Should young athletes be required to undergo cardiac screening before participating in sports? If an athlete does undergo screening, should the screening involve only a history and physical examination, or should electrocardiography (ECG) also be required? These were two of the questions posed to experts from London, Italy and the U.S during a session at AHA 2013 and as part of a clinical decision article simultaneously published in the New England Journal of Medicine.

According to Sanjay Sharma, MD, from the Department of Cardiovascular Sciences, St. George's University of London, "pre-participation cardiac screening should be required for all young athletes before they engage in organized competitive sports." He notes that "any reluctance to screen the most vulnerable cohort of athletes — those in high school — seems deplorable. The detection and proper management of a potentially life-threatening genetic or congenital cardiac disorder in such persons is associated with disproportionately better outcomes than those in persons with ischemic heart disease or heart failure — and at a much lower cost. Furthermore, evaluation of the family members of an athlete who has received a diagnosis of a genetic disorder provides an invaluable opportunity to identify other young relatives at risk."

Domenico Corrado, MD, PhD, from the Department of Cardiac, Thoracic, and Vascular Science, University of Padua, Italy, believes such screening "should include a history, physical examination, and ECG, noting that ECG is the only screening strategy that has proven effective. Recently, important advances have been made in the interpretation of ECG findings in athletes, he said, and modern criteria have been proposed with a goal of improving the ability to distinguish physiologic from pathologic ECG changes. "The application of modern criteria for ECG interpretation offers the potential to dramatically reduce the traditionally high number of false positive findings" he said.

Victoria L. Vetter, MD, FACC, from the Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, took a slightly narrower approach suggesting that pre-participation cardiovascular screening include a history and physical examination only. Not only does assessing a family history and physical examination cost less than other screening approaches, they will also result in fewer false positive findings than with an ECG, she noted. "The most valid reasons for not performing ECG universally at this time include the lack of infrastructure, the lack of educated personnel for interpretation of the ECGs and for the evaluation and care of athletes identified as potentially at risk for sudden cardiac death, and the lack of evidence-based ECG standards for young athletes that reflect the diversity of the population with respect to age, sex, race, and ethnic group," she said. Moving forward, Vetter suggests that "continued research is essential to determine the best screening methods to ensure the safety of our young athletes."

On the opposite end, N.A. Mark Estes III, MD, FACC, from the New England Cardiac Arrhythmia Center, Tufts University School of Medicine, Boston, believes that pre-participation of athletic screening is "not yet ready for prime time" since "the argument advanced by screening advocates is based solely on one observational study conducted in Italy." He notes that "all screening programs, by definition, have unintended and adverse consequences. These include falsely identifying and unnecessarily restricting athletes who are free from cardiovascular disease."

He adds that "data are needed on the incremental risk of sports, the false positive rate of screening performed by nonexperts in a diverse U.S. population, the cost of screening and subsequent tests, and outcomes that include restriction of athletic activities." Further, Estes believes that "the limited data that are available fall far short of the current standards of evidence-based medicine and health policy."

Keywords: Athletes, Health Policy, Ethnic Groups, Myocardial Ischemia, Sports, Electrocardiography, Evidence-Based Medicine, Italy, Heart Diseases, London, Heart Failure, Physical Examination, Death, Sudden, Cardiac