Aro, Aapo L.

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International Journal of Cardiology 278 (2019) 285–286Contents lists available at ScienceDirectInternational Journal of Cardiologyj ourna l homepage: www.e lsev ie r .com/ locate / i j ca rdEditorialTo screen or not to screen, what do the Paciﬁc Island athletes teach us?Aapo L. Aro ⁎Heart and Lung Center, Helsinki University Hospital, Helsinki, FinlandDOI of original article: https://doi.org/10.1016/j.ijcard⁎ Division of Cardiology, Heart and Lung Center,Haartmaninkatu 4, PL340, 00029 HUS Helsinki, Finland.E-mail address: aapo.aro@helsinki.ﬁ.https://doi.org/10.1016/j.ijcard.2018.12.0110167-5273/© 2018 Elsevier B.V. All rights reserved.a r t i c l e i n f o Nearly all data on cardiovascular screening and incidence of SCD inArticle history:Received 2 December 2018Accepted 3 December 2018Available online 5 December 2018young athletes have come from Europe or the United States, so thestudy by Chatard et al. [8] on preparticipation cardiovascular evaluationamong Paciﬁc Island athletes published in this issue of the Journal is awelcomed addition to the rapidly growing literature on this somewhatemotional and controversial subject. The authors should be commendedfor conducting a study in this sparsely populated area spanning thou-It is well established, that physical activity confers substantial health Among N2200 young athletes evaluated, 15%had abnormal family or per-beneﬁts and prolongs life [1]. Paradoxically, however, intensive exercisemay also act as a trigger for life-threatening ventricular arrhythmias incase of an underlying cardiac disease [2], occasionally leading to suddendeath of a young and apparently healthy person, a catastrophic eventwith far-reaching implications for families and communities involved.To prevent these early sports-related deaths, some countries areimplementing preparticipation evaluation of trained competitive ath-letes,which aims at identifying cardiovascular diseases capable of causingcardiac arrest in the athletic ﬁeld. While there is broad agreement thatearly detection of these cardiac disorders is an important objective inorder to prevent sudden cardiac death (SCD) [3], there has been discus-sion on appropriate methods, especially if family/personal history andphysical examination alone is sufﬁcient, or should it be complementedwith a 12-lead ECG. Sensitivity of patient history and physical examina-tion in detecting cardiac disorders with elevated risk of SCD is relativelylow, around20%, but addition of anECG to the screening increases the de-tection, as about 60% of disorders associated with cardiac arrest in youngindividuals cause ECG abnormalities [4]. Although the use ofmodern ECGinterpretation standards is likely to improve ECG's accuracy [5], thesubstantial number of false-positive ﬁndings among athletes leading tofurther investigations has prompted concerns regarding the cost-effectiveness of universal ECG screening [6]. On the other hand, sensitiv-ity of screening to detect subclinical cardiomyopathies is still suboptimalwith some false-negative results, as demonstrated in a recent studyamong adolescent soccer players, in which most athletes who experi-enced SCD during the follow-up didn't have detectable abnormalities inthe comprehensive screening [7]..2018.11.012.Helsinki University Hospital,sands of kilometers, although this lead to some difﬁculties in investigat-ing the abnormal ﬁndings further, potentially affecting the results.sonal history, or cardiovascular ﬁndings in the clinical examination. Iso-lated abnormal ECG ﬁndings were present in 1%. Overall, 3.9% ofathletes were found to have cardiovascular abnormalities, and 0.8% hadcardiac pathology carrying a potential risk of SCD, one-third of whichwere detected only by an abnormal ECG. This prevalence of signiﬁcantcardiac disorders among athletes is somewhat greater than 0.3–0.4% re-ported previously [4,7], reﬂecting some regional characteristics such asthe high prevalence of rheumatic heart disease.In the study, three SCDs occurred among the screened athletes dur-ing the follow-up, with an annual incidence of 1:2500. This magnitudeof SCD risk is signiﬁcantly higher compared tomost previous reports, al-thoughwithout screening andexclusion of athletes at risk fromcompet-itive sports, the number of deaths could have been even higher. Thehigh incidence of SCD may be partly a chance ﬁnding given the rela-tively small population studied, but it may also be related to the ethnicproﬁle and background of athletes in this geographically distinct area. Inthe literature, estimates of the incidence of cardiac arrest among ath-letes has varied widely depending on the deﬁnition (whether survivorsof cardiac arrest are included or not), methodology and athlete popula-tion studied, with most estimates falling between 1:50,000 and1:80,000 athlete years [4,9]. However, some subgroups such as men,black athletes and basketball players, appear to be at signiﬁcantly higherrisk, with risk estimates closer to this report from the Paciﬁc Islands [4].Universal athlete screening recommendations with or without ECG failto acknowledge these large regional differences in the athlete risk pro-ﬁle and prevalence of cardiovascular disorders, so this study highlightsthe need to understand local circumstances, including the prevalenceof cardiovascular disease, incidence of cardiac arrest and resources tospend on screening, when tailoring a preparticipation evaluation pro-gram for speciﬁc sports and regions.The study by Chatard et al. also hints to a particular quandary inscreening efforts limited to athletes. Given the relatively large numberof cardiovascular ﬁndings in this Paciﬁc Island population, there is a po-tential ethical dilemma in conﬁning the preventive and screening286 Editorialefforts of potentially lethal cardiac disorders only to those who chooseto engage in competitive sports, a segment of the population likely toexhibit healthier lifestyle than the rest. In a recent report from theOregon SuddenUnexpectedDeath Study, only 14% of sudden cardiac ar-rests in the young were associated with sports. In fact, the majority ofcardiac arrests even among the young struck those with traditional car-diovascular risk factors. Survival from sports related cardiac arrest wasalso signiﬁcantly better compared to cardiac arrest in non-sports set-tings [10]. Thus, SCD prevention efforts should not be conﬁned only toathletes, but to all subgroups at high risk, such as relatives of suddencardiac arrest victims and those with familial cardiac disease, cardiacsymptoms or cardiovascular risk factors. To improve SCD risk stratiﬁca-tion among the young, novel strategies, tools and risk markers areneeded to better recognize individuals with an underlying, potentiallylife-threatening cardiac disease, irrespective whether they are compet-itive athletes or not.FundingThisworkwas supported by the FinnishMedical Foundation and theSigrid Juselius Foundation.Conﬂict of interestThe authors report no relationships that could be construed as a con-ﬂict of interest.References[1] D.C. Lee, R.R. Pate, C.J. Lavie, X. Sui, T.S. Church, S.N. Blair, Leisure-time running re-duces all-cause and cardiovascular mortality risk, J. Am. Coll. Cardiol. 64 (2014)472–481.[2] D. Corrado, C. Basso, G. Rizzoli, M. Schiavon, G. Thiene, Does sports activity enhancethe risk of sudden death in adolescents and young adults? J. Am. Coll. Cardiol. 42(2003) 1959–1963.[3] A.L. Aro, S.S. Chugh, Prevention of sudden cardiac death in children and youngadults, Prog. Pediatr. Cardiol. 45 (2017) 37–42.[4] J.A. Drezner, F.G. O'Connor, K.G. Harmon, et al., AMSSM position statement on car-diovascular preparticipation screening in athletes: current evidence, knowledgegaps, recommendations and future directions, Br. J. Sports Med. 51 (2017) 153–167.[5] S. Sharma, J.A. Drezner, A. Baggish, et al., International recommendations for electro-cardiographic interpretation in athletes, J. Am. Coll. Cardiol. 69 (2017) 1057–1075.[6] B.J. Maron, B.D. Levine, R.L. Washington, et al., Eligibility and disqualiﬁcation recom-mendations for competitive athletes with cardiovascular abnormalities: task force2: preparticipation screening for cardiovascular disease in competitive athletes: ascientiﬁc statement from the American Heart Association and American College ofCardiology, Circulation 132 (2015) e267–e272.[7] A. Malhotra, H. Dhutia, G. Finocchiaro, et al., Outcomes of cardiac screening in ado-lescent soccer players, N. Engl. J. Med. 379 (2018) 524–534.[8] J. Chatard, F. Espinosa, R. Donnadieu, Pre-participation cardiovascular evaluation inPaciﬁc Island athletes, Int. J. Cardiol. 278 (2019) 273–279.[9] C.H. Landry, K.S. Allan, K.A. Connelly, et al., Sudden cardiac arrest during participa-tion in competitive sports, N. Engl. J. Med. 377 (2017) 1943–1953.[10] R. Jayaraman, K. Reinier, S. Nair, et al., Risk factors of sudden cardiac death in theyoung: multiple-year community-wide assessment, Circulation 137 (2018)1561–1570.

To screen or not to screen, what do the Pacific Island athletes teach us?

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To screen or not to screen, what do the Pacific Island athletes teach us?

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Helsingin yliopiston digitaalinen arkisto