Simplified MRI Imaging Tests May Help ID Kids at High CV Risk During Sports

Of more than 5,200 youths screened, more than 98.5% got a clean bill of health with the MRI and ECG-based protocol, say researchers.

Simplified MRI Imaging Tests May Help ID Kids at High CV Risk During Sports

WASHINGTON, DC—A screening protocol that utilizes simplified cardiac MRI testing in addition to an electrocardiogram and a detailed questionnaire assessing symptoms appears to reliability identify high-risk cardiovascular conditions in an unselected population of middle-school children, new research shows.

In more than 5,200 children aged 11 to 14 years old included in the Screen to Prevent (S2P) study, researchers identified 78 who had high-risk cardiovascular conditions, with 23 of these children having anomalous left and right coronary arteries and 40 having ECG defects, such as a prolonged QT interval.

Presenting the data during a featured clinical research session at the American College of Cardiology (ACC) 2017 Scientific Session, Paolo Angelini, MD (Texas Heart Institute, Houston), said the results suggest a simplified MRI-based protocol with ECG and a detailed history could be used to screen youths involved in sports or the military. Their data showed that 98.5% of the screened patients received a clean bill of health, with just 1.5% referred on to specialists for further testing.

We continue to talk about the deaths in athletes and the young during exercise, but we have not yet come up with serious policy or techniques to identify the carriers. Paolo Angelini

“We continue to talk about the deaths in athletes and the young during exercise, but we have not yet come up with serious policy or techniques to identify the carriers,” Angelini told TCTMD, referring to individuals at risk for sudden cardiac death. Unfortunately for some young athletes with a predisposing condition, the first sign of trouble is an acute ischemic or arrhythmic event resulting in sudden death during exercise or sporting competitions, he said.

In the United States, the American Heart Association (AHA) states that competitive athletic prescreening should include a targeted personal history, family history, and physical examination. The AHA does not recommend the widespread use of tests such as a 12-lead ECG or echocardiogram in mandatory preparticipation screening, but suggests these tests could be used as part of follow-up if screening identifies individuals who might have undiagnosed cardiovascular disease. MRI is also not recommended as part of the AHA’s screening protocol.    

Angelini, who serves as medical director of the Center for Coronary Artery Anomalies, said they adopted the use of MRI, ECG, and the symptom-based questionnaire to identify structural cardiac defects, such as high-risk anomalous coronary arteries, as well as electrical abnormalities, such Brugada syndrome, Wolfe-Parkinson-Parkinson syndrome, and prolonged QT intervals. The MRI scan specifically looks to identify left and right anomalous coronary arteries from the opposite sinus origin with intramural course, which are high-risk anomalies that during strenuous exercise predispose individuals to ischemia and sudden death.

The simplified MRI takes approximately 20% of the time required for normal cardiac MRIs, said Angelini, and it is much cheaper than a full cardiac scan.

Of the 1.5% of children with high-risk cardiovascular conditions, 29.5% had high-risk anomalous coronary arteries, 19.5% had a cardiomyopathy, and 51.2% had an ECG defect detected. For the 15 children with a cardiomyopathy, 12 had dilated cardiomyopathy and 3 had hypertrophic cardiomyopathy (HCM), amounting to 0.23% and 0.03% of the 5,255 subjects participating in the screening protocol. HCM was much less frequent in the S2P study than in reported autopsy studies of sudden death patients, which may be because subjects were quite young, noted Angelini. In older subjects, such as those aged 18 to 25 years, exercise training over the years may result in progressive hypertrophy in individuals with genetic predisposition for HCM, he said.  

Almost a quarter of the students reported cardiovascular symptoms on the questionnaire. Of these, 10.9% reported shortness of breath, 9.4% reported chest pain, 1.9% reported syncope at rest, and 1.5% reported syncope with exercise. “Normally, after this, with a history and physical only, you would send these patients with symptoms to a cardiologist to be evaluated,” said Angelini. “It’s a lot of cost and work—more than 20% of our population.”

He noted that in their analysis, patient symptoms were not correlated with any high-risk cardiac conditions identified by MRI.    

Richard Kovacs, MD (Indiana University School of Medicine, Indianapolis), who participated in an ACC panel discussing the research, noted that that widespread screening of young, competitive athletes remains controversial.

To TCTMD, Kovacs said he was impressed by the study, most notably by the researchers’ ability to screen more than 5,000 children with MRI and ECG. “It took the resources of the Texas Heart Institute to pull this kind of screening off,” said Kovacs. “Most of us would not have that kind of infrastructure for screening with MRI. It was truly novel.”

He said that some publications have shown echocardiography can identify coronary anomalies, but in most echocardiographic screening programs “it is really just not proven to be a feasible technique shown to be accurate for screening.” Regarding the wider use of MRI screening for the high-school or college-level athlete, Kovacs noted that the imaging modality is still technically intense and relatively expensive, “which makes it unlikely to be a widely adopted screening tool,” said Kovacs.

During the session, panelists also raised the issue of cost, noting that it is “the elephant in the room.” Angelini said if schools perform approximately 20 scans per day, the MRI costs around $200 to $250 in established institutions with dedicated programs. It’s more expensive, he said, to send approximately 20% of screened patients to a cardiologist—those identified with cardiovascular symptoms in this analysis—than to perform the simplified MRI scan.

Angelini said the US Army has expressed an interest in screening new recruits with the protocol, and that he is currently in the process of proposing the protocol for use in varsity athletes in high-school and college, as well as in professional sports.

  • Angelini PE, Cheong BV, Lenge VV, et al. Prevalence of high-risk cardiovascular conditions for sport-related SCD by an MRI-based study. Presented at: ACC 2017. March 17, 2017. Washington, DC.

  • Angelini reports no conflicts of interest.

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