Preventing
Screening of persons at risk
Screening of survivors of SCD and family members should include history of any cardiac symptoms: palpitations, dizziness, syncope, medications and particularly family history of syncope, SCD or unexplained deaths. The aim of the screening is to identify those with previously unrecognized structural heart disease, specifically HCMO, congenital coronary artery abnormalities and ARVD and also to exclude primary electrophysiological abnormalities of the heart. A good detailed physical examination is needed. Investigations would then include: 12 lead ECG, echocardiogram and possibly: signal averaged ECG, CMRI, long-term heart monitoring, cardiac catheterization and electrophysiological studies to assess for inducibility of tachyarrhythmia’s or conduction abnormalities. It appears most appropriate for screening and investigations to be performed by a knowledgeable physician, cardiologist with interest in sudden cardiac events or, preferably an electrophysiologist or arrhythmia expert.
Screening for sport
Screening in young persons taking part in competitive sports or planning to undertake elite training for such sports is controversial. How far does one go with the screening process? It is generally considered that the minimum is a history (especially family history), examination and ECG. Only if abnormalities are found would other investigations possibly be necessary. Since the prevalence of the cardiac diseases associated with SCD is low, some would regard screening as not cost-effective. Others have proposed a strategy of evaluating young athletes specifically targeting high-risk areas and focusing on individuals with the greatest possible risk: namely, those who have suggestive, even if minor, symptoms, and those who have a family history of sudden death or premature cardiac disease.
Those individuals with cardiac conditions that could pose a risk would generally be advised not to participate in most competitive sports. It is unlikely that any would be given professional sport employment. Recommendations for non-professional sport participation or exercise are available.
Major obstacles to the implementation of pre-participation screening are the large number of athletes and the rarity of sudden death from cardiovascular causes in this population. The Italian government has by the Medical Protection of Athletic Activities Act mandated national pre-participation screening and medical clearance including an ECG in all competitive sports. The European Society of Cardiology has drawn up a common protocol for cardiovascular pre-screening of young competitive athletes. It is believed that the implementation of such screening in Europe could reduce sports-related cardiac deaths by 50-60%. The International Olympic Committee has also adopted recommendations that athletes be screened for heart problems prior to competing.
Problems with screening. How good is screening?
Primary prevention and screening are problematic because a single ECG and echocardiogram do not exclude the cardiac diseases. Italian and European Heart Society recommendations are to perform screening tests in competitive sports-persons every 1- 2 years. The eligibility to partake in sport is dependent on the presence of a normal ECG. This poses another problem: there are rare abnormal ECG findings which are not simple to interpret and also do not have predictive value with regard to cardiac prognosis. It is felt by some that such findings do not predict SCD but may well stop a promising sporting career.
Screening and awareness has epidemiological and prognostic implications. Any syncope during or immediately after exercise must be regarded seriously and a precursor of SCD unless disproved. Therefore, syncope in young competing athletes needs evaluation. In a study of 7568 young athletes in Europe undergoing pre-participation testing, 6.2% reported having had syncope5 All the episodes of non-exertional or post-exertional syncope were typical of neurocardiogenic (vaso-vagal syncope). Of the 6 athletes with exertional syncope, one was diagnosed to have HCMO, another idiopathic VT and the remainder, neurocardiogenic mechanisms. The group without cardiac disease was followed-up for 6.4 +/- 3.1 years without adverse events. Thus, provided careful screening is performed, and those at risk of SCD are excluded, the prognosis of sport-persons with syncope is benign.
It needs to be acknowledged that even after a normal screening examination, small risks remain for SCD. This is shown in a 25 year retrospective cohort study of US military recruits 18-35 years of age. 126 nontraumatic sudden deaths were reported: 51% with a cardiac abnormality at post-mortem and 35% unexplained. They had all passed an entry screening medical examination (which rejects for enlistment those with cardiovascular diagnoses). An ECG was only performed if abnormalities on physical examination were detected. The sudden death rate was 13/100000 recruit-years. 86% of the deaths occurred during exercise.
Screening of scd victims (non-survivors)
All effort should be made to explain the death of SCD victims as this has implications for the family both with regard to bereavement management / closure and also for their life expectancy prognosis. Thus, a post-mortem, no matter how uncomfortable the consent for this may be, is essential. Unfortunately, deaths may still remain unexplained. These are probably caused by primary cardiac arrhythmias such as LQTS, other primary ventricular tachyarrhythmias, WPW and congenital atrioventricular block.4 It is important to note that genetic studies can be done with post-mortem material and may allow the diagnosis of conditions such as the ion-channelopathies: LQTS and Brugada syndrome.
"Screening is the most important way of preventing arrhythmic cardiac events. Screening involves having your ECG taken."
Screening of persons at risk
Screening of survivors of SCD and family members should include history of any cardiac symptoms: palpitations, dizziness, syncope, medications and particularly family history of syncope, SCD or unexplained deaths. The aim of the screening is to identify those with previously unrecognized structural heart disease, specifically HCMO, congenital coronary artery abnormalities and ARVD and also to exclude primary electrophysiological abnormalities of the heart. A good detailed physical examination is needed. Investigations would then include: 12 lead ECG, echocardiogram and possibly: signal averaged ECG, CMRI, long-term heart monitoring, cardiac catheterization and electrophysiological studies to assess for inducibility of tachyarrhythmia’s or conduction abnormalities. It appears most appropriate for screening and investigations to be performed by a knowledgeable physician, cardiologist with interest in sudden cardiac events or, preferably an electrophysiologist or arrhythmia expert.
Screening for sport
Screening in young persons taking part in competitive sports or planning to undertake elite training for such sports is controversial. How far does one go with the screening process? It is generally considered that the minimum is a history (especially family history), examination and ECG. Only if abnormalities are found would other investigations possibly be necessary. Since the prevalence of the cardiac diseases associated with SCD is low, some would regard screening as not cost-effective. Others have proposed a strategy of evaluating young athletes specifically targeting high-risk areas and focusing on individuals with the greatest possible risk: namely, those who have suggestive, even if minor, symptoms, and those who have a family history of sudden death or premature cardiac disease.
Those individuals with cardiac conditions that could pose a risk would generally be advised not to participate in most competitive sports. It is unlikely that any would be given professional sport employment. Recommendations for non-professional sport participation or exercise are available.
Major obstacles to the implementation of pre-participation screening are the large number of athletes and the rarity of sudden death from cardiovascular causes in this population. The Italian government has by the Medical Protection of Athletic Activities Act mandated national pre-participation screening and medical clearance including an ECG in all competitive sports. The European Society of Cardiology has drawn up a common protocol for cardiovascular pre-screening of young competitive athletes. It is believed that the implementation of such screening in Europe could reduce sports-related cardiac deaths by 50-60%. The International Olympic Committee has also adopted recommendations that athletes be screened for heart problems prior to competing.
Problems with screening. How good is screening?
Primary prevention and screening are problematic because a single ECG and echocardiogram do not exclude the cardiac diseases. Italian and European Heart Society recommendations are to perform screening tests in competitive sports-persons every 1- 2 years. The eligibility to partake in sport is dependent on the presence of a normal ECG. This poses another problem: there are rare abnormal ECG findings which are not simple to interpret and also do not have predictive value with regard to cardiac prognosis. It is felt by some that such findings do not predict SCD but may well stop a promising sporting career.
Screening and awareness has epidemiological and prognostic implications. Any syncope during or immediately after exercise must be regarded seriously and a precursor of SCD unless disproved. Therefore, syncope in young competing athletes needs evaluation. In a study of 7568 young athletes in Europe undergoing pre-participation testing, 6.2% reported having had syncope5 All the episodes of non-exertional or post-exertional syncope were typical of neurocardiogenic (vaso-vagal syncope). Of the 6 athletes with exertional syncope, one was diagnosed to have HCMO, another idiopathic VT and the remainder, neurocardiogenic mechanisms. The group without cardiac disease was followed-up for 6.4 +/- 3.1 years without adverse events. Thus, provided careful screening is performed, and those at risk of SCD are excluded, the prognosis of sport-persons with syncope is benign.
It needs to be acknowledged that even after a normal screening examination, small risks remain for SCD. This is shown in a 25 year retrospective cohort study of US military recruits 18-35 years of age. 126 nontraumatic sudden deaths were reported: 51% with a cardiac abnormality at post-mortem and 35% unexplained. They had all passed an entry screening medical examination (which rejects for enlistment those with cardiovascular diagnoses). An ECG was only performed if abnormalities on physical examination were detected. The sudden death rate was 13/100000 recruit-years. 86% of the deaths occurred during exercise.
Screening of scd victims (non-survivors)
All effort should be made to explain the death of SCD victims as this has implications for the family both with regard to bereavement management / closure and also for their life expectancy prognosis. Thus, a post-mortem, no matter how uncomfortable the consent for this may be, is essential. Unfortunately, deaths may still remain unexplained. These are probably caused by primary cardiac arrhythmias such as LQTS, other primary ventricular tachyarrhythmias, WPW and congenital atrioventricular block.4 It is important to note that genetic studies can be done with post-mortem material and may allow the diagnosis of conditions such as the ion-channelopathies: LQTS and Brugada syndrome.