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.