Two in every one hundred thousand young athletes die every year from what is known as sudden cardiac death. It is a small figure, but every single case is devastating: not only for their families and loved ones, but also for society, which will be in shock at such an unexpected death.
Currently, the main tool used to try and prevent such cases is an adjusted medical questionnaire alongside basic physical examination. Even today there is disagreement over the use of the electrocardiogram: while large scale use is advised against in the United States, in Europe it is considered a useful and advisable method. This disparity stems from “the availability of professionals trained to read and interpret them, as well as the professional fees and associated medical tests, which are much higher in the United States than in Europe,” states Marta Sitges, director of Instituto Cardiovascular del Hospital Clínic de Barcelona, also head of the Club’s Department of Cardiology.
Alongside Gonzalo Grazioli — cardiologist and collaborating researcher at the Grupo de Cardiologia Deportiva del Hospital Clinic — and Ramón Pi — sports physician in charge of carrying out the club’s medical examinations — Sitges has co-authored an article which proposes the use of four useful and cost-efficient diagnostic tests to prevent sudden death in teenagers: not only include the questionnaire and the initial physical examination, but also an electrocardiogram, an echocardiogram and a stress test. The article was published in the European Journal of Preventive Cardiology.
A large scale study
This project involved studying 1650 teenage athletes between the ages of 12 and 18 most of whom were part of the club, in a wide variety of disciplines. All of them were subjected to the four tests described, which altogether cost around 145 euros per person. The results showed that while no problems were detected in 88% of the cases, approximately 10% of athletes were recommended to undergo yearly revisions. Alterations that required treatment were detected in 10 athletes — 0.6% of the sample — after which they were able to reintegrate normally into sports practice. On the other hand, 6 teenagers — 0.36% of the sample — were advised to abandon the activity altogether on account of the high risk detected.
In addition, a cost-efficiency analysis was made. Including all the secondary tests, and considering only those 6 athletes (without even including the 10 athletes identified as potentially requiring treatment), the tests “are cost-effective according to international standards,” Gonzalo Grazioli contends. In particular, “the questionnaire and medical examination are neither powerful nor specific enough, although we do not suggest excluding them, because they are inexpensive and provide a gateway to the study. Interestingly, the electrocardiogram in particular appeared as the most powerful test, especially for detecting those situations that indicate the need to abandon sports practice. The echocardiogram and the stress tests offer added value, especially for identifying pathologies that can be treated.
The recurrent question is: Can these tests completely eradicate the risk of sudden death? “There is never one hundred percent certainty,” Grazioli admits, “but I dare say over 80% of cases can be identified. The 15-20% that could slip through would fall under one these three options: i) a badly performed study; ii) a sport done in extreme weather conditions that we are unable to reproduce in the laboratory; or iii) the consumption of drugs or toxics that are not present when doing the study and which could alter the results.”
What can be expected in the future? For the moment we know of no other test, including genetic testing, that is sufficiently reliable besides those included here,” Grazioli says reassuringly. For Ramón Pi, innovations will come with technology, with the arrival of “subtle tools, light nanotechnology which, in the form of strips or intelligent clothing, will collect the parameters to be studied and allow us to analyze them while being minimally invasive.”
For Grazioli, this work shows that “following these four points (questionnaire-examination, electrocardiogram, echocardiogram and stress test) make it possible to prevent the vast majority of cases of sudden death, and are useful even from the point of view of cost efficiency.” In fact, although this was done with a very select group of elite athletes, there is no doubt it “can be extrapolated to the rest of the population. We still don’t know what the ideal frequency is, but we do of course know that our young athletes should do it at least once in their lifetime.”
For Marta Sitges, “it is very important for these athletes who subject their hearts to high workloads to do prevention tests, just as you would check a car before setting off on a long journey.” Our study contributes new information on the value of each of the tests proposed for this purpose.”
The Barça Innovation Hub team