PracticeUpdate Cardiology Best of 2018

EDITOR’S PICKS 12

Outcomes of Cardiac Screening in Adolescent Soccer Players The New England Journal of Medicine Take-home message • This study analyzed data from the English Football Associ- ation to examine causes and incidence of sudden cardiac death in its players over a 20-year study period. Data were obtained from the screening of 11,168 English Football Association players aged 15 to 17, and sudden cardiac deaths were identified on a voluntary Football Association registry and confirmed using autopsy reports and death certificates. The screenings were mandatory for these players and included a questionnaire, a physical exami- nation, echocardiography, and electrocardiography. The screening identified 225 athletes (2%) with either congenital or valvular abnormalities and 42 (0.38%) who had cardiac disorders that are associated with sudden cardiac death. • During the time period of the study, 23 athletes died and 8 of these deaths were considered to be sudden cardiac death. Most (88%) of the sudden cardiac deaths were attributed to cardiomyopathy, and 75% (6) of these athletes had not shown cardiac abnormalities at screening. Abstract BACKGROUND Reports on the incidence and causes of sudden cardiac death among young athletes have relied largely on estimated rates of participation and varied methods of reporting. We sought to investigate the incidence and causes of sudden cardiac death among adolescent soccer players in the United Kingdom. METHODS From 1996 through 2016, we screened 11,168 adolescent ath- letes with a mean (±SD) age of 16.4±1.2 years (95% of whom were male) in the English Football Association (FA) cardiac screening program, which consisted of a health questionnaire, physical examination, electrocardiog- raphy, and echocardiography. The FA registry was interrogated to identify sudden cardiac deaths, which were confirmed with autopsy reports. RESULTS During screening, 42 athletes (0.38%) were found to have car- diac disorders that are associated with sudden cardiac death. A further 225 athletes (2%) with congenital or valvular abnormalities were identi- fied. After screening, there were 23 deaths from any cause, of which 8 (35%) were sudden deaths attributed to cardiac disease. Cardiomyopa- thy accounted for 7 of 8 sudden cardiac deaths (88%). Six athletes (75%) with sudden cardiac death had had normal cardiac screening results. The mean time between screening and sudden cardiac death was 6.8 years. On the basis of a total of 118,351 person-years, the incidence of sudden cardiac death among previously screened adolescent soccer players was 1 per 14,794 person-years (6.8 per 100,000 athletes). CONCLUSIONS Diseases that are associated with sudden cardiac death were identified in 0.38% of adolescent soccer players in a cohort that underwent cardiovascular screening. The incidence of sudden cardiac death was 1 per 14,794 person-years, or 6.8 per 100,000 athletes; most of these deaths were due to cardiomyopathies that had not been detected on screening. Outcomes of Cardiac Screening in Adolescent Soccer Players. N Engl J Med 2018 Aug 09;379(6)524-534, A Malhotra, H Dhutia, G Finocchiaro, et al. www.practiceupdate.com/c/71844

COMMENT By Barry J. Maron MD T his impressive and ambitious survey study by Malhotra et al included 11,168 competitive soccer players in the UK (asso- ciated with professional clubs) for the purpose of detecting cardiovascular disease by screening with history and physical, ECG, and echocardiography adds importantly to our understand- ing of sudden cardiac death in young athletes. In these previously screened athletes, the rate of death was 7/100,000. It is interesting to note that the results of this study largely con- firm prior observations of some investigators with regard to the causes of sudden death in athletes, consequences of screening, and the prudence of disqualification from sports individuals with underlying cardiovascular disease. Notably, of the 8 sudden cardiac deaths among the >11,000 participants, cardiomyopathies were predom- inant accounting for almost 90% (n=7). These athletes included 3 with HCM, although it is also possible that a fourth athlete with “idiopathic LVH” could possibly be within the HCM disease spectrum. HCM was the most common cardiomyopathy detected in this population, and it is also regarded as the most common cause of sudden death in young athletes in the US. Another 2 athletes had ARVC, considered to be the most common cause of sudden death in Italian athletes. Therefore, the demographics here are consistent with the predominant causes of athlete sudden deaths reported in most of the literature. In contrast, several pathology surveys have advanced the idea that structurally normal hearts (ie, sudden death arrhythmia syndrome) represent the predominant cause of sudden death in young ath- letes (in up to >40%), an observation that is likely due largely to selection and referral bias. However, only a single athlete reported in this cohort received that diagnosis as the cause of death. Also notable is that, in 5 of the 7 sudden cardiac deaths, screening failed to identify or raise the suspicion of structural heart disease during life. Therefore, it is fair to conclude from these data in this population of soccer players that screening young people in nor- mal populations for cardiovascular disease with 12-lead ECGs is highly imperfect, encumbered with the burden of frequent false– negative results, and may not be reliable for the detection of potentially lethal cardiovascular disease in athlete populations. Finally, 2 athletes with HCM who died suddenly during intense physical activity had received a recommendation to cease com- petitive sports, which they declined, supporting the prudence of the Bethesda Conference and AHA recommendations for disqualification. Therefore, the work of Malhotra et al provides important support, in a large cohort of soccer players, for established principles related to the causes of sudden death in young competitive athletes, con- cern for false–negative screening results, and the risks associated with competitive sports participation in the setting of underlying cardiovascular disease, particularly HCM.

Dr. Maron is Director of Hypertrophic Cardiomyopathy Center at Minneapolis Heart Institute Foundation in Minneapolis, Minnesota.

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