Screening young athletes: to ECG or not to ECG?

To ECG or not ECG? That is the question ever since Italian investigators claimed that adding an ECG test to the mandatory routine preparticipation screening of young athletes was feasible and effective in reducing the incidence of sudden cardiac death in young athletes. Now two new studies and an accompanying editorial have appeared in Annals of Internal Medicine. But since the papers contain quite different if not exactly contradictory messages, it is unlikely they will provide any resolution to the controversy.

510 athletes at Harvard University received an ECG in addition to routine preparticipation screening. The athletes also underwent transthoracic echocardiography (TTE) to help assess the predictive value of the ECG. Eleven of the 510 athletes were found to have cardiac abnormalities by TTE. Preparticipation screening with history and examination alone identified only 5 cases. ECG testing identified 5 more cases, yielding a 90.9% sensitivity rate. Of the 3 cases which ultimately required limitation of sports activity, all were identified by the combination of routine screening and ECG, but only 1 with routine screening alone.

The chief limitation of ECG testing was a significant increase in false positives. ECGs found 83 (16%) students with abnormalities.  The authors wrote: “A screening program that falsely identifies approximately 1 in 6 participants as having cardiac disease has substantial and perhaps prohibitive financial, emotional, and logistical ramifications.”

In the second study, Stanford researchers estimated the cost effectiveness of adding ECGs to routine screening. They found that ECG screening would save 2.06 life-years per 1000 athletes. At a cost of $89 per athletes this results in a cost-effectiveness ratio of $42,900 per life-year saved, which the authors said “can be considered cost-effective compared with common benchmarks.”

In an accompanying editorial, Barry Maron notes the “attraction” of ECG screening in this population but urges “prudent restraint.” He notes a number of problems with mandated screening in the US. In addition to various “societal, cultural, and legal considerations,” Maron makes the following points:

  • Given that most cases of sudden death occur in nonathletes, any systematic program would need to include all children in the US, not just athletes
  • The low absolute rate of events
  • The low specificity and high rate of false positives associated with ECG testing
  • The $2 billion estimated annual cost

Maron concludes:

“The attraction of the Italian screening model is perhaps understandable, given that ECG is a relatively simple and inexpensive test that the medical community is comfortable in performing. However, on closer inspection, when even such an apparently “simple” test is applied to large, healthy populations, important limitations become obvious, temporizing initial enthusiasm with prudent restraint. At this time, the aforementioned obstacles probably prohibit the creation of a mandatory, systematic preparticipation screening program with ECGs confined to young persons in competitive sports in the United States.

Previous CardioBrief coverage of this issue:

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