To the Editor:
We read with interest the editorial written by Dr. Boraita1 on sudden death and sports. In general, we agree with most of the author´s statements. However, we think that an echocardiographic study especially designed for the diagnosis of anomalies of the coronary arteries should be included in the athletic pre-participation cardiological examination (APCE).
Anomalies of the coronary arteries are the second most frequent cause of death in American athletes and the third most frequent in Italian athletes.2 In the article, published in the same number of the Journal, on the causes of sudden death associated with athletic activity in Spain, coronary anomalies are responsible for 3.2%. However, the limitations described by the authors should be considered (not all cases of sudden death associated with sports are recorded and the number of competitive or recreational athletes is not known).2 As Dr. Boraita noted in her discussion of coronary anomalies, it is true that the results of the screening assessment can be discouraging because often no clinical, or physical findings are detected. The athlete may even have a completely normal electrocardiogram and exercise stress test in the presence of a potentially lethal coronary anomaly. How can the presence of a coronary anomaly be safely excluded in high performance athletes using non-invasive techniques? Transthoracic echocardiography allows the outflow ostia of both coronary arteries to be identified, as well as the initial section of both arteries in some cases.3 Thus, transthoracic echocardiography has been widely used in pediatric patients 4 and even in high performance athletes.3 Evidently, «poor echocardiographic windows» are the principal limitation of this non-invasive technique. Nevertheless, we must note that this is a study population (young people and athletes) with a low prevalence of «poor windows.»3,4 In addition, we must consider the important advances in echocardiography in recent years, such as the introduction of devices (e.g., second harmonics) that appreciably improve the images obtained.
The question to be asked when we are confronted with a high competition athlete with a «poor echocardiographic window» that does not allow the presence of a coronary anomaly to be excluded is whether more tests are indicated. We think that they are. We must remember that we are dealing with a population of young people, under the age of 35 years, in which the presence of a coronary anomaly carries an added risk of sudden death.5 Depending on the experience of the examining team and the preferences of the athlete, we would recommend the performance of a transesophageal echocardiogram6 (which resolves all of the limitations of transthoracic echocardiograph) or a helical CT with intravenous contrast7 (a technique available in most hospitals in Spain) or, if possible, vascular magnetic resonance imaging.8
In conclusion, we believe that the correct identification of the coronary ostia (by transthoracic echography or other techniques when unclear) should be included in the cardiological examination of high performance athletes. In the future, should this be recommended for all people who practice organized sports and demanding recreational activities?