Testing Athletes for Risk of Cardiac Disease

Abstract

Abstract Although regular exercise offers a degree of protection from cardiovascular disease, there is a transient increase in the risk of sudden cardiac death (SCD) during athletic activity for both young competitive athletes (YCAs) and older leisure athletes. SCD in YCAs usually occurs as a result of inherited diseases of the heart's structure. These diseases usually cause no symptoms prior to SCD, so many sporting bodies are now recommending preparticipation screening (PPS) for all YCAs to identify and enforce restriction of sports participation in those most at risk of SCD. There is ongoing debate about the effectiveness and cost‐effectiveness of such a strategy. Premature coronary artery disease (CAD) is responsible for most cases of SCD in athletes over 35 years of age, but is not yet clear whether PPS programs in this population could also prevent SCD by detecting those most at risk. Key Concepts: Causes of sports related sudden cardiac death differ depending on the age of the athlete; CAD is most common in those over 35 years of age, and structural, usually genetic cardiac abnormalities more common in those under 35. In older leisure athletes, the cardiovascular benefits of exercise outweigh the risks of sports related SCD. Most of the diseases responsible for SCD in YCAs are detectable on ECG. Athletic training causes alterations to the ECG and echocardiogram, which can lead to diagnostic dilemmas, particularly in black, adolescent or endurance athletes. Imaging modalities such as cardiac MRI (CMR) can help differentiate physiological cardiac adaptations from pathological changes in athletes. There is evidence that PPS with an ECG may reduce the incidence of SCD in YCAs. SCD in older leisure athletes most often occurs as a result of plaque rupture in coronary arteries that were not previously critically narrowed. Most tests for coronary artery ischaemia depend on the presence of flow limiting coronary lesions, thus are of limited use in the athletic population with silent CAD. There is a paucity of evidence for the efficacy of PPS in older leisure athletes.