Screening the Hearts of Athletes:  Is the Italian approach the way to go? Reviewed by Elizabeth Klodas, MD, FACC December 18, 2008--Undiagnosed heart disease can be associated with tragic outcomes. Among athletes, sudden death during athletic competition may be the first indication of an underlying heart problem.  Overall, the risk of sudden cardiac death (SCD) in young individuals is low, reported as affecting less than 1 in 100,000 participants per year in the United States.  However, because such events are often dramatic and devastating, identifying those athletes at risk remains a priority for the medical community.

There are different philosophies regarding what constitutes appropriate pre-participation screening for young athletes. Any screening approach needs to balance cost, accuracy, and practicality.  Avoiding the erroneous exclusion of athletes from competition is also important, given the potential downstream effects on the athlete’s life.  There is currently no unified approach to pre-participation screening, with different communities creating local standards.

Heart diseases that place athletes at risk of SCD include hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, dilated cardiomyopathy, myocarditis, long-QT syndrome, Brugada syndrome, Lenègre disease, short-QT syndrome, pre-excitation syndrome (Wolff-Parkinson-White syndrome), coronary artery disease, and coronary artery anomalies.   Many of these disorders are associated with characteristic (though not necessarily specific) findings on the electrocardiogram (ECG).

In a screening program started in Italy in 1982, all young competitive athletes undergo ECG testing in addition to history and physical examination.  Specialized sports physicians are responsible for athlete ECG interpretation. Such physicians attend post-graduate residency training in sports medicine and sports cardiology full-time for 4 years, and work in medical centers devoted to screening athletes.  Athletes with suspicious ECG findings or abnormal history/physical results are referred for further testing (usually an echocardiogram). 

Since the program commenced, SCD incidence has decreased dramatically in Italy.  The literature cites an 89% decrease from 3.6/100,000 athletes/year (in 1979 to 1981) to 0.4/100,000 athletes/year after institution of this more comprehensive screening program. 

However, nearly 2% of Italian athletes have been disqualified from participation as a result of this screening – a relatively high number - and it is not clear whether similar SCD reductions could be realized elsewhere in the world (as it is not known whether the population in Italy is representative of populations in other countries).  Furthermore, performing an ECG on every young athlete in America would result in costs in the hundreds of thousands or even millions of dollars.  And the legal implications of disqualification are not insignificant.

And so the debate continues.  In the United States, routine ECG evaluations are generally not performed on young athletes.  If your child needs to undergo pre-participation screening, discussing the advisability of ECG testing should be undertaken with your child’s physician.

Sources:

Corrado D, Basso C; Schiavon M, Pelliccia A, Thiene G. Pre-Participation Screening of Young Competitive Athletes for Prevention of Sudden Cardiac Death, Journal of American College of Cardiology, 2008; 52:1981-1989