Pre-participation screening for the prevention of sudden cardiac death in athletes

Abstract

Pre-partecipation screening is the systematic practice of medically evaluating large populations of athletes before participation in sport activities for the purpose of identifying abnormalities that could cause disease progression or sudden death. In order to prevent sudden cardiac death (SCD), cardiovascular screening should include a strategy for excluding high-risk subjects from athletic and vigorous exercise. There are two major screening programmes in the world. In the United States competitive athletes are screened by means of family and personal history and physical examination. In Italy there is a mandatory screening for competitive athletes, which includes a resting electrocardiogram (ECG) for the detection of cardiac abnormalities. The most important issue to be addressed is whether a screened subject is really guaranteed that she/he is not suffering from any cardiac disease or at risk for SCD. Conceivably, the introduction of echocardiogram during the pre-participation screening, could be reasonable, despite the discrete sensitivity of ECG, in raising clinical suspicions of severe cardiac alterations predisposing to SCD. It is clear that the cost-benefit ratio per saved lives of the ECG screening is a benchmark of the Public Health policy. On the contrary, the additional introduction of echocardiography in a large population screening programme seems to be too much expansive for the Public Health and for this reason not easily practicable, even if useful and not invasive. Even if we strongly believe that a saved life is more important than any cost-efficacy evaluation, the issue of the economical impact of this approach should be further assessed.

Keywords: Sudden cardiac death; Prevention; Athletes; Pre-participation screening; Screening

Core tip: The review underlines the different incidence of sudden cardiac death (SCD) and the reason of this discrepancy as well as the different kind of approach to competitive athletes in Italy and United States. We emphasize the importance of electrocardiogram (ECG) as a simple and economical diagnostic tool, considering the opportunity of implementing the pre-participation screening (PPS) with echocardiogram, in order to detect mild structural cardiac diseases. After a cost-effectiveness analysis we finally suggest an innovative proposal in order to further prevent SCD: a rapid but focused echocardiogram assessment during the first PPS in addition to physical examination and ECG.