Structural cardiac disease diagnosed by
echocardiography in asymptomatic young male soccer players: implications for
pre-participation screening.
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.
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.
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?
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
Marc Harwood, MD
Reviewed by: Jeffrey Driban
Related Posts:
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
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.
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.
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.
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.