Exercise increases oxygen consumption, cardiac output, heart rate,
and systemic blood pressure and therefore increases cardiac work.
Children are becoming heavier, and there is an increase in childhood
obesity in Western cultures. There are many studies linking childhood
obesity to adult coronary heart disease. For the vast majority of
children, strenuous exercise would be extremely beneficial.
There are approximately 3000 to 5000 sudden-death episodes per
year in children and adolescents in the United States. There are
between 5 and 10 million children and adolescents participating
in organized sports activities, so the percentage of athletes dying suddenly
is quite small. Highly trained athletes are thought to represent
the most fit and healthy members of our society, so these tragic,
early, and unexpected deaths make a deep impression on us. The majority,
approximately 40% to 50% of sudden deaths, are
caused by hypertrophic cardiomyopathy. Between 10% and 20% will
be caused by coronary abnormalities (usually the left or right coronary
artery arising from the wrong sinus origin or a single-coronary
artery origin). The remaining 30% will be caused by such
lesions as myocarditis, dilated cardiomyopathy including noncompaction,
ion channelopathies (long QT) syndrome, Brugada syndrome, catecholaminergic
polymorphic ventricular tachycardia (CPVT), arrhythmogenic right
ventricular dysplasia (AVRD), Wolff-Parkinson-White (WPW) syndrome,
previous Kawasaki disease with undiagnosed coronary involvement,
commotio cordis, and connective tissue disorders with dilated aortic
roots (eg, Marfan’s). The incidence in the population of these
disorders is at most 0.3%. The percentage presenting for
screening would be thought to be even less, secondary to self-selection
not to participate in sports.
The pediatrician often has to verify that a child can play competitive
sports, and there is great concern about the occasional child who
dies suddenly during or just after strenuous exercise.
There is no consensus as to what should be included in cardiovascular
screening. There is no standardization of state or federal regulations,
nor is there a medical entity that establishes the precise requirements
of exercise testing. There is no screening regimen that would abolish
the risk of cardiovascular induced death. The European Society of
Cardiology recommendation of screening ECGs for all participants
is based mainly on the Italian state subsidized national program.
This program mandates that all individuals from age 12 to 35 years
participating in organized team sports or individual sports must
obtain annual medical clearance by accredited sports medicine physicians.
This medical clearance is by history, physical examination, and
At present, the American Heart Association guidelines from 2007
do not include an ECG as part of the screening process. Some of
the reasons listed for not requiring ECG include the financial resources,
manpower, and logistics needed to implement such a program. It seems doubtful
that consensus could be reached to implement a screening ECG program
secondary to the conflicting interests of the various groups involved
and the competition for money with other issues and priorities in
public health. There is also the additional problem of ...