EDITORIAL
The SPORTCOR registry: a national databank for sports cardiology
M.F. de Beus, A. Mosterd
eing physically active is generally regarded as the best buy to prevent (cardiovascular) disease. Although the positive effects of regular exercise prevail, negative aspects of sports activity, particularly sportsrelated injuries, should not be ignored. Sudden cardiac death can be regarded as the most tragic sports-related injury. The sudden death of an apparently healthy athlete has an immense impact on those left behind and invariably leads to questions: ‘Are siblings at increased risk of sudden death as well? ‘Could death have been prevented?1 The importance of solid advice on healthy and responsible exercise is widely acknowledged (www.sportzorg.nl) and has led to an increased tendency among athletes in the Netherlands to undergo (periodical) sports medical check-ups at sports medical institutions. Physiological adaptation of the heart to systematic training, known as the athlete’s heart, is generally regarded as a benign phenomenon. Unfortunately, it is often difficult to distinguish the athlete’s heart from cardiac disease, in particular cardiomyopathies.1,2 Up to 40% of ECGs taken in athletes demonstrate variations that can be deemed abnormal, such as sinus bradycardia, atrial fibrillation and ST-segment changes in the right precordial leads.2
B
The incidence of sudden death during sports in the Netherlands is estimated at 150 to 300 per year, M.F. de Beus Julius Centre for Health Sciences and Primary Care and Heart Lung Centre Utrecht, University Medical Centre Utrecht, Utrecht, the Netherlands A. Mosterd Julius Centre for Health Sciences and Primary Care and Heart Lung Centre Utrecht, University Medical Centre Utrecht, Utrecht, and Department of Cardiology, Meander Medical Centre, Amersfoort, the Netherlands Correspondence to: M.F. de Beus Julius Centre for Health Sciences and Primary Care, University Medical Centre, Str 6.118, PO Box 85500, 3508 GA Utrecht, the Netherlands E-mail:
[email protected]
Netherlands Heart Journal, Volume 15, Number 6, June 2007
although recent information regarding the occurrence and causes of sudden cardiac death in athletes is lacking.3 Sudden death in athletes older than 40 years is generally caused by coronary artery disease. In younger athletes the role of monogenetic heart disease is increasingly acknowledged.1 First-degree relatives carry a 50% chance of having the same disease. As such, sudden cardiac death before the age of 40 is a very strong risk factor for the occurrence of cardiac death in surviving relatives. This risk can be modified appreciably by interventions in family members who are found to have a (genetic) substrate for sudden cardiac death. Potentially, many sudden deaths can be prevented by routinely performing a postmortem examination, including DNA sampling, on athletes who have died suddenly without an obvious cause (trauma, intoxication) and by cardiogenetic evaluation of their family members (www.cardiogenetica.nl).4 The European Society of Cardiology recommends routine preparticipation screening of athletes: the socalled Lausanne Recommendations include a medical history, physical examination and a 12-lead ECG at rest. The Dutch Working Group on Cardiovascular Screening and Sport has endorsed these guidelines.5 The Health Council of the Netherlands (Gezondheidsraad) advises against preparticipation screening, stating that no solid scientific evidence is available to support this strategy. The Health Council does recommend research into sudden death, particularly registration, autopsy and DNA analysis.6 As illustrated by the pro and contra papers in the debate section of this edition of Netherlands Heart Journal, the discussion about preparticipation screening has not yet come to an end.7,8 The diagnostic and prognostic value of the Lausanne Recommendations is unknown and there is a lack of criteria for the evaluation of ECGs in athletes. Notwithstanding the issues that are unsolved, athletes are increasingly undergoing preparticipation screening on a voluntary basis and some sports federations, including the Royal Netherlands Football Association, are introducing preparticipation screening for elite athletes.
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EDITORIAL
The drawback of this development is the realisation of sports physicians and cardiologists that often insufficient information is available to reliably distinguish the athlete’s heart from cardiac disease. This distinction may be made possible by information from a systematic, longitudinal evaluation of ECGs obtained from a wide variety of athletes, in combination with information on type and intensity of exercise and relevant medical history. In certain cases, additional investigations such as, but not limited to, echocardiography, exercise testing, Holter recording or cardiac MRI are warranted when a suspicion of cardiac abnormalities has arisen during a sports medical examination. The SPORTCOR registry aims to provide insight into sports-related changes of the heart and to answer the aforementioned questions by: 1 Registration of athletes screened according to the Lausanne Recommendations National registration of data obtained by preparticipation evaluation according to the Lausanne Recommendations, both of elite athletes (as mandated by the respective sport federations) and recreational athletes (undergoing the evaluation on a voluntary basis) to document the occurrence of cardiovascular abnormalities and variations (particularly electrocardiographic) in athletes and to obtain insight into the diagnostic and prognostic value of the Lausanne Recommendations. 2 Registration of sudden death victims National registration of sudden death in athletes during sports as well as other activities, to document the occurrence and causes of sudden death in athletes and to document the presence of treatable non-heritable and heritable diseases in first-degree relatives of young sudden cardiac victims (cascade screening). A web-based portal (www.sportcor.nl) will be developed to facilitate inclusion and notification of potential index persons for the registry. A publicity campaign is necessary to make people aware of the existence and purpose of the website, for example by cross linking to SPORTCOR via websites of the Netherlands Society of Cardiology, the Dutch Society of Sports Medicine, Sports organisations and organisers of large sports events. Following the example set by the CONCOR project (Registry and DNA-bank of CONgenital CORvitia in adults, www.concor.net) a project group will be responsible for the day-to-day management of
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the project and a steering committee will guide and advise the overall implementation of the project. The Working Group on Cardiovascular Screening and Sport will function as an advisory board. Given the clear overlaps with existing ICIN projects (CONCOR, GENCOR) cross linking of SPORTCOR to these projects is envisioned. SPORTCOR is currently under construction. In June 2007 a pilot with data from athletes screened according to the Lausanne Recommendations will start. As of January 2008 SPORTCOR should be fully operational. Meanwhile, information posted on the website of the Netherlands Society of Cardiology, www.nvvc.nl, will be available for those interested in SPORTCOR, including persons who want to report cases of sudden death in athletes. It is time to move forward to establish SPORTCOR as a national registry that will provide the (sports) cardiology community with a wealth of information regarding the occurrence of sudden death in athletes and potential preventive measures as well as information on the value of routine preparticipation screening, in particular regarding physiological and pathological changes in the ECG of athletes. ■ References 1 2 3 4
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Maron BJ, Pelliccia A. The heart of trained athletes: cardiac remodeling and the risks of sports, including sudden death. Circulation 2006;114:1633-44. Pelliccia A, Maron BJ, Culasso F, Di Paolo FM, Spataro A, Biffi A, et al. Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 2000;102:278-84. Dolmans AJ, Pool J, Erdman-Trip JF, Smit B, Lubsen J. [The risk of dying during sports activities]. Ned Tijdschr Geneeskd 1984; 128:595-8. Tan HL, Hofman N, van Langen IM, van der Wal AC, Wilde AA. Sudden unexplained death: heritability and diagnostic yield of cardiological and genetic examination in surviving relatives. Circulation 2005;112:207-13. Corrado D, Pelliccia A, Bjornstad HH, Vanhees L, Biffi A, Borjesson M, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2005;26:516-24. Gezondheidsraad. Jaarbericht Bevolkingsonderzoek 2006. The Hague. p. 113-6. Ref Type: Generic. Inklaar H, Panhuyzen-Goedkoop NM. Periodical cardiovascular screening is mandatory for elite athletes (Pro). Neth Heart J 2007;15:221-3. Bredeweg SW, Takens LH, Nieuwland W. Periodical cardiovascular screening is mandatory for elite athletes (Contra). Neth Heart J 2007;15:224-5.
Netherlands Heart Journal, Volume 15, Number 6, June 2007
