European Heart Journal Advance Access originally published online on October 30, 2006
European Heart Journal 2006 27(23):2905-2906; doi:10.1093/eurheartj/ehl343
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Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol: reply
Department of Cardiology
University of Padua
Medical School
Padua
Italy
E-mail address: domenico.corrado{at}unipd.it
National Institute of Sports Medicine
Rome
Italy
Hospital Bergen
Norway
Institute of Pathological Anatomy
University of Padua
Padua
Italy
In her letter to the Editor regarding the ESC report on ‘Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death (SD)’,1 Dr Prescott on behalf of a Danish task force raised some concerns about efficacy, cost-effectiveness, and feasibility of pre-participation screening and reached the conclusion that it should not be recommended in Denmark.
We acknowledge that the guidelines for implementation of a common European screening program predominantly relied on Italian studies.1 However, Italy is the only country in the world where pre-participation evaluation is required by law and a mass-screening program, essentially based on 12-lead ECG, has been the practice for almost 25 years.1,2 This population-based and long-term experience has provided compelling evidence of screening efficacy in identifying athletes at risk and in preventing SD. The Italian pre-participation evaluation has been proved to successfully detect athletes with previously undiagnosed hypertrophic cardiomyopathy,2,3 which is the most important cause of athletic-field SD in young competitors.4 Moreover, during the long-term follow-up, no deaths were recorded among former athletes who were disqualified due to hypertrophic cardiomyopathy, indicating that identification and subsequent clinical management of affected athletes actually improves survival.2
A recent time-trend analysis of cardiovascular SD of young competitive athletes of the Veneto region of Italy over 26 years showed a mortality decline by almost 90% after implementation of the nationwide pre-participation screening program, whereas the incidence of SD among the unscreened non-athletic population of the same age range did not change significantly.5 Mortality reduction in athletes was predominantly due to a lower prevalence over time of SD from cardiomyopathies and paralleled the increased identification through pre-participation screening of athletes with hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy.5 All these findings definitively show that pre-participation screening is a life-saving strategy and that the 12-lead ECG is a very sensitive and powerful tool for identification, risk stratification, and management of competitive athletes.
The Italian screening program was made feasible because of the limited cost of first line cardiovascular evaluation in the setting of a mass screening.1 The presumed high percentage of false positives, i.e. athletes with a normal heart but positive screening findings, requiring additional testing (mainly an echocardiogram), was actually limited to <9% with modest proportional cost impact.2,5
We believe that the increase in athletes' awareness of symptoms that may precede cardiac arrest plays a marginal role in preventing fatalities. SD during sports is most often the first clinical manifestation of an underlying cardiovascular disease, which usually is clinically silent.2,5,6 This explains why a screening protocol based solely on the athlete's history and physical examination (without 12-lead ECG), as used in the USA, is of limited value.4
We agree that the athlete's disqualification can be associated with an important individual cost in terms of health, contentment, and even future opportunity for professional sports. However, the risk of sudden death associated with competitive sports in the setting of known cardiovascular disease is a controllable factor, and the devastating impact of even infrequent fatal events in the young athletic population justifies appropriate restriction from competition.5
It is noteworthy that a 25-year interval was required to generate the Italian data showing the actual success of the current pre-participation screening program. Until data from other athletic populations of comparable size and follow-up are obtained, the Italian studies provide the best available data which strongly support the need for implementing worldwide screening strategies for prevention of SD in the athletes.
References
- Corrado D, Pelliccia A, Bjørnstad HH, Vanhees L, Biffi A, Borjesson M, Panhuyzen-Goedkoop N, Deligiannis A, Solberg E, Dugmore D, Mellwig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Heidbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E, Blomstrom-Lundqvist C, McKenna WJ, Thiene G. (2005) Cardiovascular preparticipation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 26:516–524.
[Abstract/Free Full Text] - Corrado D, Basso C, Schiavon M, Thiene G. (1998) Screening for hypertrophic cardiomyopathy in young athletes. New Engl J Med 39:364–369.
- Pelliccia A, Di Paolo FM, Corrado D, Buccolieri C, Quattrini FM, Pisicchio C, Spataro A, Biffi A, Granata M, Maron BJ. (2006) Evidence for efficacy of the Italian national pre-participation screening programme for identification of hypertrophic cardiomyopathy in competitive athletes. Eur Heart J 27:2196–2200.
[Abstract/Free Full Text] - Maron B.J. (2003) Sudden death in young athletes. New Engl J Med 349:1064–1075.
[Free Full Text] - Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Gaetano T. (2006) Trends of sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 296:1593–1601.
[Abstract/Free Full Text] - Corrado D, Basso C, Thiene G. (2005) Assay: sudden death in young athletes. Lancet 366:Supp. 1S47–S48.
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