Screening for safe sports participation: do for yourself what you tell your patients

The sports paradox: physical activity definitely reduces your risk for cardiovascular morbidity and mortality, but the likelihood of dying suddenly is more than twice as high during sports activities than at rest. Should this frighten you away from sports? Definitely not: there is a simple way to avoid the paradox and to make sure you derive benefit of sports participation. That is what screening is about. It does not matter whether you aim for competition or recreational sports: you should have yourself checked for safe participation. Show your patients that screening is simple and not a burden. All you have to do is 1) answer a few questions, 2) undergo a simple physical examination, and 3) have an ECG recorded. The two best-known questionnaires are the American Heart Association's Bethesda questionnaire and a list of questions compiled by the International Olympic Committee and European Society of Cardiology. There is no data on the comparative sensitivity and specificity of both questionnaires. The latter is longer and more comprehensive, but has the disadvantage of being more cumbersome. The shorter one [1] comprises only eight questions and therefore may be more efficient to apply routinely. Have a look at these questions: Do you have any family member who died suddenly below the age of 40 years? Is there any family member ≤ 50 years with known cardiovascular abnormality? Was ever any heart murmur ever diagnosed in yourself? Are you known with arterial hypertension? Did you experience any unexpected fatigue during physical exercise? Did you experience any sudden dizziness or syncope during physical exercise? Did you experience any excessive or unexplained exertional dyspnoea? Although the questions are straightforward, many athletes may tend to downplay any specific symptoms such as transient dizziness or effortlessness during exercise. The essence is that the sports participant should be honest with him/herself, and not neglect important warning symptoms. If you answer any of those eight questions with a ‘yes’, additional tests beyond the ECG may be appropriate. The same holds true if any of the following findings are present during a physical examination: Heart murmur (comparing supine, standing and squatting positions) suggesting dynamic left ventricular outflow tract obstruction, Weak and delayed femoral versus radial pulses, suggestive for aortic coarctation, Physical stigmata of Marfan syndrome, Elevated blood pressure measurement. Although there is debate on the appropriateness and cost-effectiveness of an ECG in the screening process, there are good reasons to defend it as the prerequisite third pillar [2–5]. Implementation of this screening scheme in Italy over a 20-year period has shown to reduce sports-related sudden death significantly from 3.6 to 0.4/100 000 patients per year, reaching levels comparable with those in nonathletes [6]. Its sensitivity for detecting underlying cardiac disorders with an increased risk for arrhythmias or sudden death during sports, such as hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome and other disorders, is higher than that of a physical examination. Studies have shown that HCM is detectable from the ECG in 70–82% of the patients, whereas only in 3% when only relying on physical examination and history [7, 8]. The same holds true for ARVC or any of the channelopathies. There are concerns that ECG abnormalities in athletes are nonspecific, and can easily be confused with pathology, leading to unnecessary further testing or even improper disqualification from sports. However, it becomes more and more clear that there is not that much overlap, and that this concern may only apply to ± 1% of recreational athletes and 4.8% of elite competitive athletes [9–11]. It is important to differentiate signs of the athlete's heart adaptation on the ECG from pathology. The first group of changes includes sinus bradycardia and sinus arrhythmia, junctional rhythm, first-degree atrioventricular block, a pattern of ‘rSr’ in lead V1, early repolarization pattern and isolated voltage criteria for left ventricular hypertrophy. The prevalence of these changes is dependent on the amount of training, and is approximately 3.4–12% in junior athletes [6, 12] and up to 40–45% in elite athletes [10, 11]. Most athletes with only those abnormalities are free of cardiac abnormalities, and hence, no further examinations are required [13]. In contrast, signs of left atrial hypertrophy, pathological Q-waves, rhythm disturbances other than atrial premature beats, or repolarization changes such as deep (i.e. ≥ 2 mm) inverted T-waves in more than two ECG leads should raise suspicion of underlying heart disease. Ten to 50% of these athletes may have an underlying cardiac disorder. ARVC should be suspected when negative T-waves are recorded in the right precordial leads beyond V2 over the age of 12–14 years, or HCM if present in the (infero)lateral leads. Uncommon changes as potential manifestation of pathology will be present in 1.1–4% of screening ECGs, and their prevalence is not related to the level of athletic activity [6, 10, 11] Even in the absence of echocardiographic abnormalities, intensified follow-up may be warranted, as a long-term follow-up study has shown that 6% of these athletes may develop overt cardiomyopathy after an average of 9 ± 7 years. In contrast, the absence of negative T-waves on the ECG confers a good prognosis [12]. It is recommended to have a first ECG taken around the age of 12–14 years. The risk of sports-related sudden death is low in younger children, and juvenile ECG patterns that can be confused with signs of cardiomyopathy will have disappeared around this age. A repeat ECG every 2 years is advocated, especially in competitive youngsters. Most likely, you are a man older than 35 years, which means that your main risk during sports participation comes from undetected coronary heart disease. The same applies for women over 45 years of age. Therefore, if your Systematic Coronary Risk Estimation (SCORE) risk profile (see elsewhere) indicates a risk for a fatal cardiovascular event of ≥ 5% during the next 10 years, it is recommended to undergo an additional exercise ECG before you go out and practice [14]. This is especially true if you intend to engage in more than light physical activity and have lived an unhealthy, sedentary life before but now want to make good on that. An exercise test is not routinely recommended in younger athletes (< 35 years) unless they want to engage in competitive sports with high dynamic and static cardiovascular demand (class III-C, such as cycling, swimming, or rowing). Of course, an exercise test may be warranted in case of other signs or findings, even transient dizziness or sudden unexpected fatigue during exertion, which may be due to exercise-induced arrhythmias. Furthermore, an echocardiography needs to be performed only on special indication. There is no place for it in routine screening, but it may be appropriate in the case of any alerting findings (e.g. heart murmur, or repolarization abnormalities on the ECG). Although often performed routinely in high-level young competitive athletes, there is definitely no strict recommendation in this regard. Does the detection of an underlying disorder automatically disqualify you from sports? The answer is highly dependent on the nature of the findings. There are extensive recommendations available on the topic [15, 16]. For competitive athletes, the decision is not only a medical one, but also has an ethical dimension: does society have the moral obligation to refrain some from often highly visible competition and the pressures related to that, or does personal freedom prevail? The decision should be a well-informed one, balancing the risks and benefits of continuation, and evaluating the alternatives for sports participation.