Original paper
Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death in China

https://doi.org/10.1016/j.jsams.2006.07.001Get rights and content

Summary

The cardiovascular pre-participation screening proposal for young competitive athletes has the potential to save young lives. This study aimed to identify individuals at risk for potentially lethal cardiovascular diseases in athletes before competition. Between June 2005 and July 2005, 351 (170 male and 181 female) elite Chinese athletes from 21 sports were profiled. The 12-lead electrocardiogram and echocardiography were employed to evaluate cardiovascular diseases. The vast majority had no definitive evidence of cardiovascular disease. However, abnormal ECGs were identified in 16 athletes (4.5%), including 4 with distinctly abnormal and 12 with mildly abnormal patterns. Only 13 athletes (3.7%) had echocardiographic evidence of relatively mild valve regurgitation that had not been previously suspected. In three athletes with relatively mild ventricular septal hypertrophy (13–14 mm), it was not possible to discern with absolute certainty whether the wall thickening was a manifestation of hypertrophic cardiomyopathy or secondary to athletic conditioning (“athlete heart”). This screening protocol identified no athletes with definite evidence of hypertrophic cardiomyopathy, Marfan's syndrome or other cardiovascular diseases that convey a significant potential risk for sudden death or disease progression during athletic activity. This is largely due to the relative low prevalence of conditions resulting in sudden cardiac death in young athletes and high false positive/negative rates in the tests used as part of the screening process (due to a large overlap between cardiovascular changes due to pathology and those due to intense training).

Introduction

The sudden, unexpected death of a young athlete is a tragedy unparalleled in sports. Fatal sport-related injuries can result from head and cervical spine trauma, but most sudden deaths in athletes are cardiac in origin.1, 2 A prospective population-based study in the Veneto Region of Italy reported an incidence of sudden death of 2.3 (2.62 in males and 1.07 in females) per 100,000 athletes per year from all causes, and of 2.1 per 100,000 athletes per year from cardiovascular diseases.3 The prevalence of these conditions varies according to ethnic background. Hypertrophic cardiomyopathy (HCM) has been reported to be the leading cause of sudden death in young competitive athletes, accounting for up to 40% of athletic field deaths in the USA;1, 4 Arrhythmogenic right ventricular dysplasia (ARVD) is the most common cause of sudden death among Italian athletes;5 In Germany, there is a high proportion of myocarditis.5 Recently, considerable interest has been raised regarding the role of pre-participation screening for early identification of those cardiovascular diseases which are responsible for athletic field deaths and for disqualification of athletes at risk, with the expectation that such a strategy may eventually prevent sudden death. In an effort to identify clinically silent cardiovascular diseases that increase the risk for sudden death, most states have mandated pre-participation screening.6, 7 But in China, we had little knowledge about the cause and epidemiology of SCD in young athletes. In order to prevent sudden death, the athletes were screened for the cardiovascular diseases before competition.

Section snippets

Selection of subjects

Between June 2005 and July 2005, 351 athletes from 21 sports were screened for the cardiovascular diseases in Jiangsu Province. The athletes were in full training at the time of evaluation. All athletes had taken part in the seven national sport meeting in China. The athletes were aged from 13 to 34 years; 170 were male (48.4%) and 181 were female (51.6%). All were Chinese Han population.

Clinical parameters

Body surface area (BSA) where calculations were made using the following formulae: BSA (m2) = 0.00659 height

Clinical parameters

Of the 170 male athletes, the mean age was 23.04 ± 3.80 years (13–33 years), while body surface area was 2.06 ± 0.28 m2 (1.25–2.81 m2), HR was 60.86 ± 8.56 beats min (40–88 beats min), the height was 180.51 ± 12.49 cm (140–203 cm), the weight was 73.72 ± 16.87 kg (31–130 kg). SBP was 119.2 ± 13.57 mmHg (96–180 mmHg), SDP was 74.80 ± 9.30 mmHg (58–110 mmHg); of the 181 female athletes, the mean age was 20.73 ± 4.14 years (14–34 years), while body surface area was 1.82 ± 0.21 m2 (1.25–2.67 m2), HR was 61.51 ± 8.67 beats min (40–85 

Discussion

Cardiovascular screening of athletes is a challenging aspect of the pre-participation evaluation. Recently, the long QT syndrome, Brugada, syndrome, ARVD, pre-excitation syndromes, dilated cardiomyopathy, short QT syndrome, and even hypertrophic cardiomyopathy may be identified with the electrocardiogram. Overall, these conditions (including HCM) account for up to 60% of sudden deaths in young competitive athletes.11 Despite a number of previous observational surveys, the determinants and

Practical implications

  • Pre-participation cardiovascular screening should pursue any history of cardiac symptoms or family history of premature cardiac disease, as well as abnormal cardiovascular physical findings.

  • The 12-lead electrocardiogram and echocardiography should be considered and have the potential to enhance the sensitivity of the screening process for detection of cardiovascular diseases with risk of sudden death in athletes.

  • Coaches, players and the medical team should be aware for the ambitious and

Acknowledgments

This work was supported by a grant from National Natural Science Foundation of China (30570745) and High Technology Program of Jiangsu Province in China (BG2003033).

References (26)

  • F. Pigozzi et al.

    Preparticipation screening for the detection of cardiovascular abnormalities that may cause sudden death in competitive athletes

    Br J Sports Med

    (2003)
  • B.J. Maron et al.

    Eligibility recommendations for competitive athletes with cardiovascular abnormalities

    36th Bethesda conference

    J Am Coll Cardiol

    (2005)
  • D. Corrado et al.

    Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus statement of the study group of sport cardiology of the working group of cardiac rehabilitation and exercise physiology and the working group of myocardial and pericardial diseases of the European society of cardiology

    Eur Heart J

    (2005)
  • Cited by (25)

    • Preparticipation Evaluation

      2020, Primary Care - Clinics in Office Practice
      Citation Excerpt :

      Screening for predisposing conditions is difficult and limited by several coexisting issues: the low prevalence of cardiovascular diseases responsible for sudden death (SD) in the young population, the low risk of SD among those with the diseases, the large sizes of the populations proposed for screening, and the imperfection of the 12-lead ECG as a screening or diagnostic tool in this setting.65 A valid concern with ECG screening is the potential for costly second-tier follow-up testing (eg, ECHOs and MRI) while only detecting rare true-positive results.38,87–89 However, even if ECGs with false-positive results could be reduced to only 5% in the course of screening 10 million individuals (the estimated number of US competitive athletes), screening ECGs would nevertheless identify a formidable obstacle of 500,000 people who required further testing to exclude underlying heart disease and resolve eligibility for sports participants.

    • Electrocardiographic right and left bundle branch block patterns in athletes: Prevalence, pathology, and clinical significance

      2015, Journal of Electrocardiology
      Citation Excerpt :

      Incomplete left bundle branch block is defined by a QRS duration ≥ 100 ms and < 120 ms in leads I, aVL, and V5 or V6[13]. Although mostly cross-sectional in design, there have been many studies evaluating the presence of ECG abnormalities in athletes [7,15–27]. It has been well established that IRBBB is common, particularly among endurance athletes [21].

    • Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): A scientific statement from the american heart association and the american college of cardiology

      2014, Journal of the American College of Cardiology
      Citation Excerpt :

      Very few of these individuals would ultimately prove to have important disease with a risk for SD that required disqualification (113,237). Often ignored in this discussion is the importance of false-negative test results in the ECGs, which reflect low sensitivity (93,97,125,127,189,190). In the current environment, false-negative results can be expected in ≥10% of patients with HCM (the most common cause of SD in young people), with a significant proportion of these showing completely normal patterns (189).

    • Hypertrophic cardiomyopathy vs athlete's heart

      2009, International Journal of Cardiology
    • Screening for safe sports participation: Do for yourself what you tell your patients

      2009, European Journal of Cardiovascular Prevention and Rehabilitation
    View all citing articles on Scopus
    View full text