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Aims Low QRS voltages (peak to peak Methods and results The index group included 2229 Italian competitive athletes [median age 18 years (16–25), 67% males, 97% Caucasian] without major ECG abnormalities at pre-participation screening. Three control groups included Black athletes (N = 1115), general population (N = 1115), and patients with ACM or NILVS (N = 58). Echocardiogram was performed in all athletes with isolated LQRSV and cardiac magnetic resonance (CMR) in those with ventricular arrhythmias or echocardiographic abnormalities. The isolated LQRSV pattern was found in 1.1% index athletes and was associated with increasing age (median age 28 vs. 18 years; P < 0.001), elite status (71% vs. 34%; P < 0.001), body surface area, and body mass index but not with sex, type of sport, and echocardiographic left ventricular mass. The prevalence of isolated LQRSV was 0.2% in Black athletes and 0.3% in young individuals from the general population. Cardiomyopathy patients had a significantly greater prevalence of isolated LQRSV (12%) than index athletes, Black athletes, and general population. Five index athletes with isolated LQSRV and exercise-induced ventricular arrhythmias underwent CMR showing biventricular ACM in 1 and idiopathic NILVS in 1. Conclusions Unlike cardiomyopathy patients, the ECG pattern of isolated LQRSV was rarely observed in athletes. This ECG sign should prompt clinical work-up for exclusion of an underlying cardiomyopathy.

The reported causes of sudden death (SD) in young people at autopsy include a variety of structural, often genetic, heart diseases. In young competitive athletes, arrhythmogenic cardiomyopathy (AC) in Italy [(1)][1] and hypertrophic cardiomyopathy (HCM) in the United States [(2)][2] are the most

Personal and family history are invaluable components in pre-participation screening of athletes. Both the American Heart Association and the European Society of Cardiology recommend administering a questionnaire about family and personal history and performing a physical examination focused on the common signs of heart disease in the young. However, it should be kept in mind that the screening history questions that are currently recommended are based on expert opinion and enquire about common symptoms that are not specific to cardiac diseases. Moreover, many athletes show innocent cardiac murmurs which may trigger further unnecessary cardiovascular examination. Hence, the education and experience of screening physicians are critical for improving the effectiveness of history-taking and physical examination in pre-participation evaluation.

Background The burden of premature atrial beats (PABs) at 24-h electrocardiographic (ECG) monitoring correlates with the risk of atrial fibrillation. It is unknown whether prolonged and intense exercise increases the burden of PABs, thus contributing to the higher prevalence of atrial fibrillation observed in middle-aged athletes. Methods We compared the burden of PABs at 24-h ECG monitoring off therapy in 134 healthy middle-aged (30–60-year-old) competitive athletes who had practised 9 (7-11) h of endurance sports for 8 (4-15) consecutive years, 134 age- and gender-matched healthy sedentary individuals, and 66 middle-aged patients (20 athletes and 46 non-athletes) with ‘lone’ paroxysmal atrial fibrillation. Results More than 50 PABs/24 h or ≥1 run of ≥3 PABs were recorded in 23/134 (17%) healthy athletes and in 29/134 (22%) sedentary controls ( p = 0.61). Healthy athletes with frequent or repetitive PABs were older (median 50 years vs. 43 years, p 50 PABs/24 h or ≥1 run of ≥3 PABs between athletes (40%) and controls (48%, p = 0.74) . Conclusions Middle-aged endurance athletes, with or without paroxysmal atrial fibrillation, did not show a higher burden of PABs at 24-h ECG monitoring than sedentary controls. Age, but not intensity and duration of sports activity, predicted a higher burden of PABs among healthy athletes.

Changes in barometric pressure characterize both high altitude and the underwater world. These changes have a significant impact on the body’s pulmonary physiology and can affect both mountain climbers and divers. In both of these conditions, the organism must use compensatory mechanisms to adapt to the different environmental conditions. In this chapter, the environmental characteristics of altitude and underwater and their effects on the respiratory system are discussed. The body’s compensatory responses at high altitude, primarily the ventilatory response, are discussed. A section is devoted to the maladaptive response (i.e. high-altitude pulmonary oedema) and its prevention and treatment. Next, we consider the safety of high-altitude travel in patients with chronic respiratory disease, primarily chronic obstructive pulmonary disease, asthma and cystic fibrosis. In the second part of the chapter, the physiology and pathophysiology of the hyperbaric and diving environments, especially those involving the respiratory system, are described. A paragraph is dedicated to fitness for immersion, especially for the most common chronic respiratory diseases, such as asthma and COPD. In the last part of the chapter, we discuss lung interstitial oedema, its development in extreme environments or after strenuous exercise, and the diagnostic methods.

Aims Anterior T-wave inversion (TWI) is a recognized variant in athletes of African/Afro Caribbean origin and some endurance athletes; however, the presence of this specific repolarization anomaly also raises the possibility of cardiomyopathy. The differentiation between physiological adaptation and cardiomyopathy may be facilitated by examining other repolarization parameters, notably the J-point and the ST-segment. Methods and results We compared the electrocardiogram pattern of anterior TWI in a series of 80 healthy athletes (median age 21 years, 75% males); 95 patients with hypertrophic cardiomyopathy (HCM) (median age 46 years, 75% males), including 26 affected athletes; and 58 patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) (median age 32 years, 71% males), including 9 affected athletes. Athletes and patients were of either white/Caucasian or black/Afro Caribbean descent and showed TWI ≥1 mm in ≥2 contiguous anterior leads (V1–V4). We aimed to identify repolarization patterns for differentiating physiologic from pathologic TWI. After adjustment for age, gender, and ethnicity, J-point elevation

Background Whether prolonged and intense exercise increases the incidence of ventricular arrhythmias in middle-aged athletes remains to be established. Design Prospective, case-control. Methods We studied 134 healthy competitive athletes >30 years old (median age 45 (39–51) years, 83% males) who had been engaged in 9 ± 2 h per week of endurance sports activity (running, cycling, triathlon) for 13 ± 4 consecutive years. One hundred and thirty-four age- and gender-matched individuals served as controls. Both groups underwent 12-lead 24-h ambulatory electrocardiogram monitoring, which included a training session in athletes. Ventricular arrhythmias were evaluated in terms of number, complexity (i.e. couplet, triplet or non-sustained ventricular tachycardia), exercise-inducibility and morphology. Results Thirty-five (26%) athletes and 31 (23%) controls showed >10 isolated premature ventricular beats or ≥1 complex ventricular arrhythmia ( p = 0.53). Athletes with ventricular arrhythmias were older (median 48 versus 43 years old, p = 0.03) but did not differ with regard to hours of training and years of activity compared with athletes without ventricular arrhythmias. Ten (7%) athletes and six (5%) controls showed >500 premature ventricular beats/24 h ( p = 0.30): the most common ventricular arrhythmia morphologies were infundibular (six athletes and five controls) and fascicular (two athletes and one control). Conclusions The prevalence of ventricular arrhythmias at 24-hour ambulatory electrocardiogram monitoring did not differ between middle-aged athletes and sedentary controls and was unrelated to the amount and duration of exercise. These findings do not support the hypothesis that endurance sports activity increases the burden of ventricular arrhythmias. Among individuals with frequent premature ventricular beats, the predominant ectopic QRS morphologies were consistent with the idiopathic and benign nature of the arrhythmia.

Background Whether ventricular arrhythmias ( VAs ) represent a feature of the adaptive changes of the athlete's heart remains elusive. We aimed to assess the prevalence, determinants, and underlying substrates of VAs in young competitive athletes. Method and Results We studied 288 competitive athletes (age range, 16–35 years; median age, 21 years) and 144 sedentary individuals matched for age and sex who underwent 12‐lead 24‐hour ambulatory electrocardiographic monitoring. VAs were evaluated in terms of number, complexity (ie, couplet, triplet, or nonsustained ventricular tachycardia), exercise inducibility, and morphologic features. Twenty‐eight athletes (10%) and 13 sedentary individuals (11%) showed >10 isolated premature ventricular beats ( PVB s) or ≥1 complex VA ( P =0.81). Athletes with >10 isolated PVB s or ≥1 complex VA were older (median age, 26 versus 20 years; P =0.008) but did not differ with regard to type of sport, hours of training, and years of activity compared with the remaining athletes. All athletes with >10 isolated PVB s or ≥1 complex VA had a normal echocardiographic examination; 17 of them showing >500 isolated PVB s, exercise‐induced PVB s, and/or complex VA underwent additional cardiac magnetic resonance, which demonstrated nonischemic left ventricular late gadolinium enhancement in 3 athletes with right bundle branch block PVB s morphologic features. Conclusions The prevalence of >10 isolated PVB s or ≥1 complex VA at 24‐hour ambulatory electrocardiographic monitoring did not differ between young competitive athletes and sedentary individuals and was unrelated to type, intensity, and years of sports practice. An underlying myocardial substrate was uncommon and distinctively associated with right bundle branch block VA morphologic features.

Background— The clinical profile and arrhythmic outcome of competitive athletes with isolated nonischemic left ventricular (LV) scar as evidenced by contrast-enhanced cardiac magnetic resonance remain to be elucidated. Methods and Results— We compared 35 athletes (80% men, age: 14–48 years) with ventricular arrhythmias and isolated LV subepicardial/midmyocardial late gadolinium enhancement (LGE) on contrast-enhanced cardiac magnetic resonance (group A) with 38 athletes with ventricular arrhythmias and no LGE (group B) and 40 healthy control athletes (group C). A stria LGE pattern with subepicardial/midmyocardial distribution, mostly involving the lateral LV wall, was found in 27 (77%) of group A versus 0 controls (group C; P P =0.52). All athletes with stria pattern showed ventricular arrhythmias with a predominant right bundle branch block morphology, 13 of 27 (48%) showed ECG repolarization abnormalities, and 5 of 27 (19%) showed echocardiographic hypokinesis of the lateral LV wall. The majority of athletes with no or spotty LGE pattern had ventricular arrhythmias with a predominant left bundle branch block morphology and no ECG or echocardiographic abnormalities. During a follow-up of 38±25 months, 6 of 27 (22%) athletes with stria pattern experienced malignant arrhythmic events such as appropriate implantable cardiac defibrillator shock (n=4), sustained ventricular tachycardia (n=1), or sudden death (n=1), compared with none of athletes with no or LGE spotty pattern and controls. Conclusions— Isolated nonischemic LV LGE with a stria pattern may be associated with life-threatening arrhythmias and sudden death in the athlete. Because of its subepicardial/midmyocardial location, LV scar is often not detected by echocardiography.

Arrhythmogenic cardiomyopathy (AC) is an inherited heart muscle disease characterized pathologically by right ventricular (RV) fibrofatty myocardial replacement and clinically by ventricular electric instability, which may lead to cardiac arrest from ventricular fibrillation (VF), mostly in young people and athletes. AC shows a propensity for life-threatening ventricular arrhythmias during physical exercise, and participation in competitive athletics has been associated with an increased risk for sudden cardiac death (SCD). In addition, physical sport activity has been implicated as a factor promoting acceleration of disease progression. Identification of affected athletes by preparticipation screening has proved to result in mortality reduction during sports activity. This article examines the role of AC in causing SCD in young competitive athletes and addresses prevention strategy based on identification of affected athletes at preparticipation screening.

Background Because they have similar functional and clinical profiles, bronchopulmonary dysplasia (BPD) survivors are often treated as asthmatic patients. In truth, very little is known about the possible biochemical and inflammatory mechanisms playing a part in BPD survivors' lungs. The aim of this study was to measure exhaled breath temperature in BPD survivors by comparison with asthmatic cases and healthy controls. Methods Three groups of age-matched adolescents (n = 17 each), that is, BPD survivors (gestational ages

In 1982 a nationwide program of pre-participation screening including 12-lead electrocardiography (ECG) was launched in Italy. The aim of this article is to examine whether this 25-year screening program should be considered a valid and advisable public health strategy. The analysis of data coming from the long-running Italian experience indicates that ECG screening has provided adequate sensitivity and specificity for detection of potentially lethal cardiomyopathy or arrhythmias and has led to substantial reduction of mortality of young competitive athletes by approximately 90%. Screening was feasible thanks to the Italian Health System, which is developed in terms of health care and prevention services, and because of the limited costs of cardiovascular evaluation in the setting of a mass program. On the basis of current scientific evidence the implementation of a mass-screening program aimed to prevent athletic-field sudden cardiac death should be at least carefully considered by public health administrators worldwide.

Sudden death (SD) in athletes represents a cardiac ‘earthquake’ affecting apparently healthy and highly trained individuals. This is not due to excessive demands on a normal heart, as occurred to Phidippides in Marathon, because our body has built-in safeguard mechanisms—dyspnea, angina, fatigue—to protect us from physical exhaustion. Autopsy investigations reveal that SD in athletes occurs three times more often than in non-athletes, and is caused by concealed cardiovascular abnormalities, mostly structural, that are unmasked by activity-triggered electrical instability.1–5 The structural culprits may be any of the cardiovascular components, including aorta, coronary arteries, myocardium, valves, conduction system and ion channels.1 The ECG is often abnormal, and its implementation in Italy for obligatory preparticipation screening has resulted in progressive reductions by 90% of SD in athletes aged 12–35 years between 1979 and 20024 (figure 1). This was mostly attributable to identification and disqualification of people affected by cardiomyopathies. Figure 1 Annual incidence rates of sudden death (SD) per 100 000 person, among screened competitive athletes and unscreened non-athletes 12–35 years of age in the Veneto Region of Italy, from 1979 to 2002. During the study period (the nationwide preparticipation screening program was initiated in 1982), the annual incidence of SD declined by 89% in screened athletes (p for trend

Negative T waves (NTWs) in right precordial leads (V 1 to V 3 ) may be observed on the electrocardiogram (ECG) of healthy subjects but can also represent the hallmark of an underlying arrhythmogenic right ventricular cardiomyopathy (ARVC). It has been a consistent observation that NTWs usually become upright with exercise in healthy subjects without underlying heart disease. No systematic study has evaluated exercise-induced changes of NTWs in ARVC. We assessed the prevalence and relation to the clinical phenotype of exercise-induced right precordial NTWs changes in 35 patients with ARVC (19 men, mean age 22.2 ± 6.2 years). Forty-one healthy subjects with right precordial NTWs served as controls. At peak of exercise (mean power 149 ± 43 W, mean heart rate 83.6 ± 12.6% of target), NTWs persisted in 3 patients with ARVC (9%), completely normalized in 12 (34%), and partially reverted in 20 (57%). Patients with ARVC with or without NTWs normalization showed a similar clinical phenotype. The overall prevalence of right precordial T waves changes during exercise (normalization plus partial reversal) did not differ between patients with ARVC and controls (92% vs 88%, p = 1.0), whereas there was a statistically nonsignificant trend toward a greater prevalence of complete normalization in controls (56% vs 34%, p = 0.06). In conclusion, our study demonstrated that right precordial NTWs partially or completely revert with exercise in most patients with ARVC, and NTWs normalization is unrelated to the clinical phenotype. Exercise-induced NTWs changes are inaccurate in differentiating between ARVC patients and benign repolarization abnormalities.

Competitive sports activity is associated with an increase in the risk of sudden cardiovascular death in susceptible adolescents and young adults with clinically silent cardiovascular disorders. Screening including 12-lead electrocardiogram (ECG) has been demonstrated to allow identification of athletes affected by malignant heart muscle diseases at a presymptomatic stage and to lead to substantial reduction of the risk of sudden cardiovascular death during sports (primary prevention). The use of modern criteria for interpretation of the ECG in the athlete significantly improves the screeningaccuracybyreducingthefalse-positiverate(increasedspecificity),withtheimportantrequisite of maintaining the ability for detection of life-threatening heart diseases (preserved sensitivity). Screening including ECG has a more favorable cost–benefit ratio than that based on history and physical examination alone, with cost estimates per year of life saved below the threshold allowing one to consider a health intervention to be cost effective.

Intensiveathleticconditioningisassociatedwithphysiologiccardiacremodeling (known as “athlete's heart”), consisting of augmented leftventricular (LV) mass due to increase of both cavity dimension andwall thickness, which are re flected on the electrocardiogram (ECG)mostfrequentlyasanincreaseofQRSvoltages[1,2].Becauseofthepar-tialoverlapofECGsignsofLVhypertrophy,athlete'sheartisofteninthedifferentialdiagnosiswithhypertrophiccardiomyopathy(HCM),whichis the leading cause of sports-related cardiac arrest in young athletes.Patients with HCM have a variety of ECG abnormalities, includingatrial enlargement, QRS left axis deviation, increase of QRS amplitudes,ST-segment and/or T-wave abnormalities, and pathologic Q waves [3].AccordingtotherecommendationsoftheEuropeanSocietyofCardiology,the ECG changes due to cardiac adaptat ion to physical exertion, predom-inantly the physiologic increase of QRS voltages, should not cause alarmand the athlete should be allowed to participate in competitive sportswithout additional evaluation [1]. Although this ECG interpretationapproach offers the potential to lower the traditional high number offalse-positives, whether and to what extent the increased speci ficityalter the ECG sensitivity for HCM remains to be established.The present study compared the ECG abnormalities associated withthe LV remodeling of HCM (nondilated, hypertrophic LV) and that ofathlete's heart (augmented LV mass due to increase of both cavity di-mensionandwallthickness),withparticularreferencetotheprevalence,clinicalsignificance,andrelevancetoscreeningoftheECGpatternofiso-lated increase of QRS voltages. The main study objective was to evaluatethe risk to miss a diagnosis of HCM by interpreting as normal the ECGpattern of isolated increase of QRS amplitude in highly trained athletes.The HCM population included 247 consecutive patients (181 males;age 39 ± 14 years, range 15–65 years). The diagnosis of HCM wasbased on the presence of a hypertrophied and nondilated left ventriclein the absence of other diseases that could produce the magnitude ofhypertrophy evident. Echocardiographic criteria for diagnosis were amaximal LV wall thickness (LVWT) ≥ 15 mm in adult index patientsand ≥13 mm in adult relatives [4,5]. The athlete's population includeda series of 133 Caucasian healthy, highly trained athletes (116 males;age 27 ± 6 years, range 15 –65 years) who fulfilled the echocardio-graphic criteria for augmented LV mass de fined according to Devereuxet al. as ≥134 g/m

We read with interest Van Brabandt and colleagues’ review questioning the utility of pre-participation screening in preventing sudden cardiac death (SCD) in sports activity.1 The paper is not a balanced “pro and cons” analysis; rather, it seems to be a direct attack on the Italian screening programme and on the researchers who provided scientific evidence that cardiovascular evaluation of athletes is a lifesaving strategy based on more than 30 years’ experience in the Veneto region, northeast Italy.2 3 4 5 6 The paper was signed by laypersons with no experience in the field of sports cardiology, who provided a personal viewpoint and omitted the “real world” opinion of thousands of international physicians daily involved in athlete evaluation who favoured the need for pre-participation screening.7 The authors started by mistakenly reporting that Italy’s screening of competitive athletes has been mandatory since 1979. Instead, screening has been in place by law in Italy since 1982,8 which would be the correct starting point for evaluating its impact on mortality. This initial inaccuracy jeopardises the entire analysis. The inaccuracy is confirmed by the authors’ statement that the usefulness of ECG screening is confined to detecting athletes with Wolff-Parkinson-White syndrome, when in fact the main strength is …

Sudden cardiac arrest is most often the first clinical manifestation of an underlying cardiovascular disease and usually occurs in previously asymptomatic athletes. The risk benefit ratio of physical exercise differs between young competitive athletes and middle-age/senior individuals engaged in leisure-time sports activity. Competitive sports are associated with an increase in the risk of sudden cardiovascular death (SCD) in susceptible adolescents and young adults with underlying cardiovascular disorders. In middle-age/older individuals, physical activity can be regarded as a 'two-edged sword': vigorous exertion increases the incidence of acute coronary events in those who did not exercise regularly, whereas habitual physical activity reduces the overall risk of myocardial infarction and SCD. Although cardiovascular pre-participation evaluation offers the potential to identify athletes with life-threatening cardiovascular abnormalities before onset of symptoms and may reduce their risk of SCD, there is a significant debate among cardiologists about efficacy, impact of false-positive results and cost-effectiveness of routine screening. This review presents an appraisal of the available data and criticisms concerning screening programmes aimed to prevent SCD of either young competitive athletes or older individuals engaged in leisure-time sports activity.

Both the American Heart Association and the European Society of Cardiology consensus panel recommendations agree that cardiovascular screening for young competitive athletes is justifiable and compelling on ethical, legal, and medical grounds. However, there is a considerable discordance in the consensus guidelines on the pre-participation screening protocols used among European and US cardiologists/sports medicine physicians, with and without 12-lead electrocardiogram (ECG). In 1982 a nationwide program of pre-participation screening including ECG was launched in Italy. The aim of this article is to examine whether this long-running screening program should be considered a valid and advisable public health strategy. The analysis of data coming from the Italian experience indicates that ECG screening has provided adequate sensitivity and specificity for detection of potentially lethal cardiomyopathy or arrhythmias and has led to substantial reduction of mortality of young competitive athletes by approximately 90%. Screening has been feasible thanks to the Italian Health System, which is developed in terms of healthcare and prevention services, and because of the limited costs of cardiovascular evaluation in the setting of a mass program. The available scientific evidence suggests to adopt a screening protocol including ECG, which is the only screening tool proved to be effective. This article will also address the available data and criticisms concerning the screening program to prevent sudden cardiac death of middle-aged/senior athletes engaged in leisure-time sports activity.

The Italian screening protocol has adequate sensitivity and specificity for detection of potentially dangerous cardiovascular diseases, and substantially reduces mortality of young competitive athletes, mostly by preventing sudden cardiac death from cardiomyopathy. The results of the Italian preparticipation evaluation program have significant implications worldwide: this article addresses the efficacy and feasibility of preparticipation screening, essentially based on 12-lead ECG, as has been in practice in Italy for 25 years.

In adults, regular physical exercise offers protection against coronary events and SD. Conversely, sport activity is associated with a significantly higher rate of SD in adolescents and young adults. Sports does not enhance mortality per se; rather, it acts as a trigger of cardiac arrest in those athletes with silent cardiovascular conditions, mostly cardiomyopathy, premature coronary artery disease, and congenital coronary anomalies, each of which predisposes to life-threatening ventricular arrhythmias during physical exercise. These results should not discourage young people from participating in sports, but point to the need for an extensive and accurate pre-participation screening strategy aimed at early identification and disqualification of those subjects affected by cardiovascular diseases associated with the risk of SD.

Vigorous physical exercise may precipitate acute fatalities in both adults and young competitive athletes with concealed heart diseases. However, the risk-benefit ratio of physical exercise differs among these two age groups. In adults, physical activity can be regarded as a 'double-edged sword': vigorous exertion increases the incidence of acute coronary events in individuals who did not exercise regularly, whereas habitual physical activity reduces the overall risk of myocardial infarction and sudden coronary death by preventing development and progression of atherosclerotic coronary artery disease. On the other hand, in adolescents and young adults sports activity is associated with a significant increase of the risk of sudden death. Sport is not per se the cause of the enhanced mortality in this age group; rather, it acts as a trigger of cardiac arrest in those athletes who are affected by silent cardiovascular conditions, mainly cardiomyopathy, premature coronary artery disease and congenital coronary anomalies, which predispose to life-threatening ventricular arrhythmias during physical exercise.

For more than 20 years in Italy, young athletes have been screened before participating in competitive sports. We assessed whether this strategy results in the prevention of sudden death from hypertrophic cardiomyopathy, a common cardiovascular cause of death in young athletes.We prospectively studied sudden deaths among athletes and nonathletes (35 years of age or less) in the Veneto region of Italy from 1979 to 1996. The causes of sudden death in both populations were compared, and the pathological findings in the athletes were related to their clinical histories and electrocardiograms. Cardiovascular reasons for disqualification from participation in sports were investigated and follow-up was performed in a consecutive series of 33,735 young athletes who underwent preparticipation screening in Padua during the same period.Of 269 sudden deaths in young people, 49 occurred in competitive athletes (44 male and 5 female athletes; mean age, 23+/-7 years). The most common causes of sudden death in athletes were arrhythmogenic right ventricular cardiomyopathy (22.4 percent), coronary atherosclerosis (18.4 percent), and anomalous origin of a coronary artery (12.2 percent). Hypertrophic cardiomyopathy caused only 1 sudden death among the athletes (2.0 percent) but caused 16 sudden deaths in the nonathletes (7.3 percent). Hypertrophic cardiomyopathy was detected in 22 athletes (0.07 percent) at preparticipation screening and accounted for 3.5 percent of the cardiovascular reasons for disqualification. None of the disqualified athletes with hypertrophic cardiomyopathy died during a mean follow-up period of 8.2+/-5 years.The results show that hypertrophic cardiomyopathy was an uncommon cause of death in these young competitive athletes and suggest that the identification and disqualification of affected athletes at screening before participation in competitive sports may have prevented sudden death.

Background— T-wave inversion on a 12-lead ECG is usually dismissed in young people as normal persistence of the juvenile pattern of repolarization. However, T-wave inversion is a common ECG abnormality of cardiomyopathies such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy, which are leading causes of sudden cardiac death in athletes. We prospectively assessed the prevalence, age relation, and underlying cardiomyopathy of T-wave inversion in children undergoing preparticipation screening. Methods and Results— The study population included 2765 consecutive Italian children (1914 male participants; mean age, 13.9±2.2 years; range 8–18 years) undergoing preparticipation screening including an ECG. Of 229 children (8%) who underwent further evaluation because of positive findings at initial preparticipation screening, 33 (1.2%) were diagnosed with cardiovascular disease. T-wave inversion was recorded in 158 children (5.7%) and was localized in the right precordial leads in 131 (4.7%). The prevalence of right precordial T-wave inversion decreased significantly with increasing age (8.4% in children P P P P Conclusions— The prevalence of T-wave inversion decreases significantly after puberty. Echocardiographic investigation of children with postpubertal persistence of T-wave inversion at preparticipation screening is warranted because it may lead to presymptomatic diagnosis of a cardiomyopathy that could lead to sudden cardiac death during sports.

ContextA nationwide systematic preparticipation athletic screening was introduced in Italy in 1982. The impact of such a program on prevention of sudden cardiovascular death in the athlete remains to be determined.ObjectiveTo analyze trends in incidence rates and cardiovascular causes of sudden death in young competitive athletes in relation to preparticipation screening.Design, Setting, and ParticipantsA population-based study of trends in sudden cardiovascular death in athletic and nonathletic populations aged 12 to 35 years in the Veneto region of Italy between 1979 and 2004. A parallel study examined trends in cardiovascular causes of disqualification from competitive sports in 42 386 athletes undergoing preparticipation screening at the Center for Sports Medicine in Padua (22 312 in the early screening period [1982-1992] and 20 074 in the late screening period [1993-2004]).Main Outcome MeasuresIncidence trends of total cardiovascular and cause-specific sudden death in screened athletes and unscreened nonathletes of the same age range over a 26-year period.ResultsDuring the study period, 55 sudden cardiovascular deaths occurred in screened athletes (1.9 deaths/100 000 person-years) and 265 sudden deaths in unscreened nonathletes (0.79 deaths/100 000 person-years). The annual incidence of sudden cardiovascular death in athletes decreased by 89% (from 3.6/100 000 person-years in 1979-1980 to 0.4/100 000 person-years in 2003-2004; P for trend

OBJECTIVES We sought to assess the risk of sudden death (SD) in both male and female athletes age 12 to 35 years. BACKGROUND Little is known about the risk of SD in adolescents and young adults engaged in sports. METHODS We did a 21-year prospective cohort study of all young people of the Veneto Region of Italy. From 1979 to 1999, the total population of adolescents and young adults averaged 1,386,600 (692,100 males and 694,500 females), of which 112,790 (90,690 males and 22,100 females) were competitive athletes. An analysis by gender of risk of SD and underlying pathologic substrates was performed in the athletic and non-athletic populations. RESULTS There were 300 cases of SD, producing an overall cohort incidence rate of 1 in 100,000 persons per year. Fifty-five SDs occurred among athletes (2.3 in 100,000 per year) and 245 among non-athletes (0.9 in 100,000 per year), with an estimated relative risk (RR) of 2.5 (95% confidence interval [CI] 1.8 to 3.4; p < 0.0001). The RR of SD among athletes versus non-athletes was 1.95 (CI 1.3 to 2.6; p = 0.0001) for males and 2.00 (CI 0.6 to 4.9; p = 0.15) for females. The higher risk of SD in athletes was strongly related to underlying cardiovascular diseases such as congenital coronary artery anomaly (RR 79, CI 10 to 3,564; p < 0.0001), arrhythmogenic right ventricular cardiomyopathy (RR 5.4, CI 2.5 to 11.2; p < 0.0001), and premature coronary artery disease (RR 2.6, CI 1.2 to 5.1; p = 0.008). CONCLUSIONS Sports activity in adolescents and young adults was associated with an increased risk of SD, both in males and females. Sports, per se, was not a cause of the enhanced mortality, but it triggered SD in those athletes who were affected by cardiovascular conditions predisposing to life-threatening ventricular arrhythmias during physical exercise.