Making or Breaking Athletic Careers - JACC

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Athletic Careers*. Alfred A. Bove, MD, PHD. Philadelphia, Pennsylvania. When classes begin in the fall, young athletes often appear in a cardiologist's office ...
Journal of the American College of Cardiology © 2011 by the American College of Cardiology Foundation Published by Elsevier Inc.

EDITORIAL COMMENT

Making or Breaking Athletic Careers* Alfred A. Bove, MD, PHD Philadelphia, Pennsylvania

When classes begin in the fall, young athletes often appear in a cardiologist’s office because of the finding of abnormal electrocardiography (ECG) results, a murmur, or some item in the history that has triggered the consultation. Most college and high school athletic programs require a medical evaluation so that athletes are subjected in the United States to a general examination that involves a history and a physical examination. In Italy and most other countries of Europe, in addition to the history and examination, a resting ECG is mandated by law. In Israel, both a resting ECG and a symptom-limited stress test are mandated (1). See page 1291

The work of Corrado et al. (2) in Italy demonstrated a decline in sports-related sudden death after ECG screening was instituted in 1982. These results have been used to develop screening programs in Europe, but these programs have not been adopted in the United States. There are several reasons for not using ECG screening in the United States, mainly based on a cost-to-benefit ratio, but the data of Maron et al. (3,4) from Minnesota show an already low rate of sports-related sudden death and question the need for ECG screening. In this issue of the Journal, Steinvil et al. (1) challenge the Italian data on scientific grounds by showing no difference in sudden death rate among high school and college athletes before and after mandated ECG and stress test screening that started in Israel in 1997. The authors carefully reviewed newspaper reports for sudden death during sports and found 24 cases (11 before screening began, 13 after screening) that were not different in incidence when comparing pre- and post-screening periods. They raise the question of whether ECG screening is really of value in reducing the rate of sudden death in sports. The problem is compounded further by the low incidence of sudden death in this population (2.6 events per 100,000

*Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. From the Cardiology Section, Temple University School of Medicine, Philadelphia, Pennsylvania. Dr. Bove has reported that he has no relationships to disclose.

Vol. 57, No. 11, 2011 ISSN 0735-1097/$36.00 doi:10.1016/j.jacc.2010.09.071

person-years in Israel, 3.6 events per 100,000 persons pre-screened in Italy that was reduced to 0.4 events per 100,000 persons screened after 20 years of screening (1), approximately 1 event per 100,000 persons screened in Minnesota (2,3), 6.5 events per 100,000 persons screened in France (5), and 1.2 events per 100,000 persons screened in Denmark (6). Steinvil et al. (1) argue that their data are more representative because they sampled a 12-year prescreening period compared with the data of Corrado et al. (2), in which only 2 pre-screening years were used as baseline. They suggest that the demand for screening usually comes from public responses to an exceptionally high rate of sudden sports deaths, and the comparisons with a period of exceptionally high incidence then would provide the appearance that screening actually reduced the death rate. Their 12-year pre-screening sample suggests that there is significant fluctuation of sports-related sudden death and that a longer average time is needed to understand the impact of screening. Steinvil et al. (1) also discuss the concept of immortality bias that may influence the screening process. In this case, athletes at high risk who die before screening is accomplished would not be counted in the cohort, which then would seem to show a lower risk subsequent to screening. The 12-year pre-screening data to some extent would minimize the immortality bias, but the Steinvil et al. (1) data raise the question of what should be the best method for reducing the already low rate of sudden death of athletes in the United States. A variety of cardiac disorders can result in sudden death during sport activity. These include hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, Wolff-ParkinsonWhite syndrome, long QT syndrome, and Brugada syndrome (7). In athletes older than 35 years, coronary disease dominates the sudden death diagnoses (8). Complex congenital heart disease and valvular heart disease usually are known to the patient and are detectable on physical examination, but the list provided above may be occult and asymptomatic until a sudden death event occurs. Compounding the problem is the often variant nature (abnormal is not the correct word here) of the ECG (9,10) or the echocardiogram (11,12). Young athletes, particularly AfricanAmerican males often have ECG findings that are not typical of the usual normal patient ECG found in a cardiology practice (13). Tall voltages, ST-segment elevation typical of early repolarization, and T-wave inversions in the right precordial region often lead to a diagnosis of cardiomyopathy or ischemic heart disease. I personally have encountered healthy asymptomatic professional basketball players whose ECG was read as showing acute myocardial infarction and who were denied life insurance. They needed reassurances that they were capable of playing professional basketball, after a stellar career in college basketball. Pelliccia et al. (13) and Corrado et al. (14) examined the atypical ECG results in a group of athletes who died suddenly. They

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Bove Making or Breaking Athletic Careers

found some characteristics that may be predictive, but the sensitivity was low. Distinguishing the atypical ECG results of a young athlete from truly abnormal ECG results is an important goal because the prevalence of such atypical ECG results is high, and a complete evaluation of the heart (echocardiography, MRI, CT, stress test, and so on) in every one of these athletes could not be justified on the basis of cost (15). Similarly, screening of athletes with echocardiography also will lead to a high number of false positive diagnoses of cardiomyopathy. The atypical echocardiography findings in an athlete are affected by the size of the athlete and by the degree and type of training. Large athletes often are clustered in basketball and football. It is not uncommon to have athletes nearly 7 feet tall in basketball. College and professional football players also are taller than their age-related nonathletic counterparts. Increased left ventricular diastolic diameter, increased wall thickness, moderately enlarged right ventricle, trace or mild tricuspid regurgitation, or mitral regurgitation all can be found in athletes with no apparent increase in risk for sudden death and no evidence of cardiomyopathy (11,12). Here again, an extensive cardiac work-up based on these findings will result in very high costs and likely prohibition from sports for athletes who should not be disqualified. As of 2011, we do not have mandated ECG screening of athletes in the United States. It is not clear if such screening would reduce substantially the already low incidence of sudden cardiovascular death that occurs during sports activity. Wheeler et al. (15) suggest that ECG screening added to a history and physical examination would be cost effective, based on the Corrado et al. data, but their calculations likely would be different based on the data of Steinvil et al. (1), whose data challenge the concept that ECG screening in fact would disqualify those who may be at risk. The concern is that many athletes would be disqualified based on false positive ECG findings (16,17), and we do not at present have an inexpensive method for more accurate screening of the millions of high school and college athletes in the United States. Perhaps one solution would be to support research to identify the specific gene or genes that increase the sudden death risk and expect, when we all have our total genome characterized, to select those individuals for more detailed evaluation who express one or more of those genes. This, however, is not feasible at present, but likely will be in the future. At present, cardiologists who evaluate athletes should be familiar with the normal variants in echocardiography and ECG results (17–19) and should incorporate the 12 questions posed by the American Heart Association (20) for screening so that young athletes are not disqualified based on variant ECG results or normal cardiac adaptations to exercise.

JACC Vol. 57, No. 11, 2011 March 15, 2011:1297–8

Reprint requests and correspondence: Dr. Alfred A. Bove, Cardiology Section, Temple University School of Medicine, Parkinson Pavilion Suite 945, 3401 North Broad Street, Philadelphia, Pennsylvania 19140-4105. E-mail: [email protected]. REFERENCES

1. Steinvil A, Chundadze T, Zeltser D, et al. Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death: proven fact or wishful thinking? J Am Coll Cardiol 2011;57:1291– 6. 2. 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– 601. 3. Maron BJ, Haas TS, Doerer JJ, Thompson PD, Hodges JS. Comparison of U.S. and Italian experiences with sudden cardiac deaths in young competitive athletes and implications for preparticipation screening strategies. Am J Cardiol 2009;104:276 – 80. 4. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980 –2006. Circulation 2009;119:1085–92. 5. Chevalier L, Hajjar M, Douard H, et al. Sports-related acute cardiovascular events in a general population: a French prospective study. Eur J Cardiovasc Prev Rehabil 2009;16:365–70. 6. Holst AG, Winkel BG, Theilade J, et al. Incidence and etiology of sports-related sudden cardiac death in Denmark: implications for preparticipation screening. Heart Rhythm 2010;7:1365–71. 7. Lawless CE, Best TM. Electrocardiograms in athletes: interpretation and diagnostic accuracy. Med Sci Sports Exerc 2008;40:787–98. 8. Link MS, Estes M. Sudden cardiac death in athletes. Prog Cardiovasc Dis 2008;51:44 –57. 9. Papadakis M, Basavarajaiah S, Rawlins J, et al. Prevalence significance of T-wave inversions in predominantly Caucasian adolescent athletes. Eur Heart J 2009;30:1728 –35. 10. Corrado D. 12-lead ECG in the athlete: physiological versus pathological abnormalities. Br J Sports Med 2009;43:669 –76. 11. Rawlins J, Bhan A, Sharma S. Left ventricular hypertrophy in athletes. Eur J Echocardiogr 2009;10:350 – 6. 12. Lauschke J, Maisch B. Athlete’s heart or hypertrophic cardiomyopathy? Clin Res Cardiol 2009;98:80 – 8. 13. Pelliccia A, Di Paolo FM, Quattrini FM, et al. Outcomes in athletes with marked ECG repolarization abnormalities. N Engl J Med 2008;358:152– 61. 14. Corrado D, Pelliccia A, Heidbuchel H, et al. Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur Heart J 2010;31:243–59. 15. Wheeler MT, Heidenreich PA, Froelicher VT, et al. Cost effectiveness of pre-participation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med 2010;152:276 – 86. 16. Lawless CE. Return-to-play decisions in athletes with cardiac conditions. Phys Sportsmed 2009;37:80. 17. Chandra N, Papadakis M, Sharma S. Preparticipation screening of young competitive athletes for cardiovascular disorders. Phys Sportsmed 2010;38:54 – 63. 18. Pelliccia A, Zipes DP, Maron BJ. Bethesda Conference #36 and the European Society of Cardiology Consensus Recommendations revisited a comparison of U.S. and European criteria for eligibility and disqualification of competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol 2008;52:1990 – 6. 19. Le VV, Wheeler MT, Mandic S, et al. Addition of the electrocardiogram to the preparticipation examination of college athletes. Clin J Sport Med 2010;20:98 –105. 20. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation 2007;115:1643– 45. Key Words: athlete y cardiac arrest y death y electrocardiogram y screening y sudden.