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Cardiovascular screening of football referees for the 2014 FIFA Football World Cup in Brazil - time for revision of current screening concepts in competitive master athletes?
1University Hospital Zurich, Department of Cardiology - Zurich - Switzerland
2Medical School Hamburg - Hamburg - Germany
3Schulthess Clinic - Zurich - Switzerland
European Journal of Preventive Cardiology
Introduction: Sudden cardiac death is one of the most frequent causes of death in competitive sports. Football referees engage the same physical and psychological burden as football players do. As such, they represent a perfect role model for master athletes that harbor an increased risk for exercise-related sudden cardiac death, mostly due to coronary artery disease and thus challenge established screening concepts. Purpose: To assess a specifically representative large group of master athletes, i.e. football referees, with an adapted cardiac screening to detect potentially fatal cardiovascular disease. Methods: We examined all 156 preselected referees of the FIFA Football World Cup 2014 in Brazil. The cardiovascular assessment comprised personal and family history; a focused physical examination; a 12-lead resting ECG; specific laboratory tests (including lipids and glucose); a focused transthoracic echocardiography; and an exercise ECG on a treadmill. Results: Of 156 examined referees (all males, 37.4±3.8 [30 – 43] years, BMI 23.4±0.3 kg/m2), 43 (27.6%) showed abnormal laboratory findings, i.e. dyslipidemia (n=25; 16.0%), impaired fasting plasma glucose (n=17; 10.9%), and newly diagnosed diabetes mellitus (n=1; 0.6%). None of the referees had a SCORE risk of >1%. Seven (4.5%) referees featured increased blood pressure (>140/90mmHg) at rest. In 44 (28.2%) referees pathological ECG-findings were found: T-wave inversion (n=16; 10.3%, i.e. V2: n=3; V2, V3: n=2; aVF: n=8; II, aVF: n=3), ST-segment depression (n=12; 7.7%), pathological Q-waves (n=1; 0.6%), left atrial enlargement (n=11; 7.1%), and left-axis deviation/left anterior hemiblock (n=4; 2.6%). On echocardiography, six (3.8%) athletes presented with an increased diameter of the aortic root. In one (0.6%) referee a relevant and potentially dangerous coronary artery anomaly could be detected (right coronary arising from left sinus taking an intramural course). This referee had to be ultimately excluded of the championship and further competitive sports. None of the referees showed relevant pathologies during exercise testing. Conclusions: Cardiac screening of a defined group of competitive master athletes proved to be feasible. Due to our large number of pathological findings in echocardiography and laboratory testing we suggest that in competitive master athletes, the established baseline screening, integrating history, physical examination and ECG, should be complemented by specific laboratory tests to estimate the individual risk for coronary artery disease. As classical exercise testing frequently fails to detect subclinical coronary plaques at risk for plaque rupture, athletes at an increased risk should undergo further testing. Furthermore, it might be reasonable to provide an echocardiography at least once in an athlete’s career.
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