Re: Harms and benefits of screening young people to prevent sudden cardiac death
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