Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death proven fact or wishful thinking?
Steinvil A, Chundadze T, Zeltser D, Rogowski O, Halkin A, Galily Y, Perluk H, Viskin S. J Am Coll Cardiol. 2011;57(11):1291-6.
For the last few years there has been a growing debate about whether mandatory pre-participation screening for athletes should include electrocardiography (ECG) to detect cardiac pathologies associated with sudden death. The American Heart Association’s guidelines (available at advocate a thorough  cardiovascular screening of competitive college and high-school athletes but also states that they do “not believe it to be either prudent or practical to recommend the routine use of tests such as 12-lead electrocardiogram (ECG) or echocardiography in the context of a mass, universal screening.” In contrast, the International Olympic Committee consensus statement suggests that there is sufficient evidence for the role of ECG in screening athletes. Steinvil et al. attempted to determine if pre-participation ECG screening (resting and exercising) of athletes reduces the risk for sudden death. In 1997, Israel enacted a law mandating that physicians, who completed specialized accreditation, use ECG and exercise stress testing for all athletes. The medical assessment and rest ECG are repeated annually and stress tests are performed either every four years (17 to 34 year olds) or annually (over 35 years of age or any nationally competitive athlete). If an athlete tests positive then they are referred to a cardiac specialist for a final consultation. The authors performed a systematic review of 2 national newspapers from 1985 to 2009 to determine the number of cardiac arrest events (excluding trauma related events) among competitive athletes.  The national newspapers were considered appropriate since sudden death of a competitive athlete tends to garner media attention. The authors accounted for changes in athletic population size during the 24-year period. Between 1985 and 1997, 11 cases of sudden death or cardiac arrest events were reported compared to 13 cases after 1997. The average yearly incidence was similar the decade before and the decade after 1997 (2.54 and 2.66 events per 100,000 person years, respectively). The authors concluded that the mandatory screening had no effect on the risk for sudden death.

The authors recognize that prevention of sudden death among athletes is a desirable goal. They merely point out that the current screening practices may not be ideal. The authors note that because sudden death is so rare it is very expensive to conduct nation-wide tests that may not adequately identify high-risk athletes and conversely lead to many athletes being falsely identified as high-risk (leading to additional burden to the athlete and the healthcare system). The last sentence of the articles states that“…before mandatory ECG screening is endorsed universally, it is reasonable to request additional proof that such a strategy actually saves lives.” This debate is ongoing not just in sports medicine but throughout the medical community: should we screen everyone to identify a few high-risk patients; especially when there is a risk of falsely identifying a patient as high-risk.
Written by: Jeffrey Driban
Reviewed by: Stephen Thomas