10 Must-Have Features When Selecting an ECG System

Sudden cardiac arrest is the leading medical cause of death in athletes. A simple electrocardiogram (ECG) is a cost-effective method for identifying those at risk, far more effective than a physical exam and a review of medical history. There are many ECG manufacturers, and picking the right system for your needs can be challenging. Many organizations using older equipment face unmet needs that have led to cluttered and inefficient filing cabinets filled with paper. To remedy this, they must re-invest in appropriate technology.

This article highlights 10 key capabilities that are important considerations for your long term ECG system needs.

1. Digital Data. Digitally capturing every data element, observation, ECG trace, physician note, echo measurement and so on provides the flexibility that allows you to meet future and changing needs. Digital data will support your efforts in assessing program efficacy, process improvement, reporting and research studies. Don’t settle for just a 12-lead printout!

2. Customized Demographic Fields. Every organization has unique data collection needs: parent’s email address, clinic identifiers, medical illness, exercise frequency and so on. Customizable options for text entry and selection from drop-down lists are essential.

3. American Heart Association (AHA) 14 Point PPE questionnaire. The AHA recommends including these questions in the athlete’s Pre-Participation Exam. Important findings should be annotated on the ECG. For example, presence of syncope or chest pain while exercising might lead to a different recommendation or a second look at an ECG feature.

4. Modern Interpretation Criteria: The Seattle Criteria. The expected abnormal ECG rate is about 2%. Blinded studies demonstrate that it is uncommon for any physician to consistently read every record with an accuracy of 98– 100%. Obsolete ECG criteria that routinely provide misleading and inaccurate interpretations can distract the physician and reduce reading accuracy. Automatic interpretation using the recent Seattle Criteria provides strong physician support, similar to a consulting cardiologist assist, increasing accuracy and confidence that subtle features are appropriately noted and diagnosed.

5. Network Friendly, HIPAA Secure, Distributed Physician Overreading. The reviewing physician is often not onsite, or a consulting cardiologist may be required. Easy and secure network sharing and review of the ECG and associated digital data is an important consideration.

6. Post-Test Demographic Editing and Data Entry. Blunders happen, and the system needs to support post-test editing of errors and omissions and the addition of late arriving information.

7. Confirmed ECG PDF. Following physician review, a confirmed PDF of the ECG is generally required for the medical records, referring family physician and family. The confirmed ECG should include the physician’s name, date of confirmation, ECG status (Normal, Abnormal, etc), and physician comments. Creating the confirmed ECG PDF requires the digital ECG data and software tools that support electronic over reading.

8. Pre-Loaded Demographic Data. In large screening events entering the patient demographic information may be a time burden. When available in advance, it can be extremely helpful to pre-load these data so that just a mouse click populates the data entry screen. Importing an Excel spreadsheet is a convenient and efficient mechanism for this task. 

9. Cohort Reporting. Easy creation of an Excel spreadsheet containing all demographic data, responses to AHA questions, ECG measurements, abnormalities found, doctor’s confirmation notes, billing information, echo measurements, and so on is fundamental for managing and improving the screening process and research.

10. Software Updates. Over the past few years the accuracy and effectiveness of the ECG in identifying athletes at risk has dramatically improved. False positive rates have fallen from 15-20% to about 2%. This is an exciting and productive time for research focused on improving the sensitivity and specificity of the athlete ECG to detect life threatening abnormalities. Be sure your system can easily be updated to benefit from new insights, and be sure your vendor is actively participating in ECG research.

Perhaps this comes as no surprise, CardeaScreen scores a perfect 10, and is extremely easy to use! Watch the CardeaScreen video below:

Sports Health offers the CardeaScreen as a solution to help identify young athletes who are at risk of cardiac issues, at pricing well below many other systems on the market.

View the CardeaScreen and call us to talk about how the CardeaScreen can be a solution for you.

This blog has been written by David Hadley, PhD. President, Cardea Associates, Inc. 

The Case for Adding the ECG to Pre-Participation Exams

Sudden Death in Athletes – Not so Rare!

The leading medical cause of death in athletes is Sudden Cardiac Arrest (SCA). Although the purpose of the athlete Pre-Participation Exam (PPE), including review of the patient and family medical history and a brief physical exam, is to identify cardiovascular abnormalities that could progress to SCA, recent research has shown that the PPE does a particularly poor job of identifying risks. Conventional wisdom has proclaimed that including an Electrocardiogram (ECG) into the PPE to aid in finding those at-risk athletes is difficult, SCA is a rare event, and faulty initial evaluations (false positives) lead to unnecessary costs that would bankrupt the nation. But, as in most areas of health and science, technology and research can herald a new era. It’s time to take a fresh look at the value that can be garnered from the low-cost and highly sensitive ECG.

Who’s at Risk? 

Many screening organizations are reporting meaningful data on detection rates for cardiac abnormalities. It’s common to find that 2-3% of all participants actually have an ECG abnormality, compared to approximately 30 % of all participants who report abnormal findings in their medical history. Most of these abnormalities are unlikely to lead to SCA or disqualification from sports, but a significant number of them will impact the health of the participants over the course of their lives. Early detection can have a very positive impact on their lifetime health management. About 10 % of the abnormal group, or 1 in about 250 participants, have abnormalities that are strongly associated with SCA and follow-up is highly recommended.  Risks are also stratified by gender, ethnicity and sport:

Relative Risk	Higher	Lower
3x	Athletes	Non-Athletes
2x	Males	Females
3x	African-Americans	Caucasians
6.7x	Men's Basketball	All Sports

Sports that are characterized by sudden surges of energy, such as basketball, water polo and soccer, carry much higher risk than sports characterized by relatively constant effort, such as cross-country.  For an African-American male basketball player, the risk of death during 4 years of college play is about 1/1000, much higher than for other groups. These are risk levels that most of us would not knowingly accept.  It’s unconscionable to argue that high risk-athletes shouldn't be screened!

Where Do We Start?  

Available budget resources will guide how you begin a screening program that includes ECG.  We recommend that you initially gain experience and proficiency screening the higher-risk sports, with considerations for gender and ethnicity, with the goal of potentially saving the most lives possible with the available resources.  As efficiency and organizational support grow, you can extend the screening to a broader segment of your athletes.  The total cost of an ECG should be in the $10-$25 range, depending upon your providers – a fraction of the cost of a pair of athletic shoes.

What ECG system should we use?  

Most ECG systems implement automatic interpretation criteria that are outdated with respect to the best current consensus criteria for athletes, often referred to as the “Seattle Criteria,” ( Drezner, et al, British Journal of Sports Medicine, 2013). Use of these criteria have dropped false positive rates from around 12-15 % down to about 2 %, a factor of about 7x.  Although most cardiologists believe they can read an ECG correctly every time, recent blinded studies show that they are often in error 4 to 15 % of the time (reading based upon experience = 15 % error rate; reading based upon specific criteria with examples = 4 %).  An ECG device that implements the Seattle Criteria and is designed from the ground-up to deliver high-quality trace data, leveraging the tremendous data analysis capabilities of the modern PC, and with extended ECG recording time to improve beat estimates from bradycardic athletes, leads to much improved accuracy.  CardeaScreen is such a system and is being rapidly adopted in screening programs across America.

Learn more about the CardeaScreen (link includes FAQ's and video) >>

Sports Health would like to thank David Hadley, PhD, for writing this blog for us.

Dr. Hadley has over 30 years of hands-on experience blending customer needs with information technology through research and development. He spent nine years as Vice President of Research and Development for Quinton Cardiology. In this role, Dr. Hadley was responsible for rebuilding the engineering team, establishing robust new product architectures and developing the next generation of Quinton and Burdick diagnostic ECG products.

Prior to his role at Quinton Cardiology, Dr. Hadley was with Primus Knowledge Solutions and Sierra Geophysics. He earned his Ph.D. from the California Institute of Technology.

How to Save a Young Athlete’s Life: Pre-screen with an ECG

The Case for Using an ECG to Screen for Cardiac Disorders.

Does Pre-Screening Help Prevent Loss?

Each time a young athlete dies of a cardiac-related incident after athletic exertion, the debate over athletic pre-participation screening is reignited. The loss of a seemingly healthy young athlete to sudden cardiac death (SCD) is a jarring event that leaves people questioning what could have been done to prevent the tragedy. Cardiomyopathy leading to ventricular arrhythmia and SCD is actually the second leading cause of athlete death behind trauma. While SCD is rare, the statistics cause concern: almost 80 percent of athletes who die of a cardiac-related incident showed no symptoms prior to their death, and over 90 percent of SCDs in young athletes occur during or shortly after exercise. The NCAA estimates that nearly a dozen college student-athletes in the U.S. suffer sudden cardiac arrest each year.

The Gap in Current U.S. Recommendations

Current American Heart Association (AHA) standards do not recommend routine pre-participation screening for athletes, citing expense, burden to the healthcare system and false positive results. Rather, the AHA suggests use of a screening tool that includes 12 questions about personal and family medical history and a physical exam to identify aspects of an athlete’s health that could signal a cardiovascular problem.
But what about athletes who are not aware of, or do not have access to, extensive family history or who are reluctant to report these potential health issues for fear of being excluded from participation in their sport?
In 2005, the European Society of Cardiology recommended universal screening, and this position has been endorsed by the International Olympic Committee. Israel also requires ECGs as part of athletes’ pre-participation physicals (PPE).
These pro-screening policies are largely a result of a population-based study conducted in Italy which examined the athletic and nonathletic populations between the ages of 12 and 35 years. The annual incidence of SCD in athletes decreased by 89 percent between 1979 and 2004; whereas the incidence of SCD among the nonathletic population did not change significantly. Most of the reduced mortality rate was due to fewer cases of sudden death from cardiomyopathies.
Recent research supports the viability of screening with ECGs, despite concerns about cost and false positive results. A study commissioned by the NCAA screened 2,471 athletes from 14 NCAA Division 1 universities who had not previously received an ECG screening. Seven athletes were diagnosed with serious cardiac disorders, all of whom had abnormal ECGs, but only two of those athletes had an abnormal history or physical exam.

A Trend Toward Cardiovascular Screening in the U.S.

A recent survey of head athletic trainers in NCAA Division 1 football programs found that 35 of the 116 schools were already incorporating non-invasive cardiovascular screening (NICS) in their PPEs.
As the trend in the U.S. moves toward a more proactive approach to screening, and with mounting evidence pointing to the value of screening athletes with ECGs, perhaps athletic trainers and programs should consider partnering with contracted medical staff, or better yet should invest in an onsite ECG, like the ones found on Sports Health to have ECG testing readily available. After all, it could mean the difference between life and death for a young athlete.

Shop ECG Machines >>


Danielle Masursky, PhD
Janice Riley, RN, CRA

Bibliography

Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G.Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006 Oct 4;296(13):1593-601.
Coris EE, Sahebzamani F, Curtis A, Jennings J, Walz SM, Nugent D, Reese E, Zwygart KK, Konin JG, Pescasio M, & Drezner JA. Preparticipation cardiovascular screening among National Collegiate Athletic Association Division I Institutions. British Journal of Sports Medicine.2013; 47(3):182-4.
American Medical Society for Sports Medicine. NCAA-Funded Study Supports Screening NCAA Athletes for Sudden Cardiac Death Risk. [Press Release, April 21, 2013]. Retrieved from http://www.amssm.org.
American Heart Association: Pre-participation Cardiovascular Screening of Young Competitive Athletes: Policy Guidance (June 2012) Retrieved from http://newsroom.heart.org.

The ABC's of AEDs

An automated external defibrillator or AED is a portable electronic device that automatically diagnoses the potentially life threatening cardiac arrhythmias of ventricular fibrillation and ventricular tachycardia in patients and is able to treat them through defibrillation, the application of electrical therapy which stops the arrhythmia, allowing the heart to reestablish an effective rhythm. As reported in USA Today, November 12, 2003 a National Institute of Health showed defibrillators can double the survival rates of sudden cardiac arrest. It is estimated that 350,000 people die annually due to sudden cardiac arrest and that in ages 15-34 the incidence has risen 10% in the last decade. (Read more about sudden cardiac arrest and high school athletes here).

The first AEDwas originally designed and created by American biomedical engineer Joshua L. Koelker and Italian emergency medical professional Jordan M. Blondino to allow defibrillation in common public places. AEDs are designed to be simple to use for the layman, and the use of AEDs is taught in many first aid, first responder, and basic life support (BLS) level CPR classes in schools.

Conditions that the Device Treats

An automated external defibrillator is used in cases of life threatening cardiac arrhythmias which lead to cardiac arrest. The rhythms that the device will treat are usually limited to:

1. Pulseless Ventricular tachycardia
2. Ventricular fibrillation

In each of these two types of shockable cardiac arrhythmia, the heart is active, but in a life-threatening, dysfunctional pattern. In ventricular tachycardia, the heart beats too fast to effectively pump blood. Ultimately, ventricular tachycardia leads to ventricular fibrillation. In ventricular fibrillation, the electrical activity of the heart becomes chaotic, preventing the ventricle from effectively pumping blood. The fibrillation in the heart decreases over time, and will eventually reach asystole.
AEDs will not start a stopped heart, that is, it will not be effective in a coronary attack.  Its purpose is to counter a “fluttering” (fibrillation) of the heart muscle before it goes into cardiac arrest. The asystolic patient only has a chance of survival if, through a combination of CPR and cardiac stimulant drugs, one of the shockable rhythms can be established, which makes it imperative for CPR to be carried out prior to the arrival of a defibrillator. Estimates are that CPR alone is only 6-8% effective but CPR plus the use of an AED within 6 minutes is 80% effective.

The American Heart Association recommends automated external defibrillators in any place where there are large numbers of people. This includes airports, stadiums, large offices or industrial buildings, public buildings and large fitness centers, for example. 

Read more: American Heart Association Defibrillation Guidelines | eHow.com http://www.ehow.com/way_5577375_american-heart-association-defibrillation-guidelines.html#ixzz1NQ2GEXt1
Several states require scholastic coaches to be certified in first aid and CPR/AED usage. In 2010, the American Heart Association (AHA) released their updated guidelines for treating sudden cardiac arrest (SCA) and heart attacks.The purchasing and placement of AEDs at schools and during athletic events is both critical and legally prudent.  The American Heart Association recommendation is that an AED should be within a 2-minute walk from anywhere on school grounds/building.

Implement a School AED Program

While emergency response plans should be developed by both physical education and athletic departments, so too should be annual “simulated episodes” requiring staff to respond to various scenarios and in various locations on school grounds.

Request a free AED consultation and download the 10 common mistakes made by school AED programs >>

For additional information about AED usage and programs implementation go http://www.quickmedical.com/defibrillator/aha.html and Project ADAM at http://www.chw.org/display/PPF/DocID/26050/router.asp.

4 Steps to Prevent Heat Illness

Heat Acclimatization Guidelines Created to Decrease Heat Illness

In 2009, the National Athletic Trainers' Association released Preseason Heat-Acclimatization Guidelines for Secondary School Athletics to decrease the occurrence of heat illness in high school athletes participating in summer practices. Unfortunately, it wasn't until after the nation experienced "the worst week in the last 35 years in terms of athlete deaths" that states began mandating the adoption of these guidelines. In summer of 2011, three heat-related deaths were reported on high school football fields, four Arkansas football players were hospitalized for dehydration, and an endurance runner died of apparent heatstroke during a race called the Warrior Dash.

Heat Related Fatalities on the Rise

According to a study by Andrew J. Grundstein, an associate professor in the department of geography at the University of Georgia, the annual death rate was around one per year from 1980 to 1994 but rose to a yearly average of 2.8 in the next 15 years.

The Reason for the Rise of Heat Illness

In the past, simply scheduling summer practices for early morning and/or evening would be enough to avoid the highest temperatures of summer and reduce the risk of heat illness. However, according to Grundstein, morning temperatures are higher than they were decades ago.

Additionally, high school athletes are bigger than they were decades ago. According to Douglas J. Casa, chief operating officer of the Korey Stringer Institute, a nonprofit dedicated to preventing sudden death in sports, "You have 300-pound high school guys walking out to practice and you have no medical staff and they're going six hours in 100-degree temperatures."

4 Steps to Help Prevent Heat Illness

1. Follow the 14-day heat-acclimatization period recommended by the NATA.
2. Use a Wet Bulb Globe Temperature Meter (WBGT) — not the heat index — when assessing whether practice conditions are safe. The WBGT index is the most widely used and accepted way to assess heat stress in the United States, but getting coaches to move away from their reliance on the heat index is a challenge.
3. Have an ice water bath available if players show signs of heat stroke. Learn more >>
4. Have an athletic trainer present during all practices and games.

States that Mandate Student Safety During High Heat

• May 2011 - New Jersey State Interscholastic Athletic Association becomes first state organization to adopt heat-acclimatization guidelines.
• October 2011 - the University Interscholastic League in Texas bans two-a-days for the first four days of training camp and on consecutive days thereafter.
• State high school activity associations in Arkansas, Connecticut, North Carolina and Georgia follows suit, with Georgia instituting fines of up to $1,000 for school found in violation of their heat acclimatization mandate. Fifteen other state high school associations are actively considering adoption.

Heat Acclimatization Guidelines by State >>

Georgia Practice Policy for Heat and Humidity:

Why Heart Failure Can't Always Be Detected in the High School Athlete

Understand and Prepare for Sudden Cardiac Arrest Before An Emergency Occurs

Sudden Cardiac Arrest (SCA) is caused by sudden failure of proper heart function during or immediately following exercise. This often occurs with no known trauma. Since the heart loses its ability to effectively pump blood, the athlete quickly loses consciousness and will die. To stop this tragic cascade of events, normal rhythmical pumping of the cardiac muscle must be quickly restored using an automated external defibrillator (AED).

How Often Does SCA Occur and Who is Most at Risk?

Fortunately this tragic event is considered rare, happening about 100 reported times per year in the United States. The chances of a high school athlete suffering frame SCA is reported to be 1:200,000. SCA is more common in males, football, swimming and basketball and in African-Americans than in other races.

Heart Problems Are Difficult to Detect in High School Athletes

Typically, the athlete presents no symptoms of cardiac problems. The problem is caused by one or several cardiovascular abnormalities and electrical diseases of the heart that go unnoticed in healthy-appearing athletes. The most common cause is hypertrophic cardiomyopathy (HCM) which is an enlargement (hypertropci) of the heart muscle (myopathy) producing a thickening of the heart muscle which can cause serious heart rhythm problems and blockages to blood flow. The second cause is congenital abnormalities of the coronary arteries.

Warning signs to watch for include:

• Fainting, seizure or convulsions during physical activity
• Fainting or seizure from emotional stress or excitement
• Dizziness during exercise
• Chest pains at rest or during exercise
• Heart palpitations (skipping beats, irregular beats) during exercise or cool down periods after exercise
• Fatigue or tiring more quickly than others or than expected
• Shortness of breath limiting physical exertion

What steps can be taken to prevent tragedy during the annual pre-participation examination?

1. Parents and athletes should provide information to the examining physician about any experience with the signs and symptoms listed.
2. History of family members who died suddenly during or after exercise.
3. Any family member under the age of 50 experiencing sudden death in car accidents or drownings (unexplained heart stoppage may produce fainting or death an inopportune times).

Is There Any Tests That Can Detect These Heart Conditions?

Dr. Mark Russell, a pediatric cardiologist at the University of Michigan's C.S. Mott Children's Hospital, said no one screening test is able to detect the "several different heart conditions that can cause sudden death in a young athlete." EKGs may catch some defects, the echo others, while other problems may only be revealed in an exercise stress test.

How Can I Protect My Athletes?

Since detection can be elusive, consider the places where your athlete engages in activity - the swimming pool, the field, the gym, the weight room, the visitor's field - and consider having an AED available in these places to protect from the unexpected.

Find information on the AEDs available on the market today and request a FREE AED consultation >>

More blogs on the use of AEDs in schools >>

Articles That Make the Case for Placing AEDs in Schools:

Portable Defibrillator Helps Save Christian School Coach’s Life >>

Medical: Sudden Cardiac Arrests in Young Athletes Confounds >>

Additional Resources:

• www.suddendeathathletes.org
• www.4hcm.org
• www.heart.org

Phil Hossler, ATC has been an athletic trainer on the scholastic, collegiate and Olympic levels. He has authored 4 books and numerous articles and served as an officer in state and regional athletic training associations for 20 years. He is a member of four halls of fame including the National Athletic Trainers’ Association’s.

Emergency Preparedness is Now the Norm

Certified athletic trainers have always been at the forefront of being prepared. But like any science or movement, this too has been evolving. Consider the recent action by the Professional Hockey Athletic Trainers’ Society (PHATS)(NATA NEWS 2/11) to actually place an identically prepared and stocked medical/emergency bag in each of their 30 arenas so that the visiting team may always be assured that vital supplies and equipment will always be there for them. Congrats to PHATS and to Sports Health for crystallizing this forward thinking idea!

On the high school wrestling front, look at this idea which I call the Mat-O-Matic. We all know that when a wrestler comes to the edge of the mat that having all necessary supplies on hand to save time is critical. Nose bleeds, cut lips, the opponent’s blood and blood on the uniform are all routine occurrences that need to be dealt with quickly.

The Mat-O-Matic is a garbage can with a plastic bag liner mounted onto wheels. It can roll to the edge or onto the mat for both home and visiting benches. The outer rim of the garbage supports a plywood circle with multiple holes drills around its circumference. Here are the items that are able to be positioned in these circles:

• Vaseline
  
• Gauze pads
• Nose plugs
• Hand sanitizer
• Vinyl gloves
• 3-4 cups of water
• Blood Buster
• Adhesive tape
• Elastic wrap
• Pre-wrap

In addition, hanging along the sides are:

• A container of antiseptic wipes for the athlete’s skin
• A squirt bottle of mat cleaning solution
• A Swiffer-type mop to clean blood from the mat
• Additional pads for the mop cleaner

Just like the PHATS’s philosophy of visiting teams being well taken care of, the Mat-O-Matic has become the norm at my school by visiting coaches.