Can electrocardiographic screening prevent sudden death in athletes? YesBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4923 (Published 14 September 2010) Cite this as: BMJ 2010;341:c4923
- 1Institute of Sports Medicine and Science, Italian National Olympic Committee, Largo Piero Gabrielli, 1 00197 Rome, Italy
- 2Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
- Correspondence to: A Pelliccia
The European Society of Cardiology has supported electrocardiography based screening for competitive athletes since 2005, and the International Olympic Committee endorsed a similar approach in a policy statement in 2009.1 2 These position statements have raised interest in the scientific community and general public, and fuelled the current debate regarding the efficacy of pre-participation electrocardiographic screening to detect the risk of cardiovascular diseases in young athletes and to reduce deaths.
Effect of screening on mortality
Scientific data supporting the efficacy of electrocardiography derives from Italy, the only country where pre-participation screening is required by law and where a mass screening programme with electrocardiography has been in place for almost 30 years. This population based and long term programme has provided evidence of the efficacy of screening in identifying athletes with clinically silent cardiomyopathies, primarily hypertrophic cardiomyopathy.3 4 5
The incidence of sudden deaths before and after implementation of screening fell by 89%—from 3.6/100 000 athlete years before screening to 0.4/100 000 athlete years after 25 years of screening.3 Moreover, no deaths were recorded among athletes disqualified from competition because of hypertrophic cardiomyopathy, supporting the idea that timely identification of affected athletes offers the possibility to improve survival.3
Although this study was a preventive medical programme implemented in the real world and not a randomised clinical trial, the evidence for a cause and effect relation between electrocardiographic screening and reduction of mortality is supported by the following observations. Firstly, the fall in deaths among young athletes coincided with the implementation of the screening programme. Secondly, the incidence of sudden cardiac death did not change during the study period among the unscreened, non-athletic population of the same region and age range. Finally, the reduced incidence of sudden death was mostly attributable to fewer deaths from cardiomyopathies and was paralleled by the increase in young athletes identified with these cardiomyopathies and disqualified from competition during the same period.
No other studies have prospectively investigated consecutive series of sudden deaths in young people occurring in a well defined geographical area within a homogeneous ethnic group. Moreover, the strength of the Italian study was the reliability of pathological data, because the heart of each person with sudden death was collected and examined by a team of experienced cardiovascular pathologists according to a standard protocol.3
It took 25 years to generate the Italian data showing the efficacy of the pre-participation screening on mortality. Until data from other studies of comparable study design, size of cohort, and duration of follow-up are obtained, the Italian experience remains the best available evidence of efficacy of electrocardiographic screening on mortality in young athletes.
New scientific evidence
Two recent studies have provided support for the efficacy of pre-participation screening. Baggish and colleagues examined the effect of cardiovascular screening with and without electrocardiography in 510 US college athletes.6 Including electrocardiography in the screening increased the recognition of cardiomyopathies and improved the sensitivity compared with no electrocardiography from 45.5% to 90.9% and the negative predictive value from 98.7% to 99.8%.6 7
In a second article, Wheeler and colleagues applied a theoretical model to project the costs and survival rates of US high school and college athletes who had pre-participation screening.8 Adding electrocardiography to history and physical examination saved 2.1 life years per 1000 athletes screened. The incremental cost effectiveness ratio of adding electrocardiography to history and physical examination was $42 000 (£27 000; €33 000) per life year saved 8. The authors concluded that electrocardiography based screening is more cost effective than relying on history and physical examination alone.
According to the American Heart Association and the European Society of Cardiology,1 9 cardiovascular screening for young competitive athletes is justifiable on ethical, legal, and medical grounds. Moreover, the current scientific evidence suggests that screening with electrocardiography represents best clinical practice to prevent or reduce the risk of sudden cardiac death in young athletes. We therefore believe that competitive athletes (and their families) should be fully informed about the limitations of history and physical examination, and the additional value of electrocardiography, and should not be deprived of the opportunity to be screened by electrocardiography if they consider this to be of value. We also believe that high schools, colleges, and international sport federations share the implicit ethical and legal obligation to ensure that their young affiliates are screened according to the current best clinical practice.10
Cite this as: BMJ 2010;341:c4923
Competing interests: All authors have completed the unified competing interest form and declare no support for the submitted work; no relationship with any company that might have interest in the submitted work in the previous three years; their spouses, partners, or children have no financial relationship that may be relevant to the submitted work; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.