Author + information
- John P. Higgins, MD, MBA, MPhil⁎ (, )
- Susan T. Laing, MD, MS and
- Zhongxue Chen, PhD
- ↵⁎HEARTS (Houston Early Age Risk Testing & Screening Study), Department of Internal Medicine, Division of Cardiology, The University of Texas Medical School at Houston, 6431 Fannin Street, MSB 4.262, Houston, Texas 77030-1501
Steinvil et al. (1) are to be commended for bringing an important problem into the spotlight. In the past 3 weeks in the United States alone, there have been 5 deaths of student athletes. The current practice of pre-participation history and physical examination does not detect most of the athletes at risk of sudden cardiac death (SCD). However, rather than give us guidance on how to identify high-risk athletes, Steinvil et al. (1) have raised more questions.
First, their study is based on observational data and retrospective analysis, which are appropriate for generating hypotheses but not for drawing significant conclusions or recommending policy changes. Furthermore, the data used were newspaper/media reports, which have inherent limitations and could lead to information bias. For instance, the deaths of less-successful athletes may be under-reported in the media. It is unclear why the authors did not use a more complete source for mortality data, such as the National Center of Forensic Medicine, which was used for a previous similar study in Israel (2).
Furthermore, the deaths reported in this study were only for competitive athletes. The benefit of pre-participation screening may lie among those who engage in physical activity on a noncompetitive level, but such persons were excluded in this analysis. Although Steinvil et al. (1) acknowledged this limitation, they did not estimate its effects. In most populations, this cohort is actually larger than the professional athletes. For instance, in a report on SCD from 1974 to 2002 in the Israel military, there were 74 cases of SCD among Israeli soldiers ages 18 to 39 years (3). These cases were not reported in the media, and yet these cases represent young persons who were engaged in physical activity who died suddenly.
Contrary to what Steinvil et al. (1) reported, the previous large Italian study of SCD in school-age athletes (4) was a prospective study, not a retrospective study, with superior sources of outcomes data. Steinvil et al. (1) concluded that the results of the Italian study were related to a natural variation in SCD incidence rates. However, in the Italian study, incidence rates of SCD were also collected for the unscreened nonathletic young population, and this rate remained constant over the 25 observation years. We think that it is more likely that the marked variation noted in the incidence of SCD in the Steinvil et al. study is due to the source of their data (i.e., that media reporting is related to what is currently in “vogue” and that this reporting may not reflect the true population incidence rate).
We agree with Steinvil et al. (1) that to prevent SCD in this young population, we need to strive for a solution that is feasible and cost-effective. However, we believe that we cannot continue with the status quo. Young athletes continue to die suddenly, and we need to do better with identifying persons at risk. We believe that the solution will require new thinking, and we join the authors in a call for further studies on this serious societal concern.
- American College of Cardiology Foundation