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THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 3 - MARCH 2022


Groups Endorse ECG Screening for Athletes

Obstacles such as cost, staffing, and the likelihood of false-positives have prevented cardiac diagnostic tests such as 12-lead electrocardiography (ECG) from becoming a routine part of the preparticipation examination (PPE) in most countries, including the United States. Two international medical groups, however, have recently endorsed the inclusion of the 12-lead ECG in the PPE.

In December 2004, the International Olympic Committee (IOC) medical commission released a consensus statement that outlines standards for the cardiac PPE, which includes 12-lead ECG testing.1 Soon after, in February, study groups of the European Society of Cardiology published a consensus statement proposing a European standard for cardiac evaluation of athletes that includes the 12-lead ECG.2

The Scope of the Problem

Estimates of sudden death in high school athletes range from 1 in 100,000 to 1 in 300,000, and sudden death is disproportionately higher in male athletes.3,4 An Italian study5 projected that adolescents and young adults who compete in sports are more than twice as likely to die as their nonathletic peers.

In 1996, the American Heart Association (AHA) released guidelines for the cardiac PPE that are still in use.6 Since then, sports cardiologists and PPE experts have pushed for the adoption of a national standardized cardiac PPE, because the cardiac component of the PPE forms used by several states do not conform to AHA recommendations. The recently updated PPE monograph7 incorporates the AHA guidelines and provides further guidance about the cardiac component of the exam.

The AHA recommendations state that ECG testing is not cost-effective for screening large numbers of athletes because of its low specificity. Italians, however, have been doing ECG screening of athletes for 25 years as part of a government-mandated PPE policy. High-profile sudden deaths in athletes combined with high hopes that technologic advances will make noninvasive cardiac tests more cost efficient still fuel discussions about adding the ECG to the PPE.

IOC Advances Care for its Athletes

The IOC statement, commonly referred to as the Lausanne recommendations, advises that participants in competitive sports who are younger than age 35 undergo a preparticipation cardiovascular screening at least every other year that includes:

  • A detailed personal history to rule out any potentially detectable cardiovascular condition,
  • A detailed family history to detect inherited cardiomyopathies, heart rhythm problems such as long QT syndrome, and connective tissue disorders such as Marfan syndrome,
  • A physical examination, and
  • 12-lead resting ECG after the onset of puberty to detect rhythm, conduction, or repolarization abnormalities.

The Lausanne recommendations also suggest that athletes who have a positive personal history, have a family history of an inherited cardiac disease, or have positive findings on the physical exam or ECG be refereed to an age-appropriate cardiologist for further evaluation.

Joel I. Brenner, MD, director of pediatric cardiology at Johns Hopkins University in Baltimore, was part of the group that drafted the consensus statement. Brenner says the IOC's statement isn't intended to influence global cardiac PPE policies. "They're clearly making this recommendation for their own constituents: the Olympic medical community and the sports federations," he says. Brenner says the statement signals that the IOC medical commission is shifting its focus back to its original mission of safeguarding the health and safety of athletes. Doping responsibilities are now maintained by the World Anti-Doping Agency.

The consensus group realizes that not all countries have the resources to cover the cost of ECG testing their athletes. "Some can't even buy shoes for their athletes," he says.

Europeans Seek a Common Standard

Italy's 25-year history of ECG screening of athletes, and the contributions to the medical literature that have followed, are a central theme in the European recommendations that advocate inclusion of ECG testing to increase the sensitivity for conditions that increase the risk of sudden cardiac death.

In advocating for the inclusion of the ECG in the PPE, the European group states that, based on Italian findings, the 12-lead ECG may be as sensitive as echocardiography in detecting hypertrophic cardiomopathy, the leading cause of sudden death in young competitive athletes. The authors wrote: "These findings indicate that the Italian screening modality has 77% greater power for detecting HCM and expected to result in a corresponding additional number of lives saved." They estimated that the increased diagnostic power triples the cost effectiveness of the Italian strategy as compared with the US screening protocol.

The group proposes that a cardiac PPE that combines a thorough history, physical exam, and ECG screening be adopted as a European standard for medical evaluation of competitive athletes. It suggests that screening should start at the beginning of an athlete's competitive career (at about ages 12 to 14) and be repeated at least every 2 years.

Though the group recognizes that different socioeconomic and cultural conditions across Europe may make standardizing the 12-lead ECG difficult, they believe the increased cost is reasonable. They estimate that mass ECG screenings would add 10 Euros ($13.25 US) to the cost of the cardiac PPE. They add that costs are generally covered by the athlete or the sports team, and that national health systems often cover the exam for athletes who are younger than 18.

Will Statements Influence North American Policies?

In an editorial8 in the European Heart Journal that accompanied the European group's consensus statement, Barry J. Maron, MD, an expert on sudden cardiac death in athletes who directs the Hypertrophic Cardiomyopathy Center at the Minneapolis Heart Institute Foundation in Minneapolis, lauded the idea of a common European protocol and praised the group's efforts to increase awareness and interest in sudden cardiac death across Europe. Maron writes: "Extending this Italian programme to other European countries would certainly be a laudable enterprise, for it has the potential to save young lives. Nevertheless, the central challenge is one of practicality, feasibility, and implementation—with the primary potential obstacle being adequate resources and economic support.

Maron believes that it's highly unlikely that the US could adopt a cardiac PPE policy that includes mass 12-lead ECG screening. With a population of 284 million people and 12 to 15 million widely dispersed sports participants, "There are simply too many competing healthcare priorities and special interests and anticipated difficulties in cost control, as well as heightened concerns for medicolegal liability, to warrant serious consideration for such an undertaking in the United States," Maron wrote.

Though Maron says the suggestions by the European group and the IOC would be superior to the current US cardiac PPE strategies, adding ECG screening would present serious problems. "It could also be expected to be fraught with the major limitation of many false-positive test results and reevaluations, which would negatively impact available resources and increase the psychological burden on the athletes, families, coaches, and institutions."

In Canada, the obstacles are similar, despite the fact that Canadian healthcare is partially nationalized, says Andrew Pipe, MD, chair of the Canadian Centre for Ethics in Sport and a physician at the University of Ottawa Heart Institute. He says the examinations by third parties such as insurance companies or athletic organizations are not covered by provincial health services. "Thus, they would become the responsibility of the athlete or the athletic organizations requesting the test. As a consequence, it is unlikely that such testing will be formalized," Pipe says.

Pipe, like Maron, is concerned about the technical comfort levels of those who would be interpreting ECGs if widespread screening for athletes were instituted. "Our experience in addressing the concerns raised by clinicians who are unfamiliar with the ECG changes that commonly occur in athletes serves to underscore Dr Maron's point, in this regard," he says. While the public might perceive that adding an extra screening step to the cardiac PPE as a manageable change, physicians who perform PPE exams know how complex the process really is, Pipe says.

Public health would be better served if clinicians worried less about the small minority of individuals for whom exercise may be hazardous and focus more on the number of young people who are sedentary, Pipe says. "A cynic might suggest that they need a medical exam to determine whether they are able to withstand the 'rigors' and risks of a sedentary, obesogenic lifestyle!" he adds.

Brenner emphasizes that there is no perfect system for the cardiac PPE, but that the current systems can always be improved, even for Olympic-level athletes. Within the United States Olympic Committee (USOC), Brenner says he's aware of two athlete deaths during training in the last two decades. "One clearly might have been avoided if a better history had been taken, because there was evidence of syncope with activity," he says, "So it's safe to say that 50% of deaths could have been avoided." While mass ECG screening might not be realistic, clinicians can still improve the process by taking a thorough approach to the patient and family histories, Brenner says, adding that the USOC has already adopted a more rigorous cardiac history form.

Lisa Schnirring
Minneapolis

REFERENCES

  1. International Olympic Committee Medical Commission: Sudden cardiovascular death in sport: Lausanne recommendations. Available at https://www.olympic.org/uk/organisation/commissions/medical/full_story_uk.asp?id=1178. Accessed February 17, 2005
  2. Study Group of Sport 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: Cardiovascular preparticipation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Eur Heart J 2005;26(5):516-524
  3. Maron BJ, Shirani J, Poliac LC, et al: Sudden death in young competitive athletes: clinical, demographic, and pathological profiles. JAMA 1996;276(3):199-204
  4. Van Camp SP, Bloor CM, Mueller FO, et al: Nontraumatic sports deaths in high school and college athletes. Med Sci Sports Exerc 1995;27(5):641-647
  5. Corrado D, Basso C, Rizzoli G, et al: Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol 2003;42(11):1959-1963
  6. Maron BJ, Thompson PD, Puffer JC, et al: Cardiovascular preparticipation screening of competitive athletes: a statement for health professionals from the sudden death committee (clinical cardiology) and congenital cardiac defects committee (cardiovascular disease in the young), American Heart Association. Circulation 1996;94(4):850-856
  7. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine: Preparticipation Physical Evaluation, ed 3. Minneapolis, New York City, McGraw-Hill Inc, 2004
  8. Maron BJ: How should we screen competitive athletes for cardiovascular disease? Eur Heart J 2005;26(5):428-430


New Study Sheds Light on MRSA in Sports

It's not often that a professional football team, its field, and its locker room are transformed into a scientific laboratory. But that's exactly what happened during the 2003 season when the St Louis Rams experienced an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) infection.

The outbreak prompted the team to invite a roster of researchers from the Centers for Disease Control and Prevention (CDC) to investigate the outbreak. The researchers observed on-field and off-field activities, performed a retrospective cohort study to identify risk factors for infection, took nasal swabs, and cultured the artificial turf and whirlpool water. Their findings were detailed in the February 3 issue of the New England Journal of Medicine.1

Eight infections occurred in five Rams players during the 3-month study interval. Researchers reported that the infections developed at the site of abrasions on elbows, forearms, or knees. The infections progressed quickly to large (5 to 7 cm) abscesses that required incision and drainage. None of the infections required hospitalization, but the players who had infections missed a total of 17 days of practice or games.

Risk Factor Profile

In their survey of practices in the training and locker rooms, the CDC observers documented:

  • Lack of regular access to hand hygiene products among athletic trainers who provided wound care,
  • Frequent sharing of towels on the field among players,
  • Infrequent showers before players entered communal whirlpools, and
  • No routine for cleaning weight-training machines and physical therapy equipment.

Investigators' evaluation of risk factors found that linebackers and linemen had the highest risk of MRSA infection. Those who had the skin infections had a higher body mass index than players who did not develop infections. A team pharmacy log for the 2002 football season revealed that team players averaged 2.6 antimicrobial drug prescriptions that year, which is more than 10 times the rate among their peers in the general population.

Infection Control Results

The Rams' staff instituted several infection control measures at the team's training facility during the observation period. The staff:

  • Installed wall-mounted soap dispensers that contained chlorhexidine soap for routine hand washing by staff and players,
  • Instituted appropriate wound care,
  • Prescribed antibiotics that targeted MRSA, and
  • Performed regular surveillance for skin infections.

Researchers recorded only one additional case of MRSA infections after the team instituted preventive measures.

A Sport- and Community-Specific Variant?

The laboratory arm of the investigation of the MRSA that infected the five Rams players found that the organism was resistant to macrolides and oxacillin but was susceptible to ciprofloxacin, clindamycin, tetracycline, trimethoprim-sulfamethoxazole, and vancomycin.

No MRSA isolates were found in nasal swabs or environmental surfaces; however, methicillin-susceptible S aureus, which can suggest MRSA transmission patterns, was found in about 40% of nasal swabs of players and staff and on gel applicator stick for taping ankles and from whirlpool water samples.

Based on genetic analysis of the organisms, researchers determined that the organism responsible for the Rams' infections and other community outbreaks represents an emerging clone of MRSA. The clone varies from nosocomial MRSA, because it was susceptible to most antimicrobial agents, caused infections in otherwise healthy people, and exhibited a characteristic gene pattern that is associated with severe abscesses and necrotizing pneumonia.

The investigators noted that the identification of the MRSA clone makes it difficult to pin down whether transmission occurred from the community to the team or from team to team.

Jeff Hageman, MHS, an epidemiologist with the CDC who cowrote the report, says the MRSA clone seems to have adapted to the sports and community setting. "This clone seems to have emerged rapidly in just a few years. Historically, some staph clones were known to cause more disease, so perhaps we're seeing another cycle of staph disease—a cycle of more virulence and resistance," Hageman says.

Hageman says while skin abrasions are an inherent risk of playing football, some stadiums' playing surfaces, like turf at the Rams' stadium, may be more likely to cause abrasions. "Some players called it 'fuzzy concrete.' It's like steel wool on concrete," he says. Adhesive skin strips and protective sleeves should be considered for players who frequently sustain abrasions. Proper wound management is key, and players should be instructed to report their abrasions, monitor them for signs of infections, and keep them covered with bandages, Hageman adds.

The Panton-Valentine leukocidin toxin that this particular MRSA bacterium carries may produce larger abscesses with more drainage, he says, adding that prompt recognition and management of abscesses may also help prevent the spread of MRSA infections to other players.

Lisa Schnirring
Minneapolis

REFERENCES

  1. Kazakova SV, Hageman JC, Matava M, et al: A clone of methicillin-resistant Staphylococcus aureus among professional football players. N Engl J Med 2005;352(5):468-475


The New Nutrition Guidelines: Tips for Counseling Patients

When health officials announced new nutrition guidelines in January, nutrition and health experts were quick to analyze the new recommendations and highlight some of the most important changes for patients.

First published in 1980, dietary recommendations from the US Departments of Health and Human Services and Agriculture are reviewed and updated every 5 years. The food pyramid is also undergoing revision and will be released in the spring of 2005.

Marna Canterbury, MS, RD, LD, a Minneapolis-based health communicator and nutrition consultant, says one overall theme of the new recommendations is a focus on a higher-quality diet.

Increase fruit and vegetables. The recommendations raise the daily goal for fruit and vegetable servings to nine per day, which translates to 2 cups of fruit and 2-1/2 cups of vegetables. Nine servings is based on eating 2,000 calories, so some individuals will need more than nine; some need fewer. Consumers should focus attention on the fiber content of their selections and enjoy a variety of vegetable subgroups: dark green, orange, legumes, starchy vegetables, and other vegetables. "The colors are nice markers for people. The dark greens and dark oranges are highest in phytochemicals and antioxidants such as lycopene and beta-carotene," Canterbury says.

Nancy Clark, MS, RD, director of Nutrition Services at SportsMedicine Associates in the Boston area, says she's happy to see the fruit and vegetable servings clarified. "People understand 'cups' better than they do 'servings.' People will now better understand that one huge salad can count as more than one serving—it's a day's allotment," she says.

Increasing fruit and vegetable consumption might seem daunting for some lower-income patients, Canterbury says. "But dried, bulk, and canned fruit and vegetables aren't necessarily more expensive, and the nutrition is still there," she says. Farmers markets are often found in urban areas and are known to have reasonable produce prices, she says, adding that physicians can encourage this by placing farmers market guides in their waiting areas. "Food support programs such as emergency food shelves are also doing a better job with offering more fresh fruit and vegetables," Canterbury says.

More whole grains. The guidelines recommend that half of the daily intake of grains should be whole-grain choices. Though some healthcare professionals have said that half is not enough, Canterbury says the three-serving recommendation is a step in the right direction. "The literature is clear, that patients can get significant preventive health benefits by increasing whole grain servings from one to three servings per day," she says. One problem is that many people don't know how to recognize whole-grain foods. "One tip is to look at the label, and the first ingredient should be the word 'whole,' such as whole oats or whole wheat," Canterbury says. Food manufacturers are making it easier and more palatable to get more whole-grain servings. "There's even a 100% whole wheat bread that's soft," she adds.

Clark adds that the whole-grain recommendation is reasonable to achieve. "That's oatmeal or Wheaties for breakfast, and multigrain bread for lunch; no burden there," she says.

Limit bad fats. Saturated fats and trans fatty acid consumption should be kept as low as possible, with most fat intake recommended as monounsaturated fats, such as fish, nuts, and vegetable oils. Canterbury says she was happy to see the guidelines take a stand on trans fats, because they increase health risks and the food industry is gearing up to begin labeling the amounts of trans fats in 2006.

Balance eating and exercise. The new guidelines recommend balancing calories consumed with calories burned and advise small portions and varied food choices. They also list three levels of activity: 30 minutes of moderate activity on most days of the week to reduce chronic disease risk, 60 minutes a day of moderate-to-vigorous activity on most days to manage and prevent weight gain, and 60 to 90 minutes a day of moderate activity to sustain weight loss.

Though some in the lay press have lampooned the exercise guidelines as being overwhelming for most people, the activity amounts are not out of line with current research, says William O. Roberts, MD, president of the American College of Sports Medicine. Roberts, who is a family physician in St Paul, says 30 minutes of daily activity remains a cardiovascular fitness goal, but that a longer duration is needed for weight loss or maintenance. "With my patients, I'm willing to start at 40 to 60 minutes, and it seems that daily is the key," he says.

Factor in calories from beverages. The guidelines serve as a reminder to count the calories that are contained in beverages. Clark says athletes often consume a lot of calories from sports drinks, soft drinks, and juices.

Limit sodium. According to the guidelines, daily sodium intake should not exceed 2,300 mg per day, and individuals should avoid adding salt to food. "This can perhaps cause problems for athletes who are heavy sweaters or salty sweaters," Clark says, "But like all nutrition advice, it's hard to talk to the masses when nutrition should really be an individual prescription."

Lisa Schnirring
Minneapolis


Field Notes

Montreal Lab Identifies New Designer Steroid

Based on a tip from an anonymous source, researchers from a World Anti-Doping Agency (WADA)-accredited lab in Montreal have identified a second designer steroid. They announced their findings on February 1 at a media teleconference that was sponsored by WADA.

Christiane Ayotte, PhD, head of the Montreal antidoping lab, says the new substance, desoxymethyltestosterone (DMT), is similar to tetrahydrogestrinone (THG; see figure below), the substance that is at the center of another doping scandal involving athletes who obtained substances from the Bay Area Laboratory Cooperative (BALCO) near San Francisco.

Ayotte said the whistleblower, who contacted her lab in June 2004, advised scientists to investigate a vial of oily substance that had been confiscated by Canadian customs officials in December 2003 at the western US-Canada border. Several media outlets have reported that the substance was seized from a former Canadian sprinter who was allegedly attempting to import the substance from the US.

The analysis of DMT shows that the new substance is more complex than THG, Ayotte said. "Several steps went into the synthesis of DMT, and some were chemical reactions that are very dangerous, which suggests that we have serious chemists with organic chemistry background who are helping athletes," she said, adding that the drug was probably created in a lab that had the equipment for working in an anhydrous environment. Ayotte said doping experts are deeply concerned about the danger these drugs pose to athletes, because substances such as DMT can contain toxic components that remain in the drug from the chemical reactions.

Despite the sophistication, Ayotte doubted that the substance would have been undetectable. The parent compound, she says, appears to be methyltestosterone, one of the first oral testosterones. "There is a characteristic feature on that molecule," she said. "They thought that modifying it would make it invisible."

The results of the DMT analysis have been shared with other antidoping labs, which enable them to detect the new substance in urine samples. Ayotte say more work needs to be done on the metabolites and the pharmacologic properties of DMT to see if the drug has true anabolic properties.

Researchers believe that DMT, like THG, is a topically applied drug that has been combined with other substances.

Olivier Rabin, PhD, science director of WADA, says there's no evidence of a DMT epidemic among athletes. He said that thousands of previously collected samples have been tested, and that no positive results have been found.

Ayotte said scientists are tracking additional designer steroids, and she credits WADA for streamlining the investigations and sharing of information. "In this instance, we're potentially ahead of the dopers," she said. "We take this seriously, and the system is set up to show clean athletes that we're doing everything we can."


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