ABC | Volume 111, Nº6, December 2018

Viewpoint Helal et al Sudden death in young athletes Arq Bras Cardiol. 2018; 111(6):856-859 and 12-lead resting electrocardiogram (ECG), regardless of the presence or absence of risk factors. The scheme proposed by the ESC is heavily influenced by observational evidence collected in Italy. Initially, it was found that young athletes from the Veneto region were at high risk of SD during competitive sports practice, compared to other regions of the world. 9 In 2006, Corrado et al. 10 highlighted a high prevalence of Arrhythmogenic right ventricular cardiomyopathy (ARVC) and hypothesized that disqualifying athletes with a diagnosis or suspicion of that disease (or similar diseases) would be effective to reduce SDmortality at sports events. 10 These findings increased the discussion on the implementation of a specific algorithm that would make ECG mandatory in addition to anamnesis and physical examination as screening procedures for anyone engaging in a competitive and structured physical exercise program. Two years later and criticism aside, a classic study published by the same group of researchers tested the scheme and demonstrated it reduced SD cases by 89% in competitive activities involving young athletes in that country. 11 In fact, the PPE has been mandatory for more than two decades for every regulated amateur or professional athlete, with an Italian federal law that is adopted by all sports regulation entities. 12 On the other hand, the joint procedure recommended by the American College of Cardiology (ACC) and the American College of Sports Medicine (ACSM) do not include a mandatory ECG, as argue that the annual incidence of SD in the United States is much lower than in Italy. 5 In addition, they reiterate that ECG’s sub-optimal specificity for detecting anomalies in athletes may result in an excessive number of false-positive results. In this regard, the overall consequences of a false‑positive result 13 may lead to unnecessary over-investigation (e.g., echocardiography, cardiac resonance, among other examinations), with undesired financial and personal costs, or even disqualifications. However, contrary to the arguments of the American entities above, a cost-effectiveness analysis conducted by a Stanford group 14 pointed out that including ECG in the clinical examination would prevent 2.09 additional deaths per 1,000 athletes, with an estimated individual cost of U$ 89 per examination and a cost-effectiveness estimate of approximately U$ 43,000 per qualitiy-adjusted life years (QALY). For Brazil, these data are particularly important, since the Ministry of Health is currently discussing, together with the National Congress and academic entities involved in the assessment of health technologies, the threshold of willingness to pay for added technology. Because until the present the cost per QALY of a new technology is unknown, we believe it is critical that decisions be made in Brazil based on knowledge of local statistics, which again reinforces the need for a national register of SD in young athletes to be properly conducted. Why a National Register is Necessary Because the etiology of SD in sports in young athletes is diverse, with regional and genetic influences, identifying the local prevalence is of utmost importance to make decisions based on evidence. For example, ethnicity has an effect on the incidence of SD in young athletes. In the US, an increased incidence of SD was found in black basketball and football players compared with other ethnic groups, most often due to hypertrophic cardiomyopathy (HCM). 15 Autopsy data from that country showed that that twice as many black athletes died fromHCM as white athletes (20% vs. 10%). 16 Such information suggests a possible divergence in HCM presentation in different ethnic groups and that it may be more malignant in black individuals. In fact, in at least 50% of the cases, HCM presents as an autosomal dominant monogenic disease. Its overall prevalence is traditionally estimated at 1:500 individuals, 17 but more recent data indicate that it may be even more frequent than previously established, which is corroborated by advances in genetic research. 18 In Brazil, the frequency of HCM is not solidly known. Here, it is our opinion that this disease is an example of the importance of ECG in the context of competitive athletes, as it can be suspected through this examination in a high percentage of cases. Moreover, changes in the ST segment, in the T wave, as well as the presence of pathological Q waves 19 can be warning signs based on which further exams (with a higher positive predictive value) can be requested in a context of greater pretest probability. Once there is a diagnosis (clinical and/or molecular), septal ablation, myectomy, and/or an implantable cardioverter defibrillator (ICD) may be indicated. Likewise, but only in well-selected cases, disqualification may be the final outcome for the athlete’s career. 20,21 In respect to the ethnicity of the Brazilian population, which is extremely mixed and with a high prevalence of blacks, 22 knowing the causes of SD in Brazilian athletes of this race seems to us very important to classify the risk for these individuals. As for the causes of SD due to ion channel disturbance, genetic screening, 23 already included in the SBC’s 2013 guidelines, 8 has been suggested as a possible strategy to help with prevention (note of the authors: when properly indicated), given the high contribution of the genetic factor for the event’s occurrence. 24 given the high contribution of the genetic factor for the event’s occurrence. 24 In fact, some malignant mutations are already known in genes that cause Long QT Syndrome (LQTS), Short QT Syndrome, Brugada Syndrome and catecholaminergic polymorphic ventricular tachycardia (CPVT). 25,26 Here, we would like to point out that although molecular mapping is accessible and technical improvement through new generation sequencing is available in our country, requesting it is still not part of our medical culture, even in more robust clinical scenarios (e.g., breast neoplasm screening and association with BRCA genes). 27 In fact, in order for medical entities to formally encourage its request in PPE, it is necessary to know prevalence so that the technology can be submitted to the health technology assessment (HTA) process, which is similar to the processes already performed for other clinical entities. 28 The sport modality also has some bearing on the construction of a decision algorithm for PPE and SD prevention in young athletes. For example, in the United States, SD prevalence is higher in basketball and football. 29 In Europe, SD in young athletes is more frequent in field soccer players. 30 857