Commentary: The Value of the ECG in the Preparticipation Sports Physical Examination: The Italian Experience

Abstract

Editor’s note: This commentary by Dr Vitiello addresses cardiovascular preparticipation sports screening by describing the extensive Italian protocol aimed at preventing cardiovascular deaths in athletes. Presented data indicate the value of the protocol, and extending the practice across Europe has been proposed. Readers not only will find this information to be educational but also will appreciate the value of viewpoints and experiences from other countries. We hope to present more of these contributions from outside of North America in the near future.—LFNIn 1982, the Italian Ministry of Health mandated required screening for everyone who participates in competitive sports. (1) The law states that every 1 to 2 years, all competitive athletes must be certified for participation. The definition of a competitive athlete includes students in secondary schools, members of sports clubs, and professional athletes. By law, the screenings are performed at designated “Centers for Sport Medicine” and are conducted by sports medicine specialists. The evaluation includes a comprehensive family and personal history, a physical examination, a 12-lead electrocardiogram (ECG), and a urinalysis. Furthermore, athletes participating in certain high-intensity sports also must undergo exercise testing and pulmonary function testing (TableT1). Those in whom abnormalities are found on the initial screening studies are referred for additional tests, including echocardiography, 24-hour Holter monitoring, and others as necessary. (1)In Italy, there has been considerable interest in preventing sudden death in young athletes by preparticipation screenings because there is a high incidence of catastrophic deaths caused by cardiomyopathy in young athletes. (2)(3)(4)(5)The Italian preparticipation screening program, by requiring ECG studies, might reduce mortality. The thinking is that the ECG is an excellent screening test for hypertrophic cardiomyopathy (HCM), (6) the leading cause of sports-related cardiac death. (7)(8)(9)(10) Burke and associates (8) found that 24% of sudden deaths during competitive sporting events were caused by HCM. After the institution of the Italian law, Corrado and colleagues (11) prospectively studied 269 consecutive cases of sudden death in young people and observed a significant reduction of HCM-caused sudden death from the expected 24% to 2% (one case). Furthermore, recognition of the relatively more rare disease, arrhythmogenic right ventricular (RV) cardiomyopathy, as a cause of death increased. Thus, it appears that the ECG has been an extremely valuable addition to the Italian program.Besides HCM, other causes of cardiac arrest in athletes may manifest ECG abnormalities at the preparticipation cardiovascular screening. These disorders include arrhythmogenic RV cardiomyopathy, long QT syndrome, dilated cardiomyopathy, and Brugada syndrome. With this knowledge inmind, it is critical to characterize the ECG findings in these diseases fully and to disseminate this information concisely to those administering the preparticipation screenings.We believe that the Italian screening system, which by national law requires examinations and also routinely employs the ECG, results in a significant reduction in sport-related cardiac deaths. Accordingly, there has been great interest in the Italian model from the greater European medical community. Recently, the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology presented a consensus document, in which the key role of the 12-lead ECG for identification of cardiac diseases leading to sudden death was emphasized. (12) This same study group is working on updated European guidelines to be published soon, although there may be problems for the different health organizations in the European countries.