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Screening seemingly healthy young athletes?

An interesting question came from another sub-specialist–via the comments section of my recent post on the practical difficulties of screening young athletes with routine ECGs.

“I’m asked week-in and week-out about screening exams and tests for adult athletes.

What do YOU recommend for the seemingly healthy 25-45 year old male non-elite athlete who asks about screening? Annual physical? Any lab tests? ECG? Echo?

It obviously takes you just a moment to conclude that the “abnormal” ECG above is okay for an athlete, but I do realize that your expertise is not available to the millions of athletes out there in any efficient manner.”

My answer: (without checking up-to-date for the ‘right’ answer)

For “healthy” young adults (25-45) I would recommend only a periodic history and physical—probably with a screening lipid profile.

For a patient without symptoms, historical features-of-note (strong family history or a dangerous occupation like fire-fighting), or physical exam signs (like HTN or a murmur) it would be hard to justify any additional testing, like an ECG and ECHO.

As we transition from our 20s to our 40s the risk of dying from ECG-detectable congenital maladies like hypertrophic cardiomyopathy, long QT or WPW decrease somewhat, while the risk of run-of-the-mill endothelial disease (atherosclerosis) increases. The dilemma is that the first presentation of coronary disease in this young cohort is often catastrophic. Abrupt plaque rupture and thrombotic occlusion of an undetectable (by ECGs, ECHOs and treadmills) twenty percent coronary obstruction is the most common scenario. This is the Tim Russert phenomenon: one can have a normal ECG and treadmill in the morning and a major MI later that same day. (DrWes has an interesting take on the fallout of Mr Russert’s sudden death.)  The minor blockage is insignificant, until it ruptures, fissures and the cascade of thrombosis (clotting) commences.

The holy grail of cardiology will be in predicting these catastrophic occlusions before they occur, and of course, having effective primary prevention therapies. I believe strongly that, for preventing sudden cardiac events, aggressive modification of lifestyle with exercise, nutrition, sleep and stress management will prove hard to beat.  It may happen, but it will likely be many years before we have a preventive strategy better than old-fashioned healthy living.

Thus far, the magic potion has proven elusive.