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Reliable Diagnostic Testing

for Hypertrophic Cardiomyopathy

Meg Greene & Sam McCauley, ATS


Melissa Davis, LAT, ATC, Beth Funkhouser, LAT, ATC,
Randy Smith, NRP, CCEMT-P, & Dr. William Handy, MD
11/30/2018
Greene & McCauley 1

Table of Contents
CLINICAL SCENARIO 1
FOCUSED CLINICAL QUESTION 2
KEYWORDS 2
SUMMARY OF SEARCH METHODOLOGY 3
SEARCH STRATEGY 3
SOURCES OF EVIDENCE SEARCHED 3
BEST EVIDENCE REVIEWED 3
CLINICAL BOTTOM LINE Error! Bookmark not defined.
IMPLICATIONS FOR CLINICAL PRACTICE 5
RECOMMENDATIONS FOR FUTURE RESEARCH 5
REFERENCES 5
Greene & McCauley 2

CLINICAL SCENARIO
Hypertrophic cardiomyopathy is a condition where the heart becomes enlarged. This
condition will often go undiagnosed and individuals will live normal lives without
presentation of symptoms. However, athletes are more exposed to episodes or symptoms
of the condition due to the less placed stress on the heart. Causes of the condition can go
unknown but also can be related to genes. In some causes the heart with this condition can
experience too much stress causing arrhythmias or sudden death. We must ask the
question; why are heart conditions going unnoticed and leading to death at a young age?
Our question has been created to understand the best diagnostic test for diagnosing
athletes with underlying heart conditions.

Development of Clinical Question:


Every summer we hear about athletes dying of sudden cardiac arrest due to underlying
conditions. During preseason we had the privilege to travel to the Marion campus School of
Health Sciences, and meeting Randy Smith who taught us how to read an
electrocardiogram, EKG, and understand what an abnormal EKG would appear as and what
needs to be addressed to fix the rhythm. We decided after some research that many
athletes’ conditions could have been detected if some diagnostic tests were performed.
With this exciting research, we decided to do more extensive research of our own and
make it our clinical question.

Development of Investigation Committee:


The investigation committee was formed based off of expertise and knowledge on the topic
of diagnostic testing for heart conditions. Melissa Davis , a certified Athletic Trainer was
selected because our group felt that she would provide useful information about collegiate
athletes’ with heart conditions. We also decided Dr. Handy and Randy Smith for our
specialty experts. Dr. Handy is a family medicine doctor, who has experience with
diagnostic testing for heart conditions for patients of all ages. Dr. Handy has had many
years of experience with patients from athletes’ to non-athletes. Randy Smith is a nurse
and paramedic, he has a tremendous amount of experience with heart conditions from
chronic conditions to acute conditions. He also taught us over the summer about one major
diagnostic test that is done everyday for patients. Finally, Beth Funkhouser was chosen as
our faculty advisor because she is the muse of this project and has a lot of insight on our
topic.

Focused Clinical Question:


In athletes ages 16-22, what diagnostic testing is more reliable in determining the presence
of hypertrophic cardiomyopathy?

Keywords:
Hypertrophic cardiomyopathy
Diagnostic testing
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SUMMARY OF SEARCH METHODOLOGY


To answer our clinical question we decided that academic articles would help us support
our answer. The articles we decided to review contained the keywords above.

Search Strategy:
Patient: Athletes 16-22 of age
Intervention: Diagnostic tests
Outcome: Hypertrophic cardiomyopathy

Sources of Evidence Searched:


EBSCOhost
PubMed
Google Scholar

Best Evidence Reviewed:


“Hypertrophic Cardiomyopathy in Athletes”
Malhotra and Sharma expressed an article about sudden cardiac death in the
younger population. The most common cause of sudden cardiac arrest is hypertrophic
cardiomyopathy (HCM) which has been reported in athletes younger than 35 years of age.
Due to the high intense exercise an athlete's heart is able to adapt to improve their stroke
volume and performance which reveals for a greater left ventricular wall thickness. This
study expresses a wide array of clinical diagnostic testing that includes clinical symptoms
and family history, ECG, echocardiography, cardiac MRI, and exercise stress testing.
However, cardiac MRI is the gold standard imaging tool used for assessment of HCM in
athletes and nonathletes because of the ability to see the left ventricular hypertrophy with
the unique positioning of this imaging tool. This test was chosen was reported the gold
standard because this was the only imaging that could see the left ventricular wall
thickness compared to other cardiovascular tests.

“Hypertrophic Cardiomyopathy in Youth Athletes: Successful Screening


With Point‐of‐Care Ultrasound by Medical Students”
A study was conducted by the Journal of Ultrasound in medicine to determine
successful screening to find athletes with hypertrophic cardiomyopathy. Between May of
2012 and August 2013, the athletes in 12 different high schools and three different colleges
were participants who underwent point of care ultrasound performed screening for HCM
by trained medical students that were reviewed by a pediatric cardiologist. An abnormal
(positive screen) consists of the interventricular septum to left ventricular posterior wall
ratio greater than 1.25. A total of 2,332 participants participated, and there were 137
(5.8%) with a positive screening for HCM. They were able to us point of care ultrasound in
order to effectively screen for HCM in young athletes.
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“The Role of Cardiac MRI in the Diagnosis and Risk Stratification of


Hypertrophic Cardiomyopathy”
A recent study was conducted by Rowin and Maron about hypertrophic
cardiomyopathy diagnostic testing procedures. They express that a diagnosis of HCM is
made when unexplained left ventricular hypertrophy occurs. Their study included using
cardiovascular magnetic resonance, a high resolution 3D tomographic imaging technique
that provides sharp contrast between the blood pool, myocardium, and ECG. Rowin and
Maron convey that areas of left ventricular hypertrophy may be underestimated by
echocardiography. Three different studies were performed to analysis the heart. They used
the tests expressed above on six different patient with hypertrophic cardiomyopathy to see
which imaging revealed the best imaging to show left ventricular hypertrophy. The best
imaging consisted of contrast enhanced CMR. However, a contrast enhanced CMR provides
the opportunity to aid in differentiation between HCM and athletes heart given the ability
to non invasively provide tissue characterization because of the focal areas of replacement
fibrosis and expanded extracellular space. Contrast enhanced CMR has emerged as a
powerful imaging tool used daily.

“Electrocardiography Screening for Hypertrophic Cardiomyopathy”


A journal titled “Electrocardiography screening for Hypertrophic Cardiomyopathy,”
a study was conducted on the leading cause of sudden cardiac arrest, hypertrophic
cardiomyopathy. This study consisted of adolescent patients between the age of 13 and 18
with HCM as well as healthy adolescent control population. The data contained 12 standard
lead ECGs to detect abnormal ECG waveforms associated with HCM and a QRS complex
detection was performed. A total of 150 ECGs were initially identified on 24 patients with
HCM. The study data set included 22 patients representing 133 ECGs of phenotypically
positive HCM. A total of 50 healthy controls with normal ECG were used for comparison.
This showed a 90% sensitivity, 96% specificity, and 4% false positive rate. This study
demonstrates that certain features of ECG testing can be used to screen HCM, and that it is
possible to have an automated computer algorithm identify these features with a high
degree of sensitivity and specificity. This is also a reducing cost procedure for families who
cannot afford these expensive tests.

CLINICAL BOTTOM LINE


In conclusion, our research team has performed expresses that cardiac magnetic resonance
imaging is the most reliable diagnostic test to show hypertrophic cardiomyopathy.
However, there are many tests that can be performed in order to find hypertrophic
cardiomyopathy, but this test showed the best imaging for looking at left ventricular
hypertrophy. Because this imaging tool can provide the best imaging to look at the left
ventricular, cardiac MRI has been reported to be the best imaging tool to find HCM.
However, this study does not contain data on patients to prove it is a better tool than the
rest, it does provide an adequate imaging to see the left ventricle. More research would
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need to be conducted in order to obtain a better understanding for diagnostic testing for
hypertrophic cardiomyopathy

Implications for Clinical Practice


In order to diagnose hypertrophic cardiomyopathy, clinicians should focus their studies
more on comparing diagnostic tests on a larger population. This would allow them to see
the comparison from different ages, background, and family history. It would also help
express which tests are more reliable for individuals with different cardiovascular
conditions. This will help clinicians better diagnosis patients with HCM and allow for easy
and faster results.

Recommendations for Future Research


In the future, we should continue to research different types of diagnostic testing to find
the best test for hypertrophic cardiomyopathy. This search should expand to researching
larger populations to compare more tests. There should be more focus on specific tests to
compare to each other instead of a broad scope of diagnostic tests. This will then make the
question have a better comparison between two tests to prove which diagnostic tests have
better outcomes.

REFERENCES:
Campbell, M., Zhou, X., Han, C., and Webster, G. (2016). Electrocardiography Screening for
Hypertrophic Cardiomyopathy. Pacing & Clinical Electrophysiology. 2016; 39
(9):944-950.https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=11
8092728&site=ehost-live.

Fox, J. C., Lahham, S., Maldonado, G., Klaus, S., Aish, B., Sylwanowicz, L. V., … Mohan, U. R.
(2017). Hypertrophic Cardiomyopathy in Youth Athletes: Successful Screening With
Point-of-Care Ultrasound by Medical Students. Journal Of Ultrasound In Medicine:
Official

Malhotra, A., & Sharma, S. (2017). Hypertrophic Cardiomyopathy in Athletes. European


Cardiology, 12(2), 80–82. https://doi.org/10.15420/ecr.2017:12:1

Rowin, E. J., & Maron, M. S. (2016). The Role of Cardiac MRI in the Diagnosis and Risk
Stratification of Hypertrophic Cardiomyopathy. Arrhythmia & electrophysiology
review, 5(3), 197-202.

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