Electrocardiography and Preparticipation Screening of Competitive High School Athletes

Potential Conflicts of Interest: Dr. Maron is the chairperson of the AHA position paper on guidelines for athlete screening (9).

IN RESPONSE:

I read with interest Dr. Marek's reaction to my editorial. Unfortunately, my comments seem to have been largely misunderstood. First, the disparity cited between U.S. and Italian physicians performing screening examinations relates specifically to the unique cadre of sports medicine physicians solely dedicated to this program in Italy—a crucial resource that simply does not exist in the United States, making national mandatory ECG screening exceedingly difficult, if not impractical. Second, the sudden death of any young athlete is tragic, but these events are uncommon (1–3). Third, Dr. Marek's characterization of the Sudden Death in Athletes Registry (1) as “a compilation of media reports” is inaccurate. Of note, tabulation of deaths of athletes in Italy is based on events limited to the Veneto region, which comprises only 9% of the Italian population. Fourth, no evidence suggests that mortality rates due to cardiovascular disease in athletes differ between the United States and Italy (3), despite dissimilar screening strategies (3, 4). Fifth, Dr. Marek suggests that I cited obsolete data for false-positive test results (that is, 10% to 20%) and claims a rate of only 2% from his own program. I encourage Dr. Marek to publish his stratified screening data so that we may all learn from his substantial experience screening 45 000 high school students over the past 4 years. I believe that we should be “preoccupied” with false-positive ECG test results because of the potential for overburdening the system, excessive subspecialty testing, overdiagnosis, unnecessary anxiety and confusion for patients and families, and unwarranted disqualification from sports. Sixth, suggesting that the debate is about a choice between mandated ECG screening (the Italian model) and “no screening at all” is a mischaracterization of the athlete screening process in the United States. Screening of U.S. high school and college athletes (with history and physical examination) is practiced almost universally (5) and has value (6). Seventh, it is an exaggeration to suggest that our national character is somehow dependent on adopting mandatory ECG screening for athletes. Preparticipation screening in large general populations is deceptively complex and requires measured consideration (7, 8) because it is affected by practical, societal, cultural, and legal considerations relevant to the U.S. health care system (8). Perhaps most important, limiting mass screening to sports participants would undoubtedly be regarded as exclusionary, if not discriminatory, with respect to young nonathletes. Finally, although the 2007 AHA screening recommendations (9) do not endorse mandated national ECG screening for all competitive athletes, in no way do the recommendations discourage individual initiatives, such as Young Hearts for Life. Moreover, it is incorrect to characterize the many clinicians and experts who do not endorse ECG screening on a required national basis as complicit in past and future sudden deaths of young athletes because of their misguided “mindset.”