Sudden Cardiac Death in Athletes: Is Universal ECG Screening Plausible?

would like to commend Dr Farzin Halabchi and colleagues regarding their excellent review article of " Sudden cardiac death in young athletes " [1]. The identification of underlying cardiovascular disease is a primary screening objective of physicians who care for athletes. I would like to take this opportunity to clarify some points made in the article and make some suggestions for future screening and research. There is a lot of debate regarding the use of electrocardiogram (ECG) as a universal screening tool for cardiac diseases in the preparticipation physical exam (PPE). Italy has employed this and has shown a significant decrease in their athletes' mortality from sudden cardiac death (SCD). Extrapolation of data about ECG screening and decreases in SCD and its generalization to other countries has to be done with caution. The prevalence of Arrythmogenic Right Ventricular Dysplasia in Italy accounts for a large proportion of their cases of SCD. This high proportion of genetic cardiomyopathy will support the use of ECG screening as compared to populations where there are lower rates of identifiable cardiac diseases. The rate of SCD in Italy prior to national screening is quoted to be about 1:28,000 persons per year, with 0.9/100,000 directly attributable to ARVD. The largest and most statistically significant decrease of SCD from a specific cause was a decrease in death from ARVD to 0.15/100,000 [2]. Statistics of SCD from all causes in the United States vary from 1/300,000 to 1/160,000 [3]. This proportion is much lower than that found in the Italian population. The European Society of Cardiology (ESC) bases their recommendation of universal ECG screening for European athletes on the success of the Italian screening program. There is no data looking at the incidence of SCD in other European countries. If the incidence of SCD is lower along with a decrease prevalence of cardiomyopathy, the effectiveness of this universal screening protocol comes into question. The ESC estimates the cost of adding an ECG to all preparticipation evaluations would represent a 50% increase in cost [4]. This only represents about ten Euros, but there is no mention of the overall financial effects on European health care systems. Their recommendations do not take into account the availability of access to specialty care in the case of abnormal screening tests. This could have a serious impact on the health care systems of other European countries. The Italian experience has shown that universal …