The aim is to pick up potentially life-threatening problems that put young athletes at risk and to cut the numbers collapsing and dying while participating in competitive sport.
A European Society of Cardiology consensus report[1] published (Wednesday 2 February) in Europe's leading cardiology journal, the European Heart Journal[2], recommends that every young athlete involved in organised sport has a rigorous physical examination, a detailed investigation of their personal and family medical history and, most importantly, a 12-lead ECG.
The report's writers believe that screening using ECG has the potential to cut sports-related cardiac deaths in Europe by 50%-70% if it can be implemented in every country[3].
Lead author Dr Domenico Corrado from the Departments of Cardiology and Pathology at the University of Padova, Italy, said: "We know very little about the risk of sudden death associated with exercise in young competitors, so the benefits versus the hazards of sports activity pose a clinical dilemma. However, we know from a study in the Veneto region of Italy that adolescents and young adults involved in competitive sport had a two and a half times higher risk of sudden death. The young competitors who died suddenly were affected by silent cardiovascular diseases, predominantly cardiomyopathies, premature coronary artery disease and congenital coronary anomalies."
He said it was not sport that directly caused the deaths, but rather that it triggered cardiac arrest in athletes with underlying diseases predisposing them to life-threatening ventricular arrhythmias.
The consensus group was also drawing on the results of Italy's 25-year experience of systematic pre-screening in reaching its conclusions. Italy has a mandatory eligibility test involving nearly six million young people every year and the test leans heavily on the use of 12-lead ECG. In one 17-year study by the Center for Sports Medicine of Padova involving nearly 34,000 athletes under 35, over 1,000 were disqualified from competing on health grounds, 621 (1.8%) because the tests revealed relevant cardiovascular abnormalities.
Dr Corrado said that in the USA young athletes had physical examinations and personal and family history investigations, but 12-lead ECG was done only at the doctor's discretion. The American Heart Association previously assumed that ECG would not be cost-effective for screening because of low specificity[4].
"In fact, this is not the case," said Dr Corrado "The Italian screening method has proven to be more sensitive than the limited US protocol. ECG is abnormal in up to 95% of patients with hypertropic cardiomyopathy (HCM), which is the leading cause of sudden death in an athlete. ECG abnormalities have also been documented in the majority of athletes who died from other arrhythmogenic heart muscle diseases."
Comparisons between findings in Italy where ECG is used and research in the USA showed a similar prevalence of HCM in non-sport sudden cardiac death, but a significant difference – 2% versus 24% – in sports-related cardiovascular events.
"This suggests we have selectively reduced sports-related sudden death from HCM because our system, using ECG, identifies vulnerable young people," said Dr Corrado.
He said that a number of the conditions now being picked up by ECG had only recently been discovered, so diagnosis was increasing. Researchers would shortly be examining the impact on mortality of the increased detection of potentially lethal problems.
It was harder to detect premature hardening of the coronary arteries or abnormalities in the coronary artery in young competitors, he said, because baseline ECG signs of blood flow (ischaemic) problems were scarce. However, his research team had earlier reported that about a quarter of the young athletes who had died from coronary artery diseases had displayed warning signs or ECG abnormalities during screening that could raise suspicions of a cardiac disease.
The consensus group recommends that screening should start around the age of 12 to 14 and be repeated at least every two years. It should involve complete personal and family history, a physical examination that includes blood pressure measurement and a 12-lead ECG. It should be performed by a physician with specific training who could reliably identify clinical symptoms and signs associated with cardiovascular diseases responsible for exercise-related sudden death. Those who tested positive according to set criteria should be referred for more extensive tests, and if that confirmed suspicions, barred from competition and training.
"From all the evidence that we have from 25 years experience in Italy, we can state unequivocally that screening is warranted," said Dr Corrado. "It is ethically and clinically justifiable to make every effort to recognise in good time the diseases that put these athletes and risk, and to reduce fatalities.
"Screening of large athletic populations will have significant socio-economic impact and its implementation across Europe will depend on the different socio-economic and cultural backgrounds as well as on the specific medical systems in place in different countries. However, experience in Italy indicates that the proposed screening design is made feasible because of the limited cost of 12-lead ECG in a mass screening setting.
"The cost in Italy of screening, aside from equipment and training, is around €30 including the ECG and is covered by the athlete or his team, except for the under 18s for whom there is National Health System support. Although the protocol is at present difficult to implement in all European countries, we hope that the successful Italian experience will lead to its widespread adoption under European regulations." (ends)
[1] The Consensus Statement is a report by the Study Group of Sport Cardiology of the Working Group on Cardiac Rehabilitation and Exercise Physiology and the Working Group on Myocardial and Pericardial Diseases of the European Society of Cardiology.
[2] Cardiovascular pre-participation screening of young competitive athletes for the prevention of sudden death: proposal for a common European protocol. European Heart Journal. doi:10.1093/eurheartj/ehi108.
[3] There are no estimates of the prevalence of sports-related sudden cardiac death in European countries apart from Italy, where sports-related sudden death occurs in approximately 2 per 100,000 athletes per year. Screening programmes on selected groups of athletes are used in the majority of European countries, but the screening is never systematic as it is in Italy.
[4] Cardiovascular preparticipation screening of competitive athletes. Circulation 1996;94:850-856.
PDF of research paper available from Margaret Willson on request.
Please acknowledge the European Heart Journal as a source in any articles.
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Journal
European Heart Journal