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CLINICAL REVIEW: Michael Papadakis, Greg Whyte, and Sanjay Sharma Preparticipation screening for cardiovascular abnormalities in young competitive athletes BMJ 2008; 337: a1596 [Full text]

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Who will pay?

M Justin S Zaman   (15 October 2008)

Preparticipation screening of athletes - an effective tactic?

Roy J. Shephard   (6 November 2008)

Who will pay? 15 October 2008
M Justin S Zaman, Specialist Registrar in Cardiology Norfolk and Norwich University Hospital Send response to journal: Re: Who will pay?	This is an important topic primarily from the point of view that it presents as highly visible events and affects young, fit people rather than a big problem that affects a large swath of the population. From the UK perspective, given the low prevalence of the disorders implicated in sudden cardiac death during sport, the cost-effectiveness is undoubtedly going to be small. Though the current emphasis is on providing the most cost effective method for minimising sudden cardiac death, whilst we await research for this, surely the resources for such testing should be provided by accredited specialists in the private sector and funded by bodies involved in the management of competitive sport rather than within the NHS. Since also the psychological burden is greater in young athletes with a diagnosis of a potentially life threatening condition and who are excluded from competing, the need for expert psychological support should also be provided by private healthcare. The authors state that the ‘cost should be economically balanced in relation to possible expenditure on medical care as a whole’. If it is true that the vast majority of young persons who play non-competitive sport are not at risk, then perhaps the NHS should not have to pay for this. Physical activity and participation in sport should continue to be strongly encouraged for all, as the majority of these will not compete at elite levels. If the authors feel that the risk of sudden death of ‘school playground level’ activity in the general young population is low, then the health of the ‘elites’ should be safeguarded by bodies such as Olympic Committee and sporting governing bodies. This is of particular political importance considering the UK has an Olympics approaching. Putting on a show to safeguard these athletes’ health will continue to reinforce the positive sporting message that the UK wishes to propagate regarding its upcoming Olympics. This would therefore advocate the use of specialist services with knowledge on these risks as opposed to the (potentially dangerous) involvement of non-specialists (or even general cardiologists!) Competing interests: Non-competing interest - I am a NHS general cardiologist with little knowledge on this area
Preparticipation screening of athletes - an effective tactic? 6 November 2008
Roy J. Shephard, Professor Emeritus of Applied Physiology University of Toronto, M5S 2W6 Send response to journal: Re: Preparticipation screening of athletes - an effective tactic?	The issue of the pre-participation screening of young competitive athletes has exercised the minds of sports physicians for a number of years (1, 2, 3). Concerns have included the potential economic costs of extensive laboratory testing, the health costs resulting from false positive test responses (with the sequelae of anxiety and unnecessary avoidance of physical activity), and poor cost-effectiveness in terms of overall gains in quality-adjusted life expectancy. The consensus in North America, as formulated by the American Heart Association (4), has been to restrict such screening to a medical and family history, plus a focused clinical examination. But in Europe, largely at the urging of Italian physicians, the recommendation has been that an exercise ECG become mandatory (5, 6, 7). There seems general agreement that the current North American practice has limited value, since prior examination has seldom identified those who have the misfortune to die on the sports field. However, there seems a need for caution before accepting the verdict of Papadakis et al. (1, p.810) that the Italian pattern of screening “is effective in reducing sudden death from cardiomyopathy.” The strongest point in the ITalian argument seems the progressive decrease in sudden deaths among Italian competitive athletes since their testing became mandatory (5). However, several important questions remain to be answered: • If the Italian approach to screening is indeed effective, why do even the three most recent points on their mortality graph (5) show a higher incidence of sudden death than in the U.S., where ECG screening is not required? • The Italian approach has led to the exclusion of 1.8 per cent of athletes from competition (8). Assuming an incidence of sudden death of 0.5 per 100,000 per year, and an athletic career of twenty years, in the absence of testing, there would be 10 sudden deaths per 100,000 athletes. Thus, 179 athletes have been denied physical activity in the hope that the restrictions imposed on the 180th patient may be beneficial. • There have been occasional attempts to assess cost-effectiveness in terms of gains in life expectancy or quality-adjusted life expectancy (2, 10, 11), but it remains difficult to discount putative benefits by an amount that reflects the imposition of physical inactivity upon those receiving false positive diagnoses. • The suggested pattern of investigation not only fails to meet WHO criteria for screening tests (9), but (as Bayes theorem reminds us) it seems doomed to failure since tests with a limited sensitivity and specificity are being used in an attempt to detect a very rare occurrence. References 1. Papadakis M, Whyte G, Sharma S. Preparticipation screening for cardiovascular abnormalities in young competitive athletes. BMJ 2008; 337: 806-812. 2. Shephard RJ. Preparticipation screening of young athletes: An effective investment? In: Year Book of Sports Medicine, 2005, RJ Shephard, MJL Alexander, RC Cantu et al., eds. Philadelphia, PA. Elsevier/Mosby, 2005; xix-xvi. 3. Shephard RJ. Mass ECG screening of young athletes. Br J Sports Med 2008; 42: 707-708. 4. Maron BJ, Thompson PD, Ackerman MJ et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update. Circulation 2007;115:1643-1655. 5. Corrado D, Basso C, Pavei A, et al. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 2006;296:1593–1601. 6. International Olympic Committee Medical Commission. Sudden cardiovascular death in sport. International Olympic Committee Medical Commission, International Olympic Committee. http:// multimedia.olympic.org/pdf/en_report_886.pdf (accessed 5th November, 2008). 7. Corrado D, Pelliccia A, Bjornstad HH, et al. 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 Society of Cardiology. Eur Heart J 2005;26:516–524. 8. Corrado D, Basso C, Schiavon M et al.Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339:364-369. 9. Wilson JMG, Jungner G. Principles and practice of screening for disease. WHO Chronicle 1968;22:473. 10. Fuller CM, McNulty CM, Spring DA et al. Prospective screening of 5615 high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc 1997;29:1131-1138. 11. Fuller CM. Cost effectiveness analysis of screening of high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc 2000;32:887-890. Competing interests: None declared