Preventing Sudden Cardiac Death among Athletes Using Echocardiography

Dear Editor, Sudden cardiac death (SCD) among athletes is an infrequent event that occurs during or shortly after physical activity.[1] Even though the overall incidence is low among athletes, it is a major concern in the field of sports medicine owing to its fatal nature.[1] The condition is often reported among young male athletes and those who engage in high-intensity sports and is generally attributed to a wide range of etiology.[1] In athletes under 35 years, SCD results due to inherited structural and electrical heart conditions (such as hypertrophic cardiomyopathy and congenital coronary artery disease), while among older athletes, undiagnosed coronary artery disease remains the key contributor.[1,2] Echocardiography is vital in carrying out a thorough cardiac assessment as a part of screening athletes before they are enrolled for participation.[2-4] It has the potential to detect structural heart diseases (like hypertrophic cardiomyopathy), which remains one of the most common causes of SCDs.[2] It can assess the size and functions of heart chambers, aortic root dilatation that can increase the risk of aortic dissection, identification of dilated cardiomyopathy, and early detection of congenital anomalies of coronary arteries which are not detected by electrocardiography (ECG) alone.[2] Further, this tool can also aid in the identification of valvular heart disease which can predispose athletes to arrhythmias and SCD.[3] Furthermore, by measuring pulmonary artery pressure, it can give an idea about an underlying cardiovascular pathology among athletes.[3] The utility of echocardiography has also been reported in assessing the systolic and diastolic function to rule out heart failure, detection of myocarditis-related ventricular dysfunction, and pericardial diseases that can impair cardiac output.[3,4] It can also differentiate between physiological cardiac hypertrophy and pathological one, thereby reducing the chances of unnecessary disqualifications.[2,4] In continuation, it is an effective and objective tool for physicians to decide the fitness of athletes to indulge in sports or advise them about lifestyle modifications.[2] It has been recommended that a combination of ECG and echocardiography can significantly improve the diagnostic accuracy for detecting a wide spectrum of conditions that can predispose athletes to SCD.[4] Echocardiography is a safe, noninvasive, and radiation-free tool, making it ideal for routine screening and subsequent follow-ups.[2] Even though echocardiography has immense scope and utility in screening athletes and prevention of SCD by giving information to the physician about structural and functional anomalies of the heart, its inclusion as a regular tool for screening is influenced by the presence of multiple challenges.[2,4-9] This includes the requirement of special equipment, making the process of large-scale implementation expensive, especially in low-resource settings.[5] This cost factor can be dealt with by seeking funding from the government and sports organization and using portable devices which are quite cheap[5] The next concern is the need to have skilled cardiologists and sonographers who can accurately interpret results.[5] The best approach will be to train sports physicians and general practitioners in the assessment and explore the possibility of telemedicine to enable remote consultation with experts.[3,6] In the current era, another approach would be to design artificial intelligence-assisted echocardiographic assessment to help in accurate interpretation[7] There is a possibility that variations in normal heart adaptations among athletes can result in wrong diagnoses, which eventually lead to unnecessary exclusion from sports events.[3,8] This calls for the need to frame clear guidelines to differentiate physiological adaptation from pathological findings, and appointment of a secondary expert review process, at least for borderline cases[8,9] There is a thought that, unlike ECG, echocardiography is more time-consuming to perform and analyze, which makes it difficult for use in large-scale screenings of athletes.[9] This concern can be handled by developing a standardized and rapid protocol (like Focused Cardiac Ultrasound protocol recommended by the American Society of Echocardiography) for screening athletes or using it only for those athletes who have abnormal ECG or potential risk factors, especially in low-resource settings[2,3] Another concern has been the variability in recommendations proposed by different sports organizations or nations, leading to inconsistency in screening.[5] This calls for the need to conduct large-scale studies to come out with evidence-based recommendations and encourage international collaboration to frame standard screening protocols.[5,9] In conclusion, despite advancements in the medical field, early detection of cardiac problems among young athletes is a challenging task. Echocardiography is an effective tool to detect these problems that can trigger SCD, and it is the need of the hour to integrate echocardiographic evaluation selectively for risk stratification and prevent fatal cardiac events in sports. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.