ECG screening in athletes: optional or mandatory?

years bear a potential for arrhythmias, atrial fibrillation or a 20-fold higher possibility of SCD than female athletes. Ruwald et al. [6] showed recently in the European Heart Journal (EHJ, April 2015) that competitive sport is associated with a twofold increased risk of ventricular arrhythmias/death when compared with inactive patients and with patients who participated in recreational sport. When compared with inactive patients, recreational sport was not associated with an earlier onset of symptoms or increased risk of ventricular arrhythmias/death. Therefore, the question arises how to prevent these events in competitive sports, even if they are relatively rare. Do these events justify the use of all our medical armamentarium, in particular, an ECG or even an exercise ECG? In Italy in 2006, Corrado et al. [7] were able to show a reduction in the incidence of sudden cardiac death due to the screening intervention and appropriate restriction of athletes with arrhythmogenic right ventricular dysplasia. Can these results be extrapolated to other countries [8]? Perhaps it is best to focus on some achievable goals in pre-participation screening: (1) identify individuals known to be at risk and allow stratification of these risks, and (2) make recommendations regarding participation. In 2011, the Journal of the American College of Cardiology (JACC) featured an article entitled ‘Mandatory Electrocardiographic Screening of Athletes to Reduce Their Risk for Sudden Death: Proven Fact or Wishful Thinking?’, which suggests the latter [9]. The study analysed the incidence of sudden death among competitive athletes following the enactment of the 1997 USA National Sport Law, which mandates screening of all athletes with resting ECG and exercise testing. The average yearly incidence of sudden death or cardiac arrest events was 2.6 events per 100,000 athlete-years. The study concluded that mandatory ECG screening of athletes had no apparent effect on their In April 2015, it was reported by the San Antonio ExpressNews (Texas, USA) that legislation, requiring that high school student athletes should undergo electrocardiographic (ECG) screening before participating in sports, passed with a clear majority through a second reading in the Texas House. At the same time, The Dallas Morning News pointed out that the American College of Cardiology (ACC) and the Texas Pediatric Society were against the measure. There are few topics that lead to more controversy amongst physicians caring for young athletes than the correct method of pre-participation physical screening. On one hand, there is the conviction that physical screening has limited use if the end result is the final common pathway, that is unstable ventricular arrhythmias [1]; on the other hand, there is the belief that all young athletes, regardless of the sport and level of participation, require history, physical examination, (stress) ECG, echocardiography and, if necessary, even magnetic resonance imaging and computed tomography [2, 3]. What fuels such debates is the fact that sudden cardiac death (SCD) in the young athlete is estimated to occur in between 0.5 and 1 per 100,000 participating athletes below the age of 35 years [4]. In the USA, 50–75 deaths per year occur in young athletes; in France, this is approximately 10–15 [5]. Although these are very low numbers, it should be realised that competitive young male athletes suffer a fivefold higher risk of sudden cardiac death than noncompetitive athletes, and male athletes aged more than 30