CORRESPONDENCE: LETTER TO THE EDITOR
Pre-Participation Sports Clearance
Jonathan D. Reich, MD, MSc*
* Pediatric Cardiology, The Watson Clinic, LLP, 1600 Lakeland Hills Boulevard, Lakeland, Florida 33805 (Email: jdreich{at}hotmail.com).
As an outspoken critic of the current state of pre-sports screening in the U.S. (1), I applaud Corrado et al. (2) and Pelliccia et al. (3) for their scientific and thorough efforts to detect conditions responsible for sudden cardiac death in athletes and adopting standardized procedures for screening. Although I agree that routine electrocardiograms (ECGs) can help detect hypertrophic cardiomyopathy, long-QT syndrome, and arrhythmogenic right ventricular dysplasia, there is one diagnosis for which ECGs seem unhelpful: congenital anomalies of the origin of the coronary arteries (4,5).
Basso et al. (5) himself reported that this diagnosis is responsible for between 5% and 35% of all sudden cardiac death in adolescents. As a result, I was surprised that this diagnosis was given little attention by these articles. Corrado et al. (2) lumped congenital anomalies of the origin of the coronary arteries with premature coronary artery disease. These 2 diagnoses have different demographics, etiologies, prevalences, presentations, and suitability of screening. As far as I know, the findings listed in the chart on page 1,984 of his article are all diagnostic for premature coronary artery disease and are of limited or no value in diagnosing congenital anomalies of the origin of the coronary arteries (2,4). Pelliccia et al. (3) failed to mention both diagnoses in their article.
In my pediatric cardiology practice, congenital anomalies of the origin of the coronary arteries is the diagnostic possibility of the most concern in athletes, especially ones complaining of nonspecific symptoms such as chest pain. I order more echocardiograms on young athletes and spend more time personally performing and reviewing echocardiograms to make this diagnosis than with hypertrophic obstructive cardiomyopathy or long-QT syndrome, which are easier to diagnose with echocardiogram and ECG. It seems to me that no matter how powerful the ECG is for screening for the other diagnoses, we are still going to have to evaluate and personally do an echocardiogram on nearly all competitive athletes if we are going to rule out congenital anomalies of the origin of the coronary arteries and thus significantly reduce the incidence of sudden cardiac death in adolescent athletes. I fail to see how this is financially feasible.
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1. Reich JD. It won't be me next time: an opinion on pre-participation sports physicals Am Fam Physician 2002;61:2618-262025, 29.2. Corrado D, Basso C, Schiavon M, et al. Pre-participation screening of young competitive athletes for prevention of sudden cardiac death J Am Coll Cardiol 2008;52:1981-1989.[Abstract/Free Full Text] 3. Pelliccia A, Zipes DP, Maron BJ. Bethesda Conference #36 and the European Society of Cardiology Consensus revisited J Am Coll Cardiol 2008;52:1990-1996.[Abstract/Free Full Text] 4. Basso C, Maron BJ, Corrado D, Thiene G. Clinical profile of congenital coronary anomalies with origin from the wrong aortic sinus leading to death in young competitive athletes J Am Coll Cardiol 2000;35:1493-1501.[Abstract/Free Full Text] 5. Basso C, Corrado D, Thiene G. Congenital coronary artery anomalies are an important cause of sudden death in the young Cardiol Rev 2001;9:312-317.[CrossRef][Medline]
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