Should ECG Screening Be Routine for All Athletes?

Should ECG Screening Be Routine for All Athletes?

Mass Screening Reduces Overall Costs

By Wayne Kuznar

Stockholm—Every young athlete involved in an organized sport should undergo a rigorous physical examination including a 12-lead electrocardiogram (ECG) to uncover potential silent cardiovascular disease that can lead to sudden death, said Domenico Corrado, MD, of the division of cardiology at the University of Padua, Italy, at the 2005 Annual Meeting of the European Society of Cardiology.

Although many in the United States consider the cost of routine ECG screening to be prohibitive, the limited cost of 12-lead ECG screening can make mass screening of athletes feasible, said Dr Corrado. “In Italy, it is compulsory to pass screening to participate,” he said.

The impetus behind the mass screening in Italy is a recent study by Dr Corrado and colleagues (J Am Coll Cardiol. 2003;42:1959-1963) showing that the relative risk of sudden death in athletes is 2.5 times higher than in nonathletes. The study also identified male gender as an important predictor of sports-related sudden cardiac death.

The 25 years of experience with the Italian screening method have shown it to be more sensitive than the limited protocol used in the United States (ie, physical examination, personal and family history, and 12-lead ECG at the physician’s discretion).

The ECG is abnormal in up to 95% of patients with hypertrophic cardiomyopathy, which is the leading cause of sudden death in athletes.

The advanced Italian screening protocol identified hypertrophic cardiomyopathy in 0.7% of screenees, all of whom were disqualified from competing in organized sports. Importantly, among those identified with hypertrophic cardiomyopathy, none died during follow-up. “The ECG is as sensitive as echocardiography in screening for hypertrophic cardiomyopathy,” said Dr Corrado.

Comparisons of findings from Italy and the United States show a similar prevalence of hypertrophic cardiomyopathy in nonsport-related sudden cardiac death, but a significant difference—2% versus 24%—in sports-related cardiovascular events, which suggests that “we have selectively reduced sports-related sudden death from hypertrophic cardiomyopathy, because the Italian system, using ECG, identifies vulnerable young people,” he said.

Using a 12-lead ECG yields a lower cost per life-year saved compared with using a history and physical examination, he explained. “Mass screening reduces the cost,” he said. “We suggest to perform screening at least every 2 years beginning at age 12 to 14 or when beginning a competitive activity.”

For patients with existing coronary artery disease who wish to engage in sports, an appropriate evaluation consists of a determination of left ventricular systolic function, an exercise ECG to detect exercise-induced myocardial ischemia and ventricular arrhythmias, and perhaps a measure of exercise capacity, said Jean-Paul Schmid, MD, of the Swiss Cardiovascular Center, Bern, Switzerland.

Patients at risk for exertion-related complications are those with a relatively well-preserved exercise capacity that allows them to perform vigorous exercise, those with significant ischemia during exercise testing, and those who frequently violate the target heart rate limit during exercise testing. Most deaths occur in individuals who exercise infrequently or have only recently begun to exercise, Dr Schmid said.

Mildly increased risk is considered to be preserved left ventricular systolic function (ejection fraction >50%), normal exercise tolerance for age (demonstrated during treadmill or cycle ergometer exercise testing), absence of exercise-induced myocardial ischemia or complex ventricular arrhythmias, absence of hemodynamically significant stenosis in any major coronary artery, and having undergone successful myocardial revascularization.

Persons with an ejection fraction <50%, exercise-induced ischemia or complex ventricular arrhythmias, and hemodynamically significant stenosis of a major coronary artery are considered to be at substantially increased risk.

Athletes who are at mildly increased risk can participate in low-dynamic and low/moderate static competitive sports but should avoid intensely competitive situations. Those at substantially increased risk should be restricted to low-intensity competitive sports (ie, golf, cricket).