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; Clinical Rounds
BYLINE: Jancin, Bruce
BODY:
MUNICH -- New European Society of Cardiology guidelines on preparticipation
sports screening of young athletes emphasize the key role of the 12-lead ECG as
a routine component, Domenico Corrado, M.D., said at the annual congress of the
ESC.
The guidelines created by the ESC's Working Group on Cardiac Rehabilitation
and Exercise Physiology are thus at odds with those of the American Heart
Association, which state that history and physical examination are sufficient
for preparticipation cardiovascular screening of young athletes.
Unfortunately, experience has amply shown that the American approach is
completely inadequate for preparticipation identification of asymptomatic young
athletes at increased risk for sudden death due to hypertrophic cardiomyopathy
and other conditions that predispose to development of lethal ventricular
arrhythmias on the playing field, said Dr. Corrado of the University of Padua
(Italy).
In contrast, the European approach incorporating the 12-lead ECG along with
history and physical exam has been shown to reduce sports-related sudden deaths
through more than 25 years of experience in Italy. Medical clearance using this
screening strategy has been required for all participants in organized sports
under an Italian law passed in the early 1970s, he explained.
The importance of conducting a thorough preparticipation screening was
recently shown in Dr. Corrado's prospective 21-year cohort study conducted in
the Veneto region of northeast Italy. Sports participation boosted the risk of
sudden death, with a 2.5-fold increased risk in competitive athletes compared
with nonathletes (J. Am. Coll. Cardiol. 2003;42:1959-63).
Autopsy studies have shown that physical exercise triggers sudden death in
athletes with an underlying cardiovascular condition predisposing to ventricular
arrhythmias. Up to 80% of these sports-related sudden deaths are due to
ECG-detectable conditions. The most common are hypertrophic cardiomyopathy,
which accounts for roughly 40% of sudden deaths in athletes, followed by
arrhythmogenic right ventricular cardiomyopathy, responsible for 24%.
The payoff in terms of lives saved through a preparticipation screening
strategy using the 12-lead ECG was highlighted in Dr. Corrado's prospective
study of sudden death in 12- to 35-year-olds in Italy's Veneto region during
1979-96. Of 33,735 screened athletes, 9% were referred for further
cardiovascular studies. Ultimately, hypertrophic cardiomyopathy was detected
through screening in 22 athletes, all of whom were disqualified from
competition. None died during a mean 8.2 years of follow-up. As a result, there
was just a single death due to hypertrophic cardiomyopathy in screened athletes,
compared with 16 in a group of unscreened nonathletes (N. Engl. J. Med.
1998;339:364-9).
At this year's ESC congress, Dr. Corrado presented evidence that Italian
physicians are getting better at diagnosing arrhythmogenic right ventricular
cardiomyopathy, a condition discovered 22 years ago. During 1982-1991 in the
Padua area, arrhythmogenic right ventricular cardiomyopathy accounted for just
0.5% of all medical disqualifications from sports participation; during
1992-2001, the rate rose to 3.3%.
Italian economic analyses have concluded that a preparticipation screening
strategy based upon history and physical exam costs 20 euro per athlete. Adding
a 12-lead ECG study to the screening protocol raises the cost to 30 euro. It is
estimated that screening via history, physical exam, and 12-lead ECG costs 2,527
euro per year of life saved, while screening through history and physical exam
alone COSTS 7,274 euro per year of life saved.
Adding echocardiography to the preparticipation screening exam adds nothing
other than further expense, Dr. Corrado said.
BYLINE: Jancin, Bruce
BODY:
MUNICH -- New European Society of Cardiology guidelines on preparticipation
sports screening of young athletes emphasize the key role of the 12-lead ECG as
a routine component, Domenico Corrado, M.D., said at the annual congress of the
ESC.
The guidelines created by the ESC's Working Group on Cardiac Rehabilitation
and Exercise Physiology are thus at odds with those of the American Heart
Association, which state that history and physical examination are sufficient
for preparticipation cardiovascular screening of young athletes.
Unfortunately, experience has amply shown that the American approach is
completely inadequate for preparticipation identification of asymptomatic young
athletes at increased risk for sudden death due to hypertrophic cardiomyopathy
and other conditions that predispose to development of lethal ventricular
arrhythmias on the playing field, said Dr. Corrado of the University of Padua
(Italy).
In contrast, the European approach incorporating the 12-lead ECG along with
history and physical exam has been shown to reduce sports-related sudden deaths
through more than 25 years of experience in Italy. Medical clearance using this
screening strategy has been required for all participants in organized sports
under an Italian law passed in the early 1970s, he explained.
The importance of conducting a thorough preparticipation screening was
recently shown in Dr. Corrado's prospective 21-year cohort study conducted in
the Veneto region of northeast Italy. Sports participation boosted the risk of
sudden death, with a 2.5-fold increased risk in competitive athletes compared
with nonathletes (J. Am. Coll. Cardiol. 2003;42:1959-63).
Autopsy studies have shown that physical exercise triggers sudden death in
athletes with an underlying cardiovascular condition predisposing to ventricular
arrhythmias. Up to 80% of these sports-related sudden deaths are due to
ECG-detectable conditions. The most common are hypertrophic cardiomyopathy,
which accounts for roughly 40% of sudden deaths in athletes, followed by
arrhythmogenic right ventricular cardiomyopathy, responsible for 24%.
The payoff in terms of lives saved through a preparticipation screening
strategy using the 12-lead ECG was highlighted in Dr. Corrado's prospective
study of sudden death in 12- to 35-year-olds in Italy's Veneto region during
1979-96. Of 33,735 screened athletes, 9% were referred for further
cardiovascular studies. Ultimately, hypertrophic cardiomyopathy was detected
through screening in 22 athletes, all of whom were disqualified from
competition. None died during a mean 8.2 years of follow-up. As a result, there
was just a single death due to hypertrophic cardiomyopathy in screened athletes,
compared with 16 in a group of unscreened nonathletes (N. Engl. J. Med.
1998;339:364-9).
At this year's ESC congress, Dr. Corrado presented evidence that Italian
physicians are getting better at diagnosing arrhythmogenic right ventricular
cardiomyopathy, a condition discovered 22 years ago. During 1982-1991 in the
Padua area, arrhythmogenic right ventricular cardiomyopathy accounted for just
0.5% of all medical disqualifications from sports participation; during
1992-2001, the rate rose to 3.3%.
Italian economic analyses have concluded that a preparticipation screening
strategy based upon history and physical exam costs 20 euro per athlete. Adding
a 12-lead ECG study to the screening protocol raises the cost to 30 euro. It is
estimated that screening via history, physical exam, and 12-lead ECG costs 2,527
euro per year of life saved, while screening through history and physical exam
alone COSTS 7,274 euro per year of life saved.
Adding echocardiography to the preparticipation screening exam adds nothing
other than further expense, Dr. Corrado said.
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