Preventing Sudden Cardiac Death in Young Athletes: How Should We Screen?

Your last appointment of the day is with a 16-year-old boy who needs medical clearance to participate on the school basketball team. You have read about young athletes who die suddenly on the field. Is there anything you should do in addition to a history and physical examination to assure yourself that it is safe for your patient to play sports?

Of the high school and college athletes who die suddenly, many are found to have structural heart defects that were undetected. In the United States, the most common of these defects is hypertrophic cardiomyopathy.¹ In addition to structural defects, the role of arrhythmias--such as long QT syndrome--in sudden death has also been well studied.² Fortunately, such deaths are rare. When they do occur, we wonder whether, as pediatricians, we should be doing more to try to prevent them from occurring at all. We are often asked to clear adolescent patients for participation in sports: how should we be screening these teenagers for cardiac defects?

Recently in Italy, Corrado and colleagues³ looked at the impact of a nationwide preparticipation athletic screening program that included a history, physical, and an ECG on sudden cardiovascular death in athletes aged 12 to 35 years. There was a 44% decrease in the rate of sudden cardiovascular death among athletes from the prescreening period to the early screening period. There was a continued decline from the early to the late screening period. During the 26-year study period, there was an 89% decrease in the rate of sudden cardiovascular death in more than 40,000 young athletes. In contrast, there was no significant decrease in the rate of sudden cardiovascular death among unscreened athletes. Thus, the reduction in deaths among those screened was not the result of a decrease in the death rate of the overall population. The number of diagnoses of cardiomyopathy rose as a result of the screening program: those affected were subsequently disqualified from competitive sports.

The authors of an accompanying editorial call these results "provocative," but note that they do not definitively establish the role of routine ECG screening.⁴

So, getting back to our basketball player . . . If results of his history and physical examination are normal, should an ECG be done before you clear him to play sports? The jury is still out on the matter. While the Italian study is impressive in its scope and findings, it does not directly answer this question. The authors did not compare ECG screening with screening using a history and physical.

The screening of all athletes with an ECG has many implications. The additional time and cost required seems small for a single athlete but would be significant if all athletes were screened. Given the large number of screenings that would be needed to save one life, the cost would be high. But if that life were a child in your practice, wouldn't the additional time and cost be worth it?

The bottom line: controlled studies need to be done that compare screening with history and physical alone with screening using ECGs to better understand the impact on preparticipation sports evaluations. But the Italian study suggests that routine ECG screening may play an important role in the future.

References:

REFERENCES:

1.Shirley KW, Adirim TA. Sudden cardiac death in young athletes.

CPEM.

2005;6:194-199.
2. Towbin JA. Molecular genetic basis of sudden cardiac death.

Pediatr Clin North Am.

2004;51:1229-1255.
3. Corrado D, Basso C, Pavei A, et al. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program.

JAMA.

2006;296:1593-1601.
4. Thompson PD, Levine BD. Protecting athletes from sudden cardiac death.

JAMA.

2006;296:1648-1650.