Preparticipation cardiovascular exam of young athletes should include ECG

By Will Boggs MD

NEW YORK (Reuters Health) - Cardiovascular exams of young athletes before participation in sports should include an ECG, researchers from Switzerland say.

"In my opinion a preparticipation screening with ECG should be recommended at least one time in every young athlete (not before 15-16 years old if low risk) but should not be mandatory," Dr. Andrea Menafoglio from Ospedale San Giovanni Bellinzona in Bellinzona, Switzerland, told Reuters Health via email. "Follow-up ECG should be repeated in cases of potentially higher risk (abnormal personal or family history, abnormal ECG, and possibly in certain populations - black, males, certain sports such as soccer, football, basketball - where cases of SCD in sports are more prevalent)."

The European Society of Cardiology and several major sports associations have endorsed cardiovascular screening, including a resting 12-lead ECG, to prevent sudden cardiac death in young athletes, but the American Heart Association recommends a screening protocol limited to medical history and physical examination.

Dr. Menafoglio and colleagues undertook a cost and yield analysis of a preparticipation cardiovascular screening examination, including ECG, in a prospective observational study of 1070 young athletes (14 to 35 years old) in Switzerland.

Sixty-seven athletes (6.3%) required further evaluations after the screening examination: 3.9% because of an abnormal ECG, 1.4% due to physical examination, and 1.3% due to medical history.

The researchers detected a new cardiac disease in 11 athletes (1.0%). Seven had valvular diseases, systemic hypertension, or atrial tachycardia identified through positive history or abnormal physical examination.

All four athletes (0.4%) with a cardiac disease potentially responsible for sudden cardiac death (three with Wolff-Parkinson-White and one with long QT syndrome type 1) were identified with ECG alone and would have been missed if screening included only history and physical examination, according to the February 6 British Journal of Sports Medicine online report.

The estimated cost of the screening program with ECG was 147 Swiss francs per athlete (US$167) and 14,315 Swiss francs per new cardiac finding. The cost without the ECG would have been an estimated 85 Swiss francs per athlete and 13,122 Swiss francs per new cardiac finding (but it would have missed all four potential causes of sudden cardiac death).

"If costs were the only criteria, screening programs for athletes should be abolished because they are expensive and sudden cardiac deaths are rare," the researchers conclude.

"Nevertheless, if a screening program would be implemented, as widely suggested, then ECG should be part of it because it greatly improves its efficacy."

"Potential drawbacks are: false positives ECG (< 5%) requiring additional examinations, costs, anxiety, potential false diagnosis, (and) unnecessary follow-up especially when medical personnel is not qualified in the field," Dr. Menafoglio said. "Therefore, it is important that ECG should be read by qualified doctors."

Dr. James M. Galas from Wayne State University School of Medicine in Detroit, Michigan recently reviewed issues surrounding sports participation by teenagers. He told Reuters Health in an email, "There are groups that have reported success with ECG screening and advocate its use with sound reasoning. However, one must understand that there are fundamental differences in health care system infrastructure, population diversity, and prevalence of cardiac disease in different areas of the world."

"These distinctions play an integral role in determining the relative success or failure of an ECG screening program," Dr. Galas said. "For this reason it is my opinion that in 2014, ECG screening of athletes is not the best means for preventing sudden cardiac death in young athletes on a worldwide scale."

"Primary prevention of sudden cardiac arrest (SCA) through screening is desirable; however the ability to do so in a practical, reproducible, and comprehensive manner in the United States is in question," Dr. Galas said. "Currently, the use of patient history, family history, physical examination, and additional testing depending on clinical suspicion as the mainstay of preparticipation screening is recommended by the American Academy of Pediatrics and the American Heart Association."

"An understanding of signs and symptoms of cardiac diseases can alert practitioners to those who may be at risk for SCA," Dr. Galas concluded. "Evidence is growing for the effectiveness of secondary measures, such as early access to CPR and defibrillation, in preventing sudden cardiac death."

SOURCE: http://bit.ly/1fbAbRD

Br J Sports Med 2014.

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