COMMENTARY

Is SCD in Athletes Too Rare to Warrant Serious Precautions?

Sideline Consult

Bert R. Mandelbaum, MD, DHL (hon)

June 19, 2015

How Seriously Should We Take the Risk for SCD?

When midfielder Marc-Vivien Foé collapsed in the center circle of a French soccer field in 2003, sports medicine changed forever.

Foé's death during an international match showed just how poorly the world of professional sports had attended to sudden cardiac death (SCD), the leading medical cause of death among athletes. According to press reports, several minutes passed before anyone attempted to defibrillate the 28-year-old Cameroonian. An autopsy later revealed hypertrophic cardiomyopathy.^[1]

Not only could his condition have been diagnosed long before he collapsed, but immediate defibrillation also might have revived him. Now professional sports leagues have begun to institute screening and make automated external defibrillators (AEDs) available. I'd like to see both of these programs expanded throughout competitive sports.

By the 2006 World Cup, the Fédération Internationale de Football Association (FIFA) had instituted screening for professional soccer players and referees with echocardiography and electrocardiogram (ECG) as part of a comprehensive medical examination. And in 2013, the organization began distributing medical emergency bags with AEDs to all 209 member associations.

Sports medicine has been divided on the screening part of this two-pronged approach. The Sports Cardiology Study Group of the European Society of Cardiology recommends universal ECG screening prior to sports participation.^[2] But the American Heart Association (AHA) recommends only a cardiovascular-oriented history and physical examination.^[3] Opponents of mandatory ECG screening argue that it is not cost-effective and that false positives would unnecessarily bar too many athletes from sports.^[4]

Inaccurate Estimates of the Incidence of SCD

In part, these arguments rest on inaccurate estimates of the incidence of SCD. For example, the US Registry of Sudden Death in Athletes (USRSDA) attempted to extrapolate the number of sudden cardiac deaths by using media reports, reports by next of kin, and electronic databases. The researchers arrived at an incidence of 1 death in 164,000 US athletes.^[5]

But studies in US college athletes, using more precise numbers of athletes and deaths, suggest that the incidence is closer to 1:50,000.^[6]

That puts US numbers more in line with a prospective cohort study in the Veneto region of Italy, in which the reported rate was 1:28,000 from 1979 to 1980 per athlete.^[7] The incidence sank to 1:250,000 in the Veneto cohort from 2003 to 2004 following the implementation of mandatory screening with ECG throughout Italy.^[7]

There was no change in the incidence of SCD in the general population during this time, suggesting that the screening program prevented athletes' deaths by disqualifying those most at risk from sports.^[7]

Of course, initial screening will produce some false positives. But by using ECG and echocardiogram together with a detailed history and physical exam, we can flag those athletes who need further testing. Once these more extensive tests are completed, the risk for an unnecessary disqualification is low.

And it's worth noting that the AHA program of physical exams and family history without ECG can also produce false positives. In a study of 1596 US professional, college, and high school athletes, 23.8% had at least one positive response to the AHA personal and family elements questions.^[8]

As technology improves, screening will become increasingly accurate. And screening itself will improve our understanding about the way risk factors vary.

Already we have learned about important demographic differences in athletes. Male athletes appear much more likely than female athletes to suffer from SCD. The most common cause of SCD in athletes in the United States appears to be hypertrophic cardiomyopathy, while in Italians it appears to be arrhythmogenic right ventricular cardiomyopathy.^[9]

Age matters too; in the United States, arteriosclerosis is the most common cause of SCD among athletes over age 40.^[10]

FIFA has set up a registry to analyze SCD during soccer matches. As we learn more about this condition, our ability to screen for it will also improve.

Can Widespread Screening Be Cost-Effective?

Advances in technology can also address the other main objection to universal screening with ECG and echocardiogram: its price.

Cost-effectiveness projections have varied wildly. If the physical exam and family history from the AHA guidelines are combined with an ECG for an annual screening, Halkin and colleagues^[11] estimate a staggering cost of $10.6 million-$14.4 million per life saved in the United States.

On the other hand, Wheeler and coworkers,^[12] using a one-time screen, found a cost-effectiveness of $76,100 per year of life saved for the combination of history and physical and ECG, with an incremental cost-effectiveness of the ECG at $42,900.

As our healthcare system gradually shifts from fee-for-service to population health maintenance, I believe the costs of screening will come down and cost-effectiveness will increase. Step by step, we can move screening out to all of our athletes. In the future, it will become as routine as an influenza vaccination.

In the meantime, we need to take better advantage of another rapidly improving technology: automated defibrillation.

A Defibrillator at Every Athletic Venue?

In contrast to the clash over ECG screening, few experts debate the utility of making AEDs more available. The technology is rapidly improving. On newer models, once the cables are connected, the computer instructs the operator as to whether the patient can benefit from a shock, and if so, when and how many times to shock. It also explains when and even how to perform cardiopulmonary resuscitation.

But it's not only a matter of supplying a machine at every athletic venue. Staff must be prepared to act quickly. Once an athlete goes down, you have 2 minutes to shock the patient. The defibrillator must be charged and ready.

And defibrillation isn't enough. Every venue must prepare a system for swiftly evacuating patients to a medical center for more advanced care.

Last year, 25-year-old Italian soccer player Piermario Morosini suffered a sudden cardiac arrest and received defibrillation on the field.^[13] But according to press reports, the ambulance's path was blocked by a city police car, slowing his transport to the hospital. Whether or not this delay actually played a role in his death, the situation illustrates the importance of preparing for each step of the appropriate treatment of an athlete in cardiac arrest.

An example of how this can work took place in 2013 when 24-year-old Fabrice Muamba of the Bolton Wanderers, a professional soccer team in Bolton, England, also suffered a sudden cardiac arrest.^[14] This time, the team was prepared. They first defibrillated him and then swiftly transported him to a hospital. The treatment he received there saved his life.^[15]

I believe that every athlete—not just professionals—deserves this standard of care.

References

1. Austin S. Marc-Vivien Foe death: his legacy 10 years after collapsing on pitch. BBC Sport. June 26, 2013. http://www.bbc.com/sport/0/football/23052120 Accessed June 18, 2015.
2. Corrado D, Pelliccia A, Bjornstad H, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005;26:516-524. Abstract
3. Maron B J, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update. A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007;115:1643-1655. Abstract
4. Bredeweg SW, Takens LH, Nieuwland W. Periodical cardiovascular screening is mandatory for elite athletes. Neth Heart J. 2007;15:224-225. Abstract
5. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation. 2009;119:1085-1092. Abstract
6. Incidence of sudden cardiac death in athletes: a state-of-the-art review. Harmon KG, Drezner JA, Wilson MG, Sharma S. Br J Sports Med. 2014 June 24. [Epub ahead of print]
7. Corrado D, Basso C, Pavei A, et al. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006;296:1593-1601. Abstract
8. Dunn TP, Pickham D, Aggarwal S, et al. Limitations of current AHA Guidelines and proposal of new guidelines for the preparticipation examination of athletes. Clin J Sport Med. 2015 Apr 24. [Epub ahead of print]
9. Thompson PD, Levine BD. Protecting athletes from sudden cardiac death. JAMA. 2006;296:1648-1650. Abstract
10. Noakes TD. Sudden death and exercise. Sportscience. 1998. http://www.sportsci.org/jour/9804/tdn.html Accessed June 18, 2015.
11. Halkin A, Steinvil A, Rosso R, et al. Preventing sudden death of athletes with electrocardiographic screening: what is the absolute benefit and how much will it cost? J Am Coll Cardiol. 2012;60:2271-2276.
12. Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA. Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med. 2010;152:276-286. Abstract
13. Hills D. Italy mourns tragic loss of 'golden boy' Piermario Morosini. The Guardian. April 14, 2014. http://www.theguardian.com/football/2012/apr/15/piermario-morosini-italy-mourns Accessed June 18, 2015.
14. Riach J. Fabrice Muamba: we're still not doing enough to prevent cardiac deaths. The Guardian. March 17, 2014. http://www.theguardian.com/football/2014/mar/17/fabrice-muamba-cardiac-deaths Accessed June 18, 2015.

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Cite this article: Is SCD in Athletes Too Rare to Warrant Serious Precautions? Medscape. Jun 19, 2015.