In the second of our series of ‘research updates’ which focus on the achievements – and vision – of CRYs current Research Fellows, we’re delighted to introduce Dr Mihnea Casian (one of Europe’s most aspiring sports cardiologists) and to officially welcome him to the CRY family!
Originally hailing from Romania (although fluent in 5 languages and with an exceptional interest and insight into European screening protocol and practice) Dr Casian is already starting to make waves with his presentations and early research abstracts.
Just 9 months into his CRY-funded Research Fellowship, under the tutelage of Profs. Sanjay Sharma and Michael Papadakis, in this interview Dr Casian shares his views on issues surrounding the difficult decisions that cardiologists have to routinely make when screening elite and grassroots athletes – and how important it is for a highly trained, expert ‘eye’ to be reviewing these tests to ensure that “no sportsman or woman is ever unnecessarily disqualified from the game they love and have trained all their lives for.”
Dr Casian had already been working at St George’s on a grant from the Romanian Cardiac Society when he was ‘spotted’ and invited to apply for a CRY-funded Research Fellowship, allowing him to continue working with the internationally acclaimed research team and to extend his time in the UK.
He says: “It’s been a dream come true to work with Prof. Papadakis and Prof. Sharma and from the very start, I was just so excited at the prospect of being able to travel across the UK, screening 100 young people in a day.”
Firstly Dr Casian, congratulations on the recognition, interest and momentum that’s growing around your portfolio of research abstracts and presentations at conferences. Can you talk us through the topline focus of your research, being carried out as part of your CRY-funded Research Fellowship?
“So, in sports cardiology, we are always faced with the conundrum of distinguishing what’s actually related to ‘sports’; what’s normal for an elite athlete…and what’s a potential problem that we should be concerned about and need to investigate further.
“In an ICC [Inherited Cardiac Conditions] clinical setting, we are always faced with the paradox of wanting to diagnose an individual…but at the same time, wanting to avoid over diagnosis – and this can sometimes occur with a screening [when not supervised by a specially trained cardiologist]. As a doctor, it would be very painful for me to know that I’d unfairly ‘labelled’ someone with a potentially ‘career-ending’ diagnosis.
“In terms of my own research, we’ve been looking at the ECGs of a very large cohort of individuals from both the general population and professional athletes, exploring the significance of identification of an abnormal feature known as Inferior T-wave inversion, which may be a red-flag for a cardiomyopathy. But because we’re working with such a huge volume of data (around 100,000 individuals – which is all thanks to CRY!) I am really confident that we will uncover new findings about certain sub-sets of T-wave inversion and a better understanding of which are the most concerning and likely to be related to a cardiomyopathy. In the longer term, this research could be fed into the development of new ECG interpretation consensus, helping to ensure that we don’t “over-call” a diagnosis and can reduce the so-called “grey area”.
“In fact, we are all looking forward to the amended criteria for ECG interpretation in athletes (due as an update to the last guidelines in 2017), which will be developed by the ‘who’s who’ in sports cardiology, including Professors Michael Papadakis, Sanjay Sharma and international experts such as the US’s Prof Jonathan Drezner or Prof Jonathan Kim– basically experts who brought to the table the most significant and valuable information about ECG findings in athletes. Exciting times for all of us involved in this area of medicine and research!
A specific published abstract has been flagged up by CRY as being of real interest: Arrhythmogenic right ventricular cardiomyopathies (ARVC): Diagnostic challenges from imaging to genetics
https://pubmed.ncbi.nlm.nih.gov/39240923
Can you tell us a bit about this specific piece of research – and its potential implications for families and individuals affected by ARVC?
“This paper was written by me, under the guidance of my mentor from Bucharest, Prof. Ruxandra Jurcut (who co-authored the first European guidelines on cardiomyopathy) and Prof. Michael Papadakis who of course has expertise in sports cardiology, as well as inherited cardiac conditions. I feel as though I am the “product of them both” and of their specialist training.
“Which is not by accident, as I strongly believe that in order to be the best in sports cardiology (which is what I aspire to be one day) you need to have a very solid understanding of inherited heart conditions. Therefore, this paper is particularly symbolic for me. It was developed with the purpose of raising awareness amongst clinicians, warning them of the caveats in diagnosing (misdiagnosing, as well as over-diagnosing) Arrhythmogenic Right Ventricular Cardiomyopathies (ARVC).
“As part of this paper, we have been able to explore and present three cases of patients I’ve cared for both back home in Romania and in the UK, highlighting that even though we have guidelines for the diagnosis of this condition, you really need expertise to fully understand when it is appropriate to ‘press the diagnostic button’, and to prevent sudden cardiac death.
“With this in mind, something that I really like about working at St George’s is that we try to fight the stigma of a label – and refraining from labelling a young person with a diagnosis if it’s not going to add to their care.
“It takes a huge amount of knowledge to really understand how to put findings and current knowledge about a clinical scenario, into full context and to stratify risk accordingly. But this is of course hugely sensitive when we are looking after a family where there has been a sudden cardiac death, caused by a condition such as ARVC. For example, the deceased young person might be found to have had the most abnormal [the worst] phenotype – but we might only see very mild changes in other family members. This is where genetic testing comes in, although this again requires careful and sensitive explanation about the differences between ‘carrying’ and ‘displaying’ this genetic variant. We just have to be careful in this situation, as we obviously want to prevent a second fatal cardiac event in the same family. There is a difference between how we, as clinicians perceive risk, and how individuals perceive their risk, particularly in this situation. The perception of risk – particularly when coming from the place of having experienced a tragic and devastating sudden death in someone close – is so individual and I believe it’s our job as expert clinicians to guide and empower them in their decision making and personal choice.
“We are very lucky at St George’s to have access to such skilled and dedicated specialists. The MDT (multi-disciplinary team) is where we would discuss some of these cases, sharing our expertise to make the best decision possible for those in our care. Prevention is not a “one-size fits all”.
“Bereaved families, understandably, always want an answer. But we have to be so prudent that we don’t over diagnose surviving family members as it’s very hard to take a label back once you’ve called it.
“During a CRY screening, I have witnessed a case with two siblings (with a familial history of sudden death) where one had a reassuring ECG and the other had a clearly suspicious ECG for a cardiomyopathy, even though she was entirely asymptomatic. I felt it was my role to explain that further investigations now needed to be based on the suspicion of a cardiomyopathy and that it may be linked to the sudden cardiac death in their parent. You can only imagine the anxiety and emotions one can feel when confronted with this finding, knowing that they might be at risk to die suddenly. It is important to know how to convey the message in such cases and manage their expectations and concerns.
“As a CRY doctor we must always remember that we’re not in clinic – people walk through the doors ‘presuming themselves to be healthy’ – so it’s tough (although necessary) to have to tell someone 5 minutes later that they’re ‘at risk’ and their heart is ‘not normal’. We must always be aware of the psychological burden of the findings and convey their significance appropriately.”
How would you like to see the knowledge gained from your research rolled out in a ‘practical and accessible’ way?
“In the long term, I really hope my research will feed into an even better understanding of the athlete’s heart, narrowing the so-called “grey area”, as well as how we can guide and empower athletes diagnosed with a cardiac condition. I am always wondering what else is possible for athletes in terms of exercise, beyond a diagnosis or a label?
“It is always such a sensitive area – what is a normal ‘athletes’ heart’ and who should we be keeping a close (expert!) eye on. “There’s no doubt that there’s a difference between investigating an athlete’s heart to that of someone from the general population. So, I really hope my research will help to make the grey areas a little less grey.
“Things have already evolved immeasurably in the past 20 years of sports cardiology, and it is far better understood which athletes require further investigations or even treatment and an ‘exercise prescription’ specific to their condition.
“But there is still much left to understand with regards to how sports shape your heart and why some athletes are differently shaped compared to their peers”
“And, especially when it comes to our grass roots athletes – they might not be professional, but they are still an athlete. Bear in mind that we still have trouble with defining athletes! The Belgians, in my opinion, have a very clear way of explaining the difference: they say an athlete is some who does a significant amount of physical exercise, either with or without contract. With that in mind, it is also my belief that the most vulnerable group in sports cardiology are not always the elite professionals but those who play or train competitively at a grass roots level. And there’s no doubt that I’ve seen cases of this in my CRY screenings over the past 6-9 months where very sporty, young people have presented with worrying ECGs’. We really need to look out for this group.”
So, you’re currently midway (ish!) through your Research Fellowship with CRY. Can you round up what you’ve learnt so far (in terms of research achievements and your experience of attending CRY screening events)?
“In summary, I’m learning so much from both my patients at St George’s and from the people who come along to our screenings, as well as from the families who help setting these events. You hear so many stories – stories from families where there has been a sudden cardiac death; families desperately seeking answers where they’ve been told it’s ‘natural causes’, which is incredibly difficult to comprehend. It’s our role to help them navigate this difficult journey. In clinic, I have time to talk with these families which is a real privilege and often very inspiring.
“Conversely, at a CRY screening, I have 5-10 minutes, so I’m really learning how to relate to people in different scenarios and how to convey important information, quickly and precisely. I also have to be very clear, concise and certain in my interpretation of the ECG – that is to say, in what I have seen and what I am saying to that person.
“On reflection, that’s definitely one of my greatest learnings from my time with CRY, so far!
“I’ve also learnt a lot about different sports…who knew that some elements of the game of golf (which I always considered to be a low intensity, slow sport) actually involve levels of endurance training? Or that frisbee is actually very demanding!”
What first inspired you to pursue a career in sports cardiology and the study of inherited heart conditions?
“When I first started out in my career and began training in sports cardiology (in 2020), I logged onto an online CRY webinar during lockdown – and then another one organised by the European Society of Cardiology – and the names Sanjay Sharma and Michael Papadakis kept coming up! I was mesmerised!
“So, I did some further investigations and found the CRY website, and started reading about the CRY Research Fellows, past and present, all with so many accomplishments doing the sort of research that I knew I wanted to do.
“This area of research [investigating YSCD] was important to me because I come from a country where we don’t have a framework in place for fully investigating young sudden cardiac death, so this was something that I was so keen to learn more about – specifically in the UK, which is a world-leader in the management of sudden cardiac death.
“I really do think I’m in the best place in the world to understand sudden cardiac death, constantly benefiting from the input of the incredible team at the CRY Pathology Centre, headed up by Professor Mary Sheppard and Dr Joe Westaby (who I am forever ‘harassing’ with questions, which they’re always willing to discuss with me!). It has been invaluable to be able to work closely with the expert cardiac pathology team. In Romania, we do have ICC expertise (Inherited Cardiac Conditions) but very little in the way of specialist cardiac histology, molecular autopsy – and certainly no screening programme, outside of professional sport.
“The final inspiration for me to pursue my career in sports cardiology and training in the UK, came at a really pivotal moment while in Bucharest. A leading sportsman, playing for a national team, had symptoms and was seen by his club doctor. He was found to have an unusual ECG reading. He was told to stop immediately – and was left lingering, potentially facing an abrupt end to his professional career in his early-20s. A career he’d worked his whole life for and one which was also supporting his family. The implications were potentially devastating.
“Although very junior, my interest in ‘athlete’s heart’ was becoming known – but it was still to my surprise that I was asked by one of the consultants to reassess this athlete and to further investigate the ECG findings under their supervision. It was soon apparent to me that his heart was normal for such an accomplished and elite athlete and that the slightly unusual heart rhythm was of no concern (often seen in athletes).
“He was able to return to the game he loved (even though the situation had been quite traumatic for him). It further reinforced in my mind the importance of athletes requiring dedicated expertise and input. Furthermore, I wondered at that point if it’s fair or reasonable to stop an athlete only because you are uncertain of some findings. Then it occurred to me that, in order to empower an athlete in making their own decisions, you would need not only knowledge but also first-hand clinical experience. I knew then I needed to study and learn alongside some of the most revered leaders in the field – and I knew I’d find those in London.
“I was therefore incredibly fortunate to receive an initial 6-month grant from the Romanian Society of Cardiology to train at St Georges which, as I got to work with Profs Michael Papadakis and Sanjay Sharma, developed into me being awarded a prestigious Fellowship with CRY.
“Now I already find myself in a position where friends and cardiology colleagues from back home are contacting me, asking my opinion about athletes who they feel they should be stopped from playing sport. And that’s completely understandable if you haven’t seen hundreds of athletes!
“Through working with CRY, I get to see so many young athletes who have been made to feel concerned or even scared by other doctors because in reality they just are not aware of the ‘athletes’ heart. But, when a specially trained sports cardiologist takes a look, we can often offer reassurance that they are safe to play and that any particular findings are actually normal for them.
“As an example of the huge experience I’m gaining, I was asked to present a case study (at an international conference) of a clear diagnosis of cardiomyopathy which I had been looking into with Professor Michael Papadakis.
“There was much discussion and interestingly an Italian cardiologist said, “this person should not ever be allowed to compete” (referring to the law in his country). In my opinion, this decision is better discussed between the doctor and the patient – it should not be primarily a political or legal decision.
“However, it is of course good news that when it comes to professional, competitive sports, most sporting bodies will now insist that its athletes are routinely screened – but it’s still vital that these results are reviewed by experts!”
Dr Casian continues: “In terms of general population screening, I think the way CRY is doing it is the best way and is actually leading the way internationally. I believe that every young person should have access to screening and should have the choice to be screened – I don’t think we have enough evidence to say it should be mandatory…but if it’s on offer, why would anyone refuse that opportunity? Unless, like some young athletes, they are scared about “what will happen to me if something is found to be wrong.”
“So, our responsibility as cardiologists, is to turn around the narrative and carefully explain that it’s always better to know and even if we find something wrong, there is so much that can be done to address and monitor problems – and it may be a long road ahead before we’re even talking about disqualification from sport and other physical activities, if at all.
“No screening programme is ever 100% accurate – in terms of false positives or false negatives. Essentially, this means that some individuals may be flagged as abnormal even if no diagnosis will be made after investigations and follow-up – while some may experience major cardiac events, including dying suddenly, despite being cleared.
Can you summarise your first impressions of CRY – has the charity met your expectations?
“I have actually been really surprised by the size of CRY and its screening programme! I never would have imagined the sheer volume of screening taking place each year, which ultimately raise awareness regarding inherited cardiac conditions and young sudden cardiac death – otherwise considered rare. Education is power – and the team at CRY is amazing at sharing this knowledge, particularly amongst young people, in communities across the country – and on a wider level, with colleagues and cardiologists across the world, as we are turning our experience into expertise! I’m super impressed!”
Finally, do you have any further insight you’d like to share with CRY’s ‘community’ about the positive impact of a CRY Research Fellowship?
“Firstly, the families are always so welcoming and you can feel their emotions when they join us for these events. It is so important for me to know as much as I can about their experience and to talk to them about the loved one they’ve lost.
“While in some parts of the UK there will be an automatic referral to CRY’s Pathology Centre at St. George’s, other families have struggled to find answers on their own or by contacting CRY after simply ‘googling’ sudden cardiac death in a young person. Disparities still exist.
“There is always a sense of dedication and commitment, to make sure that others would not have to go through a similar experience to theirs. This speaks about their kindness and generosity of spirit.
“I now really appreciate that becoming involved with an organisation such as CRY is part of the healing process, through channelling grief into something positive that brings great benefit to their community. Their power and strength is just amazing, whether they were bereaved at 3 or 6 months or even many years ago. One mother told me that raising funds for CRY screenings in her local area was helping to change the ways she was coping with the sudden death of her son, which was very recent. I have to admit it was an inspirational and moving moment.
“Secondly, I’ve now seen with my own eyes that the awareness raised by CRY’s screening programme – and the amount of money raised by CRY supporters is incredible.
“My CRY Fellowship is not like anything I’ve ever done and not something I would have imagined doing when I started my training. Sure, it can be challenging at times and quite demanding given the steep learning-curve. Just imagine finding yourself in a foreign country, in a completely different health system, seeing 100 individuals in 8 hours! But I love being a part of this pioneering screening programme and this wonderful team, travelling to all parts of the UK and then closing the loop by seeing some of the individuals I referred myself for further investigations in our dedicated Clinic at St. George’s University Hospital of London.
“I really feel I’m thriving as a young cardiologist and part of something which is so important.
“Thank you for all your support and for making this opportunity possible.”
