenesis lies in the potassium, sodium, and calcium channels. Uh, the deaths can be triggered by several stimuli that affects athletes. One is that there's adrenergic surges that are associated with physical and emotional stress. Also, athletes are at risk for electrolyte disturbances, as well as taking performance enhancing agents. There are many different types of long QT. Um, we'll just go through the the first three, which are the most common. Um, you see all three here have abnormal T waves. In long QT3, they have a late onset T wave and the ST segment is longer, where in long QT2, they have low amplitude T waves. And then in long your T1, they have an early onset of the T wave, but it has a broader base to it. And all of this caused prolongation of the QT interval, which increases the risk of ventricular arrhythmias, and more notably, they're at risk for a polymorphic V-tac, torsos they points, and ventricular fibrillation. Now the problem is that if you, this, this figure here shows um corrected QTC interval um um with normal healthy individuals and how it overlaps in those patients that have long QT syndrome, and you can see that a third of patients that carry the gene have a QTC that um um falls within the normal range of healthy individuals, which makes it sometimes quite difficult to diagnose. And the diagnosis also lies within the scoring system, which is based on EKG abnormalities that are listed here, as well as a personal history of syncope or congenital deafness, and then also a family history. Next is Brugati syndrome. This is an ion channel disorder, most commonly um sodium, and it's autosomal dominant with the prevalence of 1 in 2000. Sudden cardiac death often occurs at rest or during sleep. Um, but hyperthermia, um, may result that results from intense exercise and enhanced vagal tone may also promote the development of fatal arrhythmias in athletes if they have this condition. And here is an example of an EKG of type 1 bogati syndrome. Um, you'll see here in the right ventricular reads the anterior leads, you have a partial right bundle branch block, um, that's followed by J point elevation and a curved ST segment elevation followed by T wave inversion. Um, again, this is, um, seen in the anterior leads in V1 and V2. This should not be mistaken for benign early repolarization, where you can see more of like a concave look to the um ST segments. Next is CPPT or catecholaminergic polymorphic ventricular tachycardia. Um, I, I only had one patient during fellowship that had this condition, and she was a college student that um every time she danced really hard she would pass out. Um, so what this is, it's um a stress-induced bidirectional ventricular tachycardia, which then can degenerate into Vfib. Um, the difficult part is that their baseline EKG is often normal, but during stress tests, you can induce multifocal, um, PVCs or uh VTEC with beat to beat, um, 180 alternating QRS axis. Um, this is bidirectional VT and in this patient we observed that during stress, she would have polymorphic PVCs. Um, the mutation is, um, due to a a cardiac rhinidine receptor in the autosomal dominant type, um, or Cas Q2 in the autosomal recessive type. And then lastly, there's Wolf Parkinson White syndrome. Um, this is a ventricular pre-excitation that is seen on EKG, um, as well as cardiac symptoms like palpitations and syncope or um paroxysmal supramaticular arrhythmias. Now, most um individuals that are asymptomatic are usually at lower risk for developing malignant arrhythmias, um, but we can do um ablation of the accessory pathway that can help decrease the risk of sudden cardiac death. When we study these patients um in the EP lab, if they find that there's a refractory period that's short, um less than 250 milliseconds, or if they have inducible SVT, then that would be an indication for um ablation. Here you can see on the baseline EKG and the red arrows, you can see the pre-excitation and the delta waves and the short PR interval. Oh, why do people with WPW um die? That's because they can develop atrial fibrillation, and then that can rapidly conduct down to the ventricles causing ventricular fibrillation and cardiac arrest. I had one person asked me if this is what um LeBron James's son had, because he had a cardiac arrest and he apparently had a procedure, and now he's playing on the Lakers, so I can't imagine what else he he could have had that we that could have been fixed, but that's just speculation. Now, other conditions, um, there is an entity that's associated with mitral valve prolapse. This is rare, but it can be associated with malignant arrhythmias, um, but usually there's some family history of sudden cardiac death or the EKG is abnormal with T wave inversions or QTC prolongation. Sometimes they're known to have um Uh, PVCs and that can arise from the mitral valve annulus or you, um, you can see scarring on the papillary muscle, and most often this is, um, by leaflet prolapse um when this occurs. Um, also, a severe aortic stenosis, um, aortic dissection, um, especially if it's associated with Marfan syndrome, some performance enhancing drugs like steroids or stimulants like ephedrine or oxygen carrying modulators like um Epo that can cause heart failure. And Komoso Cortis, I don't know if anybody remembers this in 2023, um, there was a football um player named um Demar Hamlin who played for the the Bills. He collapsed on the ground after he got hit in the chest with a helmet. Um, fortunately for him, um, he received CPR right away, um, and he survived. And so what is commercial corti? Um, that's when you have a sudden blow or impact to the precordium. This is most commonly seen in children and adolescents because their chest wall is more pliable, but if it's delivered onto the onset of the T wave, um, this can lead to ventricular fibrillation and cardiac arrest. Now, I wanted to talk about the athlete's heart because this is who we're we're discussing. When you look at the athlete's heart, there's a there's adaptation that happens and what we've observed is that there can be some findings that can overlap with some of the um Cardiac conditions that I just discussed. So for example, we can see prominent muscle trabeculations and sometimes they have um borderline low normal mildly reduced ejection fraction. Sometimes their RV is a little bit bigger or um and they have also low normal um ejection fractions. They can have abnormal EKG um findings like T wave inversions as well. And they can have increased left ventricular size, um, and some QTC prolongation. So, and that's what we worry about is when we screen athletes, we can still see some borderline findings which then leads us to more testing. So again, just stressing that an athlete's heart can have moderate increase in LV wall thickness, um, and bigger biventricular cavity size, but normally they have preserved systolic function and normal diastolic function. And what we've observed is that 13% up to 13% of athletes of African or Afro-Caribbean can also exhibit wall thickness um along the 12 to 15 millimeter, which is the gray zone, um. Of course, anyone that's above 15 millimeters, we should think about more pathologic HCM, but when you get into this gray zone, um, it becomes more difficult and like what we have to do. Do we do a cardiac MRI? Do we do a stress test? Do we decondition them by telling them to lay off sports for 3 to 6 months to see if things get better, um. And like I said, they, the highly trained athletes can have bigger LV size, but typically with low normal preserved function, and they can have prolonged QTC. Um, this is often related to the cardiac mass or consequence of autonomic adaptation. Um, less commonly do athletes have QTC above 500 though. So, to go back to this topic that we're talking about pre-participation cardiac screening, there really is no global consensus on whether or how cardiac screening should be performed. The American College of Cardiology and the European Society of um Cardiology both say medical history and physical exams should be part of the screening, but a 12 lead EKG is only proposed by the European Society of Cardiology. I know it's a busy slide here, but you, this is the the 14 point questionnaire um or evaluation. On the left is the one by AHA, the one on the right is um the one that's posted by the AAP, um, but basically it's getting a thorough personal history, family history, and, and a thorough physical exam. And if there is a positive finding, then these patients would then go on to have further testing with either an EKG or pediatric cardiology consultation um with possible um echo. Now the problem is, in our country, mass cardiac screening is still controversial, um, unlike other European countries that have national health system, um, in our country, um, there remains a problem with economic sustainability to have a nationwide screening program, and some feel that there may be uncertain benefits in terms of actually reducing sudden cardiac death. There's potential for false positives and therefore um unnecessary disqualifications, and, and most notably screening doesn't always prevent all cardiac deaths among young athletes. I wanted to talk about this Italian study um um by Colorado, um, in 1982, um, they did a nationwide program for pre-participation screening that included a 12 lead EKG, um, that was launched in Italy. They could do this because they have a national health system, so the cost was low. Um, and this, this was supported from data, um, coming from long running Italian experiences that showed that EKG provided adequate sensitivity and specificity for detecting lethal cardiomyopathy and arrhythmias. And what they found is that it led to substantial reduction of mortality of young competitive athletes by almost 90%. So here in their algorithm, they took all the competitive athletes, did a family personal history and physical exam, as well as a 12 lead EKG, and if there was any positive findings that went on further to either echo, stress tests, Holter, MRI, um, even as um an EP study, and if there was a diagnosis made that went on to management for the established protocols of their country. Here are some of the EKG abnormalities that they found in their athletes, um, agree that on the right, the least common ones um are what I would consider abnormal and would go to the segue of getting an echo or a stress test, um, depending if they had symptoms. And this is what the data they showed over a 25 year period is among athletes, they showed the reduction of sudden cardiac death. And I just wanted to show this table in Europe. These are all the European countries and what they do for their um pre-participation for athletes, and in their screening protocol, um EKG is recommended or required. But is EKG an accurate test for early detection of athletes who are at risk for cardiovascular disease? Um, it's been shown that the AHA 14 point um history and physical exam has low sensitivity. Um, because athletes who have these conditions are typically asymptomatic, and they don't exhibit abnormal physical signs. But we also know that EKG is quite effective for identifying, you know, WPW or prolonged QT or and most individuals with cardiomyopathy. Traditionally though, um, EKG is considered to be non-specific and non cost effective screening tool, at least in our country for athletes, um, mainly because of presumed high levels of false positive results. And remember what I had said that there are physiological EKG changes that we see in trained athletes, um, that can overlap significantly with pathologic EKG abnormalities. And um and lastly, misinterpretation of an EKG by someone who's inexperienced might lead to serious medical consequences and then overall reduce the cost utility of this, the whole screening process. So again emphasizing when um the mandatory pre-participation cardiac screening program was put in place in Italy, the annual incidence of sudden cardiac death in athletes decreased by 89% after they after they made it compulsory in 1982. Um, but these other two studies, one by Marin at all, they took a look at 13 cases of sudden death in high school athletes. And they showed that even though it's a small number, they showed that only 4 of these um would have been reliably detected with um um history exam and an EKG. And then there was another study in Israel that showed that When they implemented mandatory pre-participation cardiac screening with an EKG and a stress test, it didn't actually reduce um sudden cardiac events in their population of athletes. So I wanted to also discuss this study, um, this was based out of where they looked at um Um, looked at the AHA questionnaire and compared that with EKG in high school athletes, and this was a prospective study. They had um 3600 high school athletes with the mean age of 16. They found that 22.5% had positive responses to the AHA um questionnaire, almost 10% had abnormal physical exam, 2.8% had an abnormal EKG. But only 0.4% of these athletes had conditions that could be associated with sudden cardiac death, and they concluded that the sensitivity, specificity, and positive predictive value of the AHA 14 point evaluation was much lower than that of an EKG. Um, and this is just the algorithm, they, um, those that, um, went on to have a positive history exam and an EKG, um, of them, 32% had an echo, um, um, indicate um recommended, and 1100 had an echo that was completed and again showing that only 16.4% had the cardiac conditions that could be associated with sudden death. And this is the breakdown of those 16 patients. You see, the majority of them have WPW, um, some have long QT. There are 2 with hypertrophic cardiomyopathy, one with dilated aorta and one with anomalous coronary artery. So just to summarize, Of these 16 patients, the AHA 14 point evaluation was flagged abnormal in about 44%, 7 of the 16, where the EKG was flagged abnormal in 15 of the 16 cases, and none of these athletes were identified solely by having an abnormal physical exam. And so if you take the AHA 14 point evaluation as the only screening tool, um, 9 of the 16 would still remain undetected. Um, and if we took the EKG as the only screening tool, only 1 would have been missed, and that would have been um anomalous coronary artery. So prevention, um, immediate availability of quality CPR, um, by bystanders and having AEDs available, I think, um, are the most important. Um, there's a study, um, from Luxembourg that showed that the ratio of survival among patients receiving bystander after um um bystander CPR um during cardiac arrest was about 50%, um, in contrast to those that didn't receive CPR and they were all fatal. Um, the greatest determinant of survival was the time from collapse to defibrillation. Um, they showed that survival rates declined from 7 to 10% for every minute, um, that per minute for every minute lost. Um, an AED should be promptly available at first shock to be applied within 3 minutes of a collapse. And so deployment of having defibrillators in public areas and training and sports grounds can exponentially increase the chance to have better outcome in this population. So when we talk about sudden cardiac death, there's clearly knowledge gaps, um, but future directions lie on um multiple things, um, large perspective studies that um based on sudden cardiac death and athletes, having a standard definition of what an athlete is and what sudden cardiac death is, possibly more research on novel technologies for cardiac screening. Um, more implementation of, um, education of CPR and having AEDs available, um, having standardized autopsy protocols that can have, um, um, expert pathologists available, um, and possibly even having randomized controlled trials on exercise in patients with cardiovascular disease. Now stepping back, when you take a look at sudden death in young athletes, we say, you know, 10 to 25 sports related sudden cardiac death in US um among high school and college students, but then the number one cause of sudden death in teens still remains to be motor vehicle accidents, um, you know, followed by drowning. Firearm discharge. So then when we think about where do we, you know, divide our resources and our money in this country, you know, it's hard to to say we should implement a national screening program. So the take home points, um, the incidence of sudden death in high school athletes in the US is anywhere from 1 to 1 in 100,000 to 200,000, and the most common cardiac cause, um, in our country is hypertrophic cardiomyopathy, followed by coronary artery anomalies. Um, screening programs prior to sports participation do carry promise, but there's still unresolved issues. And education in the general population, having immediate quality CPR and having access to defibrillators in the public space can all help in the survival um in in these young athletes. Thank you very much. And Marjorie, thank you so much. I think, uh, you know, lots of Questions, I think, you know, I'll just start, OK? And obviously, anybody that has questions can throw them in the chat or you can unmute yourself, um, and we could talk it through a little bit. But, you know, for those of us who are kind of the boots on the ground, general pediatricians out there, we're still confused, right? So here in my practice, you know, we've added some of the screening into our You know, well visit protocols, um, and we ask these questions. I think we sometimes we ask the questions in depth enough, sometimes we don't. I think we we're still confused as to how in depth we need to go, you know, with families on this stuff, um, you know, there is, you know. In New York State, you know, there's on, on school forms now, it's asking, did we do cardiac screening on, on some of our school forms. New Jersey has had um their history for a good while now, um, asking us and, and, and, and requiring training for physicians. So it's still confusing for all of us, um, as to where we, you know, Where we need to be going. So I'd just like to hear your thoughts on it. And if it's not for all of our patients, are there certain subsets of our patients um that we should be taking this to a different level on? And I'm just thinking even of my day in the office today. Um, I saw a number of teenage athletes today, um, and a number of those teenage athletes are taking Vyvanse. OK. So, or another stimulant, and, you know, whenever I see those kids and I'm like, oh, this kid's on a high dose of Vyvanse, um, and is also, you know, a pretty, you know, high-end athlete. Does that buy that ticket, uh, that patient a ticket to your office? And is there a subset of patients that uh might be included in that cohort? Um, well, from my experience, and it may be limited, but I think It's been shown that stimulants doesn't increase that risk of sudden death, so that wouldn't be one of those patients that I would want you to bring to my office to clear for, um, you know, sports. Um, I think the data is there that shows that it doesn't really increase the risk, um, any higher than the general population, but I think for general pediatricians, it is a hard thing to have to talk about because you want to do the best and make sure that you You screen as much as you can and do everything that you can, and I'm not against having an EKG of course not, but you have to take that with a grain of salt because like I had said, you know, some of these athletes have some overlap with the conditions that we worry about, which means if we do find something that means more and more testing, right? And so, um, I think yes, having a good, um, you know, history, personal history, good family history, all these things that if any of those are flagged, they should certainly be seen by pediatric cardiologists, um, and I think having a baseline EKG, um, I don't think it needs to be for everyone. Um, certainly it's more the cost, right? Like I, I feel like. If I, when I go for an EKG it's not that much, but if you're talking about thousands and thousands of athletes, it becomes difficult, and then you're talking about Um, false positives and where that goes, and I haven't had to personally tell an athlete to stop exercising and decondition to see if things resolve and that it's just from being highly trained, but um I think that becomes a difficult question where we, we might have to say, hey, we don't know, and I think you might have to stop for a little bit. Um, and I think it's, it is a difficult question. Um, I think screening program wise it's from country to country, it's different, and I think for me it's, it's the cost which I hate to have that be the answer. Um, Right. So, and, and the cost, I mean, I'm just thinking also technology, you know, our patients. Everybody's embracing technology and is there remote technology? I mean, I know you obviously have technology that people do EKGs at home and it comes across um to you guys and all the rest of it and um that's still not going to change all the false positives that'll happen, but just, you know, is there, um, are people talking about using technology, um, so people don't have to come over to your office, for example, um, to get EKGs and such things, um, and you know, is there any way to embrace that? Um, I don't know of yet like what AI, what, what, um, what parents can do from home. I know that there are some pediatric practices that um um do EKGs in their offices, um, and sometimes I have to tell the families when they come in because they had an abnormal EKG from the pediatrician's office and then I do the EKG and it becomes normal. Um, it, you know, lies in the expertise on who's doing the EKG and then who's reading that EKG. Um, I think remotely if someone was doing, um, EKGs at their office and then that was being sent to expert pediatric cardiologists to read, I, um, I think that would be better. Than having the general pediatricians look at the readout of the EKGs because the machines always overcall. Right. So, of course, fair enough. Somebody raised their hand, but you're called Zoom user. I don't know who it is. Do you want to unmute yourself and ask your question? Yes, uh, hello, uh, hello, Marjorie, um, so Antonio Quiros here. um, Hello, uh, let me take it to the opposite end. Patients who have been chronically ill, uh, cancer patients post chemo, uh, patients who have been on steroids for a long period of time, for oral steroids for different causes, um. Any specific requirements for screening if they wanna go into sports, um, or that they should get, should they get an echo, not get an echo, or only the EKG is abnormal should thoughts on that. Um, I'm not aware, um, of, um, being on chronic steroids. I think we worry more about like anabolic steroids and that and its effects on the heart. Um, not aware of, um, Screening those that have been like on chronic steroids, um, and the, the patients that you're talking about, um, are these, are we talking about like highly competitive sports in these patients, or are we talking about like recreational, um, Um, well, we, you know, aerobic patients, for example, the little girl who at age 14 has to stop, get diagnosed with a lymphoma and has stopped playing competitive soccer for, you know, a year, then I'll take her to get through chemo and everything else, and the question becomes, and all of a sudden she's done with chemo. She considered to be, you know, at least, uh, at least in remission. Um, and, uh, it's undergoing her basically on her main stable chemo regimen, and also she wants to go back to playing soccer. Hm. Well, I think those patients, um, If they have um undergone chemotherapy that um is cardiotoxic or can be cardiotoxic, I do think that they should be evaluated to get an echo to make sure that they didn't stain any um ongoing effects or late onset um of those type of um uh chemotherapy drugs. Um, but it's not standardized, but if you're just asking me personally if someone who's had chemo. Um, and wants to go back to play, um, I would ask, do they get medications that could have affected their heart and if so, they should, um, have an evaluation with the EKG and an echo, personally, that's what I would think. Doctor, you have a comment? Yeah, I just, uh, well, two things. Um, I think that it's hard to answer that question that um was posed because, uh, of course, every situation is different. Uh, patients who have oncological problems and are treated with cancer are usually very Closely followed because of the known cardiotoxic effects of some of those agents. The reason I raised my hand though, uh, Mike, was you had asked about EKGs and any new technology. I think one of the things that's coming down the pike is artificial intelligence interpretation of EKGs. Uh, already the Mayo Clinic has programs to very accurately measure the uh the QTC interval, which is a notoriously difficult and as Marjorie suggested overread. Interval and uh they have um trained models where they can read them with a similar accuracy to Mike uh Ackerman, who's the guru in the country on long QT syndrome. um and um what's really remarkable is that some of their studies show that not only can they determine if you have long QT but they can sometimes actually identify which form of long QT from it and It can do a lot of other unusual things. For example, it can actually identify the sex of the patient. And we don't actually understand how it is that the AI model can tell whether it's a male or a female because there's nothing about electrocardiography that at least to our knowledge should easily detect that difference. And so I do think that, you know, uh if we get to an age where AI can be uh leveraged to read electrocardiograms, it may change the calculus that Marjorie was talking about, about doing uh ECGs or not. I think, uh. At the present time, I certainly would say in the vast majority of cases, we do not recommend ECG screening, but obviously, uh, the history is very important and, um, you know, any, any family history of any of the conditions that Marjorie discussed, of course, would warrant at least an ECG or at minimum a very careful history. But I do think that the uh age of uh AI interpretation of ECGs that will be as accurate or more accurate than a cardiologist are are coming very quickly actually. And I, and one thing I want to distinguish, that is not though the program on most ECG machines today that are giving the interpretation. Those are just based on some rules-based assessments and uh as Marjorie suggested, they tend to overcall things, but I do think that the age of really exceptional machine machine's ability to accurately interpret an ECGR is coming very soon. Good to know. Interesting. AI, little scary in some ways, of course, so, but all good. So, um, I think it's difficult for us also when you talk about getting an accurate history in the office, how to get an accurate history in the office, you know, in a timely manner when you're in the middle of your checkup and and all that sort of stuff and how detailed do we have to get, I think we've debated that in our office and Um, you know, the value and the history that we get, is it valuable enough, um, and such things that we still grapple with. So, um, I just wanna jump back very quickly just to medication. Um, and I had brought up stimulants. Um, you didn't bring up any other standard medications that our teenage athletes are on, OK? We have lots of patients on other medications, including things like SSRIs, which I assume is another category that You didn't include, um, and just, I have lots of conversations with my teenage athletes in the office about supplements, OK? Um, and I'm still trying to figure out a way to convince my people not to be using a lot of creatine and such things. And there's, you know, lots of discussion out there about that. Can you give me any cardiac risks that I might be able to throw to my teenagers about creatine? Oh I, I mean, I've had some, some athletes, um, that come and say that they use those, and, you know, I basically say, you know, if you, you know, cause kidney problems, and then that will cause hypertension and then hypertension when will then affect your heart and talk about that realm, um. I don't know if that actually scares them or not, um, so. Um, I feel like teenagers are so superficial that it has to be something like, oh, it makes you have acne or something for them to not want to to take those supplements. Um, but yes, when they come to my office and the parents are asking me to tell their kids to stop taking it, of course I say no, you should stop taking it, it's bad for you, and I tell them the effects of that can happen in the heart, that would be the one thing that I would. I think, um, from the heart perspective, I don't know if anybody else um has better ideas of what you can tell your patients. I don't honestly know myself. Yeah, I mean, I'm just curious if there's any known, you know, true cardio toxicity that I could, you know, present to my patients, but it doesn't necessarily sound that way. I, I think though the point about the stimulants is an important one. As Marjorie uh eloquently said, there's no evidence that that causes arrhythmias or enhances the risk of sudden cardiac death, uh, in patients. It's sort of one of those things where we, as doctors all think it might, but there's actually no evidence for that at all. What it is, what it can do though is it can raise blood pressure modestly. So that certainly is something that should be monitored in patients who are being started on stimulants, but Uh, there's actually no evidence that ECGs help in, you know, uh, managing that or that people need cardiac evaluation for that. But, um, you know, I think my understanding is that the impact on blood pressure is quite modest, but perhaps if you are borderline in your blood pressure and then you take a stimulant, it might kick you into a category where you might need therapy or at least more close follow-up. Anybody else with any other questions out there? I think, you know, I think cardiovascular screening in general, you know, it's still all this, it's still all pretty unclear. I mean, I'm, I'm going for my annual checkup for me to the doctor next week, right? I'm a marathon runner, right? I'm a long distance runner. I've done, you know, a lot of them like I still have no idea what it's. Done for my heart in a good way or a bad way, and I know I'll go and ask, do I need to go um and get a bunch of fancy tests done now, cardiac wise. I have a strong family history, um, of older people, you know, with heart disease and such, and you can get a lot of different answers. Yeah, I think I, I read somewhere where I'm sure you leak a little bit of troponins when you do um high intensity things like that. Um, but, um, I think when you get older though, you have to think factor all the other things that can affect your heart. So I think that for you, for an older person, it's harder to say, hey, like what kind of screening do you need? And I think nothing more than the norm. Right, sure. So, I think somebody else raised their hand. Did I see another hand up? Mike, it's Suzanne. Suzanne, I don't have my hand up. I don't see where to put a hand up on this thing. That's all good, but you have a comment? Yeah, I just, you know, with the, with the questionnaire, um, that you put on the screen, Laura and I have included an abbreviated questionnaire for for our kids that are doing sports, but You know, I have a problem with the questionnaires. I like shortness of breath. I mean, my God, every time I'm exercising, I'm short of breath. How does anyone, if if they're not short of breath, they're not, they're not doing cardio. Like I find the questions very difficult to, to scale, to score. And I think that there are certain kids, if I ask them that question, they're always gonna say yes and other kids that I've asked them that question, they're always gonna say no. It's, it's, I don't know how to, I don't really know how to score the questionnaire and the one that you put on the screen. It is so extensive. I would never get through my day in the month of May with all of our adolescents coming in for pre-camp physicals. Um, can you give us any advice on how to, how to ask those questions because it's just not, it's not tenable. Well, I think to the shortness of breath question, and again we're if we're talking about athletes um that you're trying to fill out their pre-participation screening, you know, it's always, do you get more short of breath than the next person? Um, that's you're on the team with, and so, you know, if they can keep up with the other kids and they get short of breath just around the same time that other kids are getting short of breath, then I say, your level of shortness of breath, I'm not as worried about if you can keep up with the other kids and you're just as short of breath with peak exercise like your peers. So I always compare it to their peers. Um, so, you know, I had one patient where I felt like I needed to do more because it was out of her norm. She was an athlete, she was, you know, a senior, and she was just more short of breath, um, with exercise than she's used to. And so when there's a, when there's a change or when you're comparing it to their peers and it's different, then that would That would make me um suspicious and do more studies, um, and I agree with you, the questionnaire is very extensive. Um, I don't know if there's a way to, uh, for those that are getting clearance for sports, um, in high school, um, to have that like a questionnaire that they fill out so that when they come in. You, you look at their answers and you go through um whatever was positive and I know for teenagers like everything is positive, like did you have chest pain? Yeah, I had chest pain yesterday when I was getting up from bed, um, but like. I don't know if there's a way to have the the personal and the family history as a form and to give it just for the pre-participation for athletes. I'm not talking about all kids, just the one, just those. I do agree with that, yeah, I asked that question a little differently than you do, Suzanne. I ask, do you have shortness of breath or chest pain that you can't explain. It's different. And um I, I think it's a better way of asking the question because in when I asked it the other way, every, yes, everybody gets short of breath, but if is it different and can you explain it? And I I that's helpful. Great, thanks. Right. Any other comment out there? Looks like we're just about at the 7 o'clock hour. Marjorie, really interesting, and I still think this is one an example of something that we're all dealing with, you know, on a daily basis, um, and still kind of trying to figure out, right? Like, you know, Suzanne, you bring up, you know, I think in our practice, you know, we do an abbreviated version, you know, you know, not the, not the full checklist, but we've kind of come up with what we thought was, you know, kind of the most important parts of this to make sure that we covered, um, what we think is the right things to be asking. But I don't think we completely satisfied with it. I, I I'm not so sure we feel that, um, you know, it's, you know, I mean, it's not a validated tool because we've kind of just implemented on our own, taking bits and pieces from places, but it's, it's still some difficult, um, kind of decision making on how to do this screening. Um, and it's become a little bit more in the forefront now based on, um, New York State and New Jersey, at least where most of our patients are from, kind of mandating some sort of screening at this point, at least when we're filling out school forms. Yeah, it's, it was a tough topic, and I, and I already knew that there was not going to be an answer at the end of this talk, so. Yeah, you told me that right before we started it, so appreciate it, absolutely. So, all right, well, listen, thank you for joining us. Uh, Marjorie's contact information is up there, um, at least there's a phone number for out of Valley. Marjorie, you can be found on Mount Sinai email, um, as well, I presume. So if anybody has any questions or they'd like to get in touch with Marjorie, I'm sure she'd be happy to speak with you. Um, and, um, we can access her both here in the city and out in Jersey. Um, again, I thank her for joining. I thank all of you for joining as well. Um, it's always nice seeing everybody out there, and I enjoy these hours. So we'll see you next month. I think next month we're gonna be talking about concussion, um, which is another interesting discussion, of course. So stay tuned there, um, and we'll send out an email, um, just confirming that date and topic, um, and again, thanks for joining. Thank you. Have a good night all.
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