Challenges Associated With Evaluating Athletes for Underlying Pathological Conditions

A paper published March 4 in the Journal of the American College of Cardiology provides insight into the challenges and dilemmas faced when evaluating athletes for the underlying pathological conditions capable of causing sudden cardiac death (SCD).

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The incidence of SCD is greater in athletes compared with their nonathletic counterparts due to the increased risk associated with strenuous exercise in the context of quiescent cardiac abnormality. The authors note that cardiomyopathy, including hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC) is the most common cause of exercise-related SCD. The reported prevalence of HCM is 0.2 percent in the general population and 0.07 percent to 0.08 percent in athletes. ARVC has a reported prevalence of 1/1,000 in the general population, and "a 5-fold higher risk of SCD in ARVC has been demonstrated during competitive sports compared with sedentary activity."

Prevention of SCD by pre-participation cardiovascular screening (PPS) is recommended by the European Society of Cardiology (ESC), the American Heart Association (AHA) and the International Olympic Committee. The authors add that the evaluation of athletes for conditions predisposing to SCD must incorporate clinical history, physical examination, 12-lead ECG and trans-thoracic echocardiography with further investigations as required.

However, the AHA does not support routine use of ECG despite strong evidence for incorporating ECGs in PPS. "The primary argument against electrocardiographic screening include concerns regarding false-positive results, cost-effectiveness, and psychological implications for athletes and their families," note the authors.

"Sudden cardiac death in the sports arena is rare but devastating," the authors conclude. "Preventative strategies such as large-scale PPS of competitive athletes and increasing availability of automated external defibrillators are challenges requiring significant infrastructure and expertise but should be considered achievable aims rather than impossible goals"

Further, the authors note that victims of SCD are often entirely asymptomatic before their initial presentation and demonstrate only subtle abnormalities on investigation. "It is therefore recommended that cardiac evaluation of an athlete is performed by trained cardiologists and sports physicians familiar with the conditions capable of causing SCD and the impact of demographic factors associated with the individual athlete," they add.

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