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Routine ECG screening discouraged for young people
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In a new statement, the American Heart Association and American College of Cardiology do not recommend mass screening with 12-lead ECGs for CV abnormalities in the general population of healthy young people aged 12 to 25 years.
A writing panel for the two organizations cited low evidence of CV-related sudden death in young people, a high rate of false positives and false negatives associated with ECGs, and high costs and difficult logistics of setting up a national or other large-scale general screening program.
No public health benefit
“The writing group acknowledges the tragic nature of [sudden deaths] in the young, but does not believe the available data support a significant public health benefit from using the 12-lead ECG as a universal screening tool,” panel chair Barry J. Maron, MD, FACC, and colleagues wrote. “The writing group, however, does endorse more widespread dissemination of automated external defibrillators, which are effective at saving young lives on the athletic field and elsewhere.”
Instead, the panel recommends used of the AHA’s 14-point screening guidelines as part of a comprehensive medical history and physical examination to detect physical abnormalities. According to those guidelines, preparticipation screening of competitive athletes is only necessary in certain cases depending on medical history, family history and physical examination results.
Screening with 12-lead ECGs or echocardiograms in conjunction with medical history and physical examination to detect CV abnormalities may be considered in small cohorts of young people aged 12 to 25 years. This recommendation is not necessarily limited to athletes, according to the statement. However, such programs should only be undertaken if close physician involvement and proper quality control are achieved, the panel wrote.
If such a program is undertaken, known and anticipated limitations of the 12-lead ECG as a screening test, the expected frequency of false-positive and false-negative results, and the required costs must be understood, Maron and colleagues wrote.
Rationale for recommendations
In 2007, an AHA panel estimated that the cost of a national CV screening program for high school and college athletes would be approximately $2 billion annually in the early years. The writing panel for the new statement noted that $2 billion is the approximate annual budget of the NHLBI. Therefore, they wrote, it would be most cost-effective to devote resources to prevention of more frequent cases of death in young people, such as driving while intoxicated or distracted, drug use and suicide.
Among US individuals younger than 25 years, 76 athletes die each year of CV causes that would have been detectable by ECG screening vs. 11,015 deaths from motor vehicle accidents, 5,717 deaths from homicides and 4,189 deaths from suicide per year, according to the statement.
False-positive rates for ECG detection of CV abnormalities can be high, especially for hypertrophic cardiomyopathy, in black men and boys.
“At a high-enough rate, false-positive ECGs can create excessive and costly second-tier testing … within the system, and in the process greatly exceeding true-positive results,” the panel wrote. “However, even if ECGs with false-positive results could be reduced to only 5% in the course of screening 10 million individuals (the estimated number of US competitive athletes), screening ECGs would nevertheless identify a formidable obstacle of 500,000 people who required further testing to exclude underlying heart disease and resolve eligibility for sports participants. Very few of these individuals would ultimately prove to have important disease with a risk for [sudden death] that required disqualification.”
In addition, false-negative rates of ECG testing for hypertrophic cardiomyopathy, the most common cause of sudden death in young people, are greater than 10%, according to the statement.
The statement was endorsed by the Pediatric and Congenital Electrophysiology Society and the American College of Sports Medicine.
For more information:
Maron BJ. Circulation. 2014;doi:10.1161/CIR.0000000000000025.
Maron BJ. J Am Coll Cardiol. 2014;doi:10.1016/j.jacc.2014.05.006.
Disclosure: See the full statement for relevant financial disclosures of the writing panel and reviewers.