Introduction

In 1901, Dr W Collier1 submitted a paper to the British Medical Journal entitled, ‘The effects of severe muscular exertion, sudden and prolonged, in young adolescents’. This early article demonstrated the predicament faced by physicians when dealing with athletes suspected of, or diagnosed with, a cardiovascular disease. Collier describes the case of an Oxford University mile runner who was performing poorly and presented for medical consultation. Physical examination at rest was normal, but upon mild exercise, the athlete demonstrated a very distinct systolic murmur. Rightly or wrongly, Collier stated that he ‘had no doubt that it was over-dilation of the right ventricle’ and disqualified the athlete from competition. He even sent the athlete on a sea voyage, where the temptation to exercise was effectively removed. Despite much medical, academic and technological advancement in the 100 years after Collier's initial insights, many sports medicine physicians who undertake cardiovascular preparticipation screening may argue that following the diagnosis of an inherited cardiac disease, the limited ability to adequately risk stratify and provide evidence-based disqualification criteria for athletes indicates our management remains just as inadequate and imprecise.

Athletes are perceived as the epitome of health, owing to their unique lifestyle and physical achievements. However, a small proportion of athletes die suddenly from a pathological heart condition; so-called sudden cardiac death (SCD). Most of the deaths in athletes under 35 years, are attributed to inherited or congenital disorders of the heart that predispose to malignant ventricular arrhythmias. Due to the steady trickle of SCD's in young athletes, several major sport governing bodies, including the International Olympic Committee and Fédération Internationale de Football Association have ‘recommended’ the implementation of systematic cardiac screening programmes—a trend increasingly being adopted by national and international sport governing bodies worldwide. Despite differences in screening methodology, both the American College of Cardiology/American Heart …