Cardiovascular evaluation, including resting and exercise electrocardiography, before participation in competitive sports: cross sectional study
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a346 (Published 03 July 2008) Cite this as: BMJ 2008;337:a346All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
The concept of mandatory exercise ECG screening of athletes (1, 2)
remains controversial (3, 4), due mainly to concerns about costs and the
adverse health impact of a high proportion of false positive diagnoses
when a fallible test is used to seek a rare condition. A number of
organisations have expressed interest in requiring exercise ECG screening
of all competitors, although the supporting papers cited by Sofi and
associates (2) are all from the same group of investigators, based in
Italy (5-8).
The Italian group have made several claims for the efficacy of
mandatory ECG screening (6, 7, 9). In the first five years after
enactment of such legislation, sudden cardiac deaths among young athletes
in Italy (3.0-3.5/100,000) remained substantially higher than in the U.S.
(where ECG screening is not required). During the period 1994-2004, the
incidence of sudden exercise deaths among Italian competitors apparently
dropped substantially, to an average of about 1.0/100,000 (6). However,
it remains unclear whether the decrease reflects greater compliance with
the 1982 testing legislation, greater diagnostic sophistication, or even a
chance statistical variation (since the absolute number of exercise deaths
among young athletes in any given year was extremely small).
In order to reduce the sudden exercise death rate from 3.0-
3.5/100,000 to 1/100,000, 3914 (9 per cent) of some 42,000 Italian
athletes faced the anxiety of further screening that included various
combinations of echocardiography, Holter monitoring, magnetic resonance
imaging and contrast angiography. Moreover, 879 (2 per cent) were still
ultimately disqualified from competition (6). There were no deaths among
the 879 disqualified individuals over the follow-up period; Corrado and
associates (6) interpreted this as evidence that the disqualification was
warranted, although their finding could also indicate that in all or most
of the athletes concerned the disqualification was unnecessary.
In nations where medical evaluations are paid from the public purse,
cost/benefit analyses are important to maximizing the benefit obtained
from finite health-care budgets. The simple step test used by many
Italian sports physicians was estimated to cost about $40/athlete, or $4
million in a population of 100,000 competitors. Nine percent of the
Italian sample required further evaluation, at a cost of perhaps $300 per
individual, bringing the total cost to $6.7 million per 100,000 athletes.
Let us make the generous assumption that all of the secular trend to a
reduction of sudden exercise deaths in Italy was due to the introduction
of mandatory ECG screening. The Italian figures would then suggest a
saving of 2.0-2.5 deaths per 100,000 athletes, at a cost of about $3
million per life saved. If the athlete had a subsequent life expectancy
of 60 years, the cost would be some $50,000 per life-year saved, a value
that at first inspection might appeal to a health economist.
Unfortunately, this apparent gain would be more than offset by the
unnecessary reduction in the quality of life, the premature dependency and
premature death in the 2 percent who were told, inappropriately, that they
should not exercise.
Plainly, there remains a need for a comprehensive analysis, carefully
weighing the downside as well as the apparent gains from the required
exercise ECG testing of athletes.
References
1. Drezner JA, Khan K. Sudden cardiac death in young athletes. BMJ
2008;337:61-62.
2. Sofi F, Capalbo A, Pucci N, J. G, Condino F, Alessandri F, et al.
Cardiovascular evaluation, including resting and exercise
electrocardiography, before participation in competitive sports: cross
sectional study. BMJ 2008;337:88-92.
3. Shephard RJ. Preparticipation screening of young athletes: An
effective investment? In: Shephard RJ, Alexander M, Cantu RC, Feldman DE,
McCrory P, Nieman DC, et al., editors. Year Book of Sports Medicine, 2005.
Philadelphia, PA: Elsevier Mosby, 2005:xix-xxv.
4. Shephard RJ. Mass ECG Screening of Young Athletes. Br J Sports
Med: BMJ, 2008:Online First: 7 May 2008. doi:10.1136/bjsm.2008.048843.
5. Corrado D, Pelliccia A, Vanhees L, Biffi A, Borjesson M, et al.
Cardiovascular pre-participation screening of young competitive athletes
for prevention of sudden death: proposal for a common European protocol.
Eur Heart J 2005;26:516-524.
6. Corrado D, Basso C, Pave A, Michieli P, Schiavon M, Thiene G.
Trends in sudden cardiovascular death in young competitive athlete after
implementation of a pre-participation screening program. JAMA
2006;296:1593-1601.
7. Pelliccia A, Di Paolo FM, Corrado D, Buccolieri C, Quattrini FM,
Pisicchio C, et al. Evidence for efficacy of the Italian national pre-
participation screening programme for identification of hypertrophic
cardiomyopathy in competitive athlete. Eur Heart J 2006;27:2196-2200.
8. Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R,
Castagna W, et al. Prevalence of abnormal electrocardiograms in a large,
unselected population undergoing pre-participation cardiovascular
screening. Eur Heart J 2007;28:2006-2010.
9. Pelliccia A, Di Paolo FM, Quattrini FM, Basso C, Culasso F, Popoli
G, et al. Outcomes in athlete with marked ECG repolarization
abnormalities. N Engl J Med 2008;358:152-161.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor:
In my opinion it is not really of great help to follow established
guidelines or define what is an athlete to diagnose the disease
responsible for syncope and sudden death. The reasons being are that these
are definite disease entities such as hereditary hypertrophic obstructive
cardiomyopathy or congenital bicuspid aortic valve stenosis, or congenital
or acquired prolonged Q T interval,and their diagnosis depends on the
acumen and skill of the physician and his knowledege of cardiology.
Furthermore, treatment of these mentioned diseases will reduce or
prevent the occurence of sudden death and syncope from these specific
diseases.Beta blockesrs and certain calcium channel blockes have been used
very effectively in Hypertrophic obstructive cardiomyopathy.
Also surgical myomectomy is quite definitive and this procedure was first
introduced by Dr. Cleland at the Brompton Hospital of London some 50 or so
years ago.
Similarly, prosthetic valve replacement for critical symptomatic bicuspid
aortic valve stenosis. Lastly, beta blockers and or other measures have
been used in treating a prolonged Q-T interval such as stopping offending
drugs that prolong the Q-T interval in certain individuals
Sincerely,
Munir (Mounir) E. Nassar, M.D., FACP, FAHA
Competing interests:
None declared
Competing interests: No competing interests
Reducing sudden death in athletes in a worthy aim.(BMJ 2008;337:a346)
but much more clarity about the targets of such screening is needed.
What is a " competitive athlete"? Does participation in a 5km charity
run count? Or only if you try to beat the woman in front? What is an
"officially sanctioned sport" in Italy?
Is such screening a one off for young people? Or should it recur as
we encourage older adults to "get fit"? False positives could harm those
who avoid sport as a result.
When articles about screening are published a rigorous analysis of
whether they fit Wilson and Junger's criteria should accompany the
evidence presented.
( Wilson, J. M. G., and G. Junger. 1968. The principles and practice of
screening for disease. Public Health Papers:WHO 34 )
Competing interests:
None declared
Competing interests: No competing interests
Editor,
I read with great interest the article by Sofi et al (1) and its
associated editorial (2). The sudden death of seemingly exceptionally
healthy individuals has a profound effect on communities, serving as a
reminder of our own mortality. Efforts to try to lesson these events
taking place are to be actively supported and as is rightly pointed out by
Dresner & Kahn (2), the time has come to seriously consider population
based pre-participation cardiovascular screening.
This article raises three key issues for pre-participation screening
implementation. The consensus statement of the European Society of
Cardiology on screening (3) recommends the use of a three pronged
approach; namely history, physical examination and 12 lead resting
electrocardiograms (ECG). This has been shown to reduce the incidence of
sudden cardiac deaths in athletes by 90% (4). The addition of the
exercise ECG, in the BMJ article, serves to identify further
cardiovascular problems, even in athletes who would have been otherwise
passed fit by the original triple assessment approach. With this evidence
available should exercise ECG become incorporated into this screening
programme?
The addition of exercise ECG will undoubtedly raise screening costs.
Current programmes using a triple assessment approach in the UK are
available for approximately £35(5); this may even double if exercise ECG
is added. In Italy, this is largely self-funded (4). A similar approach
here, in light of a National Health Service (NHS) that is free at the
point of delivery, may be off-putting to those considering entrance into
competitive sports and may discourage physical activity at a time when
obesity levels are rising.
The third problem is that of interpretation of screening results. In
order to provide a safe and effective service; the involved physicians
must be competent to identify abnormal results and provide realistic
exercise advice according to the Bethesda guidelines (6). This specialist
knowledge requires 4 years to assimilate in Italy, working almost
exclusively in this area (3). The obvious choice for doctors to perform
screening would be from the new specialty of sport & exercise medicine
(SEM); however current curriculum documents do not require the trainee
doctor to acquire a thorough competence in this area and only really
mention screening in passing (7). Competent interpretation of screening
tests in athletes is an area that few cardiologists have a special
interest in and that routine cardiology training would not provide. I
feel that there is a real opportunity here for the new faculty of SEM to
provide the NHS with doctors who are trained and competent in this area if
they address these specific learning needs in preparation for mass pre-
participation screening.
Reference:
1. 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
2. Drezner J, Khan K: Sudden cardiac death in young athletes. BMJ
2008;337:a309
3. Corrado D, Pelliccia A, Bjornstad HH, Vanhees L, Biffi A, Borjesson M,
et al. Cardiovascular pre-participation screening of young competitive
athletes for prevention of sudden death: proposal for a common European
protocol. Eur Heart J 2005;26:516-24
4. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends
in sudden cardiovascular death in young competitive athlete after
implementation of a pre-participation screening program. JAMA
2006;296:1593-601
5. http://www.c-r-y.org.uk/ecg.htm
6. Marron B & Zipes D: 36th Bethesda Conference, Introduction:
Eligibility recommendations for competitive athletes with cardiovascular
abnormalities – general considerations. J Am Col Cardiol 2005 45, 81318-21
7. Faculty of Sport & Exercise Medicine UK. SEM Specialty Training
Curriculum, September 2006, page 25. http://www.fsem.co.uk
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor:
Thank you for publishing the paper of Sofi and colleagues on
"Cardiovascular evaluation, including resting and exercise
electrocardiography before participation in competitive sports: Cross
sectional study. " BMJ 2008, 337, a346.
This is a wake up call for physicians, especially those in charge of
college health services for their students, to prevent syncope and sudden
death with althletic events.
I would like to emphasize the inportance of history and cardiac
physical exam before an electrocardiogram stress test and duplex two
dimensional echocardiogram are undertaken to confirm the diagnosis.
Since Hypertrophic cardiomyopthy,(most common in the young) and bicuspid
aortic valve stenosis, are a family hereditary diseases, a family history
of syncope or sudden death in the family would be highly suspicious to
proceed with further diagnostic tests in the presence of rapid carotid
artery upstroke and a sustained left ventricular impulse. In Congenital
bicuspid aortic valve disease, a systolic ejection click is heard and A2
is delayed sometimes producing paradoxical splitting of the second heart
sound depending on how severe is the stenosis, and a tardive pulse with
systolic thrills over the aortic area and suprasternal notch.
The exercise electrocaradiogram test should be carefully supervised or
avoided entirely, because of risk of syncope etc, and instead reliance on
the duplex two dimensional echocardiogram be accomplished to clinch the
diagnosis.
Finally, a resting electrocardiogram be done to rule in or out
prolonged Q-T interval; and holter monitoring of athletes to document
arrhythmias would be exceedingly worth while.
Sincerely,
Munir (Mounir) E Nassar, M.D., FACP, FAHA
mnassar1@rochester.rr.com
Competing interests:
None declared
Competing interests: No competing interests
Italy clearly is the leader in the research about how to prevent
sudden cardiovascular death in young competitive athletes, because it
introduced a national mandated pre-participation screening program for
athletes already in 1982. This screnning program reduced sudden cardiac
death due to cardiomyopathy by ~90% (1).
Sofi et al. report in their study the superiority of exercise
electrocardiography over taking a history and resting ecg alone in
detecting persons at risk for sudden cardiac death among young competitive
athletes.
One might wonder, if including echocardiography in this program would not
be an even more efficient approach.
Of course arrhythmogenic right ventricular cardiomyopathy (ARVC) and
hypertrophic obstructive (HOCM) and non-obstructive cardiomyopathy (HCM)
confer a high risk, but their prevalence in the general population is
quite low.
In persons 30 years of age or older, many of which might start with
competitive activities like marathon running, left ventricular hypertrophy
(LVHT) as a consequence of arterial hypertension has a much higher impact
on mortality on the population level than these rather rare abnormalities.
Cardiovascular risk in the presence of LVHT is more than doubled according
to long-known Framingham data.(3)
The prevalence of hypertension in general is rising and Germany has one of
the highest hypertension prevalences worldwide (4). Prevention First is
one of the leading institutions in Germany performing regular health check
-ups for employees of large companies. We see a high prevalence of unknown
hypertension (25% or more) and LVHT in our routine echocardiography
(unpublished data), which is an indication for immediate blood-pressure
lowering treatment.
As echocardiography has a much higher sensitivity and specificity than
resting or exercise ecg in detecting cardiac abnormalities like LVHT (and
ARVC, HOCM and HCM, too), it seems logical, that a screening program
including "once-a-life echocardiography" before starting any ambitioned
sports activities could be even more efficient in preventing sudden
cardiac death in athletes and even in beginners at an age of >30 years.
(1) 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 prepartici-pation screening program. JAMA.
2006;296:1593-1601.
(2) Francesco Sofi, Andrea Capalbo, Nicola Pucci, Jacopo Giuliattini,
Francesca Condino, Flavio Alessandri, Rosanna Abbate, Gian Franco Gensini,
and Sergio Califano. Cardio-vascular evaluation, including resting and
exercise electrocardiography, before participation in competitive sports:
cross sectional study BMJ 2008 337: a346.
(3) Kannel,W.B.; Gordon,T.; Offutt,D. Left ventricular hypertrophy by
electrocardiogram. Prevalence, incidence, and mortality in the Framingham
study. Ann Int Med 1969; 71: 89-105.
(4) Wolf-Maier K, Cooper RS, Banegas JR, et al. Hypertension
prevalence and blood pressure levels in 6 European countries, Canada, and
the United States. JAMA. 2003;289:2363-2369.
Competing interests:
None declared
Competing interests: No competing interests
Why exercise EKG
Dear Editor:
I read with interest, the remarks of Professor Jey Sheppard.I
personally would not advocate the practice of exercise EKG testing for
reasons that exercise may provoke serious arrhytmias or cardiac arrest in
those conditions that are the cause of the problem due to exercise.The
conditions are Hypertrophic obstructive cardiomyopathy,
congenital bicuspid aortic valve stenosis, and prolonged Q-T interval
discovered in a 12 lead electrcardiogram, which I have discussed in my
rapid responses.
Sincerely,
Mounr(Munir) E Nassar, M.D. FACP, FAHA
mnassar1@rochester.rr.com
Competing interests:
None declared
Competing interests: No competing interests