Testing Athletes for Risk of Cardiac Disease

Abstract

Although regular exercise offers a degree of protection from cardiovascular disease, there is a transient increase in the risk of sudden cardiac death (SCD) during athletic activity for both young competitive athletes (YCAs) and older leisure athletes. SCD in YCAs usually occurs as a result of inherited diseases of the heart's structure. These diseases usually cause no symptoms prior to SCD, so many sporting bodies are now recommending preparticipation screening (PPS) for all YCAs to identify and enforce restriction of sports participation in those most at risk of SCD. There is ongoing debate about the effectiveness and cost‐effectiveness of such a strategy. Premature coronary artery disease (CAD) is responsible for most cases of SCD in athletes over 35 years of age, but is not yet clear whether PPS programs in this population could also prevent SCD by detecting those most at risk.

Key Concepts:

  • Causes of sports related sudden cardiac death differ depending on the age of the athlete; CAD is most common in those over 35 years of age, and structural, usually genetic cardiac abnormalities more common in those under 35.

  • In older leisure athletes, the cardiovascular benefits of exercise outweigh the risks of sports related SCD.

  • Most of the diseases responsible for SCD in YCAs are detectable on ECG.

  • Athletic training causes alterations to the ECG and echocardiogram, which can lead to diagnostic dilemmas, particularly in black, adolescent or endurance athletes.

  • Imaging modalities such as cardiac MRI (CMR) can help differentiate physiological cardiac adaptations from pathological changes in athletes.

  • There is evidence that PPS with an ECG may reduce the incidence of SCD in YCAs.

  • SCD in older leisure athletes most often occurs as a result of plaque rupture in coronary arteries that were not previously critically narrowed.

  • Most tests for coronary artery ischaemia depend on the presence of flow limiting coronary lesions, thus are of limited use in the athletic population with silent CAD.

  • There is a paucity of evidence for the efficacy of PPS in older leisure athletes.

Keywords: preparticipation screening (PPS); sudden cardiac death (SCD); young competitive athletes (YCAs); leisure athletes; electrocardiogram (ECG); maximal exercise stress test (MXT)

References

Baggish AL, Hutter A, Wang F et al. (2010) Cardiovascular screening in college athletes with and without electrocardiography: a cross‐sectional study. Annals of Internal Medicine 152(5): 269–275.

Basavarajaiah S, Boraita A, Whyte G et al. (2008) Ethnic differences in left ventricular remodeling in highly trained athletes relevance to differentiating physiologic left ventricular hypertrophy from hypertrophic cardiomyopathy. Journal of the American College of Cardiology 51(23): 2256–2262.

Bessem B, Groot FP and Niewland W (2009) The Lausanne recommendations: a Dutch experience. British Journal of Sports Medicine 43(9): 708–715.

Corrado D, Basso C, Pavei A et al. (2006) Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. Journal of the American Medical Association 296(13): 1593–1601.

Corrado D, Basso C, Schiavon M, Pelliccia A and Thiene G (2008) Pre‐participation screening of young competitive athletes for prevention of sudden cardiac death. Journal of the American College of Cardiology 52(24): 1981–1989.

Corrado D, Pelliccia A, Heidbuchel H et al. (2010) Recommendations for interpretation of 12‐lead electrocardiogram in the athlete. European Heart Journal 31: 243–259.

Corrado D, Schmied C, Basso C et al. (2011) Risk of sports: do we need a pre‐participation screening for competitive and leisure athletes? European Heart Journal 32(8): 934–944.

Corrado D, Thiene G, Nava A, Rossi L and Pennelli N (1990) Sudden death in young competitive athletes: clinicopathologic correlations in 22 cases. American Journal of Medicine 89(5): 588–596.

Detrano R and Froelicher VF (1988) Exercise testing: uses and limitations considering recent studies. Progress in Cardiovascular Diseases 31(3): 173–204.

Drezner J, Asif I, Owens D et al. (2012) Accuracy of ECG interpretation in competitive athletes: the impact of using standardised ECG criteria. British Journal of Sports Medicine 46: 335–340.

Elston J and Stein K (2009) Public health implications of establishing a national programme to screen young athletes in the UK. British Journal of Sports Medicine 45: 576–582.

Fagard R (2003) Athlete's heart. Heart 89(12): 1455–1461.

Gibbons RJ, Balady GJ, Bricker JT et al. (2002) ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 106(14): 1883–1892.

Harmon K, Asif I, Klossner D and Drezner J (2011) Incidence of sudden cardiac death in national collegiate athletic association athletes. Circulation 123: 1594–1600.

Kim JH, Malhotra R, Chiampas G et al. (2012) Cardiac arrest during long‐distance running races. New England Journal of Medicine 366(2): 130–140.

La Gerche A, Heidbuchel H, Burns A et al. (2011a) Disproportionate exercise load and remodeling of the athlete's right ventricle. Medicine and Science in Sports and Exercise 43(6): 974–981.

La Gerche A, MacIsaac A and Prior D (2011b) Should pre‐participation cardiovascular screening for competitive athletes be introduced in Australia? A timely debate in a sport‐loving nation. Heart Lung and Circulation 20(10): 629–633.

Ljungqvist A, Jenoure P, Engebretsen L et al. (2009) The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes. British Journal of Sports Medicine 43(9): 631–643.

Luijkx T, Cramer MJ, Prakken N et al. (2012) Sport category is an important determinant of cardiac adaptation: an MRI study. British Journal of Sports Medicine. Doi:10.1136/bjsports‐2011‐090520 [Epub ahead of print].

Magalski A, Maron BJ, Main ML et al. (2008) Relation of race to electrocardiographic patterns in elite American football players. Journal of the American College of Cardiology 51(23): 2250–2255.

Magalski AM, McCoy M, Zabel M et al. (2011) Cardiovascular screening with electrocardiography and echocardiography in collegiate athletes. American Journal of Medicine 124(6): 511–518.

Malhotra R, West JJ, Dent J et al. (2011) Cost and yield of adding eletrocardiography to history and physical in screening Division I intercollegiate athletes: A 5‐year experience. Heart Rhythm 8: 721–727.

Marijon EM, Tafflet M, Celermajer D et al. (2011) Sports‐related sudden death in the general population. Circulation 124(6): 672–681.

Maron BJ, Doener J, Hass T et al. (2009) Sudden deaths in young competitive athletes analysis of 1866 deaths in the United States, 1980–2006. Circulation 119: 1085–1092.

Maron BJ, Thompson PD, Ackerman M et al. (2007) AHA scientific statements recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update. Circulation 115: 1643–1655.

Marwick TH, Nemec JJ, Pashkow FJ, Stewart WJ and Salcedo EE (1992) Accuracy and limitations of exercise echocardiography in a routine clinical setting. Journal of the American College of Cardiology 19(1): 74–81.

Mathews SC, Marotsky D, Bernholt D et al. (2012) Mortality among marathon runners in the United States, 2000–2009. American Journal of Sports Medicine 40(7): 1495–1500.

Migliore F, Zorzi A, Michieli P et al. (2012) Prevalence of cardiomyopathy in Italian asymptomatic children with electrocardiographic T‐wave inversion at preparticipation screening. Circulation 125(3): 529–538.

Mitten MJ, Maron BJ and Zipes D (2005) Task Force 12: legal aspects of the 36th Bethesda Conference recommendations. Journal of the American College of Cardiology 45(8): 1373–1375.

Mohlenkamp S, Lehmann N, Breuckmann F et al. (2008) Running: the risk of coronary events: prevalence and prognostic relevance of coronary atherosclerosis in marathon runners. European Heart Journal 29(15): 1903–1910.

de Noronha S, Sharma S, Papadakis M et al. (2009) Aetiology of sudden cardiac death in athletes in the United Kingdom: a pathological study. Heart 95(17): 1409–1414.

Papadakis M, Whyte G and Sharma S (2008) Preparticipation screening for cardiovascular abnormalities in young competitive athletes. British Medical Journal 337: a1596.

Paterick TE, Paterick TJ, Fletcher G and Maron B (2005) Medical and legal issues in the cardiovascular evaluation of competitive athletes. Journal of the American Medical Association 294(23): 3011–3018.

Pelliccia A, Di Paolo FM and Corrado D (2006) Evidence for efficacy of the Italian national pre‐participation screening programme for identification of hypertrophic cardiomyopathy in competitive athletes. Europen Heart Journal 27(18): 2196–2200.

Pelliccia A, Fagard R, Bjornstad H et al. (2005) Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Europen Heart Journal 26(14): 1422–1445.

Prakken NH, Velthuis BK, Cramer M and Mosterd A (2009) Advances in cardiac imaging: the role of magnetic resonance imaging and computed tomography in identifying athletes at risk. British Journal of Sports Medicine 43(9): 677–684.

Prior DL and La Gerche A (2012) The athlete's heart. Heart 98(12): 947–955.

Schmied C, Zerguini Y, Yunge A et al. (2012) Cardiac findings in the precompetition medical assessment of football players participating in the 2009 African Under‐17 Championships in Algeria. British Journal of Sports Medicine 43: 716–721.

Siscovick DS, Weiss NS, Fletcher R and Lasky T (1984) The incidence of primary cardiac arrest during vigorous exercise. New England Journal of Medicine 311(14): 874–877.

Sofi FA, Capalbo A, Pucci N et al. (2008) Cardiovascular evaluation, including resting and exercise electrocardiography, before participation in competitive sports: cross sectional study. British Medical Journal 337: a346.

Steinvil A, Chundadze T, Zelstor D et al. (2011) Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death proven fact or wishful thinking? Journal of the American College of Cardiology 57(11): 1291–1296.

Thompson PD, Funk EJ, Carleton RA and Sturner WQ (1982) Incidence of death during jogging in Rhode island from 1975 through 1980. Journal of the American Medical Association 247(18): 2535–2538.

Thompson PD, Franklin BA, Balady G et al. (2007) Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 115(17): 2358–2368.

Webner D, Duprey KM, Drezner JA, Cronholm P and Roberts WO (2012) Sudden cardiac arrest and death in United States marathons. Medicine and Science in Sports and Exercise. Doi: 10.1249/MSS.0b013e318258b59a [Epub ahead of print].

Weiner RB, Wang F, Hutter AM et al. (2012) The feasibility, diagnostic yield, and learning curve of portable echocardiography for out‐of‐hospital cardiovascular disease screening. Journal of the American Society of Echocardiography 25(5): 568–575.

Wilson M, Basavarajaiah S, Whyte GP et al. (2008) Efficacy of personal symptom and family history questionnaires when screening for inherited cardiac pathologies: the role of electrocardiography. British Journal of Sports Medicine 42: 207–211.

Wyman RA, Chiu RY and Rahko PS (2008) The 5‐minute screening echocardiogram for athletes. Journal of the American Society of Echocardiography 21(7): 786–788.

Young MC, Thomson FP, Thompson N and Lee K (1999) Sudden death due to ischaemic heart disease in young aboriginal sportsmen in the Northern Territory, 1982‐1996. Medical Journal of Australia 170(9): 425–428.

Further Reading

Pelliccia A, Zipes D and Maron BJ (2008) Bethesda conference #36 and the European Society of Cardiology consensus recommendations revisited a comparison of U.S. and European criteria for eligibility and disqualification of competitive athletes with cardiovascular abnormalities. Journal of the American College of Cardiology 52(24): 1990–1996.

Uberoi A, Stein R, Perez M et al. (2012) Interpretation of the electrocardiogram of young athletes. Circulation 124(6): 746–757.

Contact Editor close
Submit a note to the editor about this article by filling in the form below.

* Required Field

How to Cite close
Brosnan, Maria J, and Prior, David L(Oct 2012) Testing Athletes for Risk of Cardiac Disease. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0024204]