Some Common Ground Emerges in Debate Over ECGs for Athletes
Benjamin Levine, MD, sports cardiologist at University of Texas Southwestern Medical Center and a long-time critic of the universal use of ECGs for athlete preparticipation physical examination, recently took an unusual step. He recruited academics and advocates of wider ECG screening to participate in a pilot randomized trial comparing American Heart Association–recommended preparticipation screening with this screening plus ECG.
The hope is that the study may provide evidence needed to help answer one of the most persistent and vexing questions in sports cardiology: Do the benefits of adding ECGs to preparticipation screening outweigh the risks?
Proponents of wider ECG screening argue such screening could save lives. Some advocates, including parents who have lost children to sudden cardiac death during athletics, have pushed for laws at the state level that would require ECGs to be included in sports physicals. But critics like Levine, director of the Institute for Exercise and Environmental Medicine run by University of Texas Southwestern and Texas Health Resources, argue that such additional screening may not save lives and could cause harm to otherwise healthy individuals.
Now, both sides are finding some common ground. There is growing consensus that those reviewing athlete ECGs need to be appropriately skilled and have resources in place for downstream care. There is also growing recognition of the potential value of screening those at highest risk of sudden cardiac death.
What We Know
Preparticipation health screening for athletes, including a physical examination and personal and family history, is recommended by the American Heart Association and the National Collegiate Athletic Association.
Critics of these screening protocols argue that they are not adequate, and multiple studies have shown they may miss cases, explained Dermot Phelan, MD, PhD, director of the sports cardiology clinic at the Cleveland Clinic.
“Current screening protocols are not very sensitive or specific for identifying subclinical cardiac disorders that put athletes at risk,” Phelan said. “ECG improves the sensitivity and specificity in identifying these issues.”
But there has been no consensus on whether adding ECGs would be beneficial. Both American Heart Association and National Collegiate Athletic Association recommendations suggest they a may be used in select circumstances when adequate resources are available, and some National Collegiate Athletic Association programs do routinely use these tests.
There are currently few data showing that early detection reduces athlete deaths. For example, Levine noted that the majority of sudden cardiac deaths do not occur during sports competitions, so simply stopping a person from participating does not necessarily prevent death. There also may not be a clear treatment option, he said. But there are potential harms to early detection, for example, unnecessary restriction of activity, or risks associated with procedures like ablation, implantation of a cardioverter-defibrillator, or surgery, Levine noted.
Opponents of wider ECG screening also cite practical barriers. Many athletes may not have insurance and may be unable to access follow-up testing and care or be burdened by the costs of follow-up care. This may be a particular concern for individuals who have a false-positive result on the initial ECG. Also, there may be a shortage of individuals with the appropriate expertise to interpret preparticipation ECGs in some areas.
“If screening with ECGs should be undertaken, it is vitally important these are done by people who have experience reading ECGs in athletes and that adequate provisions are in place to appropriately coordinate and read downstream testing to avoid misdiagnosis,” Phelan said
Phelan explained that there is a large overlap between normal adaptations that may occur in the hearts of healthy athletes and pathological changes. For example, chamber volume and wall thickness may increase in athletes to accommodate the hemodynamic stress associated with exercise. There are also pathological conditions that may cause wall thickening such as the genetic disorder hypertrophic cardiomyopathy, he said.
“Experienced sports cardiologists understand the limits of athletic adaptation which differ depending on the age, race, sex, and training regimen of the athlete,” he said. “But there are frequently cases where the line between physiology and pathology is very blurred and it can take a lot of work and experience to differentiate the two.”
Tragic deaths of young athletes from sudden death periodically thrust the debate over whether to include ECG in preparticipation screening into the spotlight. A bill being considered by Texas lawmakers would require it. It is the third time the state has considered such legislation. But physicians on both sides of the debate, including the American Medical Society for Sports Medicine, do not endorse such mandatory screening.
“I wish desperately that we could prevent all deaths, but I fear we might actually cause more pain and suffering than we will prevent,” Levine said. “So, until we have convincing evidence that we save more lives than we hurt people, we should never mandate ECG screening from a legislative perspective.”
There is growing consensus on when and how it may be appropriate to use ECGs. Both sides agree that college athletics programs that have the resources and expertise to incorporate ECGs may choose to do so.
“I would start with our college athletes,” said Jonathan Drezner, MD, director for the Center for Sports Cardiology at the University of Washington.
There is also growing consensus on prioritizing ECG screening for those at highest risk, noted Phelan. In 2015 in Circulation, Drezner and his colleague Kim Harmon showed that male athletes have a 3 times higher incidence of sudden cardiac death than females (1 in 37 790 athlete-years versus 1 in 121 593 athlete-years). Black athletes have a 3 times higher risk than white athletes (1 in 21 491 athlete-years versus 1 in 68 354 athlete-years), with Division 1 male basketball players having the highest risk (1 in 5200 athlete-years).
“If they can start with these high-risk groups, team physicians and cardiology consultants at these schools may over time decide they are ready or able to apply it to others as well,” said Drezner. For example, University of Washington started by screening basketball players, and then expanded it to all its college athletes, and to high school students being screened at the University, he said.
Another area that is gaining support is the effort to improve the training of physicians reading athlete ECGs.
“No one is calling for bad ECG screening,” Drezner said.
For example, both Drezner and Phelan highlighted the newly released International Guidelines, which provide a step-by-step roadmap for evaluating each potential abnormality detected by an ECG.
“We’ve been using International criteria in our practice and they are better,” said Drezner. “I think that will be a very valuable resource to help people to understand what the current standard is.”
The Texas pilot study will also send out its participants’ ECG screenings to cardiologists to evaluate how effective they are at distinguishing normal adaptations from pathology, said Levine.
The pilot, which enrolled 2000 student athletes and marching band members from 2 Texas school districts who were invited to participate, has already completed the screening. The Cody Stevens Go Big or Go Home Foundation, which is led by Scott Stevens, a man who lost his son Cody to sudden cardiac death and a proponent of the Texas legislation, funded the ECGs provided through the study. The Dallas-based Living for Zachary Foundation, which promotes high-quality ECG testing using a standardized protocol and offers such testing for a reduced fee through a Texas hospital, provided assistance with the ECGs.
Going forward, student participants and their parents will receive an encrypted text message with a link that asks whether the student has had or been diagnosed with heart disease in the past 6 months.
“The key to doing these studies is being able to track outcomes,” Levine said.
Even if this follow-up protocol proves feasible, a fully powered study would need to enroll 800 000 to 1 million students, something Levine acknowledged would be a tall order.
As these efforts move forward, there is universal agreement that access to defibrillators and cardiopulmonary resuscitation by individuals trained in secondary prevention is also crucial. Phelan noted that schools have made huge strides in making sure there are automated external defibrillators on site at athletic competitions and that staff are trained to use them and to do cardiopulmonary resuscitation. But it is important that these resources be available at all sporting events, Phelan noted.
“If there is a big focus put on that,” Phelan said. “That will absolutely save lives.” n
Circulation is available at http://circ.ahajournals.org.
- © 2017 American Heart Association, Inc.