Lessons Learned from Preparticipation Cardiovascular Screening in a State Funded Program

Zeltser, Ilana; Cannon, Bryan C.; Silvana, L; Fenrich, Arnold L.; George, Jayni; Schleifer, Jessica; Garcia, Michelle; Barnes, Aliessa; Rivenes, Shannon M.; Patt, Hanoch; Rodgers, George P.; Scott, William

doi:10.1016/j.amjcard.2012.05.018

Cited by 47 publications

(27 citation statements)

References 32 publications

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“…[20][21][22] In comparison, a recent limited echocardiographic screening study of >2000 children did not show any cases of ACAOS or high-risk CAAs. 22 The use of transesophageal echocardiography for screening is greatly limited by this method's invasiveness and cost; also, the ability to evaluate the severity of individual ACAOS cases is limited, because transesophageal echocardiography lacks precision …”

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confidence: 99%

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Novel Imaging of Coronary Artery Anomalies to Assess Their Prevalence, the Causes of Clinical Symptoms, and the Risk of Sudden Cardiac Death

Angelini¹

2014

Circ: Cardiovascular Imaging

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Downloaded from Circ Cardiovasc ImagingJuly 2014 population with echocardiography or magnetic resonance angiography (MRA) have finally established the conditions for improving our knowledge of the denominator in the risk fraction (the number of cases of SCD divided by the number of persons with CAAs in the general population rather than only in autopsy series). 15,[19][20][21][22] Definitive data about CAA-associated mortality are still lacking, because of a lack of studies based on defined and controlled populations. 13This report attempts to clarify this matter by presenting an overview of more recent and precise approaches to CAA screening, pathophysiology, and clinical evaluation. Systematic Screening for CAAsBecause CAAs are potential causes of severe clinical events in young persons and cannot be identified on the basis of a history and physical examination, various imaging modalities are being tested for their detection. Magnetic Resonance ImagingAt our Center for Coronary Artery Anomalies, recent MRAbased screening of a continuous preliminary series of 1836 students (aged between 11 and 15 years) has finally presented credible data regarding the prevalence of ACAOS. These data are essential for discovering the risk of SCD. Our method is precise, extensive, and related to a general population (the denominator).19 It involves the use of an Achieva 1.5 T A-Series scanner with 32-channel coils (Philips, Amsterdam, the Netherlands) in a mobile unit that has been visiting several public middle schools in Houston. In this ongoing study, we do not use any sedation, contrast medium, or medication.We routinely acquire standard 2-chamber, 4-chamber, and left ventricular outflow tract gradient echo steady-state free precession cine images, followed by a stack of short-axis cine images from the left ventricle, with in-plane resolution of 1.8×1.8 mm and an 8-mm slice with a 2-mm gap for 30 cardiac phases. Coronary MRA images are obtained with a 3-dimensional steady-state free precession electrocardiography-gated echo-navigator sequence with T2 prepreparation. The aortic root and the left ventricular outflow tract are included to ensure identification of the coronary ostia and proximal segments. Acquisition takes a total of 15 to 25 minutes, making this method a much simplified version of cardiac MRI.One foundational finding of this study has been that CAAs are the most frequent high-risk cardiovascular condition for SCD in young persons: indeed, 40% of young people with a high-risk cardiovascular condition have a CAA. 19 Our basic plan was to screen ≈10 000 children for only the types of CAAs capable of causing ischemia and SCD. 13,19 The term ACAOS was refined to include only unusual coronary patterns involving an anomalous aortic origin that the literature suggested could result in a high-risk cardiovascular condition: patterns characterized by an intramural aortic course (previously "located between the aorta and pulmonary artery," or interarterial). 6,10,12,17 Unfortunately, this matter has not been totally resolv...

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“…15,[19][20][21][22] Definitive data about CAA-associated mortality are still lacking, because of a lack of studies based on defined and controlled populations. …”

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confidence: 99%

Novel Imaging of Coronary Artery Anomalies to Assess Their Prevalence, the Causes of Clinical Symptoms, and the Risk of Sudden Cardiac Death

Angelini¹

2014

Circ: Cardiovascular Imaging

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“…Several recent studies add additional information to fill evidence gaps. Zeltser et al 18 report the results from a state-funded screening program in Texas using health questionnaires, physical examinations, electrocardiography, and limited echocardiograms. Health questionnaires were of limited value.…”

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Cardiac Arrest in Children and Young Adults

Atkins

2012

Circulation

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“…24 The ECG was abnormal in 2.3% with many false-positive results by history. Only 0.4% eventually received a positive diagnosis and 66.7% did not return for follow-up, including one-third of those suspected of HCM after ECG and echocardiogram.…”

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Electrocardiographic Screening of All Infants, Children, and Teenagers Should Be Performed

Vetter

2014

Circulation

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Vetter ECG Screening of All Youth 689associated with screening, prevalence of SCD conditions, time and frequency of screening, targeted or nontargeted screening, outcomes of those excluded from sport or accommodations to allow sport to continue, and the natural history of conditions identified by screening in asymptomatic individuals. 10In the young, SCA is associated with structural and electric cardiac abnormalities, including hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy, long QT syndrome (LQTS), other electrophysiological conditions including Brugada syndrome, Wolff-ParkinsonWhite syndrome, catecholaminergic polymorphic ventricular tachycardia, coronary artery anomalies, congenital heart defects, myocarditis, Marfan syndrome, and others.11 It has been estimated that 10% to 15% of cases labeled as SIDS are actually related to channelopathies. 12,13 SCA is the major cause of death in young athletes with death reported to occur with or shortly after exercise in 80% of athlete deaths. 9 What Is the Purpose of Screening in Children?A difficult issue that confounds the discussion about ECG screening is whether the purpose of cardiac screening is to identify those potentially at risk for a SCA or only to prevent SCD. Ultimately, we all want to prevent SCD, but we cannot prevent what we do not see. Identification allows the application of clinical guidelines with surveillance for changes in symptoms or clinical status.There is no evidence that current screening practice of using history and physical examination (H&P) alone is decreasing the overall occurrence of SCD.14 Screening with an ECG has been shown to identify at-risk youth and should be considered a good first step, but it cannot be considered definitive because additional testing often is required for diagnostic confirmation. We know from multiple clinical reports that death in individuals with SCD-related conditions can be prevented once treatment using standard medical practices is initiated. It is logical to consider that any method that identifies at-risk individuals allows us to use recommended interventions to prevent death. Reports of ECG Screening in Youth ECG Screening of Newborns in ItalySchwartz reported on a newborn ECG screening program to identify prolonged QT intervals. 15,16 Of 33 000 neonates studied, half of 24 infants who died of SIDS had QTc of >0.44 s with 4 ≥0.46 s. 15 Molecular genetic studies have shown that ≈10% of SIDS cases have functionally significant genetic variants or mutations in LQTS genes. 12,17 The Italian neonatal screening program also showed an incidence of prolonged QTc >0.47 s of 0.07% and identified a LQTS mutation in 50% of those genotyped with QTc intervals of >0.46 s. 16 Early identification and treatment has the potential to provide lifetime protection for those identified with LQTS. Additionally, identification of a neonate can lead to the identification of multiple family members and could prevent SCD in these individuals. 18 ECG Screening in JapanMass screening of school c...

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Lessons Learned from Preparticipation Cardiovascular Screening in a State Funded Program

Cited by 47 publications

References 32 publications

Novel Imaging of Coronary Artery Anomalies to Assess Their Prevalence, the Causes of Clinical Symptoms, and the Risk of Sudden Cardiac Death

Novel Imaging of Coronary Artery Anomalies to Assess Their Prevalence, the Causes of Clinical Symptoms, and the Risk of Sudden Cardiac Death

Cardiac Arrest in Children and Young Adults

Electrocardiographic Screening of All Infants, Children, and Teenagers Should Be Performed

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