Sudden Cardiac Death and Preparticipation Screening: The Debate Continues—In Support of Electrocardiogram-Inclusive Preparticipation Screening

doi:10.1016/j.pcad.2012.01.001

Progress in Cardiovascular Diseases

Volume 54, Issue 5, March–April 2012, Pages 445-450

https://doi.org/10.1016/j.pcad.2012.01.001 Get rights and content

Abstract

Sudden cardiac death (SCD) is the leading cause of death in young athletes during exercise, and there is international agreement among major medical and sporting bodies that young athletes should undergo preparticipation cardiovascular screening. However, there is currently no universally accepted screening protocol, and substantial debate exists about what constitutes the ideal approach to preparticipation screening. The primary objective of preparticipation screening is the detection of intrinsic structural or electrical cardiovascular disorders that predispose an athlete to SCD. Considerable evidence exists suggesting that screening athletes with only a history and physical examination leaves most athletes with a serious underlying cardiovascular disease undetected and, thus, cannot adequately achieve the primary objective of screening. Preparticipating cardiovascular screening inclusive of an electrocardiogram (ECG) greatly enhances the ability to identify athletes at risk and is the only model shown to be cost-effective and may reduce the rate of SCD. The major obstacle to ECG screening in the United States is the lack of a physician workforce skilled in interpretation of an athlete's ECG. However, recent studies have demonstrated a capacity to distinguish physiologic ECG alterations in athletes from findings suggestive of underlying pathology that is both feasible and has a low false-positive rate. Efforts are underway to increase physician education in ECG interpretation. After 2 decades debating the proper screening strategy to identify athletes at risk, the weight of scientific evidence suggests that a screening program inclusive of ECG is the only strategy that merits promotion.

Section snippets

Background

Sudden cardiac death (SCD) in athletes is one of the most devastating events in sports and is usually caused by the presence of an underlying structural or electrical cardiovascular disorder.1, 2, 3 Although regular exercise promotes health, intense physical activity carries an increased risk for SCD in persons with underlying cardiovascular disease.4, 5, 6 Cardiovascular screening is routinely recommended by major medical and sporting societies including the American Heart Association (AHA),

Sudden cardiac death: more common than previously recognized

The value of cardiovascular screening in young athletes hinges on an accurate assessment of SCD incidence. Unfortunately, many studies have relied on media reports as the primary means of case ascertainment and underestimate the true incidence of SCD because of incomplete identification of all cases.³^,14, 15, 16 A recent study by Harmon et al¹ on the incidence of SCD in National Collegiate Athletic Association athletes found that media sources captured only 56% of the SCD cases between the

Purpose of preparticipation cardiovascular screening

Preparticipation cardiovascular screening is the systematic practice of evaluating athletes before participation in sports for the purpose of identifying or raising suspicion of abnormalities that could lead to sudden death.⁷ The AHA states that the principal objective of screening is to reduce the cardiovascular risks associated with physical activity and enhance the safety of athletic participation.⁷ The American College of Cardiology also contends that the ultimate objective of

Limitations of history and physical-based screening

A significant challenge to screening by history and physical examination alone is that asymptomatic, apparently healthy athletes may harbor unsuspected cardiovascular disease.22, 25 In young athletes, sudden death is the first manifestation of a cardiac disorder in up to 80% of cases.26, 27, 28, 29 Only 21% of athletes who died of hypertrophic cardiomyopathy (HCM), and 44% of athletes who died of an anomalous coronary artery had any signs or symptoms of cardiovascular disease in the years

ECG screening using modern standards for interpretation

A screening strategy inclusive of ECG increases the likelihood of detecting lethal cardiovascular abnormalities predisposing athletes to SCD. Inherited cardiomyopathies are the most common cause of SCD in young athletes, with HCM accounting for more than one third of cases in the United States and arrhythmogenic right ventricular cardiomyopathy predominating in Italy.3, 11 Approximately 95% of individuals with HCM and 80% of individuals with arrhythmogenic right ventricular cardiomyopathy

Cost-effectiveness

The AHA cost-effectiveness analysis, which is cited as unfavorable for ECG screening, uses underestimations for the incidence of SCD along with high false-positive rates before the implementation of contemporary screening standards.7, 49 Notably, the cost-effectiveness of ECG screening is significantly improved when modern ECG criteria to guide interpretation and updated SCD incidence data are considered.⁴⁹ In a cost-effectiveness study of cardiovascular screening in college-aged athletes,

Creating infrastructure to meet preparticipation screening objectives

For an ECG screening program to be successful, physicians who perform cardiovascular preparticipation screening should be educated on appropriate interpretation criteria. A recent study of 60 primary care and cardiology physicians assessed the accuracy of ECG interpretation in athletes.⁵² Physicians were asked to interpret 40 ECGs from normal athletes randomized with ECGs from patients with known cardiovascular conditions at risk for SCD, both before and after the use of an ECG criteria tool to

Conclusion

There is no debate on whether to screen athletes, only on how to screen. The traditional US model for cardiovascular screening in athletes using only history and physical examination has a low sensitivity and is of marginal benefit when applied alone. Most athletes who have SCD have no warning symptoms, making the effectiveness of an evaluation rooted in symptom identification limited and with little future predictive value that a normal screen establishes safety during athletic participation.

Statement of Conflict of Interest

All authors declare that there are no conflicts of interest.

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Cited by (46)

Reprint of: ECG in sportsmen: Distinguishing the normal from the pathological
2020, Journal Europeen des Urgences et de Reanimation
La réalisation d’un ECG est recommandée par la société française de cardiologie lors de la visite d’absence de contre-indication à la pratique sportive.
L’activité physique intense et prolongée (> 4 heures de sport intense/semaine) peut entrainer un remodelage électrique d’origine physiologique.
Outre l’activité physique (type, intensité, durée), il convient d’interpréter l’ECG en fonction de l’origine ethnique et de l’âge du sportif.
Il est nécessaire de connaître les modifications physiologiques en lien avec la pratique sportive pour éviter d’une part les fausses réassurances et d’autre part la réalisation d’examens complémentaires injustifiés du fait d’une mauvaise interprétation.
La dernière classification internationale de l’ECG de l’athlète publiée en 2017 permet de repérer chez quel athlète des examens complémentaires sont recommandés (figure 1).
An ECG is recommended by the French Society of Cardiology in the screening of a competitive athlete.
An intense and prolonged physical activity (> 4 hours of intense sport/week) can lead to a physiological electric remodeling.
In addition to physical activity (type, intensity, duration), the ECG should be interpreted according to the athlete's ethnicity and age.
It is necessary to know the physiological modifications related to sport practice to avoid either false reassurances or the realization of unjustified additional examinations because of a wrong interpretation.
The latest athlete ECG classification published in 2017 can be used to identify in which athlete additional tests are recommended (figure 1).
ECG in sportsmen: Distinguishing the normal from the pathological
2019, Presse Medicale
La réalisation d’un ECG est recommandée par la société française de cardiologie lors de la visite d’absence de contre-indication à la pratique sportive.
L’activité physique intense et prolongée (> 4 heures de sport intense/semaine) peut entrainer un remodelage électrique d’origine physiologique.
Outre l’activité physique (type, intensité, durée), il convient d’interpréter l’ECG en fonction de l’origine ethnique et de l’âge du sportif.
Il est nécessaire de connaître les modifications physiologiques en lien avec la pratique sportive pour éviter d’une part les fausses réassurances et d’autre part la réalisation d’examens complémentaires injustifiés du fait d’une mauvaise interprétation.
La dernière classification internationale de l’ECG de l’athlète publiée en 2017 permet de repérer chez quel athlète des examens complémentaires sont recommandés (figure 1).
An ECG is recommended by the French Society of Cardiology in the screening of a competitive athlete.
An intense and prolonged physical activity (> 4 hours of intense sport/week) can lead to a physiological electric remodeling.
In addition to physical activity (type, intensity, duration), the ECG should be interpreted according to the athlete's ethnicity and age.
It is necessary to know the physiological modifications related to sport practice to avoid either false reassurances or the realization of unjustified additional examinations because of a wrong interpretation.
The latest athlete ECG classification published in 2017 can be used to identify in which athlete additional tests are recommended (figure 1).
Sudden Cardiac Death in the Adolescent Athlete: History, Diagnosis, and Prevention
2019, American Journal of Medicine
Citation Excerpt :
Studies have shown that physical examination alone is unlikely to detect a significant number of cardiac issues that may lead to sudden cardiac death. One study found that the sensitivity of history and physical examination alone was just 12%, but when ECG was added, the sensitivity increased to 88%.28 The same study found that a negative ECG conferred a 99.98% negative predictive value for acute cardiac pathology with the potential to lead to sudden cardiac death.
Sudden cardiac death in young athletes is a devastating condition that occurs without warning. While most middle and high school athletes require preparticipation screening, many predisposing conditions go undiagnosed until they occur. The frequency of sudden cardiac death is often under-reported because there is no mandatory system for reporting sports-related death in high school sports. Additionally, there is debate about the cost-effectiveness of more advanced screening tests, such as electrocardiogram, due to high false-positive rates. It is, however, accepted that participants with a family history of sudden cardiac death should undergo more in-depth screening. If sudden cardiac arrest occurs, it is important for the patient to undergo immediate defibrillation. Community outreach to ensure that automated external defibrillators are present at athletic events, as well as cardiopulmonary resuscitation training for coaches, could potentially save lives. Ultimately, prevention of sudden cardiac death depends on physician awareness of how to properly screen and identify those at risk, and how to best be prepared if sudden cardiac arrest occurs.
Sports in children with congenital heart diseases
2017, Presse Medicale
La pratique d’une activité physique est un des éléments essentiels pour la santé en général mais aussi pour le bien-être et la qualité de la vie.
Elle est hautement souhaitable, y compris chez les enfants atteints de cardiopathies congénitales, compte tenu de tous les bénéfices associés à cette pratique (qualité de vie, espérance de vie), et ce, d’autant plus que ces enfants ont souvent une capacité limitée (en raison de leur cardiopathie mais souvent aussi par un déconditionnement relatif).
S’il existe bien une augmentation transitoire du risque de complications cardiaques lors d’une activité intense, il serait néanmoins inapproprié de contre-indiquer des activités physiques dont on connaît bien le bénéfice à moyen et long terme.
Le risque lié à la pratique d’une activité physique doit s’apprécier, d’une part, au regard de la sévérité de la cardiopathie et, d’autre part, en fonction de la nature et de l’intensité de l’activité envisagée. Le test d’effort est un outil essentiel dans ce domaine car il permet d’évaluer les capacités physiques et les adaptations cardiorespiratoires à l’effort.
Les recommandations internationales concernant les sports de compétition permettent généralement de donner un avis adapté pour ce type de pratique mais ne doivent pas faire négliger la pratique d’une activité modérée ou des sports de loisirs qu’il est souhaitable, au contraire, d’encourager fortement.
The practice of physical activity is one of the essential elements for health in general but also for the well-being and the quality of life.
It is highly desirable to encourage physical activities in children with congenital heart diseases, taking into account all the benefits associated with this practice (quality of life, life expectancy) and this especially since these children often have limited capacity (due to their heart disease but also often by relative deconditioning).
While there is a transient increase in risk of cardiac complications during intense activity, it would nevertheless be inappropriate to contra-indicate physical activities considering the well-known benefits in the medium and long term.
The risks associated with the practice of physical activity must be assessed, on one hand, in terms of the severity of the heart disease, and on the other hand, on the nature and intensity of the activity. The stress test is here an essential tool because it helps to assess the physical capacity and cardiorespiratory adaptations to exercise.
The international recommendations for competitive sports generally give an appropriate advice for a specific situation but the practice of moderate activity or leisure sports which are highly desirable should not be neglected and be strongly encouraged.
Benign and pathological electrocardiographic changes in athletes
2015, Revista Portuguesa de Cardiologia
A morte súbita cardíaca é a principal causa de morte em atletas durante a prática desportiva. É um evento trágico, com grande impacto nos média, gerando discussão dentro da comunidade no intuito de perceber se tudo foi feito para o evitar. A prática regular de exercício físico causa uma remodelagem cardíaca, tanto a nível mecânico como elétrico, conhecida como «coração de atleta», que se repercute num eletrocardiograma considerado «anormal» quando comparado com o da população geral. Algumas destas alterações do eletrocardiograma são consideradas normais/fisiológicas em atletas, enquanto outras traduzem, efetivamente, doença cardíaca de base, com potencial de causar morte súbita cardíaca. Assim, urge definir quais os padrões eletrocardiográficos que «permitem» ou, por outro lado, «proíbem» a prática desportiva, diferenciando‐os em função do género, etnia e idade. Esta revisão pretende reunir a informação mais atual sobre as alterações eletrocardiográficas consideradas benignas ou patológicas encontradas tipicamente em atletas e analisar, de forma crítica, os critérios mais recentes para a classificação do eletrocardiograma nesta população (os Critérios de Seattle), comparando‐os com as guidelines anteriores e com os estudos mais recentes sobre o tema. É também objetivo desta revisão dar a conhecer a problemática da inclusão do eletrocardiograma no programa de rastreio pré‐desportivo, as perspetivas americana e europeia, e os dados mais recentes sobre a sensibilidade, especificidade e custo‐efetividade do uso do eletrocardiograma em atletas.
Sudden cardiac death is the leading cause of death in athletes during sport. It is a tragic event that generates significant media attention and discussion throughout society as to whether everything possible had been done to prevent it. Regular physical exercise causes cardiac remodeling at both the mechanical and electrical level, known as athlete's heart, resulting in an electrocardiogram (ECG) considered abnormal compared with the ECGs of the general population. Some of these electrocardiographic changes are considered normal or physiological in athletes, while others suggest underlying cardiac disease with the potential to cause sudden cardiac death. There is thus an urgent need to define the electrocardiographic patterns that allow or prohibit participation in sports, and to differentiate them in terms of gender, ethnicity and age. The purpose of this review is to present the latest data on the electrocardiographic changes considered benign or pathological that are typically found in athletes and to critically analyze the most recent criteria for classifying ECGs in this population (the Seattle criteria), comparing them with previous guidelines and with the latest studies on the subject. This article also examines the question of including ECGs in preparticipation screening programs, the US and European approaches to the subject, and the most up‐to‐date data on the sensitivity, specificity and cost‐effectiveness of the ECG in athletes.
My patient wants to perform strenuous endurance exercise. What's the right advice?
2015, International Journal of Cardiology
Citation Excerpt :
The increasing popularity of extreme endurance sports has resulted in a growing number of poorly trained participants with underlying CVD, and this might have contributed to the growth of SEE-related CA over the last decade [59], thus supporting the importance of establishing reliable preventive screening. PPS aimed to identify athletes at risk of SCD or disease progression due to sports participation [62,63], is recommended by major medical and sporting societies, the American Heart Association (AHA) [63], the European Society of Cardiology (ESC) [64], and the International Olympic Committee [65]. Although there is an ongoing debate regarding the actual preventive value of PPS, and especially which screening strategy is more effective, the inclusion of ECG should be promoted [62].
Prolonged strenuous endurance exercise (SEE) such as marathon running has recently been associated with potential deleterious cardiac effects, particularly increased risk of atrial fibrillation (AF). This topic is medically important due to the increasing number of participants in SEE events lasting several hours, including older people. The aim of this narrative review is to provide a summary of the evidence available on SEE and related issues such as cardiovascular mortality, AF, potential cardiac remodeling, cardiovascular events during exertion, or the need for pre-participation screening (with a special focus on beginners). This type of information can help physicians giving advice to their patients and the general public regarding safe SEE practice.

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: Statement of Conflict of Interest: see page 449.

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Sudden Cardiac Death and Preparticipation Screening: The Debate Continues—In Support of Electrocardiogram-Inclusive Preparticipation Screening

Abstract

Section snippets

Background

Sudden cardiac death: more common than previously recognized

Purpose of preparticipation cardiovascular screening

Limitations of history and physical-based screening

ECG screening using modern standards for interpretation

Cost-effectiveness

Creating infrastructure to meet preparticipation screening objectives

Conclusion

Statement of Conflict of Interest

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Heart Rhythm

J Am Coll Cardiol

Heart Rhythm

Incidence of sudden cardiac death in national collegiate athletic association athletes

Circulation

Sudden death in young athletes

N Engl J Med

Sudden deaths in young competitive athletes: analysis of 1866 deaths in the united states, 1980-2006

Circulation

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

Sports-related sudden death in the general population

Circulation

Circulation

The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes, March 2009

Clin J Sport Med

Eur Heart J

Development and implementation of a standardized precompetition medical assessment of international elite football players—2006 FIFA World Cup Germany

Clin J Sport Med

Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program

JAMA

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JAMA

Screening for sudden cardiac death in the young: report from a National Heart, Lung, and Blood Institute working group

Circulation

Nontraumatic sports death in high school and college athletes

Med Sci Sports Exerc

Incidence of sudden cardiac death in athletes: where did the science go?

Br J Sports Med

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Ann Intern Med

Prospective screening of 5,615 high school athletes for risk of sudden cardiac death

Med Sci Sports Exerc