Evidence Does Not Support Widespread Preparticipation ECG Screening in Young Athletes

Screening young athletes with a resting electrocardiogram is not recommended given that the effectiveness of such testing to reduce the risk of sudden cardiac has not been substantiated, according to researchers who conducted a new review of the literature.

The potential of ECG screening to reduce sudden death is likely to be low given the poor detection rate and uncertain effectiveness of managing cardiovascular diseases identified in asymptomatic individuals, they conclude. 

Speaking with TCTMD, lead investigator Hans Van Brabandt, MD (Belgian Health Care Knowledge Center, Brussels), said that sudden cardiac death is a rare occurrence and that the small risk needs to be accepted given the widespread benefits of physical activity and sports participation

“I say to people here in Belgium that it’s like driving a car,” said Van Brabandt. “We know that if you’re driving a car there’s a small chance of dying due to an accident. Nevertheless, the benefits of driving a car are so large that we accept the risk. We all drive a car, and we accept there is a small risk of dying. I think the same should be done with sports.”

The review was published April 20, 2016, in the BMJ.

Much Debate Over ECG Screening

Preparticipation ECG screening for cardiovascular abnormalities that might cause sudden cardiac death in young athletes remains a contentious issue, with differing recommendations from regulatory bodies.

In the United States, the American Heart Association (AHA) and the American College of Cardiology (ACC) do not recommend the use of ECGs for cardiovascular screening of athletes, instead relying on a detailed family history and physical examination. The National Collegiate Athletic Association (NCAA) recently published a report based on the recommendations of a multidisciplinary task force, which included collaboration with the AHA and ACC, and also concluded that the “knowledge base” and “infrastructure” are inadequate to recommend across-the-board ECG screening of their athletes. They do provide a framework for colleges to follow should they choose to independently pursue ECG screening, however.

The European Society of Cardiology (ESC), on the other hand, does recommend use of a 12-lead ECG as part of the screening process, although Italy and Israel are the lone countries mandating it. Numerous sports organizations, including the International Olympic Committee (IOC) and Fédération Internationale de Football Association (FIFA), recommend screening athletes with a 12-lead ECG for the detection of cardiac abnormalities.

The debate over preparticipation ECG screening stems largely from a seminal 2006 paper published in JAMA by Italian researchers showing a large reduction in sudden cardiac deaths in the Veneto region following the implementation of a nationwide mandatory preparticipation screening program. Over a period of 26 years, the annual incidence of sudden cardiac death in athletes was reduced by 89%, the study showed.

The Belgian review, which was conducted for the country’s health authorities, is an attempt to address the still unsettled issue of preparticipation screening with an ECG.

“Nobody knows if there’s any benefit,” said Van Brabandt. “We don’t know, and we’ll probably never know. It’s a pity the Italians when they started mandatory screening in the early 70s didn’t start with a randomized trial. For example, randomize different regions in Italy to mandatory and nonmandatory screening. If they had done so, we might know today [if screening reduces sudden cardiac death]. Today, it’s no longer possible to do a randomized trial.”

The issue of sudden cardiac death in young athletes is fraught with emotion, he added, making randomization nearly impossible. From an ethical point of view, you’d be unlikely to find parents willing to randomize their children to a study that didn’t include ECG testing. Moreover, sudden cardiac death is a very rare event in young athletes.

The researchers state that rare genetic and acquired heart disorders that can lead to sudden death are present in approximately 0.3% of the population. Some of these individuals might develop symptoms, such as fainting or dizziness, but most will lead a normal life. Of young athletes with unrecognized heart disease, sudden cardiac death will be the first and only manifestation of their disease in 1% of cases. Hypertrophic cardiomyopathy, the most common underlying cause of sudden death in young athletes, is believed to occur in 0.5 to 1.0 per 1,000,000 individuals.     

With sudden cardiac deaths attributable to underlying cardiovascular disease considered a relatively low-event phenomenon, there are harms to widespread screening, said Van Brabandt.

“The damage is that you have a lot of false positives,” he told TCTMD. “We have searched the literature and found that as many as 30% of screens—involving history, physical examination, and electrocardiogram—will have the screening physician decide there might be something wrong. If we start with 100 people, 30 will have to go to a cardiologist for further examination.”

Of that 30%, most will be cleared for participation by one or two visits to the cardiologist. However, there will still be “thousands who remain with doubts,” said Van Brabandt, referring to people who fail to have the underlying concerns resolved. He said that approximately 2% of individuals screened in Italy are disqualified from competitive sports for life based on the ECG findings. “This is a major harm because you have an impact over their whole life, not only in terms of sport participation but in the medical implications,” he told TCTMD.

Aaron Baggish, MD (Massachusetts General Hospital, Boston, MA), a cardiologist who focuses on heart function and heart disease in athletic individuals, said the debate is unlikely to end anytime soon. The data needed to answer the question—conclusive evidence that mandatory ECG screening impacts the incidence of sudden cardiac death—are not available and likely never will be given the low event rate and massive costs and infrastructure needed to conduct such a study.

Even the existing the observational datasets, such as those from Israel and Italy, are flawed, making their interpretation impossible, said Baggish. 

“One of the things we have to accept is that no matter how we screen it will never be perfect,” he told TCTMD. “We will never eradicate the problem. Some screening is probably better than no screening, with the caveat being that screening has to be done well. I would feel very comfortable saying that screening done improperly certainly does more harm than good. And that applies across modalities, whether it’s a family history, electrocardiogram, or anything else we bring to the screening arsenal. If you don’t know how to do it, and you don’t have the appropriate resources in place, you’re going to hurt more people than you’re going to help.”

A poorly done history and physical can generate just as many false positives as a poorly interpreted ECG, he added.

Raising Awareness, Looking for Symptoms

In an editorial accompanying the Belgian report, Christopher Semsarian, MD, and Jodie Ingles, MD (University of Sydney, Australia), point to a previous cost-benefit analysis that showed 33,000 young athletes (< 35 years) would need to be screened to save one life at a cost of $1.32 million US dollars. Like Van Brabandt, they say there are psychological harms of false-positive tests, such as temporarily or permanently being disqualified from competitive sports, as well as the financial burden of further medical investigation.

Outside of screening, the editorialists state that education can play an important role, such as raising awareness among primary care doctors to check for previously undetected symptoms. A small proportion of patients might have unexplained syncope or a family history of cardiovascular disease or sudden death, and this could trigger a referral to a cardiologist for further assessment, they state.

They add that at the community level, ensuring training in cardiopulmonary resuscitation, particularly coaches and players, as well as the availability automated defibrillators at sporting venues, would increase the chances for survival after cardiac arrest. 

Richard Kovacs, MD (Indiana University School of Medicine, Indianapolis), who recently coauthored eligibility and disqualification criteria for athletes, said the contentiousness surrounding ECG screening often emerges at the community level, especially when those communities suffer a tragedy, like an athlete dying from sudden death on the sports field. With the goal of preventing future tragedies, well-intentioned communities will often want to add an ECG as part of the screening process, he said.

“It’s so counterintuitive,” Kovacs told TCTMD, referring to the death of a young, seemingly healthy athlete. Unfortunately, sudden death, while rare, will continue to happen and screening will not prevent every adverse event. “You have to come into this with the mind of a statistician,” said Kovacs. “It’s probabilities. To say it will never happen again is not the right attitude.”

Currently, the AHA states that an ECG might be “considered” as part of screening in a relatively small population—high schools, colleges, or communities—provided there is close physician involvement and sufficient quality-control measures in place (class IIb, level of evidence C). However, as Kovacs emphasized, the goal of the physicians is to first “do no harm” and screening, despite the best intentions, can take athletes away from sports unnecessarily and end careers unnecessarily.

The UK Government Gets Involved

Interestingly, the Belgian researchers reached out to the Italian group who published the landmark study showing that preparticipation screening could reduce sudden cardiac death. The Belgian group asked for more data, first in June 2014, but was told by the Italian researchers, including Domenico Corrado, MD (University of Padua, Italy), such follow-up data were currently being analyzed and that an updated report was not yet ready. Van Brabandt said they reached out a second time, in January 2015, but never heard back.  

“They must have enormous amounts of data,” he told TCTMD. “Since the 1970s, in the whole of Italy, they have published only one study.” Van Brabandt complained that the Italian investigators have repeated their results at “every congress, every meeting,” as well as in secondary papers, and have an ethical obligation to provide more data.

In 2015, researchers from the United Kingdom also tried to obtain additional data from the Italian screening program, but they took a much more formal approach. Jeremy Hunt, the secretary of state for health for England, made a formal request to Beatrice Lorenzin, the Italian minister of health, about additional data that could be provided to the UK National Screening Committee, but as the BMJ reports, he did not receive any information requested.

Related Stories:

• New Guidance Offers Hands-On, Big-Picture Approach to Preparticipation CV Screening
• Even a Little Exercise Yields Big Benefits, but Harm Unlikely at High Activity Levels
• Half of Sudden Cardiac Arrest Patients Have Warning Symptoms, But Most Ignore Them