Opinion
VIEWPOINT
Barry J. Maron, MD Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota. Bo Gregers Winkel, MD, PhD Danish National Research Foundation Centre for Cardiac Arrhythmia, University of Copenhagen, Denmark; and Laboratory of Molecular Cardiology, Department of Cardiology, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. Jacob Tfelt-Hansen, MD, DMSc Danish National Research Foundation Centre for Cardiac Arrhythmia, University of Copenhagen, Denmark; and Laboratory of Molecular Cardiology, Department of Cardiology, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
Corresponding Author: Barry J. Maron, MD, Minneapolis Heart Institute Foundation, 920 E 28th St, Minneapolis, MN 55407 (hcm.maron @mhif.org).
Perspectives on Cardiovascular Screening Sudden death in young people during competitive sports is devastating and counterintuitive, but fortunately a relatively uncommon event.1 Such athletes epitomize the healthiest and most vigorous element of society, voluntarily participating in activities that the community intuitively considers benign and free of significant mortality risk. Screening of young, healthy, general populations to detect cardiovascular diseases responsible for these deaths has been of intense interest in the physician community and general public at the intersection of cardiology, pediatrics, and family practice with public health policy, and largely involving a variety of complex and relatively uncommon genetic disorders or congenital heart diseases responsible for these sudden and unexpected events. A vast literature and polarized debate have evolved, arguing all sides of this deceptively complex issue.1 Universal screening of competitive athletes with 12-lead electrocardiogram (ECG; including on a mandatory national basis) has been promoted by European investigators, 2,3 whereas others have vigorously opposed this position citing lack of evidence that screening with ECG reduces mortality.4-7 Also, routine screening with ECG can produce large numbers of false-negative test results, as well as false-positive test results that promote expensive secondary testing, leading to economic and resource burdens on clinical practice and the health care system.1
25 years of age: (1) 4 deaths/year in National Collegiate Athletic Association athletes1; (2) less than 1 death/year in Minnesota high school athletes1; (3) 1 to 2 deaths/year in Denmark4,6; and (4) 2 deaths/year in the Veneto region of Italy.1 The annual incidence of cardiovascular sudden death in athletes ranges from 1:80 000 to 1:200 000,1 which is much less common than for sudden death in the general population.4 An assessment of proportionality is useful in judging the effect of athlete deaths on the sensibilities of individual citizens as well as public health policy. There are numerous preventable causes of sudden death in young people, virtually all of which are substantially more common than cardiovascular disease in trained athletes.3 For example, deaths from motor vehicle crashes in the United States are 150-fold more common and deaths from illicit drugs and suicide are 60 times more frequent than sudden death in athletes, whereas deaths attributable to lightning strikes are similar in number to deaths due to cardiovascular diseases in young athletes.1 Similarly, illicit drugs and suicide account for as many deaths in college athletes as do cardiac diseases.1 However, sudden death from cardiovascular disease may be viewed differently from these other rare causes for a number of reasons, including widespread perception that sports in young people is a healthy and innocent endeavor for which sudden and unexpected death from underlying and unsuspected cardiac disease becomes a highly counterintuitive (and emotional) event.
Perspectives on Screening Limited to Athletes Guidelines 1 from the American Heart Association/ American College of Cardiology do not recommend mandatory, universal, or national screening with 12-lead ECG in young people aged 12 to 25 years to identify genetic or congenital heart diseases. Screening may, however, be considered in relatively small cohorts of young healthy people, not necessarily limited to athletes (eg, in high schools, colleges or universities, and local or regional communities). However, these recommendations unavoidably raise an ethical conundrum. Should this opportunity to detect potentially lethal disease be confined to students who choose engagement in competitive sports, and at the same time, arbitrarily exclude others who do not elect such activities, but who nevertheless may be at the same risk and could benefit from screening? A second major issue central to the discussion of athlete screening focuses on the prevalence and incidence with which cardiovascular sudden death occurs related to sports. Indeed, the media has unintentionally created the mistaken perception that these deaths are more common than they actually are, and paradoxically that the only individuals susceptible to these events are young athletes.1 Evidence for the relative infrequency of these tragic events in young people comes from forensic databases tabulating data in millions of athletes younger than
jama.com
Danish Initiatives to Reduce Sudden Deaths With these considerations in mind, it is useful to look toward Denmark, a relatively small European country (population 5.5 million). The Danish medical community found that sudden death seldom occurred in competitive athletes or in recreational sports participants, and also occurs less commonly than in the general population.4,5 This recognition supported the decision of Denmark to reject European proposals for universal ECG screening of athletes.3 Instead, the Danish medical establishment and health authorities have directed their energies and resources toward other effective societal initiatives that target prevention of death due to out-of-hospital cardiac arrest, suicide, illicit drugs, motor vehicle crashes, and gun violence in young people (athletes and nonathletes alike) as well as the consequences of obesity and systemic hypertension. Several governmental and private public health initiatives implemented in Denmark over the last 2 decades address sudden death prevention in the young, 3 of which are discussed herein. Each program focuses on large inclusive populations, extending far beyond the potential of screening programs that target only those voluntarily engaged in competitive sports. JAMA January 6, 2015 Volume 313, Number 1
Copyright 2015 American Medical Association. All rights reserved.
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31
Opinion Viewpoint
Figure. Evidence for Decrease of Mortality in Young People Associated With Danish Social Programs B
No. of Motor Vehicle Fatalities
15 to 24 y, Denmark, 1981-2012 120
No. of Suicides
100 80 60 40 20 0 1980
1990
2000
2010
Motor vehicle fatalities in adolescents and young adults aged 15 to 24 y, Denmark, 1981-2012 250 200 150 100 50 0 1980
C
Bystander resuscitation and survival after hospital arrival, Denmark, 2001-2010
Patients Resuscitated From Cardiac Arrest, %
A Suicides in adolescents and young adults aged
1990
Year
2000
2010
50 40
Bystander CPR
30 20 10 Survival on arrival at the hospital 0 2000
Year
2002
2004
2006
2008
2010
Year
Part C is adapted from Wissenberg et al.6
Out-of-Hospital Cardiac Arrest Survival
Several initiatives have greatly enhanced resuscitative efforts for cardiac arrest in the community (Figure). Registered automatic external defibrillators outside of hospitals have increased 600-fold since 2007 (now >15 000). Mobile emergency care units staffed with anesthesiologists or paramedics are distributed throughout the country. Bystander cardiopulmonary resuscitation rates have doubled (to 45% in 2010), together with substantially increased survival on hospital arrival from 8% to 22%, and 3-fold increase in 30-day survival to 11%. Together these initiatives have increased survival from out-of-hospital cardiac arrest by 175%.6 Suicide Prevention
Suicide is a major but preventable cause of death in young people. Outpatient centers or clinics and telephone hotlines established for suicide prevention have been in place throughout Denmark since 1989, targeting vulnerable citizens. The Life-Line organization receives 13 000 inquiries each year from persons contemplating suicide and has more than 1000 active volunteers trained in counseling. In addition, availability of over-the-counter drugs that can be used to commit suicide have been restricted. Consequently, there has been a 60% decrease in suicides in Denmark from 1981 to 2012 for the age group of 15 to 24 years.8 Motor Vehicle Fatalities
A multitude of nationwide initiatives in place for decades from 43 organizations and public authorities target driving habits of young ARTICLE INFORMATION Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age). Circulation. 2014;130(15):1303-1334. 2. Thiene G, Corrado D, Schiavon M, Basso C. Screening of competitive athletes to prevent sudden death. Heart. 2013;99(5):304-306.
32
Danish citizens, including deterring operation of a motor vehicle while under influence of alcohol or other drugs, and encouraging seatbelt use. Since 1980, motor vehicle fatalities decreased by 86% in young people (to 50/year), including alcohol-related fatalities, which have decreased 12%, even though vehicles on the road increased by 90% during this time.8 Furthermore, seatbelts are mandatory, with high compliance among 94% of drivers and 81% of passengers. In Denmark, prevention of suicide and motor vehicle fatalities alone were associated with saving 220 lives/year in young people aged 15 to 24 years, whereas only 1 to 2 competitive athletes suddenly die of heart disease each year.4,5 Therefore, these national social initiatives have had substantial effect on the Danish public health, with the number of deaths averted far exceeding those potentially avoided by screening athletes for rare cardiovascular diseases with ECGs.4
Conclusions The Danish experience can be considered a compelling argument for revisiting and refocusing the screening debate for young healthy populations (including competitive athletes). Specifically, greater resources could be devoted to more effective public policy initiatives dedicated to prevention of the most common causes of sudden death in this age group. Such an expanded perspective on public health has the potential to benefit greater numbers of young people beyond the select minority who choose to engage in competitive sports.
3. Corrado D, Pelliccia A, Bjørnstad HH, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death. Eur Heart J. 2005;26(5):516-524.
cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA. 2013;310(13): 1377-1384.
4. Winkel BG, Holst AG, Theilade J, et al. Nationwide study of sudden cardiac death in persons aged 1-35 years. Eur Heart J. 2011;32(8): 983-990.
7. Maron BJ, Haas TS, Doerer JJ, et al. Comparison of US and Italian experiences with sudden cardiac deaths in young competitive athletes and implications for preparticipation screening strategies. Am J Cardiol. 2009;104(2):276-280.
5. Risgaard B, Winkel BG, Jabbari R, et al. Sports-related sudden cardiac death in a competitive and a noncompetitive athlete population aged 12 to 49 years. Heart Rhythm. 2014;11(10):1673–1681.
8. Statistics Denmark. Populations and elections: DOD1: deaths by sex, age and cause of death. http: //www.statbank.dk/statbank5a/default.asp?w= 1440. Accessed July 9, 2014.
6. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve
JAMA January 6, 2015 Volume 313, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Michigan User on 05/19/2015
jama.com
VIEWPOINT
Barry J. Maron, MD Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota. Bo Gregers Winkel, MD, PhD Danish National Research Foundation Centre for Cardiac Arrhythmia, University of Copenhagen, Denmark; and Laboratory of Molecular Cardiology, Department of Cardiology, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. Jacob Tfelt-Hansen, MD, DMSc Danish National Research Foundation Centre for Cardiac Arrhythmia, University of Copenhagen, Denmark; and Laboratory of Molecular Cardiology, Department of Cardiology, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
Corresponding Author: Barry J. Maron, MD, Minneapolis Heart Institute Foundation, 920 E 28th St, Minneapolis, MN 55407 (hcm.maron @mhif.org).
Perspectives on Cardiovascular Screening Sudden death in young people during competitive sports is devastating and counterintuitive, but fortunately a relatively uncommon event.1 Such athletes epitomize the healthiest and most vigorous element of society, voluntarily participating in activities that the community intuitively considers benign and free of significant mortality risk. Screening of young, healthy, general populations to detect cardiovascular diseases responsible for these deaths has been of intense interest in the physician community and general public at the intersection of cardiology, pediatrics, and family practice with public health policy, and largely involving a variety of complex and relatively uncommon genetic disorders or congenital heart diseases responsible for these sudden and unexpected events. A vast literature and polarized debate have evolved, arguing all sides of this deceptively complex issue.1 Universal screening of competitive athletes with 12-lead electrocardiogram (ECG; including on a mandatory national basis) has been promoted by European investigators, 2,3 whereas others have vigorously opposed this position citing lack of evidence that screening with ECG reduces mortality.4-7 Also, routine screening with ECG can produce large numbers of false-negative test results, as well as false-positive test results that promote expensive secondary testing, leading to economic and resource burdens on clinical practice and the health care system.1
25 years of age: (1) 4 deaths/year in National Collegiate Athletic Association athletes1; (2) less than 1 death/year in Minnesota high school athletes1; (3) 1 to 2 deaths/year in Denmark4,6; and (4) 2 deaths/year in the Veneto region of Italy.1 The annual incidence of cardiovascular sudden death in athletes ranges from 1:80 000 to 1:200 000,1 which is much less common than for sudden death in the general population.4 An assessment of proportionality is useful in judging the effect of athlete deaths on the sensibilities of individual citizens as well as public health policy. There are numerous preventable causes of sudden death in young people, virtually all of which are substantially more common than cardiovascular disease in trained athletes.3 For example, deaths from motor vehicle crashes in the United States are 150-fold more common and deaths from illicit drugs and suicide are 60 times more frequent than sudden death in athletes, whereas deaths attributable to lightning strikes are similar in number to deaths due to cardiovascular diseases in young athletes.1 Similarly, illicit drugs and suicide account for as many deaths in college athletes as do cardiac diseases.1 However, sudden death from cardiovascular disease may be viewed differently from these other rare causes for a number of reasons, including widespread perception that sports in young people is a healthy and innocent endeavor for which sudden and unexpected death from underlying and unsuspected cardiac disease becomes a highly counterintuitive (and emotional) event.
Perspectives on Screening Limited to Athletes Guidelines 1 from the American Heart Association/ American College of Cardiology do not recommend mandatory, universal, or national screening with 12-lead ECG in young people aged 12 to 25 years to identify genetic or congenital heart diseases. Screening may, however, be considered in relatively small cohorts of young healthy people, not necessarily limited to athletes (eg, in high schools, colleges or universities, and local or regional communities). However, these recommendations unavoidably raise an ethical conundrum. Should this opportunity to detect potentially lethal disease be confined to students who choose engagement in competitive sports, and at the same time, arbitrarily exclude others who do not elect such activities, but who nevertheless may be at the same risk and could benefit from screening? A second major issue central to the discussion of athlete screening focuses on the prevalence and incidence with which cardiovascular sudden death occurs related to sports. Indeed, the media has unintentionally created the mistaken perception that these deaths are more common than they actually are, and paradoxically that the only individuals susceptible to these events are young athletes.1 Evidence for the relative infrequency of these tragic events in young people comes from forensic databases tabulating data in millions of athletes younger than
jama.com
Danish Initiatives to Reduce Sudden Deaths With these considerations in mind, it is useful to look toward Denmark, a relatively small European country (population 5.5 million). The Danish medical community found that sudden death seldom occurred in competitive athletes or in recreational sports participants, and also occurs less commonly than in the general population.4,5 This recognition supported the decision of Denmark to reject European proposals for universal ECG screening of athletes.3 Instead, the Danish medical establishment and health authorities have directed their energies and resources toward other effective societal initiatives that target prevention of death due to out-of-hospital cardiac arrest, suicide, illicit drugs, motor vehicle crashes, and gun violence in young people (athletes and nonathletes alike) as well as the consequences of obesity and systemic hypertension. Several governmental and private public health initiatives implemented in Denmark over the last 2 decades address sudden death prevention in the young, 3 of which are discussed herein. Each program focuses on large inclusive populations, extending far beyond the potential of screening programs that target only those voluntarily engaged in competitive sports. JAMA January 6, 2015 Volume 313, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Michigan User on 05/19/2015
31
Opinion Viewpoint
Figure. Evidence for Decrease of Mortality in Young People Associated With Danish Social Programs B
No. of Motor Vehicle Fatalities
15 to 24 y, Denmark, 1981-2012 120
No. of Suicides
100 80 60 40 20 0 1980
1990
2000
2010
Motor vehicle fatalities in adolescents and young adults aged 15 to 24 y, Denmark, 1981-2012 250 200 150 100 50 0 1980
C
Bystander resuscitation and survival after hospital arrival, Denmark, 2001-2010
Patients Resuscitated From Cardiac Arrest, %
A Suicides in adolescents and young adults aged
1990
Year
2000
2010
50 40
Bystander CPR
30 20 10 Survival on arrival at the hospital 0 2000
Year
2002
2004
2006
2008
2010
Year
Part C is adapted from Wissenberg et al.6
Out-of-Hospital Cardiac Arrest Survival
Several initiatives have greatly enhanced resuscitative efforts for cardiac arrest in the community (Figure). Registered automatic external defibrillators outside of hospitals have increased 600-fold since 2007 (now >15 000). Mobile emergency care units staffed with anesthesiologists or paramedics are distributed throughout the country. Bystander cardiopulmonary resuscitation rates have doubled (to 45% in 2010), together with substantially increased survival on hospital arrival from 8% to 22%, and 3-fold increase in 30-day survival to 11%. Together these initiatives have increased survival from out-of-hospital cardiac arrest by 175%.6 Suicide Prevention
Suicide is a major but preventable cause of death in young people. Outpatient centers or clinics and telephone hotlines established for suicide prevention have been in place throughout Denmark since 1989, targeting vulnerable citizens. The Life-Line organization receives 13 000 inquiries each year from persons contemplating suicide and has more than 1000 active volunteers trained in counseling. In addition, availability of over-the-counter drugs that can be used to commit suicide have been restricted. Consequently, there has been a 60% decrease in suicides in Denmark from 1981 to 2012 for the age group of 15 to 24 years.8 Motor Vehicle Fatalities
A multitude of nationwide initiatives in place for decades from 43 organizations and public authorities target driving habits of young ARTICLE INFORMATION Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age). Circulation. 2014;130(15):1303-1334. 2. Thiene G, Corrado D, Schiavon M, Basso C. Screening of competitive athletes to prevent sudden death. Heart. 2013;99(5):304-306.
32
Danish citizens, including deterring operation of a motor vehicle while under influence of alcohol or other drugs, and encouraging seatbelt use. Since 1980, motor vehicle fatalities decreased by 86% in young people (to 50/year), including alcohol-related fatalities, which have decreased 12%, even though vehicles on the road increased by 90% during this time.8 Furthermore, seatbelts are mandatory, with high compliance among 94% of drivers and 81% of passengers. In Denmark, prevention of suicide and motor vehicle fatalities alone were associated with saving 220 lives/year in young people aged 15 to 24 years, whereas only 1 to 2 competitive athletes suddenly die of heart disease each year.4,5 Therefore, these national social initiatives have had substantial effect on the Danish public health, with the number of deaths averted far exceeding those potentially avoided by screening athletes for rare cardiovascular diseases with ECGs.4
Conclusions The Danish experience can be considered a compelling argument for revisiting and refocusing the screening debate for young healthy populations (including competitive athletes). Specifically, greater resources could be devoted to more effective public policy initiatives dedicated to prevention of the most common causes of sudden death in this age group. Such an expanded perspective on public health has the potential to benefit greater numbers of young people beyond the select minority who choose to engage in competitive sports.
3. Corrado D, Pelliccia A, Bjørnstad HH, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death. Eur Heart J. 2005;26(5):516-524.
cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA. 2013;310(13): 1377-1384.
4. Winkel BG, Holst AG, Theilade J, et al. Nationwide study of sudden cardiac death in persons aged 1-35 years. Eur Heart J. 2011;32(8): 983-990.
7. Maron BJ, Haas TS, Doerer JJ, et al. Comparison of US and Italian experiences with sudden cardiac deaths in young competitive athletes and implications for preparticipation screening strategies. Am J Cardiol. 2009;104(2):276-280.
5. Risgaard B, Winkel BG, Jabbari R, et al. Sports-related sudden cardiac death in a competitive and a noncompetitive athlete population aged 12 to 49 years. Heart Rhythm. 2014;11(10):1673–1681.
8. Statistics Denmark. Populations and elections: DOD1: deaths by sex, age and cause of death. http: //www.statbank.dk/statbank5a/default.asp?w= 1440. Accessed July 9, 2014.
6. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve
JAMA January 6, 2015 Volume 313, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Michigan User on 05/19/2015
jama.com
