Heart checks on young athletes don't save lives

25th April 2016

Heart checks should not be done on young athletes because there is no proof it saves lives, suggests an analysis published last week in the respected British Medical Journal (BMJ).

The findings, researchers say, show that the harm outweighs any benefits, and there is no robust evidence to show it prevents deaths.

The study, from the Belgian Health Care Knowledge Centre, estimated that around 0.001% of young athletes die suddenly from a cardiac arrest every year, often caused by an underlying heart condition, such as cardiomyopathy.

Sudden cardiac death in a young person on a sports field is a devastating event, the researchers said. But pre-participation heart checks to identify these heart conditions and prevent deaths was controversial.

So they carried out a detailed review of the medical literature on the harms and benefits of such pre-participation screening  to prevent cardiac arrest in non-professional athletes aged 18-34 years.

The American Heart Association recommends taking a personal and family history along with a physical examination. But very few people at risk of sudden cardiac death are detected this way.

Only four out of 115 young athletes who died suddenly had a standard pre-participation evaluation, and the condition that led to death was identified in only one athlete.

The European Society of Cardiology also recommends an electrocardiogram (ECG), a test that checks for problems with the electrical activity of the heart.

While ECGs can be better at detecting certain conditions, these don't pick up all signs and symptoms associated with heart disease, and the sensitivity of this test is generally low.

Overall, 25% of people with a condition that may lead to a sudden cardiac death would not be identified, say the authors.

At the same time, there are a high number of false positives associated with screening, meaning healthy people are inappropriately identified as having a potential condition, leading to over diagnosis and overtreatment.

Up to 5% of healthy people can be suspected of having disease following ECGs, and up to 30% of those screened may be referred for additional heart testing.

These additional tests can lead to unnecessary harms associated with anxiety and psychological trauma, over diagnosis and over treatment. And athletes can be subjected to temporary or lifelong restrictions and exclusion from sport, and problems with getting insurance and employment.

Doctors also don't agree on standard treatments for the conditions. Most people with commonly identified conditions will lead normal lives with no symptoms, and the risk of death associated with some treatments for these diseases is similar to that of sudden cardiac death.

"As long as those at high risk of sudden death cannot be reliably identified and appropriately managed, young athletes should not be submitted to pre-participation screening," said the authors.

The only piece of evidence that suggests screening saves lives comes from the Veneto study, by Italian researchers, that shows a 90% reduction of deaths in the region following mandatory screening in 1976.

The Italian investigators have played an important role in the introduction of pre-participation screening, but critics say their findings do not prove lives were saved because of the study's limitations.

"Some of the concerns might be clarified if the Italian investigators provide access to additional unpublished data," say the Belgian authors, who have made repeated requests to the investigators directly, and through the UK and Italian health ministers.

The BMJ contacted Professor Domenico Corrado, a lead author of some of the Italian studies. He said they "were analysing new data on sport-related mortality in the Veneto region of Italy during the last decade and that updated data was not available for public release yet".

He repeated that the "the long-running Italian experience with universal pre-participation screening shows that systematic ECG screening of young competitive athletes... is life-saving."

In a linked editorial, Christopher Semsarian from the University of Sydney says this latest analysis "brings into sharp focus the uncertainties surrounding the effectiveness of pre-participation screening."

More research is needed to "fill in the many gaps and take us nearer to the ultimate goal of preventing rare but tragic sudden deaths in young people," he says. But this will be costly and take a long time because the condition is rare.

Other solutions include developing better screening tools to limit over diagnosis as well as improving education and raising awareness among athletes and doctors..

Coaches and players should be trained in resuscitation, and defibrillators should be available at all sporting venues to improve chances of survival after a cardiac arrest, he adds.

For the full article see here. See our views on screening.