Pre-participation sport screening: Don’t miss focus

‘In all debates, let truth be thy aim, not victory, or an unjust interest’

W. Penn

The letter by Braillon¹ contains a known list of criticisms of preparticipation screening (PPS), focusing on economy (‘Screening is a public health issue, not simply performing a test: screening can divert resources’²), stress on the athletes (‘screening exposes to overdiagnosis, a euphemism for harm due to unnecessary treatment, a major concern in healthy subjects’³), false priority (‘the marketing of tragic event nurtures excessive activity’⁴) and punchy comments which ‘deserves a strong comment’, as he said. Here it comes, but slowly.

Remarkably, he criticises the PPS in general, he does not criticise the main objective of Panhuyzen-Goedkoop’s article:⁵ ‘to assess whether the existing ECG criteria for detecting high risk cardiac conditions in young athletes can be applied to master athletes’, which contains limitations well described by Serratosa in his editorial.⁶ But we do agree with Braillon that ‘screening is a public health issue, not simply performing a test’. This is why consensus statements and position papers have been released to help in performing PPS and why several doctors have assessed the utility of these consensus criteria, presently by Panhuyzen-Goedkoop et al.⁵ Yes, it is true that ‘screening exposes to overdiagnosis, a euphemism for harm due to unnecessary treatment’, but this is the nature of a screening: not to treat, but to prevent, reducing the probability of manifesting diseases in a harmful pattern. Yes, ‘athletes show considerably lower all-cause and cardiovascular diseases-related standard mortality ratios than the general population’. The point is: why? Among others, thanks to that screening and the ‘deep scrutiny about minor changes on ECG’, so much criticized by Braillon.¹ Let us also remind ourselves of Corrado’s milestone sports cardiology paper,⁷ showing that athletes are at substantially higher risk of sudden cardiac death than non-athletes. Consequently, sport appears to be a trigger of potential risk; not to mention that up to 80% of young athletes are asymptomatic prior to their sudden cardiac arrest,⁸ nor that most diseases associated with sudden cardiac death seldom exhibit abnormal findings on a simple clinical examination. These articles constitute reasons for which comparisons between screening strategies have consistently shown the failure of the PPS based only on medical history and physical examination.⁹ Also, the recently published updated international recommendations for electrocardiographic interpretation have importantly increased the specificity.¹⁰ These quoted papers belong to a body of articles which are part of the evidence-based medicine that Braillon, surprisingly, states is missing.

We do agree with Braillon that there are too many differences among countries regarding the modality of screening, although it is well established that at least an electrocardiogram (ECG) is cost-effective.^11,12 And when it comes to the ‘E’ of ‘emotion’ rather than ‘evidence’, as said by Braillon, we even think that an ECG is not enough; we reason that a life is worthy of the marketing of a full-screening:¹³ we, ‘emotion’- and ‘evidence’-based doctors, think that such a screening should be applied not only to professional and elite athletes, but also to non-professional athletes, as they may have more cardiovascular risk factors and perform uncontrolled and unstructured sport activity. Emotional engagement may precede scientific activities. No reason to be negative to them even if also we fully acknowledge, and practise, the strict, objective rules of science.

Also in agreement with Braillon: ‘medicine is first about communication’. We like his reminder on doping and the use of illegal substances in athletes. However, the connection between doping and sudden cardiac arrest is weakly documented, but suspected. Another main point is how to manage the athlete post-screening? Even though we think that ‘safe is better than sorry’, we also consider that a balance should be maintained between safety and mental health. It is well documented that screening does not distress athletes.¹⁴ Undeniably, to stop an athlete from exercising may produce damage to their life and mental health. This is why several studies published in elite journals have been performed to assess the safety of exercise in affected individuals on therapy.^15,16 More debatable in our opinion is the frequency of PPS: may a less frequent and therefore cheaper screening maintain the same efficacy compared with the yearly one?

Last, Braillon criticizes the peer review process based on the first reference 17 of Panhuyzen-Goedkoop et al.⁵ That reference, which Braillon, somewhat unusually, defines as an ‘Italian publication’, is a consensus statement¹⁷ involving many European experts in the field of sports cardiology. Moreover, the publication of the two recent recommendations represents a joint consensus between European and American experts.^10,18 We do respect and welcome the opinions of Braillon and others. We hope it is mutual. Nevertheless, we also think that the opinion of expert physicians from different countries is not to be underestimated, that Google Scholars not necessarily have studied at university and have not all the experience of those experts. But the sports cardiology milieu has learned from the opponents of PPS.

The debates on PPS tend to be rather emotional. Every actor, including us, should reflect upon ‘why’. Of course, PPS still has a lot of deficiencies. But the reader may take a stand: shall you hamper or stop the screening wave, or shall you join in the developing of the screening tool and organization? We would advocate the latter because we think that a further developed screening is part of future medicine, highlighting more prevention of diseases. To sharpen the screening instruments, by the way, has also been the challenge of vast public health issues such as breast and prostate cancer.

Concluding our commentary, the debate on how to perform a PPS is a long one. Several opinions have been – and will be – expressed. What should not be missed is ‘the focus’: save the athlete, professional or not. Remember, a victim is a person, not a number.

‘It was hard to avoid the feeling that somebody, somewhere, was missing the point. I couldn’t even be sure it wasn’t me.’ D. Adams

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References