By: Dr. Geoffrey Modest
The American Heart Association and American College of Cardiology (and endorsed by American College of Sports Medicine) published guidelines on EKG screening in healthy 12-25 year olds (see DOI: 10.1161/CIR.0000000000000025 ). Most of the data are from studies on screening young people in competitive athletic programs, with the goal to decrease sudden death, a rare but clearly bad outcome. There is a significant difference in the different recommendations: the European Society of Cardiol has recommended national EKG screening initiatives of athletes based on studies there (positive in Italian study, though not replicated in an Israeli one), but the AHA has consistently been against them (prior blogs have detailed the reasons, including the fact that the most common cause of athlete-associated sudden death in Veneto Italy, the site of the most positive intervention study, is from a specific genetic condition causing arrhythmogenic right ventricular cardiomyopathy/dysplasia, which is very uncommon in the US).
The AHA recommends the following preparticipation screen for all competitive athletes, defined as “those who participate in an organized team or individual sport that requires regular competition against others as a central component, places a high premium on excellence and achievement, and requires some form of systematic (and usually intense) training”. the 14-element checklist is:
- Medical history
- Personal history (especially with parental verification)
- chest pain/discomfort//tightness/pressure related to exertion
- unexplained syncope/near syncope (not including neurocardiogenic/vasovagal)
- excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
- prior recognition of a heart murmur
- elevated systemic blood pressure
- prior restriction from participation in sports
- prior testing for the heart, ordered by a physician
- Family history
- premature death (sudden and unexpected, or otherwise) before 50 years of age, attributable to heart disease in >= 1 relative 9. disability from heart disease in close relative <50 yo 10. hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arryhthmias; specific knowledge of genetic cardiac conditions in family members
- Physical exam
11. heart murmur (only if felt to be organic, not innocent murmur. auscultate in supine and standing positions — or with valsalva — to identify murmurs of dynamic left ventricular outflow tract obstruction)
12. femoral pulses to exclude aortic coarctation
13. physical stigmata of Marfan syndrome
14. brachial artery blood pressure (sitting position), preferably taken in both arms
- the formal recommendations of the AHA group are, for people aged 12-25:
–do the 14-point screen above to detect genetic/congenital and other cardiovasc diseases for preparticipation for sports
–consider EKG in those with suspicion of cardiac abnormality by questionnaire (not just in athletes);
–not do routine EKG (whether athlete or not)
–not recommended to do above questionnaire for general population
Some of the rationale for not doing EKGs are: sudden death seems to be more common in athletes, but is clearly not limited to them (ie, where do we draw the line on whom to do EKGs); the frequency of sudden death is very low (eg, for individuals<25 yo, number of deaths in the US/year: car accidents 11K, homicides 6K, suicide 4K, cancer 2K, major cardiovasc disease 1K, US athletes from cardiovascular causes 76, lightning strikes 25, NCAA athletes from cardiovasc causes 9); interpretation of the EKG can be difficult, esp in athletes, with many false positives; in studies comparing EKG with echo, EKG misses about 1/2 of concerning cardiac conditions (echo is much more sensitive for the most common cause of sudden death in the US, hypertrophic cardiomyopathy — HCM. EKG is needed for the less common causes of arrhythmias, WPW); and EKG testing, with attendant echo/MRI if questionable EKG, is really expensive even if applied only to athletes — for example, a screening study in Texas with a $1M grant, only 2350 school children could be screened, finding 1 new patient with HCM and 9 with mitral valve prolapse, and the Center for Medicare and Medicaid Services estimate the cost of $2B for a full US testing program/year. Pretty much everyone agrees that we should be doing routine history/fam hx/physical evaluation as above, and that it should be done in a systematic way.It should be pointed out however that there are very limited data to support this. One retrospective study of competitive athletes who died after screening with a standard history and physical found <5% had a confirmed cardiac diagnosis during life. Personal/family history is also pretty inaccurate (for example, there was a 17% discordance in the Framingham Study between the recorded family history and the known history of heart disease, other studies have found even higher discordance, in the 30-40% range), and this consideration is used by some to do more aggressive screening, eg by EKG. The questionnaire above is also problematic, for example, in relying on the often difficult and inconsistent determination of whether a murmur is innocent or not, or what constitutes a positive/concerning answer about chest pain (which, in my experience, is really common in adolescents).
So, what is one to do??? I must admit that I have been encouraging EKG testing as part of preparticipation evaluation, given the horribleness of missing a kid with hypertrophic cardiomyopathy. Sudden death is obviously a rare event but we have had a few of kids who have died in Boston over the past several years while playing sports, attributable to HCM. Any study showing benefit overall would have to be really huge, given the low incidence of potentially dangerous cardiac conditions, though the above Texas study of finding 1 kid in 2350 with HCM is probably a pretty good outcome (however, it is not clear what % of kids found with HCM on screening would actually die if they participated in sports). The Israeli study (the other big one) did not find benefit of aggressive screening in those participating in organized sports activities, but this was in comparing the 12-year period before screening with the 12-year period after (and if compared to the 2-year period before, as done in the Veneto study, there would have been documented benefit of screening). Another (unmentioned issue) is that finding a potential problem on more aggressive screening with EKGs has the strong negative effect of restricting exercise in kids (and then as they become adults) without clear evidence of benefit and with documented adverse effects from not doing exercise. So, unlike in all my other blog posts, I really don’t know what is right in the absence of a very large randomized controlled trial. My tendency, given the huge uncertainty, is tepidly and unenthusiastically to follow the recommendations…..