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EDITORIALS: Jonathan A Drezner and Karim Khan Sudden cardiac death in young athletes BMJ 2008; 337: a309 [Full text]

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Resus is the answer, screening inefficient and too expensive for the NHS

Jonathan R Hanson   (12 July 2008)

Unintended Consequences

Laurie R. Davis   (13 July 2008)

Should young athletes be screened?

Julian Elston, Ken Stein, Professor of Public Health, Peninsula College of Medicine and Dentistry   (18 July 2008)

Detect risk with Automate Exercise ECG

C. Kevin Connolly   (18 July 2008)

The disputable role of exercise electrocardiography in preparticipation screening of young athletes

Christian van der Werf, Irene M. van Langen, clinical geneticist, Arthur A.M. Wilde, Professor of Cardiology   (11 August 2008)

Resus is the answer, screening inefficient and too expensive for the NHS 12 July 2008
Jonathan R Hanson, rural practitioner iv45 8rs Send response to journal: Re: Resus is the answer, screening inefficient and too expensive for the NHS	Sir, Currently a resting ECG costs £35 through CRY. Variable penetrance for HCM with obstruction, means that one off resting ecg screening will miss the commnest cause of sudden athletic death in the under 35's unless it is repeated on up to an annual basis. Although a combination of family symptoms, family history and resting ecg will increase the sensitivity of a screening prgramme, upgrading to stress ECG's and on probably an annual basis just wont work on the NHS due to cost. Thus by definition such a "screening" programme is by definition ineffective. The obvious question is what do we do with the positive screening tests. Do we truely have a right to prevent participation in sport? Especially for example, the african runner, who's sporting prowess provides food and water for his whole village. The Seattle experience suggests that the availability of advisory external defibrillators is a positive step in improving survival from community cardiac arrest. Thus rather than creating hysteria and false reassurment form a normal one off ecg for the general population, we should be investing in improving the resus skills and equipment at venues where athletic activity is likely to take place. The 2005 European resus council evidence suggests that early electricity saves lives. We need more focus on community defibs and training, rather than trying to (unreliably) screen the general public and create a nation of fat people through telling them not to exercise. Jonathan Hanson Rural Practitioner and sports physician Competing interests: course author and co-ordinator Scottish Rugby Union Medical cardiac and pitchside skills. (SCRUMCAPS)
Unintended Consequences 13 July 2008
Laurie R. Davis, GP Principal South Hermitage Surgery,South Hermitage, Shrewsbury SY3 7JS Send response to journal: Re: Unintended Consequences	What an extraordinary suggestion ; that we should medicalise sport and prevent involvement of those with suspicious findings.Have the Authors not noticed that we are living in an epidemic of obesity? Obviously the prevention of sudden death is laudable, but how many people will be put off sporting involvement by the concept of its dangerous nature ,and the cost and inconvenience involved in getting medical investigation? Those on the periphery of involvement particularily ,one assumes. Furthermore , are we to prevent the sporting involvement of those with IHD risk factors such as smokers and hypercholestrolaemics? And does playing football with your children in the park count as sport? It seems surprising that the Italians have accepted it; but it is easy to frighten people about their hearts and the screening arguement is superficially attractive. The Italian approach ,which clearly fails many of Wilson's screening criteria , is presumably particularily popular with those doctors and health providers who are benefiting from offering their services.. Competing interests: I have LVH that I hope is due to Athletic Heart
Should young athletes be screened? 18 July 2008
Julian Elston, Academic Specialist Trainee in Public Health South West region, Ken Stein, Professor of Public Health, Peninsula College of Medicine and Dentistry Send response to journal: Re: Should young athletes be screened?	The forty years of careful consideration of screening since Wilson and Jüngner(1) appear to have by-passed Drezner and Khan.(2) Every sudden cardiac death (SCD) is a tragic event and traumatic experience for family and relatives, but in truth the burden to society is small. The death of a high profile athlete is inevitably followed by a loud clamour for pre-participation screening. But carefully consideration of the evidence in relation to the national criteria is essential if screening is to do more good than harm. The benefit of screening has yet to be demonstrated. Drezner and Khan point to evidence from the Italian national screening programme.(3) This describes a nearly five-fold fall in incidence of SCD in athletes over a twenty year period in comparison to a lower stable rate among non athletes. However, observational studies are subject to a range of biases, several of which were not accounted for in this study i.e. changes in training regimes and diet and the absence of blinding in case ascertainment. More significantly, no study has compared the incidence of SCD in athletes with cardiovascular disease who have been screened with those who have not.(4) In Italy, one in eleven athletes screened are referred for specialist assessment, only a quarter of whom are disqualified. Thus, screening results in high numbers of false positives, creating unnecessary anxiety. Indeed, many disqualifications may be unwarranted, as the risk of SCD is poorly characterised in a number of cardiomyopathies, which make up to half of all SCD.(5,6) Thus, the level of unnecessary harms to well-being, insurance costs and future employment remains unknown. There are further uncertainties, not least the cost-effectiveness and organisational implications of screening. The apparent nonchalent advocation of screening is ill-founded, premature and ethically dubious. We advocate a comprehensive synthesis of existing evidence as the basis for an informed debate, rather than Drezner and Khan’s partial approach. Reference List (1) Wilson JMG, Jüngner, G. Principles and Practice of Screening for Disease. Public Health Papers No. 34. WHO Chronicle 1968; 22(11):473. (2) Drezner JA, Khan K. Sudden cardiac death in young athletes. BMJ 2008; 337:a309. (3) Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. J Am Med Assoc 2006; 296(13):1593-1601. (4) Thompson P, Franklin B, Balady G, Blair S, Corrado D, Estes NA et al. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 2007; 115(17):2358-2368. (5) Corrado D, Basso C, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden cardiac death? J Cardiovasc Med (Hagerstown) 2006; 7(4):228-233. (6) Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. J Am Med Assoc 1996; 276(3):199-204. Competing interests: None declared
Detect risk with Automate Exercise ECG 18 July 2008
C. Kevin Connolly, Retired Respiratory Physician Richmond DL117TP Send response to journal: Re: Detect risk with Automate Exercise ECG	The evidence shows that resting ECG fails on both essential criteria for a screening test, high specificity and high sensitivity, in that order. Low specificity inevitably generates unnecessary worry and expense. It is not unreasonable to assume that an exercise ECG satisfies both criteria so far as the target abnormality, induced exercise-induced cardiac arrhythmia, is concerned. An an initially blinded automated system similar to that used in defibrillators provides the solution. The system would allow the test to proceed unless the resting trace showed a clearly dangerous resting abnormality and stop the test if one developed. Although no trace would show the memory would retain it for necessary refence. Required training would be little more than that necessary to understand and operate the accompanying defibrillator. If this practice became prevalent the cost would fall rapidly particularly if the accompanying treadmill was dual purpose being available for general use at other times. Competing interests: None declared
The disputable role of exercise electrocardiography in preparticipation screening of young athletes 11 August 2008
Christian van der Werf, Research fellow Cardiology Academic Medical Centre, University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, The Netherlands, Irene M. van Langen, clinical geneticist, Arthur A.M. Wilde, Professor of Cardiology Send response to journal: Re: The disputable role of exercise electrocardiography in preparticipation screening of young athletes	Drezner and Khan discuss in their editorial the article by Sofi et al, the most recent report on the continuing debate on preparticipation screening of young athletes to prevent sudden cardiac death (SCD).(1)(2) In the report by Sofi et al. 153 of the 159 athletes were disqualified from competitive sports because of cardiac abnormalities that would have been overlooked on history and physical examination alone. Therefore they conclude that adding resting electrocardiography (ECG) to the preparticipation screening (PPS) is important, as pertinent in the Lausanne Recommendations.(3) However, it should be noted that among the 159 athletes, 126 (79.2%) had a normal pattern on resting ECG. Thus, by not performing an exercise ECG only 33 to 39 (dependent on an overlap between athletes indentified by resting ECG and by history and physical examination) of the group disqualified from competitive sports in the Sofi article would have been indentified. For that reason Sofi et al. conclude that an exercise ECG can show clear pathological findings in participants with negative or innocent findings at physical examination and resting ECG. Considering the described results, we would like to emphasize the high yield of an exercise ECG in identifying athletes with relevant cardiac abnormalities as a proxy for SCD, which in our opinion is somewhat neglected in the editorial. Thus, these data can not be used to promote baseline resting ECG as part of PPS, but should on the contrary be regarded a plea for performing an exercise ECG. This plea, however, is not yet supported by follow-up data on SCD, which is its weakness compared to the earlier data on the effect of exclusion based on resting ECG abnormalities.(4) Similar to the debate on the role of a resting ECG in the PPS of young athletes to prevent sudden cardiac death, factors as costs, the need for expert evaluators and unknown false-positive and -negative rates make adding exercise ECG to PPS disputable. (1) Drezner JA, Khan K. Sudden cardiac death in young athletes. BMJ 2008; 337:a309. (2) Sofi F, Capalbo A, Pucci N, Giuliattini J, Condino F, Alessandri F et al. Cardiovascular evaluation, including resting and exercise electrocardiography, before participation in competitive sports: cross sectional study. BMJ 2008; 337:a346. (3) Bille K, Figueiras D, Schamasch P, Kappenberger L, Brenner JI, Meijboom FJ et al. Sudden cardiac death in athletes: the Lausanne Recommendations. Eur J Cardiovasc Prev Rehabil 2006; 13(6):859-875. (4) Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 2006; 296(13):1593-1601. Competing interests: None declared