Response from Dr Steven Cox, Deputy Chief Executive Cardiac Risk in the Young
Friday October 2nd 2015
On page 47 of the consultation document in the section “Theme Nine: Safety and Wellbeing”
it states;
Specific Safety Issues
We know that sport carries risks. It is vital that where possible we mitigate these risks. That is why Government is committed to promoting safety and wellbeing at all levels and we are keen to hear what more could be done. Italy, for example, is the only country in the world that screens all of its professional and amateur athletes for heart problems each year, and has been doing so since 1982. Between 1979 and 2004 the death rate in screened athletes fell by 89% compared to the rest of the population. Other options might include ensuring wide availability of defibrillators where sport is played or improving the handling of cases of suspected concussion. Government and the wider sector already has an important role here, but we need to understand if there are areas where more could be done – to protect those at both grassroots and elite level.
Government would welcome views on:
(i) what particular safety and wellbeing challenges we should be seeking to address for participants in sport; and
(ii) how to make improvements if necessary.
The following document will address these two points.
It is important for all young people to be involved in sport and therefore any reference to a sporting body relates to any organisational structure within the sports sector, both publicly and privately funded. Those young people who are engaged in sport within those sporting bodies have been referred to as members/participants.
Government would welcome views on:
(i) what particular safety and wellbeing challenges we should be seeking to address for participants in sport; and
There needs to be greater awareness of the importance of:
– first-degree blood relatives being refereed for testing if there is a history of young sudden cardiac death or cause-unascertained young sudden death in the family;
– signs and symptoms of cardiac conditions in young people; and,
– screening prior to participation in sport.
(ii) how to make improvements if necessary.
There is already a high level of awareness of the importance of cardiac screening at an elite level in sports in the UK with all sporting bodies operating either formal or informal screening services for their elite athletes. However, there needs to be greater awareness down to grassroots level in all sports in the UK.
The Two Main Areas for Improvement
1. Increase awareness of young sudden cardiac death in grassroots sport.
Sporting bodies could play a significant role in highlighting the importance of screening throughout their sports down to grassroots level where the majority of young sudden deaths occur. Through increased awareness the sporting community will understand the specialist cardiac services available for the primary prevention of cardiac arrests in young athletic individuals, as well as how to respond effectively when a cardiac arrest occurs.
2. Establishing and maintaining policies and good practice that minimise the incidence of young sudden cardiac death.
All sporting bodies should identify clear policies on the prevention of young sudden cardiac death incorporating comprehensive emergency action plans (EAP). These policies should include the following.
Cardiac screening policy, identifying if they have:
1. no policy to raise awareness of screening services;
2. a policy to raise awareness of screening services and international (ESC/AHA) cardiac screening guidelines;
3. a policy to recommend cardiac screening for membership/participants at their own cost;
4. a policy to recommend cardiac screening for membership/participants through internal budgets; and/or,
5. a policy to mandate cardiac screening for membership/participants.
6. Other…
Cardiac awareness policy (family history, signs and symptoms), procedures to:
1. identify young people with a family history of young sudden cardiac death;
2. identify young people reporting or experiencing cardiac symptoms; and/or,
3. advise those with a family history of young sudden cardiac death or with cardiac symptoms.
AED policy, identifying if they have:
1. no AED;
2. AED not required (why?); or,
3. AED required, including;
a. placement of AED
b. training of staff
c. awareness of membership/participants, public, etc.
4. Other…
CPR policy, to ensure all members/participants are trained in CPR (and AED):
1. dissemination of training apps (e.g. CPR11);
2. dissemination of training videos (e.g. approx. 20 minute video “Mini Anne”);
3. informal training in CPR/AED; and/or,
4. formal (certified) training in CPR/AED.
5. Other…
Background on Cardiac Screening
In 80% of cases of young sudden cardiac death (YSCD) there are no prior symptoms of a heart defect. The frequency of YSCD can be dramatically reduced by making heart screening available to all young people between the ages of 14 and 35. In Italy where screening is mandatory in organised sport they have reduced the incidence of young sudden cardiac death by 89%.
Systematic screening programmes are needed to establish the prevalence of cardiac conditions in the young. The aim of a screening programme is to detect an underlying cardiac condition. 1 in 300 people tested will be identified with a potentially life threatening cardiac condition. 1 in 100 people tested are identified with cardiac conditions that cause problems in later life if not monitored. Once detected, preventative or therapeutic interventions can be implemented and the disease can be treated while it is less advanced. In the case of cardiac conditions, the aim is to put in place treatments and lifestyle changes that will minimise the risk of a sudden cardiac death. These preventative actions may include medications, surgery or lifestyle changes. Often specific medications or drugs will need to be avoided. In some cases the condition can be cured with the risk of sudden cardiac death entirely removed.
A simple way to diagnose most cardiac abnormalities is a quick, painless and non-invasive test called an electrocardiogram (ECG) which records the electrical activity of the heart. If a more detailed image is required, an ultrasound scan of the heart – called an echocardiogram – can be taken. Any person between the ages of 14 and 35 can book a place at a CRY screening event through www.testmyheart.org.uk. There is usually no charge for the testing. CRY operates screening programmes for the general public (aged 14 to 35) in schools, universities, sports clubs and community health centres.
Athletic and occupational cardiac screening
There are now many career paths and professions that either mandate or recommend cardiac screening, such as in the fields of professional sport, aviation and the military.
The European Society of Cardiology (ESC 2010) and International Olympic Committee (IOC) recommend cardiac screening for any young person taking part in competitive sport. Sport itself does not lead to cardiac arrest, but can trigger a sudden death by aggravating an undetected cardiac abnormality (see also cardiac-related sudden deaths in sport).
In the US, professional sports governing bodies like the NBA and NFL and many universities require all their athletes to be screened. The American Heart Association (AHA) agree all young athletes need to be screened with a Pre-Participatory Questionnaire however, they disagree with the ESC requirement to include the ECG.
The latest AHA guidelines (2014) state, “Although the present 2014 AHA guidelines do not require testing with 12-lead ECGs as part of mass screening for cardiovascular abnormalities, it is advisable to inform young athletes and their parents of the potential benefits and limitations of testing with 12-lead ECGs in detecting cardiovascular disease, to answer their questions, and to suggest they contact their personal physician if its use as an additional screening tool in individual cases is desired.”
The AHA (2014) recommendation 3 states, “Screening with 12-lead ECGs (or echocardiograms) in association with comprehensive history-taking and physical examination to identify or raise suspicion of genetic/congenital and other cardiovascular abnormalities may be considered in relative small cohorts of young healthy people 12 to 25 years of age not necessarily limited to athletes (e.g. in high schools, colleges/universities, or local communities), provided that close physician involvement and sufficient quality control can be achieved. If undertaken, such initiatives should recognise the known and anticipated limitations of the 12-lead ECG as a population screening test, including the expected frequency of false-positive and false negative test results, as well as the cost required to support these initiatives over time (Class IIb; Level of Evidence C)”.
In the UK, screening is required or recommended in most professional sports. (Refer to Appendix 1 for sports (and governing bodies) CRY currently work with or have worked with in the past). Increasingly, European countries are developing similar policies to those in Italy, expecting their athletes to be tested prior to participation. When screening is mandated or recommended as part of a career pathway it is essential to identify those at risk at an early stage, before personal and financial commitments are made towards career goals. Consequently, awareness of the importance of screening from a young age (post puberty) is important.
Sport is still immersed in the screening debate, with differing opinions between the European and American perspectives. However it is important to recognize that most young sudden cardiac deaths do not occur in sport. 80% of SADS (sudden arrhythmic death syndrome) deaths occur during sleep or at rest so the essential message to promulgate is that screening must be extended beyond sport and into local communities.
General population cardiac screening
In a society where disease prevention is becoming increasingly important, young people should have the opportunity to be tested. Annually, tens of thousands of people in the UK will be personally affected by young sudden deaths and may require reassurance.
Proactive testing is usually the only way a person can learn if they are at risk of sudden death. When screening is not provided – or even discouraged (as is the current case) – our society is being condemned to accept that every year a significant group of young people will die of these conditions.
UK National Screening Committee
The current UK national screening policy is it at odds with both European and American screening policies. It is based on a gross underestimation of the incidence of YSCD, the tests used to identify people at risk, and the management strategies to reduce risks. Current policy is failing to prevent young sudden cardiac deaths in the UK.
All sporting bodies will have had members who have suffered young sudden cardiac deaths. They all have either informal or formal guidelines for screening their elite athletes. Many will also have established comprehensive emergency action plans (EAP) that include the provision of CPR and AEDs to respond to a cardiac arrest.
Many sporting bodies have to adhere to international screening guidelines (making the UK National Screening Committee guidelines irrelevant) if they want their elite athletes to represent their country abroad.
Some institutions in the UK follow the NSC guidelines to the word resulting in a rejection of any form of screening policy and subsequent deaths have occurred in populations that would have benefitted from greater awareness. However, most sporting bodies have taken a proactive approach and introduced screening at the highest level. The issue now is to extend this down to grassroots for all young people.
Comprehensive Emergency Action Plan (EAP) – AEDs and CPR
AEDs alone are not sufficient for adequate emergency preparedness, but should be part of a more comprehensive emergency action plan (EAP). Essential elements for a comprehensive EAP include:
1. establishing an effective communication system;
2. establishing a coordinated and practiced response plan;
3. risk reduction to prevent injuries;
4. training of likely first responders in CPR and AED use; and,
5. access to early defibrillation and/or implementation of an AED programme.
The most important factors influencing survival from sudden cardiac arrest are the presence of a trained rescuer to initiate CPR and access to early defibrillation through on-site AEDs.
o The British Heart Foundation (BHF) provides grants that can support the cost of a defibrillator. To be awarded with the grant the applicant must provide for ongoing maintenance and community-based groups should be trained regularly and meet specific criteria relating to the placement of the defibrillator: www.bhf.org.uk/heart-health/nation-of-lifesavers/using-defibrillators
o More information on the BHF campaign for a nation of lifesavers (CPR): www.bhf.org.uk/heart-health/nation-of-lifesavers
o In 2010, the Resuscitation Council published guidelines on the use of AEDs: www.resus.org.uk/pages/aed.pdf
Appendix 1
Sports that have screened through Cardiac Risk in the Young:
Olympic Summer Sports:
• Archery: Archery GB is the national governing body for Olympic archery in the UK
• Athletics: UK Athletics is the national governing body for Olympic athletics in the UK
• Badminton: Badminton England is the national governing body for Olympic badminton in the UK
• Basketball
• Beach Volleyball
• Boxing: The British Amateur Boxing Association is responsible for the delivery of the world-class programme for Olympic boxing in Great Britain
• Canoeing: British Canoeing is the national governing body for Olympic canoeing in the UK
• Cycling: British Cycling is the national governing body for cycling in the UK
• Diving: British Swimming is the national governing body for Olympic diving in the UK
• Fencing: British Fencing is the national governing for Olympic fencing in the UK
• Football
• Gymnastics: British Gymnastics is the national governing body for gymnastics in the UK
• Handball
• Hockey: England Hockey is the national governing body for hockey in England and the ‘nominated country’ responsible for Olympic hockey in the UK
• Judo: British Judo is the national governing body for Olympic judo in the UK
• Modern Pentathlon: Pentathlon GB is the national governing body for modern pentathlon in the UK
• Rowing: British Rowing is the national governing body for Olympic rowing in the UK
• Rugby
• Sailing: The Royal Yachting Association is the national governing body for Olympic sailing in the UK
• Swimming: British Swimming in the national governing body for Olympic swimming in the UK
• Synchronised Swimming
• Table Tennis
• Taekwondo: GB Taekwondo is the high performance organisation for Olympic taekwondo in the UK
• Tennis
• Trampoline
• Triathlon: British Triathlon is the national governing body for Olympic triathlon in the UK
• Volleyball
• Waterpolo
• Weightlifting: British Weightlifting is the national governing body for Olympic weightlifting in the UK
Olympic Winter Sports:
• Bobsleigh: The British Bobsleigh and Skeleton Association is the national governing body for Olympic bobsleigh in the UK
• Short Track Speed Skating: National Ice Skating Association of Great Britain & NI is the national governing body for Olympic short track speed skating in the UK
• Skeleton: The British Bobsleigh and Skeleton Association is the national governing body for Olympic skeleton in the UK
• Ski & Snowboarding: British Ski and Snowboard is the national governing body for Olympic skiing and snowboarding in the UK
Paralympic Sports:
• Disability Shooting Great Britain is the national governing body for Paralympic shooting in the UK
• The British Table Tennis Association for People with Disabilities is the national governing body for Paralympic table tennis in the UK
• Para Athletics: British Athletics is the national governing body for Paralympic athletics in the UK
• Para Canoe: GB Canoeing is the national governing body for Paralympic canoeing in the UK
• Para Cycling: British Cycling is the national governing body for cycling in the UK
• Football: Blind Football, Cerebral Palsy
• Para Rowing: British Rowing is the national governing body for Paralympic rowing in the UK
• Para Sailing: Royal Yachting Association is the national governing body for Paralympic sailing in the UK
• Para Swimming: British Swimming is the national governing body for Paralympic swimming in the UK
• Para Triathlon: British Triathlon is the national governing body of Paralympic triathlon in the UK
• Wheelchair Basketball: British Wheelchair Basketball is the national governing body of Paralympic wheelchair basketball in the UK
• Wheelchair Tennis: The Tennis Foundation is the national governing body for Paralympic wheelchair tennis in the UK
Other Professional Sports/Teams:
• SKY Pro Cycling
• ONE Pro Cycling
• England Rugby Union (Rugby Football Union is the governing body): Seniors, Saxons, U20s, U18s, U17s, U16s, Sevens, Womens
• Welsh Rugby Union
• Premiership Rugby: Bath Rugby, Exeter Chiefs, Gloucester, Harlequins, London Wasps, London Irish, Saracens, Sale Sharks, Worcester Warriors, Newcastle Falcons, Leicester Tigers, Northampton Saints
• Guinness Pro 12 Rugby: Ospreys, Newport Gwent Dragons, Scarlets, Cardiff Blues
• Championship Rugby: London Welsh, Leeds Carnegie, Bedford Blues
• Rugby Football League (Governing Body): GB and England Teams, National Academies
• Rugby Football League (Super League): Huddersfield Giants, Leeds Rhinos, Wigan Warriors, St Helens, Castleford Tigers, Warrington Wolves
• Rugby Football League (Super 8S): Hull KR, Salford Reds, Wakefield Wildcats, Bradford Bulls, Leigh Centurions, Halifax RLFC, Featherstone Rovers
• England Cricket and England Womens Cricket (England & Wales Cricket Board is the governing body)
• County Cricket: Lancashire, Yorkshire, Warwickshire, Worcestershire, Kent, Essex, Middlesex
• Football: The Football Association (Governing Body), Manchester City FC, Watford FC, Ipswich Town FC, Brighton and Hove Albion FC, Burnley FC, Bolton Wanderers FC, Millwall FC, West Ham FC, Tottenham FC, Blackburn Rovers FC, England Women’s Football
• Royal Ballet Company
• Squash (England Squash & Racketball is the governing body)
• Lawn Tennis Association (Governing Body for Tennis)
• English Institute of Sport Regional Centres (venue hosts for screenings primarily for Olympic/Paralympic and potential athletes, but other athletes also invited in)
Other sports clubs include:
Welwyn Pegasus FC, Effingham & Leatherhead RFC, Northampton Swimming Club, Bedwell Rangers, Burnage Rugby Club, Cheshunt Boxing club, Hayden Youth FC, Lytham ST Annes Club, Sutton Tennis, Cinderford RFC, Berkhampsted Raiders CFC, J Nicholson Rugby Club, K Swan Hertfordshire Club…
