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NFL CARDIAC TESTING Greg Mcmillan (Buffalo Bills’ ATC) Considerations for the ATC When Screening Professional Football Athletes

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NFL CARDIAC TESTING Greg Mcmillan (Buffalo Bills’ ATC) Considerations for the ATC When Screening Professional Football Athletes 1/27/2010 As an Athletic Trainer, What is our responsibility to our players??? Quote by NFL CARDIAC TESTING Greg McMillan (Buffalo Bills’ ATC) Considerations for the ATC when screening Professional Football Athletes Presented By: Athletic Heart Mobile Testing & Research Institute Athletic Heart Mobile Testing & Joe Rogowski MA, ATC/L, CSCS Research Institute • University of Central Florida – Exercise • ATCs, Exercise Physiologists, Physiology Program Cardiologists • Orlando Magic • Educate Professional, Collegiate, & High • NBA Combine and Summer League School ATCs on the Specifics of SCD Cardiac Coordinator • The Largest Database of Elite Athletes • Founder of Athletic Heart Mobile Testing • Specific for Athletes and Research Institute Previous Screening Problems • Affordable • Convenience • Lack of Database • Specific for Athlete Population • Advances in Testing and Equipment (2010) • Current Cardiologists Politics 1 1/27/2010 We are surrounded by false information Previous Screening Problems when it comes to screening this Addressed: population: • Cost!!! – Average Stress Test = $1,000 – $1,500/ player. Magic = $500.00/ player w/ gas analysis, HRR, etc.. • Basketball Player’s Hearts are different • Convenience Factor for Players & Athletes– At Facility – 1 Day of Testing than Football Players Hearts. – Marfan, HCM, ACA, AS, • Specialized Athlete EKG and Echo Techs – Certified in Athletic Testing – How many NBA players have died in the last 5 years compared to football, hockey, and MLB? • Advanced Technology and Equipment – (Treadmill, EKG, ECHO, Automated BP, Gas Analysis) • Coaches!!!! • My Player will be disqualified from Competition (Magic has had 2 w/ HCM) • Your Team’s Cardiologist Still Primary – Several Players in NBA played with HCM • One of a kind Elite Athlete Database – Meds and monitoring – NBA Players Disqualified? 2 1/27/2010 Sudden Cardiac Death in Young Causes of Sudden Death CORONARY ANOMALY 24% HYPERTROPHIC MARFAN CARDIOMYOPATHY 5% 36% AORTIC STENOSIS 4% MYOCARDITIS 3% ARVD 3% OTHER 25% JAMA. 1996; 276: 199-204 X-Ray at the stadium NBA Combine • Cardiologists and Orthopedists – Diagnosis!!!!! – Not Logistics – Unfortunately have no idea how to run a test. Dwight Howard Scott Charley 3 1/27/2010 Italian National Screening Study: Epidemiology (out dated?) 1979 – 2004 ( 33,735 young athletes) • Maron, MD started a registry of all cases of sudden death in athletes in 1985 – 158 sudden deaths that occurred in trained athletes Sharp Decrease in annual throughout the United States from 1985 through incidence of SCD 1995 were analyzed A 90% reduction • Sudden Death Most often Triggered by Exercise (90%) Only 4.8% needed further Most common in basketball & football (68%) Most common in male ( 9 to 1 ) testing Most common death in black male athletes Overwhelming Majority were • National Center for Catastrophic Sports Injury Research True Negatives identified 160 sudden deaths in college athletes from 1983 – 1993 (78% cardiac causes) EKG 98.8% sensitive – College athletes had 2 times greater death rate identifying abnormalities • Certain Heart Abnormalities revealed only during exercise – (i.e.) T wave inversions JAMA. 1996; (276): 199-204 , J Am Coll Cardiol. 2003; (41): 974 -980, Med Sci Sports Exer. 1995; (94): 850-856 JAMA. 1982; (247): 2535-2538, Heart: The Athlete’s Heart. 2001; (86): 722-726 Causes of Cardiac Death Among Sudden Cardiac Death in Young Young Athletes How common are the conditions that cause SCA? Hypertrophic Cardiomyopathy 1/500 Other CM/Myocarditis 1/1000 Long QT Syndrome 1-3/3000 WPW 1-3/1000 BrugadaSyndrome 1-3/10,000 Other Primary Electrical Conditions 1/1000 Coronary Artery Anomalies 1-3/1000 ~6-7/1000 Number of Sudden Athlete Deaths Number of Sudden Athlete Deaths Compared by Sport Compared by Race 4 1/27/2010 Routine Screening For Heart Sudden Death in Elite Athletes Abnormalities in Athletes • What conditions are we screening for? • Jason Collier (NBA) 27 y/o – Congenital heart disease occurs in 0.8% of births – HCM (8/1000) • Thomas Herrion (NFL) 23 Half of these are diagnosed shortly after birth, but y/o some are missed – Ischemic heart disease • ASD and PAPVR • Hank Gathers (NBA) 23 y/o – HCM • AS and Bicuspid aortic valve • HCM • Reggie Lewis (NBA) 27y/o • Coronary artery anomalies and coronary cameral – HCM fistulae • Mitral Valve Prolapse • Pete Marovich (NBA) 40 y/o – Congenital Coronary • PDA Artery Anomaly • VSD, usually small • PS fp.uni.edu/evans/Gen med con/.../SuddenDeathAmongAthletes notes.htm Sudden Death in Elite Athletes Heart Complications • Mickey Renaud (NHL) 19 y/o • Jesse Sapolu (NFL) 36 y/o – ? – Enlarged aortic root • Antonio Puerta (Soccer)22 y/o • Etan Thomas (NBA) 29 y/o • Anton Reid (Soccer)16 y/o – Aortic root leak • Ryan Shay (TRACK) 28 y/o – HCM • Juwan Howard (NBA)33 y/o – Myocarditis • Darryl Kile (MLB) 33 y/o – Congenital Coronary Artery • Fred Hoiberg (NBA) 33 y/o Anomaly – Enlarged aortic root • Damien Nash (NFL) 24 y/o • Eddie Curry (NBA) 22 y/o – HCM – HCM? • Phil O'Donnell (NHL) 35 y/o – HCM • Teddy Bruschi (NFL) 32 y/o – Stroke • Joe Kennedy (MLB) 28 y/o – HCM • Ronny Turaif (NBA) 22 y/o – Enlarged aortic root Moran et al. - Abnormal EKG in up to 95% of Patients with Hypertrophic The Athletic Heart Cardiomyopathy 5 1/27/2010 Koester et al. – Normal Coronary Artery Anatomy vs. Abnormal Coronary Artery Abnormalities Coronary Artery Anatomy. 10-20% of sudden death in athletes 97% with sudden death from coronary artery abnormalities are < 22 yrs 78% with coronary artery abnormalities and sudden death died with or immediately after exercise ECG Hypertrophic Cardiomyopathy 75-95% Abnormal 3D Echocardiography in Assessment HCM ECHO of Cardiac Function Normalize for Age and Body Size (BSA) Z score 6 1/27/2010 Bruce vs. Athlete: Critical! Cardiac Testing in the NBA Athlete Ramp • Exercise Physiologists vs. Stress Tests Bruce Test RNs TIME STAGE SPEED GRADE METS HEART RPE Stage Speed/Gra MET Heart Blood RPE RATE de S Rate Pressur e Baseline Supine / • 3D Echos 0-1 1 1.0 0.0 1.8 1-2 2 2.4 1.5 3.2 Baseline / • Wireless EKGs 2-3 3 3.0 2.5 4.1 Modified 1.7/0.0% 2.3 / 3-4 4 3.6 3.5 5.2 Bruce Modified 1.7/5.0% 3.5 / • Marfan’s Screening & HR Analysis 4-5 5 4.2 4.5 9.3 Bruce 5-6 6 4.8 5.5 10.2 1 1.7/10.0% 4.6 / (GHENT) 6-7 7 5.4 6.5 11.7 2 2.5/12.0% 7.0 / 7-8 8 6.0 7.5 13.3 3 3.4/14.0% 10.2 / 8-9 9 6.6 8.5 15.0 • Automated BP 9-10 10 7.2 9.5 16.7 4 4.2/16.0% 13.5 / 10-11 11 7.8 10.5 18.6 5 5.0/18.0% 17.2 / • Gas Analysis 11-12 12 8.4 11.5 20.5 6 5.5/22.0% 23.8 / • Protocol i.e. Bruce • Collective Research Effort from all ATCs Gas Analysis – An Additional Tool Level 1 • VO2 Max • Lactate • Resting EKG (high school / Threshold smaller budget universities) • Specific HR – Inexpensive: $20 - $50 zones • Specific Calorie – Less Accurate (coronaries, HCM, Expenditure exercise induced abnormalities) • Specific – Abnormal electrical readings during Conditioning rest. Programs – Total Time = 3 minutes Level 2 Level 3 • Stress EKG, Stress Echo, • Resting EKG & Echo – Recovery HR Analysis – (college / Professional) (College / Professional) – Addition of Echo allows diagnosis of – Treadmill (Athlete Ramp not Bruce). (HCM, Stenosis, Prolapse, etc.) • Higher HR = Increased accuracy of readings – Exercise Induced Arrhythmias – Cost: Appx. $150 - $250 – Recovery HR Analyzed – Total Time = 18 minutes – Max HR readings – BP readings – Conditioning Levels (METS) – Recovery HR – Cost: Appx . $400 • Total Time = 33 minutes 7 1/27/2010 Cardiac Trevor Ariza 8:00 AM Schedule JJ Redick 8:45 AM 09/01/07 James Augustine 9:30 AM Marcin Gortat 10:15 AM Tony Battie 11:00 AM Hedo Turkoglu 11:45 AM Pat Garrity 12:30 PM Jameer Nelson 1:15 PM Dwight Howard 2:00 PM Keith Bogans 2:45 PM Bo Outlaw 3:30 PM Rashard Lewis 4:15 PM Adonyle Foyle 5:00 PM Carlos Arroyo 5:45 PM Keyon Dooling 6:30 PM Coaches Stan Van Gundy 7:15 PM Patrick Ewing 8:00 PM Steve Clifford 8:45 PM Bob Bayer 9:30 PM 8.
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