Screening Does Not Reduce Sudden Death in Young Athletes

March 07, 2011

March 7, 2011 (Tel-Aviv, Israel) — A mandatory screening program of athletes that involves an electrocardiogram (ECG) before participating in sports does not reduce the incidence of sudden death, according to a new analysis [1]. The new data, from Israel, where a mandatory medical screening program has been in place since 1997, show that the incidence of sudden death or cardiac arrest did not decline with the introduction of the preparticipation screening protocol, report investigators.

From 1985 to 2009, there were 24 documented cases of sudden death or cardiac arrest among competitive athletes, with 11 cases occurring prior to 1997 when the Israel Sport Regulations on Athletes Medical Testing was enacted, and 13 events occurring after the legislation. During this time, the average yearly incidence was 2.6 events per 100 000 athlete-years, a rate that was nearly identical in the decade before and after the mandatory medical screening was put in place.

Published in the March 15, 2011 issue of the Journal of the American College of Cardiology, the study results highlight a widely debated topic in cardiovascular screening--the mandatory preparticipation screening of athletes engaging in competitive sports. Some countries have adopted mandatory ECG screening, most notably Italy in 1982, and the current guidelines from the European Society of Cardiology (ESC) advocate mandatory ECG screening, although not everybody supports such measures.

"There is an ethical issue about whether screening should be mandatory," Dr Sami Viskin (Tel-Aviv University, Israel), the senior investigator of the Israeli analysis, told heartwire . "The evidence showing that colonoscopy reduces death from colon cancer is larger by several orders of magnitude than the evidence showing that screening does anything for athletes, but I don't know if society would tolerate a law mandating that everybody must undergo a colonoscopy once they're over the age of 50. Mandatory ECG screening is performed in pilots and in soldiers, but here we have a population of people who want to play sports, most for fun, some for a living, and we're forcing them to undergo a test that will affect their lives. The question is whether screening should be mandatory when there is limited proof supporting it."

Paternalism and False Positives

Most organizations and agencies recommend that young athletes should be screened prior to participating in sports, but the consensus stops there. The current screening guidelines for individuals participating in sports differ from organization to organization, with the American College of Cardiology and the American Heart Association, for example, limiting screening to a physical examination and medical history. The ESC and International Olympic Committee, on the other hand, recommend resting 12-lead ECG to detect cardiac abnormalities.

Speaking with heartwire , Viskin said the investigators conducted the analysis in light of recent debates about the merits of preventive strategies that use resting and exercise ECGs to determine whether young athletes should participate in sports. In contrast with the Italian studies, which assessed the effectiveness of the ECG screening program by comparing rates of sudden death in the two years before the program was implemented with mortality rates two decades after it was implemented, Viskin and colleagues compared the incidence of sudden death or cardiac arrest in the 10 years before and after the legislation was enacted. This, said Viskin, helps to avoid random variations in the data, most notably in that there tend to be a number of high-profile deaths preceding any legislation, which can skew the data.

Overall, the incidence of sudden death or cardiac arrest was 2.6 events per 100 000 athlete years. Prior to mandatory ECG screening, the incidence was 2.54 events per 100 000 athlete-years, while it was 2.66 events per 100 000 athlete-years in the decade following legislation (p=0.88). The data challenge the benefits of screening observed in Italy and are in line with results observed in Denmark and Minnesota, said Viskin.

"The chances of really making a big difference with screening are very small," said Viskin. "The issue is that sudden death in athletes is very rare and abnormalities in the electrocardiogram are very common, so the ratio between the false positives and true positives is very large."

High Costs and Other Roadblocks

When a young athlete dies, the family, public, and media are often mystified, and the death generates a lot of public attention. The most recent example is the tragic case of Wes Leonard, a 16-year-old basketball player from Fennville, MI, who collapsed last week on the court after scoring the game-winning basket in overtime and later died at the hospital. Media reports are suggesting he died of dilated cardiomyopathy.

"Every time an athlete dies, it generates a lot of consternation and it generates a lot of, 'Oh my, what could we have done?' " Dr Benjamin Levine (University of Texas Southwestern Medical Center, Dallas), an expert in cardiovascular screening of athletes, told heartwire .

Levine, who was not affiliated with the Israeli study, said the biggest killers of young athletes are accidents and trauma and that if the US is serious about reducing student-athlete deaths more money should be spent on safeguarding transportation or banning alcohol from campuses. He notes that motor-vehicle accidents kill one in 84 individuals and accidental firearm discharge kills one in 5000. Best estimates suggest sudden death kills one in 250 000 young athletes.

"It would be hard for me to sit here and argue against ECG screening for a single individual--the chance of picking up underlying heart disease is better with an ECG than without it," Levine told heartwire . "That's the argument proponents of the ECG make--namely, that family history and a physical doesn't pick up all that much. We know that an ECG has better screening potential. What we don't know, and what I'm concerned about, are the long-term implications of that process."

High Costs of Screening

One of those implications would be the possibility of indefinitely benching a young asymptomatic athlete who has an abnormality picked up by screening, or worse, the possibility of sidelining athletes with false-positive results. In addition, screening would subject individuals to long-term therapies associated with significant morbidity, such as an implantable cardioverter defibrillator (ICD).

In an editorial accompanying the published study [2], Dr Alfred Bove (Temple University School of Medicine, Philadelphia, PA) notes that cardiologists who evaluate athletes "should be familiar with the normal variants in echocardiography and ECG results and should incorporate the 12 questions posed by the American Heart Association for screening, so that young athletes are not disqualified based on variant ECG results or normal cardiac adaptations to exercise."

Not surprisingly, there is also the issue of cost. An AHA panel estimated the cost of a mandatory ECG screening program to be in the neighborhood of $2 billion. "In the grand scheme of things, you have to decide how you're going to spend your limited healthcare resources and what you are going to try to prevent," said Levine.

To heartwire , Viskin said that it's unlikely the Israeli mandatory screening program will be changed, despite the data showing it is not reducing the incidence of sudden death. Preventing deaths requires more effort than simply identifying the at-risk athletes.

"To be able to prevent the sudden death of one athlete, first of all, you have to be able to detect [the underlying cardiac abnormality]," said Viskin. "Once you detect it, and you tell them to stop playing sports, they might not necessarily stop. Instead of exercising in the protective environment of a team, they might go into another sport or start training on their own, where they'll be even less protected. Also, there is no guarantee that if you stop them from playing sports they'll not die from the disease they have anyway."

The authors report no conflicts of interest.

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