COMMENTARY

Sudden Cardiac Death in Teen Athletes: Does Screening Make a Difference?

William T. Basco, Jr., MD, MS

Disclosures

October 16, 2018

Sudden Cardiac Death in Soccer Players

Reliable estimates of the incidence of sudden cardiac death in young athletes are hard to come by. Malhotra and colleagues[1] analyzed 10 years' worth of data (1996-2016) from a long-term UK screening program involving more than 11,000 soccer-playing adolescents aged 15-17 years.

The athletes completed a questionnaire, physical examination, 12-lead electrocardiography (ECG), and echocardiography as part of baseline screening for participation in club soccer. All of the tests were interpreted by regional cardiologists. After that initial evaluation, the athletes were classified into one of three groups:

  • Normal;

  • Needs further evaluation; or

  • Cardiac disease detected.

Any athletes requiring further evaluation were seen regionally. Certain abnormalities led to stress testing, Holter monitoring, and even MRI.

Several disorders are known to be associated with sudden cardiac death, including hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, and Wolff-Parkinson-White syndrome. If one of these cardiac disorders was found, the athlete was advised not to compete.

The primary outcome of interest—death—was either through voluntary reporting to the English football authority or by retrospective surveys completed by healthcare professionals to try to capture any deaths. When a potential death was identified, the investigators obtained the death certificate from the government and completed an additional medical record review.

Screening was conducted on 11,168 players with a mean age of 16.4 years. Only 7% (830) of the athletes initially screened required further investigation. Of those, 287 had no abnormality after completion of the in-depth evaluation.

A disorder associated with sudden cardiac death was diagnosed in 42 athletes, 26 of whom had Wolff-Parkinson-White syndrome and five of whom had hypertrophic cardiomyopathy. Eight adolescents died from cardiac-related disease, but in only two cases did the initial screening evaluation detect the condition. The remaining six adolescents died from cardiac-related causes that had not been detected by the initial or the follow-up evaluation. During the same period, 23 athletes died from all other causes.

Among athletes in this study, the rate of sudden cardiac death was 1 in every 14,800 person-years, corresponding to 6.8 per 100,000 athletes. Overall, the screening program identified diseases associated with sudden cardiac death in 0.38% of the athletes. Among the eight deaths, six athletes (75%) had received normal screening evaluation results.

Viewpoint

This is a really tough one. Current recommendations do not suggest universal ECG screening, but provide targeted questions to help practitioners decide who might benefit from screening.[2] The fact that most of the sudden cardiac deaths in this study occurred in athletes who had received a normal preliminary evaluation, coupled with the very low death rate, certainly could support the argument that routine cardiac evaluation beyond history and physical is not appropriate. However, two of the five athletes whose cardiomyopathy was detected by screening died during the follow-up period, having participated in soccer despite warnings to the contrary. So for a very small number of these screened athletes, the findings of screening can be critical. This report exposes the magnitude of the "needle in the haystack" problem, and may help providers and parents make an informed discussion.

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