Methodological Considerations on Pre-Sport Cardiac Evaluation in Children: Detection of Risks Other Than Sudden Cardiac Death

Abstract

We read with interest the recent article by Öncül and Gülyüz (n.d.) evaluating cardiovascular screening in pediatric athletes using electrocardiography and echocardiography. The authors are to be commended for addressing this important topic and for highlighting the role of pre-participation cardiovascular screening in identifying potentially significant cardiac abnormalities among young athletes. Their work adds valuable evidence to this evolving field. However, several methodological limitations merit consideration, as they may affect the interpretation and generalizability of the findings.

First, the single-center, hospital-based retrospective design introduces selection bias and limits generalizability. Because participants were referred to a tertiary pediatric cardiology center for sports clearance rather than randomly selected from the community, the reported prevalence of cardiac abnormalities (9.3%) and major cardiac conditions (2.3%) may overestimate that in the general pediatric athletic population. Malhotra et al. (2018) demonstrated that outcomes of cardiac screening depend strongly on the characteristics of the screened population and the screening environment.

Second, there is an absence of a control group without ECG/ECHO abnormalities in the study. Without comparison with children who underwent routine evaluation but had normal findings, it is difficult to determine whether detected abnormalities are clinically meaningful or represent common benign pediatric variations. This may lead to overinterpretation of minor structural or electrical findings as disease. Maron et al. (2014) emphasized that screening tests in healthy young populations must be interpreted against false-positive rates and predictive values.

Third, there is no long-term follow-up in order to determine clinical significance of detected abnormalities. The study identifies structural abnormalities such as mitral valve regurgitation, MVP, bicuspid aortic valve, LV hypertrophy, and arrhythmias, but it does not demonstrate whether these findings progressed, caused symptoms, affected sports participation, or resulted in cardiovascular events. Therefore, the conclusion that early detection improves future morbidity remains hypothetical. Corrado et al. (2006) demonstrated that screening findings require outcome validation rather than only detection.

Fourth, there is an absence of standardized diagnostic criteria or blinded interpretation of ECG/ECHO findings. The article reports ECG and echocardiographic abnormalities but does not clarify whether interpretation was performed by multiple blinded cardiologists or whether interobserver agreement was assessed. Pediatric echocardiographic interpretation, especially for MVP, valve regurgitation, and LV hypertrophy, may vary between observers. This introduces measurement bias. Fritsch et al. (2017) emphasized that variability in echocardiographic assessment of MVP and cardiac remodeling has been recognized as an important issue.

Finally, there is limited evaluation of arrhythmias because Holter monitoring and exercise testing were performed only in selected cases. The study may underestimate clinically relevant rhythm disorders because continuous rhythm monitoring was not systematically performed. Intermittent arrhythmias, exercise-induced ventricular ectopy, and concealed channelopathies may remain undetected. Williams et al. (2019) showed ECG improves detection but also highlighted limitations of isolated resting evaluation.

Future research should employ multicenter, population-based prospective designs with standardized recruitment and pediatric echocardiographic protocols, including blinded image interpretation and healthy control groups. Long-term follow-up should assess disease progression and clinical outcomes, while standardized Holter monitoring, exercise testing, and genetic evaluation in selected patients would improve diagnostic accuracy and risk stratification.

In conclusion, this study provides valuable insights into cardiovascular screening in pediatric athletes. However, the methodological limitations discussed may influence the interpretation and generalizability of the findings. Future well-designed multicenter prospective studies with standardized diagnostic protocols and long-term follow-up are needed to strengthen the evidence and optimize cardiovascular screening strategies in young athletes.

All the authors meet the ICMJE authorship criteria and have made significant and equal contributions to this manuscript. All authors approved the final version and agree to be accountable for all aspects of the work, ensuring the accuracy and integrity of the data and interpretation.

The authors have nothing to report.

Guarantor statement: All authors have read and approved the final version of the manuscript. They took complete responsibility for the data's integrity and the data analysis's accuracy.

Transparency statement: The Authors affirm that this manuscript is an honest, accurate, and transparent account of the study being reported, that no important aspects of the study have been omitted, and that any discrepancies from the study as planned (and if relevant, registered) have been explained.

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The authors declare no conflicts of interest.

Data sharing does not apply to this article as no datasets were generated during the current study; all data were sourced from published literature.