To screen or not to screen: that is the question!

This commentary refers to ‘Value of screening for the risk of sudden cardiac death in young competitive athletes’, by P. Sarto et al., https://doi.org/10.1093/eurheartj/ehad017 and the discussion piece ‘Pre-participation screening for safe sports activity’, by D. Corrado et al., https://doi.org/10.1093/eurheartj/ehad288. The value of every intervention in medical practice is determined by the net effect of harms and benefits. Do we help the person considering potential harm? According to the study ‘Value of screening for the risk of sudden cardiac death in young competitive athletes’1 and the accompanying editorial, the value of preparticipation screening (PPS) in preventing sudden cardiac death (SCD) among children is set in stone. However, Sarto et al. present the value of screening in finding diseases, not in patient-centred outcomes. The novel ESC VA SCD 2022 guideline2 downgraded PPS in competitive athletes from class I to IIa due to a low level of evidence.3 Professional organizations and societies recommend PPS. However, the evidence of PPS mainly relies upon a single observational study,4 and screening of the broader athletic population remains controversial. No randomized trial has tested the effect of PPS, and due to the rareness of the outcome, there probably never will be one. Screening as a preventive measure is seemingly intuitive. However, cardiopulmonary screening studies have failed the key test of randomization repeatedly: the DANCAVAS-trial, NELSON-trial, and LOOP-study all succeeded in detecting more disease, like the study of Sato et al., but with no improvement in survival. A screening program should be measured on its ability to reduce patient-centred outcomes, not its ability to detect diseases. Among all 22 324 screened athletes, Sarto et al. found 69 children with a diagnosis prohibiting them from participating in competitive sports. How many SCD and sudden cardiac arrest (SCA) were prevented by excluding these children? We do not know, but surely not 69. The incidence rate of SCA in this screened population was similar to recent estimates of sports-related SCA in an unscreened population.5 An additional 334 children were diagnosed with a cardiac disease unassociated with SCD. Have they benefitted from being diagnosed? Again—we do not know, as no data support such a claim. Most importantly, the authors fail to address the harm screening children may have. The medicalization of otherwise healthy children, inflicted by mandatory annual cardiac evaluations, is not addressed. Neither are the risks of overdiagnosis and overtreatment. The PPS comes at the risk of false positives with significant consequences for the individual: mental stress, unnecessary additional evaluations, and exclusion from activities that are regarded as essential parts of a healthy, social life. Screening programs should be based on voluntary participation and shared decision-making. Mandatory screening prior to engagement, combined with enforced exclusion upon detection of disease in children, is not shared decision-making; it is removing the liberty of a child. We believe that education on first response, resuscitation, and implementation of AEDs, quick reaction and work-up on symptoms, and thorough investigation in cardiac arrest cases and relatives of sudden death victims is a more appropriate approach with less risk of harm. The PPS might prevent SCD in athletes, but at what cost? Prohibition of exercise and medicalization of how many healthy children is acceptable to prevent one cardiac arrest? As with any other aspect of evidence-based medicine, initiatives must be grounded in solid evidence. No new data were generated or analysed in support of this article.