Preparticipation screening for cardiovascular abnormalities in young competitive athletesBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1596 (Published 29 September 2008) Cite this as: BMJ 2008;337:a1596
All rapid responses
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
• 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.
1. Papadakis M, Whyte G, Sharma S. Preparticipation screening for
cardiovascular abnormalities in young competitive athletes. BMJ 2008; 337:
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,
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
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,
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
11. Fuller CM. Cost effectiveness analysis of screening of high
school athletes for risk of sudden cardiac death. Med Sci Sports Exerc
Competing interests: No competing interests
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
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
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!)
Non-competing interest - I am a NHS general cardiologist with little knowledge on this area
Competing interests: No competing interests