Should young athletes be screened?
The forty years of careful consideration of screening since Wilson and Jüngner(1) appear to have by-passed Drezner and Khan.(2)
Every sudden cardiac death (SCD) is a tragic event and traumatic experience for family and relatives, but in truth the burden to society is small. The death of a high profile athlete is inevitably followed by a loud clamour for pre-participation screening. But carefully consideration of the evidence in relation to the national criteria is essential if screening is to do more good than harm.
The benefit of screening has yet to be demonstrated. Drezner and Khan point to evidence from the Italian national screening programme.(3) This describes a nearly five-fold fall in incidence of SCD in athletes over a twenty year period in comparison to a lower stable rate among non athletes. However, observational studies are subject to a range of biases, several of which were not accounted for in this study i.e. changes in training regimes and diet and the absence of blinding in case ascertainment. More significantly, no study has compared the incidence of SCD in athletes with cardiovascular disease who have been screened with those who have not.(4)
In Italy, one in eleven athletes screened are referred for specialist assessment, only a quarter of whom are disqualified. Thus, screening results in high numbers of false positives, creating unnecessary anxiety. Indeed, many disqualifications may be unwarranted, as the risk of SCD is poorly characterised in a number of cardiomyopathies, which make up to half of all SCD.(5,6) Thus, the level of unnecessary harms to well-being, insurance costs and future employment remains unknown.
There are further uncertainties, not least the cost-effectiveness and organisational implications of screening. The apparent nonchalent advocation of screening is ill-founded, premature and ethically dubious. We advocate a comprehensive synthesis of existing evidence as the basis for an informed debate, rather than Drezner and Khan’s partial approach.
(1) Wilson JMG, Jüngner, G. Principles and Practice of Screening for Disease. Public Health Papers No. 34. WHO Chronicle 1968; 22(11):473.
(2) Drezner JA, Khan K. Sudden cardiac death in young athletes. BMJ 2008; 337:a309.
(3) 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. J Am Med Assoc 2006; 296(13):1593-1601.
(4) Thompson P, Franklin B, Balady G, Blair S, Corrado D, Estes NA et al. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 2007; 115(17):2358-2368.
(5) Corrado D, Basso C, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden cardiac death? J Cardiovasc Med (Hagerstown) 2006; 7(4):228-233.
(6) Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. J Am Med Assoc 1996; 276(3):199-204.
Competing interests: No competing interests