Sports Medicine Research: In the Lab & In the Field: Adding Echocardiography to Pre-participation Screening (Sports Med Res)
Wednesday, May 23, 2012

Adding Echocardiography to Pre-participation Screening

Structural cardiac disease diagnosed by echocardiography in asymptomatic young male soccer players: implications for pre-participation screening.

Rizzo M, Spataro A, Cecchetelli C, Quaranta F, Livrieri S, Sperandii F, Cifra B, Borrione P, Pigozzi F. Br J Sports Med. 2012 Apr;46(5):371-3. Epub 2011 Jul 26.

One of the main goals of pre-participation screening (PPS) is to identify unknown cardiac alterations in asymptomatic athletes with the intent to prevent sudden death in athletes.  In Italy, it is mandatory by law that all children entering competitive activity must receive screening that includes physical examination and electrocardiogram (ECG), which is usually first done between the ages of 8 to 12 years of age.  This mandatory screening has been shown to be effective in preventing sudden cardiac death in athletes, but some structural cardiac alterations are still missed.  The aim of this study was to evaluate the usefulness of adding echocardiography to the PPS to detect structural cardiac abnormalities.  In this study, 3100 male soccer players between the ages of 6 and 17 years were evaluated with the conventional Italian PPS with ECG and physical examination with the addition of a complete echocardiogram.  The physical examination and ECG were performed and interpreted by 3 sports medicine physicians, while the echocardiograms were performed by 3 cardiologists and 2 different sports medicine physicians.  All examinations were then reviewed by a cardiologist with extensive experience in pediatric cardiology.  A total of 3044 echocardiograms were found to be normal, while 56 (1.8%) found a structural cardiac lesion.  Of the 56 hearts with structural cardiac lesions, 2 (0.06%) were hypertrophic cardiomyopathy (HCM), 24 (0.77%) were bicuspid aortic valve, 10 (0.32%) were mitral valve prolapse, and 20 (0.65%) were atrial septal defects.

Cardiac screening in athletes is a hot topic in the sports medicine community right now for the United States.  Italy has mandated ECG screening for several years and this question of whether or not to include echocardiogram is the next step for them.  Screening protocols vary amongst college and professional teams with some performing ECG on all athletes.  An even smaller proportion of teams include an echocardiogram.  Some professional teams even require a treadmill stress test.  From the results of this study, the authors suggest adding echocardiogram to the initial PPS only.  There might be infrastructure to incorporate this in Italy, but at this point in the United States, this would be very difficult to implement.  Their ideal solution would be to have the sports medicine physicians performing the echocardiograms themselves.  One of the arguments against ECG screening in the United States is that there are too many false positives due to inadequate training in interpreting an athlete’s ECG [see Hill et al review]. Adding echocardiogram training would be even more difficult.  Another point to look at is the significance of the 56 abnormal echocardiograms they found.  If the echocardiogram can detect abnormalities not seen on ECG or history/physical, and these abnormalities are clinically significant, the echocardiogram would be an acceptable addition to the already required ECG.  The 2 patients that were found to have HCM on echocardiogram had ECG abnormalities that would have required a subsequent echocardiogram.  With the findings of a bicuspid aortic valve, according to the 36th Bethesda Conference Recommendations, restrictions are only placed with aortic root dilation greater than 40mm, which likely would only be able to be assessed by echocardiogram if asymptomatic.  With mitral valve prolapse and atrial septal defects, most of the significant cases that would require restrictions with play would have required an echocardiogram due to findings in history and physical if one wasn’t mandatory.  With these recommendations in mind, the echocardiogram findings were only significant for 2 athletes in this study (0.065%).  The underlying question for cardiac screening is how much of a risk is society willing to take and invest in, if the statistical benefit is low, but the end result of not preventing a sudden death is devastating. What are your thoughts on ECG or echocardiogram screening in athletes?  What are your screening protocols at your program?

Written by: Kris Fayock, MD and Marc Harwood, MD
Reviewed by: Jeffrey Driban

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Rizzo, M., Spataro, A., Cecchetelli, C., Quaranta, F., Livrieri, S., Sperandii, F., Cifra, B., Borrione, P., & Pigozzi, F. (2011). Structural cardiac disease diagnosed by echocardiography in asymptomatic young male soccer players: implications for pre-participation screening British Journal of Sports Medicine, 46 (5), 371-373 DOI: 10.1136/bjsm.2011.085696

4 comments:

Timothy said...

I have often wondered why there wasn't more thought about echo testing. With positive findings that low it also seems like it might be limited because of cost, just like ECG.

Kris Fayock said...

Thanks for the comment Timothy. Cost and infrastructure are going to be the big hurdles needed to overcome before echo is added to all screening protocols. It definitely gives more and different information than H&P and ECG. Once a decision is reached on ECG screening, this will be the next debate.

Megan said...

I am really happy to see some more research being done on the use ECG and echocardiograms in pre-participation physicals. I think that if it has the possibility to save someone's life, it is worth doing. There are many complications being discussed right now on the implementation of these tools here in the US due to cost and other factors. I think that if we can implement it in steps it can be accomplished. I think if we can market the usefulness of having these tests completed at a young age outside the realm of preventing sport/exercise related death we might be able to get more attention on this topic and get a foot in the door in implementing these tests. I think further research similar to this study would be helpful in showing the usefullness of these tools in saving lives here in the US. Even though there were only significant findings for 2 patients in this study doesn't mean that the results for the other 54 patients was not important. Knowledge of the outcomes of the tests for the 54 other patients can be useful as well. Knowledge of any type of abnomality could be just as useful in preventing sudden death in sports because just knowing your condtion can make you aware and allow you to make changes in your daily life to keep you safe.

Kris Fayock said...

Thanks for the comment Megan. This is going to be a difficult debate, especially when the lives of young athletes are at risk. One thing to think about on whether the echo findings were important or clinically significant is what do these findings now mean for the patient? Now that these "abnormalities" are found, how does it affect the patient when he/she applies for health/life insurance or jobs down the line? I don't know what the right answer is or if it should factor in to the decision, but this is one of the things we need to consider when screening protocols are put into place. Some abnormalities are clinically significant and some will never affect a patient.

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