Echocardiographic Reporting of Proximal Coronary Artery Origins in Young Competitive Athletes
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Introduction
Coronary artery anomalies are an important cause of sudden cardiac death in young competitive athletes.1 Current imaging guidelines for young competitive athletes recommend routine assessment of proximal coronary anatomy to assess for the presence of high-risk anomalies regardless of the indication for transthoracic echocardiography (TTE).2 Prior studies have documented the ability of TTE to define proximal coronary anatomy, but the frequency with which proximal coronary origins are evaluated and reported in real-world practice remains unknown. The primary aim of this study was to examine the reporting frequency of proximal coronary anatomy among echocardiography laboratories in ORCCA (Outcomes Registry for Cardiac Conditions in Athletes).
This prospective observational cohort study included colleges from the National Collegiate Athletic Association that submitted data to ORCCA from September 1, 2020, to May 21, 2021, as previously reported.3 The inclusion criterion for this study was at least 1 TTE report from a participating echocardiography laboratory. A total of 56 echocardiography laboratories met this inclusion criterion. All available TTE reports were reviewed to assess for the presence of proximal coronary anatomy reporting. “Consistent reporters” were defined as echocardiography laboratories that reported coronary anatomy or the inability to visualize coronary origins in >90% of clinical reports, while “variable reporters” were defined as laboratories that reported coronary data <90% of the time. All aspects of this study were approved by the Massachusetts General Brigham Institutional Review Board (protocol #2020P002667).
Complete reports were available for 1,529 of 3,027 athletes (51%) who underwent transthoracic echocardiographic screening (mean age 20 ± 3 years, 31% women, 27% Black race), representing 25 unique sporting disciplines, 35 colleges and universities, and 56 distinct echocardiography laboratories. A total of 429 of 1,529 athletes (28%) had proximal coronary anatomy reported. Only 10 of 56 echocardiography laboratories (18%) reported on coronary anatomy, among which 5 (9%) were consistent reporters and 5 (9%) were variable reporters (Figure 1A). The majority of cases from consistent reporters were provided by 2 laboratories (Figure 1B). Among athletes with reported coronary artery anatomy, the left main coronary artery was visualized in 396 of 429 athletes (92%) and the right coronary artery in 389 of 429 athletes (91%). Only 1 coronary anomaly, dual left-sided coronary ostial anatomy, was detected.
Overview of Proximal Coronary Artery Reporting Among Echocardiography Laboratories
(A) Breakdown of proximal coronary artery reporting among 56 echocardiography laboratories. No reporting, proximal coronary anatomy not reported in any transthoracic echocardiography (TTE) report; consistent, >90% of TTE reports included proximal coronary anatomy; variable, <90% of TTE reports included proximal coronary anatomy. (B) Number of athletes with and without reporting of proximal coronary anatomy for each echocardiography laboratory (n = 10) with at least 1 TTE report including proximal coronary anatomy.
In this study we examined the reporting frequency of proximal coronary anatomy during TTE among young competitive athletes, with the following key findings. First, only 10 of 56 echocardiography laboratories (18%) reported coronary anatomy, with only 5 of 56 (9%) reporting coronary anatomy more than 90% of the time. Second, among athletes with reported coronary anatomy, the left main and right coronary arteries were identified in 92% and 91% of cases, respectively, consistent with prior studies.4 Third, coronary anatomy was not assessed in 72% of athletes who underwent TTE despite current imaging guidelines. Finally, only 1 of 389 athletes (0.3%) with complete transthoracic echocardiographic coronary data harbored a coronary artery anomaly, a benign variant dual left-sided coronary ostia.
High-risk anomalous coronary anatomy is a well-established cause of sudden cardiac death in young, otherwise healthy populations, including competitive athletes.1 Accordingly, contemporary multimodality competitive athlete imaging guidelines recommend universal assessment and reporting of proximal coronary anatomy whenever TTE is performed.2 Our data indicate that 91% of echocardiography laboratories performing TTE in the context of athlete evaluations do not consistently fulfill this recommendation. Efforts to improve compliance with clinical practice guidelines and the uniform assessment and reporting of coronary anatomy in young competitive athletes undergoing TTE is urgently needed.
References
1. "Aetiology and incidence of sudden cardiac arrest and death in young competitive athletes in the USA: a 4-year prospective study". Br J Sports Med 2021;55:1196-1203.
2. "Recommendations on the use of multimodality cardiovascular imaging in young adult competitive athletes: a report from the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance". J Am Soc Echocardiogr 2020;33:523-549.
3. "SARS-CoV-2 cardiac involvement in young competitive athletes". Circulation 2021;144:4: 256-266.
4. "The feasibility, diagnostic yield, and learning curve of portable echocardiography for out-of-hospital cardiovascular disease screening". J Am Soc Echocardiogr 2012;25:568-575.
Footnotes
This work was funded in part by a grant from the American Medical Society for Sports Medicine Foundation and the American Medical Society for Sports Medicine Collaborative Research Network. Dr Moulson is supported by the University of British Columbia Clinician Investigator Program. Dr Patel is an advisory board member for Amgen, Bayer, Janssen, HeartFlow, and Medscape; has received grant funding from the National Heart, Lung, and Blood Institute, Bayer, Janssen, HeartFlow, and Idorsia; and is also supported by the Joel Cournette Foundation for research on athlete’s hearts. Dr Baggish has received funding from the National Heart, Lung, and Blood Institute, the National Football Players Association, and the American Heart Association; and receives compensation for his role as team cardiologist from the U.S. Olympic Committee/U.S. Olympic Training Centers, U.S. Soccer, U.S. Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University. Dr Harmon has stock options for 98point6, for which she is also on the medical advisory board. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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