, et al
Cardiovascular screening in college athletes with and without electrocardiography: a cross-sectional study
Ann Intern Med

Investigators from Massachusetts General Hospital and Harvard conducted a prospective cross-sectional study to determine whether adding 12-lead electrocardiographic (ECG) testing to the traditional sports pre-participation history and physical examination improves screening performance.

Between 2006 and 2008, incoming student athletes aged 18 years and older at Harvard University were enrolled in the study. Study participants received both a standard history and physical examination, and additionally received both a resting ECG and transthoracic echocardiography (TTE). Based on TTE results, participants were characterized as normal, mildly abnormal, or suggestive or diagnostic of cardiac disease.

A total of 510 participants, mean age of 19 years and 61% male, were evaluated. Based on the TTE results 110 (22%) had mildly abnormal findings consistent with physiologic remodeling (eg, mild left ventricular hypertrophy) and 11 (2%) had concerning cardiac findings. Three of these 11 athletes met criteria for sports restriction (one each with pulmonic valve stenosis, hypertrophic cardiomyopathy, and myocarditis). Screening with history and examination alone detected abnormalities in 5 of 11 participants with cardiac abnormalities (sensitivity, 45.5%) and 1 of 3 for whom restriction was indicated. ECG detected 10 of 11 (sensitivity 90.9%) and all three with restriction. However, including ECG reduced the specificity of screening from 94% for history and physical only to 82.7% and was associated with a false positive rate of 16.9% (vs 5.5% for screening with history and physical only).

The authors conclude that compared to history and physical examination alone, the addition of ECG testing increased sensitivity and negative predictive value at the expense of decreased specificity and positive predictive value.

The combination of ECG testing and standard pre-participation history and physical examination is better at identifying athletes with cardiac disease than history and physical alone. Whether ECG screening should become part of the pre-participation sports physical remains controversial. Similar to previous reports (see AAP Grand Rounds, June 2008;19:63–64 1), routine history and physical examination failed to detect more than half of the screened athletes with serious cardiovascular disease. The ECG-integrated approach, however, did identify all of the three participants with TTE-identified cardiac abnormalities that met criteria for restriction – but at what cost? Once again, the positive predictive value was quite low – bringing into question the effectiveness of the ECG as a screening tool.

Confusing the matter further are the opposing recommendations from various professional organizations. The European Society of Cardiology and International Olympic Committee recommend use of ECG for screening, while the American Heart Association does not “believe it to be either prudent or practical to recommend the routine use of tests such as 12-lead ECG or echocardiography in the context of mass, universal screening.”2 

Despite the demonstrated low yield of history and examination, the overall risk of reported sudden death is also...

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