Young athletes: Preventing sudden death by adopting a modern screening approach? A critical review and the opening of a debate
Paolo Angelini, Raja Muthupillai, Alberto Lopez, Benjamin Cheong, Carlo Uribe, Eduardo Hernández, Stephanie Coulter, Emerson C. Perin, Silvana Molossi, Federico Gentile, Scott D. Flamm, G Lorenz, Flavio D’Ascenzi, Jonathan M. Tobis, Roberto Sarnari, Antonio F. Corno, James L. Furgerson, Amedeo Chiribiri, Adriana Villa, F Orzan, Pedro Brugada, John L. Jefferies, P Aubry, Jeffrey A. Towbin, Gaetano Thiene, Robert J. Tomanek
Abstract
Preventing sudden cardiac death (SCD) in athletes is a primary duty of sports cardiologists. Current recommendations for detecting high-risk cardiovascular conditions (hr-CVCs) are history and physical examination (H&P)-based. We discuss the effectiveness of H&P-based screening versus more-modern and accurate methods. In this position paper, we review current authoritative statements and suggest a novel alternative: screening MRI (s-MRI), supported by evidence from a preliminary population-based study (completed in 2018), and a prospective, controlled study in military recruits (in development). We present: 1. Literature-Based Comparisons (for diagnosing hr-CVCs): Two recent studies using traditional methods to identify hr-CVCs in >3,000 young athletes are compared with our s-MRI-based study of 5,169 adolescents. 2. Critical Review of Previous Results: The reported incidence of SCD in athletes is presently based on retrospective, observational, and incomplete studies. H&P’s screening value seems minimal for structural heart disease, versus echocardiography (which improves diagnosis for high-risk cardiomyopathies) and s-MRI (which also identifies high-risk coronary artery anomalies). Electrocardiography is valuable in screening for potentially high-risk electrophysiological anomalies. 3. Proposed Project: We propose a prospective, controlled study (2 comparable large cohorts: one historical, one prospective) to compare: (1) diagnostic accuracy and resulting mortality-prevention performance of traditional screening methods versus questionnaire/electrocardiography/s-MRI, during 2-month periods of intense, structured exercise (in military recruits, in advanced state of preparation); (2) global costs and cost/efficiency between these two methods. This study should contribute significantly toward a comprehensive understanding of the incidence and causes of exercise-related mortality (including establishing a definition of hr-CVCs) while aiming to reduce mortality.