Download association of new left anterior fascicular block with structural heart

Association of New Left Anterior
Fascicular Block with Structural Heart
Disease in U.S. Air Force Military
Aircrew
Talib Y. Ali, MD, MPH
Lt Col, USAF, MC, FS
USAF School of Aerospace
Medicine
WPAFB, OH
RAM 2013
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Disclosure Information
84th Annual Scientific Meeting
Dr. Talib Y. Ali
I have no financial relationships to disclose.
I will not discuss off-label use and/or investigational
use in my presentation.
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Introduction
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Left anterior fascicular block (LAFB) may be a
marker of underlying structural heart disease
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Coronary artery disease – LAD coronary artery
Arterial hypertension
Aortic heart disease
Certain cardiomyopathies
Varies in prevalence from 0.9% to 6.2% in the
general population1 and 0.01% to 0.9% in the
military aviator2,3
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Introduction
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Military aircrew are healthier than the general
population
Current USAF policy requires further
evaluation in aircrew with LAFB4
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Age > 35 years
• Exercise treadmill testing and echocardiogram
Age ≤ 35 years
• Echocardiogram
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Introduction
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1.2 million ECGs in the USAF School of
Aerospace Medicine (USAFSAM) ECG Library
dating back to 1950
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281,737 unique aviators (current as April 2013)
Expand upon research by Yoosefian, Lopez,
and Kruyer5
Review LAFB evaluation results to assess the
usefulness of the current USAF policy
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Methods
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LAFB
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Displacement of the mean QRS axis in the frontal plane to
between -45° and -90°, and
A qR complex in leads I and AVL, an rS complex in leads II,
III and AVF, and
Normal or only slightly prolonged QRS duration
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Methods
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Reviewed the records of 702 unique military
aircrew with new LAFB contained in the
USAFSAM ECG Library with demographics
(BP, Age, Ht, Wt)
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Testing data available limited to diagnostics
performed at USAFSAM only
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Methods
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Echocardiogram classification
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Normal
Normal Variant
Abnormal
Exercise treadmill testing classification
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Normal
Borderline
Abnormal
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Results
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Demographics (561 unique aircrew)
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Average Age: 36 yr (19 to 63 yr)
Average Height: 71" (62 to 79")
Average Weight: 180 lb (114 to 260 lb)
• BMI 25.1
Demographics (359 unique aircrew)
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Average BP: 121/77 mmHg
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Systolic 96 to 172 mmHg
Diastolic 60 to 116 mmHg
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Results
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41 underwent echocardiography
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7 (17%) were interpreted as Normal
23 (56%) were interpreted as Normal Variant
11 (27%) were interpreted as Abnormal
56 underwent exercise treadmill testing
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52 (93%) were interpreted as Normal
1 (2%) were interpreted as Borderline
3 (5%) were interpreted as Abnormal
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Results
11 (27%) with Abnormal Echocardiography
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2 - Bicuspid AV
2 - Mild LAE
2 – Septal motion abnormalities
1 – Mild RV hypertrophy
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1 - Mild AI
1 – AV thickening
1 – MVP
1 – Mild PI
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Results
3 (5%) with Abnormal Exercise Treadmill Testing
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1 with ST Segment Depression
1 with LBBB/AV Block
1 with PVCs and Ventricular Tachycardia
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Results
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Transient LAFB
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31 aviators - NSR → LAFB
9 aviators - NSR → LAFB → NSR
4 aviators - NSR → LAFB → NSR → LAFB
4 aviators - LAFB → NSR
4 aviators - LAFB → NSR → LAFB
LAFB Prevalence = 0.249% (702/281737)
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Conclusion
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Inconclusive if isolated LAFB in USAF aircrew
appears to be predictive of underlying heart
disease
Stress testing is likely warranted over age 35 in
the setting of LAFB
Echocardiography is likely warranted in the
setting of LAFB
ECG Library has limitations, particularly if
studies performed locally
Further investigation required
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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References
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5.
Elizari MV, Acunzo RS. Hemiblocks Revisited. Circulation. 2007;115(8):115463.
Hiss RG, Lamb LE. Electrocardiographic findings in 122,043 individuals.
Circulation. 1962;25(6):947-961.
Rotman M, Triebwasser JH. A clinical and follow up study of right and left
bundle branch block. Circulation. 1975;51(3):477-484.
Yoosefian F, Lopez FM, Kruyer W. Association of new left anterior or posterior
fascicular block with structural heart disease in military aircrew. Aviat Space
Environ Med 2010;81(3):291.
US Air Force Aeromedical Consultation Service Central Electrocardiographic
Library. Disposition of ECG findings in USAF Aircrew. Oct 2009:4.
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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Questions?
Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2294, 13 May 2013
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