Sudden cardiac death during exercise

No i shall be at work tommorow watching people have them before they exercise in our Cardiac Rehabiltation classes - thats why i am interested in the research and the implications it may or not have for cardiac health screening and effective disease prevention -but if i got the opportunity to get wired up to an ECG and do an Exercise Stress Test sometime i would gladly - i'd rather find out if i had any problems  earlier when i could do something about it than later when i may not have a lot of choice

Maybe everyone will eventually be better screened - it could be cheaper in the long run - we are least soon beginning Vascular Checks for the Over 40's which may be a good early indicator of CHD (although not specifically Sudden Cardiac Death) but we can hope that the Prevention agenda gets taken seriously

Talk about having an agenda Buney!

Has I said in a earlier post, I'm not against anyone having a medical check up (the full works) if they are concerned for their health. It would be the sensible thing to do!

Anyone else think FtP is the perfect candidate for high BP and a cardiac?  Feel the Anger more like............

Screening should  always be cheap, easy to perform and with the purpose of providing a solution to a problem which otherwise could present itself with serious consequences.

I guess whether you opt in or out of screening comes down to the usual informed consent but wouldn't it be lovely to have that option.

Personally running is important but not more important than living to see my children grow. I'd have the test 

Very interesting stuff, in my short life, I've personally known three young fit athletes die suddenly with heart failure (one footballer and two runners). It breaks your heart when it happens (scuse the pun)

I'd be for universal screening at school.

FtP is strangely familiar.... it's almost like we've met before... surely not?

Another thing with screening is that it should be done on a population at risk and who would otherwise be unaware of the issue - i.e. not those who would turn up at the GP suspecting a problem or concerned for their health

A good discussion from this thread - my only interest would be the risk/benefit and seeing evidence for this

Well I'm glad someone else finds it interesting!

FtP - it's not unworkable - it's been going on in Italy for years - this is not a piece of speculative research, it's a report of a day-to-day service.

I don't know how one would model the costs/benefits, but I'm sure there will be a follow up paper reporting Italy's data.

The paper does not detail exactly the conditions picked up by the test - so I don't know whether there is a cure/management plan for those people weeded out - it's certainly true that without some benefit for the subjects then there is no great benefit to having the test - you can hardly avoid getting your heartrate up for the test of your life. But an ECG will probably pick up rhythm problems, most of which can be successfully treated, so I expect that there is some positive outcome/health protection for these folk.

One last thought - a 1:500 risk may not sound like much, but that ratio is a higher incidence than the 3 yearly risk of cervical cancer (for which we already have a very sophisticated screening program), neonatal hypothyroidisn and PKU, which all babies are tested for. Not as high as breast cancer, but of a similar order. It would be a huge task to set a program up + coordinate it for interval screening across the population, but we already do it for a number of other conditions.

My prediction is that it will be coming to a BUPA package near you soon (ie choose it if you wish), then will be a condition of insurance to participate in sport abroad where the healthcare costs are potentially huge (eg NY marathon), because the cost/benefits to insurance co.s will be clear. Not sure whether it will trickle down to the NHS sooner or later, though

>> I imagine those who were screened out were reasonably grateful that they could carry on living a long and full life providing they did not engage in over strenuous activities - pity they were not followed up in the study for analysis.

A life without doing sport of any kind, without sex, without jumping up and down in front of the telly when your team wins, without those stressful work sessions where you are racing an important deadline or preparing for an interview etc. You can't even run down the stairs to get out of the office on a Friday afternoon!

What kind of life is that? I would rather run the 1:500 risk of death, I doubt I would modify my lifestyle even if I was diagnosed (but you never really know until it happens).

My whole concern with these reports BtB is that they cause easily influenced people alot of unneccesary stress (not me Mrs Pig thx.)

The 1 in 500 is a ridiculous figure. Theres millions of people that participate in sport and get enormous pleasure from it.

I'm just guessing but there must be 30/40 million people in this country alone that have actively participated in a sport ( as a child or adult) or still do. Thats a figure of 60,000 to 80,000 people that have put their life at risk! and we are talking about a sudden heart attack while doing a sport.

Insurance, medical certificates......It doesn't take alot to see who will get the real benefit from this scare mongering.

Check the small print....A medical/insurance company probally sponsored the research!

Mrs Pig you said you would have the test!.................You don't have to wait, book yourself in. Let me know how you get on.

Walk the walk.....talks cheap

FtP - they weren't sponsored as far as I can see, but I share your cynicism/realism on who makes a profit on screening. There has been a lot of work done looking at the psychological harm of screening, even if the tests prove negative (even going for a BP check makes people feel less well), but my feeling is that on the pro's outweigh the con's, as long as there is something in it for the individual concerned, not just society at large (ie global cost savings). In this case I think there is, although using it for insurance purposes won't acheive that.

Incidentally - 1 in 500 isn't ridiculous - it is a true representation of what was found. There is a lot of hidden heart disease out there. Not all of it is guaranteed to kill you, but it will kill someone, and it may or may not be you. It is entirely up to you whether you go looking for it (I doubt I would personally, but that's a personal standpoint). Some people are more risk-averse than others - they have as much right to be screened as you and I have not to be.

>> Check the small print....A medical/insurance company probally sponsored the research!

Agreed, this is much more likely to be a wheeze thought up by insurers than it is something that will actualy benefit real people. Its like genetic predisposition tests, why would anyone on earth have one of these when their main impact is to hammer your insurance premiums?

The results were inconclusive and the study was meant to find out if weeding out those at risk would reduce the number of sudden deaths so as yet is not complete as they will have now to compare mortality rates pre and post screening.

As many of those with abnormalities were in the older age group - and presumably had developed heart problems later in life rather than having the much rarer condition that causes sudden death in the young - it would mean that screening would have to be done regularly to be effective.

BtB..After this long and interesting debate its great to see that you agree with me.

P.S. ...1 in 500 is ridiculous. ( we are talking about deaths when performing a sport). You're probally a little proud to stand down but its O.K.

It's not only sport and exertion that raises the heart rate. There's stress and anxiety as well. I've just come back from the dentist. I keep telling myself to wear my hrm just out of curiosity because I seriously sense that my hr goes through the roof as soon as he fires up that drill.

Ditto sudden shock. I was wearing my hrm once when out for a plod and confronted by a large dog. All it did was slobber over me and give me a tail-whipping but when I looked at the file afterwards my hr had hit a figure close to max. Only momentarily, but still ...

I'm not passing opinion on the rights or wrongs of screening but thought I'd add some info about the publication itself since it's been raised that it might be sponsored. 

Having read the small print, this was not a sponsored study. There is no commercial involvement at all. And the BMJ would be working very closely to strict guidelines that ensure all conflicts of interest/commercial involvements are disclosed (medical publications is my area of expertise)

" <!-- null --> Contributors: All the authors participated in study design, analysis, interpretation of results, drafting of the article, and approval of the final draft. FS is guarantor.

<!-- null --> Funding: None.

<!-- null --> Competing interests: None declared.

<!-- null --> Ethical approval: Research ethics board of the Institute of Sports Medicine of Florence.

<!-- null --> Provenance and peer review: Not commissioned; externally peer reviewed."

The BMJ is a high tier journal so (and admitedly I haven't read the full paper) its peer review will have been extensive and by leading doctors in the field. It does, however state that it's a preliminary study and that it makes no claim about preventing deaths.

'Because of the observational design of this study, we were unable to show if these clinical evaluations are effective in reducing the risk of mortality or incidence of cardiac accidents in sports participants.'

This sort of research is a step in the direction of determining a cause and effect, and potentially a preventative programme, under which screening would be useful. Until you have some data from which to make a conclusion, we can only speculate. This brings us one step closer.

To add to Pink's point - this was not a piece of prospective research ('I wonder what would happen if we....') but retrospective data ('what has actually happened since we...). The preventative program is alive and well in Italy. This gives it more significance since the numbers involved are very large and, in this instance, unlikely to be confounded by any other variables.

As a couple have mentioned - it's the death rate that really matters. Well - following up this reference from the original paper it appears that the death rate amongst young athletes (in a different part of Italy)dropped by 89% during the study - almost all through identification of cardiomyopathies.

(Which is very impressive, but they had to prevent 879 athletes from competing (2% of the total through the doors) to prevent 60 athletes with cardiomyopathies from competing. So it's a pretty blunt tool.)

All studies are imperfect, but data from longstanding, consistent and accurately monitored schemes such as this are about as reliable as we are going to get.

My guess is that, in time, it will become more clear which abnormalities are specifically related to sudden death. You do, however, need populations such as these, ie screened, to get any meaningful data.  If they are able to perform follow-up analyses on this population as well as prospective studies we might have enough information for the NHS to adopt screening. Knowing that NICE and, hence the NHS, are very conservative in terms of what they'll support, I would doubt this would be adopted in the UK for a good number of years.

Incidentally, (and for those who are interested and I haven't bored to tears already...), Lipitor (atorvastatin) the largest selling drug globally (treats cardiovascular disease), requires 99 patients to be treated to prevent 1 cardiovasular event (eg heart attack) in a 3 year period (look at the example in the link)  Yes, I know it's Wikipedia! 

In comparison, if you call preventing an athlete competing 'treatment', in BtB's example you are 'treating' 14 patients to prevent one death in 5 years. The numbers are really quite small in comparison to the most successful drug being marketed today.

>> (Which is very impressive, but they had to prevent 879 athletes from competing (2% of the total through the doors) to prevent 60 athletes with cardiomyopathies from competing. So it's a pretty blunt tool.)

I wonder what the 819 false-positives who were prevented from competing thought of the program.