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• Cardiovascular preparticipation screening
  Fabio Pigozzi
  Published on: 11 October 2022
• Cardiovascular screening of athletes: a unique opportunity for an epidemiological experiment
  Roy J. Shephard
  Published on: 11 October 2022

• Published on: 11 October 2022

  Cardiovascular preparticipation screening

  • Fabio Pigozzi, Professor of Trauma and Orthopaedic Surgery
  • Other Contributors:
    • A Spataro, F Fagnani, and Nicola Maffulli

  Dear Editor

  The presence of false positive ECGs is without doubt a limit to the diagnostic capability of this investigation in the contest of cardiovascular screening of athletes. These abnormal ECG appearances result mainly from the morphological adaptations of the heart to training and to the actual sport practised. For example, endurance athletes show a higher rate of ECG abnormalities than athletes practising ‘tec...

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  Dear Editor

  The presence of false positive ECGs is without doubt a limit to the diagnostic capability of this investigation in the contest of cardiovascular screening of athletes. These abnormal ECG appearances result mainly from the morphological adaptations of the heart to training and to the actual sport practised. For example, endurance athletes show a higher rate of ECG abnormalities than athletes practising ‘technical sports’ such as sailing, horse riding or pistol shooting. Cardiac adaptation is correlated with training time and training intensity. Furthermore, males and young athletes present more frequently such anomalies, possibly a consequence of their more marked training-induced cardiac adaptation capability. In recreational athletes, these morphological adaptations are reduced or assents, as consequence of the lower the cardiovascular stress and the effects of training on the heart. Pelliccia et al recently showed that ECG has a high negative predictive value (96%), showing that a normal ECG (as indeed it does in non-athletic individuals) is able to discriminate with a high index of accuracy the presence of cardiovascular anomaly.[1] On the other hand, an abnormal ECG points towards a heart problem and further investigations. This is confirmed by Basso et al, who showed that it is possible to identify, using electrocardiography, subjects with hypertrophic cardiomyopathy, a cause of sudden death in athletes.[2] These individuals were not allowed to take part in competitive sports, and, eight years after the electrocardiographic diagnosis, did not present with sudden cardiac death. Therefore, the identification of subjects at risk and the proscription of competitive sports activity seem to be the right strategy to prevent sudden cardiac death. Pre-participation screening for the detection of cardiovascular abnormalities used in Italy has up to now shown to be an effective tool to prevent cardiovascular accidents in this context.

  References

  (1) Pelliccia A, Maron BJ, Culasso F, Di Paolo FM, Spataro A, Biffi A, Caselli G, Piovano P. Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 2000; 102 (3): 278-84.

  (2) Basso C, Thiene G, Corrado D, Buja G, Melacini P, Nava A. Hypertrophic cardiomyopathy and sudden death in the young: pathologic evidence of myocardial ischemia. Hum Pathol 2000;31(8):988-98.

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  Conflict of Interest:
  None declared.

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• Published on: 11 October 2022

  Cardiovascular screening of athletes: a unique opportunity for an epidemiological experiment

  • Roy J. Shephard, Medical Scientist

  Dear Editor

  The Italian requirement that all professional and amateur athletes obtain medical certification of their ability to participate in their chosen sport dates from 1950.[1] In 1971 and 1982 this mandate was reinforced by specific legislation of the Italian Ministry of Health, covering both competitive and non-competitive participants.[2] Consequently, large numbers of symptom-free and ostensibly health...

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  Dear Editor

  The Italian requirement that all professional and amateur athletes obtain medical certification of their ability to participate in their chosen sport dates from 1950.[1] In 1971 and 1982 this mandate was reinforced by specific legislation of the Italian Ministry of Health, covering both competitive and non-competitive participants.[2] Consequently, large numbers of symptom-free and ostensibly healthy young Italians have undergone ECG and echocardiographic screening, with the intent of avoiding sudden, exercise-induced cardiovascular death.[3,4]

  Such procedural norms are in striking contrast with those of other countries such as Canada, where it is maintained that the constraints of Bayes theorem limit the value of laboratory cardiovascular testing in symptomless young athletes.[5,6] Indeed, it is argued that by generating an undesirable number of false positive responses, such a policy creates much unnecessary anxiety, and leads to unnecessary warnings against exercise, effectively worsening the individual's prognosis.

  In their most recent article, Pigozzi and associates [1] speak of the efficacy of the Italian screening programme, although they admit to an alarming 40% of false positive results from ECG testing. Corrado and associates [7] found that 9% of Italian athletes had "abnormal" ECGs, and were required to undergo the additional expense of echocardiographic screening; on the basis of the latter investigation, it appears that 2% were barred from athletic participation.

  Plainly, there is a unique opportunity to compare the health consequences of the Italian approach with that of other countries who believe that detailed laboratory examination is unwarranted. Are there fewer episodes of sudden exercise-induced death per 100,000 hours of competitive and non-competitive athletic activity in Italy than elsewhere? And which approach gives the smaller number of unnecessary cardiac neuroses?

  To my knowledge, no one has yet made such an analysis, and in its absence I would suggest it is premature to conclude that the Italian "state law is noteworthy for the positive results that it has produced."

  References

  (1) Pigozzi F, Spataro A, Fagnani F, et al. Preparticipation screening for the detection of cardiovascular abnormalities that may cause sudden death in competitive athletes. Br J Sports Med 2003;37:4-5.

  (2) Decree of the Italian Ministry of Health, February 19, 1982. Norme per la tutela dell'attività agonistica. Gazetta Ufficiale 1982: Mar 5: 63.

  (3) Maron BJ, Shirani, J, Poliac LC, et al. Sudden death in young competitive athletes. JAMA 1996; 276: 199-204.

  (4) Maron BJ. Considerations for preparticipation cardiovascular screening in young competitive athletes. In: Shephard RJ, Åstrand PO, (Eds) Endurance in Sport, 2nd ed. Oxford, Blackwell, 2000; Pp. 667-681.

  (5) Shephard RJ. The athlete's heart: Is big beautiful? Br J Sports Med 1996;30:5-10.

  (6) Shephard RJ. Medical surveillance of endurance sport. In: Shephard RJ, Åstrand PO, (Eds) Endurance in Sport, 2nd ed. Oxford, Blackwell, 2000; Pp.653-666.

  (7) Corrado D, Basso C, Schiavon M, et al. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998; 339:364-369.

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  Conflict of Interest:
  None declared.

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