Heart screening fails the test

3 minute read

Testing young athletes for undiagnosed heart conditions doesn’t reduce sudden deaths, experts argue


Testing young athletes for undiagnosed heart conditions doesn’t reduce sudden deaths, experts argue

While the sudden cardiac death of a young athlete is a devastating event, pre-participation screening programs are ineffective and should be abandoned, experts say.

The potential for such programs to reduce deaths was low because of a poor detection rate, and uncertainty around the management of conditions detected in asymptomatic people, the authors of a wide-ranging analysis of the evidence published in the BMJ said.

In the 1970s, Italy introduced a national mandatory ECG screening program for athletes, which has been mirrored by sports authorities in Australia and internationally.

But the new analysis suggests the potential for pre-participation screening to reduce deaths is likely to be low. Sudden cardiac deaths were so rare among young athletes, with estimates ranging from one in 917,000 to one in 3000, that the number of people needed to screen to prevent a death was high.

Hypertrophic cardiomyopathy is the most common underlying cause of sudden cardiac death, while other conditions include premature coronary artery disease, congenital anomalies of the coronary arteries, and a predisposition to arrhythmias such as Wolff -Parkinson-White syndrome.

An estimated 33,000 athletes would need to be screened at a cost of $1.7 million to save one life, Australian cardiologist, Professor Christopher Semsarian, said in an accompanying editorial.

With a false positive rate of up to 30%, mass pre-participation screening may unfairly prevent many athletes from taking part in competitive sport and deter them from ongoing physical activity.

Dr Maria Brosnan, a cardiologist at St Vincent’s Hospital in Melbourne and Baker IDI, said that “athletes should be allowed to opt in or opt out of screening after careful explanation of the risks and benefits”.

Most of the push for screening had hinged on Italian investigators claiming sudden cardiac deaths had fallen 90% since mandatory screening was introduced, but there had been doubts around these findings and the researchers have not been forthcoming with unpublished data.

“The Italian data is flawed and it’s a massive leap to take their reported observation and suggest that ECG screening should be mandatory,” Dr Brosnan, who has a doctorate on ECG abnormalities and underlying cardiac conditions in elite athletes, said.

In Australia, pre-participation screening was recommended for most elite athletes, and all new scholarship holders at the Australian Institute of Sport and State sports institutes were recommended to undergo ECG screening, she said.

Among the general population, screening was not even recommended for those with a family history of proven cardiac disease associated with sudden cardiac death, despite having a 50% chance of having the condition or being a carrier.

Conversely, red flag symptoms, particularly exertional syncope, chest pain or palpitations should be taken seriously and prompt a thorough examination, and in most cases, referral, she said.

There was a misconception that ECG screening was a one-off “tick” test that could off er reassurance the athlete was not harbouring a condition associated with sudden cardiac disease, Dr Brosnan said.

But tests had variable age penetration, and false negatives were not uncommon either, she said.

BMJ 2016; online 20 April

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