Sportscreening: nuttig? nodig? overbodig? Pieter Koopman Cardiologie Elektrofysiologie Sportgeneeskunde Cardiogenetica

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2 Sportscreening: nuttig? nodig? overbodig? Pieter Koopman Cardiologie Elektrofysiologie Sportgeneeskunde Cardiogenetica

3 Screening ECG 1 Asymptomatische 17-jarige voetballer VRAAG: Zou u zijn sportkeuringsattest tekenen? ANTWOORD: 1. Ja 2. Nee

4 ECG s

6 ECG s

8 ECG s

9 Screening ECG s ECG 1: Aritmogene rechter ventrikel cardiomyopathie ECG 2: Brugada type II (saddleback) ECG 3: gezonde Afrikaanse profvoetballer met normale holter, echografie en MRI, normaal klinisch onderzoek en geen familiale plotse dood

10 Overzicht Plotse dood Sportscreening Preventie plotse dood

11 Plotse dood Eerste casus Pheidippides 490BC

12 Plotse dood Epidemiologie zeldzaam! / / j M:V = 10:1 enorme emotionele en psychologische impact jong! gezond! 40% <18j gem. 23j

13 Plotse dood Epidemiologie Plotse dood Sporttype voetbal wielrennen lopen zwemmen worstelen volleybal tennis baseball GOLF 33% 20% 16% 4.8% 3.8% 2.9% 2.9% 2.9% < 1%

14 Plotse dood Oorzaak DUURSPOR T = trigger x2.5

15 Plotse dood Oorzaak congenitaal CMP elektrisch <35j atherosclerose Fatale aritmie: VT of VF >35j

16 Oorzaak plotse dood bij atleten <35j

17 Plotse dood Etiologie TOP 10 HCM 10-35% ARVC 5-20% Coronaire anomalie 15% Commotio cordis 5-20% Aorta ruptuur / dissectie 5% DCM 2.5% Aorta stenose 2.5% Myocarditis 2.5% Getunnelde LAD 2.5% ANDERE Brugada syndroom Lang QT syndroom WPW syndroom Coronaire atherosclerose ASD Totaal AV blok Ebstein anomalie Marfan syndroom Cerebraal aneurysma

18 Hypertrofe Cardiomyopathie Incidentie 1/500 1/1000 Gen mutatie sarcomeer proteine Plotse dood door VT/VF Risico 1% per jaar 1/3 plotse dood bij atleten

19 HCM - ECG

20 HCM - Sporthart structurele remodelling, verbetert of normaliseert met detraining geen relatie tot hemodynamische belasting LV diameter >55mm vs <55mm

21 Sporthart LVH voltages vroege repolarisatie sinus bradycardie (+ AV geleidingsstoornissen)

22 Sporthart Sporttype

23 ARVC Incidentie 1/500 1/1000 Gen mutatie desmosoom proteine Plotse dood door VT/VF 15% plotse dood bij atleten Epsilon wave

24 ARVC - ECG

25 Congenitale anomalie Meestal - LCA vanuit rechter sinus van Valsalva - RCA vanuit linker sinus van Valsalva kinking compressie 1/3 symptomen bij inspanning - angor - syncope - palpitaties

26 Plotse dood: te vermijden? 1. Screening 2. Preventie

27 Screening Anamnese Klinisch onderzoek ECG SAECG Echocardiografie MRI Holter Inspanningstest Provocatietest EFO screening identificeer meeste pathologie identificeer (bijna) alle pathologie

28 Screening - Modellen USA ITALIE Anamnese Anamnese Klinisch onderzoek Klinisch onderzoek Sensit 45% cheap 12-lead ECG 10% abnormaal Echo: verdere investigatie, geen screening tool

29 Screening - Modellen HCM 95% ARVC 80% ECG goede detectie van cardiomyopathieën

30 Screening - ECG ½ SCD 2x cost

31 Screening pro/contra PRO CONTRA Publieke opinie Zeldzaam / divers Jongeren, veel levensjaren Kosteffectiviteit? Beperkte onderzoeken Vals positieven / negatieven! Sensitieve onderzoeken Vals gevoel van veiligheid!

32 Screening pro/contra 0.5% = zeldzaam!! BAYES theorema ECG: 90% Echo: 85% PPW = 3% NPW = 99.8% PPW = 4% ECG: 85% Echo: 90% 97% van abnormale ECG s zijn vals positief 96% van abnormale echo s zijn vals positief

33 Screening pro/contra Vals positieven atleten 1000 atleten Kosten / baten Anamnese + KO Anamnese + KO + ECG /QALY overlijden vermeden /LY

34 Screening pro/contra coronaire anomalie onvolledige expressie CMP en channelopathie elektrolieten stoornissen VALS NEGATIEVE N commotio cordis prematuur ASHD myocarditis

35 Screening Protocol Vanaf welke leeftijd? Om de hoeveel jaar? Socio-economische impact! Initiatief Vlaamse regering Internationaal: Seattle criteria

36 Preventie (Competitie)sport vermijden Cardiologische opvolging ICD / AED

37 Preventie - Defibrillator ICD hoog risico patienten AED bystander CPR vergemakkelijken publieke locaties computer-analyse van hartritme beslist of shock nodig is onderhoud? training?

38 Preventie ICD hoog risico patienten AED bystander CPR vergemakkelijken publieke locaties computer-analyse van hartritme beslist of shock nodig is onderhoud? training?

39 Take Home Messages Plotse dood bij atleten is extreem zeldzaam Belangrijke publieke impact! Screeningsprogramma is nuttig, niet sluitend Belang van ECG in screeningsprogramma Nog veel vragen op te lossen vooraleer systematische screening!

40 Take Home Questions WIE screenen? WANNEER screenen? HOE VAAK screenen? WELK protocol? WAT is abnormaal bij een atleet? WIE voert screening uit? WIE zal dat betalen? WAAR is infrastructuur, personeel en expertise? WIE zal de atleet na diagnose begeleiden?

41 Take Home Reassurance

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