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• W4310777744 abstract "HomeCirculationVol. 146, No. 23Yield of Cardiac Magnetic Resonance Imaging in a Preparticipation Cohort of Young Asian Males With T Wave Inversion Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBYield of Cardiac Magnetic Resonance Imaging in a Preparticipation Cohort of Young Asian Males With T Wave Inversion Nishanth Thiagarajan, Wilbert H.H. Ho, Daniel Y.Z. Lim, Wesley T.W. Loo, Goy Shen, Vahul Sundar, Huai Yang Lim, Lian Kiat Lim, Terrance S.J. Chua, Paul C.Y. Lim, Hak Chiaw Tang, Choong Hou Koh, Tee Joo Yeo and Daniel T.T. Chong Nishanth ThiagarajanNishanth Thiagarajan Correspondence to: Nishanth Thiagarajan, MBBS, Medical Classification Centre, Central Manpower Base, Singapore Armed Forces, 3 Depot Rd, Singapore 109680, Singapore. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0082-6163 Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.). Search for more papers by this author , Wilbert H.H. HoWilbert H.H. Ho Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.). Search for more papers by this author , Daniel Y.Z. LimDaniel Y.Z. Lim https://orcid.org/0000-0002-9715-6970 Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.). Search for more papers by this author , Wesley T.W. LooWesley T.W. Loo Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.). Search for more papers by this author , Goy ShenGoy Shen Search for more papers by this author , Vahul SundarVahul Sundar Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.). Search for more papers by this author , Huai Yang LimHuai Yang Lim Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.). Search for more papers by this author , Lian Kiat LimLian Kiat Lim Search for more papers by this author , Terrance S.J. ChuaTerrance S.J. Chua Department of Cardiology, National Heart Centre Singapore (T.S.J.C., P.C.Y.L., T.H.C., K.C.H., D.T.T.C.). Search for more papers by this author , Paul C.Y. LimPaul C.Y. Lim Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.). Department of Cardiology, National Heart Centre Singapore (T.S.J.C., P.C.Y.L., T.H.C., K.C.H., D.T.T.C.). Search for more papers by this author , Hak Chiaw TangHak Chiaw Tang Department of Cardiology, National Heart Centre Singapore (T.S.J.C., P.C.Y.L., T.H.C., K.C.H., D.T.T.C.). Search for more papers by this author , Choong Hou KohChoong Hou Koh Department of Cardiology, National Heart Centre Singapore (T.S.J.C., P.C.Y.L., T.H.C., K.C.H., D.T.T.C.). Search for more papers by this author , Tee Joo YeoTee Joo Yeo https://orcid.org/0000-0002-2462-6257 Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.). Department of Cardiology, National University Heart Centre Singapore (T.J.Y.). Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (T.J.Y.). Search for more papers by this author and Daniel T.T. ChongDaniel T.T. Chong Medical Classification Centre, Central Manpower Base, Singapore Armed Forces (N.T., W.H.H.H., D.Y.Z.L., W.T.W.L., G.S., V.S., H.Y.L., L.K.L., P.C.Y.L., T.J.Y., D.T.T.C.). Department of Cardiology, National Heart Centre Singapore (T.S.J.C., P.C.Y.L., T.H.C., K.C.H., D.T.T.C.). Search for more papers by this author Originally published5 Dec 2022https://doi.org/10.1161/CIRCULATIONAHA.122.061271Circulation. 2022;146:1802–1804Among competitive athletes, the association between abnormal T wave inversion (ATWI) on preparticipation screening ECG and underlying myocardial disorders including cardiomyopathy and myocarditis is well described.1 Current guidelines2 recommend evaluation of ATWI with transthoracic echocardiography (TTE) followed by cardiac magnetic resonance imaging (CMR) if TTE is normal (ie, echo-negative). However, the yield of CMR evaluation of echo-negative ATWI in nonathletic cohorts is unclear.All Singaporean males undergo preparticipation screening with ECG before compulsory military service at 18 years of age. Consecutive Singaporean males who underwent preparticipation screening between May 2019 and April 2021 were studied. Individuals with ATWI which met the International Criteria definition2 (ie, ATWI of ≥1 mm depth in ≥2 contiguous leads, excluding leads aVR, III, and V1) underwent TTE at a tertiary institution, where ECG was repeated for those with normal TTE. CMR was performed for echo-negative persons with persistent ATWI, with subsequent follow-up for cardiovascular hospitalizations and/or mortality. Ethics approval was obtained from the local institutional review board. The data that support the findings of this study are available from the corresponding author upon reasonable request.A total of 48 115 individuals underwent preparticipation screening (Figure). Of the 133 (0.3%) who displayed ATWI, 122 (91.7%) had a normal TTE, 3 (2.3%) were diagnosed with hypertrophic cardiomyopathy, and 6 (4.5%) had incidental findings of hypertensive heart disease, bicuspid aortic valve, mitral valve prolapse, and atrial septal defect. Two (1.5%) individuals were lost to follow-up before TTE. Among 122 individuals with normal TTE, 11 (9.0%) did not display ATWI on repeat ECG, while 6 (4.9%) were lost to follow-up.Download figureDownload PowerPointFigure. Findings and correlation of ATWI localization A, Overview of findings. B, Correlation of the localization of ATWI with CMR findings in echo-negative individuals. ATWI indicates abnormal T wave inversion; CMR, cardiac magnetic resonance imaging; DCM, dilated cardiomyopathy; HCM, hypertrophic cardiomyopathy; MRI, magnetic resonance imaging; PPS, preparticipation screening; and TTE, transthoracic echocardiogram.Of the echo-negative individuals (mean age, 17.9±1.1 years; ethnicity: Chinese, 79%; Malay, 8.6%; Indian, 5.7%; other, 6.7%), 105 had persistent ATWI and underwent CMR, which identified myocardial disorders in 7 (6.7%) individuals. This comprised 5 (4.8%) with a cardiomyopathy and 2 (1.9%) with presumed previous myocarditis with residual scar. Four individuals were diagnosed with hypertrophic cardiomyopathy based on left ventricular wall thickness ≥15 mm or left ventricular wall thickness Z score >4 without an alternative cause for hypertrophy, while 1 individual was diagnosed with dilated cardiomyopathy based on systolic dysfunction and reduced myocardial contractile reserve (increase in cardiac index <10th percentile for age and sex) after additional exercise CMR testing. The 2 individuals diagnosed with presumed previous myocarditis demonstrated nonischemic patterns of late gadolinium enhancement in the absence of features of hypertrophic cardiomyopathy or dilated cardiomyopathy.Among echo-negative individuals, those with CMR-positive myocardial disorders more commonly had ATWI ≥2 mm (7/7 [100.0%] vs 60/98 [61.2%]; P=0.047 by Fisher exact test), ATWI in lateral (4/7 [57.1%] vs 20/98 [20.4%]; P=0.046) or all 3 territories (3/7 [42.9%] vs 4/98 [4.1%]; P=0.006), and concomitant ST segment depressions (5/7 [71.4%] vs 28/98 [28.6%]; P=0.030). CMR also identified changes consistent with exercise-induced cardiac remodeling in 12 other echo-negative individuals. Additional incidental findings were pericardial effusion, patent foramen ovale, and left ventricular clefts. During follow-up of 12±8 months (range, 1–34), no deaths were noted. Three individuals with normal CMR were hospitalized with atypical chest pain, with no new pathologic diagnoses made.To our knowledge, this is the first population-level study of ATWI in a cohort without predetermined athletic ability. Compared with a cohort comprising competitive athletes,1 the prevalence of ATWI (0.3%) and myocardial disorders (7.5%) among individuals with ATWI in our study are lower. This could be a result of a lower baseline prevalence or later age of phenotypic manifestation of cardiomyopathies in our Asian cohort.3 The higher reported prevalence of myocardial disorders in competitive athletes could also be attributable to considerable overlap in imaging characteristics of cardiomyopathies and exercise-induced cardiac remodeling.4CMR demonstrated additional diagnostic utility in the evaluation of echo-negative ATWI in our cohort of young Asian males. The absolute increase in diagnostic yield with CMR among individuals with ATWI and normal TTE is lower than in athletes (6.7% vs 25.5%)1, likely reflective of the lower prevalence of myocardial disorders (7.5% vs 45%). However, the relative increase in diagnostic yield with CMR is >3-fold in our cohort; among the 10 individuals with myocardial disorders, 3 were diagnosed on TTE, while the other 7 were diagnosed with CMR after a normal TTE. This is greater than the 1.6-fold increase described in the athletic cohort. The yield with CMR in our study was higher for ATWI in lateral or all 3 territories, in keeping with the known association with pathology in athletes.2ATWI depth of <2 mm demonstrated a 100% negative predictive value for myocardial disorders, consistent with findings in a population of male Korean pilots.5 A focused approach to evaluating ATWI using depth cut-off ≥2 mm for CMR evaluation may thus be more cost-effective in health care settings with resource limitations.Limitations of our study include an entirely male cohort and the availability of only short-term outcomes. A longer follow-up duration would be useful in identifying incident cases of cardiomyopathy or adverse cardiac events that may manifest later.1 Further studies to assess the generalizability of our findings in young Asian males to other populations are warranted.Article InformationSources of FundingNone.Nonstandard Abbreviations and AcronymsATWIabnormal T wave inversionCMRcardiac magnetic resonance imagingTTEtransthoracic echocardiographyDisclosures None.FootnotesCirculation is available at www.ahajournals.org/journal/circFor Sources of Funding and Disclosures, see page 1804.Correspondence to: Nishanth Thiagarajan, MBBS, Medical Classification Centre, Central Manpower Base, Singapore Armed Forces, 3 Depot Rd, Singapore 109680, Singapore. Email nishanth.[email protected]com.sgReferences1. Schnell F, Riding N, O’Hanlon R, Lentz PA, Donal E, Kervio G, Matelot D, Leurent G, Doutreleau S, Chevalier L, et al. Recognition and significance of pathological T-wave inversions in athletes.Circulation. 2015; 131:165–173. doi: 10.1161/circulationaha.114.011038LinkGoogle Scholar2. Drezner JA, Sharma S, Baggish A, Papadakis M, Wilson MG, Prutkin JM, La Gerche A, Ackerman MJ, Borjesson M, Salerno JC, et al. International criteria for electrocardiographic interpretation in athletes: consensus statement.Br J Sports Med. 2017; 51::704–731. doi: 10.1136/bjsports-2016-097331CrossrefMedlineGoogle Scholar3. Ng CT, Chee TS, Ling LF, Lee YP, Ching CK, Chua TSJ, Cheok C, Ong HY. Prevalence of hypertrophic cardiomyopathy on an electrocardiogram-based pre-participation screening programme in a young male south-east Asian population: results from the Singapore Armed Forces electrocardiogram and echocardiogram screening protocol.Europace. 2011; 13:883–888. doi: 10.1093/europace/eur051CrossrefMedlineGoogle Scholar4. Baggish AL, Battle RW, Beaver TA, Border WL, Douglas PS, Kramer CM, Martinez MW, Mercandetti JH, Phelan D, Singh TK, et al. 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. doi: 10.1016/j.echo.2020.02.009CrossrefMedlineGoogle Scholar5. Kim SS, Choi WH, Kim HY, Kim SH, Bang D-H, Kang KW, An CH, Lim JG, Kwak J-J, Kwon SU, et al. Clinical implications of T-wave inversion in an asymptomatic population undergoing annual medical screening (from the Korean Air Forces Electrocardiogram Screening).Am J Cardiol. 2014; 113:1561–1566. doi: 10.1016/j.amjcard.2014.02.008CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails December 6, 2022Vol 146, Issue 23 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.122.061271PMID: 36469595 Originally publishedDecember 5, 2022 KeywordsSingaporesudden cardiac deathyoung adultcardiomyopathiesmagnetic resonance imagingelectrocardiographymass screeningPDF download Advertisement SubjectsCardiomyopathyEchocardiographyElectrocardiology (ECG)ImagingMagnetic Resonance Imaging (MRI)" @default.
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