Review Recommends Skipping Sudden Cardiac Death Screening in Young Athletes

Patrice Wendling

April 25, 2016

BRUSSELS, BELGIUM — Screening young athletes with physical examination, history taking, and resting ECG to prevent sudden cardiac death (SCD) should be abandoned, according to a new review of the literature[1].

The researchers, led by cardiologist Dr Hans Van Brabandt (Belgian Health Care Knowledge Center, Brussels), conclude that the effectiveness of screening has not been substantiated and that its potential to reduce deaths is likely to be low because of the poor detection rate and uncertain effectiveness of managing cardiovascular diseases in asymptomatic individuals.

"Some people accept that it might be useless, but we go one step further and say that it's even harmful, and this seems to be something new," Van Brabandt told heartwire from Medscape.

The researchers write that 5% of healthy people will be suspected of having cardiovascular disease when screened by an experienced physician, even if the most stringent Seattle criteria for ECG interpretation are applied.

The high number of false positives can lead to anxiety and psychological harm and disqualification from sports, which can have lifelong health consequences, he said. In the seminal and controversial study from the Veneto region of Italy, 2%, or 20,000 of the one million people screened, were ultimately disqualified from participating in competitive sports.

If diagnosed with hypertrophic cardiomyopathy (HCM), the most common reason for SCD, there is no consensus on how to manage the asymptomatic patient. Moreover, most people with asymptomatic HCM can reach an age of 70 or 90 years without any problems, and more than 70% who die suddenly are dying at rest, Van Brabandt said, "So disqualification from competitive sports will be of no help."

For athletes diagnosed with Wolff-Parkinson-White Syndrome, the most often detected anomaly on screening, he said the risk of SCD is about 1:10,000 patients, or roughly the same as the risk of dying from the cure, catheter ablation of the accessory pathway.

"As long as those at high risk of sudden death cannot reliably be identified and appropriately managed, young athletes should not be submitted to preparticipation screening," according to the review, published April 20, 2016 in the BMJ.

Not All Athletes Are the Same

Asked to comment, Dr Jonathan Drezner (University of Washington, Seattle) told heartwire , "I feel that honestly this paper should have been written a decade ago. It uses an old perspective and old data and really brings nothing new to the table."

He argues that the authors rely too heavily on studies that use media reports and catastrophic insurance claims like those previously reported from Minnesota high school students in claiming a very low SCD incidence and rely on a very high false-positive rate, implying that 30% of athletes would require unnecessary investigations. Studies that use mandatory reporting systems like that in Italy or the US military or robust data like that from the National Collegiate Athletic Association (NCAA) report much higher incidence rates that are relatively consistent.

"Why this paper is so outdated is that it tries to group all athletes as the same entity," Drezner said. For instance, male college basketball players have been repeatedly shown to have the highest SCD risk at about 1:5000 for any division 1 player and 1:4000 for an African American player. That's dramatically different from the 1:200,000 number cited in the review, which may be the risk for a female high school athlete, he said.

The addition of ECG, while still imperfect, will increase detection and can be done with a low false-positive rate and high quality when proper infrastructure and skilled cardiology resources are available, said Drezner.

"At least in the sports-medicine community, people who advocate for ECG are not advocating for mandates, we're not advocating for universal screening, we're advocating for better education and the development of infrastructure to try to prevent sudden death," he said.

Infrastructure Is Missing

Widespread ECG screening is conspicuously absent from a new interassociation consensus statement on cardiovascular evaluation and care of college athletes by a multidisciplinary task force that was convened by the NCAA with involvement from several medical organizations, including the American College of Cardiology (ACC), American Heart Association (AHA), and American College of Sports Medicine, and recently published in the Journal of the American College of Cardiology[2].

Task-group leader Dr Brian Hainline (Sports Science Institute, NCAA, Indianapolis, IN) explained to heartwire that the document provides a pathway for institutions that screen with ECG, but that gaps in knowledge and infrastructure kept the group from making a universal ECG recommendation.

Not only are there very few sports cardiologists in the US, but even where there are, the literature base shows a "wide degree of disagreement in terms of sports cardiologists interpreting elite athletes' ECGs, which some say are abnormal and some say are normal," he said. As a result, one person may recommend putting in a ventricular defibrillator, another cardiac catheterization, another no play, and still another play under any circumstances.

At the school level, the infrastructure base varies widely among the 1100 NCAA member institutions, many of which are in rural areas and have a team physician but don't have a sports cardiologist within 100 miles. Others have a cluster of sports cardiologists within a mile of the school, he said.

The document, which was more than a year in the making, recommends the creation of regional referral centers so all athletes suspected or known to have a cardiovascular problem can have access to a top sport cardiologist, "but these are things that are probably going to take 2 or 3 years to develop," Hainline said.

The document recommends the AHA 14-element history and physical evaluation for all college athletes and also focuses on what Hainline described as "low-hanging fruit," the creation of an emergency action plan by all NCAA member schools for athletes with a cardiac emergency. The plan should be written and address appropriate training in CPR and AED use, rapid and coordinated communication, easy access to AEDs, and predetermined emergency medical routes.

Where Do We Go From Here?

At the community level, training in CPR for everyone, especially coaches and players, coupled with availability of AEDs at all sporting events "will provide the best possible chance of survival after a cardiac arrest," Dr Christopher Semsarian and Dr Jodie Ingles (Centenary Institute, Newtown, Australia) write in an editorial accompanying the literature review[3].

Raising awareness among primary-care doctors is also particularly important in preventing SCD in athletes, as recognition of unexplained syncope or a family history of CVD or sudden death may trigger referral to a cardiologist for further assessment.

With regard to screening, Semsarian and Ingles write, "When compared with accepted criteria for a good screening tool, the 12-lead ECG looks limited" because SCD is very rare among athletes, large populations need to be screened, false-positive rates are relatively high, and cost/benefit analyses suggest that 33,000 athletes would need to be screened to save one life at a cost of $1.32 million.

The editorialists join Van Brabandt and his colleagues in calling for more robust and open sharing of SCD data. An important first step would be a detailed independent review of the Veneto, Italy data, which reported an 89% decrease in the annual incidence of SCD in athletes by 2004 after mandatory screening with 12-lead ECG was introduced in Italy in 1979, while SCD was unchanged in the unscreened general population. Van Brabandt and researchers in the UK have been unsuccessful in their demands for release of data collected before 1979 and after 2004.

The decline in SCD may reflect improvements in resuscitation or simply the growing number of female athletes, Van Brabandt said. The high incidence at the start of the study (3.6:100,000 person-years) was also calculated on just 14 cases and might represent mere random variation.

"We cannot overestimate the influence of the Italian data," he said, adding that the data are increasingly taken as proving a causal relationship and that a randomized controlled trial of SCD is unlikely at this point.

The authors and editorialists report no relevant financial disclosures, as does Drezner.

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