Electrocardiogram Screening as Part of the Preparticipation Examination: An Idea Whose Time Has Come?
Abstract
In the past several years, the use of electrocardiograms as part of the routine preparticipation physical examination has became a popular and controversial topic in the field of sports medicine. This article reviews some of the potential benefits of this strategy, as well as some of the confounding factors that may make implementation difficult.
Introduction
When an episode of sudden cardiac death (SCD) occurs in an athlete, it can be devastating for the family and community involved. The issue of SCD and effective screening for the anomalies most often associated with it has been a vexing problem to those who provide preparticipation examinations (PPEs) for athletes. Scant data confirm the overall usefulness of PPEs in preventing injury and death1,2; nevertheless, screening for SCD has still risen to the forefront as a result of both our desire as health care providers to actively prevent catastrophic outcomes in our athletes and the emotionally charged nature of this topic for the public.
Recently, the American Medical Society for Sports Medicine convened a special session, “Prevention of Sudden Cardiac Death in Athletes,” in conjunction with its 2009 annual meeting.3 The speakers challenged conventional thought about this issue and offered opinions both for and against various forms of screening. The most common cardiac test to be considered for application in mass screening is the electrocardiogram (EKG). Several countries and organizations, including the International Olympic Committee, mandate an EKG as part of the routine PPE. There are a number of studies, including one of the most well-known by Corrado at al,4 that show a decreased rate of SCD after the implementation of EKG screening. Although proponents of EKG screening cite the lower mortality rate as proof of its effectiveness, some qualifiers must be made. At the end of the Corrado et al,4 the rate of SCD in Italy was equivalent to the rate of SCD in the United States at the current time. The Veneto region of Italy, where this study was based, has a higher predominance of arrhythmogenic right ventricular dysplasia as compared with the United States, where hypertrophic cardiomyopathy is the most common etiology of SCD. A similar study performed in North America is needed to determine the effectiveness of such screening for our population.
Other forms of advanced cardiovascular screening could include the echocardiogram. The cost and limited availability of cardiologists to provide interpretation in all regions are barriers to implementing it as a screening measure. The continuing development of hand-held two-dimensional ultrasounds may lead to their use in PPEs in the future; however, a literature review revealed no studies using the tool for this purpose, and, again, cost may be prohibitive. There has also been some suggestion that enhanced history review (review of the American Heart Association screening questions) and provocative cardiovascular screening with Valsalva maneuver could also be beneficial.5 Other forms of testing could include coronary computerized tomography scan and cardiac magnetic resonance imaging. Given the limitations and lack of studies for these alternative screening methods, most attention has remained focused on the EKG as the potential tool of choice to prevent SCD in athletes.
Any form of evaluation must have adequate sensitivity and specificity to be useful in screening. There are certainly problems with the specificity of EKG as a mass screening tool, as many athletes, adolescents in particular, have EKG changes often considered abnormal in the general population but that are actually due to adaptations made by an athletic heart.6,7 In Italy, EKG interpretation criteria used in a mass screening of young athletes resulted in a reasonable rate of positives (4.8%) that required follow-up testing.8,9
To determine cost effectiveness, the true incidence of SCD in sports must be determined. This is fraught with difficulties because currently, there is no mandatory reporting mechanism for such occurrences. Instead, most quantitative attempts are estimated from mediums such as media reports. Until recently, the incidence of SCD was thought to be 1:200,000 athletes.10 However, this estimate has been challenged, with some studies approximating the incidence to be less than 1 per 20,000 athletes.11 The current attempt to form a national registry for SCD is a welcome development that should prove beneficial in determining a true incidence rate. Although there is no monetary value that can be placed on life, a more accurate incidence rate is needed to determine whether EKG screening in conjunction with PPEs is cost effective, because insurance companies will use this information to determine whether these services should be covered as part of a PPE.
Any discussion regarding costs must also address the overall estimated cost to provide such testing. A conservative estimate of the number of high school athletes in the United States each year is approximately 7,000,000. If each athlete was screened upon matriculation into high school, a rough estimate of approximately 1.75 million EKGs annually would result. Based on this number, the overall additional cost to the U.S. health care system would be an additional $70 million dollars per year, assuming that the estimated cost per test is $40. This estimate does not factor in further evaluation for those with positive findings that would trigger further testing. However, in most public health discussions, screening recommendations are often considered cost effective if implementation results in a cost of less than $50,000 per life-year saved. One study that examined the cost effectiveness of EKG as part of the PPE examination provides an estimated cost of $44,000 per life-year saved, even with further workup of approximately 10% of the study population.12 Once again, more studies and cost analyses would be helpful in determining the true cost of adding an EKG to the existing examination.
In conclusion, physicians involved in determining athletes' risk of participation would welcome any addition to the armamentarium for preventing SCD. Adding an EKG to a screening protocol has merit; however, it is reasonable to require that additional screening measures be thoroughly vetted with cost and outcome studies performed in the target population prior to widespread implementation, particularly in a society coping with pending health care reform and budgetary constraints.
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