Clinical Journal of Sport Medicine:
Is Electrocardiogram Screening of North American Athletes Now Warranted?
Shephard, Roy J MD, PhD
From the Faculty of Physical Education & Health, University of Toronto, Toronto, Ontario, Canada.
Submitted for publication November 12, 2010; accepted March 15, 2011.
The author reports no conflicts of interest.
Corresponding Author: Roy J. Shephard, MD, PhD, PO Box 521, 41390 Dryden Rd, Brackendale, BC V0N 1H0, Canada (firstname.lastname@example.org).
Some confusion may have been created by a recent suggestion that both the American Heart Association (AHA) and the European Society of Cardiology call for cardiovascular screening of athletes to prevent sudden exercise-induced death.1 In fact, there remains a sharp continental divide on the issue of mandatory electrocardiogram (ECG) screening. With the support of the European College of Cardiology,2 Italian investigators have long argued for such screening. Medical certification became a condition of participation for Italian athletes, both amateur and professional, beginning in 1950.3,4 Since 1982, more than 5 million Italian competitors aged 12 to 35 years have theoretically undergone an assessment that includes an annual clinical examination, a 12-lead resting ECG, a simple bench-type stress test, and basic spirometry5 (although it is less clear how complete screening has been de facto4). National ECG screening has also been introduced for children and young adults in Japan.6 There have been occasional suggestions of adopting a similar plan in North America,7 but in general, support has continued for the AHA policy of avoiding ECG screening, except for those failing an initial 12-point physical examination.8-11 This commentary weighs several pieces of recent evidence advanced in support of mandatory ECG screening,12 relevant information surrounding an apparent recent reduction in sudden cardiac arrests among Italian athletes after the introduction of ECG screening protocols,13 a direct comparison of clinical evaluation against clinical plus ECG testing as a means of detecting cardiac abnormalities,14 and calculations of cost-effectiveness for the ECG testing of athletes.15
The claim that mandatory ECG screening reduces the incidence of sudden cardiac death (SCD) in athletes is based on a study of some 20 000 athletes aged 12 to 35 years living in the Veneto region of Italy.13 Between 1979 and 2004, a total of 50 male and 5 female SCDs were reported in this population. A trend analysis suggested a statistically significant decline of SCD incidents from 3.5 to 4.0 per 100 000 in 1979 to 1982 to 0.4 per 100 000 between 2001 and 2004; however, in nonathletes, the rate remained relatively consistent at 0.9 per 100 000 over the same period. The decrease in SCD among the athletes was attributed mainly to a reduced incidence of right ventricular arrhythmic cardiomyopathies. There have been a number of criticisms of these data. Although for most sports physicians, the avowed objective of mandatory testing is to avoid exercise-induced deaths, the Italian incidents were not necessarily exercise related. Further, there was no comparison of screened versus nonscreened athletes. Rather, the initial SCD incidence was compared with subsequent findings for the same population. However, the initial rate (3.5 to 4.0 per 100 000 per year) was very high; thus, the final figure for Italian competitors (after 10 years of screening) remains similar to that in North America (where ECG screening of athletes is not a routine practice). Little information is provided about the type of athlete or the level of competition in the Italian study. The group was “competitive” but apparently included about 15% of the regional population in the age category of 12 to 35 years. If we are to attribute the secular trend of SCDs to mandatory ECG screening, it also remains puzzling why rates remained high for 5 years after introduction of the new policy, from 1982 to 1987. Perhaps, the most alarming aspect of the report from the patient's viewpoint is that 9% of all athletes required further diagnostic testing, and even after completion of additional tests, 2% were excluded from further sport.
Baggish et al14 recently attempted a direct comparison of the efficacy of a history and physical examination alone against a combination of such data with 12-lead resting ECG records obtained on the same subject as a means of detecting “dangerous” cardiac anomalies. Given that such anomalies are rare in athletes, their sample was rather small (510 unselected US college athletes, presumably men, although this is not specified in their article). The outcome of such a comparison necessarily depends on the respective skills of the clinician and the quality of ECG interpretation. Baggish et al14 indicate that the clinical examination was conducted by noncardiologists from the University Health Service; individuals other than dedicated sports physicians made evaluations lasting an average of 8 minutes. The ECG records were analyzed using European College of Cardiology standards of normality, which are based on healthy members of the general population rather than athletes. Finally, the “gold standard” adopted to compare the 2 diagnostic approaches was not the subsequent incidence of SCD, but rather a cross-sectional comparison of findings with reports of suggestive or diagnostic abnormalities as seen during “limited” echocardiographic imaging. This forms the basis for a claim that 11 individuals with dangerous abnormalities were detected after ECG testing, as against only 5 athletes identified by history and physical examination alone. It seems inherently unlikely that 11 of 510 unselected college athletes were at imminent risk of exercise-induced SCD death; most estimates (including the data of Corriado et al,13 as discussed above) put the annual risk at 0.5 to 1.0 incidents per 100 000 athletes. Moreover, only 3 of the 11 athletes identified by Baggish et al14 were asked to restrict their sport participation, and in my view, it seems excessive to have excluded even 3 of 510 ostensibly healthy athletes from subsequent sport. We are given no information to judge whether this restriction of physical activity might lengthen or shorten the individual's subsequent overall or quality-adjusted life span.
The high cost of mandatory ECG screening has been an important criticism of the practice,11 whether this expense is borne by the individual (as in the United States) or by state health services (as in many other countries). Although some reports16,17 have suggested that the ECG screening of athletes can be cost effective, the AHA set the likely cost at $2 billion per year in the United States alone,8 with an expenditure of some $330 000 needed to complete the examination of each athlete suspected of having cardiovascular disease. Wheeler et al15 recently estimated the cost-effectiveness of adding resting ECG screening to a clinical examination. Their costs were drawn from 2004 figures of the US National Center for Health Statistics, but their estimate of effectiveness was based on the somewhat puzzling apparent decrease of mortality among Italian athletes after the introduction of mandatory ECG screening.13 Their calculations suggested that the added expense of ECG screening added 1 life-year for an expenditure of US $42 900. At the first inspection, this figure seems in the range ($20 000-$100 000) that might be regarded as a worthwhile preventive expenditure. However, the cost estimate of Wheeler et al15 is based on a single ECG evaluation, whereas the Italian evidence of apparent benefit is based on annual screening, a change that would boost expenditures by a factor of 10 to 20. Moreover, as the Italian data itself shows ECG screening inevitably creates a large volume of false-positive diagnoses, and the accounting of Wheeler et al13 did not examine either the direct costs arising from unnecessary restrictions of physical activity and a resulting deterioration in health or the less direct impact of further testing and prohibition of exercise upon the well-being and productivity of both those individuals wrongly identified as at increased risk and their next of kin.
Some 40 years ago, Wilson and Jungner specified 10 criteria needed for the efficacy of any screening procedure.12 Despite some refinements, these criteria remain widely accepted by both epidemiologists and the World Health Organization. In the context of ECG screening, the success of any such program requires that there be a substantial disease prevalence and an appropriate level of sensitivity and specificity in the proposed test procedure. Even if the apparently weak claims of a reduction in SCD,13 diagnostic efficacy,14 and an appropriate cost-benefit ratio15 were to be substantiated, the fundamental barriers to effective ECG screening remain unaddressed.18 Sudden exercise-induced death in young athletes is an extremely rare event and attempts to detect those individuals at risk using a resting ECG face severe problems from a limited test sensitivity and specificity. We may conclude that on current evidence, North American practice8 is more appropriate than the policies presently advocated in many European countries.2
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