Is electrocardiogram screening of North American athletes now warranted?

Some confusion may have been created by a recent suggestion that both the American Heart Association (AHA) and the European Society of Cardiology call for cardiovascular screening of athletes to prevent sudden exercise-induced death. In fact, there remains a sharp continental divide on the issue of mandatory electrocardiogram (ECG) screening. With the support of the European College of Cardiology, Italian investigators have long argued for such screening. Medical certification became a condition of participation for Italian athletes, both amateur and professional, beginning in 1950. Since 1982, more than 5 million Italian competitors aged 12 to 35 years have theoretically undergone an assessment that includes an annual clinical examination, a 12-lead resting ECG, a simple bench-type stress test, and basic spirometry (although it is less clear how complete screening has been de facto). National ECG screening has also been introduced for children and young adults in Japan. There have been occasional suggestions of adopting a similar plan in North America, but in general, support has continued for the AHA policy of avoiding ECG screening, except for those failing an initial 12-point physical examination. This commentary weighs several pieces of recent evidence advanced in support of mandatory ECG screening, relevant information surrounding an apparent recent reduction in sudden cardiac arrests among Italian athletes after the introduction of ECG screening protocols, a direct comparison of clinical evaluation against clinical plus ECG testing as a means of detecting cardiac abnormalities, and calculations of costeffectiveness for the ECG testing of athletes. The claim that mandatory ECG screening reduces the incidence of sudden cardiac death (SCD) in athletes is based on a study of some 20 000 athletes aged 12 to 35 years living in the Veneto region of Italy. Between 1979 and 2004, a total of 50 male and 5 female SCDs were reported in this population. A trend analysis suggested a statistically significant decline of SCD incidents from 3.5 to 4.0 per 100 000 in 1979 to 1982 to 0.4 per 100 000 between 2001 and 2004; however, in nonathletes, the rate remained relatively consistent at 0.9 per 100 000 over the same period. The decrease in SCD among the athletes was attributed mainly to a reduced incidence of right ventricular arrhythmic cardiomyopathies. There have been a number of criticisms of these data. Although for most sports physicians, the avowed objective of mandatory testing is to avoid exercise-induced deaths, the Italian incidents were not necessarily exercise related. Further, there was no comparison of screened versus nonscreened athletes. Rather, the initial SCD incidence was compared with subsequent findings for the same population. However, the initial rate (3.5 to 4.0 per 100 000 per year) was very high; thus, the final figure for Italian competitors (after 10 years of screening) remains similar to that in North America (where ECG screening of athletes is not a routine practice). Little information is provided about the type of athlete or the level of competition in the Italian study. The group was ‘‘competitive’’ but apparently included about 15% of the regional population in the age category of 12 to 35 years. If we are to attribute the secular trend of SCDs to mandatory ECG screening, it also remains puzzling why rates remained high for 5 years after introduction of the new policy, from 1982 to 1987. Perhaps, the most alarming aspect of the report from the patient’s viewpoint is that 9% of all athletes required