Author + information
- Antonio Pelliccia, MD⁎ ( and )
- Domenico Corrado, MD, PhD
- ↵⁎Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
The recent paper by Steinvil et al. (1) raised our concern and prompted the present considerations. The intriguing title conceals the idea that pre-participation screening including 12-lead electrocardiography is ineffective for modifying the occurrence of sudden cardiac deaths (SCDs) in young athletes, in contrast with previously reported Italian data (2).
The authors claim that the yearly incidence of SCDs has remained unchanged (i.e., 2.54 to 2.66 per 100,000 persons) in the periods 1985 to 1996 and 1997 to 2009, despite implementation of the screening program in Israel (1). Their conclusion was that efforts to prevent SCDs in young athletes by the electrocardiographic screening were worthless.
However, we believe that certain methodological limitations do greatly hamper the apparent strength of their conclusion. Primarily, both the number of cardiac events and the population of competitive athletes at risk were only roughly estimated.
First, the number of SCDs was derived only from 2 Israel newspapers, and not from a national prospective registry. Newspapers focus on fatalities occurring in elite/national-level professional athletes, whereas reports of SCDs in the much larger population of adolescents/adults engaged in nonprofessional/regional sports are usually overlooked. Moreover, an increase in the number of sports-related fatal events in more recent years in Western countries has been reported, a phenomenon that simply reflects enhanced public recognition due to increased media attention (3). This may also explain the relative lower prevalence of fatal events reported in the past decades and confirms the unreliability of estimating the time trend of SCDs in athletes based only on media reporting.
Second, the population of competitive athletes at risk is not known. Authors state that the number of registered competitive athletes was 45,000 in 2009. They claim that proportion of Israel population engaged in competitive sports remained unchanged over time, but the actual size doubled, based not on national records, but on the U.S. track and field road running records (1).
In conclusion, in this article, the incidence of SCDs was calculated from an uncertain number of events over an estimated number of athletes. The lack of solid numbers for both the numerator and denominator makes the death rates not reliable.
Moreover, we were surprised that results of the Israel screening program were completely ignored: no information was provided regarding the implementation of the national screening, the number of examined athletes, the proportion of disqualified ones, and the cardiac abnormalities discovered. In short, no data derived from the direct experience of sport physicians support the alleged inefficacy of the screening program in Israel.
By comparison, the Italian data were gathered according to a prospective study design with systematic investigation of all young individuals (competitive athletes and sedentary controls) who died suddenly. All of the hearts were examined according to a definite protocol by expert cardiovascular pathologists. Moreover, the number of competitive athletes registered within the athletic sport organizations and undergoing the pre-participation screening program was known for certain. The large diversity of Israel and Italian screening reports make their direct comparison inappropriate.
The Italian experience showed a significant decrease in mortality over the entire time period after the implementation of the screening program (p for trend <0.001), through analysis of the time trend of death rates with Poisson regression of the number of SCDs in each year against the calendar year, including the log of the amount of person-time at risk in each year as an offset term. Poisson regression analysis of the mortality trend over 26 years allowed the potential limitation of a relatively short pre-screening period to be overcome.
Indeed, the comparison of the SCD trend between screened athletes and unscreened nonathletes (i.e., a control population of the same age from the same geographic area) during the same study period provided compelling evidence of the selective decrease in mortality in young athletes undergoing screening.
Although the authors' aim to explain the trend of SCDs in Israel athletes is laudable, their conclusion that the mortality rate in young athletes cannot be changed by implementing pre-participation screening is not supported by scientifically reliable data.
- American College of Cardiology Foundation
- Steinvil A.,
- Chundadze T.,
- Zeltser D.,
- et al.
- Maron B.J.,
- Doerer T.S.,
- Tierney D.M.,
- Mueller F.O.