In a recent BMJ report, Van Brabandt and colleagues present their assessment of cardiovascular (CV) screening in athletes to prevent sudden cardiac death (SCD) from the perspective of a health economist.
The authors make several points of which we agree:
1) the diagnostic yield of CV screening by history and physical examination alone is extremely low and with little supporting evidence;
2) national, universal screening should not be mandated, especially without appropriate physician infrastructure;
3) CV screening will detect disorders associated with SCD but with an unclear absolute risk of CV events; and
4) the potential benefits and harms of different CV screening programs are not fully understood.
However, we disagree with their conclusion, “As long as those at high risk of sudden death cannot reliably be identified and appropriately managed, young athletes should not be submitted to pre-participation screening.” We wish to share a different perspective on why early detection of CV disorders in athletes is both justified and can save lives.
Purpose and Assumptions
The premise of CV screening in athletes is that early detection of cardiac disorders associated with SCD has the potential to reduce morbidity and mortality through individualized and evidence-driven disease-specific management. Without this belief, then screening by any strategy is called into question. If one believes in early detection, screening by history and physical examination alone is inadequate. The addition of ECG, while still imperfect, will increase detection of disorders at elevated risk of SCD and can be achieved with a low false-positive rate and high quality when proper infrastructure and skilled cardiology resources are available.