Would you support routine ECG screening for young competitive athletes?

As a group, [the monograph writing group] is heavily supportive of conducting a good personal and family history. I think that’s critical in any well child or pre-athletic screening. But then I think we all acknowledge that even after doing that, we’ll still miss many children, or perhaps the majority of children, who actually have underlying heart problems because they may not have symptoms. That’s where the ECG comes in as a potential way to help us do a more sensitive screen.

The panel agreed that routine use of ECGs is likely not feasible at this time. College and professional teams usually have more financial resources and may be able to incorporate additional testing, whereas middle school and high school athletic departments generally do not have the funds to support regular ECG screening.

Also, there is a potential for false positive results if those reading ECGs are not experienced or are not using the appropriate criteria.

With all that said, studies with more rigorous methodology, involving mandatory reporting systems, like they have in Italy, or prospective studies using data logged through the universal EMS database, indicated that the incidence of cardiac arrest in youth and adolescents was one in 28,000, as opposed to the estimate of one in 150,000 to 200,000 found in other research.

When you look at prevalence of disease in studies that have used more rigorous screening, like ECG, they all say that it’s about 0.3%, which is about three in 1,000, translating to one in 350 kids or young athletes, and that’s a significant number. While all of those kids don’t go on to develop an adverse event, thankfully, in terms of identifying those at risk, there are more out there than we know of.

Jonathan Drezner, MD, is a member of the monograph writing group and associate professor in the department of family medicine at the University of Washington in Seattle, and team physician for the Seattle Seahawks and University of Washington Huskies.

There is enough reason and evidence to support ECG testing in young adults.

First, the Italian data showed that supplementing the standard history and physical with ECG screening in young athletes can have a significant impact on detecting and reducing the sudden deaths that occur as a result of serious, underlying cardiac conditions.

Second, research conducted by Atkins et al in 11 Canadian and U.S. cities indicated a high sudden cardiac death rate in young adults. If one extrapolated from the incidence that they found in their population, physicians could expect anywhere between 2,000 and 3,000 deaths per year. These findings are important because people arguing against ECG testing for young adults cite lower incidence of sudden cardiac death in the United States when compared with the Italian data, but that is not the case. That’s because they focus on athletes using a narrow definition rather than all young adults. Is one’s life not worth saving because one is not on the varsity team?

The issue of economic feasibility is also misunderstood. Physicians may charge anywhere from $40 to $70 for an ECG in their offices, but those are different from high-volume, screening ECGs — which can be done for less than $20 per individual. Additionally, visiting a physician for a physical may cost $75 to several hundred dollars, so EKG testing actually may not be that costly in comparison.

Research highlighting studies with high abnormal rates also inspires hesitancy about using ECG testing, but those studies employed an exceptionally broad margin and identified many minor aberrations as abnormal. Subsequent research and our own experience in 45,000 ECGs place the abnormal rates for ECGs between 2% and 5% as opposed to the previously estimated 10% to 40% range. Moreover, other tests, including mammography and PKU screening, have high false positive rates; yet physicians accept them as standard practice without question.

Furthermore, ECG screening should extend beyond athletes to all young adults. Some instances of sudden cardiac death in children do not appear in the media because they occurred at home or the children are not considered “athletes,” such as dancers or drill team members. Therefore, regular ECG testing would be beneficial for all young adults.

The issue should not be about false positive rates or whether EKGs are currently cost-effective. Instead, the focus should be on how best to adapt EKG screening so that it can be economical, efficient and available for all children.

Joseph Marek, MD, practices cardiology with Midwest Heart Specialists in Downers Grove, Illinois.

Every patient is an athlete of sorts. Life is a contact sport, after all.

Ideally, a PPE would be a tool that every primary care doctor who takes care of children and adolescents could use to help them guide their patients about sports participation.

Regarding the issue of routine use of ECGs, however, most of the monograph writers felt that the practicality of implementing routine ECGs would be problematic.

Although the Italian data did note benefit, Italian physicians conduct thousands of PPEs per year, whereas those in the United States — were this to be implemented — would potentially be performing millions annually. Furthermore, ECG screening in the Italian study was conducted in an area where levels of arrhythmia were high and the population was small.

Cost is an issue but more important is the number of false positives and the personal cost to individuals and families with false positive results. Even a 2% to 8% false positive rate would be 700-2,800 athletes a year in Minnesota alone who would require extensive workups to be allowed to play to potentially find the one person at risk in an annual pool of 35,000 full exam athletes.

You have to have a burden of disease that makes screening worthwhile, and there is some debate about whether the burden of disease rises to that level in this case.

William W. Dexter, MD, is director of the sports medicine program at the Maine Medical Center in Portland, and professor at Tufts University School of Medicine in Boston, and one of the monograph’s authors.