Preventing sudden cardiac death in athletes: finding the needle in the haystack or closing the barn door?

The sudden, unexpected demise of an athlete is a devastating event that invariably leads to calls for prevention. In this edition of the journal, Corrado and colleagues provide an overview of strategies to prevent sudden cardiac death during sports. Timely identification of asymptomatic athletes at increased risk of sudden cardiac death (finding the needle in the haystack) or prompt resuscitation efforts with the use of an automated external defibrillator if an athlete suffers a cardiac arrest (closing the barn door) are two complementary strategies. The former strategy is largely based on the Italian practice of mandatory preparticipation screening of young athletes (aged 35 years or younger) launched in 1982. The latter strategy is addressed in the pioneering work of Drezner, co-author of Corrado et al. The Italian experience, which has provided the sports medicine community with a wealth of information on different cardiologic aspects of (intense) training, forms the basis for the 2005 European Society of Cardiology (ESC) consensus statement that essentially recommends routine preparticipation screening of young athletes. As such these recommendations are based on information from a population-based, observational study and expert opinion, which would qualify the level of scientific evidence for this intervention (mandatory preparticipation screening) as Class II B (usefulness/efficacy is less well established by evidence/ opinion) and level of evidence C. This view is reflected in the 2007 American Heart Association scientific statement ‘Exercise and Acute Cardiovascular Events, placing the risks into perspective’: ‘. . . other strategies, such as screening patients before participation in exercise. . . appear prudent, but have not been systematically evaluated’. Professor Corrado is one of the authors of this statement. The ESC recommendations have provoked fierce debates and opponents of mandatory screening have made their case, often noting that the Italian setting is likely to differ from that in many other countries, both in terms of incidence and causes of sudden death in young athletes and, more importantly, in the availability of highly trained physicians that perform the preparticipation evaluation of many thousands of athletes on a 2-yearly basis. Notwithstanding the intrinsic appeal of screening to prevent future events, the harsh reality is that only few screening programmes live up to the expectations. Even the case for diabetes mellitus screening, a highly prevalent condition that is well studied in terms of diagnostic tests, prognosis, and treatment, is not very strong. It seems evident that, at this moment in time, accepted prerequisites for screening are not met for routine preparticipation screening of young athletes, as discussed below.