Position Paper on Pre-Participation Cardiovascular Evaluation to Prevent Sudden Death in Participants in Atheletic Events
abstract
This article is open access.
Access this abstract nowSudden cardiac death (SCD) associated with athletic activity is a rare but devastating event. Victims are usually young and apparently healthy, and while many of these deaths remain unexplained, a substantial number of victims harbour an underlying and potentially detectable cardiovascular (CV) disease. The vast majority of these events are due to malignant tachyarrhythmias, usually ventricular fibrillation (VF) or ventricular tachycardia (VT) degenerating into ventricular fibrillation (VF), occurring in individuals with arrhythmogenic disorders (e.g. hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, channelopathies). Intensive exercise training and competitive sport participation is a trigger that may favour insurgence of ominous ventricular tachyarrhythmias in predisposed individuals. Consequently, there is a great interest in early identification of at-risk individuals for whom appropriate treatment, followed or not by physical activity adjustment, may be implemented to minimize the risk of SCD. However, the role of pre-participation evaluation (PPE) in athletes as a feasible and efficient strategy to identify individuals at risk has remained controversial.
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Pre-Participation Cardiovascular Evaluation for Athletic Participants to Prevent Sudden Death: Position Paper from the EHRA and the EACPR, Branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE
Europace 2016 Nov 04;[EPub Ahead of Print], L Mont, A Pelliccia, S Sharma, A Biffi, M Borjesson, JB Terradellas, F Carré, E Guasch, H Heidbuchel, A Gerche, R Lampert, W McKenna, M Papadakis, SG Priori, M Scanavacca, P Thompson, C Sticherling, S Viskin, M Wilson, D Corrado, , GY Lip, B Gorenek, CB Lundqvist, B Merkely, G Hindricks, A Hernández-Madrid, D Lane, G Boriani, C Narasimhan, MF Marquez, D Haines, J Mackall, PM Marques-Vidal, U Corra, M Halle, M Tiberi, J Niebauer, M PiepoliFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The sudden death of an athlete due to an undiagnosed cardiac abnormality such as hypertrophic cardiomyopathy or a channelopathy is a rare but tragic event. How best to screen athletes to identify potentially lethal cardiac conditions, particularly regarding whether or not to include an ECG along with the standard history and physical exam, has been a matter of intense debate in both the US and Europe, with cardiology societies on both sides of the Atlantic putting together working groups to shape consensus statements in recent years.
The European Society of Cardiology’s (ESC) recent position paper endorsed by the US Heart Rhythm Society and other international heart rhythm associations, starts with a comprehensive discussion of the incidence and causes of sudden death in the athlete, with helpful information on diagnosis of these disorders as well as differentiating them from normal athletic changes. The document then discusses the role of pre-participation evaluation (PPE) of athletes for cardiovascular disease, as well as the various modalities for screening, presenting the benefits and limitations of the addition of ECG, as well as other modalities, in a balanced manner.
Based on the available data, the ESC working group came to agreement on a number of points. First, overall, PPE is a preventive medical program that identifies conditions predisposing to sudden cardiac arrest as well those that may be worsened by athletic training, and may provide a platform for general prevention as well; thus, PPE is recommended. A 2015 statement from the AHA/ACC, “Assessment of the 12-Lead Electrocardiogram as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age),” similarly concludes that PPE is valuable.
In consideration of whether to include ECG as well as history and physical exam in the PPE, the ESC document takes into consideration studies show that the addition of an ECG increases the yield of screening in identifying potentially lethal cardiac conditions. Advances in interpretation of the athlete’s ECG have greatly improved the specificity. However, only two studies have evaluated whether this strategy saves lives, both population-based studies comparing athlete deaths before and after initiation of national screening programs, with benefit shown in an Italian study but not replicated in a subsequent Israeli one; both studies have much-discussed limitations.
The ESC document concludes, “The protocol of PPE including clinical history, physical examination, and 12-lead ECG demonstrates to have superior diagnostic capability than just clinical history and physical examination. There is compelling scientific evidence that the 12-lead ECG improves substantially the diagnostic power of PPE, mostly due the capability to identity arrhythmogenic conditions at risk (cardiomyopathies and channelopathies).”
Here, the ESC and AHA/ACC recommendations differ, with the US document continuing to recommend PPE based on history and physical only. Ultimately, however, the two sides of the Atlantic may not be that far apart. The AHA/ACC document does not recommend against inclusion of ECG with H&P in small programs or research studies, but rather concludes the data are not sufficient to widely mandate inclusion of the ECG. The ESC writing group notes that, in the context of national differences in cultural, legal, social, logistic, and economic frameworks, as well as differences in interpretation of available scientific evidence, it is beyond the scope of that document to suggest global mandatory PPE. Further research to improve sensitivity, specificity, cost-effectiveness, and to continue to quantify the clinical impact of different PPE programs will be key.