Cardiac Screening in Adolescent Soccer Players

Study Questions:

What is the incidence of and what are the etiologies of sudden cardiac death in adolescent soccer players?

Methods:

In the English Football (soccer) Association, 11,168 athletes, 95% male, on average 16 years of age, underwent cardiac screening over a 20-year period. Screening consisted of a questionnaire, physical examination, electrocardiography (ECG), and transthoracic echocardiogram.

Results:

Out of the 11,168 screened athletes, 830 (7.4%) were flagged as needing further workup. Forty-two athletes (0.38%) were found to have conditions that are associated with sudden cardiac death: the most common was Wolff-Parkinson-White pattern on ECG (26 out of 42), followed by hypertrophic cardiomyopathy (5), long QT syndrome (3), arrhythmogenic right ventricular cardiomyopathy (ARVC) (2), and coronary artery anomaly (2). Two athletes with hypertrophic cardiomyopathy continued to play against medical advice and died during exercise. Another 225 had valvular or congenital disorders such as bicuspid aortic valve (68 out of 225), atrial septal defect (62), aortic insufficiency (29), and mitral valve prolapse (24). There were 23 deaths in total, 8 (35%) of which were due to a cardiac cause. The second most common cause was road traffic accidents in 7 (30%). Of the 8 sudden cardiac deaths, 4 athletes were white, and 6 had passed the screening process as within normal. The time between screening and death ranged from <1 year to 13.2 years. Autopsy data were available for all the deaths.

Conclusions:

The calculated incidence of sudden cardiac death was 1 per 14,794 person-years or 6.8 per 100,000 athletes. Most of the deaths were due to cardiomyopathies that were not identified during the screening process. The overall prevalence of cardiac diagnoses associated with sudden cardiac death was 0.38%.

Perspective:

  1. In this large and well-defined cohort study of predominantly male adolescent soccer players in the United Kingdom, the incidence of sudden cardiac death was approximately threefold higher than some previous studies. This study provides further evidence that the incidence of sudden cardiac death varies with the cohort (e.g., type of sport) studied.
  2. ECG interpretation identified almost all the conditions that should have been identified by ECG at the time of the screen. Thirty-six of the forty-two cases with concerning cardiac conditions had an abnormal ECG. The 6 out of 42 that were “missed” were ARVC (1), coronary artery anomaly (2), and bicuspid aortic valve (3). All athletes diagnosed with hypertrophic cardiomyopathy, dilated cardiomyopathy, long QT syndrome, and Wolff-Parkinson-White pattern had an abnormal screening ECG.
  3. There were 8 deaths; and 6 had had “negative” initial screens at age 16, and 5 of these were ultimately diagnosed with a cardiomyopathy. These findings underscore a decreased sensitivity for one-time screening at age 16 if a disease process has yet to manifest. Demographics and type of sport can influence disease progression. Age-related penetrance in hypertrophic cardiomyopathy and exercise-induced stress over time on the cardiac structures are important factors. In studies of patients with known hypertrophic cardiomyopathy, the ECG can be normal approximately 15% of the time. The age of death was approximately 7 years after the screen. Hence, the European Football Association just announced that screenings will be repeated at ages 18 and 20, and possibly 25. How often and for which cohorts repeat screenings are indicated is not yet clear, and requires further study.
  4. Importantly, screening did identify 501 athletes who warranted continued follow-up; 225 had disorders such as bicuspid aortic valve, atrial septal defect, ventricular septal defects, and mitral valve prolapse. Five patients out of the forty-two with a condition associated with sudden cardiac death underwent corrective surgery and then returned to play. Twenty-four of the twenty-six athletes with Wolff-Parkinson-White ECG patterns underwent catheter ablation before returning to play. Of note, none of the patients with mitral valve prolapse had sudden cardiac death.
  5. Limitations of the study include a focused cohort in terms of sport, gender, location; mortality data relied on recall on questionnaire by the football/soccer clubs, so not all cases may have been captured; and an impressive screening program including ECG, echo, and renowned expert consultants that would not be easily replicated elsewhere.
  6. Cardiopulmonary resuscitation training, automated external defibrillator availability, and up to date Emergency Action Plans are paramount to safety in sport, no matter the screening program in place.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Valvular Heart Disease, Implantable Devices, EP Basic Science, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, Acute Heart Failure, Echocardiography/Ultrasound, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and Imaging

Keywords: Aortic Valve Insufficiency, Arrhythmias, Cardiac, Arrhythmogenic Right Ventricular Dysplasia, Athletes, Cardiomyopathy, Dilated, Cardiomyopathy, Hypertrophic, Cardiopulmonary Resuscitation, Catheter Ablation, Death, Sudden, Cardiac, Defibrillators, Echocardiography, Electrocardiography, Heart Defects, Congenital, Heart Failure, Heart Septal Defects, Atrial, Heart Septal Defects, Ventricular, Heart Valve Diseases, Long QT Syndrome, Mitral Valve Prolapse, Physical Examination, Primary Prevention, Soccer, Sports, Wolff-Parkinson-White Syndrome


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