At Issue: ECG screening as part of the pre-participation exam for young athletes
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Key takeaways:
- There is no consensus on whether an ECG should be included as part of the pre-participation exam for young athletes.
- Benefits and risks of an ECG screening program should be carefully weighed.
Pre-participation screening, particularly whether an ECG should be included as part of a pre-participation exam for young athletes, is one of the most widely debated topics in sports cardiology.
Performing an ECG as part of pre-participation screening improves the chances of identifying an underlying cardiac condition and gives athletes and their families more information about their health, but there is no hard evidence that doing so prevents sudden cardiac death, and a false positive could lead to unnecessary downstream tests, procedures and disqualification. Thus, there is no strong consensus in the sports cardiology field on the matter.
Healio spoke with several sports cardiologists for their thoughts on whether a screening ECG should be part of a pre-participation exam for young athletes.
David Shipon, MD, FACC, FACP
Caring for the hearts of athletes has evolved considerably. Data show that young Black male basketball players in the NCAA’s Division I have a one in 2,000 chance of sudden cardiac arrest, while white male NCAA Division I basketball players have a one in 5,000 chance of sudden cardiac death (Petek BJ, et al. Circulation. 2024;doi:10.1161/CIRCULATIONAHA.123.065908). No longer is the clinician responsible for “passing” or “failing” an athlete based on screening criteria. The onus is now to engage in critical shared decision-making with the athlete. To accomplish this, the athlete must understand inherent risks tailored to his or her personal health profile. Sports cardiologists need objective information to do this with skill and equipoise (Mitropoulou P, et al. Heart. 2022;doi:10.1136/heartjnl-2022-321050).
In this regard, the screening ECG is vital. Consensus documents such as the international criteria of ECG interpretation in athletes and the American Heart Association’s 14-point screening questionnaire allow for fewer false positives, especially when used in combination (Williams EA, et al. J Am Heart Assoc. 2019;doi:10.1161/JAHA.119.012235). Often, the etiology for sudden cardiac arrest in the athlete is unknown. But, left ventricular hypertrophy/hypertrophic cardiomyopathy is the most commonly known pathology. More than 90% of athletes with HCM will have an abnormal ECG (Emery MS, et al. JACC Heart Fail. 2018;doi:10.1016/j.jchf.2017.07.014). Other significant pathology can be found with ECG screening such as long QT syndrome, Wolff-Parkinson-White syndrome, arrhythmogenic right ventricular dysplasia, Brugada pattern and others.
A high rate of false positives has historically been the major criticism of ECG screening endeavors. Cost has been another consideration. Using the aforementioned guideline tools, however, has lowered false-positive rates to less than 3%. As biomedical technology naturally evolves, ECG machines are now more accessible and more affordable (Conway JJ, et al. Clin J Sport Med. 2022;doi:10.1097/JSM.0000000000000858; Hyde N, et al. J Electrocardiol. 2019;doi:10.1016/j.jelectrocard.2019.07.001). The use of AI platforms also increases diagnostic accuracy (Martínez-Sellés M, et al. J Cardiovasc Dev Dis. 2023;doi:10.3390/jcdd10040175).
Careful, thoughtful implementation of these strategies allows for shared decision-making. This thereby gives many athletes a chance to safely participate in sports they love, despite a potentially lethal diagnosis. Effective screening ensures that many athletes receive necessary care like beta-blockers, defibrillators and contingency action plans (Johnson JN, et al. JAMA. 2012;doi:10.1001/jama.2012.9334; Martinez KA, et al. J Am Coll Cardiol. 2023;doi:10.1016/j.jacc.2023.05.059; Ommen SR, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jacc.2020.08.044; Pelliccia A, et al. Eur Heart J. 2021;doi:10.1093/ehaa605; Tobert KA, et al. Mayo Clin Proc. 2022;doi:10.1016/j.mayocp.2022.03.024). Return to sport after diagnosis of CVD is now endorsed by the guidelines (Lampert R, et al. JAMA Cardiol. 2023;doi:10.1001.jamacardio.2023.1042).
Screening programs additionally provide an opportunity for young individuals to engage with the health care system, including those persons who might not have otherwise seen a doctor. Physicians have a chance to educate at these encounters. The addition of a accurately read ECG to primary and secondary prevention counseling for the prevention of heart disease is undoubtedly beneficial.
The notion that ECG screening should not be done in athletes is antiquated. Effective guideline-based screening should be done on a wide scale, especially in high-risk sports and patient demographics. Our athletes deserve to be informed, and they deserve to play safely.
Shipon is director of preventive cardiology, cardiovascular rehabilitation and sports cardiology at Jefferson Health, clinical assistant professor of medicine and rehabilitation medicine at Sidney Kimmel Medical Center, chief medical officer of Simons Heart and director of the Athlete Health Organization of Thomas Jefferson University.
Eli M. Friedman, MD
The prism within which we view ECG screening of athletes in the United States has shifted significantly, though not less passionately, in the last several years. This shift has occurred within an overall much larger paradigm shift of athletes competing at the highest level of sport with established CVD relevant to sudden cardiac arrest during sport participation. Sports cardiology, once guided by consensus opinion only, now finds itself using data and risk stratification combined with shared decision-making to help guide our athletes on return-to-play decisions.
Therefore, no longer should the debate of ECG screening be focused on whether or not it will be used. The ECG can be performed on athletes and is currently being used by countless amateur and professional sporting organizations across the country. The debate now centers on how the screening will be conducted as part of a comprehensive package for pre-participation sport evaluation.
Before proceeding, I must disclose that I am responsible for screening ECG interpretation and follow-up for athletes ranging from high school to professional and Olympic sport. Our program takes great pride in performing the study accurately and ensuring timely and appropriate follow-up for our athletes with a positive screen. We go to great lengths to ensure the athlete’s findings on the ECG are properly adjudicated and, if pathology is identified, treated and risk stratified with proper shared decision-making to make every effort to return our athletes to sport as safely as possible.
With that being said, I submit that I am strongly against any ECG screening program that does not include the following:
- Comprehensive shared decision-making and education with organizational stakeholders prior to starting a program to discuss the infrastructure related to the screening with an emphasis on the knowledge that no modality will fully prevent sudden cardiac arrest in sport.
- ECG screening education for the athletes and their support systems. All too often, the ECG is obtained and is abnormal and the athlete and his/her support system were unaware of what was required after. Possible restriction from sport, follow-up appointments and further investigation come as an unwelcome surprise to many.
- Interpretation of the ECG by a health care provider well versed in the International Consensus Standards for Electrocardiographic Interpretation in Athletes (Sharma S, et al. J Am Coll Cardiol. 2017;doi:10.1016/j.jacc.2017.01.015).
- Access to a cardiologist comfortable with the care of athletes and working knowledge of the required testing needed in athletes with a positive ECG screen. This cardiologist should also be comfortable in contemporary standards for sport-specific risk stratification or have access to collaborate with or refer to one who does.
- Comprehensive and collaborative shared decision-making to review all findings, discussion of the knowns and unknowns and acknowledgement of the need for longitudinal follow-up.
- Avoidance of targeted screening of self-identified racial groups that are at higher risk for sudden cardiac arrest in sport. Scientific evidence does not support screening in these groups only (Kim JH, et al. American College of Cardiology. https://www.acc.org/Latest-in-Cardiology/Articles/2023/08/17/15/45/Avoidance-of-Sport-and-Race-Specific-Cardiac-Screening-of-Athletes. Published Aug. 17, 2023. Accessed June 18, 2024).
- Agreement for an equal emphasis on emergency action planning with education for all stakeholders on sudden cardiac arrest in sport combined with CPR and automated external defibrillator training (Friedman EM. American College of Cardiology. https://www.acc.org/Latest-in-Cardiology/Articles/2021/09/24/12/05/How-To-of-Emergency-Action-Planning. Published Sept. 24, 2021. Accessed June 18, 2024; Martinez MW, et al. Healio | Cardiology Today. https://www.healio.com/news/cardiology/20230907/the-best-defense-against-sudden-cardiac-deathemergency-action-plans-cpr-and-aeds. Published Sept. 7, 2023. Accessed June 18, 2024).
If all the above criteria cannot be met, it is recommended to use the traditional cardiac-focused history and physical exam screen only without an ECG. The addition of an ECG risks avoidable harm to athletes and their support systems via false-positive readings, unnecessary restriction from sport and worsening mental and physical health. Reassurance can be provided in this circumstance, though. While data do show that the ECG is better at screening for cardiac pathology than a history and physical exam alone, no data has shown that this ultimately prevents sudden cardiac arrest.
The debate of “yea or nay” to ECG screening is a thing of the past. The question organizations must now answer is whether their ECG screening program is up to the contemporary standard of screening to identify and risk-stratify. If the answer is “no,” then it is clear that the ECG should not be used.
Friedman is medical director of sports cardiology at Miami Cardiac & Vascular Institute, part of Baptist Health South Florida.
James Sawalla Guseh II, MD, and Ryan J. Quinn, MD
ECG screening has been at the center of debate since data from northern Italy indicated an 89% reduction in sudden cardiac death with pre-participation ECG screening. Criticized for unusually high baseline sudden cardiac death rates and a lack of replication, this study nevertheless propelled ECG screening into the spotlight. Further supporting the efficacy of ECG, a 2015 meta-analysis across 15 studies confirmed its superior sensitivity (94%) in detecting conditions associated with sudden cardiovascular arrest or sudden cardiac death compared with history (20%) or physical exams (9%). These findings highlighted the role of the ECG in revealing hidden cardiac risks and set the stage for the broader benefits of screening (Harmon KG, et al. J Electrocardiol. 2015;doi:10.1016/j.electrocard.2015.02.001).
Screening with ECG not only identifies relevant conditions that merit longitudinal follow-up, but screening writ large engages young athletes who might otherwise avoid regular health checkups. Screening encourages young athletes to reflect on their health, including their family history. Moreover, screening acts as an initial touchpoint with the health care system. This early interaction ensures that should future symptoms or concerns arise, athletes are more likely to seek prompt medical attention, having already established a relationship with their medical team.
Despite these benefits, ECG screening presents significant challenges. Despite the ECG’s ability to detect conditions tied to sudden cardiac arrest/death, these conditions do not always lead to sudden cardiac arrest/death. Moreover, many predisposing conditions for sudden cardiac arrest/death, such as coronary disease, coronary anomalies or sudden arrhythmic death syndrome — the most common cause of death among young athletes — are not readily identifiable by ECG. A Canadian study examining three contemporary sudden cardiac death autopsy studies found that only about one in four of these deaths would have potentially been detectable by ECG (McKinney J, et al. Can J Cardiol. 2019;doi:10.1016/j.cjca.2019.08.023). These detection limitations not only contest the efficacy of ECG screening but also lead to significant financial and practical challenges.
Implementing ECG screening incurs significant costs, including the expenses of the tests themselves, follow-up testing and the emotional toll on athletes who face activity restrictions. Estimates vary, but approximately 2% to 7% of ECGs are abnormal, necessitating further testing for nearly one in 14 athletes. These follow-up procedures often involve echocardiograms, stress testing, ambulatory rhythm monitoring and cardiac MRI. Institutions who screen need to swiftly conduct these follow-up tests to minimize disruptions for the athletes. Recent data from the NCAA sudden death registry show that the overall incidence of sudden death among NCAA athletes is about one death per 62,682 athlete-years, or one death per 15,921 over a 4-year collegiate career (Petek BJ, et al. Circulation. 2024;doi:10.1161/CIRCULATIONAHA.123.065908). Despite extensive pre-participation screening, there is a notable gap between the frequency of abnormal ECG findings and actual CV deaths. For instance, a study that identified 6.6% of ECGs as abnormal in a sample of 5,505 athletes found only 15 (0.27%) were diagnosed with conditions linked to sudden cardiac death, highlighting a significant inconsistency between initial screenings and ultimate serious health findings (Sheikh N, et al. Circulation. 2014;doi:10.1161/CIRCULATIONAHA.113.006179).
Moreover, while unproven to save lives, ECG screening is proven to create distinct inequities. Due to higher rates of false positives, athletes from Black and minority backgrounds will likely face increased time commitments, unnecessary activity restriction, additional testing and greater financial burdens. Programs that employ screening should be aware of this challenge to health equity created by screening and work to mitigate them.
ECG screening is one of many tools available to sports cardiologists and has become a cornerstone of modern athlete care. It is essential for clinicians to fully understand the benefits and limitations of ECG screening and to apply it judiciously. It is not proven to prevent sudden cardiac arrest or sudden cardiac death. However, when well executed, the ECG offers advantages. Clinicians are encouraged to not only fully grasp the nuances of ECG screening, but also to proactively address its limitations, ensuring a balanced and informed approach that maximizes its benefits, minimizes potential risks and avoids false assurances.
Guseh is director of the Cardiovascular Performance Program in the cardiology division at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School. Quinn is a cardiovascular performance fellow at Massachusetts General Hospital.
For more information:
Eli M. Friedman, MD, can be reached at elifr@baptisthealth.net.
James Sawalla Guseh, MD, can be reached at jguseh@mgb.org; X (Twitter): @jsawallagusehmd.
Ryan J. Quinn, MD, can be reached at rjquinn@mgh.harvard.edu.
David Shipon, MD, FACC, FACP, can be reached at david.shipon@jefferson.edu.
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