Sudden cardiac deaths.

Introduction Sudden cardiac deaths in young people are devastating and personally tragic events, which fortunately occur uncommonly.1–7 Unsuspected genetic or congenital heart dis- eases, as well as blunt trauma and c ommotio cordis, have been recognized as causes of sudden cardiac deaths for >30 years.1–3,5,8,9 Considerable public debate has arisen in the lay and medical communities about establishing the most effective strategies for reducing or eliminating these events.6,10–25 For competitive athletes, much attention has been directed towards reducing head trauma and concussions in contact sports such as football,26–28 but also in devising prepartici- pation screening approaches for identifying potentially lethal cardiovascular diseases.6 In the process, a vast literature has been assem- bled, comprising both original data and a myriad of editorial commentaries.6

ORDER CUSTOM, PLAGIARISM-FREE PAPER

Although initially regarded as personal and family tragedies, the sudden deaths of young competitive athletes have become highly reported events over the past few

decades, achieving prominence in the public consciousness.1,5,6,10 Indeed, the sudden deaths of young people are counterintuitive and inconsistent with our expectations for sports competition. This discourse has been driven by the ubiquity of traditional and new social media, creating an exaggerated impres- sion of the incidence of these events that is disproportionate to the true effect that such deaths have on overall public health. Indeed, the strong influence of the media might have even fuelled the misconception that deaths are more common on athletic fields than they actually are, that these events might be largely limited to athletes, and that they are abso- lutely preventable by electro cardiographic screening.6,29 In this Perspectives article, we place many of these issues into the appro- priate context, with particular focus on the ethical considerations related to the prac- tice of limiting cardiovascular screening to c ompetitive athletes.

Historical context Interest in the preferential screening of young athlete populations (lately with electro cardiograms) has been justified on the assumption that sudden death owing to

underlying and unsuspected cardiovascular disease is largely explained by the physi- cally vigorous and stressful lifestyle to which young athletes are uniquely exposed by virtue of competition and systematic training regimens—that these deaths occur in athletes because they are athletes.6,30,31 However, the data supporting a strong link between com- petitive sports participation and the risk of sudden death remains incomplete.6,32–37 For example, sudden arrhythmic deaths were reported in 2014 to be most common at rest or during sleep.38

In the USA, a long-standing customary practice is to screen young people before they engage in sanctioned competitive sports in high school or college, using a personal and family history and physical examination, such as the 14 elements recom- mended by the AHA/ACC.6 This process has generally included all student athletes (at high school or college), independently of their level of achievement and performance. Indeed, Israel, Italy, and the USA are the only countries with systematic, broad-based screening of the athlete population.5,6,10,22,25

Mass population screening with the 12-lead electrocardiogram (including on a national basis) has been heavily promoted by Italian cardiologists,5,10,17–19 and by some in the US sports medicine community,16,31 despite the lack of both conclusive evidence and general agreement that adding electro- cardiograms to the screening examination substantially reduces cardiovascular mortality (Figure 1).6,23,25,37 Indeed, the Italian proposal has triggered a decade-long debate among cardiologists, paediatricians, and family prac- titioners about the merits of various cardio- vascular screening strategies.4,6,7,15–25,30 Many in the US cardiology community,1,4,7,20,21,23,24 including the AHA/ACC, regard mass electro cardiographic screen ing as excessive, if not inadvisable.6,39 This view is predicated on the considerable number of expected false-positiv e and false-negative test results, and the costs triggered by secondary ‘down- stream’ diagnostic testing (largely, but not necessarily, limited to echocardiography), which is wasteful of resources that could otherwise be used to promote improved pop ulation health.40 These factors, as well as other obstacles associated with limited resources, have led to the view that national

OPINION

Ethics of preparticipation cardiovascular screening for athletes Barry J. Maron, Richard A. Friedman and Arthur Caplan

Abstract | Preparticipation screening for unsuspected cardiovascular disease is a controversial topic in the medical and lay communities. Much attention has been directed towards young competitive athletes, particularly the proposed strategy of incorporating 12‑lead electrocardiograms into the screening process, even on a national or worldwide basis. However, sudden deaths of young athletes owing to genetic or congenital heart diseases have a low incidence in the general population. Furthermore, young people not engaged in competitive sports can harbour the same conditions that cause sudden death in athletes, which has gone largely unrecognized. Notably, sudden deaths from these diseases are numerically far more common in the much larger population of nonathletes. In this Perspectives article, we propose that an ethical dilemma has emerged, raising the important public‑health issue of whether young individuals should be arbitrarily excluded from potentially life‑ saving clinical screening evaluations because they do not engage in competitive sports programmes. Sudden cardiac deaths.