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Cardiac Screening in Sport

Cardiologists Questions:

Should all professional sports people be screened for heart disease, and if so, how often?


Following Fabrice Muamba’s cardiac arrest during an FA Cup tie in March of this year, there has been “a surge” in requests for heart screenings from young people. In your opinion…

Dr Duncan Dymond
Consultant Cardiologist
Barts and The London NHS Trust

Should all professional sports people be screened for heart disease, and if so, how often?

In an ideal world the answer is yes, although I suppose it depends on your definition of a professional sportsman. We are talking about screening young apparently super-fit people for the sort of rare diseases that cause sudden death during extreme levels of physical exercise. So a darts champion might not qualify, although many of them look high risk of coronary disease! There is much debate on how athletes should be screened, but most of us agree that a detailed history and full physical examination, plus a 12 lead ECG is the minimum. We ask if there is any family history of sudden unexplained death in a young family member, although we must recognise that high earning athletes might not admit to anything that could jeopardise their income.

Experts disagree on whether screening should always include an echocardiogram, and cost is cited as an argument against the routine use of echo’s. It is true that a completely normal 12 lead ECG makes a diagnosis if Hypertrophic Cardiomyopathy  (HCM) unlikely, but then again, I have picked up various degrees of mitral valve prolapse and bicuspid aortic valves in professional athletes. These might not be important now but could be in later life.

Many of our best athletes are of Afro-Caribbean origin and the resting ECG may be difficult to interpret because of  racial differences in ST segments and T waves compared to their white counterparts. Also, many athletes have  physiological left ventricular hypertrophy which produces ECG changes and some conduction abnormalities. Echocardiography can reassure that all is well, and my own view is that an echo is so easy to do, quick, carries no risk, and provides such clear information that wherever possible it should be done.
In the wake of  Fabrice Muamba’s illness much has been said about the need for all athletes to undergo cardiac MRI scans, but quite honestly there is no real evidence yet that it would make a difference. Of course MRI is much less widely available, expensive and time consuming so it is not practicable.

How often to screen an athlete is a moot point. The real worry is that HCM can become expressed during the twenties or even early thirties, so a normal echo at one point in time may not be enough. A test every two years is recommended by many experts, and is currently what many professional football clubs do.

What do you say to those young people out there who play competitive, but non-professional sport, who might be worried about a similar fate as that of Fabrice’s?

First of all let’s remember that what happened to Fabrice is incredibly rare but of course in the modern world information about catastrophes during sports is spread globally within hours. Its hard not to worry, but statistically you are more likely to come to grief crossing the road than during sport. My daughter is about to run a half marathon, and as a concerned father I am arranging for her to have an ECG and an echo beforehand!! That is the real world answer!!

 

Dr Adam Fitzpatrick
Consultant Cardiologist & Electrophysiologist
Manchester Royal Infirmary

Should all professional sports people be screened for heart disease, and if so, how often?

The answer is yes, at least once.  The main reason is that minor abnormalities could have a major consequence, and the numbers to be screened are small.  The virtue of repeated screening is less clear, since the major abnormalities, WPW, Long QT, Brugada Syndrome, ARVD, HCM will likely show up first time.  If the ECG and echo are completely normal, I doubt that there would be an abnormality that could be detected and a disaster prevented.  If there are subtle or uncertain electrocardiographic abnormalities, then repeated ECGs should be done, sooner rather than later.  The ECG in Brugada Syndrome can change minute-to-minute, and the ECG in Long QT can vary.  However, they usually don’t look right in the first place.

What do you say to those young people out there who play competitive, but non-professional sport, who might be worried about a similar fate as that of Fabrice’s?

In Italy, all schoolchildren must be screened before they can participate in sport.  This practice has been questioned like all screening has been questioned.  A very large number of people must be screened to find one case at risk, because these conditions are generally rare.  The exception is probably WPW which is present in about 1:500 people.  However, sudden death occurs in less than 1% of these, and the question to be asked is whether ablation should be offered when an asymptomatic patient is discovered.  Adult cardiologists may not be familiar with the appearances of the ECG in children which can look abnormal to the adult cardiologist’s eye.  In general, there is a reasonable argument that the mass-screening of asymptomatic young people could result in a lot of unnecessary worry, misdiagnoses, unnecessary procedures and a few diagnoses that could save a life.

 

Dr Simon Modi
Consultant Cardiologist & Electrophysiologist
Liverpool Heart and Chest Hospital

Should all professional sports people be screened for heart disease, and if so, how often?

High level competitive sports undoubtedly increase a person’s risk for sudden cardiac arrest (SCA).  This is not to say that sport causes heart disease but that adrenaline surges unmask latent conditions such as ischaemic heart disease in the ‘older sports person’ and hypertrophic cardiomyopathy, right ventricular cardiomyopathy and long QT syndrome in the young.  Although screening for SCA comes under debate regularly, I personally believe that provisions should be made to screen professional sports people, probably on a 1-2 yearly basis.  The principle reasons for not rolling out screening are cost (lots of tests to find one abnormal), risk of false positives (many athletes have ‘abnormal’ ecgs and echocardiograms when compared to the normal population and distinguishing ‘abnormal’ from ‘normal for an athlete’ can be challenging), risk of ‘medicalizing’ normals (the sporting career of people with these borderline tests may be affected), a significant body of evidence suggesting that screening doesn’t save lives (principally from USA where athletes were not screened by doctors specialising in screening).  The principle reasons for screening are the founded in the large Italian cohort of professionally screened (sports cardiologists) sportsmen and women in whom a 3 fold reduction in SCA was noted since screening began, the quest to further our knowledge about what constitutes a normal athletic heart (and thereby reduce the number of false positive tests), and the quest to reduce the highly emotive and publicised sudden deaths of those people perceived to be the least likely suffer ill health, i.e. athletes.
What do you say to those young people out there who play competitive, but non-professional sport, who might be worried about a similar fate as that of Fabrice’s?

The risk of sudden death is very low, but is increased by competing regularly in sports.  Undertaking screening is entirely voluntary and if you do opt for screening then you must be made aware that screening is not absolutely fail safe (as seen with each of the professional sports people above that were screened) and there is a small chance of having ‘borderline’ tests for which further tests may be required.  In rare cases repeated annual tests may be recommended, and in certain rare situations you may be asked to ‘detrain’ for a period of 3 months to see if ‘bordeline’ tests return to normal.  Nevertheless, screening is really the only way we have of reducing the incidence of tragic events seen above.  If you suffer from dizzy spells or faints/blackouts, particularly during sporting activity, have symptoms of chest pain, palpitations or excessive shortness of breath or if there is anyone in the family who has died at a young age, drowned, had an unexplained motor vehicle accident, known sudden infant death, uncontrolled epilepsy or recurrent miscarriages then you should definitely undergo screening for inherited cardiac conditions that predispose to SCA.

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