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• W2112700736 abstract "HomeCirculationVol. 119, No. 8Preparticipation Screening of Competitive Athletes Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBPreparticipation Screening of Competitive AthletesSeeking Simple Solutions to a Complex Problem Paul D. Thompson, MD Paul D. ThompsonPaul D. Thompson From the Department of Cardiology and the Athlete’s Heart Program, Hartford Hospital, Hartford, Conn, and Department of Medicine, University of Connecticut, Farmington. Search for more papers by this author Originally published16 Feb 2009https://doi.org/10.1161/CIRCULATIONAHA.108.843862Circulation. 2009;119:1072–1074Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 16, 2009: Previous Version 1 Sports used to be simple. The major decision my friends and I faced as youngsters was who would get to be Y.A. Tittle of the New York Giants in our Sunday afternoon football pickup games. The preparticipation screening of athletes also used to be simple and generally consisted of a medical form completed by a parent and a cursory physical examination performed in the gym by a general physician. Now, recreation for many young Americans requires formal play dates, and there are T-ball leagues for those too young to hit an unsupported baseball. The preparticipation screening of athletes also has become more formalized and is, in some countries, a legally regulated activity.1 The goal of both increased athletic supervision and formalized preparticipation screening is to protect young athletes from the risks inherent in athletic participation, but how best to accomplish this goal is now in hot debate.Article p 1085Screening athletes has received increased attention because the issue of sudden cardiac death (SCD) in athletes and during exercise has become a prominent health issue. Public interest in these events probably arises from both the importance of sport in many societies and the paradox that physical activity can have both a positive and negative impact on an individual’s health.2 It is clear that vigorous exertion transiently increases the risk of SCD in individuals with established cardiovascular disease.2 Atherosclerotic coronary artery disease is the primary pathological finding in individuals >40 years of age who die during physical activity, whereas inherited cardiovascular conditions are primarily responsible for such events in younger athletes.2 Hypertrophic cardiomyopathy (HCM), an entity described shortly before Tittle played for the Giants,3 accounts for most (36% to 44%) of these deaths in American athletes, with other abnormalities, including anomalous coronary arteries (17%), myocarditis (6%), arrhythmogenic right ventricular cardiomyopathy (4%), mitral valve prolapse (4%), intramyocardial coronary arteries (4%), coronary artery disease (3%), aortic stenosis (2%), and aortic rupture (2%), associated with many of the remaining deaths.4 The young age of the victims and the fact that many were previously asymptomatic have prompted the interest in preparticipation cardiac screening.Italy has legally mandated the screening process. Under a law first passed in 1971 and revised in 1982, Italian athletes participating in organized competitive sports must undergo a physical examination, 12-lead ECG, and 3-minute exercise step test.1 An ECG is performed before and after but not during the step test for athletes <40 years of age. Athletes >40 years of age must undergo a more formal treadmill or bicycle exercise stress test (A. Pelliccia, D. Corrado, written communication, December 2008). It is the legal responsibility of the athletic team’s manager to ensure that this testing is done, although compliance with this law has not been universal even in Italy (A. Pelliccia, written communication, December 2008). The Italian screening is performed by sports medicine physicians who have undergone an additional 4 years of postgraduate training in sports medicine and sports cardiology.5 The professionalism of this screening process is in marked contrast to the American system, in which such examinations have in the past been rendered by other providers, including chiropractors and naturopathic physicians.6Results published on the Italian experience suggest that this program has altered the profile of athletic SCD in Italy and remarkably reduced its incidence. For example, Corrado and colleagues7 screened 33 735 athletes using the tests delineated above. Additional testing was required in 3016 athletes (8.9%), and 621 (1.8%) were ultimately disqualified from participation, 22 for HCM. Only 5 of the athletes with HCM had a cardiac murmur or family history of the disease, whereas 18 had some ECG abnormality, supporting the value of the ECG in this screening process.5 There were 49 deaths among successfully screened athletes (1.6 per 100 000 person-years) but only 1 death from HCM among screened athletes and none among the 22 excluded HCM subjects over 8.2±5 years of follow-up.7 The low prevalence of HCM athletic deaths contrasts with that from the United States, leading the authors to attribute these differences to the screening process.7 Corrado and colleagues8 also have reported incidence figures for SCD in Italian athletes from the Veneto region before and after the initiation of preparticipation screening. The annual incidence of SCD in athletes decreased from 3.6 per 100 000 person-years in 1979 to 1980 to only 0.4 in 2003 to 2004. There was no change in the death rate among nonathletes. Deaths in athletes attributed to cardiomyopathies decreased, and the number of athletes disqualified for cardiomyopathies increased.The Italian researchers are convinced that these data prove the value of their screening process and have aggressively argued for its export to other countries.5 In a recent review of these results, Corrado and colleagues5 acknowledge that their study “. . . was not a randomized trial and that unequivocal conclusions . . . cannot be drawn . . .” (p 1985) but also state that the reduction in deaths among athletes “. . . should remove all doubt of the efficacy of screening . . . and its ability to save lives” (p 1985). Both the American Heart Association and the European Society of Cardiology (ESC) recommend preparticipation athletic screening, but the AHA recommends a brief personal and family history and physical examination,4 whereas the ESC, largely on the basis of the Italian experience, recommends a considerably more extensive history and a 12-lead ECG.9 Some US experts have joined the cacophony in favor of more extensive testing. Myerberg and Vetter10 have questioned the logic, financial considerations, and even the ethics of the AHA’s 2007 update on screening. Douglas,11 in an editorial entitled “Saving Athletes’ Lives: A Reason to Find Common Ground,” lamented the lack of consensus on screening and asked, “Don’t our athletes deserve more than this?”What our athletes deserve are good data on US athletes and a thoughtful consideration of the benefits and possible untoward consequences of any recommended screening process. The issues with the Italian results have been summarized.12 The most salient points are that these results are from an observational study and are not a controlled comparison of various screening strategies, that the death rate among athletes (3.6 per 100 000 person-years) before screening was surprisingly high, and that the best rate achieved in the Italian study approximates estimates for the United States.12 There is also the perplexing question of whether those with asymptomatic cardiac conditions found on screening have the same prognosis as symptomatic patients.12 Did the 22 HCM athletes identified by the Italian screening process survive because they were spared the danger of athletic competition, or were they at low risk anyway? Only 3 ultimately received β-adrenergic blocking agents or amiodorone,5 but it seems unlikely that restriction from athletic activity alone was responsible for their good prognosis. In addition, no one enjoys discussing the cost of such programs because each life is precious, but there are no reliable estimates of the ultimate cost of extensive screening. The added cost of such programs is not the pittance required to obtain ECGs on thousands of athletes but the cost of the additional testing generated by screening programs. Approximately 9% of athletes evaluated in Italy by sports cardiology specialists require additional testing.5 Similarly, Fuller and colleagues13 reported that 10% of 5615 high school athletes required echocardiography when screened by ECG and cardiologists, but there are no estimates of how much additional testing will be generated when nonspecialists perform these evaluations. Even Myerberg and Vetter10 recognize that using ECGs to screen athletes will represent a research opportunity that will better evaluate the relationship between nonspecific ECG changes and other testing techniques, but they argue against delay in implementing ECG screening because of the additional deaths that would occur while waiting. And that is the key issue. Is extensive preparticipation screening a solution for a major problem or a solution in search of a problem?Into this complex context Maron and colleagues14 report very important results from their 27-year registry of 1866 US athletes who died or survived (n=85) cardiac arrest. The results are not limited to exercise-related cardiac events. Only 80% of deaths were associated with physical exertion, and the results include athletes who died of noncardiac events, including blunt trauma (n=416, 22%), commotio cordis (n=65, 4%), and heat stroke (n=46, 2%). Nevertheless, the majority (n=1049, 56%) were attributed to definite (n=690) or probable (n=359) cardiac causes. This registry was assembled from multiple sources and therefore lacks the precision associated with the regionalized case ascertainment techniques used by Corrado and colleagues,8 but the results provide the best data to date on the US experience with cardiac events in athletes. Only 576 events (31%) occurred in the 1980 to 1993 time period, whereas 1290 (69%) occurred between 1994 and 2006. This suggests either that the death rate is increasing or, more likely, that there is increased media attention and reporting of these events. Even 1 death is a terrible tragedy, but the absolute national death rate from cardiac causes averaged only 66 deaths per year over the last 6 years. Furthermore, the authors estimated a recent US death rate for athletes as only 0.6 per 100 000 person-years. This figure is similar to the lowest annual rate reported from the Veneto region of Italy of 0.4.8These results clearly do not end the debate about how best to evaluate competitive athletes. These data are imperfect. First, there is no guarantee that all cases of SCD in athletes were identified, and the authors argue for a national athlete SCD registry. Second, this calculation of the athletic death rate, like others,15 estimated the absolute number of athletes participating by using the assumption that each high school and college athlete participates in 1.9 and 1.2 sports, respectively. This is a reasonable estimate, but only an estimate. Third, the present data contain noncardiac events and events that do not occur during athletic activity, making it harder to estimate the benefit of cardiovascular screening programs in protecting athletes from the cardiac risks of athletic participation.Although these data will not end the debate, they should elevate the discussion on preparticipation screening. The imperfections of these data should prompt a serious effort to establish a national athlete SCD registry. Clearly, this must happen if we are ever going to have a clear understanding of the magnitude of the problem. We need to know far more about these cases to develop effective prevention strategies. How many are truly asymptomatic? How many had known disease? How many had passed screening exams? These data, despite possible imperfections, can be used with appropriate error estimates and varying assumptions to construct better US estimates of the cardiac risks of athletic participation and the benefits and costs, financial and otherwise, of screening. In addition, as suggested by Myerberg and Vattner,10 we should perform similar risk-to-benefit analyses on screening in general. Athletes are presently the focus, but is more widespread screening of youngsters worthwhile?Experience suggests that when experts disagree, there is a dearth of reliable data. The present data14 suggest that the problem, at least in the United States, is not so huge that we must leap to action. We need more and better data on the cardiovascular risks of athletics, the false-positive rate of screening strategies when used by nonexperts, the cost of tests and procedures generated by screening, and if possible, actual controlled trials of screening strategies. Good data often simplify complex problems.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.DisclosuresDr Thompson is an author of the American Heart Association’s position paper on screening athletes. He also owns shares of Zoll Medical, a manufacturer of cardiac defibrillators.FootnotesCorrespondence to Paul D. Thompson, MD, Cardiology, Hartford Hospital, 80 Seymour St, Hartford, CT 06102. E-mail [email protected] References 1 Pelliccia A, Maron BJ. Preparticipation cardiovascular evaluation of the competitive athlete: perspectives from the 30-year Italian experience. Am J Cardiol. 1995; 75: 827–829.CrossrefMedlineGoogle Scholar2 Thompson PD, Franklin BA, Balady GJ, Blair SN, Corrado D, Estes NA 3rd, Fulton JE, Gordon NF, Haskell WL, Link MS, Maron BJ, Mittleman MA, Pelliccia A, Wenger NK, Willich SN, Costa F, for the American Heart Association Council on Nutrition, Physical Activity, and Metabolism; American Heart Association Council on Clinical Cardiology; American College of Sports Medicine. 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: 2358–2368.LinkGoogle Scholar3 Teare D. Asymmetrical hypertrophy of the heart in young adults. Br Heart J. 1958; 20: 1–8.CrossrefMedlineGoogle Scholar4 Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, Dimeff R, Douglas PS, Glover DW, Hutter AM Jr, Krauss MD, Maron MS, Mitten MJ, Roberts WO, Puffer JC, for the American Heart Association Council on Nutrition, Physical Activity, and Metabolism. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007; 115: 1643–1655.LinkGoogle Scholar5 Corrado D, Basso C, Schiavon M, Pelliccia A, Thiene G. Pre-participation screening of young competitive athletes for prevention of sudden cardiac death. J Am Coll Cardiol. 2008; 52: 1981–1989.CrossrefMedlineGoogle Scholar6 Glover DW, Glover DW, Maron BJ. Evolution in the process of screening United States high school student-athletes for cardiovascular disease. Am J Cardiol. 2007; 100: 1709–1712.CrossrefMedlineGoogle Scholar7 Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med. 1998; 339: 364–369.CrossrefMedlineGoogle Scholar8 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. JAMA. 2006; 296: 1593–1601.CrossrefMedlineGoogle Scholar9 Corrado D, Pelliccia A, Bjornstad 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. Cardiovascular pre-participation 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. 2005; 26: 516–524.CrossrefMedlineGoogle Scholar10 Myerburg RJ, Vetter VL. Electrocardiograms should be included in preparticipation screening of athletes. Circulation. 2007; 116: 2616–2626.LinkGoogle Scholar11 Douglas PS. Saving athletes’ lives: a reason to find common ground? J Am Coll Cardiol. 2008; 52: 1997–1999.CrossrefMedlineGoogle Scholar12 Thompson PD, Levine BD. Protecting athletes from sudden cardiac death. JAMA. 2006; 296: 1648–1650.CrossrefMedlineGoogle Scholar13 Fuller CM, McNulty CM, Spring DA, Arger KM, Bruce SS, Chryssos BE, Drummer EM, Kelley FP, Newmark MJ, Whipple GH. Prospective screening of 5,615 high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc. 1997; 29: 1131–1138.CrossrefMedlineGoogle Scholar14 Maron BJ, Doerer JJ, Hass TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980–2006. Circulation. 2009; 119: 1085–1092.LinkGoogle Scholar15 Van Camp SP, Bloor CM, Mueller FO, Cantu RC, Olson HG. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc. 1995; 27: 641–647.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Erickson C, Salerno J, Berger S, Campbell R, Cannon B, Christiansen J, Moffatt K, Pflaumer A, Snyder C, Srinivasan C, Valdes S, Vetter V and Zimmerman F (2021) Sudden Death in the Young: Information for the Primary Care Provider, Pediatrics, 10.1542/peds.2021-052044, 148:1, Online publication date: 1-Jul-2021. Dennison R, Kerkhof D, Honda T, Calatroni R and Corrado G (2019) Feasibility of a Novel Strategy for Cardiovascular Screening During the Preparticipation Physical Examination, Clinical Journal of Sport Medicine, 10.1097/JSM.0000000000000770, 31:5, (407-413), Online publication date: 1-Sep-2021. Siaplaouras J, Apitz C, Fritsch P, Wilhelm M and Kriemler S (2019) Das 12-Kanal-Ruhe-EKG in der sportmedizinischen Untersuchung von Kindern und JugendlichenThe 12-lead resting ECG in sport medical examinations of children and adolescents, Monatsschrift Kinderheilkunde, 10.1007/s00112-019-00796-9, 167:12, (1157-1161), Online publication date: 1-Dec-2019. Gleason C, Kerkhof D, Cilia E, Lanyi M, Finnoff J, Sugimoto D and Corrado G (2017) Early Screening for Cardiovascular Abnormalities With Preparticipation Echocardiography, Clinical Journal of Sport Medicine, 10.1097/JSM.0000000000000379, 27:5, (423-429), Online publication date: 1-Sep-2017. Maron B, Friedman R and Caplan A (2015) Ethics of preparticipation cardiovascular screening for athletes, Nature Reviews Cardiology, 10.1038/nrcardio.2015.21, 12:6, (375-378), Online publication date: 1-Jun-2015. Maron B, Friedman R, Kligfield P, Levine B, Viskin S, Chaitman B, Okin P, Saul J, Salberg L, Van Hare G, Soliman E, Chen J, Matherne G, Bolling S, Mitten M, Caplan A, Balady G and Thompson P (2014) Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age), Circulation, 130:15, (1303-1334), Online publication date: 7-Oct-2014. 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March 3, 2009Vol 119, Issue 8 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.108.843862PMID: 19221215 Originally publishedFebruary 16, 2009 Keywordsexerciseathletedeath, suddenEditorialsPDF download Advertisement SubjectsCongenital Heart DiseaseEchocardiographyElectrocardiology (ECG)Ethics and PolicyRehabilitation" @default.
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