Q&As with Antonio Pelliccia, cardiologist for athletes

For journal club we looked at the paper below. You can read a summary of this paper here.

Pelliccia A, Di Paolo FM, Quattrini FM, et al. Outcomes in athletes with marked ECG repolarization abnormalities. N Engl J Med 2008. 10: 152-61.

I was given the unique opportunity to ask the lead author, Antonio Pelliccia, some questions about his research. You can find out more about Antonio and his resarch here. I hope you find this Q&A session interesting and it gives you a better insight into his research and sudden cardiac death in athletes.

Q. Why did you decide to carry out this research?

A. The reason we carried out this work derived from our clinical practice. Not infrequently we observed, in our Olympic program, abnormal ECG patterns in the absence of any evidence for structural cardiac abnormality, symptoms or family evidence of cardiomyopathies. We were extremely curious to understand if these abnormal patterns, i.e., markedly and diffusely  inverted T-waves, were related to training or were the first and unique expression of unexpressed cardiac disease (i.e., cardiomyopathies).

Q. Why did you carry out a case-control design study and not a cohort?

A. The study started simply as an observational, prospective study on a cohort of athletes with abnormal repolarization pattern. Subsequently, the Editor of the NEJM asked for a control group and, therefore, we adapted our study population consistently. This has made our results more reliable and strengthen our observations.

Q. As a result of your research and other research in this area, do you think the regulations need changing for screening athletes?

A. Our result support the utility of ECG in screening athlete population during childhood and youth. Our results suggest that individuals showing abnormal repolarization patterns need to undergo serial (annual) evaluation, because they have the risk to develop a clinically patent disease.

Q. If athletes and the general public are worried about the increased media coverage of sudden cardiac death in athletes, what advice would you give to them?

A. Apparently, this is a period the media pay particular attention to the sudden deaths in elite and competitive athletes. Information should possibly include the effective value of the pre-participation screening, capable to pick most (although not all) subjects with cardiomyopathies. However, the screening does not guarantee the zero risk, due to lack of reliable strategies to identify in life other conditions, such as congenital coronary artery anomalies. Therefore, we should also support the implementation of the AEDs on the athletic fields as largely as possible.

Q. I recently attended the Marathon Medicine 2012 conference in London where we were informed about the differences in risk between men and women for sudden cardiac death. Were the athletes with cardiovascular conditions in your study male or female and do you think this affected your results?

A. In our study population, majority were males (63, or 78%) at the study entry. This disproportion between sexes reflects the larger proportion of male vs. female competitive athletes, as well as the larger incidence of abnormal repolarization patterns in males vs. females. Finally, all the events we reported in this study occurred in males. Our observations are in agreement with previous reports describing larger proportion of either abnormal ECGs and incidence of cardiac events, including sudden deaths, in males vs. females.

Q. Are you carrying out any further research in this field to see if the abnormal ECGs are initial expressions of heart disease or innocent expressions of cardiac remodelling that is associated with an athlete’s heart?

A. We are still working on this field. In particular, we were wondering why the largest  proportion of athletes we observed after a long-term did not develop symptoms or morphologic evidence for a disease. We want to be sure that this proportion does not reflect uniquely the limitations of the imaging testing or their still relative young age, and we want to asses which is the impact of their participation to competitive events for a long time period. So far, we had the chance to observe a few of these athletes reaching senior age without experiencing symptoms, or any structural cardiac disease.

Q. And finally, do you think pre-screening is really worth it if athletes continue to play on despite their awareness of an underlying heart condition?

A. The pre-participation screening is really worthy to identify individuals with silent cardiomyopathies that may be at risk. Then, appropriate evaluation and risk stratification should follow, including appropriate management and treatment (that occasionally includes drugs, or ICD, and/or withdrawn from competitive sport). Playing sport despite contrary advice is senseless and, as physician’s opinion requires condemnation  on behalf of the family, sport bodies  and scientific association. In Italy there is a federal law supporting the final physician decision and, therefore, playing against proper physical advice is illegal.

Thank you to Antonio for giving us a great insight into his research and for taking the time out to answer the questions.

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