Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol: reply

Domenico Corrado

Department of Cardiology
University of Padova
Italy
E-mail address: domenico.corrado{at}unipd.it

Antonio Pelliccia

Institute for Sports Sciences
Rome, Italy

Hans Halvor Bjørnstad

Department of Heart Disease
Haukeland University Hospital
Bergen, Norway

Gaetano Thiene

Institute of Pathological Anatomy
University of Padova
Italy

We thank Dr Wren for his interest in the recent consensus statement of the Sports Cardiology Study Group of the ESC. We believe that his concerns have been fully addressed in our primary report.1 In the consensus document, we considered young competitive athletes as individuals aged 35 years or less who are engaged in regular fashion in exercise training and participate in official athletic competitions. We stated that the screening should start at the beginning of competitive athletic activity for the majority of sports disciplines that corresponds to an athlete age of 12–14 years. Systematic screening of younger athletes is not justified because the phenotypic manifestations, both ECG abnormalities and arrhythmic substrates, of most inherited heart diseases at risk of sudden death in the young is age-dependent and occur during adolescence or young adulthood. Screening of children is expected to have a low sensitivity for detection of cardiomyopathies, cardiac ion channel diseases (except for long QT syndrome), and progressive cardiac conduction diseases that usually develop during the later period of life. It is noteworthy that a prospective study in the Veneto region of Italy demonstrated that sport-related sudden death is an exceptional event in individuals under 12 years.2 There is the need of repeating the screening in order to timely identify delayed phenotypic manifestations, disease progression, or substrate worsening over the time. Accordingly, we stated that the screening should be repeated on a regular basis at least every 2 years.

By analogy with competitive athletes, identification of potentially lethal diseases by screening general population is expected to reduce mortality. At present, however, systematic cardiovascular evaluation of non-athletic population is not justified because of prohibitive costs. Screening may be reasonably applied to some subgroups such as individuals with employment- and occupation-related activities involving physically vigorous and intense lifestyles (e.g. firemen and other emergency personnel, and so on), which may increase the risk of cardiovascular events.3

We recognized that screening of large athletic populations is costly and stressed that strategies for implementing the proposed programme across Europe depend on the peculiar socio-economic and cultural background as well as the specific medical system in practice in different countries.

According to Italian data, the number of ‘false-positives’ (i.e. athletes with normal heart but with positive findings at the screening) who are referred for an expert cardiologic assessment and require evaluation by further tests is not exceeding 9%.4 This partial limitation is offset by the low cost of the basal screening including the 12-lead ECG and its proven ability to detect cardiovascular diseases at risk of sudden death.

In the 25 year Italian experience, systematic pre-participation evaluation including 12-lead ECG has definitively proved to be effective in identifying hypertrophic cardiomyopathy, which is the most common cause of sport-related sudden death, and in preventing sudden death in athletes.4 The 1996 AHA consensus panel recommendations stated that cardiovascular screening for young competitive athletes is justifiable and compelling on ethical, legal, and medical grounds.5 If one accepts this principle, the available evidence suggests to adopt a screening protocol on the basis of 12-lead ECG, the only proved to be effective.

References

  1. Corrado D, Pelliccia A, Bjornstad HH, Vanhees L, Biffi A, Borjesson M, Panhuyzen-Goedkoop N, Deligiannis A, Solberg E, Dugmore D, Mellwig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Heidbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E, Blomstrom-Lundqvist C, McKenna WJ, Thiene G. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2005;26:516–524.[Abstract/Free Full Text]
  2. Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol 2003;42:1959–1963.[Abstract/Free Full Text]
  3. Maron BJ, Chaitman BR, Ackerman MJ, Bayes de Luna A, Corrado D, Crosson JE, Deal BJ, Driscoll DJ, Estes NA III, Araujo CG, Liang DH, Mitten MJ, Myerburg RJ, Pelliccia A, Thompson PD, Towbin JA, Van Camp SP; Working Groups of the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention; Councils on Clinical Cardiology and Cardiovascular Disease in the Young. Recommendations for physical activity and recreational sports participation for young patients with genetic cardiovascular diseases. Circulation 2004;109:2807–2816.[Abstract/Free Full Text]
  4. Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339:364–369.[Abstract/Free Full Text]
  5. Maron BJ, Thompson PD, Puffer JC, McGrew CA, Strong WB, Douglas PS, Clark LT, Mitten MJ, Crawford MH, Atkins DL, Driscoll DJ, Epstein AE. Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the sudden death committee (clinical cardiology) and congenital cardiac defects committee (cardiovascular disease in the young), American Heart Association. Circulation 1996;94:850–856.[Free Full Text]




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