LAUSR

Preventing sudden cardiac death (SCD) in athletes is a somewhat emotional topic. Although these tragic events are rather rare (1 per 100,000 competitive athletes per year or 1 per 100,000 competition hours are commonly cited estimates), they are given widespread media coverage, and each case, of course, is a tragedy of its own. Diverging recommendations have been put forward to prevent SCD in sports, involving more or less medical technology. The causes of SCD in athletes were extensively studied and can be divided into two predominant classes: coronary heart disease in athletes over 35 years of age, and congenital heart disease (structural defects, including cardiomyopathies, or channelopathies) in the young. Many, but not all, of the known causes may be amenable to detection, which enables disqualification of athletes from dangerous activities before the occurrence of symptoms or SCD. However, intensive (although noninvasive) testing is necessary to miss the lowest possible number of potentially fatal anomalies. With preventive testing, the anticipated beneficial effects must be weighed against the aspects of cost and tolerability. This is of some importance, since there will be more than 95% negative tests, given the low incidence of the anomalies in question. In addition, an accurate diagnosis is warranted, because a false positive test may result in unnecessary disqualification with sometimes devastating consequences for the athlete. The study by Grazioli et al. reported in this issue of European Journal of Preventive Cardiology adds some important information to this discussion. The study was conducted in teenage competitive athletes in Spain. For various reasons, the results may not strictly be applicable to other age groups or recreational athletes. The diagnostic power of various test instruments is put into perspective. Doppler-echocardiography seems to have the best yield, followed by resting and exercise ECG, whereas a structured questionnaire is less powerful. From the data presented, one might argue that all of the proposed tests should indeed be performed, at least in young competitive athletes at the beginning of their career. The cost per disqualified case was 45,000 Euros in the setting of this Spanish programme. Doppler echocardiography in Spain is priced particularly low (50 Euros). Costs would therefore be higher (by up to a factor of 3 to 5) in many other countries, but in such circumstances negotiations might eventually lead to a more moderate tariff for this indication. Does this seem too high a price? Consider, for example, that similar resources are allocated to the prevention of one death per year by statin therapy in atherosclerotic populations at intermediate risk. We should certainly be able to afford a similar investment which pays off over 10 years or more in young healthy members of society!