Sudden cardiac death (SCD) in young competitive athletes is a devastating event caused by various cardiovascular conditions. To prevent such tragedies, multiple medical associations and sports federations worldwide recommend preparticipation screening (PPS) of athletes. However, the optimal PPS protocol remains debatable, particularly regarding including a screening electrocardiogram (ECG), the appropriate starting age and frequency of repeat evaluations, and the eligibility of athletes diagnosed with cardiovascular diseases at risk of SCD.
According to European Heart Journal, the Italian program of cardiovascular preparticipation screening (PPS) has been implemented to identify cardiovascular diseases at risk of sudden cardiac death (SCD) in young, competitive athletes. This study aimed to report the long-term findings of the PPS, including the diagnostic yield, costs, and outcomes of the program in a large population of Italian children aged 7 to 18 years.
Over an 11-year study period, 22,324 consecutive children underwent a total of 65,397 annual evaluations, which included medical history, physical examination, resting electrocardiogram, and stress testing. Cardiovascular diseases at risk of SCD were identified in 69 children (0.3%), and the estimated cost per diagnosis was 73,312€. The PPS program identified cardiovascular diseases at risk of SCD over the whole study age range of children and, more often, on repeat evaluations. The incidence of sport-related cardiac arrest during long-term follow-up was low.
The risk of sudden cardiac death (SCD) in young competitive athletes due to underlying cardiovascular conditions is a growing concern. Preparticipation screening (PPS) is recommended worldwide to identify athletes with cardiovascular disease at risk of SCD and prevent sport-related fatalities. However, there is still debate over the optimal PPS protocol, including screening electrocardiogram (ECG) and the appropriate starting age and frequency of repeat cardiovascular evaluations.
An outcome study on English football players undergoing a single PPS session reported a high incidence of SCD over long-term follow-up. In contrast, the Italian PPS program, which has been in practice since 1982, mandates annual PPS for athletes beginning at the start of athletic activity and entails the non-eligibility of athletes diagnosed with cardiovascular disease at risk of SCD. This study aims to evaluate the results of the Italian PPS program in a large population of children, including the diagnostic yield of heart diseases at risk of SCD, the costs of serial cardiovascular evaluations, and long-term outcomes.
The study population included children aged 7–18 who underwent cardiovascular screening before participating in competitive sports activity from 2009 to 2019 at the Center for Sports Medicine of Treviso, Veneto Region of northeastern Italy. The primary surveillance outcome was sudden cardiac death or resuscitated cardiac arrest in the screened athletic population. The Ethical Committee of the Treviso province approved the study, and consent was waived. The cost per diagnosis and the incremental cost-effective ratio for screening older vs. younger children were calculated and the surveillance period lasted from the first evaluation to the end of 2021.
A new study has revealed that out of 22,324 consecutive athletes, who underwent a total of 65,397 annual preparticipation cardiovascular evaluations over 11 years, 8.9% required additional investigations. These included echocardiography, 24-h ambulatory ECG monitoring, maximal exercise testing, and cardiac magnetic resonance imaging. An invasive electrophysiologic study or coronary angiography was performed on only 14 athletes. The reasons for these additional investigations were positive family history, abnormal physical examination, alterations of resting 12-lead ECG, or exercise testing.
The study also found that at-risk cardiovascular conditions included congenital heart diseases in 17 athletes, channelopathies in 14, cardiomyopathies in 15, post-inflammatory or idiopathic non-ischemic left ventricular scar (NILVS) with ventricular arrhythmias in 18, and other conditions in 5. Of 69 athletes diagnosed with a disease associated with sudden cardiac death (SCD), 74% participated in team sports, while 18 practiced various individual sports disciplines.
Moreover, the study showed that 29% of athletes with a diagnosis of a disease associated with SCD had a positive family history, symptoms, and abnormal physical examination, 59% had abnormalities on resting 12-lead ECG, and 52% demonstrated abnormalities on exercise testing. The median age at the first screening was 12 years, and the study population comprised 62% males and 89% Caucasians. These findings emphasize the importance of preparticipation cardiovascular evaluations for athletes, particularly for those participating in team sports. Identifying at-risk cardiovascular conditions in athletes is crucial in preventing sudden cardiac death and ensuring their safe participation in sports.
