Contemporary approaches to the identification of athletes at risk for sudden cardiac death

Accuracy of the "International Criteria" for ECG screening in athletes in comparison with previous published criteria: rationale and design of a diagnostic meta-analysis

INTRODUCTION

The impact of the International Criteria for ECG interpretation in athletes has further improved the diagnostic accuracy of the 12-lead ECG use for preparticipation screening (PPS); moreover, these criteria have been evaluated in different populations of athletes and settings proving good results.

EVIDENCE ACQUISITION

We aimed to perform a comprehensive review of the use of the International Criteria for ECG interpretation in athletes, stemming from a systematic review to diagnostic meta-analysis, limiting our inclusion only to observational studies to determine the diagnostic accuracy of ECG for detecting cardiac anomalies related to sudden cardiac death in athletes.

EVIDENCE SYNTHESIS

This meta-analysis is expected to include several important studies related to PPS on different populations of athletes comparing different ECG criteria and detail important data on the diagnostic accuracy of ECG in PPS. Furthermore, we intend to highlight the advantage of using ECG in PPS.

CONCLUSIONS

The present diagnostic meta-analysis results will aid sports medicine physicians and cardiologist in adhering to the most accurate criteria for ECG evaluation in athletes and it may help to solve controversies aroused regarding the excess cost of ECG in PPS related to the amount of false positive cases.

N-terminal pro-brain natriuretic peptide and sudden cardiac death in hypertrophic cardiomyopathy

OBJECTIVE

Elevated levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) are associated with heart failure-related death in hypertrophic cardiomyopathy (HCM), but the relationship between NT-proBNP level and sudden cardiac death (SCD) in HCM remains undefined.

METHODS

The study prospectively enrolled 977 unrelated patients with HCM with available NT-proBNP results who were prospectively enrolled and followed for 3.0±2.1 years. The Harrell's C-statistic under the receiver operating characteristic curve was calculated to evaluate discrimination performance. A combination model was constructed by adding NT-proBNP tertiles to the HCM Risk-SCD model. The correlation between log NT-proBNP level and cardiac fibrosis as measured by late gadolinium enhancement (LGE) or Masson's staining was analysed.

RESULTS

During follow-up, 29 patients had SCD. Increased log NT-proBNP levels were associated with an increased risk of SCD events (adjusted HR 22.27, 95% CI 10.93 to 65.63, p<0.001). The C-statistic of NT-proBNP in predicting SCD events was 0.80 (p<0.001). The combined model significantly improved the predictive efficiency of the HCM Risk-SCD model from 0.72 to 0.81 (p<0.05), with a relative integrated discrimination improvement of 0.002 (p<0.001) and net reclassification improvement of 0.67 (p<0.001). Furthermore, log NT-proBNP levels were significantly correlated with cardiac fibrosis as detected either by LGE (r=0.257, p<0.001) or by Masson's trichrome staining in the myocardium (r=0.198, p<0.05).

CONCLUSION

NT-proBNP is an independent predictor of SCD in patients with HCM and may help with risk stratification of this disease.

Comparison of cardiovascular screening in college athletes by history and physical examination with and without an electrocardiogram: Efficacy and cost

BACKGROUND

Preparticipation screening for conditions associated with sudden cardiac death (SCD) is required in college athletes. Previous cost analyses used theoretical models based on variable assumptions, but no study used real-life outcomes.

OBJECTIVE

The purpose of this study was to compare disease prevalence, positive findings, and costs of 2 different screening strategies: history and physical examination alone (H&P) or with an electrocardiogram (H&P+ECG).

METHODS

De-identified preparticipation data (2009-2017) from Pacific-12 Conference institutions were abstracted for cardiovascular history questions, cardiovascular physical examination, and ECG result. Secondary testing, cardiac diagnoses, return to play outcomes, and complications from testing were recorded. The costs of screening and secondary testing were based on the Centers for Medicare & Medicaid Services Physician Fee Schedule.

RESULTS

A total of 8602 records (4955 H&P, 3647 H&P+ECG) were included. Eleven conditions associated with SCD were detected (2 H&P only, 9 H&P+ECG). The prevalence of cardiovascular conditions associated with SCD discovered with H&P alone was 0.04% (1/2454) compared to 0.24% (1/410) when ECG was added (P = .01) (odds ratio 5.17; 95% confidence interval 1.28-20.85; P = .02). Cost of screening and secondary testing with H&P alone was $130 per athlete and in the ECG-added group was $152 per athlete. The cost per diagnosis was $312,407 in the H&P group and $61,712 in the ECG-added group. There were no adverse outcomes from secondary testing or treatment.

CONCLUSION

H&P with the addition of ECG is 6 times more likely to detect a cardiovascular condition associated with SCD than without. The addition of ECG improves the cost efficiency per diagnosis by 5-fold and should be considered at college institutions with appropriate resources.

Cardiac screening to prevent sudden death in young athletes

Sudden cardiac death (SCD) is a sudden and unexpected death caused by loss of heart of function. SCD may occur in any population, but when it occurs on the playing field in a young individual, communities worldwide are affected. Although these events are rare, media coverage of sudden cardiac arrests in young athletes have created the impression that these events are far more common than they appear. With a heightened awareness of SCD in young athletes, screening methods have been developed to try and prevent these events from occurring. The American Heart Associations (AHA) currently employs history and physical examination alone during the preparticipation physical exam (PPE), which clears a young athlete for participation in sports. There has been recent discussion on whether to include screening electrocardiogram (ECG) in the PPE especially after one study in Italy by Corrado et al. found that using routine ECG reduced the annual incidence of SCD by 90%. In this article we will discuss how effective the current screening recommendations are, whether routine ECG use should be included in the PPE and if it is cost effective, and review other screening modalities that may be useful in the detection of young athletes at risk for SCD.

Death in Community Australian Football: A Ten Year National Insurance Claims Report

While deaths are thought to be rare in community Australian sport, there is no systematic reporting so the frequency and leading causes of death is unknown. The aim of this study was to describe the frequency and cause of deaths associated with community-level Australian Football (AF), based on insurance-claims records. Retrospective review of prospectively collected insurance-claims for death in relation to community-level AF activities Australia-wide from 2004 to 2013. Eligible participants were aged 15+ years, involved in an Australian football club as players, coaches, umpires or supporting roles. Details were extracted for: year of death, level of play, age, sex, anatomical location of injury, and a descriptive narrative of the event. Descriptive data are presented for frequency of cases by subgroups. From 26,749 insurance-claims relating to AF, 31 cases were in relation to a death. All fatalities were in males. The initial event occurred during on-field activities of players (football matches or training) in 16 cases. The remainder occurred to people outside of on-field football activity (n = 8), or non-players (n = 7). Road trauma (n = 8) and cardiac conditions (n = 7) were the leading identifiable causes, with unconfirmed and other causes (including collapsed or not yet determined) comprising 16 cases. Although rare, fatalities do occur in community AF to both players and people in supporting roles, averaging 3 per year in this setting alone. A systematic, comprehensive approach to data collection is urgently required to better understand the risk and causes of death in participants of AF and other sports.

Survival from sports-related sudden cardiac arrest: In sports facilities versus outside of sports facilities

BACKGROUND

We sought to evaluate frequency, characteristics, and outcomes of sudden cardiac arrest (SCA) during sports activities according to the location of occurrence (in sports facilities vs those occurring outside of sports facilities).

METHODS AND RESULTS

This is an observational 5-year prospective national French survey of subjects 10 to 75 years old presenting with SCA during sports (2005-2010), in 60 French administrative regions (covering a population of 35 million people). Of the 820 SCA during sports, 426 SCAs (52%) occurred in sports facilities. Overall, a substantially higher survival rate at hospital discharge was observed among SCA in sports facilities (22.8%, 95% CI 18.8-26.8) compared to those occurring outside (8.0%, 95% CI 5.3-10.7) (P < .0001). Patients with SCA in sports facilities were younger (42.1 vs 51.3 years, P < .0001) and less frequently had known cardiovascular diseases (P < .0001). The events were more often witnessed (99.8% vs 84.9%, 0.0001), and bystander cardiopulmonary resuscitation was more frequently initiated (35.4% vs 25.9%, P = .003). Delays of intervention were significantly shorter when SCA occurred in sports facilities (9.3 vs 13.6, P=0.03), and the proportion of initially shockable rhythm was higher (58.8% vs 33.1%, P < .0001). Better survival in sports facilities was mainly explained by concomitant circumstances of occurrence (adjusted odds ratio 1.48, 95% CI 0.88-2.49, P = .134).

CONCLUSIONS

Sports-related SCA is not a homogeneous entity. The 3-fold higher survival rate reported among sports-related SCA is mainly due to cases that occur in sports facilities, whereas SCA during sports occurring outside of sports facilities has the usual very low rate of survival.

Sudden cardiac arrest during sports activity in middle age

BACKGROUND

Sports-associated sudden cardiac arrests (SCAs) occur mostly during middle age. We sought to determine the burden, characteristics, and outcomes of SCA during sports among middle-aged residents of a large US community.

METHODS AND RESULTS

Patients with SCA who were 35 to 65 years of age were identified in a large, prospective, population-based study (2002-2013), with systematic and comprehensive assessment of their lifetime medical history. Of the 1247 SCA cases, 63 (5%) occurred during sports activities at a mean age of 51.1±8.8 years, yielding an incidence of 21.7 (95% confidence interval, 8.1-35.4) per 1 million per year. The incidence varied significantly by sex, with a higher incidence among men (relative risk, 18.68; 95% confidence interval, 2.50-139.56) for sports SCAs compared with all other SCAs (relative risk 2.58; 95% confidence interval, 2.12-3.13). Sports SCA was also more likely to be a witnessed event (87% versus 53%; P<0.001) with cardiopulmonary resuscitation (44% versus 25%; P=0.001) and ventricular fibrillation (84% versus 51%; P<0.0001). Survival to hospital discharge was higher for sports-associated SCA (23.2% versus 13.6%; P=0.04). Sports SCA cases presented with known preexisting cardiac disease in 16% and ≥1 cardiovascular risk factors in 56%, and overall, 36% of cases had typical cardiovascular symptoms during the week preceding the SCA.

CONCLUSIONS

Sports-associated SCA in middle age represents a relatively small proportion of the overall SCA burden, reinforcing the idea of the high-benefit, low-risk nature of sports activity. Especially in light of current population aging trends, our findings emphasize that targeted education could maximize both safety and acceptance of sports activity in the older athlete.

Modern standards of ECG interpretation in young athletes: yield and effectiveness

Although cardiovascular screening is recommended before participating in competitive sports, the role of the 12-lead electrocardiogram (ECG) has been debated. When added to the medical history and physical examination, an ECG used during the pre-participation screening (PPS) of young athletes can greatly enhance the ability to detect underlying cardiovascular pathology. Concerns over false positive rates, however, have posed an obstacle to large-scale implementation. The recent development of modern athlete-specific ECG interpretation criteria has dramatically reduced false positive rates to levels below other commonly used screening tests (e.g. breast cancer, prostate cancer) and subsequently improved cost effectiveness. There are also emerging data that certain sub-groups have a higher prevalence of ECG abnormalities, including males, athletes of Afro-Caribbean descent, basketball players, and endurance athletes. While false positive rates from a number of studies are reduced with the improved standards, there may be room for continued improvements. Future efforts should focus on refining criteria based on age, race, gender, ethnicity, and sport, while also clearly delineating the appropriate work-up strategies for those with abnormal findings, as this can lead to improved resource utilization.

Row for your life: a century of mortality follow-up of French olympic rowers

BACKGROUND/AIM

Strenuous endurance training required to participate in the highest sports level has been associated with deleterious effects on elite athletes' health and cardiac abnormalities. We aimed to describe overall mortality and main causes of deaths of male French rowers participating in at least one Olympic Game (OG) from 1912 to 2012 in comparison with the French general population.

METHODS

Identity information and vital status of French Olympic rowers were validated by National sources from 1912 to 2013 (study's endpoint) among 203 rowers; 52 out of 255 (20.3%) were excluded because their vital statuses could not be confirmed. Main causes of deaths were obtained from the National registry from 1968 up to 2012. Overall and disease-specific mortalities were calculated through standardised mortality ratios (SMRs) with its 95% confidence intervals (CIs). The overall mortality was calculated for the whole rowers' cohort (PT) and for two periods apart: (P1) including rowers from 1912 to 1936 OG, a cohort in which all rowers have deceased and (P2) considering rowers from 1948 to 2012 OG.

RESULTS

Among the 203 rowers analysed, 46 died before the study's endpoint, mainly from neoplasms (33%), cardiovascular diseases (21%) and external causes (18%). PT demonstrates a significant 42% lower overall mortality (SMR: 0.58, 95% CI: 0.43-0.78, p<0.001), P1 a 37% reduction (SMR: 0.63, 95% CI: 0.43-0.89, p = 0.009) and P2 a 60% reduction (SMR: 0.40, 95% CI: 0.23-0.65, p<0.001) compared with their compatriots. Mortality due to cardiovascular diseases is significantly reduced (SMR: 0.41, 95% CI: 0.16-0.84, p = 0.01) among rowers.

CONCLUSIONS

French Olympic rowers benefit of lower overall mortality compared with the French general population. Among rowers' main causes of death, cardiovascular diseases are reduced in relation to their compatriots. Analytical studies with larger samples are needed to understand the reasons for such reductions.

Pathogeneses of Sudden Cardiac Death in National Collegiate Athletic Association Athletes

Background—

The pathogenesis of sudden cardiac death in college athletes has not been defined by systematic case identification.

Methods and Results—

A total of 45 cases of sudden cardiac death were identified in National Collegiate Athletic Association (NCAA) athletes from 2004 to 2008 based on an internal reporting system and review of media reports. Autopsy reports were reviewed and adjudicated by a multidisciplinary panel. Cause of death could be reasonably determined in 36 cases; 3 athletes had no autopsy, 5 autopsy reports could not be obtained, and 1 autopsy had insufficient information to determine cause of death. The most common finding at death was a structurally normal heart or autopsy-negative sudden unexplained death (11, 31%), followed by coronary artery abnormalities (5, 14%), dilated cardiomyopathy (3, 8%), myocarditis related (3, 8%), aortic dissection (3, 8%), and idiopathic left ventricular hypertrophy/possible hypertrophic cardiomyopathy (HCM; 3, 8%). There was 1 case each (3%) of hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, commotio cordis, and Kawasaki disease. There was 1 case of death in a sickle cell positive athlete who also had left ventricular hypertrophy. The adjudicated diagnosis agreed with the official pathology report in only 59% of cases.

Conclusions—

Unexplained death with a structurally normal heart is the most common finding after suspected sudden cardiac death in NCAA athletes. Hypertrophic cardiomyopathy is infrequently seen, and conclusions in autopsy reports may not accurately reflect the pathological findings. Standardized protocols for cardiovascular autopsies in athletes are needed, including postmortem genetic testing, particularly in autopsy-negative cases.

Characteristics and Outcomes of Sudden Cardiac Arrest During Sports in Women

Background—

No specific data are available on characteristics and outcome of sudden cardiac death (SCD) during sport activities among women in the general population.

Methods and Results—

From a prospective 5-year national survey, involving 820 subjects 10 to 75 years old who presented with SCD (resuscitated or not) during competitive or recreational sport activities, 43 (5.2%) such events occurred in women, principally during jogging, cycling, and swimming. The level of activity at the time of SCD was moderate to vigorous in 35 cases (81.4%). The overall incidence of sport-related SCD, among 15- to 75-year-old women, was estimated as 0.59 (95% confidence interval [CI], 0.39–0.79) to 2.17 (95% CI, 1.38–2.96) per year per million female sports participants for the 80th and 20th percentiles of reporting districts, respectively. Compared with men, the incidence of SCDs in women was dramatically lower, particularly in the 45- to 54-year range (relative risk, 0.033; 95% CI, 0.015–0.075). Despite similar circumstances of occurrence, survival at hospital admission (46.5%; 95% CI, 31.0–60.0) was significantly higher than that for men (30.0%; 95% CI, 26.8–33.2; P =0.02), although this did not reach statistical significance for hospital discharge. Favorable neurological outcomes were similar (80%). Cause of death seemed less likely to be associated with structural heart disease in women compared with men (58.3% versus 95.8%; P =0.003).

Conclusions—

Sports-related SCDs in women participants seems dramatically less common (up to 30-fold less frequent) compared with men. Our results also suggest a higher likelihood of successful resuscitation as well as less frequency of structural heart disease in women compared with men.

Mortality of French participants in the Tour de France (1947-2012)

AIMS

In the context of recent concerns regarding performance enhancing techniques and potential negative health effects of high-level physical activity, data on the long-term outcomes and causes of death in elite endurance cyclists are of particular interest.

METHODS AND RESULTS

Characteristics and vital status of all French participants in the Tour de France were collected for the 1947-2012 period. Causes of death were obtained from 1968. Overall and disease-specific mortalities were compared with the French male population using overall and specific standardized mortality ratios (SMRs) with their 95% confidence intervals (CIs). Among the 786 French cyclists who participated at least once between 1947 and 2012, 208 (26%) died by 1 September 2012. Neoplasms and cardiovascular diseases accounted for 61% of deaths. We observed a 41% lower mortality in French cyclists (SMR: 0.59, 95% CI: 0.51-0.68, P < 0.0001), which did not change over time (P = 0.70). It was observed for main mortality causes: for neoplasms (SMR: 0.56; 95% CI: 0.42-0.72, P < 0.0001) and for cardiovascular death (SMR: 0.67; 95% CI: 0.50-0.88, P = 0.004), except mortality related to external causes (SMR: 1.06, 95% CI: 0.71-1.53, P = 0.80).

CONCLUSION

We observed a substantially and significantly lower mortality in participants in the Tour de France, compared with the general male population. However, our results do not allow us to assess in detail the balance between positive effects of high-level sports activity and selection of healthy elite athletes, vs. any potential deleterious effects of excessive physical exercise or alleged doping.

Exercise acts as a drug; the pharmacological benefits of exercise

The beneficial effects of regular exercise for the promotion of health and cure of diseases have been clearly shown. In this review, we would like to postulate the idea that exercise can be considered as a drug. Exercise causes a myriad of beneficial effects for health, including the promotion of health and lifespan, and these are reviewed in the first section of this paper. Then we deal with the dosing of exercise. As with many drugs, dosing is extremely important to get the beneficial effects of exercise. To this end, the organism adapts to exercise. We review the molecular signalling pathways involved in these adaptations because understanding them is of great importance to be able to prescribe exercise in an appropriate manner. Special attention must be paid to the psychological effects of exercise. These are so powerful that we would like to propose that exercise may be considered as a psychoactive drug. In moderate doses, it causes very pronounced relaxing effects on the majority of the population, but some persons may even become addicted to exercise. Finally, there may be some contraindications to exercise that arise when people are severely ill, and these are described in the final section of the review. Our general conclusion is that exercise is so effective that it should be considered as a drug, but that more attention should be paid to the dosing and to individual variations between patients.

Rate of cardiac arrhythmias and silent brain lesions in experienced marathon runners: rationale, design and baseline data of the Berlin Beat of Running study

Background

Regular exercise is beneficial for cardiovascular health but a recent meta-analysis indicated a relationship between extensive endurance sport and a higher risk of atrial fibrillation, an independent risk factor for stroke. However, data on the frequency of cardiac arrhythmias or (clinically silent) brain lesions during and after marathon running are missing.

Methods/ Design

In the prospective observational “Berlin Beat of Running” study experienced endurance athletes underwent clinical examination (CE), 3 Tesla brain magnetic resonance imaging (MRI), carotid ultrasound imaging (CUI) and serial blood sampling (BS) within 2-3 days prior (CE, MRI, CUI, BS), directly after (CE, BS) and within 2 days after (CE, MRI, BS) the 38^th BMW BERLIN-MARATHON 2011. All participants wore a portable electrocardiogram (ECG)-recorder throughout the 4 to 5 days baseline study period. Participants with pathological MRI findings after the marathon, troponin elevations or detected cardiac arrhythmias will be asked to undergo cardiac MRI to rule out structural abnormalities. A follow-up is scheduled after one year.

Results

Here we report the baseline data of the enrolled 110 athletes aged 36-61 years. Their mean age was 48.8 ± 6.0 years, 24.5% were female, 8.2% had hypertension and 2.7% had hyperlipidaemia. Participants have attended a mean of 7.5 ± 6.6 marathon races within the last 5 years and a mean of 16 ± 36 marathon races in total. Their weekly running distance prior to the 38^th BMW BERLIN-MARATHON was 65 ± 17 km. Finally, 108 (98.2%) Berlin Beat-Study participants successfully completed the 38^th BMW BERLIN-MARATHON 2011.

Discussion

Findings from the “Berlin Beats of Running” study will help to balance the benefits and risks of extensive endurance sport. ECG-recording during the marathon might contribute to identify athletes at risk for cardiovascular events. MRI results will give new insights into the link between physical stress and brain damage.

Trial registration

clinicaltrials.gov NCT01428778

Economic evaluation of strategies to reduce sudden cardiac death in young athletes

OBJECTIVE

There is controversy about appropriate methods to reduce sudden cardiac death (SCD) in young athletes, but there is limited evidence on costs or consequences of alternative strategies. The objective of this study was to evaluate the cost-effectiveness of adding electrocardiogram (ECG) screening to the currently standard practice of preparticipation history and physical examination (H&P) to reduce SCD.

METHODS

Decision analysis modeling by using a societal perspective, with annual Markov cycles from age 14 until death. Three screening strategies were evaluated: (1) H&P, with cardiology referral if abnormal (current standard practice); (2) H&P, plus ECG after negative H&P, and cardiology referral if either is abnormal; and (3) ECG only, with cardiology referral if abnormal. Children identified with SCD-associated cardiac abnormalities were restricted from sports and received cardiac treatment. Main outcome measures were costs of screening and treatment, quality-adjusted life years (QALYs), and premature deaths averted.

RESULTS

Relative to strategy 1, incremental cost-effectiveness is $68800/QALY for strategy 2 and $37700/QALY for strategy 3. Monte Carlo simulation revealed the chance of incremental cost-effectiveness compared with strategy 1 was 30% for strategy 2 and 66% for strategy 3 (assumed willingness to pay ≤$50000/QALY). Compared with strategy 1, strategy 2 averted 131 additional SCDs at $900000 per case, and strategy 3 averted 127 SCDs at $600000 per case.

CONCLUSIONS

Under a societal willingness to pay threshold of $50000/QALY, adding ECGs to current preparticipation evaluations for athletes is not cost-effective, with costs driven largely by false-positive findings.

Sudden cardiac death and preparticipation screening: the debate continues-in support of electrocardiogram-inclusive preparticipation screening

Sudden cardiac death (SCD) is the leading cause of death in young athletes during exercise, and there is international agreement among major medical and sporting bodies that young athletes should undergo preparticipation cardiovascular screening. However, there is currently no universally accepted screening protocol, and substantial debate exists about what constitutes the ideal approach to preparticipation screening. The primary objective of preparticipation screening is the detection of intrinsic structural or electrical cardiovascular disorders that predispose an athlete to SCD. Considerable evidence exists suggesting that screening athletes with only a history and physical examination leaves most athletes with a serious underlying cardiovascular disease undetected and, thus, cannot adequately achieve the primary objective of screening. Preparticipating cardiovascular screening inclusive of an electrocardiogram (ECG) greatly enhances the ability to identify athletes at risk and is the only model shown to be cost-effective and may reduce the rate of SCD. The major obstacle to ECG screening in the United States is the lack of a physician workforce skilled in interpretation of an athlete's ECG. However, recent studies have demonstrated a capacity to distinguish physiologic ECG alterations in athletes from findings suggestive of underlying pathology that is both feasible and has a low false-positive rate. Efforts are underway to increase physician education in ECG interpretation. After 2 decades debating the proper screening strategy to identify athletes at risk, the weight of scientific evidence suggests that a screening program inclusive of ECG is the only strategy that merits promotion.

Phidippides cardiomyopathy: a review and case illustration

Phidippides was a Greek messenger who experienced sudden death after running more than 175 miles in two days. In today's world, marathon running and other endurance sports are becoming more popular and raising concern about sudden deaths at these events. Once etiologies such has hypertrophic cardiomyopathy, anomalous coronary arteries, and coronary atherosclerosis have been excluded, there is now an additional consideration termed Phidippides cardiomyopathy. Because endurance sports call for a sustained increase in cardiac output for several hours, the heart is put into a state of volume overload. It has been shown that approximately one-third of marathon runners experience dilation of the right atrium and ventricle, have elevations of cardiac troponin and natriuretic peptides, and in a smaller fraction later develop small patches of cardiac fibrosis that are the likely substrate for ventricular tachyarrhythmias and sudden death. Cardiac magnetic resonance imaging is emerging as the diagnostic test of choice for this condition. This review and case report summarizes the key features of this newly appreciated disorder.

Pre-competition cardiac screening in professional handball players - setting up at the EHF European Handball Championship 2010 in Austria

In many sports, regular cardiac screening for exercise-associated sudden cardiac death is still not provided. To set up the current situation in top-skilled handball players qualified for the 2010 European Handball Championship in Austria, a standardised questionnaire was sent to every team. The fact that only 42.7% of the players returned the questionnaire may lead to the conclusion that the awareness of the problem is quite low. However, 82% of these players have been screened according to current recommendations. Half of the teams were screened inhomogeneously: 5 players (4.1%) have not been screened within the last years, 1 athlete (0.8%) was screened without an ECG. While 69% of the athletes got their first screening only after the age of 18, 16 players (13.1%) never went through a specific screening ever. We identified 17 athletes (13.9%) with a highly suspicious history, 2 of them (1.6%) never underwent a medical screening at all.

A pilot study of the feasibility of heart screening for sudden cardiac arrest in healthy children

BACKGROUND

In children, sudden cardiac arrest (SCA) is associated with structural and electrical cardiac abnormalities. No studies have systematically screened healthy school children in the United States for conditions leading to SCA to identify those at risk.

METHODS

From June 2006 to June 2007, we screened 400 healthy 5- to 19-year-olds (11.8 ± 3.9 years) in clinical offices at The Children's Hospital of Philadelphia using a medical and family history questionnaire, weight, height, blood pressure, heart rate, cardiac examination, electrocardiogram (ECG), and echocardiogram (ECHO). Our goals were to determine the feasibility of adding an ECG to history and physical examination and to identify a methodology to be used in a larger multicenter study. A secondary objective was to compare identification of cardiovascular abnormalities by history and physical examination, ECG, and ECHO.

RESULTS

Previously undiagnosed cardiac abnormalities were found in 23 subjects (5.8%); an additional 20 (5%) had hypertension. Potentially serious cardiac conditions were identified in 10 subjects (2.5%); 7 were suspected or identified by ECG and 3 more only by ECHO. Only 1 of the 10 had symptoms (previously dismissed); none had a positive family history.

CONCLUSIONS

It is feasible to screen for conditions associated with SCA in healthy children by adding ECG to history and physical examination. In this nongeneralizable sample, ECG identified more cases compared to history and physical examination alone, with further augmentation from ECHOs. Improvements in ECG and echocardiographic normative standards, representing age, gender, race, and ethnicity, are needed to increase the efficacy of screening in a young population.

Incidence of sudden cardiac death in National Collegiate Athletic Association athletes

BACKGROUND

The true incidence of sudden cardiac death (SCD) in US athletes is unknown. Current estimates are based largely on case identification through public media reports and estimated participation rates. The purpose of this study was to more precisely estimate the incidence of SCD in National Collegiate Athletic Association (NCAA) student-athletes and assess the accuracy of traditional methods for collecting data on SCD.

METHODS AND RESULTS

From January 2004 through December 2008, all cases of sudden death in NCAA student-athletes were identified by use of an NCAA database, weekly systematic search of public media reports, and catastrophic insurance claims. During the 5-year period, there were 273 deaths and a total of 1 969 663 athlete participant-years. Of these 273 deaths, 187 (68%) were due to nonmedical or traumatic causes, 80 (29%) to medical causes, and 6 (2%) to unknown causes. Cardiovascular-related sudden death was the leading cause of death in 45 (56%) of 80 medical cases, and represented 75% of sudden deaths during exertion. The incidence of SCD was 1:43 770 participants per year. Among NCAA Division I male basketball players, the rate of SCD was 1:3100 per year. Thirty-nine (87%) of the 45 cardiac cases were identified in the NCAA database, only 25 (56%) by use of public media reports, and 9 (20%) from catastrophic claims data.

CONCLUSIONS

SCD is the leading medical cause of death and death during exercise in NCAA student-athletes. Current methods of data collection underestimate the risk of SCD. Accurate assessment of SCD incidence is necessary to shape appropriate health policy decisions and develop effective strategies for prevention.

Is there evidence for recommending electrocardiogram as part of the pre-participation examination?

Sudden cardiac death (SCD) is the leading cause of death in young athletes on the playing field and typically the result of undiagnosed structural or electrical cardiovascular disease. Cardiovascular screening in athletes is routinely practiced and endorsed by most major sporting and medical associations, but universal agreement on a single screening strategy to identify athletes at risk for SCD remains a topic of tremendous debate. The pool of scientific evidence supporting the efficacy and cost-effectiveness of electrocardiogram (ECG) screening for athletes is growing. However, feasibility and practical concerns regarding false-positive results, cost-effectiveness, physician infrastructure, and health care resources for large-scale implementation of ECG screening still exist. This article examines the evidence related to ECG screening in athletes and presents a contemporary model for primary prevention of SCD in sport.

The pre-participation examination for leisure time physical activity: general medical and cardiological issues

BACKGROUND

There is current debate on the appropriate type and extent of medical testing for amateur and hobby athletes before they engage in sports. In particular, views diverge on the value of an ECG at rest.

METHODS

We selectively searched the Medline and Embase databases for relevant publications that appeared from 1990 to 2008. The most pertinent ones are discussed here along with current reviews and guidelines that give recommendations on pre-participation testing for amateur athletes.

RESULTS

History-taking and physical examination are standard around the world. The American guidelines on pre-participation examination do not recommend an ECG at rest, yet the guidelines for most European countries explicitly recommend it. No prospective cohort studies have been performed to date that might provide high-grade evidence (class and level) to support this practice. We discuss the pros and cons of an ECG at rest and also present the guideline recommendations on exercise-ECG testing for amateur athletes over age 40.

CONCLUSION

In accordance with the current European recommendations, and in consideration of the risks of athletic activity, we recommend that all persons participating in sports should undergo a pre-participation examination that includes an ECG at rest. Although primary-prevention campaigns advise physically inactive persons to get regular exercise, prospective studies are still lacking as a basis for recommendations in this group.

Expert opinion and controversies in musculoskeletal and sports medicine: preventing sudden cardiac death in young athletes

Sudden cardiac death in young athletes has become a highly visible public health concern. Over the past 2 decades, unexplained or premature deaths of numerous athletes at the youth, collegiate, and professional levels have garnered extensive media coverage and stimulated a discussion centered on prevention of such tragic events. A number of issues related to the prevention and management of sudden cardiac arrest on the playing field are currently debated in the medical literature, including the true incidence of sudden death in the young athletic population, the adequacy of the preparticipation physical evaluation, and the emergency response and effectiveness of secondary prevention strategies such as use of automated external defibrillators in the athletic setting. Clinicians who care for competitive athletes and/or cover youth sporting events must be aware of the benefits and limitations of different preparticipation screening programs to identify at-risk athletes, and they must be prepared to respond to life-threatening emergencies during athletic participation.

Recommendations for interpretation of 12-lead electrocardiogram in the athlete

Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed.

Athletes at Risk for Sudden Cardiac Death

High school athletes represent the largest group of individuals affected by sudden cardiac death, with an estimated incidence of once or twice per week. Structural cardiovascular abnormalities are the most frequent cause of sudden cardiac death. Athletes participating in basketball, football, track, soccer, baseball, and swimming were found to have the highest incidence of sudden cardiac death. Screening of athletes prior to participation in competitive sports usually falls short of recommended guidelines. Poorly defined legislation and the absence of a national standard for sports physicals have contributed to inadequate health screenings of athletes. This article will describe the incidence and causes of sudden cardiovascular death in young athletes as well as guidelines intended to prevent this unfortunate problem.