Some confusion may have been created by a recent suggestion that both the American Heart Association (AHA) and the European Society of Cardiology call for cardiovascular screening of athletes to prevent sudden exercise-induced death. In fact, there remains a sharp continental divide on the issue of mandatory electrocardiogram (ECG) screening. With the support of the European College of Cardiology, Italian investigators have long argued for such screening. Medical certification became a condition of participation for Italian athletes, both amateur and professional, beginning in 1950. Since 1982, more than 5 million Italian competitors aged 12 to 35 years have theoretically undergone an assessment that includes an annual clinical examination, a 12-lead resting ECG, a simple bench-type stress test, and basic spirometry (although it is less clear how complete screening has been de facto4). National ECG screening has also been introduced for children and young adults in Japan. There have been occasional suggestions of adopting a similar plan in North America, but in general, support has continued for the AHA policy of avoiding ECG screening, except for those failing an initial 12-point physical examination. This commentary weighs several pieces of recent evidence advanced in support of mandatory ECG screening, relevant information surrounding an apparent recent reduction in sudden cardiac arrests among Italian athletes after the introduction of ECG screening protocols, a direct comparison of clinical evaluation against clinical plus ECG testing as a means of detecting cardiac abnormalities, and calculations of cost-effectiveness for the ECG testing of athletes.
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