Sudden cardiac death during exercise

New study in the BMJ

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07/07/2008 at 15:44

Still here and interested

That's the problem with health-related studies, longitudinal research takes sooo long. Guess prediction studies may be the way to initiate screening in the absence of 'waiting to die' data  Someone needs to do a meta-analysis with multiple populations... now that would be interesting.

07/07/2008 at 16:28

>> This is only a 5 year study. They may still be at risk in the rest of their lifetime. Not necessarily false positives.

They  may not necessarily be false positives but they will be denied health insurance for any sport based on that test so their sporting careers and hobies are over for life regardless of the validity of the diagnosis.

It may also prevent them from getting travel insurance and raise their general insurance premiums.

The point is that, unless the problem is treatable, their lives will be measurably degraded by a test that is purely precautionary.

Edited: 07/07/2008 at 16:31
07/07/2008 at 16:36

Given the numbers, I wonder if it's possible to work out the overall
effect of the screening programme in Italy on mortality?
Whether it's positive or negative?

I.e., is the number of people "saved" from sudden death
(or, really, the number of years of life "saved")
greater than the loss of years of life caused by the fact that
some people will be put off exercise (either by actually being screened
or just by the overall impression that exercise is dangerous
caused by the screening programme) and thereby might
shorten their life expectancies by not exercising?

I wonder if there's any data on whether general participation
in running fell in Italy when the screening was introduced
simply as a result of the negative impression?

(It's very like the argument about cycling helmets.... I've been
in that one too ... if you make them compulsory, you may save
some lives, but you may also cost some by putting people
off cycling, and thereby shorten peoples lives.... and in that
case, the data actually suggest that making helmets
compulsory would cost lives .... I still wear mine).

07/07/2008 at 16:41

>> Given the numbers, I wonder if it's possible to work out the overall
effect of the screening programme in Italy on mortality?
Whether it's positive or negative?

There is more to life than just living for as long as possible.

07/07/2008 at 16:45

Well, that's certainly true...

... which makes it harder to understand the costs and benefits...

a life lived without vigorous exercise is a tragedy, and as someone said,

a loss of a young person from preventable sudden death is also a tragedy...

07/07/2008 at 16:48

... but I suspect if you asked a large sample of the public to rate it:

"how bad would you feel if we told you you could never do vigorous exercise again?"

and

"how bad would you feel if your child died doing their first race / soccer match / whatever?"

the balance might favour the screening.

Pink    pirate
07/07/2008 at 17:29

It's a difficult question and one very worthy of a thread

Unfortunately, decisions like these are made based on economic benefits (at least in the UK, NICE have a very tight hold on the purse strings)

Would preventing 2% of the population strenuous exercise have further (and greater) health implications on society (relating to CV, obesity, diabetes etc) than would be gained by screening. Would those people given a 'managed/low impact exercise regime' to prevent those implications (assuming strenuous exercise is the initiator). What would the cost of that be...?

Lots of influencing factors. It's not necessarily a case of if you can screen you should screen.

Clearly the Italians have reviewed some of these factors and made a decision on that basis. But we should also take into account other baseline information such as rates of obesity/heart attacks/diabetes etc. These can vary quite considerably between populations. We would have to review it for the UK population taking into consideration our risk factors.

al.
07/07/2008 at 17:43
Wasn't it 0.2% (1 in 500), not 2%?

Still, if you've done a few marathons/ironmans/cyclosportifs and then you go and get this test done and you're disqualified from entering them anymore, you wouldn't be best pleased. I'd rather shoot myself.
al.
07/07/2008 at 17:57

alhill hit the nail on the head here. The Italian example isn't about people being offered screening and then choosing not to take part, it is them having screening forced on them and then being banned from competition as a result.

For me this takes it out of the arena of people being offered choices about their health and into the area where event organisers are making a decision based on the bottom line and then forcing that decision on competitors.

Once compulsion enters into it this is a totally different argument.

>> "how bad would you feel if we told you you could never do vigorous exercise again?"

>> "how bad would you feel if your child died doing their first race / soccer match / whatever?"

What about "how bad would you feel if you were forcably tested and then told that because the test says that you have a 1 in 500 chance of a problem you will not be permitted to do any sport or exciting activity ever again?"

07/07/2008 at 17:58

Sorry to confuse - the original paper found 0.2% have a significant 'potentially fatal' exercise induced cardiac abnormality on ECG

One of their references was to another, earlier study from a different city, but looking at the same program. They found 2% of the study group had an exercise induced anomaly sufficient to prevent competitive exercise (may be different criteria - it doesn't specify on the abstract and I can't get the full text), with a 89% reduction in death in the study period, compared with pre-study. In the general population the death rate had not changed over the same period. I can only assume the 10-fold difference is down to different definitions of 'dangerous'.

al.
07/07/2008 at 18:35
Dr. Gaetano Thiene with the Padua Center for Sports Medicine said, "The major effort indeed is to identify these people and then disqualify from sport activity. Don't forget that the sport activity and effort is a trigger for sudden death in people affected."

I don't like the sound of that at all. Surely the major effort should be to improve people's quality of life or fund research into finding a cure or something?
al.
08/07/2008 at 11:39

Back again re MF's comment about 'how bad would you feel if your child died during their firt race etc.....

Actually a version of this dilemna faced my parents when my brother then aged 10 was found to have a small hole in his heart.  As it was over 50 years ago there was little that could be done and my parents were advised that he should 'be careful with hime'.  His older brother heard my parents saying that they would never prevent him from doing what he wanted to do and he grew up to be a talented squash, hockey and golf player.  His death 3 years ago after a short run ago was a result of progressive heart enlargement.  However, he lived knowing the risks but still doing what he wanted, and more importantly in his early years my parents had not stopped him.  Knowing his character his life would have been much poorer and possibly no longer if he had grown up not able to participate in the activities he enjoyed so much. 

   

08/07/2008 at 13:07

The bottom line is whether or not there is a cure. If there isn't you shouldn't screen is my view.

Running is obviously the be all and end all for some people enough to take that risk -it's not for me. So if 'not  running' was the cure, I wouldn't run.

However I would need to know the hard evidence to support that and I would also investigate exactly what impact in other areas of my life it would make - I only started running when I was 40 and the previous 40 years were certainly not wasted 

08/07/2008 at 13:09

It also should be 'opt in' rather than compulsory screening. Most screening is though. (If not all?)

No one has been held down for a smear/mammo/aneurysm screen/ultrasound scan or blood test/BP check etc to my knowledge? 

08/07/2008 at 13:10

It partly depends on where you are in your life, as well.

There have been times in my life (with young children etc) when I'd have felt compelled to "keep myself safe" for their sake, and other times when I'd have felt more at liberty to take the risk if  wanted to.

08/07/2008 at 15:30
my dad collapsed last sunday when out on a run with his club.  massive heart attack.  shouldn't have survived, apparently.  different situation, obviously, to the one you are discussing on this thread, as not a youngster (66) and not a genetic fault (although hereditary they think).  but to give parents this option (my son is only 2 so not quite in the category of aspiring athlete, although pretty nifty in the swimming pool!) of having screening in the same way as babies are screened for various other inherited diseases which they can do nothing about treating (heel prick test after birth) and preventitively vaccinated (again at the parents' wishes), can't be a bad thing, surely?
08/07/2008 at 15:40

>> but to give parents this option of having screening in the same way as babies are screened for various other inherited diseases which they can do nothing about treating and preventitively vaccinated can't be a bad thing, surely?

Its not a bad thing at all, however that is not that is being talked about. The Itallian scheme is all about compulsion and banning people from taking part rather than offering parents or athletes the option - thats the problem.

08/07/2008 at 15:52

in the same way presumably as my local swimming pool has banned me from wearing my glasses (have complex prescription which can't be corrected by contacts or swimming goggles and not being able to see is not an option when i take my son swimming) and therefore banned me from going swimming with my son - because glasses wearers are apparently a hazard to other people...

isn't it all at some level about the risk of event organizers / sporting venues getting sued?

08/07/2008 at 16:03

>> in the same way presumably as my local swimming pool has banned me from wearing my glasses (have complex prescription which can't be corrected by contacts or swimming goggles and not being able to see is not an option when i take my son swimming) and therefore banned me from going swimming with my son - because glasses wearers are apparently a hazard to other people...

Except that someone with a heart defect is only a hazard to themselves and, IMHO, people have a right to risk their own lives if they want to.

Its probably about the cost of event insurance and the level of medical cover that event organisers need to make available.

08/07/2008 at 16:16

given that my local pool said i had to leave the pool because i might sue them if i broke my own glasses in the pool (?!), then maybe someone somewhere is worried a bereaved relative might sue an event organizer if someone died on a course.  or perhaps the trainer would be sued?  i'm sure there's a precedent somewhere out there.

anyway - about to take my life in my own hands on the M4...

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