Answer to Van Brabandt and Colleagues based on SMILE’s study results.
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