Mandatory Electrocardiographic Screening of Athletes to Reduce Their Risk for Sudden Death: Proven Fact or Wishful Thinking?

Study Questions:

Does preparticipation screening of athletes with a strategy including resting and exercise electrocardiography (ECG) reduce their risk for sudden death?


A systematic search of the two main newspapers in Israel was conducted to determine the yearly number of cardiac arrest events among competitive athletes. The size of the population at risk was retrieved from the Israel Sport Authority and was extrapolated to the changes in population size over time. Results were compared before and after a 1997 law in Israel mandating compulsory screening with resting ECG and exercise testing.


During the years 1985 through 2009, there were 24 documented events of sudden death or cardiac arrest events among competitive athletes. Eleven occurred before the 1997 legislation and 13 occurred after it. The average yearly incidence of sudden death or cardiac arrest events was 2.6 events per 100,000 athlete-years. The average yearly incidence during the decade before the 1997 legislation was 2.54 events per 100,000 person-years, compared to 2.66 events per 100,000 person-years in the decade after the legislation (p = 0.88).


The incidence of sudden death of athletes in this study is within the range reported by others. However, mandatory ECG screening of athletes had no apparent effect on their risk for cardiac arrest.


Based on data from the Veneto region of northern Italy, a large number of countries and athletic entities mandate preparticipation ECG screening of athletes with the aim of preventing sudden cardiac death. However, objective data are sparse. The Italian experience showed a dramatic reduction in sudden deaths among athletes, albeit (a) only to a level that is seen in the United States without ECG screening, and (b) predominantly related to an unusually high incidence of arrhythmogenic right ventricular dysplasia that is not observed as commonly in other regions. Meanwhile, the potential ‘costs’ of excessive testing run beyond financial ones, and include disqualification of many athletes who are not at risk. This is an important observational study with findings that are directly contradictory to those from Italy. In the absence of prospective randomized trials that likely will not be forthcoming, policies of mandatory screening should be reconsidered in light of absence of supporting data.

Clinical Topics: Arrhythmias and Clinical EP, Sports and Exercise Cardiology, SCD/Ventricular Arrhythmias, Sports and Exercise and ECG and Stress Testing

Keywords: Sports, Electrocardiography, Mandatory Testing, Death, Sudden, Cardiac, United States, Exercise Test

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