An Electrocardiogram Should Not Be Included in Routine Preparticipation Screening of Young Athletes
The sudden death of a young athlete during competition is a tragic yet rare occurrence that results in significant public and media attention. Increased catecholamine response to maximum stress in subjects with underlying structural heart disease is a well-known cause of lethal cardiac arrhythmias.1 In 1996, the American Heart Association issued a scientific statement advocating universal cardiovascular preparticipation screening for high school and college athletes in an attempt to identify those at increased risk of cardiovascular events.2 The recommendations included a 12-point complete history and physical examination (including brachial artery blood pressure measurement) before competitive sports (Table 1) and reserved noninvasive testing such as a 12-lead ECG, echocardiogram, exercise testing, and cardiovascular consultation for athletes in whom any abnormality was detected.
Response by Myerburg and Vetter p 2615
The recommendations include repeat cardiovascular screening every 2 years with an abbreviated examination in intervening years. Parental participation in gathering a proper history in younger athletes was encouraged. The committee recommended a national standard for preparticipation cardiovascular medical evaluation and education of all healthcare providers who screen athletes because of the marked heterogeneity in the design and content of preparticipation cardiovascular screening and variable experience of healthcare screeners at the time. Routine diagnostic tests (ie, a 12-lead ECG) as part of the screening procedure were excluded primarily for cost-efficacy considerations. In the 2007 update,3 recently published in Circulation, the 12-point recommendations listed in Table 1 remain unchanged and do not include universal 12-lead ECG recordings as part of every preparticipation history and physical examination, unless, of course, the athlete fails the 12-point examination.3 The European Society of Cardiology (ESC) and the International Olympic Committee (IOC) screening questionnaires serve a purpose similar to that of the 12-point AHA questionnaire, although they include more questions and the content is slightly different4 (Table 2). However, the prescreening strategy of the ESC and IOC differs significantly from the American approach in that universal 12-lead rest ECGs are recommended for athletes <35 years, leading to an important controversy between the American and European positions on the need for routine ECG recording.5 The IOC-ESC consensus document published in 2004 to 2005 relied heavily on the 25-year Italian experience of systematic preparticipation screening of competitive athletes.4–8
The Italian Experience
In 1971, the Italian government passed a law to provide medical protection for athletes participating in organized competitive athletic events. In 1982, the law was revised to stipulate that preparticipation screening include, at a minimum, a general physical examination, 12-lead ECG, and submaximal exercise test and that the screening protocol be conducted annually.8 Under Italian law, it is the responsibility of the examining physician to determine, with a reasonable degree of medical certainty, whether a particular athlete is free of cardiovascular abnormalities that could increase risk during participation in athletic training and competition. In 2006, Corrado and colleagues6 reported the Italian experience using the screening process in subjects 12 to 35 years of age. The annual incidence of sudden cardiac death in athletes decreased from 3.6 deaths per 100 000 person-years (1 death per year per 27 777 athletes) in 1979 to 1981 to 0.4 deaths per 100 000 person-years (1 death per year per 250 000 athletes) in 2003 to 2004, an 89% reduction. No change occurred in the mortality rates among the unscreened nonathletic population. Of the 42 386 screened athletes, 3914 (9%) required additional cardiovascular testing, and 879 (2%) were ultimately prohibited from athletic participation. The progressive reduction in mortality with implementation of more aggressive screening that includes routine 12-lead ECG recordings may lead to the conclusion that this screening approach should be applied universally in all countries. However, there are important limitations in the Corrado report, as pointed out by Thompson and Levine in a thoughtful accompanying editorial.9 The study was a population-based observational report and not a temporally controlled comparison of screening versus nonscreening in athletes; a separate analysis of the routine use of ECGs compared with more limited screening in identifying athletes at increased risk is not provided; the annual death rate before the initiation of the program was 1 per year per 27 000 athletes, which is relatively high compared with other studies; and the lowest annual death rate achieved with screening was 0.4 deaths per 100 000 person-years. These rates are similar to the 0.44 sudden deaths per 100 000 person-years reported for high school and college athletes in the United States from 1983 to 1993.10 In addition, the event rates in the Italian study included all events, not those that occurred only with exertion.
The Japanese Experience
In 1973, a national screening system for cardiovascular diseases was introduced in Japan for all 1st, 7th, and 10th grade students. The primary screening process includes a questionnaire and an ECG for all students, regardless of athletic participation. Tanaka et al11 reported results in 68 503 young adolescents entering seventh grade in Kagoshima who underwent primary screening. During the study period, 30 696 moved out of the area in the 10th grade, leaving a total of 37 807 students available for serial analysis and follow-up for 6 consecutive years. At the 7th and 10th grades, 975 and 901 students (2.7%) failed the primary screening and had secondary screening by physical examination, exercise tests, or echocardiography. During follow-up, 3 sudden deaths occurred in boys without syncope or family history of cardiac disease. Among the 3 deaths, one 14-year-old boy had hypertrophic cardiomyopathy identified during screening and died while jogging. The remaining 2 students, 13 and 16 years of age, died during handball and basketball, respectively. Both had a normal ECG and no autopsy, illustrating the difficulty in identifying the rare young athletes at increased risk of sudden death during competition even with ECG screening. In this series of high school students, the risk of sudden death averaged 1.32 per 100 000 per year.
Population Differences and Disease Prevalence Rates
An issue in generalizing the findings observed in other countries to the United States is the comparability of the populations. Genetic and age differences can result in variable phenotypic expression and detectable disease rates in different studies and populations. In the Veneto region of Italy, hypertrophic cardiomyopathy accounted for only 2% of sudden deaths among athletes from 1979 to 1996.7 Arrhythmogenic right ventricular dysplasia accounted for 22% of the deaths, followed by coronary atherosclerosis in 18% and coronary anomalies in 12% of cases. Most of the 49 deaths (90%) occurred in men, a finding observed in most series. In contrast, in the United States, the single most common cause of death in young athletes participating in competitive sports is hypertrophic cardiomyopathy (approximately one third of the deaths), followed by coronary artery anomalies.3 The United States has a diverse ethnic population; for example, blacks represented ≈12% to ≈13% of the US population in 2001. Young blacks account for >50% of the high school and college student athletic field deaths resulting from hypertrophic cardiomyopathy and have a relatively high prevalence of early repolarization changes and a relatively high maximal ventricular septal thickness on echocardiography that make it difficult to distinguish an athletic heart from mild anatomic expressions of nonobstructive hypertrophic cardiomyopathy.12–15
Unsuspected cardiovascular disease is estimated to be present in 0.3% of the general athlete population in the United States. The detection of some types of cardiovascular disease does not mean that sudden death will occur with exercise. Although it is difficult to estimate the precise incidence rate of sudden death in young athletes, a Minnesota study of 1.4 million high school student-athlete participants in 27 sports over 12 years reported a rate of 1:200 000 per year (3 deaths).10 In other reports summarized in a recent AHA update, the sudden rates are even smaller, less than the postscreening rates published by Corrado et al.16 It would be very difficult for the 12-lead resting ECG to separate out low- and high-risk subjects at risk of sudden death during competitive activities with sufficient diagnostic accuracy, even if resources were sufficient to provide universal ECG recordings as part of preparticipation screening.
Routine ECG Recordings in Young Athletes
The attraction of adding a rest 12-lead ECG to the screening process is the potential to detect conditions associated with exercise-induced cardiac arrhythmias and sudden death. In 1 retrospective analysis of 134 high school and collegiate athletes who died suddenly, only 3% of the examined athletes had abnormalities suspected by a standard history and physical.15 Abnormal ECGs are common in some conditions such as hypertrophic cardiomyopathy (in which as many as 90% of ECGs are abnormal) and in myocarditis, arrhythmogenic right ventricular dysplasia, long- and short-QT syndrome, congenital atrioventricular block, Brugada syndrome, and preexcitation syndrome. Other conditions associated with sudden death during exertion such as Marfan syndrome, coronary artery anomalies, or catecholamine-induced ventricular tachycardia might not be detected with a resting ECG. Table 3 lists the ECG criteria for an abnormal response proposed by the ESC.5 These criteria have not been tested prospectively to determine the incremental value in identifying athletes at increased risk of sudden death during competition, and some criteria are relatively common in a normal population such as increased voltage, T-wave flattening in 2 leads, or even a slightly prolonged QTc interval.17,18 ECG abnormalities are more common in athletes and may be due to cardiac remodeling from training effects.14 Maron and colleagues19 prospectively screened 501 intercollegiate competitive athletes at the University of Maryland using a process that included a baseline 12-lead ECG. Of the 501 subjects, 102 (20%) had at least 1 abnormality, and 13% had an abnormal ECG. Of 83 athletes with alterations on 1 study alone, 57 (69%) occurred because of the ECG, 16 (19%) were detected on the physical examination, and 10 (12%) had an abnormal history. The greater frequency of abnormal ECG responses compared with the history and physical has been reported by others.20 Thus, one would anticipate a high rate of false-positive results if routine ECGs were added to clinical screening as a preparticipation requirement for competitive athletics from bayesian principles.
Several studies have proposed that adding an ECG to the screening process is cost-effective.11,21 In 1 report, Fuller21 reported that the ECG was the most cost-effective modality in terms of approximate costs per year of life (≈$44 000) saved for a high school athlete participating in sports activities compared with a history and physical examination or echocardiogram, assuming a risk of sudden death of 1 per 100 000 per year.21 This risk is twice that actually observed in the Minnesota experience and is significantly greater than that reported in US population by others.10,16 The cost-effectiveness of universal ECG screening was calculated in the 2007 AHA Update with a different set of assumptions, resulting in an estimate of $330 000 to completely screen each athlete for suspected relevant cardiac disease. The annual cost of a mass screening program that includes a prescreening ECG was estimated at $2 billion each year in the 2007 AHA report.3
It is of interest that the medical screening program in Italy, a country with a population 19% that of United States, has been in place for >20 years but has not been implemented completely because of the magnitude of the medical screening requirements and the lack of adequate financial support.8 The United States comprises ≈25 000 000 competitive athletes involved in a network of sporting activities and 10 000 000 high school and college athletes. The strategy of adding a more detailed specific questionnaire to identify the extremely rare high school or college athlete in the United States at risk of exercise-related death is prudent but requires prospective testing. More research is needed into the type of questionnaire/physical examination needed for athletes of both genders and of different ethnic backgrounds and for different types and intensities of physical activity to optimize the detection of high-risk individuals. For example, the risk of exertional sudden death is greatest for sports like football and basketball and is uncommon in young female athletes of any race compared with men, occurring in a ratio of 1:9. The risk of exercise-related death in young women is 1 per 769 000 in 1 US series and includes all sports-related nontraumatic events, not just cardiovascular, far less than the event rates reported by Corrado et al6 and Van Camp et al10 with ECG screening. Adding universal 12-lead resting ECG screening to this large segment of the US population when the strategy has not been sufficiently tested does not make sense unless prospective studies demonstrate that doing so reduces exercise-related acute cardiovascular events in a cost-effective way. Trying to identify the extremely rare young athlete at risk of nontraumatic sudden death during sports activities removes resources from the healthcare system in the United States and abroad that could be allocated to other urgent healthcare needs that are present in a much greater percentage of high school and college age students, such as the escalating risks of obesity, diabetes mellitus, and other conditions that reduce long-term life expectancy in this age group.
I am indebted to my good friend Victor Froelicher, MD, for reading this article and for providing meaningful insightful commentary.
Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman BR, Fromer M, Gregoratos G, Klein GJ, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy CM. ACC/AHA/ESC 2006 guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patient With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). Circulation. 2006; 114: e385–e484.
Maron BJ, Thompson PD, Puffer JC, McGrew CA, Strong WB, Douglas PS, Clark LT, Mitten MJ, Crawford MH, Atkins DL, Driscoll DJ, Epstein AE. Cardiovascular preparticipation screening of competitive athletes: a statement for health professional from the Sudden Cardiac Death Committee (Clinical Cardiology) and Congenital Cardiac Defects Committee (Cardiovascular Disease in the Young), American Heart Association. Circulation. 1996; 94: 850–856.
Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, Dimeff R, Douglas PS, Glover DW, Hutter AM, Krauss MD, Maron MS, Mitten MJ, Roberts WO, Puffer JC. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007; 115: 1643–1655.
IOC Medical Commission. IOC preparticipation cardiovascular screening. December 10, 2004. Available at: http://multimedia.olympic.org/pdf/en_report_886.pdf. Accessed November 11, 2007.
Corrado D, Pelliccia A, Bjornstad HH, Vanhees L, Biffi A, Borjesson M, Panhuyzen-Goedkoop N, Deligiannis A, Solberg E, Dugmore D, Mellwig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Heidbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E, Blomstrom-Lundqvist C, McKenna WJ, Thiene G. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol: consensus statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005; 26: 516–524.
Van Camp SP, Bloor CM, Mueller FO, Cantu RC, Olson HG. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc. 1995; 27: 641–647.
Tanaka Y, Yoshinaga M, Anan R, Tanaka Y, Nomura Y, Oku S, Nishi S, Kawano Y, Tei C, Arima K. Usefulness and cost effectiveness of cardiovascular screening of young adolescents. Med Sci Sports Exerc. 2006; 38: 2–6.
Maron BJ, Pelliccia A. The heart of trained athletes: cardiac remodeling and the risks of sports, including sudden death. Circulation. 2006; 114: 1633–1644.
Thompson PD, Franklin BA, Balady GJ, Blair SN, Corrado D, Estes NAM, Fulton JE, Gordon JF, Haskell WL, Link MS, Maron BJ, Mittleman MA, Pelliccia A, Wenger NK, Willich SN, Costa F. Exercise and acute cardiovascular events: placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology: in collaboration with the American College of Sports Medicine. Circulation. 2007; 115: 2358–2368.
Hiss RG, Lamb LE. Electrocardiographic findings in 122,043 individuals. Circulation. 1962; 25: 947–961.
Fuller CM, McNulty CM, Spring DA, Arger KM, Bruce SS, Chryssos BE, Drummer EM, Kelley FP, Newmark MJ, Whipple GH. Prospective screening of 5,615 high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc. 1997; 29: 1131–1138.
Fuller CM. Cost effectiveness analysis of screening of high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc. 2000; 32: 887–890.
Response to Chaitman
Robert J. Myerburg, MD, and Victoria L. Vetter, MD
Willingness to reconsider and amend a course of action on the basis of evolving information and current circumstances is a reflection of wisdom and strength and leads to coherent policy recommendations. Applying this principle to the question of ECG screening of young athletes leads to the conclusion that a rational basis exists for the American Heart Association (AHA) to reconsider its position on this issue. In his analysis of the currently held position of the AHA, Dr Chaitman accurately summarizes the information relied on by the authors of the AHA 2007 Update to arrive at their position. He supports their conclusions but does not explore beyond the largely historical considerations. We believe the multiple factors cited in our article, based on current and forward-looking considerations, support our position that the AHA should amend its recommendation. Among the reasons for our conclusion are the following:
It is undisputed that a high percentage of athletes at risk for sudden cardiac arrest (SCA) can be identified or suspected from a screening ECG.
The differences in causes of SCA among athletes in Italy and the United States actually support the strategy of ECG screening in the United States because the most common cause in the United States, hypertrophic cardiomyopathy, is more reliably identified by an ECG than is the most common cause in the Italian study, and such deaths are unevenly distributed among specific segments of the heterogeneous US population.
ECGs can often distinguish normal athletic heart from hypertrophic cardiomyopathy.
It is agreed that better standards for “normal” are needed, but they will not emerge from a prohibitive posture, inhibiting large-scale use of this screening strategy.
Although the ECG is not perfect, it is intended only as the first line in the screening process. It is not claimed to be absolutely “diagnostic.” Moreover, conditions that the ECG cannot identify (coronary artery anomalies or catecholaminergic polymorphic ventricular tachycardia) cannot be identified by the currently recommended screening.
The fact that the current AHA 12-element system has not been effective in identifying those at risk for SCA is another argument for addition of ECGs.
SCA is likely more common than was recognized in the articles cited, and a high proportion of sudden cardiac deaths occur as the first clinical expression of a disorder.
Many more years of life are gained by saving an adolescent with most of the conditions responsible for sudden cardiac death than would be saved by screening strategies that target older populations.
Identifying an athlete with a genetically based SCA condition may serve many others in the family. This is not just about preventing death on the athletic field.
From a cost-benefit perspective, a realistic estimate of cost for such a program is far below what we spend on other cardiovascular initiatives with no better payback in terms of efficacy and efficiency of preventive strategies.
Dr Chaitman’s statement on investments in other predictors of cardiovascular disease that are sorely in need of additional funding is absolutely on target. However, this is simply a reflection of the general fact that support for preventive medicine and research into individual risk profiling in the United States is far below what a country of its wealth should be placing into such efforts. It is not for the scientific, clinical, and organizational communities to prioritize health dollars but rather to indicate what is needed and provide the supporting arguments. The decision to spend money on preventing some finite number of potentially avoidable deaths in adolescents and young adults is a priority determination that belongs in the hands of the public. Ask any parent.
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.