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Dr. Vincent Gouttebarge, FIFPro's Chief Medical Officer, discusses the current status of the pre-competition medical assessments to prevent sudden cardiac arrest. He advises all national and international football authorities to follow his recommendations and improve the current system.

Sudden death in sports is a tragic event that always creates much publicity. The occurrence of sudden death of young athletes aged from 12 to 35 years old participating in an organised sports programme requiring regular training and competition has been estimated at 0.6 to 3.6 deaths per 100,000 athletes per year, which is 2.8 times higher than in non-athletes (people not participating in an organised sports programme) (Corrado 2003; Maron 2009; Borjesson 2011).

The majority (over 90 %) of these deaths are due to cardiovascular causes, and are referred to as sudden cardiac death (SCD) (Corrado 2003; Bille 2006; Maron 2009). Sports-related SCD is defined as non-traumatic, non-violent, unexpected death due to cardiac causes within one hour of sports participation (26th Bethesda Conference 1994). Reported in almost all sports, SCD occurs most frequently (30 %) in football (Corrado 2003; Maron 2009).

Of all fatalities that occurred in professional football in the past seven years, nearly 25 % were due to cardiac reasons, of which 45 % were directly related to football participation (FIFPro 2014).

In many sports, a large variety of pre-participation screening protocols are available and applied in order to prevent SCD.

The Lausanne protocol
In 2004, the Medical Commission of the International Olympic Committee introduced the Lausanne Recommendations (Corrado 2005). The Lausanne protocol aims to present a uniform and accepted screening protocol in order to identify cardiovascular diseases or abnormalities and prevent SCD (Corrado 2005; Bille 2006). The Lausanne protocol relies on anamnesis (self-reported medical history), physical examination, blood analysis and rest-electrocardiogram (ECG) (Corrado 2005; Bille 2006).

For many years, pre-competition cardiovascular assessment following the Lausanne protocol has been widely adopted by many (inter)national sports organisations.

However, the validity of this cardiovascular screening protocol has repeatedly been questioned (Corrado 2005; Inklaar 2007). The Dutch Health Council stated in 2006 that due to its lack of quality, the protocol had no scientific basis for recommendations for periodical screening of competitive athletes for SCD. Also, abnormal ECG has been reported in 40 % of healthy athletes, which might lead to unjustified disqualification from competition (Elston 2009; La Gerche 2010).

Despite the doubt about its interpretation, ECG still plays an important role in the cardiovascular assessment (Drezner 2013). In professional i.e. elite sports, more extensive cardiovascular examinations are often conducted such as echocardiography or stress ECG, echocardiography being of unchallenged value in the diagnosis of cardiac risk (Thunenkotter 2010). Despite the conflicting opinion about the effectiveness of SCD screening, pre-participation screening protocols following the Lausanne Recommendations have been made mandatory for elite athletes in many sport disciplines, including professional football.

The Pre-competition medical assessment in professional football
Before the 2006 World Cup in Germany, FIFA asked the physicians of all participating teams to conduct a pre-competition medical assessment in order to detect risk factors challenging players' health with regard to injuries and SCD among other things. The SCD part of the FIFA pre-competition medical assessment (PCMA) relies strongly on the Lausanne protocol, replacing the rest-ECG by a stress-ECG and adding echocardiography (Dvorak 2009). Such a PCMA has been implemented since then for all international competitions (men, women, youth).

In its Medical Regulations (2013), the UEFA has included a similar PCMA for SCD which has to be completed before the start of the competition and has to be renewed annually. This PCMA is mandatory for several competitions such as UEFA Champions League, Europa League as well as for national team championships (men, women and youth). But for other UEFA competitions it is only a recommendation.

At national level, PCMA has been included as a requirement in regulations of many national associations or in Collective Bargaining Agreements. However, based on a recent survey, FIFPro found that only 65% of the national footballers' unions was aware of a mandatory PCMA in their national competitions.

FIFPro concerns

  • Predictive validity of the PCMA: as acknowledged previously, the validity of the Lausanne protocol has been questioned, especially the usefulness of ECG to identify pathological myocardial disease. Even if the cost-effectiveness issue might be relevant, the PCMA of any professional football organisation should involve additional examination such as echocardiography, to conform with the FIFA PCMA.
  • Equality of all professional footballers: FIFPro – the voice of all players worldwide – emphasises that professional footballers, being workers i.e. employees in the eyes of the law, should have the same rights from one employer to another for any matters, especially with regard to health and safety. Consequently, the governing bodies within professional football (FIFA, UEFA, etc) should not only consider the necessity of PCMA for players participating in highest international or continental competitions, but for all professional players participating in any professional national competition, regardless of the continent or country.
  • Compliance with the mandatory character of PCMA in national competitions: the governing bodies within professional football have made PCMA mandatory for players participating in the highest international and continental competitions, and only recommend it for other competitions. At national level, PCMA has been made mandatory by the football associations in many countries through regulations or Collective Bargaining Agreement. However, it seems that the mandatory character of PCMA is not fully respected by all professional clubs (Gouttebarge 2013). Consequently, FIFPro is concerned that clubs i.e. employers do not comply strictly with (national) regulations and might jeopardise the health of the players.

Recommendations

  • Further research should be conducted into the validity of PCMA for the prevention of undesirable complications during football and for the reduction of SCD. Especially, the added value and predictive validity of echocardiography to the standard Lausanne protocol should be evaluated, while attention should be given to the quality and interpretation of the results. In addition, the self-reported medical history through questionnaire should be followed by an in-depth interview in order to avoid any potential misunderstandings by players.
  • The PCMA protocol in professional football across continents and countries should be standardised to conform with the latest scientific evidence. As FIFPro advocates the equality of all professional footballers across continents and countries, it is hard to explain to our players – all employees from the same occupational category – why they could be assessed differently within the same club (international players vs. non-international players) or from one club (employer) to another.
  • The PCMA should be made mandatory at all professional levels by the (inter)national governing bodies regardless of continents or countries. In addition, cardiac evaluation based on detailed personal and family history and on thorough physical examination should be made mandatory for all youth players from any professional football club academy, starting at an age of 12-14 years old.
  • The mandatory character of the PCMA for all professional footballers (including youth) previously advocated should be guaranteed. Therefore, evaluation committees should visit worksites in order to control and monitor the application and quality of preventive cardiac evaluation in professional clubs among other things. A potential sanction system should be developed and implemented by the governing bodies within professional football if a professional club jeopardises the health and safety of its employees i.e. professional footballers.

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Email:
v.gouttebarge@fifpro.org
r.beaard@fifpro.org