We know very little about the risk of sudden death associated with exercise in young competitors, so the benefits versus the hazards of sports activity pose a clinical dilemma. However, we know from a study in the Veneto region of Italy that adolescents and young adults involved in competitive sport had a two and a half times higher risk of sudden death. The young competitors who died suddenly were affected by silent cardiovascular diseases, predominantly cardiomyopathies. Sport did not directly cause the deaths, but rather it triggered cardiac arrest in athletes with underlying diseases predisposing them to life-threatening ventricular arrhythmias.
Italy has a mandatory eligibility test involving nearly six million young people every year and the test leans heavily on the use of 12-lead ECG. In one 17-year study by the Centre for Sports Medicine of Padua involving nearly 34,000 athletes under 35 years old, over 1,000 were disqualified from competing on health grounds, 621 (1.8%) because the tests revealed relevant cardiovascular abnormalities.
In the US young athletes had physical examinations and personal and family history investigations, but 12-lead ECG was done only at the doctors discretion. The American Heart Association previously assumed that ECG would not be cost-effective for screening. The results of Italys 25-year experience of systematic pre-participation evaluation show that the Italian screening method is more sensitive than the limited US protocol. ECG is abnormal in up to 95% of patients with hypertropic cardiomyopathy (HCM), which is the leading cause of sudden death in an athlete. Comparisons between findings in Italy where ECG is used and research in the US showed a similar prevalence of HCM in non-sport sudden cardiac death, but a significant difference – 2% versus 24% – in sports-related cardiovascular events. This suggests we have selectively reduced sports-related sudden death from HCM because the Italian system, using ECG, identifies vulnerable young people.
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