The National Hockey League regular schedule is about to kick off, but for millions of Canadian children and youth the sports season is already in full swing - be it hockey, soccer, basketball, gymnastics, swimming, football, volleyball, badminton, or whatever.
Here's a prediction one can make with chilling accuracy: During the fall-winter season, a few of those young people will die suddenly; their hearts will stop, revealing an undetected cardiac abnormality.
Professional athletes like those in the NHL undergo a battery of tests including electrocardiograms (ECGs) that can reveal potential problems. So too do Olympians and some varsity athletes.
But, in Canada, amateur athletes do not.
Should they?
In the most recent edition of the British Medical Journal, leading experts in the field square off on this long-standing and always pertinent question.
It makes for fascinating reading and provides much-needed context for high-profile stories in recent years such as the deaths of 19-year-old Windsor Spitfires player Mickey Renaud, Russian hockey player Alexei Cherepanov and Cameroon soccer star Marc-Vivien Foé.
Antonio Pelliccia, scientific director of the Institute for Sports Medicine of the Italian Olympic Committee in Rome, argues strongly in favour of mass screening of young athletes.
Italy is the only country that does mass screening for cardiomyopathies (diseases of the heart muscle). A 25-year study (1979-2004) in the Veneto region saw every athlete aged 12 to 35 undergo heart tests before they were allowed to participate in any organized sport.
Dr. Pelliccia says the program has been a lifesaver. The incidence of sudden death has fallen 89 per cent, from 3.6 deaths per 100,000 athlete-years to 0.4 per 100,000 athlete-years. In other words, it has fallen from a tiny number to an infinitesimal one.
Further, Dr. Pelliccia notes that the rate of sudden cardiac deaths among non-athletes has not changed, which suggests screening is making a difference.
He also cited a recent U.S. study of 510 college athletes, which looked at the benefits of adding ECGs to standard testing, which consists of a physical exam and examining family history. (Many heart conditions are genetic, so anyone with a family member who died of a heart condition before the age of 50 is considered high-risk, as is anyone with unexplained fainting.)
The U.S. study found that for every 1,000 athletes tested with an ECG, 2.1 life-years were saved. The cost per life-year saved was pegged at $42,000 (U.S.), an amount deemed cost-effective.
Dr. Pelliccia's conclusion: "The current scientific evidence suggests that screening with electrocardiography represents the best clinical practice to prevent or reduce the risk of sudden cardiac death in young athletes," and he believes there is a legal and ethical obligation to screen amateur athletes.
Roald Bahr, a professor of sports medicine at the Oslo Sports Trauma Research Centre in Norway, using the same evidence, takes a contrary view.
It is indisputable, he says, that some athletes will die during competition or training and that vigorous physical activity can trigger those tragic events.
It is true too that screening can identify some people with heart abnormalities that put them at risk.
But Dr. Bahr uses the example of Norway to demonstrate that such an approach is inefficient and costly.
Norway has a population of 4.9 million, including about 325,000 people in the 15 to 34 age range who could be classified as amateur athletes. According to the country's death registry, there are about three sudden deaths in that age group annually, which translates to 0.9 deaths per 100,000 population (similar to what is seen in other Western countries).
Dr. Bahr points out that ECGs are not foolproof; they can identify about 50 per cent of heart abnormalities, and that rate varies widely depending on the condition.
ECGs are pretty good for identifying cardiomyopathies, but not effective at all for identifying atherosclerosis (hardening of the arteries) and other congenital abnormalities, which account for roughly half of sudden deaths.
Cardiomyopathies account for up to 60 per cent of sudden deaths and ECGs catch about half of them - so half of 60 per cent is about one-third.
In other words, a screening program could prevent, at best, one in three deaths - approximately one a year in Norway. And the cost is significant.
Another important factor, Dr. Bahr notes, is that there is a high rate of false positives with ECG screening. That rate can be as high as 40 per cent. Those false positives can necessitate far more expensive follow-up testing like echocardiography and magnetic resonance imaging. Many young athletes will also be excluded from participating in sports even though they are not really at risk; how will their long-term heart health suffer?
"Screening hundreds of thousands of athletes to save possibly one life, as would be the case in Norway, cannot be justified," Dr. Bahr writes.
Unless, of course, your child is that one whose life is saved.
It is a classic conundrum of preventive medicine: How much do you spend to potentially prevent a death? And how many more lives could be saved by spending that money otherwise?
André Picard