Harms and benefits of screening young people to prevent sudden cardiac deathBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1156 (Published 20 April 2016) Cite this as: BMJ 2016;353:i1156
All rapid responses
Re: Harms and benefits of screening young people to prevent sudden cardiac death. Answer to Providencia’s rapid response.
We read with interest the comments by Providencia et al. on our paper related to pre-participation screening in young athletes . The authors stress the importance of the concepts of informed consent and patient empowerment in modern medicine. We fully agree that patients – and asymptomatic individuals and their families in the context of screening alike – have to be involved in medical decision making. Providencia et al. conclude that if an athlete is diagnosed with a cardiac condition, it is crucial to inform him about this, and to involve him in decisions on eligibility and future care. They argue that this will allow the athlete to have the best treatment and will avoid future health problems.
We are not sure that detecting a disease that may lead to sudden cardiac death (SCD) in an asymptomatic young athlete, and correctly informing him, will avoid future health problems. Every diagnosis leads to additional investigations, treatments and decisions that may induce both beneficial and harmful effects. The most prevalent diseases detected at screening are the Wolff-Parkinson-White syndrome (WPW) and hypertrophic cardiomyopathy (HCM). SCD is extremely rare in asymptomatic subjects affected with one of those diseases. HCM is the most common underlying cause of SCD in young people with an absolute risk of 1 per million athletes per year. Some experts argue that asymptomatic people do not need to be treated. Other experts will proceed to catheter ablation or implantation of a defibrillator in selected individuals. They argue that, although it has not been shown that these interventions reduce the risk of SCD, there is a pathophysiological rationale for it. However, those treatment modalities have their proper mortality risk which may be of a similar magnitude of the SCD risk of asymptomatic affected individuals . This means that it cannot be taken for granted that lives will be saved because of the detection of those diseases at screening.
All screenees considered at risk for SCD after full investigation, will have to be advised on how to proceed further in life. Some will be temporarily or permanently disqualified from sports participation. Others will be proposed a lifelong cardiologic follow-up or will be treated with drugs, some through invasive procedures. Since the absolute risk of SCD in these thoroughly investigated individuals (comprising both true- and false-positives) remains very low, most of them will not benefit from the recommendations they have been proposed, yet incur the harms induced. Temporary or permanent disqualification from sports participation obviously may directly induce psychological harm both in the screenee and his family, whereas the generally accepted beneficial effects of physical activity on mental and physical health may be lost. The anxiety mongering resulting from overemphasising extremely rare events, and the resulting medicalisation of the life of the healthiest individuals of our society, raise ethical questions. Taking into consideration the very small risk of SCD in true-positives and the very small mortality risk associated with invasive testing and/or treatment of all positives, the harm induced by screening might be larger than the benefit.
The absence of evidence of benefit of pre-participation screening has recently been confirmed in a recommendation issued by the American Heart Association, stating that “Mandatory and universal mass screening with 12-lead ECGs in large general populations of young healthy people 12 to 25 years of age (including on a national basis in the United States) to identify genetic/congenital and other cardiovascular abnormalities is not recommended for athletes and non-athletes alike (Class III, no evidence of benefit; Level of Evidence C)” .
Therefore, in our view, patient involvement should not start at the moment a potential problem is detected, but at the very start of the process before any investigation is done. Athletes and their families should be fully informed about the aforementioned uncertainties surrounding the potential benefits and harms of screening. However, while informing the screenee is a necessary condition to obtain a relevant consent, it is certainly not a sufficient one. The (young) age and the capability of the screenee to understand and to use the information have to be taken into account. We know that health literacy, a determinant factor of effective use of medical care, is characterised by a socioeconomic gradient and that the weakest of the society have also the lowest level of literacy [4,5]. Practitioners involved in screening have to be trained to correctly communicate this information to lay people in whom they eventually may propose to stop participating in competitive sports and in whose healthy lifestyle they interfere.
We agree that empowerment of screenees (before screening) and of patient-athletes (after the detection of a disease) are crucial for the provision of effective and equitable healthcare, but we have to make these concepts tangible and we have to be sure that they can be applied in the real world.
1. Van Brabandt H, Desomer A, Gerkens S, et al. Harms and benefits of screening young people to prevent sudden cardiac death. BMJ 2016;353:i1156.
2. Desomer A, Gerkens S, Vinck I, et al. Cardiovascular pre-participation screening in young athletes. Belgian Health Care Knowledge Centre (KCE), 2015. KCE Reports 241. https://kce.fgov.be/publication/report/cardiovascular-pre-participation-...
3. Maron BJ, Levine BD, Washington RL, et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation 2015;132(22):e267-72.
4. Sorensen K, Van den Broucke S, Fullam J, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health 2012;12:80.
5. Van den Broucke S, Renwart A. La littéracie en santé. Un médiateur des inégalités sociales et des comportements de santé. Louvain-la-Neuve: Université Catholique de Louvain - Faculté de psychologie et des sciences de l'éducation, 2014.
Competing interests: No competing interests
Re: Harms and benefits of screening young people to prevent sudden cardiac death. Answer to Assanelli’s rapid response.
Assanelli et al. make 2 major points. First, differences across health care systems in different countries may affect the impact of pre-participation screening. Second, they suggest that pre-participation screening may be cost-effective .
The dissimilarity in the cardiac conditions diagnosed in the SMILE study  in Europe versus Algeria is predominantly due to a remarkable high number of Wolff-Parkinson-White (WPW) syndromes detected in Algeria. Among 5,563 European screenees, 1 asymptomatic and 1 symptomatic WPW were detected. In Algeria, among 1,071 screenees they identified 12 asymptomatic and 11 symptomatic cases. The fact that at screening a high number of symptomatic WPWs are identified in Algeria can be explained by difference in the local health care system, as suggested by Assanelli et al. . In western countries, most if not all of these symptomatic individuals, would have been identified and treated appropriately through standard medical care. As discussed in our report  the detection of asymptomatic WPW individuals has no impact on the mortality rate in screened athletes. Sudden cardiac death (SCD) is extremely rare as a presenting symptom in an individual with WPW and there is no consensus on how to prevent such devastating event in asymptomatic subjects. Some experts argue that asymptomatic people do not need to be treated. Others will proceed to catheter ablation or implantation of a defibrillator in selected individuals. They argue that, although it has not been shown that these interventions reduce the risk of SCD, there is a pathophysiological rationale for it. However, those treatment modalities have their proper mortality risk which may be of a similar magnitude of the SCD risk of asymptomatic affected individuals.
Our main objection against the assertion that pre-participation screening is cost-effective is that it has not been shown that such screening saves lives. On the contrary, overall harms may even exceed benefits. The absence of evidence of benefit of screening has recently been confirmed in a recommendation issued by the American Heart Association, stating that “Mandatory and universal mass screening with 12-lead ECGs in large general populations of young healthy people 12 to 25 years of age (including on a national basis in the United States) to identify genetic/congenital and other cardiovascular abnormalities is not recommended for athletes and nonathletes alike (Class III, no evidence of benefit; Level of Evidence C)” . Also the UK National Screening Committee recommended in July 2015 not to screen 12 to 39 year olds to prevent SCD (http://legacy.screening.nhs.uk/suddencardiacdeath).
In the context of an uncertain clinical effectiveness, economic considerations can only provide additional arguments against screening. Assanelli’s comment nevertheless shows the importance of critically appraising the input variables and assumptions of economic evaluations before taking any decision based on their conclusions. The study of Wheeler et al. , that is often cited to support the cost-effectiveness of cardiovascular screening and the economic evaluation cited in Assanelli’s answer  provide good examples of this requirement. We conducted a systematic review of economic evaluations published up to December 2014 . From this review, 5 economic evaluations were identified [5-9]. After having analysed their quality, it appears that those 3 that were in favour of pre-participation screening [5,6,9], incorrectly based their conclusion on the assumption that history-taking and physical examination (H&P) was the standard of care and therefore the comparator. Nevertheless, there is no evidence showing that H&P should be the current standard practice. If no screening was considered in the comparators, additional analyses performed in the study of Wheeler et al. showed that adding an ECG to H&P would give an ICER superior to $100 000/QALY. All other economic evaluations concluded against screening.
Moreover, all economic evaluations (including the study referred to in the letter ) based effectiveness parameters of their model on data extracted from the Veneto study . We have discussed this point at great length, both in our paper and in the original Health Technology Assessment [3, 11]. The essential problem with this study is that it does not include a valid control population, i.e. young people who participate in competitive sports and who are not screened. This study does not allow making causal inferences. We simply do not know what would have happened with the SCD rate in Italy if there were no mandatory screening program.
Furthermore, in the study of Corrado et al. , a yearly screening is performed while in all economic evaluations, including the study referred to in the letter , a one-time screening is assessed only including the cost of one screening round (comprising screening tests and further examinations). All authors optimistically assumed that such a one-time screening has the same effect as a yearly screening. Most importantly, the study of Wheeler et al.  explored this in sensitivity analyses and showed that “annual screening of any kind, or extending screening to all middle and high school students, is highly unlikely to be cost-effective in terms of reduction of sudden cardiac death”.
Negative implications of a (false) positive screening result is also usually not taken into account (lifestyle restrictions and/or sport disqualification, long term side effects of nontrivial therapies and anxiety associated with living with a heart disease). Figure 1 illustrates the impact of a cardiovascular pre-participation screening with H&P and ECG in Belgium (for a prevalence of 0.3%, a sensitivity of 0.75 and a specificity between 0.70 and 0.95). From a medical point of view, there is a low prevalence of people at risk of SCD (yellow circle in the blue circle), a very high number of false-positives in the short term (orange circle – size depending on test-specificity), and a relatively high number of people being disqualified or treated (red circle) in relation to the real risk of SCD (small dot at the right). From an economic point of view, based on Belgian cost data from a health care payer perspective (including screening, diagnosis, and patient management costs in the long term), the balance between the very high costs and the uncertain treatment effect makes the intervention no good investment of limited resources. The visual representation in figure 1 might help physicians to explain to young asymptomatic athletes and their parents why it is better not to screen them for SCD.
1. Assanelli D, Levaggi R, Carre F, et al. Cost-effectiveness of pre-participation screening of athletes with ECG in Europe and Algeria. Internal and emergency medicine 2015;10(2):143-50.
2. Assanelli D, Ermolao A, Carre F, et al. Standardised pre-competitive screening of athletes in some European and African countries: the SMILE study. Internal and emergency medicine 2014;9(4):427-34.
3. Desomer A, Gerkens S, Vinck I, et al. Cardiovascular pre-participation screening in young athletes. Belgian Health Care Knowledge Centre (KCE), 2015. KCE Reports 241. https://kce.fgov.be/publication/report/cardiovascular-pre-participation-....
4. Maron BJ, Levine BD, Washington RL, et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation 2015;132(22):e267-72.
5. Wheeler MT, Heidenreich PA, Froelicher VF, et al. Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Annals of internal medicine 2010;152(5):276-86.
6. Fuller CM. Cost effectiveness analysis of screening of high school athletes for risk of sudden cardiac death. Medicine and science in sports and exercise 2000;32(5):887-90.
7. Halkin A, Steinvil A, Rosso R, et al. Preventing sudden death of athletes with electrocardiographic screening: what is the absolute benefit and how much will it cost? J Am Coll Cardiol 2012;60(22):2271-6.
8. Leslie LK, Cohen JT, Newburger JW, et al. Costs and benefits of targeted screening for causes of sudden cardiac death in children and adolescents. Circulation 2012;125(21):2621-9.
9. Schoenbaum M, Denchev P, Vitiello B, et al. Economic evaluation of strategies to reduce sudden cardiac death in young athletes. Pediatrics 2012;130(2):e380-9.
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 : the journal of the American Medical Association 2006;296(13):1593-601.
11. Van Brabandt H, Desomer A, Gerkens S, et al. Harms and benefits of screening young people to prevent sudden cardiac death. BMJ 2016;353:i1156.
Competing interests: No competing interests
In a recent article published in this journal  Van Brabandt and colleagues look at the evidence on the benefits of screening young people to prevent sudden cardiac deaths and conclude that screening before participation in competitive sports is not cost-effective.
Their conclusions are based on the following main considerations:
1) The number of false positives: “If screening is performed by experienced physicians, even with the application of the most stringent “Seattle” criteria for electrocardiography, 5% of healthy people will be suspected of having a disease. In a more realistic scenario up to 30% of those screened may be referred for additional testing”.
2) Monetary and non-monetary costs related to the tests. The number of individuals found to have a problem is small compared to the population that need to be screened. Evidence from Italy suggests that only 2% of screened athletes were finally disqualified. Tests may cause anxiety and psychological harm, impediments to insurability or employment opportunities as suggested by the evidences they report.
3) The number of lives that can be actually saved by this compulsory screening. The most prevalent diseases detected are the Wolff-Parkinson-White syndrome, congenital anomalies of the coronary arteries and hypertrophic cardiomyopathy; most people with these diseases will remain asymptomatic, leading a normal life, and there is no consensus about the most correct treatment.
With these arguments in mind, they conclude that compulsory pre-participation screening is not health-improving or cost-effective.
We are not going to dispute the conclusions of this analysis; our aim is to point out that their review of the evidence is not complete. In this note we would like to draw attention to the results of the SMILE study [2,3], which was conducted in a cohort of 6634 individuals, mainly young professionals and recreational athletes from Algeria (1071) and Europe (France, Germany, Greece). Each athlete performed a clinical examination, an ECG test, and filled in a Bethesda questionnaire concerning cases of sudden death in their family, personal history and medical evaluation. If found healthy, the athlete was allowed to continue the sport activity. In case of suspect of a possible problem, the medical records were reviewed for a second and third opinion. The details of the protocol are described elsewhere .
A summary of the results is presented in table 1 
In our study the ICE ratio is very low both for Europe (4,071 purchasing-power-parity-adjusted $-$PPP) ) and Algeria (582 $PPP).
The SMILE study clearly shows that the conclusions presented above should be contextualised at least over two dimensions:
1) Presence of other screening programmes. The SMILE study allows comparison of the results for European countries and Algeria. While the number of athletes found positive in Europe is in line with the findings of the literature, the number of disqualified athletes (or found positive and treated before being given a green ticket) soars for Algeria. We argue that this difference may well be due to the presence in Europe of other parallel systems to detect problems at an earlier stage. Their effectiveness affects the decision of compulsory screening. In our study the ICE ratio per expected year of statistical life saved is very low both for Europe (4,071 $PPP) and Algeria (582 $PPP). In our study we do not take into account non-monetary costs related to the test, but our measures are well below the threshold for intervention.
2) False positives: by considering data resulting from the application of 2010 ESC guidelines, the rate of false positive athletes was 10%, while the rate of false-negative subjects was 0.2% . Although we are not able to correctly calculate the number of false positive diagnosis only from our data , if we apply Weiner’s false-negative rate to our data, we can estimate a false-positive rate of about 3% (Algeria: 8.78%, Europe: 1.85%). This lower false-positive value could be explained by the involvement of a network of sports cardiologists with a larger experience in the evaluation of athletes’ ECG. This could have allowed the observed reduction of further instrumental evaluations and the false positive rate.
For this reason we think that:
- There is not a unique model effective in any context: with a better prevention, as in France, Greece and Germany in our article [1,2] and France, Minnesota and Israel in your article, it is difficult to support, in a long-term perspective, the effectiveness of pre-competitive screening. Without prevention, as in Algeria, the pre-competitive screening is very effective, according to our results. With poor prevention as in Italy, the effectiveness of the screening seems more sustainable.
- A standardised and digital collection of anamnestic data and clinical information as well as symptoms description and digital ECG favours the effectiveness of the pre-screening network and probably reduce the occurrence of false positive athletes.
 Van Brabandt, H. Desomer, A. Gerkens S. and Neyt, M (2016) Harms and Benefits of Screening Young People to Prevents Sudden Cardiac Death, BMJ, 2016;353:i1158
 Assanelli D, Ermolao A, Carre F, Deligiannis A, Mellwig K, Mellwig K, Tahmi M, Cesana BM, Levaggi R, Aliverti P, Sharma S. Standardised pre-competitive screening of athletes in some European and African countries: the SMILE study. Intern Emerg Med. 2014 Jun;9(4):427-34. doi: 10.1007/s11739-013-0955-5. Epub 2013 May 26. Erratum in: Intern Emerg Med. 2014 Sep;9(6):709. Deodato, Assanelli [corrected to Assanelli, Deodato]; Andrea, Ermolao [corrected to Ermolao, Andrea]; François, Carré [corrected to Carre, François]; Asterios, Deligiannis [corrected to Deligiannis, Asterios]; Klaus, Mellwig [corrected to Mellwig, Klaus]; Mohamed, Tahmi [corrected to Tahmi, Mohamed]; Mario, Cesana Bruno [corrected to Cesana, Bruno Mario]; Rosella, Levaggi [corrected to Levaggi, Rosella]; Paola, Aliverti [corrected to Aliverti, Paola]; Sanjay, Sharma [corrected to Sharma, Sanjay]. PubMed PMID: 23709052.
 Assanelli D, Levaggi R, Carré F, Sharma S, Deligiannis A, Mellwig KP, Tahmi M, Vinetti G, Aliverti P. Cost-effectiveness of pre-participation screening of athletes with ECG in Europe and Algeria. Intern Emerg Med. 2015 Mar;10(2):143-50. doi: 10.1007/s11739-014-1123-2. Epub 2014 Aug 28. PubMed PMID: 25164412.
 Weiner RB, Hutter AM, Wang F, Kim JH, Wood MJ, Wang TJ, Picard MH, Baggish AL. Performance of the 2010 European Society of Cardiology criteria for ECG interpretation in athletes. Heart. 2011 Oct;97(19):1573-7. doi: 10.1136/hrt.2011.227330. Epub 2011 May 20. PubMed PMID: 21602522.
Competing interests: No competing interests
Cardiac Disorders and the Risk of Sudden Cardiac Death: Athletes Should Have The Right to Know and Decide.
The diagnosis of heart rhythm disorders or cardiomyopathies in a competitive athlete most frequently leads to the discontinuation of their sporting career due to concerns of disease progression and exercise-induced sudden cardiac death. However, potential career-ending decisions are complex, associated with medical, and ethical challenges, and may result in significant psycho-social and economic adverse consequences for the athlete.
The recently published systematic review by Van Brabant et al. suggests that “as long as those at high risk of sudden death cannot reliably be identified and appropriately managed, young athletes should not be submitted to pre-participation screening” . We think that this may be an over-simplified interpretation of data which neglects two important concepts of 21st Century Medicine which complement each other: Informed Consent and Empowerment.
According to Van Brabant and colleagues, screening for potentially arrhythmic disorders in athletes currently provides a high rate of false positives and findings of uncertain significance . However, we believe that through abandoning the current system, which is clearly imperfect, not screening at all would cause the loss of transparency and safety we have been slowly trying to achieve. This may inadvertently place individuals at risk of life-threatening events. There is a delicate balance between overprotection of the athlete and complete abandonment of any screening process due to the limitations of current screening regimens. Through taking Informed Consent & Empowerment into account we could ensure athlete (patient)-centred medical practice where the athlete is made fully aware of the clinical findings and their significance with the opportunity to be involved in the decision-making process. It is now morally and ethically accepted that: the patient has the right to know, the right to decide and be involved in treatment decisions or participating in situations that can put his health at risk. This approach would help redress the current uncertainties regarding screening.
The Right to Know: Informed Consent
When a condition is detected and the risk of lethal events is uncertain, a thorough discussion between the involved parties is crucial to avoid future health issues, and/or legal problems . Furthermore, it is also known that even when all screening tests are negative, the risk of sudden arrhythmic events is still not zero even though it is extremely low . This means that in theory all athletes should undergo such a consent process, and it is vital that all sports organizations provide appropriate means to deal with sports-related cardiac arrest.
Obtaining patients’ informed consent has now become a routine and mandatory part of medical practice . Involving the different parties (athlete/patient, physician and sports team/organization) in a joint informed consent, where parties involved assume their duties and obligations could be of benefit, as it would ensure good communication, truth, and exchange of information, and increase the awareness of potentially life-threatening situations (even if the risk is very low). This should lead to wider availability of automatic external defibrillators on playing fields, advantageous to both athletes (with known or unknown cardiac conditions), and non-athlete bystanders/supporters. Athletes’ relatives could also benefit from this practice, as these conditions are often hereditary.
The Right to Decide: Empowering Athletes with Cardiac Disorders
Empowerment is a process through which people are involved over the decisions and actions that affect their own lives. In the context of a cardiac disorder, empowerment means giving an athlete the chance to participate in the decision about whether or not to remain active in competition. In recent decades, patient empowerment has been gaining increasing momentum in clinical decision-making , but unfortunately it has failed to make its transition to the field of cardiac disorders in competitive athletes. Usually, athletes have little say and are not asked to play an active role in the final decision regarding possible disqualification or eligibility. A model of empowerment that contemplates the athlete’s preferences, and helps in balancing the pros and cons of continuing/discontinuing sports practice, and gives the individual the opportunity of having a last word in the final decision, if he so chooses, is crucial.
Our perspective is that the eligibility process should be kept as transparent and safe as possible, and therefore, athletes should be granted with the right to know if they have a cardiac condition, and then be given the opportunity to decide accordingly (to make an informed-decision). If an athlete is diagnosed with a cardiac condition, namely if its risk is uncertain (“grey area”), he/she should play an active role in the decision-making process of eligibility vs. disqualification. It is our belief that this is crucial for protecting the athlete’s best interest, informing him/her about his/her cardiac condition, introducing transparency in the management of the situation, and planning the future health care of the patient. This will allow the athlete to have the best treatment, avoiding health and legal problems-ultimately it is a matter of respect for the individual’s human rights. Examples of problems (deaths, severe disability, depression, economic problems, and litigation) arising from lack of communication and failure to provide information regarding the ongoing cardiac disorder, and consequently not providing the best possible and lifesaving treatment are abundant in the literature . This could potentially be avoided by involving the athlete in the whole process.
1. Van Brabandt H, Desomer A, Gerkens S, Neyt M. Harms and benefits of screening young people to prevent sudden cardiac death. BMJ. 2016;353:i1156.
2. Maron BJ, Mitten MJ, Quandt EK, et al. Competitive athletes with cardiovascular disease: the case of Nicholas Knapp. N Engl J Med. 1998;339:1623–5.
3. Rosso R, Kogan E, Belhassen B, et al. J-point elevation in survivors of primary ventricular fibrillation and matched control subjects: incidence and clinical significance. J Am Coll Cardiol. 2008;52(15):1231-8.
4. General Medical Council. Consent: Patients and Doctors Making Decisions Together. 2008;6-33. Available at: www.gmc-uk.org/guidance
5. Chamberlin, J. A working definition of empowerment. Psychiatric Rehabilitation Journal. 1997;20, 43-46.
6. Hamed v Mills & Tottenham Hotspur Football Club  EWHC 298 (QB). Royal Courte of Justice, Strand, London, WC2A 2LL, Date: 16/02/15, available online:
http://www.39essex.com/content/wp-content/uploads/2015/02/Final-Hamed-v-... , last
Competing interests: No competing interests
We read with attention the review paper by Van Brabandt et al. (1), questioning the utility of pre-participation screening for prevention of sudden cardiac death (SCD) during sports activity. The paper is not a balanced “pro and cons” analysis; rather, it appears as a direct attack to the Italian screening program and to the Italian researchers that provided scientific evidence that cardiovascular evaluation of athletes is a life-saving strategy based on the >30 years experience in the Veneto Region, North-East Italy (2-6).
The paper is signed by laypersons with no experience in the field of sports cardiology, who provided a divorced from reality personal viewpoint. Surprisingly, the analysts omitted the “real world” opinion of thousands international physicians daily involved in athletes evaluation, who overwhelmingly favoured the need of pre-participation screening (7) (Figure 1).
The Authors started by mistakenly reporting that the Italian screening of young competitive athletes has been mandatory since 1970 (or 1979). Instead, screening has been in practice by law in Italy since 1982 (8), which is the correct starting time for evaluating its impact on mortality. This initial inaccuracy jeopardizes the entire “analysis”.
The inaccuracy is confirmed by their statement that usefulness of ECG screening is confined to the detection of athletes with Wolff-Parkinson-White syndrome, which clearly demonstrates the ignorance that the strength of ECG screening is the identification of inherited cardiomyopathies and channelopathies, which are ECG detectable causes of SCD. In this regard, it is amazing that the review did not mention our fundamental study proving the efficacy of pre-participation ECG screening for pre-symptomatic identification of hypertrophic cardiomyopathy (Figure 2), which is the leading cause of SCD in the athlete worldwide (2,9,10).
It is not surprising that the economic model developed by the Stanford University to demonstrate that screening is cost-effective for prevention of SCD in the athlete necessarily relied on the Italian data on mortality trends, being the only available (11). Considering that 30-40% of conditions at risk of SCD in the young are genetically transmissible, the aim of the screening is not only to safeguard the athlete’s life, but also the relatives’ lives by cascade screening, including genetic analysis.
We are fully aware that some diseases at risk, mostly premature coronary atherosclerosis and congenital coronary anomalies, may escape identification at screening (5,6,12,13) and we agree that secondary prevention, by dissemination of external defibrillators in playgrounds and training for cardiopulmonary resuscitation, should be recommended as well (14-16).
The most misleading assertion by Van Brabandt et al. (1) is that our study does not provide evidence that screening was the cause of the 90% mortality reduction in competitive athletes (4), because there was no unscreened control population. Although a randomized study design was not feasible because screening is compulsory by law, the study was actually a comparison of incidence rates for SCD in screened athletes versus unscreened non-athletes aged 12–35 years, before and during this screening programme. Systematic pre-participation evaluation, coupled with sports restriction, resulted in a decline in deaths among screened athletes from 3.6 per 100 000 person-years in the 2 years before screening implementation to 0.4 per 100 000 person-years two decades later. In contrast, there was no change in deaths among unscreened non-athletes. The strong cause–effect relationship between ECG screening and the substantial reduction of SCD is supported by several results: (i) there was a coincident timing between decline of SCD in young competitive athletes and screening implementation; (ii) most of the reduced incidence of SCD was due to fewer deaths from cardiomyopathies and it was accompanied by a concomitant increase in the proportion of competitive athletes who were identified affected by these diseases and disqualified from competition at the Center for Sports Medicine; and iii) the incidence of SCD did not change among the unscreened non-athletic population of the same age range. Although additional factors—environmental, socio-economic, or medical/surgical—may have contributed to mortality reduction over the time, such factors are expected to impact mortality similarly in screened young athletes and unscreened young non-athletes, and hence cannot explain the declining trend.
The database of SCD in the Veneto region of Italy is unique in so far as cases are collected according to a prospective study design with systematic investigation of all young people (≤35 years), including competitive athletes, who die suddenly and undergo a standardized pathologic investigation of the heart by a team of cardiovascular pathologists. The heart specimens (Figure 3), as well as the clinical records of all SCD victims since 1979, are stored at the Registry of Cardiovascular Pathology, University of Padova, giving the chance to go back and review the case (6,12). This reflects the indisputable reliability of our data on causes and trends of SCD in young people and athletes. Reports on SCD from other countries were mostly based on retrospective analysis of data from public media reports and insurance claims, which unavoidably led to an inaccuracy with mortality underestimation.
Finally, we were astonished at reading the strong “accuse” that we have refused to share the updated findings (1,17). Our published data on the efficacy of pre-participation screening were referring to the time interval 1982-2004 (4). As anticipated in private correspondence, in 2015 we completed another 10 years interval with follow-up of screened athletes. The results were not ready at the time of the request because we rigorously investigate each SCD victim both clinically and pathologically, according to a standardized protocol which implies in selected cases the study of the conduction system and molecular autopsy. This protocol represents the basis for the Guidelines for Autopsy Investigation of SCD by the Association for European Cardiovascular Pathology (18).
Our strict policy is to provide and publish only conclusive results. Moreover, we firmly believe that accurate collection and analysis of data are vital requisites for an unbiased scientific research (19). Definite results on the 2005-2014 decade of SCD monitoring are now available and will be submitted for publication in a peer-reviewed journal, that is the only way to disseminate original data: we can anticipate that they confirm the trend of decreasing mortality in screened athletes.
The pre-participation screening represents a major achievement of the Italian National Health System and an application of our Bill, where health and life are fundamental rights to be warranted. 1.8% of young to be engaged in sports are disqualified (2), because they are found affected by life-threatening cardiac conditions. By no way it should be considered discriminatory, on the opposite it is an ethical, deontological attitude to safe life.
1. Van Brabandt H, Desomer A, Gerkens S, Neyt M. Preparticipation screening for the prevention of sudden cardiac death in young non-professional athletes: harms outweigh benefits. BMJ 2016;352:i1156.
2. Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339:364–9
3. Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol 2003;42:1959-63
4. 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 pre-participation screening program. JAMA. 2006;296:1593-601.
5. Thiene G, Carturan E, Corrado D, Basso C. Prevention of sudden cardiac death in the young and in athletes: dream or reality? Cardiovasc Pathol. 2010;19:207-17
6. Thiene G: Sudden Cardiac Death and Cardiovascular Pathology: from Anatomic Theater to Double Helix Am J Cardiol 2014;114:1930-1936
7. Colbert JA. Clinical decisions. Cardiac screening before participation in sports--polling results. N Engl J Med. 2014;370:e16
8. Decree of the Italian Ministry of Health, February 18, 1982. Norme per la tutela sanitaria dell'attività sportiva agonistica (rules concerning the medical protection of athletic activity). Gazzetta Ufficiale March 5, 1982:63.
9. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation. 2009;119:1085-92.
10. Myerburg RJ, Vetter VL. Electrocardiograms should be included in preparticipation screening of athletes. Circulation. 2007;116:2616-26
11. Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA. Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med 2010;152:276-286
12. Thiene G, Corrado D, Basso C. Sudden Cardiac Death in the Young and Athletes. Text Atlas of Pathology and Clinical Correlates. Springer Verlag, Milan 2016
13. Basso C, Maron BJ, Corrado D, Thiene G. Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes. J Am Coll Cardiol. 2000;35:1493-501
14. Corrado D, Drezner J, Basso C, Pelliccia A, Thiene G. Strategies for the prevention of sudden cardiac death during sports. Eur J Cardiovasc Prev Rehabil. 2011;18:197-208.
15. Semsarian C, Ingles J. Preventing sudden cardiac death in athletes. BMJ. 2016;353:i1270
16. d'Amati G, De Caterina R, Basso C. Sudden cardiac death in an Italian competitive athlete: Pre-participation screening and cardiovascular emergency care are both essential. Int J Cardiol. 2016 Mar 1;206:84-6
17. Cohen D. Data on benefits of screening for sudden cardiac death are withheld. BMJ. 2016 Apr 20;353:i2208
18. Basso C, Burke M, Fornes P, Gallagher PJ, de Gouveia RH, Sheppard M, Thiene G, van der Wal A; Association for European Cardiovascular Pathology. Guidelines for autopsy investigation of sudden cardiac death. Virchows Arch 2008;452:11-8
19. Solberg EE, Borjesson M, Sharma S, Papadakis M, Wilhelm M, Drezner JA, Harmon KG, Alonso JM, Heidbuchel H, Dugmore D, Panhuyzen-Goedkoop NM, Mellwig KP, Carre F, Rasmusen H, Niebauer J, Behr ER, Thiene G, Sheppard MN, Basso C, Corrado D; Sport Cardiology Section of the EACPR of the ESC. Sudden cardiac arrest in sports - need for uniform registration: A Position Paper from the Sport Cardiology Section of the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Prev Cardiol. 2016;23:657-67.
Response to 2013 online poll by the New England Journal of Medicine on the need of screening before participation in sports.
The website of the Journal received 1266 votes from 86 countries. Overall, only 18% opposed cardiac screening of young athletes before participation in sports; among the remaining, 24% favoured screening with a history and physical examination only, and 58% favoured screening with a history, physical examination, and ECG. The figure shows the online polling results for voters from the USA as compared with voters from Italy. The vast majority of voters favoured screening before participation in sports, either in the USA (80%) or in Italy (88%). Screening with ECG was recommended by 66% of the voters from Italy versus 45% of those from the USA (from Colbert JA. Clinical decisions. Cardiac screening before participation in sports — Polling Results. N Engl J Med 2014; 370:e16)
Italian athlete screening program disqualifications. A) Among 33 735 athletes screened, 621 (1.8%) were disqualified for cardiovascular (CV) diseases. B) Among the 22 patients with a diagnosis of HCM, 18 (82%) had an abnormal ECG, whereas only 5 (23%) had a positive family history (FH) or cardiac murmur. Thus, in the absence of ECG the majority would have been considered eligible and exposed to the risk of SCD. In the follow-up, none of the 22 disqualified HCM athletes suffered SCD. (from Myerburg RJ, Vetter VL. Electrocardiograms should be included in pre-participation screening of athletes. Circulation. 2007;116:2616-26)
Registry of SCD, Cardiovascular Pathology Unit, at the University of Padova, Italy.
The heart specimens of all young people including athletes, who have died suddenly since 1979, are stored and available for re-examination, together with clinical records.
Competing interests: No competing interests
In the article on harms and benefits of screening young athletes to prevent sudden cardiac death, published in BMJ 2016;353:i1156 (1), Van Brabant and colleagues cite the Italy’s experience of mandatory screening and the unique evidences of its efficacy from an observational study conducted in the Veneto Region between 1979 and 2004 (2). I would like to provide some updates about the Italian regulations aimed to prevent the sudden cardiac death in athletes.
In 2014, the Italian Ministry of Health developed guidelines and implemented a law that had been passed by the Italian Parliament in 2013 that mandates not only competitive athletes but also those involved in non-competitive sports must obtain a certificate before being allowed to participate in sporting activities (3). Such a certificate, which requires a medical visit and a resting electrocardiogram (EKG), is required for students who participate in school sports and those who practice school-organized extra-curricular sports activities, for all those engaged in sports activities organized by sport federations. The certificate has a validity of only one year. While health care is generally provided free of charge in Italy, the costs for the examination and EKG required for the certificate are usually out of pocket. The law is estimated to affect approximately 12 million people who engage in sports in our country. (4)
The Italian experience shows that EKG pre-participation screening of competitive athletes can function as a gateway to expand the use of EKG to other groups in an attempt to eliminate sudden cardiac death triggered by physical exercise. The consequences of this wider screening are potentially great. Expanded screening increases the number of persons with false positive EKGs who may be discouraged from further activities. It also increases the costs of being engaged in sports and serves as a new barrier to physical activity. Furthermore, it increases inequalities, since the additional costs may be out of reach of lower income families.
The impetus behind this law, in the absence of solid evidence on the effectiveness of EKGs as a preventive tool for sudden cardiac death and during a time of severe economic crisis, is not entirely clear. However, it is likely that the motivation was not medical but a response to media attention to these rare events. Scenes of a soccer player who dies on the field are aired by TV countless times and further diffused through social media, making these events unforgettable and increasing the perception of risk out of proportion to the real risk of such events, which are estimated at 1 in 100,000. This phenomenon, first identified by Kahneman, is known as the availability heuristic, and posits that people judge the frequency of events based on the availability of examples (5). As a result of this perception, the public as well as interest groups from the medical and sport world apply pressure Members of Parliament to act to prevent further such episodes, and the response is usually to query the Ministry of Health about the adoption of remedies that now have included not only the preventive visits and EKGs mandated by law but also the placement of defibrillators in all public places.
Public policies should, however, be based on solid facts weighed with wisdom and not on emotion induced by media sensationalism, and Ministries of Health have a key role in ensuring that decision-making, especially one with considerable financial and health implications, be thoroughly evaluated.
1. Van Brabandt H, Desomer A, Gerkens S, et al. Harms and benefits of screening young people to prevent sudden cardiac death. BMJ 2016;353:i1156 doi: 10.1136/bmj.i1156 (Published 20 April 2016)
2. 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;296:1593-601.
3. Ministero della Salute. Decreto 8 agosto 2014: Approvazione delle linee guida in materia di certificati medici per l'attività sportiva non agonistica. Gazzetta Ufficiale della Repubblica Italiana 2014, SG n. 243.
4. ISTAT. Indagine multiscopo sulle famiglie “Aspetti della vita quotidiana”. La pratica sportiva in Italia nel 2013. Available at: http://www.istat.it/it/archivio/128694
5. Kahneman D. Thinking, fast and slow. New York, Macmillan, 2011.
Competing interests: No competing interests
In a recent BMJ report, Van Brabandt and colleagues present their assessment of cardiovascular (CV) screening in athletes to prevent sudden cardiac death (SCD) from the perspective of a health economist.1 The authors make several points of which we agree: 1) the diagnostic yield of CV screening by history and physical examination alone is extremely low and with little supporting evidence; 2) national, universal screening should not be mandated, especially without appropriate physician infrastructure; 3) CV screening will detect disorders associated with SCD but with an unclear absolute risk of CV events; and 4) the potential benefits and harms of different CV screening programs are not fully understood. However, we disagree with their conclusion, “As long as those at high risk of sudden death cannot reliably be identified and appropriately managed, young athletes should not be submitted to pre-participation screening.” We wish to share a different perspective on why early detection of CV disorders in athletes is both justified and can save lives.
Reframing the Debate
Once again electrocardiogram (ECG) screening is presented as an “all or none” response – either mandated and provided on a national level to all athletes, or not recommended at all. These polarized options provide little assistance to physicians responsible for pre-participation screening and lack considerations that drive sound medical practice, specifically an assessment of individualized risk and physician skills and resources.
Few preventive services are performed in medicine without accounting for individualized patient risk. There is robust data from independent datasets that some athlete groups have a substantially higher risk than others.2,3 In the U.S., black male college athletes have an annual SCD risk of 1 in 16,000, male basketball athletes 1 in 9,000, and male black basketball athletes 1 in 4,400.2 We would argue that these rates are not “extremely rare” but rather alarmingly high.
Purpose and Assumptions
The premise of CV screening in athletes is that early detection of cardiac disorders associated with SCD has the potential to reduce morbidity and mortality through individualized and evidence-driven disease-specific management. Without this belief, then screening by any strategy is called into question. If one believes in early detection, screening by history and physical examination alone is inadequate. The addition of ECG, while still imperfect, will increase detection of disorders at elevated risk of SCD and can be achieved with a low false-positive rate and high quality when proper infrastructure and skilled cardiology resources are available.
A Call for Comparable Scrutiny
Van Brabandt and colleagues question the 25-year Italian investigation without applying comparable scrutiny to other studies cited in opposition.4 Several points should be clarified. First, the high incidence at the beginning of the Italian study is consistent with other studies using a mandatory reporting system, specifically data from the U.S. military, and is unlikely to be “simple random variation”.5 If the high initial incidence was an anomaly, why did it last nearly 8 years before decreasing? Second, results from Israel are scientifically flawed as the study used only a retrospective review of newspaper clippings and surely did not capture all SCD cases (or perhaps even the majority) during the 24-year period.6,7 Studies reporting case capture methods demonstrate that media reports identify only 18-56% of SCD cases in competitive athletes.8-10 Lastly, the authors reference incidence estimates from Minnesota to suggest that the incidence of SCD in the U.S. (without ECG screening) is no different than the rate of SCD in Italy. However, the 1 in 200,000 incidence reported in Minnesota does not represent current estimates in the U.S. and is derived largely from catastrophic insurance claims in high school athletes – a mechanism for case identification shown to be inadequate.11,12 The selective reporting of statistics without a critical examination of the methodology in each study may explain why the authors have restated old arguments that are misleading. Accounting for more recent incidence data may yield a different conclusion when choosing an appropriate CV screening strategy, especially in athletes deemed high risk. (Figure 1)
Disease Oriented Outcomes Evidence
Is a randomized trial the only evidence that will support early detection through ECG screening? Van Brabandt and colleagues make no reference to the mounting disease-specific data that early detection of pathologic cardiac disorders followed by individualized risk stratification and management lowers mortality for some conditions. For example, large cohort studies have demonstrated improved survival and low mortality rates in children and young adults with hypertrophic cardiomyopathy (HCM) using current therapeutic measures.13,14 For children diagnosed with long QT syndrome, individualized management and in-depth counseling have shown low cardiac event rates and no deaths in two independent cohorts of young athletes.15,16 For asymptomatic athletes identified with Wolff-Parkinson-White pattern, expert consensus guidelines define risk stratification and management strategies to reduce risk.17,18 Lastly, updated eligibility recommendations from the American College of Cardiology also affirm from cardiology experts that early detection of conditions at risk has the potential for individual benefit.19
The primary goal of CV screening in competitive athletes is to detect cardiac disorders early in their natural history to mitigate the risk of SCD through risk stratification, targeted management, and evidence-driven activity recommendations. When CV screening programs inclusive of ECG can be performed with quality, we believe the potential benefits will be greater than the potential harms. CV screening remains ethically compelling in high risk athletes until a proper study demonstrates otherwise. To effectively impact safe sports participation, the focus of preventing SCD in athletes must change from a debate regarding national mandates to the development of a trained physician infrastructure to conduct more effective screening for targeted athlete populations.
1. Van Brabandt H, Desomer A, Gerkens S, Neyt M. Harms and benefits of screening young people to prevent sudden cardiac death. BMJ. 2016;353:i1156.
2. Harmon KG, Asif IM, Maleszewski JJ, et al. Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review. Circulation. 2015;132(1):10-19.
3. Maron BJ, Haas TS, Murphy CJ, Ahluwalia A, Rutten-Ramos S. Incidence and causes of sudden death in U.S. college athletes. J Am Coll Cardiol. 2014;63(16):1636-1643.
4. 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 preparticipation screening program. JAMA. 2006;296(13):1593-1601.
5. Eckart RE, Shry EA, Burke AP, et al. Sudden death in young adults an autopsy-based series of a population undergoing active surveillance. J Am Coll Cardiol. 2011;58(12):1254-1261.
6. Steinvil A, Chundadze T, Zeltser D, et al. Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death proven fact or wishful thinking? J Am Coll Cardiol. 2011;57(11):1291-1296.
7. Drezner JA, Harmon KG, Borjesson M. Incidence of sudden cardiac death in athletes: where did the science go? Br J Sports Med. 2011;45(12):947-948.
8. Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of sudden cardiac death in national collegiate athletic association athletes. Circulation. 2011;123(15):1594-1600.
9. Holst AG, Winkel BG, Theilade J, et al. Incidence and etiology of sports-related sudden cardiac death in Denmark--implications for preparticipation screening. Heart Rhythm. 2010;7(10):1365-1371.
10. Risgaard B, Tfelt-Hansen J, Winkel BG. Sports-Related Sudden Cardiac Death: How to Prove an Effect of Pre-Participation Screening? Heart Rhythm. 2016.
11. Maron BJ, Gohman TE, Aeppli D. Prevalence of sudden cardiac death during competitive sports activities in Minnesota high school athletes. J Am Coll Cardiol. 1998;32(7):1881-1884.
12. Drezner JA, Harmon KG, Marek JC. Incidence of sudden cardiac arrest in Minnesota high school student athletes: the limitations of catastrophic insurance claims. J Am Coll Cardiol. 2014;63(14):1455-1456.
13. Maron BJ, Rowin EJ, Casey SA, et al. Hypertrophic Cardiomyopathy in Children, Adolescents, and Young Adults Associated With Low Cardiovascular Mortality With Contemporary Management Strategies. Circulation. 2016;133(1):62-73.
14. Maron BJ, Maron MS. Contemporary strategies for risk stratification and prevention of sudden death with the implantable defibrillator in hypertrophic cardiomyopathy. Heart Rhythm. 2016.
15. Johnson JN, Ackerman MJ. Return to play? Athletes with congenital long QT syndrome. Br J Sports Med. 2013;47(1):28-33.
16. Aziz PF, Sweeten T, Vogel RL, et al. Sports Participation in Genotype Positive Children With Long QT Syndrome. JACC Clin Electrophysiol. 2015;1(1-2):62-70.
17. Cohen MI, Triedman JK, Cannon BC, et al. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm. 2012;9(6):1006-1024.
18. Al-Khatib SM, Arshad A, Balk EM, et al. Risk Stratification for Arrhythmic Events in Patients With Asymptomatic Pre-Excitation: A Systematic Review for the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016;133(14):e575-586.
19. Maron BJ, Zipes DP, Kovacs RJ. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Preamble, Principles, and General Considerations: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2343-2349.
Competing interests: No competing interests
Screening against sudden cardiac death in young non-professional athletes: the KCE and insurance companies.
The Health Technology Assessment on cardiovascular pre-participation screening in young athletes, produced by the Belgian Health Care Knowledge Centre (KCE) warrants comment.(1)
First, KCE, once more, must be commended for its assessments: simple, comprehensive, well-evidence based and, avoiding conflict of interest. Clearly, the small kingdom of Belgium outperforms France.(2) Moreover, KCE is a beacon with a true concern for shared decision making: Eg. for breast cancer screening it provides leaflets with clear pictographs (absolute numbers with a consistent denominator (/1000 screened) and time frames employing the same scale for information on gains and losses of the options).(3) I am not aware of such information leaflets from another national agency in Europe.
Second, the long lasting Italian embargo on data about sport-related mortality is not only shocking but also depressing.(4) Sadly, science integrity, even when financial industrial interests are not present, is not the motto yet.
Third, all these important efforts (1,4,5) may remain useless: a) recommendations from professional associations such as the French one stating “ … and a 12-lead resting ECG from 12 years at the issuing of the first license, renewed every three years, then every 5 years from 20 years to 35 years” may not be updated soon;(6) b) insurance companies will continue to dictate the rule, unless forbidden to request medical certificates.
1 Van Brabandt H, Desomer A, Gerkens S, Neyt M. Preparticipation screening for the prevention of sudden cardiac death in young non-professional athletes: harms outweigh benefits. BMJ 2016;352:i1156.
2 Prescrire.[Clinical practice guidelines from the National Health Authority: too many hidden conflicts of interest.] Rev Prescrire 2009; 29 (309):546.
3 Belgian Health Care Knowledge Center. Report 216. [Breast cancer screening: messages for an informed choice]. 2014. Available at http://kce.fgov.be/fr/publication/report/d%C3%A9pistage-du-cancer-du-sei.... Accessed 9 May 2016.
4 Cohen D. Data on benefits of screening for sudden cardiac death are withheld. BMJ 2016 20;353:i2208.
5 Semsarian C, Ingles J. Preventing sudden cardiac death in athletes. BMJ 2016 20;353:i1270.
6 Brion R, Carré F. [Recommendations on cardiovascular check for practicing sports in competition among the 12 and 35 y old]. Société Française de cardiologie. After 2007. Available at http://www.sfcardio.fr/sites/default/files/pdf/edito_ECG.pdf. Accessed 9 May 2016.
Competing interests: No competing interests
In this literature review, Van Brabandt et al. conclude recommending against screening young athletes to prevent sudden cardiac death.  They stressed that only one study carried out in Italy, and published in 2006 by Corrado et al., showed screening benefit. Requests to obtain additional data from the Italian screening study were not successful. Such behaviour is in agreement with critical comments to a paper about outcomes in athletes with marked ECG repolarization abnormalities, published in New England Journal of Medicine, with two coauthors of Corrado paper . That article, by Pelliccia et al., had serious limitations (as reporting their cohort study as a matched case-control study). However, although many messages sent to NEJM, my letter was not published. 
 Van Brabandt H, Desomer A, Gerkens S, Neyt M. BMJ 2016; 353:i1156 doi: 10.1136/bmj.i1156
 Corrado et al. JAMA 2006
 Pellicciani et al. NEJM 2008
 Eluf-Neto J. Rev Bras Epidemiol 2008.
Competing interests: No competing interests
Exercise is good for our health, but strenuous training for achieving athletic records and winning trophies is not.
After a certain point, agonistic sports can and will be harmful to the overall health of young people who strive for monetary gains and fame.
In Ancient Greece, Olympic athletes were amateur citizens, not paid professionals.
Nowadays, corporate sponsors compete for athletic performances, using young athletes as marketing strategies.
Whoever chooses to go along their game, seeking profits, must be aware of the devastating consequences that often accompany this way of living to the edge: debilitating skeletal injuries, and yes, sudden cardiac death.
Competing interests: No competing interests