Debating ECG Screening in Young Athletes: The Time for Policy Change is Now!

Each year, sudden cardiac death occurs in nearly 100 young athletes in the United States. According to data from a 2011 study in Circulation, the incidence of sudden death in college athletes is often underestimated and approximates 1 in 900,000 athlete participant-years.¹ In this five-year observational study, cardiovascular causes of sudden death accounted for nearly half of all deaths, and of these cases of sudden cardiac death, nearly 75% occurred during periods of exertion. In a previous examination of sudden cardiac death in a cohort of high school athletes in Minnesota, Maron et al found that the rate of cardiovascular death was nearly 1 in 500,000 athlete participations and that the risk of sudden death over a high school career was 1 in 75,000.² Other epidemiologic studies indicate that the incidence of sudden death is approximately 1 in 200,000 persons annually.³ While it is relatively rare for young athletes to experience sudden cardiac death, the consequences and emotional costs associated with the death of a child are devastating. The untimely death of one young athlete negatively impacts parents, families, schools and entire communities. 

The most common causes of sudden death in young athletes include hypertrophic cardiomyopathy (HCM), congenital heart diseases such as anomalous coronary arteries, valvular heart disease, long QT syndrome (LQTS), and myocarditis (Table 1). The vast majority of these conditions result in spontaneous ventricular arrhythmias, particularly during the exertion and physical activity that occurs with sports participation. The risk for sudden death in athletes is 2.5 times that of the general population, and nearly 90% of all sudden death episodes in athletes occur during or immediately after a training session or competition. HCM accounts for 30–50% of all cases of sudden cardiac death in athletes, and is easily identifiable with 2D echocardiography or on routine 12-lead electrocardiogram tracings. In cases of HCM or other congenital or acquired cardiovascular disease, interventions can be made to prevent sudden death if we are able to accurately identify patients with these conditions prior to a devastating event. In some cases, implantable cardioverter defibrillators (ICDs) are required. In others, drug therapy, surgical correction of a particular abnormality, and/or sports participation restriction may be necessary in order to prevent tragedy. The critical step, however, is the identification and evaluation of those who are at risk. 

Why is it, then, that in the U.S. today, we do not require screening ECGs in all athletes prior to participation in organized sporting activities? Many argue that it is the cost of testing, the challenges of organizing an adequate local screening infrastructure, or the standardization of the evaluation process. 

Where Do the Guidelines Stand Now? 

There has been much debate over the last 20 years as to how to effectively screen high school and college athletes, in a cost-effective way, in order to identify those at risk for sudden death. Currently there are discrepant guidelines that have been issued by the American Heart Association (AHA), American College of Cardiology (ACC), and the European Society of Cardiology (ESC). The AHA recommends that all athletes receive a preparticipation physical that includes a comprehensive family history and cardiovascular examination. The AHA does not recommend routine ECG or echocardiography, and proponents of this approach argue that there is not enough data to support the expense of noninvasive screening tests in athletes for the prevention of sudden cardiac death. The ESC, by contrast, now recommends that all athletes receive not only a history and physical exam, but also have routine ECG testing performed prior to any participation in sports activities. Parents of young athletes whom have succumbed to sudden cardiac death on the playing field are beginning to build a significant lobby to change the way in which healthcare providers approach screening. In fact, the lay press, including The New York Times, has begun to publish stories surrounding this debate, and many parent advocacy groups are becoming increasingly active in pressuring organizations such as the AHA for a change in guidelines. 

There have been several good studies demonstrating that the use of routine preparticipation history and physical exams can effectively screen athletes and identify many of those at risk for sudden cardiac death. Data from 1996 in the Journal of the American Medical Association suggested that most sudden death episodes are precipitated by symptoms, and study authors concluded that because of these very predictive historical clues, testing adds very little to the comprehensive history and physical exam.⁴ In contrast, other studies indicate that routine ECG screening would in fact identify a few more individuals at risk and would benefit a small number of patients in a meaningful way (i.e., saving a life through prevention). Moreover, these authors concluded that the addition of ECG screening would also remain cost effective.⁵ The ESC appears to be much more progressive in their recommendation for screening of young athletes. The European guidelines were amended to include routine ECG screening in addition to history and physical exam on the basis of a large Italian study conducted in young athletes in 2006.⁶ In this study, the addition of ECG provided a significant reduction of nearly 98% in sudden death in young athletes; it was the basis for the state-mandated screening process in Italy for more than a decade. The ESC has developed “athlete-specific” ECG criteria that are utilized in accurately identifying at-risk young athletes with very low false positive rates.⁷

What is the Cost of a Young Life?

Opponents of routine screening argue that ECG testing would add unnecessary costs to the healthcare system and produce too many false positives. The average cost of an ECG is roughly $150, and many insurance companies will cover nearly 80–100% of this cost. ECG testing, while not as comprehensive as imaging tests such as 2D echocardiography, can identify many conditions that put athletes at risk for sudden cardiac death, including HCM and LQTS. Arguments against the use of routine ECG screening rely on the fact that the incidence of sudden death is quite rare, but do not take into account the improvements in ECG interpretation — most opponents of ECG screening rely on older, outdated studies. Data presented at Heart Rhythm 2014, the Heart Rhythm Society’s 35th Annual Scientific Sessions, suggests that ECG screening is cost effective and was significantly better at predicting abnormalities related to sudden cardiac death than the history and physical exam alone.⁸ ECG screening in this study resulted in the identification of 71% of abnormalities as compared to history and physical exam, which identified 60%. Moreover, the ECG screening was associated with fewer false positives as compared to history and physical exam alone — approximately 3.4% for ECG compared to 23% for history and 14% for physical exam.

Moving Forward—Advocating for Change

While the AHA guidelines have been based on older data associated with a different set of ECG criteria, newer studies, such as the one presented at Heart Rhythm 2014 and published in the British Journal of Sports Medicine, suggest that we must consider a guideline update. Many parent-organized groups and private schools in the U.S. have begun to organize efforts to push for guideline reform.⁹ The debate over ECG screening is gaining national attention, as evidenced by discussions on national media outlets such as the Fox Business Network.

In communities where a student has died suddenly, many parents are willing to pay “out of pocket” to obtain a more thorough preparticipation screening for their children. However, I believe that we must provide the best available screening technology to all students throughout the U.S. The loss of any life is devastating — the loss of a young life to a preventable sudden cardiac arrest event is tragic. ECG testing is relatively inexpensive and, based on the latest data, appears to provide higher diagnostic yield than history and physical exam alone — all while maintaining a very low false positive rate. Ultimately, EP physicians and EP-related allied health professionals must take the lead and insist that the AHA work to reform the outdated 2007 guidelines. While the AHA does admit, in its most recent opinion paper from 2012, that we must be open to novel approaches to preparticipation screening of athletes, they have not taken any new action on guideline reform. Instead, the AHA is advocating for more rigorous study and scientific investigation. I believe that the latest data published in the British Journal of Sports Medicine provides enough evidence on screening ECGs to immediately warrant a guideline update. As EP healthcare professionals, we must advocate for change in our local communities and increase awareness of the risks of sudden cardiac death in athletes. ECG screening is more cost effective than many other medical interventions that are routinely utilized in the U.S. today — the cost per year of life saved is $42,000 (as compared to $80,000 per year of life saved for hemodialysis).⁵

As we wait for changes in the AHA guidelines to ultimately be recommended, we must continue to lead the way in raising public awareness of sudden cardiac death and prevention. For now, we must ensure that CPR training is commonplace in our own local communities. We must advocate for more widespread CPR certification as well as educate local officials and school leaders. In addition, we must work diligently to have AEDs placed in all schools, athletic facilities, and practice fields, in order to provide the proper tools for a quick response to any arrest that occurs. It is my hope that routine ECG screening will be part of any preparticipation evaluation of young athletes within the next year. 

References

1. Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of sudden cardiac death in National Collegiate Athletic Association athletes. Circulation. 2011;123:1594-1600.
2. Maron BJ, Gohman TE, Aeppli D. Prevalence of sudden cardiac death during competitive sports activities in Minnesota high school athletes. J Am Coll Cardiol. 1998;32(7):1881-1884. 
3. Ferreira M1, Santos-Silva PR, de Abreu LC, et al. Sudden cardiac death athletes: a systematic review. Sports Med Arthrosc Rehabil Ther Technol. 2010;2:19. 
4. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA. 1996;276:199-204.
5. Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA. Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med. 2010;152:276-286.
6. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006;296:1593-1601.
7. Weiner RB, Hutter AM, Wang F, et al. Performance of the 2010 European Society of Cardiology criteria for ECG interpretation in athletes. Heart. 2011;97:1573-1577.
8. Toresdahl B, Pelto H, Fudge J, et al. Effectiveness of Cardiac Screening Inclusive of ECG in Young Athletes. Br J Sports Med. 2014;48:667.
9. Mahle WT, Sable CA, Matherne PG, et al. Key concepts in the evaluation of screening approaches for heart disease in children and adolescents: a science advisory from the American Heart Association. Circulation. 2012;125:2796-2801.