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Rapid Responses: Rapid Responses published:
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Echocardiography would even perform better on a population-based level
- Johannes G. Scholl, 80804 Munich, Germany (4 July 2008)
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Clinical evaluation of young athletes to prevent syncope or sudden death prior to exercise field events
- Munir (Mounir) E Nassar (9 July 2008)
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Issues for Pre-participation Screening in the U.K.
- Alan T Rankin (12 July 2008)
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How is "athlete"defined?
- Avril F Danczak (14 July 2008)
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Taking prevention to a relative curative level.
- Munir (Mounir) E. Nassar (21 July 2008)
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Mandatory ECG Screening of Athletes
- Roy J. Shephard (10 August 2008)
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Why exercise EKG
- Mounir(Munir) E Nassar (14 September 2008)
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Johannes G. Scholl, President of the German Academy for PrevePrevention First - Private Practice for Preventive Medicine Prevention First Munich, 80804 Munich, Germany
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Italy clearly is the leader in the research about how to prevent sudden cardiovascular death in young competitive athletes, because it introduced a national mandated pre-participation screening program for athletes already in 1982. This screnning program reduced sudden cardiac death due to cardiomyopathy by ~90% (1). Sofi et al. report in their study the superiority of exercise electrocardiography over taking a history and resting ecg alone in detecting persons at risk for sudden cardiac death among young competitive athletes. One might wonder, if including echocardiography in this program would not be an even more efficient approach. Of course arrhythmogenic right ventricular cardiomyopathy (ARVC) and hypertrophic obstructive (HOCM) and non-obstructive cardiomyopathy (HCM) confer a high risk, but their prevalence in the general population is quite low. In persons 30 years of age or older, many of which might start with competitive activities like marathon running, left ventricular hypertrophy (LVHT) as a consequence of arterial hypertension has a much higher impact on mortality on the population level than these rather rare abnormalities. Cardiovascular risk in the presence of LVHT is more than doubled according to long-known Framingham data.(3) The prevalence of hypertension in general is rising and Germany has one of the highest hypertension prevalences worldwide (4). Prevention First is one of the leading institutions in Germany performing regular health check -ups for employees of large companies. We see a high prevalence of unknown hypertension (25% or more) and LVHT in our routine echocardiography (unpublished data), which is an indication for immediate blood-pressure lowering treatment. As echocardiography has a much higher sensitivity and specificity than resting or exercise ecg in detecting cardiac abnormalities like LVHT (and ARVC, HOCM and HCM, too), it seems logical, that a screening program including "once-a-life echocardiography" before starting any ambitioned sports activities could be even more efficient in preventing sudden cardiac death in athletes and even in beginners at an age of >30 years. (1) Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a prepartici-pation screening program. JAMA. 2006;296:1593-1601. (2) Francesco Sofi, Andrea Capalbo, Nicola Pucci, Jacopo Giuliattini, Francesca Condino, Flavio Alessandri, Rosanna Abbate, Gian Franco Gensini, and Sergio Califano. Cardio-vascular evaluation, including resting and exercise electrocardiography, before participation in competitive sports: cross sectional study BMJ 2008 337: a346. (3) Kannel,W.B.; Gordon,T.; Offutt,D. Left ventricular hypertrophy by electrocardiogram. Prevalence, incidence, and mortality in the Framingham study. Ann Int Med 1969; 71: 89-105. (4) Wolf-Maier K, Cooper RS, Banegas JR, et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA. 2003;289:2363-2369. Competing interests: None declared |
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Munir (Mounir) E Nassar, retired clinical cardiologist Pittsford, NY 14534
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Dear Editor: Thank you for publishing the paper of Sofi and colleagues on "Cardiovascular evaluation, including resting and exercise electrocardiography before participation in competitive sports: Cross sectional study. " BMJ 2008, 337, a346. This is a wake up call for physicians, especially those in charge of college health services for their students, to prevent syncope and sudden death with althletic events. I would like to emphasize the inportance of history and cardiac physical exam before an electrocardiogram stress test and duplex two dimensional echocardiogram are undertaken to confirm the diagnosis. Since Hypertrophic cardiomyopthy,(most common in the young) and bicuspid aortic valve stenosis, are a family hereditary diseases, a family history of syncope or sudden death in the family would be highly suspicious to proceed with further diagnostic tests in the presence of rapid carotid artery upstroke and a sustained left ventricular impulse. In Congenital bicuspid aortic valve disease, a systolic ejection click is heard and A2 is delayed sometimes producing paradoxical splitting of the second heart sound depending on how severe is the stenosis, and a tardive pulse with systolic thrills over the aortic area and suprasternal notch. The exercise electrocaradiogram test should be carefully supervised or avoided entirely, because of risk of syncope etc, and instead reliance on the duplex two dimensional echocardiogram be accomplished to clinch the diagnosis. Finally, a resting electrocardiogram be done to rule in or out prolonged Q-T interval; and holter monitoring of athletes to document arrhythmias would be exceedingly worth while. Sincerely, Munir (Mounir) E Nassar, M.D., FACP, FAHA
Competing interests: None declared |
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Alan T Rankin, Specialty Trainee, Core Medicine Musgrave Park Hospital, Stockman's Lane, Belfast. BT9 7JB
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Editor, I read with great interest the article by Sofi et al (1) and its associated editorial (2). The sudden death of seemingly exceptionally healthy individuals has a profound effect on communities, serving as a reminder of our own mortality. Efforts to try to lesson these events taking place are to be actively supported and as is rightly pointed out by Dresner & Kahn (2), the time has come to seriously consider population based pre-participation cardiovascular screening. This article raises three key issues for pre-participation screening implementation. The consensus statement of the European Society of Cardiology on screening (3) recommends the use of a three pronged approach; namely history, physical examination and 12 lead resting electrocardiograms (ECG). This has been shown to reduce the incidence of sudden cardiac deaths in athletes by 90% (4). The addition of the exercise ECG, in the BMJ article, serves to identify further cardiovascular problems, even in athletes who would have been otherwise passed fit by the original triple assessment approach. With this evidence available should exercise ECG become incorporated into this screening programme? The addition of exercise ECG will undoubtedly raise screening costs. Current programmes using a triple assessment approach in the UK are available for approximately £35(5); this may even double if exercise ECG is added. In Italy, this is largely self-funded (4). A similar approach here, in light of a National Health Service (NHS) that is free at the point of delivery, may be off-putting to those considering entrance into competitive sports and may discourage physical activity at a time when obesity levels are rising. The third problem is that of interpretation of screening results. In order to provide a safe and effective service; the involved physicians must be competent to identify abnormal results and provide realistic exercise advice according to the Bethesda guidelines (6). This specialist knowledge requires 4 years to assimilate in Italy, working almost exclusively in this area (3). The obvious choice for doctors to perform screening would be from the new specialty of sport & exercise medicine (SEM); however current curriculum documents do not require the trainee doctor to acquire a thorough competence in this area and only really mention screening in passing (7). Competent interpretation of screening tests in athletes is an area that few cardiologists have a special interest in and that routine cardiology training would not provide. I feel that there is a real opportunity here for the new faculty of SEM to provide the NHS with doctors who are trained and competent in this area if they address these specific learning needs in preparation for mass pre- participation screening. Reference: 1. Sofi F, Capalbo A, Pucci N, Giuliattini J, Condino F, Alessandri F et al: Cardiovascular evaluation, including resting and exercise electrocardiography, before participation in competitive sports: cross sectional study. BMJ 2008;337:a346 2. Drezner J, Khan K: Sudden cardiac death in young athletes. BMJ 2008;337:a309 3. Corrado D, Pelliccia A, Bjornstad HH, Vanhees L, Biffi A, Borjesson M, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Eur Heart J 2005;26:516-24 4. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athlete after implementation of a pre-participation screening program. JAMA 2006;296:1593-601 5. http://www.c-r-y.org.uk/ecg.htm 6. Marron B & Zipes D: 36th Bethesda Conference, Introduction: Eligibility recommendations for competitive athletes with cardiovascular abnormalities – general considerations. J Am Col Cardiol 2005 45, 81318-21 7. Faculty of Sport & Exercise Medicine UK. SEM Specialty Training Curriculum, September 2006, page 25. http://www.fsem.co.uk Competing interests: None declared |
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Avril F Danczak, GP The Alexandra Practice, 365 Wilbraham Rd Manchester M16 8NG
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Reducing sudden death in athletes in a worthy aim.(BMJ 2008;337:a346) but much more clarity about the targets of such screening is needed. What is a " competitive athlete"? Does participation in a 5km charity run count? Or only if you try to beat the woman in front? What is an "officially sanctioned sport" in Italy? Is such screening a one off for young people? Or should it recur as we encourage older adults to "get fit"? False positives could harm those who avoid sport as a result. When articles about screening are published a rigorous analysis of whether they fit Wilson and Junger's criteria should accompany the evidence presented. ( Wilson, J. M. G., and G. Junger. 1968. The principles and practice of screening for disease. Public Health Papers:WHO 34 ) Competing interests: None declared |
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Munir (Mounir) E. Nassar, Retired clinical cardiologist Pittsford, New York
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Dear Editor: In my opinion it is not really of great help to follow established guidelines or define what is an athlete to diagnose the disease responsible for syncope and sudden death. The reasons being are that these are definite disease entities such as hereditary hypertrophic obstructive cardiomyopathy or congenital bicuspid aortic valve stenosis, or congenital or acquired prolonged Q T interval,and their diagnosis depends on the acumen and skill of the physician and his knowledege of cardiology. Furthermore, treatment of these mentioned diseases will reduce or prevent the occurence of sudden death and syncope from these specific diseases.Beta blockesrs and certain calcium channel blockes have been used very effectively in Hypertrophic obstructive cardiomyopathy. Also surgical myomectomy is quite definitive and this procedure was first introduced by Dr. Cleland at the Brompton Hospital of London some 50 or so years ago. Similarly, prosthetic valve replacement for critical symptomatic bicuspid aortic valve stenosis. Lastly, beta blockers and or other measures have been used in treating a prolonged Q-T interval such as stopping offending drugs that prolong the Q-T interval in certain individuals Sincerely, Munir (Mounir) E. Nassar, M.D., FACP, FAHA Competing interests: None declared |
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Roy J. Shephard, Professor Emeritus Brackendale, BC V0N 1H0
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The concept of mandatory exercise ECG screening of athletes (1, 2) remains controversial (3, 4), due mainly to concerns about costs and the adverse health impact of a high proportion of false positive diagnoses when a fallible test is used to seek a rare condition. A number of organisations have expressed interest in requiring exercise ECG screening of all competitors, although the supporting papers cited by Sofi and associates (2) are all from the same group of investigators, based in Italy (5-8). The Italian group have made several claims for the efficacy of mandatory ECG screening (6, 7, 9). In the first five years after enactment of such legislation, sudden cardiac deaths among young athletes in Italy (3.0-3.5/100,000) remained substantially higher than in the U.S. (where ECG screening is not required). During the period 1994-2004, the incidence of sudden exercise deaths among Italian competitors apparently dropped substantially, to an average of about 1.0/100,000 (6). However, it remains unclear whether the decrease reflects greater compliance with the 1982 testing legislation, greater diagnostic sophistication, or even a chance statistical variation (since the absolute number of exercise deaths among young athletes in any given year was extremely small). In order to reduce the sudden exercise death rate from 3.0- 3.5/100,000 to 1/100,000, 3914 (9 per cent) of some 42,000 Italian athletes faced the anxiety of further screening that included various combinations of echocardiography, Holter monitoring, magnetic resonance imaging and contrast angiography. Moreover, 879 (2 per cent) were still ultimately disqualified from competition (6). There were no deaths among the 879 disqualified individuals over the follow-up period; Corrado and associates (6) interpreted this as evidence that the disqualification was warranted, although their finding could also indicate that in all or most of the athletes concerned the disqualification was unnecessary. In nations where medical evaluations are paid from the public purse, cost/benefit analyses are important to maximizing the benefit obtained from finite health-care budgets. The simple step test used by many Italian sports physicians was estimated to cost about $40/athlete, or $4 million in a population of 100,000 competitors. Nine percent of the Italian sample required further evaluation, at a cost of perhaps $300 per individual, bringing the total cost to $6.7 million per 100,000 athletes. Let us make the generous assumption that all of the secular trend to a reduction of sudden exercise deaths in Italy was due to the introduction of mandatory ECG screening. The Italian figures would then suggest a saving of 2.0-2.5 deaths per 100,000 athletes, at a cost of about $3 million per life saved. If the athlete had a subsequent life expectancy of 60 years, the cost would be some $50,000 per life-year saved, a value that at first inspection might appeal to a health economist. Unfortunately, this apparent gain would be more than offset by the unnecessary reduction in the quality of life, the premature dependency and premature death in the 2 percent who were told, inappropriately, that they should not exercise. Plainly, there remains a need for a comprehensive analysis, carefully weighing the downside as well as the apparent gains from the required exercise ECG testing of athletes. References 1. Drezner JA, Khan K. Sudden cardiac death in young athletes. BMJ 2008;337:61-62. 2. Sofi F, Capalbo A, Pucci N, J. G, Condino F, Alessandri F, et al. Cardiovascular evaluation, including resting and exercise electrocardiography, before participation in competitive sports: cross sectional study. BMJ 2008;337:88-92. 3. Shephard RJ. Preparticipation screening of young athletes: An effective investment? In: Shephard RJ, Alexander M, Cantu RC, Feldman DE, McCrory P, Nieman DC, et al., editors. Year Book of Sports Medicine, 2005. Philadelphia, PA: Elsevier Mosby, 2005:xix-xxv. 4. Shephard RJ. Mass ECG Screening of Young Athletes. Br J Sports Med: BMJ, 2008:Online First: 7 May 2008. doi:10.1136/bjsm.2008.048843. 5. Corrado D, Pelliccia A, Vanhees L, Biffi A, Borjesson M, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Eur Heart J 2005;26:516-524. 6. Corrado D, Basso C, Pave A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athlete after implementation of a pre-participation screening program. JAMA 2006;296:1593-1601. 7. Pelliccia A, Di Paolo FM, Corrado D, Buccolieri C, Quattrini FM, Pisicchio C, et al. Evidence for efficacy of the Italian national pre- participation screening programme for identification of hypertrophic cardiomyopathy in competitive athlete. Eur Heart J 2006;27:2196-2200. 8. Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R, Castagna W, et al. Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J 2007;28:2006-2010. 9. Pelliccia A, Di Paolo FM, Quattrini FM, Basso C, Culasso F, Popoli G, et al. Outcomes in athlete with marked ECG repolarization abnormalities. N Engl J Med 2008;358:152-161. Competing interests: None declared |
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Mounir(Munir) E Nassar, Retired from clinical cardiiology practice Pittsford, New York 14534
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Dear Editor: I read with interest, the remarks of Professor Jey Sheppard.I personally would not advocate the practice of exercise EKG testing for reasons that exercise may provoke serious arrhytmias or cardiac arrest in those conditions that are the cause of the problem due to exercise.The conditions are Hypertrophic obstructive cardiomyopathy, congenital bicuspid aortic valve stenosis, and prolonged Q-T interval discovered in a 12 lead electrcardiogram, which I have discussed in my rapid responses. Sincerely, Mounr(Munir) E Nassar, M.D. FACP, FAHA mnassar1@rochester.rr.com Competing interests: None declared |
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