Feasibility and diagnostic performance of including point-of-care ultrasound (POCUS) in preparticipation screening of young competitive athletes

Optimal pre-participative screening in young athletes is still controversial. We sought to evaluate the strategy of including point-of-care ultrasound to electrocardiogram. In total, 1188 young competitive athletes were screened in different sports institutions. This proved to be a useful strategy by improving diagnostic performance primarily with respect to detect structural abnormalities and also by minimising positive false cases of electrocardiogram alone.

6124Aorta and sports. the silent threat

Background Thoracic aorta is the less known component of the athlete's heart and current publications shown that may be larger in athletes. It is known that high static training and body collision sports could increase the risk of sudden death, especially in patients with aortic disease (AD). Large scale traditional screening detects underlying cardiovascular diseases which may cause sudden cardiac death (SCD), however AD might be subdiagnosed. OBJECTIVE To describe AD burden on preparticipation screening and to assess diagnostic precision of traditional screening for AD detection in trained athletes. Methods Different sports athletes were recruited to follow current European guidelines (clinical history and cardiac examination, including resting 12-lead ECG) for preparticipation screening program (PSP). Bidimensional transthoracic echocardiography (TTE) was performed in all patients to detect AD: bicuspid aortic valve (BAV), thoracic aorta dilatation by Z score (TAD) and BAV plus TAD (BAD). Athletes were excluded from competition following international criteria. Sensitivity (Sn) and specificity (Sp) were calculated with 95% Clopper-Pearson confidence intervals and results are expressed as percentajes. McNemar paired chi-square test for one sample of individuals was used to compare diagnostic precision (Sn, Sp) of PSP vs gold standard: complete assessment (for sport exclusion, SpE) or TTE (for AD or BAD detection). Significance was set at p<0.05 Results Included population (n=1123) was 22.3±6.2 y-o and 222 (19.8%) female. Five athletes (0.44% of total) were excluded from competition due to different causes. AD was found on 11 athletes (0.98%) and 4 of them had BAD (0.36%), a high risk condition with poor prognosis. Three patients with BAD were competitive cyclists and close follow up was indicated. The remaining patient with BAD was a rugby player and was excluded from competition (one out of 5 excluded patients, 20%). Diagnostic precision of PSP was better for SpE than for AD or BAD diagnosis. PSP tended to have less Sn for AD [36.4 (10.9–69.2)] and BAD [25 (0.6–80.6)] detection, than for SpE [80 (28.4–99.5); p=NS]. PSP had significant less Sp for AD [91.1 (89.3–92.7)] and BAD [90.9 (89–92.5)] diagnosis, than for SpE [97.2 (96.1–98.1); p<0.05]. Conclusions AD is subdiagnosed by current PSP and its burden may be overlooked. Despite BAD is less frequent, its finding is determinant in a significant proportion of cases to decide exclusion from competitive (high static or body collision) sports. Although PSP has good sensitivity to detect potential pathologies of SCD, AD cannot be ruled out only by normal ECG and clinical examination. Diagnostic precision of PSP for AD and BAD detection could be enhanced by TTE screening, new studies with a larger number of athletes may answer the question.

4252Additional value of stress testing for evaluation of ventricular arrhythmias in athletes undergoing preparticipation screening

Introduction The optimal protocol of athletes pre-participation screening is a matter of debate. The aim of this study is to test the additional value of exercise testing (ET) for evaluation of ventricular arrhythmias (VA) in athletes with otherwise normal findings. Methods The study included 10,975 competitive athletes who underwent preparticipation screening including ECG and stress testing. Athletes with ≥3 isolated premature ventricular beats or ≥1 repetitive VA underwent second-line investigations (echocardiography and 24-hour ambulatory ECG monitoring with a training session) and, in case of frequent, complex or exercise-induced VA or echocardiographic abnormalities, also cardiac magnetic resonance (CMR). Results 451 (4,1%) athletes were excluded for abnormalities at history, physical examination and baseline ECG. Among the remaining 10524 athletes, 524 (5%)showed VA at ET, 87 of whom underwent CMR.Echocardiography identified major cardiac abnormalities in 5 athletes and regional ventricular systolic dysfunction in 7, which were confirmed by CMR in 6. Other 12 patients with normal echocardiography had a positive CMR. In particular, in 16 subjects the CMR showed left ventricular late gadolinium enhancement suggesting myocardial fibrosis with a non-ischemic distribution. At multivariate analysis, VA observed at high work load at ET, the presence of complex VA at ET and the presence of a morphology other than infundibular or fascicular predicted an underlying pathological myocardial substrate while the presence of frequent (>500/24-hour) premature ventricular beats did not. Predictors of underlying pathological myocardial substrate Substrate Univariate Multivariable YES (n=23) NO (n=501) OR (95% IC) P OR (95% IC) P Age 17 [13–43] 15 [14–17] 1.03 [0.98 -1.06] 0.18 – Male gender 15 (65%) 184 (37%) 3.2 [1.3–7.7] <0.001 1.6 [0.7–4.8] 0.28 >500 PVBs/24-hour 7 (30%) 98 (20%) 1.8 [0.7–4.5] 0.21 – VA at high work-load 10 (44%) 78 (16%) 4.2 [1.8–9.8] <0.001 1.6 [1.1–4.7] 0.02 Couplets/NSVT at ET 14 (61%) 117 (23%) 6.2 [2.5–15] <0.001 8.5 [2.5–29] 0.01 PVBs other than infundibular/fascicular 17 (74%) 118 (24%) 6.1 [2.4–16] <0.001 3.9 [1.4–11] 0.008 Conclusions VA at ET may represent the only sign of a pathological myocardial abnormalities, such as the “isolated nonischemic left ventricular scar”, that could be the substrate for life-threatening ventricular arrhythmias. Addition of ET to baseline ECG may increase the sensitivity of PPE of competitive athletes.

P4422Myocarditis: a deceitful but not infrequent athletes' enemy

Introduction Myocarditis represents a not negligible cause of sudden death (SD) in athletes, representing the cause of 4%-14% cardiac arrests and deaths in athletes. Preparticipation screening including 12-leads basal electrocardiogram could drastically reduce SD in athletes and screening programs are therefore now recommended by most medical and sport association. At the moment, no data in literature are available about incidence of concealed myocarditis in athletes but there is general consensus about disqualification from competitive sport in the presence of myocardial fibrosis (MF). Purpose Purpose of our study was to quantify incidence of MF consistent with past myocarditis in athletes that referred to our Sport Cardiology Center for ventricular arrhythmias (VA) +/− repolarization abnormalities (RA) detected at preparticipation screening. Methods In our study we retrospectively evaluated all athletes with VA +/− RA and we quantified how many were found to have MF consistent with myocarditis at cardiac MRI. Furthermore, we evaluated characteristics of presentation in terms of clinical symptoms of myocarditis and frequency and morphology of VA. Finally, we analyzed findings of invasive diagnostic workout when performed. Results In the last two years we evaluated 111 athletes for VA +/− RA and we found MF consistent with myocarditis in 18 (16%) of them. Only 2/18 referred past febrile status probably correlated with myocarditis and 1 had symptoms consistent with acute myocarditis. Number of VA was not correlated with MF fibrosis, while polymorphic VA and exercise-correlated VA were the most frequent finding. 5/18 (28%) had also rest and/or exercise induced RA. 10/18 (55%) athletes underwent electrophysiological study without any induction of arrhythmias. 7/18 (39%) underwent also electroanatomical mapping (EAM) with pathological findings in 5/7 (71%). All of these 5 underwent endomyocardial biopsy guided by EAM and in 2 cases bioptic findings were consistent with arrhythmogenic cardyomyopahty (ACM). All 18 athletes were disqualified from competitive sport as for Italian Sport Medicine protocols. Conclusion MF consistent with past myocarditis is a not infrequent finding in athletes with VA with or without RA. Morphology and exercise behavior of VA are the most important “alarm bell”, while VA number is not correlated with MRI pathological findings. Sometimes MF interpreted as consistent with past myocarditis is actually the manifestation of ACM. Identification of these diseases is of extreme importance for athletes' safety.