More local data needed for athlete screening programs

Medical Tribune August 2008 SFV
David Brill

The introduction of a national screening program in Italy has helped to substantially reduce the incidence of sudden cardiac death (SCD) among young athletes.

However more regional data is needed before introducing similar programs in Singapore, a cardiologist has advised.

Speaking at the National Medical Convention of the Singapore Medical Association in July, Dr. Ong Hean Yee said that the results from Italy were “very, very impressive,” but noted that the causes of SCD in athletes vary around the world.

While hypertrophic cardiomyopathy is highly prevalent in the US, for example, arrhythmogenic right ventricular dysplasia and congenital heart disease seem to be responsible for more cases of SCD in Italy.

“In South East Asia we do not know. We do not have the data on the prevalence of cardiac abnormalities,” said Ong, a consultant cardiologist at Alexandra Hospital who was part of the medical committee for last year’s Standard Chartered Singapore Marathon.

“What works for the Italians might not work for Singapore. The demographics are quite different and we don’t want to be spending time and money doing something which doesn’t work.”

Italy introduced nationwide preparticipation screening in 1982. Research published in 2006 showed that the annual incidence of SCD in athletes dropped by 89 percent between 1979 and 2004 – from 3.6 to 0.4 deaths per 100,000 person-years. [JAMA 296(13):1593-601]

A total of 55 SCDs occurred among screened athletes during this period, compared to 265 deaths among those who were not screened.

Ong believes that awareness of the benefits of screening needs to be raised among the medical community.

“I think doctors are afraid because of all the negative publicity. But the guidelines are quite simple to follow, and if non-specialists do what the European Society of Cardiology [ESC] recommends they cannot go too far wrong,” he said.

Screening guidelines are also available from the American Heart Association (AHA), including a simple 12-step process covering personal history, family history and physical examination. [Circulation 2007 Mar 27;115(12):1643-455]

The ESC guidelines are similar but include performing a 12-lead electrocardiogram as standard. [Eur Heart J 2005 Mar;26(5):516-24]

At Alexandra Hospital, Ong said, screening follows the AHA’s 12 steps but includes electrocardiography, lipid and glucose testing, and a urine dipstick.

People who are at high cardiovascular risk, have a family history of heart disease, are aged over 40, are novices, or are doing very high-intensity sports should presently be screened, he said.

Ong added that it is currently hard to know where to draw the line between people who should obviously be screened and those for whom it is unnecessary. The issue of automated external defibrillators – at which events they are required, how many, and where to place them – also remains undefined.

He also described the reliance on further testing to identify heart problems as a “very controversial” area, noting that tests such as MRI, electrocardiography and the exercise treadmill test can all yield false negatives.

“There are a lot of unanswered questions,” he concluded.