CARDIOVASCULAR SCREENING IN YOUNG ATHLETES IN SARAJEVO CANTON

Potential risk of sudden death during sports participation makes screening of competitive athletes of vital importance. Congenital cardiac anomalies and non-atherosclerotic, acquired myocardial conditions are primary causes underlying exercise-induced cardiac death in young patients. Since cardiovascular conditions are the leading causes of non-traumatic, exercise-induced cardiac events, cardiovascular screening preceding sports participation in mandatory. S e objectives of this study were to determine prevalence of cardiac conditions through cardiovascular screening of young athletes and to establish preventive strategy. S e study was conducted at the Sports Medicine Center of Sarajevo Canton and at the Pediatric Clinic of University of Sarajevo Clinics Centre in the period -. S e study was supported by Canton Sarajevo Ministry of Health and Ministry of sports, science and culture. S e study targeted a group of  athletes, - years of age with average age being ,. S e group was subdivided into fi ve groups according to the age. After taking the anamnesis (family, personal and cardiological) patients were subjected to the measuring of body mass and height, blood pressure and heart rate and oxygen saturation, recording of -lead ECG, specialist examination (pediatrician, sports medicine specialist and cardiologist) and complete heart echocardiography. No examined athletes expressed subjective discomfort. Congenital cardiac anomalies were not diagnosed in any athlete. Also, cardiovascular abnormalities requiring additional evaluation, positive cardiac anamnesis, abnormal auscultatory fi ndings, hypertension or abnormal ECG fi ndings were not recognized in any patient. Moderate correlation was found among the left ventricle mass and heart rate (p<,). In order to minimalize or even possibly prevent the risk of sudden cardiac death it is necessary to establish an adequate strategy of cardiovascular screening of young athletes.


Introduction
In younger athletes, atherosclerotic conditions are rare causes of exercise-induced cardiac events.e occurrence of myocardial infarction in this age group ought to initiate investigation into non-atherosclerotic causes such as: coronary anomalies, vasculitis, drug abuse (including cocaine and possible anabolic steroids) or hereditary anomalies of lipid metabolism ().e prevention of exercise-induced cardiac events is complicated because those events are rare.It heavily depends on the selective screening of the participants and detailed evaluation of symptomatic athletes prior to the authorization of their participation in sports ().Physical activity is benefi cial regarding numerous risk factors including triglycerides, high density lipoproteins (HDL), cholesterol, blood pressure, insulin sensitivity and body mass.Modern approach is to subject all the children and adolescents involved with sports clubs to the systematic evaluation once in six months which, in Sarajevo Canton, is performed by the Sports Medicine Center.Systematic evaluation include physical examination, body mass and height measuring (anthropometric body measures compared with reference values supply key information on child's growth and development, they reflect child's health and nutritive status), ECG, blood analysis, oxygen saturation, heart rate and blood pressure.Also, the athletes must meet certain physical requirements determined by the type of sports.Obviously, such systematic evaluation cannot identify children and adolescents with no apparent diffi culties but who may have underlying congenital cardiac anomalies or myocardial conditions.Myocardium may be evaluated by ECG and provide an insight into an athletes health.In current era, all the sports demand extreme efforts.Accidents might ensue that are caused by a combination of extreme physical eff ort and underlying condition that remained undetected or not perceived.
e objectives of this study were to determine prevalence of cardiac conditions through pediatric clinical, sports-medicine examinations and non-invasive tests that include echocardiography in children and adolescent athletes and to establish prevention and healthcare.The procedure includes evaluation of: -heart morphology, -heart haemodynamics, -determination of heart ejection power, -origins of coronary arteries.
Education of parents and sports workers on the prevention of coronary diseases is conducted simultaneously.

Patients
e prospective study included  boys.e subjects' age ranged between  and .All the subjects were from the area of Sarajevo Canton.The inclusion criterion was active sports participation.e study protocol included taking the medical history (family, personal and cardiological) followed by specialist examinations conducted by three independent physicians: pediatrician, sports medicine specialist and pediatric cardiologist.

Methods
Within the examination scope the following health services were provided: . measuring body mess (kg) and height (cm) using stadiometer and calibrated scale and determination of body mass index (BMI), . measuring blood pressure (mmHg), heart rate, oxygen saturation in  using digital sphygmomanometer and pulse oxymeter, . standard -lead ECG recording, . heart echocardiography was performed using Toshiba and GE apparatus, . MHz probes, with standard sections using M mod, B mod, CW Color Doppler technique.e analyzed parameters are presented in millimeters (mm) per body mass (BM) in kilograms (kg): LV end-diastolic diameter (EDD LV), LV end-systolic diameter (ESD LV), intraventricular septum diameter (S), LV posterior wall (LVPW), LV reduction fraction (RF) with supramitral fl ow (SMF).Thus, the target group included children and adolescents who actively pursue sports activities within sports clubs.e methods of descriptive statistics were applied.

Statistics
All statistical analyses were performed using Med-Calc for Windows, version ... (MedCalc Software, Mariakerke, Belgium).Means and standard deviations (SD) were calculated for all variables.Univariate relationship between left ventricular mass and BSA or pulse was assessed with Pearson correlation analysis.A value of p<, was regarded as a statistically significant difference.

Results
e processed data pool pertained to  boys whose age ranged between  and  years.Average age was , years (SD ,).e group was divided into fi ve subgroups according to body mass: G (- kg), G (- kg), G (- kg), G (- kg) and G (- kg).Anthropometric data is presented in Table .
Average blood pressure values were , (SD ,) mmHg for systolic and , (SD ,) mmHg for diastolic.Average heart rate was , (SD ,) beat/min.Both blood pressure values and hart rate were within reference range for the appropriate age.Auscultatory heart finding and cardiac anamnesis were negative in all the subjects as well as visual examination for syndromes including Marfan.ECG analysis showed the usual average values: PR interval was , (SD ,) msec, QRS complex was , (SD ,) msec and QTc was , (SD ,).The observed ECG values were concurrent with the range appropriate for this age group.

Echocardiographic measurements
Echocardiographic data analyzed for all the subject groups are presented in Table .e data include mean values and standard deviations for the following parameters: left ventricular diastolic diameter (LVDD), left ventricular systolic diameter (LVSD), interventricular septum diastolic thickness (IVSd), LV posterior wall diastolic thickness (LVPWd), left ventricular mass (LV Mass) and left ventricular index mass (LV Index Mass).
We analyzed correlation between left ventricle mass and body surface and established significant correlation at p<, (r=,,  CI ,-,) (Chart ).The results were simmilar in the analyses of correlation between left ventricle mass and hight (p<,, r=,,  CI ,-,) and between left ventricle mass and body mass (p<,, r=,,  CI ,-,).Moderate correlation was established between left ventricle mass and heart rate p<,, r=-,,  CI -, to -,) (Chart ).().None of the listed anomalies were identifi ed in our group of athletes.Also, revision of athletes' histories in Sarajevo Canton revealed no exercise-induced deaths over the last  years.Unlike Italian athletes series (,), the most frequent causes of exercise-induced death were right ventricular cardiomyopathy or right ventricular dysplasia.Incidence of mayor cardiovascular complications during exercise is low in young individuals because of low prevalence of cardiac abnormalities.Furthermore, an existent cardiac abnormality does not necessarily result in cardiac event.For example, the prevalence of echo-cardiographic finding of LVH that is consistent with HCM is / or ,  in American adolescents () but the incidence of exercise-induced sudden cardiac death (SCD) is much lower.is fact may be explained by self elimination of the aff ected individuals from sports, effi cient screening program or genetic variation of these conditions.American Heart Association recommends the evaluation of personal and family anamnesis and physical examination for highschool students prior to sports participation as well as regular systematic examination once in four years ().e examination includes visual inspections for signs of Marfan syndrome, blood pressure, auscultation in standing and sitting positions and by Valsalva maneuver.Routine ECG or echocardiographs are not recommended although extensive examinations are recommended in the cases with recognized cardiac symptoms.is document underlines the importance of the presence of a skilled coach with certificate in basic reanimation as well as additional personnel present in training sessions and during competition ().In their study on  highschool athletes Fuller et al. report on the significance of medical anamnesis, cardiac auscultation and ECG recording ().
In  athletes additional evaluation was required because of cardiovascular abnormalities that included: suggestive cardiac anamnesis (), abnormal auscultatory findings (), hypertension (,) or abnormal ECG (,).Further sports participation was discontinued for  athletes due to serious aortic insuffi ciency (n=), serious hypertension (n=), WPW fi ndings (n=), premature ventricular contractions (n=), right branch block (n=) and supraventricular tachycardia (n=).The authors conclude that ECG screening does increase possibility for the detection cardiac abnormalities; however, most of the signifi cant abnormalities may be detected by physical examination.In our study, cardiac anamnesis was negative in all the participants as well as auscultatory finding.We did not detect congenital cardiac anomalies, abnormal coronary arteries outflow, significant hypertension, WPW finding or supraventricular tachycardia.Incomplete right branch block was diagnosed in n= athletes (,).
Long-term physical activities lead to structural adjustments in the heart, for example increase in LV thickness, LV EDD diameter, LV mass and other features of "athletic heart".LV wall thickness is generally mild but rarely it may be signifi cant and lead to the diagnosis of HCM. is is of fundamental importance since HCM is a leading cause of sudden death in young athletes.
The distinction between physiological athlete heart and HCM mainly depends on the fi nding whether the size of left ventricular hypertrophy (LVH) surpasses the expected response to exercise.Although the distinction may be established based on either ECG or echocardiographic fi nding in certain cases HCM has no diagnostic value and the diagnosis must be supported echocardiographically.Our echocardiographic measurements of relevant parameters: EDD, ESD, S, LVPW did not confirm/indicate inscipient HCM in any of the subjects between  and  years of age.
Italian experts underline the importance of routine echocardiograph ().According to the national low passed in  all the athletes must be subjected to the examination prior to the active sports participation.e physician responsible for the examination of athletes is legally accountable for medical events that may have been prevented (,).e basic examination includes evaluation of medical history, physical examination with ECG and step test.e athletes with abnormalities undergo h ECG monitoring, echocardiograph and formal stress test.Similar strategy is implemented in Sarajevo Canton since .In  the program was amended with echocardiography and spiroergometry with the intention of making them part of regular systematic examination.In the Italian study, of  examined athletes,  were examined echocardiographically while  athletes were removed from further sports participation ().Among the disqualifi ed athletes , had cardiac problems including  athletes with HCM.Among the disqualified athletes there were  deaths although none of those with HCM.The death rate is  in  athletes.The authors compared the frequencies of HCM caused deaths in American and Italian athletes and concluded that low prevalence of HCM as a cause of death in the deceased athletes was the result of screening programme.ere are no confi rmed measures for the reduction of risk of exercise induced cardiac events in children.We support the recommendations of American heart association (AHA) for the screening of athletes which essentially include medical history evaluation and physical examination ().A simple examination and cardiac auscultation may frequently reveal numerous conditions associated with exercise-induced sudden death syndrome.AHA does not endorse routine ECG or echocardiography because of high cost and frequent false positive findings.Possibly the most effi cient strategy for the reduction of cardiac events in young athletes is careful exclusion of cardiac conditions in athletes who exhibit exertion-related symptoms.Many of the athletes who died during sports participation exhibited symptoms but were never fully examined.Also, we underline the importance of basic reanimation training for athletic coaches and the others involved with athletes.When an athlete collapses those individuals are present and they may provide valuable assistance until the arrival of the professionals.Screening of athletes for cardiovascular conditions is an ambitious project which involves intrinsic diffi culties and limitations related to the cost and sustainability.The program of athlete's screening involves numerous challenges beginning with organization, implementation, efficiency and financial demands.Preparticipation screening provides an opportunity for the prevention of sudden death in competitive athletes and it still remains disputable.Italian long-term preparticipation screening has been implemented for  years and it deserves to be mentioned because of its objectivity and the results.Italian program routinely includes standard ECG and it may identify or warn of most of cardiac events possibly responsible for sudden death in athletes including HCM, ARVC and DCM.Also, due to ECG their screening of trained athletes frequently leads to false positive fi ndings, hence routine ECG frequently requires additional diagnostic procedures in order to exclude cardiac diseases.There is still no consensus regarding adequate strategies for the screening of young athletes.It involves possible implementation of national medical programme that targets millions of young athletes (approximately  million athletes in the USA,  million in Italy and , in Canton Sarajevo) with main intent of revealing wide spectrum of medical conditions.e costs of diagnostic tests performed during screening need to be taken into consideration.Possibility of false positive fi ndings by ECG and echocardiography raises the whole range of legal claims that pertain to the removal of athletes from beneficial effects of physical activity.erefore, AHA has issued recommendations with clear guidelines for this segment of sports medicine.In this prospective study of young athletes, the need for maintenance of basic education certificate on reanimation procedures for all sports' clubs coaches was instigated in cooperation with Red Cross Organization in Sarajevo Canton.ree physicians with diff erent specialties identifi ed no major diff erences in auscultatory heart examination, which stands for honest and professional approach.All the athletes of school and adolescent age ought to be examined by pediatrician, school medicine and sports medicine specialists.When indicated by basic physical examination, auscultation, vital parameters measures and standard ECG a visit to the

Conclusion
is study was the fi rst organized cardiovascular screening of young athletes conducted in Bosnia and Herzegovina.e study included  young athletes.No signifi cant anomalies with the potential to cause lethal outcome in young athletes were found.ECG failed to identify signifi cant anomalies in heart rhythm.Also, deviations of blood pressure and heart rate from normal ranges for the relevant age were not established.Echocardiography did not reveal anomalies in LV wall thickness or EDD, ESD that may indicate possible HCM.Also, anomalies in coronary arteries outfl ow were not detected.Moderate correlation between left ventricular mass and heart rate was established (p<,).Institution of national screening programme of young athletes for cardiovascular conditions should be planned.cardiologist should be recommended.In accordance with fi nancial prospects, defi brillators for sports fi elds should be procured along with certified coaches, in order to prevent sudden death in young athletes.Institution of national screening programme of young athletes for cardiovascular conditions should be planned.

TABLE 2 .
Echocardiographic data for all the subject groups