Why Cardiovascular Screening in Young Athletes Can Save Lives
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.
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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.
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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