Sudden Cardiac Death in Athletes: Big Trouble, Not So Little Asia

he review by Dr. Halabchi, et al [1] is an excellent summary and reiteration of the importance of the addition of ECG screening to the pre-participation exam (PPE) for athletic competition. To pioneer this campaign in Asia, is a noble endeavor and is no small feat. As highlighted by this review, the general consensus for enforcing ECG as a requisite for participation varies greatly by the governing bodies making the suggestions and the demographic which they represent. The controversies most commonly discussed in the literature are the issues of lack of consensus for how to advise patients with ECG aberrations, false positive tests and the negative implications of such results; and cost effectiveness of mass screening. Not only does this manuscript briefly confront these topics, it also raises novel ideas regarding the unique milieu within the Asian cohort that may affect the risks for sudden cardiac death. In evaluating the natural history of ECG recommendations, the pendulum has shifted from one extreme to the other in support or dissent with mandating ECGs to the PPE. Since the incorporation of the ECG in Italy in 1986 by law, the prevalence of athletic SCD death decreased by nearly 90% in a small part of Italy and was attributed mostly to early identification of arrhythmogenic right ventricular dysplasia (ARVD) [2]. On the contrary, the Israeli experience [3] showed neither utility nor cost effectiveness. Despite the Israeli National Sport Law implement-tation in 1997, there was no difference in incidence of SCD in athletes before or after required athlete ECG screening. This may be a consequence of the Israeli population not being subject to the most common causes traditionally associated with athlete SCD that would be identified on ECG (hypertrophic cardiomyopathy, dilated cardiomyopathy, valvular heart disease, ARVD, long QT syndrome, Brugada's Syndrome). It may be that Israeli athletes die from causes such as Marfan's Syndrome, anomalous coronary arteries, catecholamine related arrhythmias, or commotio cordis, which would not be detected by a resting ECG. However, as the Israelis demonstrate, serial studies of the addition of ECG screening suffer from the wide variation in sport related deaths from year to year and that a randomized trial is needed. Perhaps another explanation for the disparity between the Italians and Israelis is the cultural and genetic differences of the populations studied in different countries. Genetic variation within a single country may explain the US experience with ECG as a …