Comparison of three ECG criteria for athlete pre-participation screening
Introduction
Sudden cardiac death (SCD) in young athletes is rare, tragic, and generates significant community attention and debate. Best estimates for the risk of SCD in young athletes range from 0.24 to 2.6 SCDs per 100,000 athlete years, or one death every three days [1], [2], [3], [4]. Young male athletes are at greatest risk for SCD, but overall, both male and female athletes' risks for SCD are nearly twice that of their nonathletic counterparts [5], [6]. Common causes of SCD in young athletes are shown in Table 1 [7].
Mandatory screening to identify young athletes at risk for SCD was first introduced in Italy in 1982. Remarkably over the proceeding thirty year period, the risk for SCD has fallen by approximately 90% [5]. Though not mandatory in the U.S., the American Heart Association (AHA) in 1996 and again in 2012 [8], recommended pre-participation screenings for young athletes [9]. The screening recommendations consist of a 12-question medical history and physical exam (Table 2) [10]. The total cost of adopting pre-participation screening nationwide has been estimated to be upwards of $750 million per year [10].
Following the recommendations by the AHA, pre-participation screenings have become more common. However debate surrounds whether or not it is beneficial to add an electrocardiogram (ECG) to routine screening. Currently the AHA does not recommend the inclusion of a mandatory ECG to pre-participation screening, largely due to the high rate of false positive findings. Instead, the AHA reserves the use of an ECG to follow-up investigations of athletes who initially tested positive on the AHA 12-point exam [8], [11].
Others argue that the ECG should be added to pre-participation screening routinely, as it is a relatively inexpensive non-invasive test that may uncover subclinical pre-existing cardiac disease. Recently the New England Journal of Medicine polled physicians on their attitudes toward pre-screening [12]. Of the respondents (n = 1266), 18% thought screenings should not be required, 23% believed screenings should be required and involve a history and physical exam, and the majority (58%) thought that not only should it be required, but consist of a history and physical exam, as well as an ECG [13]. Although an ECG is included in the Italian pre-screening assessment, it is feared that the addition of an ECG to U.S. screenings will result in an unacceptably high number of false positive exams and an abundance of unnecessary cardiovascular investigations, resulting in exorbitant costs [7]. Cost projections for the addition of an ECG to pre-participation screenings vary widely, with estimates ranging from $68,893 per diagnosis [14], or between $21,200 to $71,300 [15] and up to $1,320,000 per life saved [16], at a total cost of nearly $2 billion each year [10].
As the debate regarding the utility of adding the ECG to pre-participation screenings continues, the European Society for Cardiology has released criteria to aid clinicians in interpreting the ECGs of young athletes [17]. In 2011 a Stanford led coalition revised these criteria [18], and more recently in 2013 these were further revised with the release of the ‘Seattle’ criteria [19]. The new Seattle criterion improves specificity over other criteria, by attempting to distinguish between normal and abnormal training-related variations in the ECG. Normal ECG variants are those that represent electrical or structural remodeling as a consequence of regular or sustained exercise [20], while abnormal ECG variants are those that are unrelated to regular training or expected physiological adaptation to exercise and may suggest underlying pathological cardiovascular disease [19]. To date few studies have directly compared the performance of these three interpretation criteria. In this study we applied the three ECG interpretation criteria to a diverse young athlete cohort, to determine the best criteria for clinical use. The ideal criteria would be one that produces the least number of false positives, minimizing the costs associated with unnecessary follow-up with clinical investigations, and maintaining acceptable sensitivity for detecting disorders associated with sudden cardiac death.
Section snippets
Study population
We analyzed standard ECGs from 1417 U.S. athletes obtained as part of their pre-participation health screening. Testing was completed between March 2011 and February 2013. Subjects were drawn from three distinct cohorts: high school (HS) (n = 307), collegiate (Col) (n = 826), and professional athletes (Pro) (n = 284). The majority of athletes participated in football, crew/rowing, or basketball (Table 3); a sport was not listed by 244 of the athletes. All athletes received complete assessment and
Sample
Overall 1417 athletes were evaluated. Men were over represented in all cohorts (Table 5). The majority of athletes were white (62%). Racial composition was 21% black, 10% Asian, 4% Hispanic, 1% Pacific Islander, 0.5% Native American, and 1% ‘other’. Mean age was 20 years ± 4 (range 14–35 years) and varies appropriately across cohorts (HS 16 years ± 1, Col 19 years ± 1, Pro 27 years ± 5, p < .0005).
Heart rate
Mean heart rate significantly decreased as cohort's age: HS = 69 ± 13 bpm, Col = 63 ± 11 bpm, Pro = 60 ± 10 bpm (F = 13.6, df = 2, p <
Discussion
In our study, athletes were free from any cardiovascular disease precluding participation in sports. One athlete was found to have an accessory pathway that did not require treatment. When assessing the utility of the ECG to detect pre-existing cardiovascular disease indicating a risk of SCD, we find a large number of abnormal ECG variants using the European criterion (n = 371, 26%). The Stanford criterion reduced the number of identified abnormalities by approximately one-third of those
Limitation
A key limitation to this study is the lack of clinical outcome data. Similar to all studies to date evaluating athlete pre-participation screenings, the very low prevalence of cardiac disorders and the rarity of SCD in this population result in an inability to test whether criteria are sensitive to detect underlying cardiovascular disease. Due to our relative small sample size and lack of follow-up data, we are unable to evaluate for changes in sensitivity among the criteria.
Conclusion
This study determines that the Seattle criterion for athlete ECG interpretation results in the lowest rate of abnormal variants. Compared to the European criterion, the Seattle criterion reduces the need for secondary investigation and follow-up by 78%. The majority of this variation is due to criterion-specific differences in identifying intraventicular conduction delay, QTc prolongation, and short QT interval. Continued research is needed to further understand normal training related
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