The prevalence of sudden cardiac death (SCD) in young athletes is relatively low. The most common cause of SCD in this population is congenital cardiovascular disease, with hypertrophic cardiomyopathy being the most common cause. The American Heart Association (AHA) calls for screening with physical history and exam, but others, notably in Europe, include a 12-lead ECG to the screening paradigm.
In the CARDIA (Coronary Artery Risk Development in [Young] Adults) study, researchers found the prevalence of echocardiographically defined hypertrophic cardiomyopathy to be two per 1,000 young adults (Circulation 1995;92:785-789).
Initiating echo as part of a screening regimen has several problems including its cost relative to the low incidence of cardiomyopathy in the young population. Yet, many clinicians will admit that the standard history and physical exam come up short.
Maron et al found that medical evaluations failed to identify 47 of 48 cases of hypertrophic cardiomyopathy (JAMA 1996;276:199-204). In a recent study, Vetter et al found the ECG alone identified six patients at risk, while echo supported three other identifications.
In several European countries, including Italy, it is common to include a 12-lead ECG in the physical exam of young athletes. There are data from Italian registries to support its use, and the European Society of Cardiology recommends the use of 12-lead ECG, while the AHA awaits randomized trials before fully endorsing ECG in athletic screenings. It's not quite known how many deaths an ECG screen can prevent, but estimates range between one in 50,000 to 200,000.
It could be, however, that the U.S. is reaching a tipping point for the inclusion of ECG in pre-competitive screening. Many more U.S. researchers are examining the role of ECGs.
Vetter et al at the Children's Hospital of Philadelphia found the inclusion of ECG to be feasible in terms of the addition time (less than 10 minutes) and the sensitivity of the technique to identify young athletes at risk of sudden cardiac death compared with echo. They did not study its cost-effectiveness, but note that ECG machines are relatively inexpensive and portable.
When a young athlete suffers a sudden cardiac arrest, his or her chances of survival increase incrementally when CPR and/or defibrillation are applied. There has been an ongoing mission by organizations to ensure that schools and other places of recreational sports are equipped with automated external defibrillators (AEDs) and personnel experienced in CPR.
In an effort to "simplify" CPR, the AHA recently changed its recommendations for out-of-hospital sudden cardiac arrest CPR to include hands-only compression before attempting mouth-to-mouth resuscitation, as studies have increasingly found that the two techniques are comparable. In some cases, the hands-only technique tended to be slightly better than CPR with ventilation. Researchers are finding that continuous chest compressions, particularly by laypersons, are better for increasing blood flow to the brain, at least until a professional arrives on the scene with an AED.
While the death of a young athlete is always tragic, researchers have to study protocols and techniques to minimize the risk and provide evidence of their superiority and cost-effectiveness. We seem to heading in that direction regarding the inclusion of ECG into pre-competitive screening. In the meantime, cardiologists and other healthcare professionals would be wise to inquire of their young patients interested in sports whether there are AEDs in close proximity to the sport venue and whether there are coaches and other personnel sufficiently trained in CPR.
Let us know of your experiences with young athletes.
Editor of Cardiovascular Business