Can electrocardiographic screening prevent sudden death in athletes? Yes
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4923 (Published 14 September 2010) Cite this as: BMJ 2010;341:c4923All rapid responses
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Sir.
The issues around ECG screening for sudden athletic cardiac death
(SACD) are deeper than Pellicia et al (1) and Bahr(1) have described.
Essentially, Pellicia et al(1) are supporting screening based on a
programme that was set up 30 yrs ago, in a discrete population and that
excludes individuals deemed at risk from all organised activity. Although
there is no doubt that having a large database is generally preferable in
terms of significance, the key point here is that this is essentially a
model that was set up 20-30 years ago. The world is a very different place
today both medically, financially and socially.
Bahr(1), quite rightly and succinctly illustrates that screening for
lesions that may cause sudden cardiac death is not an effective screening
programme under the conventional WHO criteria. The key factors here are
that sudden cardiac death is an extremely rare event (quoting an incidence
of 0.4 -3.6/100,000 years(1)), ECG screening can have a poor specificity
(quoting false positives between 16-40%(1)) for many of the pathologies
attributable to SACD and that the spectrum of congenital pathology
responsible has a wide geographical variation. Thus no-one has
successfully reproduced the Veneto successes.
This means an awful lot of individuals will be labelled of wrongly
being at risk from something which has a tiny risk anyway. Nobody knows
what the effects of being a young adult who is a false positive will have
on the attitude of banks, insurance companies or potential future career
paths and earning potential. In the 1980's the social implications of
being a false positive for an incredibly rare fatal event (but one with an
extremely high media profile were it to happen) were probably of much less
significance than they would be in 2010, especially given the current
global financial state, attitudes to risk and the practice of holistic
medical care.
Pellicia et al(1) make reference to the important need for informed
consent of the athlete and his parents when discussing the improved
sensitivity of a screening test that includes an ECG over history and
symptoms. With a false positive rate of up to 40%(1), I would argue truly
informed consent should include a discussion of the possibility that the
athlete may be unable to obtain life insurance or continue his chosen
career as a pilot. But be reassured that he has an excellent chance of
living to a ripe old age.
If we then add further concerns about "one off" ECG screening, such
as that of the complex genetics of the cardiomyopathies and variable
penetrance(2) (the phenomenon that suggests the phenotypic features of a
genetic condition appear over a variable time frame) and that a
significant proportion of causes of SACD are due to acquired pathology
such as viral myocarditis(3), then in the bigger picture of heterogeneous
responsible pathology, the sensitivity of ECG screening for identifying
those at risk of sudden cardiac death also looks less rosey than is
implied.
Some specialists suggest that screening could be improved by adding
in echocardiography, which only illustrates Bahrs point further in terms
of cost and feasibility as a screening test. Even if used as a second line
investigation to look further at those who are identified by ECG, another
can of worms is opened between the features of hypertrophic cardiomyopathy
and the trained athletic heart. It is suggested that echo features which
could be attributable to HCM (left ventricular hypertrophy without
cardiovascular cause) are present in up to 1 in 500(4) of the general
population. Given the incidence of sudden cardiac death,this is not
helpful. Some units suggest a period of detraining to tell the two apart.
This is often not acceptable to the athlete either.
When it comes to potential treatments, things have also moved on
considerably since the 1980's. The video of a Belgian professional
footballer collapsing on field and then being defibrillated by his own
internal device fitted some years previously is widely available on the
internet. Also, given the obesity and inactivity epidemic we now find
ourselves on the edge of and the tiny risk of SACD, is it wise (from a
health economics perspective) or ethical to exclude individuals from
activity? Is it also truely possible? Do such individuals never run for
the bus or hurry because they are late? Elliot et al describe a series
that up to 14% of deaths due to hypertrophic cardiomyopathy occur at
rest(5).
If we look at what can we do, the case of the Belgian footballer is
telling (device sited following investigations for cardiac symptoms, so
unrelated to screening asymptomatic populations). Drezner has reported a
prospective series of athletic on field cardiac arrests in which support
staff performed high quality basic life support, had immediate access to
defibrillators and followed international guidelines with encouraging
results(6). Obviously, given the rarity of such an event, the numbers in
this series are small. Public access defibrillator programmes have already
been heavily invested in. Drezner suggests the addition of an emergency
action plan can improve survival(6). Many sports governing bodies are
acting to ensure pitchside staff are adequately trained to act in the
unlikely event of a cardiac arrest in a sports setting(7).
The drive for cardiac screening increases after each high profile
death is reported in the media. It is still a rare event and screening
incorporating an ECG would still miss a significant proportion of cases of
on field death(1), yet could potentially ruin the lives of many false
positive cases. The deaths that are not prevented via a screening
programme will always remain high profile in the media, the practical
burden of those labelled as at risk will not.
In terms of organisation, the provision of public access
defibrillators is advancing all of the time. In the current financial
climate it makes sense to focus our attention on maximising this route as
a method of preventing on field cardiac death rather than developing a
controversial screening programme of an asymptomatic population that will
not prevent a significant proportion of this extremely rare but tragic
event.
1. Pellicia A, Corrado D, Bahr R. Head to Head. Can ECG screening
prevent sudden death in athletes? BMJ 2010; 341:c4914
2. Maron BJ. Hypertrophic cardiomyopathy: a systematic review. JAMA
2002;287:1308 -20.
3. Eckart RE, Scoville S et al Sudden Death in Young Adults: A 25-
Year Review of Autopsies in Military Recruits. Ann Int Med 2004. 141(11)
829-834
4. Maron BJ. Distinguishing hypertrophic cardiomyopathy from
athlete's heart: a clinical problem of increasing magnitude and
significance. Heart 2005;91:1380-2.
5. Elliot PM, Poloniecki J et al. Sudden death in hypertrophic
cardiomyopathy: identification of high risk patients. J Am Coll Cardiol,
2000; 36:2212-2218
6. Drezner JA, Ashwin L. et al Effectiveness of Emergency Response
Planning for Sudden Cardiac Arrest in United States High Schools With
Automated External Defibrillators Circulation. 2009;120:518-525.
7. Hanson JR. Sports pre-hospital immediate care training in the UK.
Attempting to 'treat' sudden athletic cardiac death. SMJ 2010 55(2): 35
Competing interests: JH is an Advanced Life support Instructor and teaches on a selection of sports pre-hospital immediate care courses.
How strong is "new evidence" for mandatory ECG screening of athletes?
Pelliccia and Corrado (1) have recently advanced what they claim to
be new support (2, 3) for the controversial practice (4-8) of mandatory
pre-participation ECG screening of athletes as a means of preventing
exercise-related sudden death. The same article (1) also created some
confusion by suggesting that both the American Heart Association (AHA) and
the European Society of Cardiology call for cardiovascular screening,
although in fact the AHA has firmly recommended against the ECG screening
of athletes (9).
How strong is the additional evidence presented by Pelliccia and
Corrado (1)? The first of the recent studies cited is by Baggish et al.
(2). They used what seems a rather small sample (510 unselected U.S.
college athletes, presumably male, although this is not stated) to
investigate a very rare problem They compared the diagnostic efficacy of
history and physical examination alone against a combination of such
information with the findings from a 12-lead resting ECG obtained on the
same subjects. The outcome of their comparison necessarily depends on the
skill used in making the respective evaluations. We read that an 8-minute
clinical examination was conducted by non-cardiologist clinicians from the
University Health Service, individuals who were not dedicated sports
physicians; further, the subsequent ECG evaluation was based on European
College of Cardiology standards, which do not take account of athlete-
specific criteria of normality. Moreover, the gold standard for a correct
diagnosis was not subsequent cardiac death as observed by a prospective
trial, but rather a cross-sectional comparison of the two data sets with
reports of suggestive or diagnostic abnormalities as seen during a limited
echocardiographic imaging. Thus, the methods adopted to compare the two
diagnostic approaches must be judged as relatively weak. Nevertheless,
this provides the basis for their claim that after considering the results
of ECG testing, 11 individuals with dangerous abnormalities were detected,
as against only five athletes who were identified by history and physical
examination alone. It is hard to believe that 11 of 510 unselected
college athletes were at imminent risk of exercise-induced sudden death;
most estimates put the annual risk at around 1 incident per 100,000
athletes. It thus seems significant that only three of the 11 athletes
identified were asked to restrict their sport participation; in my view,
even this number seems excessive. Furthermore, we have no information
whether the restriction of physical activity lengthened or shortened the
subsequent life span of the individuals concerned!
The second piece of evidence advanced by Pelliccia and Corrado (1) is
a paper by Wheeler et al. (3). This sought to estimate the cost-
effectiveness of adding ECG screening to clinical examination. Costs were
based on 2004 figures from the US National Center for Health Statistics,
but the risks of sudden exercise-induced death were drawn from a somewhat
puzzling non-randomized Italian data set (10); the Italian statistics
suggested a very high initial prevalence of sudden exercise-induced death,
and figures have remained above those in the U.S. despite an apparent
decrease of mortality among the Italian athletes following the
introduction of mandatory ECG screening. Theoretical calculations
suggested an added expense of US $42,900 per life-year saved. At first
inspection, this figure might seem comparable with the cost-effectiveness
of other accepted procedures such as renal dialysis. However, the Italian
recommendation has been for annual rather than once only screening of
athletes, and this would immediately boost expenditures by a factor of 10-
20. Moreover, the ECG screening of an athletic population inevitably
creates a large proportion of false positive diagnoses, and the accounting
of Wheeler et al. (3) did not examine either the worsening of health
imposed by unnecessary restrictions upon physical activity, or the impact
of essential further testing upon the well-being and productivity of the
next of kin and those individuals wrongly identified as at increased risk
on the basis of their ECG records.
The new evidence in the papers of Baggish et al. (2) and Wheeler et
al. (3) thus seems far from convincing. More importantly, the recent
paper of Pelliccia and Corrado (1) does not answer the fundamental
question. How can their approach satisfy the classical Wilson-Jungner
criteria for any useful screening procedure (11), including particularly a
substantial disease prevalence and an appropriate level of sensitivity and
specificity in the test procedure?
References
1. Pelliccia A, Corrado D. Can ECG screening prevent sudden death in
athletes? Yes. BMJ 2010; 341:c4923.
2. Baggish AL, Hutter AM, Wang F, Yared K, Weiner RB, Kupperman E,
Picard MH, Wood MJ. Cardiovascular Screening in College Athletes With and
Without Electrocardiography. A Cross-sectional Study. Ann Intern Med 2010;
152: 269-275.
3. Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Wheeler
EAA, Cost-Effectiveness of Preparticipation Screening for Prevention of
Sudden Cardiac Death in Young Athletes. Ann Intern Med 2010; 152: 276-286.
4. Shephard RJ. Mass ECG screening of young athletes Br J.Sports Med.
2008;42;707-708.
5. 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.
6. Chaitman R. An Electrocardiogram Should Not Be Included in Routine
Preparticipation Screening of Young Athletes. Circulation 2007;116;2610-
2615.
7. Myerburg RJ, Vetter VL. Electrocardiograms Should Be Included in
Preparticipation Screening of Athletes. Circulation 2007;116;2616-2626.
8. Bahr R. Can ECG screening prevent sudden death in athletes? No.
BMJ 2010; 341:c4914.
9. Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D,
Dimeff R, Douglas PS, Glover DW, Hutter AM, Krauss MD, Maron MS, Mitten
MJ, Roberts WO, Puffer JC. Recommendations and Considerations Related to
Preparticipation Screening for Cardiovascular Abnormalities in Competitive
Athletes: 2007 Update: A ScientificStatement From the American Heart
Association Council on Nutrition, Physical Activity, and Metabolism:
Endorsed by the American College of Cardiology Foundation. Circulation
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10. 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.
11. Andermann A, Blancquaert I, Beauchamp S, Deryc V. Revisiting
Wilson and Jungner in the genomic age: a review of screening criteria over
the past 40 years. Bull World Health Organ. 2008; 86:317-319.
Competing interests: No competing interests