Cardiovascular Screening of Young Athletes: A Newsmaker Interview With Antonio Pelliccia, MD

Laurie Barclay, MD

February 04, 2005

Feb. 4, 2005 — The European Society of Cardiology (ESC) has issued a consensus statement, published online Feb. 2 in the European Heart Journal , recommending that every young competitive athlete undergo cardiovascular screening. As in the U.S., the recommended protocol calls for a complete physical examination and personal and family medical history. However, the ESC also mandates a 12-lead electrocardiogram (ECG), which has not been required in the U.S. to date.

Lead author Domenico Corrado, from the University of Padova in Italy, and colleagues suggest that including the ECG in cardiovascular screening may decrease sports-related cardiac deaths in Europe by 50% to 70% if implemented in every European country. Although applicability of these guidelines to the U.S. still needs to be determined, the recent sudden death of a young athlete highlights the need for improved screening.

Eastern Connecticut basketball player Antwoine Key died on Jan. 20 after collapsing during the first few minutes of a game at Worcester State. Despite emergency use of defibrillators, Key was pronounced dead after being rushed to St. Vincent's Hospital in Worcester, Massachusetts.

To learn more about the ramifications of cardiovascular screening, Medscape’s Laurie Barclay interviewed coauthor Antonio Pelliccia, MD, a cardiologist at the National Institute of Sports Medicine, a division of the Italian National Olympic Committee, in Rome, Italy.

Medscape: What was the impetus and research base behind the creation of the consensus statement?

Dr. Pelliccia: The rationale for the consensus statement comes from the wide clinical perception, supported by scientific evidence, that sudden death and other adverse cardiac events occur more frequently in individuals with silent cardiovascular disease than in normal subjects.

Specifically, Dr. Corrado and his group, in a previous investigation ( J Am Coll Cardiol. 2003;42:1959-1963) assessed the incidence of sudden death in the athletic and nonathletic young population, ages 12 to 35 years, of the Veneto region of Italy. They showed that competitive sport activity increases by 2.5 times the risk of sudden death in adolescents and young adults.

In this study, young competitive athletes who died suddenly were affected by silent cardiovascular diseases, predominantly consisting of cardiomyopathies, premature coronary artery disease, and congenital coronary anomalies. Therefore, sports activity was not per se a cause of the increased mortality; rather, it acted as a trigger of cardiac arrest upon those underlying cardiovascular diseases predisposing to life-threatening ventricular arrhythmias.

Thus, it seems ethically and clinically justifiable that every effort should be made to recognize the risk of such diseases in the athlete [in a timely manner], given the perspective that disqualification of affected individuals makes it possible to prevent athletic field death. The purpose of the study group of Sport Cardiology of the European Society of Cardiology was, therefore, to offer a consensus document with recommendations for a more feasible and efficient strategy to quickly identify these individuals at risk.

Medscape: How frequent are cardiovascular events and sudden death in young athletes, and what mechanism is involved?

Dr. Pelliccia: In Italy, the incidence of sudden death is 2.3 (2.62 in men and 1.07 in women) per 100,000 athletes per year from all causes, and 2.1 per 100,000 athletes per year from cardiovascular diseases. Different rates in other countries may be related to different underlying pathologic substrates which, in part, also reflect differences in ethnic and genetic factors.

Pathologic substrates responsible for death are different according to age: in athletes over 35 years, atherosclerotic coronary artery disease is by far the most common cause of fatal events; in young competitive athletes, a broad spectrum of cardiovascular causes, including hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), dilated cardiomyopathy, congenital coronary artery anomalies, myocarditis, and long QT syndrome have been reported.

HCM has been implicated as the principal cause of sport-related cardiac arrest, accounting for more than one third of sudden deaths in the U.S., while ARVC is the leading cause in Italy. Other frequent causes include anomalous origin of coronary artery from the wrong coronary sinus, while the remaining causes are less frequently involved (myocarditis, premature coronary atherosclerosis, conduction system abnormalities, and Marfan’s Syndrome). Mechanism of cardiac arrest is usually arrhythmic in origin, with the exception of aortic root rupture in the case of Marfan’s.

Regardless of the exact incidence of sudden death, which apparently would appear not to represent a large social issue, the occurrence of sudden and unexpected death in a young athlete raises a large concern in the lay public and among the physicians. Athletes represent a very special subset of our societies, and they epitomize health and invulnerability, capable as they are of extraordinary physical performances. Indeed, the more famous the athlete dying, the more intense the public concern and the debate regarding the cause of sudden death, and, ultimately, the strategy to prevent sudden death. This large public concern justifies the special attention to this issue by the study group of the European Society of Cardiology.

Medscape: Which young athletes should be screened?

Dr. Pelliccio: The consensus statement suggests that the young “competitive athletes” should be screened, defined as individuals who are 35 years or less, who are regularly engaged in exercise training, and who participate in official athletic competitions. Official competition is defined as an organized team or individual sport event, placing high premium on athletic excellence and achievement and included in the agenda of a national or international athletic association. Characteristics of competitive athletes are their strong inclination to extend themselves to their physical limits and to improve performance.

Medscape: What should screening consist of?

Dr. Pelliccia: The recommended cardiovascular evaluation should consist of complete personal and family history, physical examination with blood pressure measurement, and 12-lead ECG. The inclusion of 12-lead ECG represents the additional value of this screening protocol and is based on the consideration that the ECG offers the potential to detect, or to raise clinical suspicion for, potentially lethal conditions, including HCM, ARVC, dilated cardiomyopathy, myocarditis, long QT syndrome, Lenègre disease, Brugada syndrome, cathecolaminergic ventricular tachycardia, short QT syndrome, and Wolff-Parkinson-White (WPW) syndrome. Based on published series from the U.S. and Italy, these conditions, including HCM, account for up to 60% of sudden deaths in young competitive athletes.

Medscape: How easy or difficult would it be to implement this type of screening program?

Dr. Pelliccia: Strategies for implementing the proposed screening program across Europe depend on the particular socioeconomic and cultural background, as well as on the specific medical system in place in different countries. Therefore, a variety of scenarios are now in place across Europe. In Italy, a systematic preparticipation screening, predominantly based on 12-lead ECG, in addition to history and physical examination, has been in practice for more than 25 years, supported by a legislative action ( Am J Cardiol. 1995;75:827-829). The Italian law mandates that every subject engaged in competitive sports activity must undergo a clinical evaluation and obtain eligibility before entering in competitive sports. This law has largely helped the implementation of a large-scale preparticipation program, which at present involves nearly six million athletes of all ages annually, representing about 10% of the overall Italian population.

Key points for implementation of the program in Italy have also been the large number of medical facilities where athletes are evaluated, ie, sports clinics, which are run on a private basis, but are under the control of the Italian Federation of Sports Medicine, and the appropriate scientific education of the examining physicians. In Italy, physicians responsible for preparticipation screening and eligibility for competitive sports should attend postgraduate residency training programs in sports medicine (and sports cardiology) virtually full-time for four years.

Medscape: What benefits are anticipated from screening in terms of prevention of cardiac events and sudden death, and how cost-effective will this be?

Dr. Pelliccia: It seems reasonable that the screening protocol including ECG will be efficient to identify and reduce the risk of sudden death in athletes with HCM and ARVC, contrary to what occurs in screening without the ECG.

For instance, the screening of U.S. high-school and college athletes, based on medical history and physical examination without ECG, was shown to be lacking in identifying cardiovascular abnormalities increasing risk of sudden death. In a U.S. retrospective study, only 3% of trained athletes who died suddenly of heart disease had been suspected of having cardiovascular abnormalities on the basis of preparticipation screening, and none with HCM was identified during life ( JAMA. 1996;276:199-204).

By comparison, the Italian experience shows that screening was able to identify asymptomatic HCM athletes, and the observation of these HCM athletes during a long-term follow-up suggests that withdrawal from competition has the potential to improve their survival ( N Engl J Med. 1998;339:364-369). Indeed, analysis of the Italian data shows that less than one fourth of young competitive athletes diagnosed with HCM had had a positive family history or an abnormal physical examination. Thus, the majority of them would have not been identified by a screening protocol without 12-lead ECG. The threefold greater number of athletes with HCM, identified by the Italian screening and disqualified from competitive sports, is expected to result in a corresponding additional number of lives saved compared with the American Heart Association strategy.

In addition, 12-lead ECG offers the potential to identify asymptomatic athletes with other conditions presenting with ECG abnormalities such as ARVC/dysplasia (ARVC/D), dilated cardiomyopathy, Lenègre conduction disease, WPW syndrome, long- and short-QT syndromes, and Brugada syndrome. It is noteworthy that a number of these conditions have been discovered only recently, so that diagnosis at preparticipation screening will likely increase over time.

With regard to Italian screening for ARVC/D, Corrado previously reported that over 80% of athletes who died from this disease had ECG changes and/or ventricular arrhythmias. Recently the same investigator compared two decades of screening at the Center for Sport Medicine in Padua and found that the prevalence of athletes with ARVC/D identified and disqualified was significantly greater from 1992 to 2001 compared with the previous decade. A plausible explanation is that ARVC/D is a condition discovered recently — 20 decades ago — and for a long time it has been either underdiagnosed or regarded with skepticism by cardiologists. This suggests that with the increased awareness of clinical findings of ARVC/D, more affectedathletes will be identified by ECG at screening and protected from the risk of athletic competition.

Medscape: Who should pay for the costs of screening?

Dr. Pelliccia: Screening large athletic populations has a significant socioeconomic impact. Italian experience indicates that the proposed screening design is made possible because of the limited cost of 12-lead ECG in the setting of mass screening. The cost of performing a preparticipation cardiac history/physical examination and the 12-lead ECG by a qualified physician is 30 euros (about $40, at present) per athlete. This low cost is dictated by the Italian Federation of Sports Medicine and represents a reasonable compromise between an honorarium for a medical activity and a large mass population to be screened, most of whom are expected to be totally normal. The cost of screening is covered by the athlete or by his athletic team, except for younger athletes aged less than 18 years, for whom the expenses are covered by the National Health System.

Medscape: How applicable do you believe these guidelines will be in the U.S.?

Dr. Pelliccia: Whether this program could be perceived as a priority and worthy to be implemented in the U.S. is uncertain to me; however, the long-term implementation in Italy and recently in a few other European countries suggests that is certainly feasible. Just recently, on Dec. 10, 2004, the International Olympic Committee Medical Commission published a statement entitled “Pre-Participation Cardiovascular Screening,” which addressed specifically the issue of which protocol is recommended for preventive cardiovascular evaluation of competitive athletes. This document states that ECG should be included in this evaluation, in complete agreement with our consensus statement. Thus, it seems there is large agreement, at least in Europe, regarding this issue.

Eur Heart J. Published online Feb. 2, 2005.

Reviewed by Gary D. Vogin, MD

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