Pre-participation screening of asymptomatic athletes
Neth Heart J
Pre-participation screening of asymptomatic athletes
A. Mosterd 0
0 Department of Cardiology, Meander Medical Center , Amersfoort , The Netherlands
Catastrophic events, be it traffic accidents, natural disasters or homicides, always lead to scrutiny. Could we have seen the event coming and could it have been prevented? In the case of a sudden cardiac arrest of a seemingly healthy athlete the public outcry is not any different. Despite an intrinsic appeal for screening to prevent similar events, there is no evidence that justifies routine cardiovascular pre-participation screening of athletes. On balance, cardiovascular screening in athletes will most likely do more harm than good. Fatal exercise-related cardiac arrests do not occur very often. The true diagnostic yield of the pre-participation evaluation is not known and once a cardiac condition has been identified, the most appropriate intervention is often unclear. It follows that pre-participation screening of large groups of athletes without known cardiac disease will inevitably result in many false positive findings, while at the same time providing a false sense of security to those screened negative. Except for compelling reasons (e. g. cascade screening, research settings, professional athletes), physicians should not engage in routine examination of asymptomatic athletes to prevent cardiac events.
Athletes; Cardiovascular; Screening; Sudden cardiac death
Catastrophic events, be it traffic accidents, natural disasters
or homicides, always lead to scrutiny. Could we have seen
the event coming and could it have been prevented? In
the case of a sudden cardiac arrest of a seemingly healthy
athlete the public outcry is not any different.
Despite an intrinsic appeal for screening to prevent
similar events, the sobering 2006 conclusion by the Health
Council of the Netherlands, stating there is no evidence that
justifies routine cardiovascular pre-participation screening
in young athletes, still stands [
]. As a matter of fact, there
is increasing evidence supporting the appeal to steer away
from routine pre-participation screening [
recommendations from the UK’s national screening
committee, as well as from the American Heart Association, advise
against screening [
In this point of view, I build on earlier commentaries
and provide a brief overview of recent developments in the
field of the cardiovascular evaluation of athletes, notably the
extensive review of the literature undertaken by the Belgian
Health Care Knowledge Centre [
2, 9, 10
A brief history of cardiovascular pre-participation
Italian experience with mandatory pre-participation
screening since the 1980s formed the basis for the 2005
European Society of Cardiology (ESC) consensus statement
on pre-participation screening of young athletes (aged
12–35 years) [
]. The recommended evaluation to
prevent exercise-related cardiac arrests consists of a
personal and family medical history, a physical examination
and a 12-lead resting electrocardiogram. The ESC
statement has led to a heated debate between proponents and
opponents of mandatory pre-participation screening [
It is important that we realise that the ESC statement
is a proposal for a common European protocol rather than
a guideline with an imperative to screen. Guideline
recommendations are preferably based on randomised controlled
trials. We have no such trials on the effects of
pre-participation screening and given the sheer size of a trial required
to address this issue (the Dutch National Institute for
Public Health and the Environment calculated that a trial would
involve two groups with at least 1,200,000 person-years
follow-up), a randomised evaluation will probably never see
the light of day [
Observational data, without a contemporary control
group of non-screened athletes, from the Veneto region
showed a decrease in the incidence of sudden cardiac death
in young athletes in the 1980s that was attributed to
preparticipation screening [
]. In contrast, a nationwide study
in Israel could not demonstrate a decline in the incidence
of sudden cardiac death in athletes after the introduction of
mandatory screening in the mid-1990s [
]. The very recent
Canadian study on sudden cardiac arrests, conducted from
2009 through 2014 in athletes, competitive and
non-competitive, aged 12–45 years, reported that pre-participation
screening would have missed more than 80% of cases [
The main findings of an extensive literature review of
pre-participation screening in young athletes commissioned
by the Belgian government were summarised in the British
Medical Journal in April 2016 [
● An estimated 0.001% of young athletes die suddenly
● Up to 30% of those screened may be referred for
● Screening would not detect around 25% of those at risk
of sudden death
● On balance, cardiovascular screening in young athletes is
likely to be more harmful than beneficial.
Taken all together, it does not come as a surprise that the
latest (2017) ESC statement strikes a more cautious tone
in relation to the benefits of pre-participation screening (‘It
goes far beyond the scope of the document to suggest global
national pre-participation evaluation programmes’) [
Pitfalls of screening
Screening programmes generally do not live up to
expectations and the real implications of screening are not
appreciated by the majority of physicians, let alone the lay
]. A successful screening programme
cost-effectively addresses a common condition (A), the presence of
which can reliably be diagnosed with an affordable test (B)
which subsequently will predictably result in adverse events
that can be prevented by an accepted intervention (C).
A. Fatal exercise-related cardiac arrests do not occur very
often, less than 1 per 100,000 per year in those aged
35 years or younger and five to ten times more frequently
in those older than 35 years, with an overwhelming male
preponderance (10:1) [
]. The cause of cardiac arrest
in athletes aged 35 years or younger is a mixed bag of
inherited cardiac disease (cardiomyopathies, electrical
heart disease), coronary anomalies, myocarditis, blunt
chest trauma and coronary artery disease. In older
athletes, coronary artery disease is the main cause [
B. The true diagnostic yield/accuracy of the proposed
cardiovascular pre-participation evaluation, essentially
consisting of a medical history, physical examination and
the resting 12-lead electrocardiogram as a cornerstone,
is not known. Coronary anomalies and premature
coronary artery disease, for example, will not be found with
this approach and even a seemingly straightforward
electrocardiogram diagnosis of long QT syndrome is known
to be missed by experienced cardiologists . The fact
that exercise per se results in electrocardiogram changes
complicates matters even more, notwithstanding efforts
to standardise and improve the electrocardiogram
analysis of athletes [
C. Once a cardiac condition has been identified, the next
challenge presents itself; should we advise restricting
sporting activities and should we otherwise intervene
in those who are truly asymptomatic [
]? With regard
to the former: many athletes decide to continue their
activities, which recently led to a plea to strike a less
paternalistic tone in the counselling of athletes with
cardiovascular disease [
]. With regard to the latter: at least
two studies demonstrated that lifelong intensive
exercisers are likely to have coronary atherosclerosis more often
than their counterparts with lower lifelong exercise
]. However, the most active athletes showed
a more benign pattern of coronary atherosclerosis; less
mixed plaques and more often only calcified plaques.
Currently, we have no guidance on how to treat these
athletes, if at all. The presence of coronary
atherosclerosis is associated with a worse outcome in the general
population, but in athletes who have exercised intensively
for many years this association may be altered given the
more benign aspect of their atherosclerotic plaques.
It follows that routine pre-participation screening of large
groups of athletes without known cardiac disease will
inevitably result in a large number of false positive findings
(leading to substantial psychological distress and costly
additional investigations—just to be sure—, not to mention
insurance issues) while at the same time providing a false
sense of security in those who screened negative.
Alternatives to screening
Accepting the fact that timely identification of athletes
at increased risk of sudden cardiac death is currently not
possible, what other options do we have? Studies from
Canada, the Netherlands and France have convincingly
shown that exercise-related cardiac arrest is becoming
a treatable condition (with nearly 50% of victims surviving
in areas with an adequate chain of resuscitation actions) [
]. Prompt bystander resuscitation efforts with the use
of increasingly available automated external defibrillators
have resulted in increased survival rates, not restricted to
A solid infrastructure for cardiogenetic evaluation
(including cascade screening, i. e. the systematic testing of
relatives of a known mutation carrier to identify those who
might benefit from an intervention) of persons with
inherited cardiac disease may help timely identification of those
at an increased risk of adverse cardiovascular events.
“First, do no harm”
Except for compelling reasons (e. g. cascade screening,
research settings, professional athletes), physicians should not
engage in routine examination of asymptomatic athletes
to prevent cardiac events. To quote former US president
Barack Obama: “Don’t do stupid stuff”.
Conflict of interest A. Mosterd declares that he has no competing
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