Advertisement
Canadian Journal of Cardiology

The Atlantic Rift: Guidelines for Athletic Screening—Where Should Canada Stand?

      Abstract

      Sudden cardiac death (SCD) in a young seemingly healthy athlete is a tragic and often highly publicized event. Preparticipation screening aims to identify those affected by cardiovascular diseases who may be at higher risk of SCD during sports participation. There are conflicting recommendations from the American Heart Association and the European Society of Cardiology regarding screening electrocardiograms (ECGs) before participation in sports. The use of an ECG as a screening strategy has been questioned, with a large number of abnormal test results observed in athletes resulting from the electrocardiographic changes that occur in a highly trained individual overlapping with findings suggestive of a pathologic condition. An abnormal 12-lead ECG triggers further examinations, which are expensive given the low diagnostic yield of most abnormal electrocardiographic patterns. Universal screening of young athletes poses logistic and financial challenges. There are currently no Canadian guidelines regarding preparticipation screening of athletes. Screening of athletes ignores the much larger group of young nonathletes who participate in vigorous recreational activity and who collectively represent a population in which a much larger number of SCDs can be predicted to occur. While waiting for the best screening approach in Canada, increased awareness of and access to automated external defibrillators, along with training in cardiopulmonary resuscitation, can help reduce the number of SCDs. In some jurisdictions, electrocardiographic screening has been eschewed in favour of such an approach. Specific physician training in the field of sports cardiology with availability of experts throughout Canada may be a useful start. We provide suggestions and call for the development of Canadian guidelines by appropriate organizations.

      Résumé

      La mort subite d’origine cardiaque (MSOC) chez les jeunes individus apparemment en santé est un événement tragique et souvent très publicisé. Le dépistage avant la participation à un sport vise à déceler les individus atteints de maladies cardiovasculaires qui sont exposés à un risque plus élevé de MSOC. Des recommandations contradictoires proviennent de la Société Américaine de Cardiologie et la Société Européenne de Cardiologie concernant les électrocardiogrammes de dépistage (ÉCG) avant la participation. L’utilisation des ÉCG comme stratégie de dépistage a souvent été remise en question du fait d’un grand nombre de résultats anormaux observés lors des examens réalisés chez des athlètes en raison de modifications à l’ÉCG qui apparaissent chez les individus très entraînés et qui se superposent à des résultats évocateurs d’une pathologie. L’ÉGG à 12 dérivations qui est positif entraîne d’autres examens dispendieux étant donné le faible rendement diagnostique de la plupart des tracés anormaux d’ÉCG. Le dépistage universel des jeunes athlètes pose des difficultés logistiques et financières. Il n’existe actuellement pas de lignes directrices canadiennes concernant le dépistage des athlètes. Le dépistage des athlètes ne tient pas compte du groupe plus nombreux de jeunes non-athlètes qui participent à des activités récréatives vigoureuses et qui représentent collectivement une population chez qui l’on peut prédire la survenue d’un nombre beaucoup plus grand de MSOC. Dans l’attente d’une meilleure approche de dépistage au Canada, une sensibilisation accrue et un accès aux défibrillateurs externes automatiques ainsi qu’une formation en RCR peuvent aider à réduire le nombre de MSOC. Certaines autorités ont rejeté le dépistage par ÉCG en faveur d’une telle approche. Une formation particulière des médecins dans le domaine de la cardiologie du sport ainsi que la disponibilité d’experts à travers le Canada peut constituer un point de départ utile. Nous donnons des suggestions et demandons l’élaboration de lignes directrices canadiennes par les organismes appropriés.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Harmon K.G.
        • Drezner J.A.
        • Wilson M.G.
        • Sharma S.
        Incidence of sudden cardiac death in athletes: a state-of-the-art review.
        Br J Sports Med. 2014; 48: 1185-1192
        • Gerardin B.
        • Collet J.P.
        • Mustafic H.
        • et al.
        Registry on acute cardiovascular events during endurance running races: the prospective RACE Paris registry.
        Eur Heart J. 2015 Dec 28; ([e-pub ahead of print]) (pii: ehv675)
        • Marijon E.
        • Uy-Evanado A.
        • Dumas F.
        • et al.
        Warning symptoms are associated with survival from sudden cardiac arrest.
        Ann Intern Med. 2016; 164: 23-29
        • Baggish A.L.
        Athlete safety is a shared responsibility: insights from the RACE Paris Registry.
        Eur Heart J. 2016 Jan 18; ([e-pub ahead of print]) (pii: ehv740)
        • Maron B.J.
        • Zipes D.P.
        Introduction: eligibility recommendations for competitive athletes with cardiovascular abnormalities-general considerations.
        J Am Coll Cardiol. 2005; 45: 1318-1321
        • Corrado D.
        • Basso C.
        • Rizzoli G.
        • Schiavon M.
        • Thiene G.
        Does sports activity enhance the risk of sudden death in adolescents and young adults?.
        J Am Coll Cardiol. 2003; 42: 1959-1963
        • Toresdahl B.G.
        • Rao A.L.
        • Harmon K.G.
        • Drezner J.A.
        Incidence of sudden cardiac arrest in high school student athletes on school campus.
        Heart Rhythm. 2014; 11: 1190-1194
        • Risgaard B.
        • Winkel B.G.
        • Jabbari R.
        • et al.
        Sports-related sudden cardiac death in a competitive and a noncompetitive athlete population aged 12 to 49 years: data from an unselected nationwide study in Denmark.
        Heart Rhythm. 2014; 11: 1673-1681
        • Marijon E.
        • Tafflet M.
        • Celermajer D.S.
        • et al.
        Sports-related sudden death in the general population.
        Circulation. 2011; 124: 672-681
        • Corrado D.
        • Basso C.
        • Thiene G.
        Sudden cardiac death in young people with apparently normal heart.
        Cardiovasc Res. 2001; 50: 399-408
        • Chandra N.
        • Bastiaenen R.
        • Papadakis M.
        • Sharma S.
        Sudden cardiac death in young athletes: practical challenges and diagnostic dilemmas.
        J Am Coll Cardiol. 2013; 61: 1027-1040
        • Kim J.H.
        • Malhotra R.
        • Chiampas G.
        • et al.
        Cardiac arrest during long-distance running races.
        N Engl J Med. 2012; 366: 130-140
        • Harmon K.G.
        • Drezner J.A.
        • Maleszewski J.J.
        • et al.
        Pathogeneses of sudden cardiac death in national collegiate athletic association athletes.
        Circ Arrhythm Electrophysiol. 2014; 7: 198-204
        • Eckart R.E.
        • Shry E.A.
        • Burke A.P.
        • et al.
        Sudden death in young adults: an autopsy-based series of a population undergoing active surveillance.
        J Am Coll Cardiol. 2011; 58: 1254-1261
        • Harmon K.G.
        • Drezner J.A.
        • Wilson M.G.
        • Sharma S.
        Incidence of sudden cardiac death in athletes: a state-of-the-art review.
        Heart. 2014; 100: 1227-1234
        • Harmon K.G.
        • Asif I.M.
        • Maleszewski J.J.
        • et al.
        Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association athletes: a decade in review.
        Circulation. 2015; 132: 10-19
        • Maron B.J.
        • Gohman T.E.
        • Aeppli D.
        Prevalence of sudden cardiac death during competitive sports activities in Minnesota high school athletes.
        J Am Coll Cardiol. 1998; 32: 1881-1884
        • 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
        • 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: 1291-1296
        • Maron B.J.
        • Thompson P.D.
        • Ackerman M.J.
        • 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: 1643-1655
        • Corrado D.
        • Pelliccia A.
        • Bjornstad H.H.
        • et al.
        Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport 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. 2005; 26: 516-524
        • Maron B.J.
        • Friedman R.A.
        • Kligfield P.
        • et al.
        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): a scientific statement from the American Heart Association and the American College of Cardiology.
        J Am Coll Cardiol. 2014; 64: 1479-1514
        • Maron B.J.
        • Levine B.D.
        • Washington R.L.
        • et al.
        Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes: a scientific statement from the American Heart Association and American College of Cardiology.
        J Am Coll Cardiol. 2015; 66: 2356-2361
        • Maron B.J.
        • Shirani J.
        • Poliac L.C.
        • et al.
        Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles.
        JAMA. 1996; 276: 199-204
        • Dunn T.P.
        • Pickham D.
        • Aggarwal S.
        • et al.
        Limitations of current AHA guidelines and proposal of new guidelines for the preparticipation examination of athletes.
        Clin J Sport Med. 2015; 25: 472-477
        • Maron B.J.
        • Friedman R.A.
        • Kligfield P.
        • et al.
        Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology.
        Circulation. 2014; 130: 1303-1334
        • Wilson M.G.
        • Basavarajaiah S.
        • Whyte G.P.
        • et al.
        Efficacy of personal symptom and family history questionnaires when screening for inherited cardiac pathologies: the role of electrocardiography.
        Br J Sports Med. 2008; 42: 207-211
        • Magalski A.
        • McCoy M.
        • Zabel M.
        • et al.
        Cardiovascular screening with electrocardiography and echocardiography in collegiate athletes.
        Am J Med. 2011; 124: 511-518
        • Brosnan M.
        • La G.A.
        • Kalman J.
        • et al.
        The Seattle Criteria increase the specificity of preparticipation ECG screening among elite athletes.
        Br J Sports Med. 2014; 48: 1144-1150
        • Bessem B.
        • Groot F.P.
        • Nieuwland W.
        The Lausanne recommendations: a Dutch experience.
        Br J Sports Med. 2009; 43: 708-715
        • Corrado D.
        • Basso C.
        • Schiavon M.
        • Thiene G.
        Screening for hypertrophic cardiomyopathy in young athletes.
        N Engl J Med. 1998; 339: 364-369
        • Harmon K.G.
        • Zigman M.
        • Drezner J.A.
        The effectiveness of screening history, physical exam, and ECG to detect potentially lethal cardiac disorders in athletes: a systematic review/meta-analysis.
        J Electrocardiol. 2015; 48: 329-338
        • Schnell F.
        • Riding N.
        • O'Hanlon R.
        • et al.
        Recognition and significance of pathological T-wave inversions in athletes.
        Circulation. 2015; 131: 165-173
        • Halkin A.
        • Steinvil A.
        • Rosso R.
        • et al.
        Preventing sudden death of athletes with electrocardiographic screening: what is the absolute benefit and how much will it cost?.
        J Am Coll Cardiol. 2012; 60: 2271-2276
        • Viskin S.
        Antagonist: routine screening of all athletes prior to participation in competitive sports should be mandatory to prevent sudden cardiac death.
        Heart Rhythm. 2007; 4: 525-528
        • Corrado D.
        • Basso C.
        • Thiene G.
        Pros and cons of screening for sudden cardiac death in sports.
        Heart. 2013; 99: 1365-1373
        • Drezner J.A.
        • Ackerman M.J.
        • Anderson J.
        • et al.
        Electrocardiographic interpretation in athletes: the 'Seattle criteria'.
        Br J Sports Med. 2013; 47: 122-124
        • Bessem B.
        • de Bruijn M.C.
        • Nieuwland W.
        The ECG of high-level junior soccer players: comparing the ESC vs the Seattle criteria.
        Br J Sports Med. 2015; 49: 1000-1006
        • Wasfy M.M.
        • DeLuca J.
        • Wang F.
        • et al.
        ECG findings in competitive rowers: normative data and the prevalence of abnormalities using contemporary screening recommendations.
        Br J Sports Med. 2015; 49: 200-206
        • Riding N.R.
        • Sheikh N.
        • Adamuz C.
        • et al.
        Comparison of three current sets of electrocardiographic interpretation criteria for use in screening athletes.
        Heart. 2015; 101: 384-390
        • Pickham D.
        • Zarafshar S.
        • Sani D.
        • Kumar N.
        • Froelicher V.
        Comparison of three ECG criteria for athlete pre-participation screening.
        J Electrocardiol. 2014; 47: 769-774
        • Corrado D.
        • Pelliccia A.
        • Heidbuchel H.
        • et al.
        Recommendations for interpretation of 12-lead electrocardiogram in the athlete.
        Eur Heart J. 2010; 31: 243-259
        • Sheikh N.
        • Papadakis M.
        • Ghani S.
        • et al.
        Comparison of electrocardiographic criteria for the detection of cardiac abnormalities in elite black and white athletes.
        Circulation. 2014; 129: 1637-1649
        • Papadakis M.
        • Carre F.
        • Kervio G.
        • et al.
        The prevalence, distribution, and clinical outcomes of electrocardiographic repolarization patterns in male athletes of African/Afro-Caribbean origin.
        Eur Heart J. 2011; 32: 2304-2313
        • Gati S.
        • Sheikh N.
        • Ghani S.
        • et al.
        Should axis deviation or atrial enlargement be categorised as abnormal in young athletes? The athlete's electrocardiogram: time for re-appraisal of markers of pathology.
        Eur Heart J. 2013; 34: 3641-3648
        • Zaidi A.
        • Ghani S.
        • Sheikh N.
        • et al.
        Clinical significance of electrocardiographic right ventricular hypertrophy in athletes: comparison with arrhythmogenic right ventricular cardiomyopathy and pulmonary hypertension.
        Eur Heart J. 2013; 34: 3649-3656
        • Brosnan M.
        • La Gerche A.
        • Kumar S.
        • Lo W.
        • Kalman J.
        • Prior D.
        Modest agreement in ECG interpretation limits the application of ECG screening in young athletes.
        Heart Rhythm. 2015 Jan; 12: 130-136
        • Berte B.
        • Duytschaever M.
        • Elices J.
        • et al.
        Variability in interpretation of the electrocardiogram in young athletes: an unrecognized obstacle for electrocardiogram-based screening protocols.
        Europace. 2015; 17: 1435-1440
        • Krahn A.D.
        • Healey J.S.
        • Chauhan V.
        • et al.
        Systematic assessment of patients with unexplained cardiac arrest: Cardiac Arrest Survivors With Preserved Ejection Fraction Registry (CASPER).
        Circulation. 2009; 120: 278-285