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Pre-participation cardiovascular evaluation of young athletes: Should they sweat or not?

Sudden cardiac death (SCD) in young competitive athletes is a rare but devastating event. The primary scope of pre-participation cardiovascular evaluation (PPE) is to identify silent cardiac diseases that may be associated with exercise-related sudden cardiac arrest or death. In 2016, the European Heart Rhythm Association (EHRA) and European Association of Preventive Cardiology (EAPC) branches of the European Society of Cardiology (ESC) published a consensus statement on PPE. The proposed protocol for PPE includes clinical history, physical examination, and a 12-lead resting electrocardiogram (ECG). The panel recommended to consider and advise for PPE in individuals performing regular, intense exercise, after proper information of both its benefits and limitations. The evidence of favouring PPE comes from an observational study in the Vento region of Italy, where PPE for young competitive athletes is mandatory by Italian law since 1982. The Italian PPE protocol differs from the European recommendation by including a constantload ECG stress test (EST). Up to now, two large-scale studies have reported data on EST in PPE. Sofi and colleagues evaluated an unselected population of 30,065 non-professional and professional athletes of a broad age range from 5 to 92 years (mean age 31 years), referred to obtain eligibility for competitive sports. EST showed an abnormal pattern in 4.9% of cases, with 0.2% being complex ventricular arrhythmia (VA). Overall, 0.6% of the total population was considered ineligible for competitive sports. No follow-up was performed. Verdile and colleagues screened 5283 professional athletes, selected for inclusion in national or Olympic teams (mean age 25 years), with the Italian protocol. 5.1% were excluded due to cardiovascular abnormalities. Of the remaining athletes, 0.7% exhibited complex VA and were temporarily disqualified from competitive sports. Two-thirds of the disqualified athletes experienced a reduction of VA over a period of 3 to 12 months and were allowed to resume competitive sports. Half of the remaining athletes consented to radiofrequency ablation, were successfully treated and competitive sports was permitted afterwards. No life-threatening arrhythmia occurred during a mean follow-up of 7.4 5 years. In this issue of the journal, Alessandro Zorzi and colleagues added an interesting piece of evidence by studying EST in predominantly adolescent athletes with a prospective follow-up. The novelty in that study is an advanced imaging strategy, using cardiac magnetic resonance imaging (CMR) in athletes with complex VA. The authors enrolled 10,985 consecutive non-professional athletes (median age 15 years) undergoing annual PPE. In the total cohort, 9% of the athletes had abnormal findings, 4% were detected with medical history, physical examination or resting ECG alone and another 5% only during EST. Importantly, ‘abnormal’ EST was defined as the occurrence of VA, most commonly premature ventricular beats, with couplets and non-sustained ventricular tachycardias in 14% of cases. No data are provided on ECG patterns suggestive of myocardial ischaemia, probably because of the young age of the population. Subsequent examinations in athletes with exercise-induced VA included 24-hour Holter monitoring and transthoracic echocardiography in all, and CMR in athletes with complex VA (17%). Genetic testing for catecholaminergic polymorphic ventricular tachycardia was performed in 1% of the athletes. Overall, 0.49% of athletes showed a cardiac pathology at risk of SCD and were disqualified from competitive sports, a number comparable with the study of Sofi et al., despite the different study design and age ranges. Compared to routine PPE, the addition of EST increased the diagnostic yield by 75%. Twothirds of the cardiac diseases at risk detected by EST were due to two diagnoses, namely idiopathic nonischaemic scar (43%) and arrhythmogenic right