Level 2: Mid-level evidence

In Italy, nationwide systematic preparticipation athletic screening was introduced in 1982. First-line screening included family and personal history, physical exam, and 12-lead ECG. Preparticipation screening with exam and ECG was associated with reduced rate of sudden cardiovascular (CV) death, according to a population-based study that collected data before and after the initiation of national screening (JAMA. 2006;296:1593-1601).

The annual sudden CV death rates were analyzed for competitive athletes aged 12-35 years in the Veneto region of Italy from 1979-2004. Incidence per 100,000 person-years was 1.9 in screened athletes (55 cases during 2,938,730 person-years of observation) compared with 0.79 in unscreened nonathletes (265 cases during 33,205,370 person-years of observation). The incidence of sudden CV death in screened athletes (per 100,000 person-years) decreased from 3.6 in 1979-1980 to 0.4 in 2003-2004 (P <.001).

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A substantial portion of reduced mortality was attributable to a decrease in sudden death from cardiomyopathies (from 1.5 to 0.15 per 100,000 person-years), especially arrhythmogenic right ventricular cardiomyopathy (down from 0.9 to 0.15 per 100,000 person-years). The overall rate of disqualification from sports among screened athletes was 2%; about 20% of those disqualifications were due to ventricular arrhythmias.

An accompanying editorial advises caution in extrapolating results from Italy to the United States (JAMA. 2006;296:1648-1650). The predominant cause of exercise-related sudden death in the United States is hypertrophic cardiomyopathy, whereas the predominant cause of exertion-related sudden death in Italy is arrhythmogenic right ventricular cardiomyopathy. The prescreening annual death rate in Italy was higher than in most other studies. Additionally, the lowest annual death rate achieved (0.4 per 100,000 person-years) was similar to the reported rate for high school and college athletes in the United States from 1983-1993 (0.44 per 100,000 person-years).