Ultrasound Screening Strategy Devised to Prevent Cardiovascular Complications in Sports

Alexander Kisko, a physician from Presov (Slovakia). EuroEcho-Imaging 2013 is the official annual meeting of the European Association of Cardiovascular Imaging (EACVI), a registered branch of the European Society of Cardiology (ESC), which took place during December 11–14, 2013, in Istanbul (Turkey).

“Trained athletes are generally considered the healthiest people in society, seemingly invulnerable and often capable of extraordinary physical achievement. Their unexpected death during training or competition is a tragic event that assumes a high public profile and continues to have a considerable impact on the general public and the medical community. Sudden cardiac death [SCD] in young and apparently healthy athletes has long been considered rare but there is evidence that deaths occur as often as once every three days. These deaths are usually caused by undiagnosed cardiovascular abnormalities but diagnostic screening is considered too expensive and is delivered sporadically. The medical community must become more involved in reducing the incidence and prevalence of SCD through an improved preparticipation screening process,” noted Dr. Kisko.

The optimal preparticipation screening (PPS) protocol in sports is cost-effective, has high diagnostic accuracy, and is practicable in large populations. The European PPS protocol consists of personal and family history, physical examination, and 12-lead electrocardiogram (ECG). There is controversy over whether adding echocardiography (ECHO) to the protocol increases the accuracy of screening and is cost-effective.

In the current pilot study, 500 healthy athletes aged 16–32 years (average age 21±5 years) including 446 males and 54 females (8:1 ratio) participating in sports like football, athletics, handball, cycling, basketball and gymnastics were examined in 2011–2013. All athletes were screened according to the European PPS protocol. Cardiovascular abnormalities were not detected in any of the athletes.

Traditional echocardiography screening (M-mode and 2D modalities) was performed in all athletes. Cardiovascular abnormalities were found in 14 instances (2.8%). Seven (1.4%) had mitral valve prolapse (hemodynamically significant in one case), three (0.6%) had bicuspid aortic valve (significant aortic stenosis in one case), and four (0.8%) had myocarditis, myocardial bridging, noncompaction of the left ventricle, or coronary artery fistula.

Dr. Kisko said, “In four athletes the abnormalities we found with conventional ECHO required them to stop sports temporarily or permanently. The standard protocol was not accurate or sensitive enough to pick up potentially life-threatening cardiovascular defects. But the addition of M-mode and 2D ECHO exams, which are quick and simple to perform and quite inexpensive, picked up abnormalities in 14 athletes.”

Preparticipation sports screening is not very popular with athletes because they do not want to be excluded from their sport if a cardiac abnormality is discovered, according to Dr. Kisko. However, when an apparently healthy athlete dies suddenly, it is a tragic event that may lead the public to believe that exercise is not good for them. This small pilot study, according to Dr. Kisko, revealed that screening with traditional M-mode and 2D echocardiography modalities added to the standard protocol is more effective for identifying cardiac abnormalities that are otherwise undetectable and therefore has the potential to become part of the standard screening protocol.

“It is time to reignite the professional debate on mandatory pre-participation sports screening on a legal basis, and whether ECHO should be added to the standard protocol. We believe that in the beginning, ECHO could be reserved for screening of athletes starting a professional career in high intensity sports [such as marathon, cycling, triathlon, cross-country skiing, football] and athletes at increased risk of SCD,” Dr. Kisko concluded.

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