Sports and arrhythmias: to screen or not to screen

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Jacob Tfelt-Hansen
Jacob Tfelt-Hansen

Screening athletes for the risk of sudden cardiac arrest has been a topic of discussion for many years. Jacob Tfelt-Hansen, author of a Danish study on this subject, gave an overview about different positions and studies that favour or disfavour this practice. He will be speaking on this at Venice Arrhythmias (27–29 October, Venice, Italy).

To be, or not to be, that was the question and most famous quote from the Danish Prince Hamlet. For many years in sports cardiology the most important debate may be boiled down to the question: to screen or not to screen, as sports related sudden cardiac death has received much attention, both in the media as well as in the world of medical science. This is in part owing to the pivotal discussion about preparticipation cardiovascular screening of competitive athletes. Preparticipation screening has already been implemented on different levels in many countries. The most extensive preparticipation screening programmes in the world have been taking place in Italy and Israel. In Denmark, the Danish society of cardiology recommends in two reports (2006 and 2010) not to screen for cardiovascular disease in athletes. The Danish recommendation is not in line with the general European Society of Cardiology (ESC) recommendation.1 The reasons for our point of view on this topic are multiple. First, there is a high number of disqualifications (false positives). Second, the impact on quality of life that a disqualification can have for the athlete, including socioeconomic changes. Third, the loss of beneficial effects of sport on health and fourth the economic costs. Last and most important, there is the question whether there is a proven effect of preparticipation screening.


In a perfect world, a randomised study of preparticipation screening should be conducted, but the scale required is extremely large. As a consequence, the evidence regarding the efficacy of preparticipation screening is based on observational studies.

The most interesting and solid data on the potential effect of screening are of course the well-known and published results from the Veneto Region in Italy. The prospective, initially retrospective, Italian study shows that preparticipation screening lowers the incidence rate of sports related sudden cardiac death in young competitive athletes.2 However, data from Israel, USA and from our own study (from Denmark) suggest that screening is of no or limited effect.3,4,5 In our study we found a comparable low incidence of sports related sudden cardiac death to the one in the Veneto Region. In contrast to the Italian data, our incidence of sudden cardiac death in the general population was around three times higher than the incidence of sports related sudden cardiac death. This has led Maron et al to question whether the screening for sports related sudden cardiac death is ethical when the general population has a three times higher risk of sudden cardiac death.6


Thus my answer is: not to screen (and more data are needed).


References

1. Pelliccia, A. et al. Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur. Heart J. 26, 1422–1445 (2005).

2. Corrado, D. et al. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. Jama J. Am. Med. Assoc. 296, 1593–1601 (2006).

3. Maron, B. J., Doerer, J. J., Haas, T. S., Tierney, D. M. & Mueller, F. O. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation 119, 1085–1092 (2009).

4. Steinvil, A. et al. Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death proven fact or wishful thinking? J. Am. Coll. Cardiol. 57, 1291–1296 (2011).

5. Holst, A. G. et al. Incidence and etiology of sports-related sudden cardiac death in Denmark: implications for preparticipation screening. Heart Rhythm 7, 1365–1371 (2010).

6. Maron, B. J. Diversity of views from Europe on national preparticipation screening for competitive athletes. Heart Rhythm 7, 1372–1373 (2010).


Jacob Tfelt-Hansen is associate professor from the Department of Cardiology, Copenhagen
University Hospital, Rigshospitalet, Denmark

 

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