Preparticipation Electrocardiogram Screening for School Athletes

Pre-participation electrocardiogram (ECG) screening for athletes can be useful in discovering various cardiac conditions, albeit with certain limitations. Despite its effectiveness in decreasing sports-related sudden cardiac arrest in certain settings, it continues to be somewhat controversial.

Purpose

The purpose of pre-participation ECG screenings is to increase efficacy and power of the pre-participation screening process, in order to decrease the incidence of sudden cardiac arrest. The pre-participation history and physical examination are considered the primary screening tool. Sensitivity and specificity are considered to be low, leading to the recommendation of screening ECG, which can significantly improve sensitivity and specificity of the screening.

Considerations

Pre-participation screening of athletes can be a very reasonable approach to identify people at risk of sports related cardiac arrest and to potentially prevent death. However, there are a few aspects to be considered:

1. No guarantees

There is no assurance that ECG screening prevents sudden cardiac deaths in all student athletes. Many reports have been published from Italy since the introduction of nationwide ECG screening for athletes in 1982. Several showed reduction of sports related sudden cardiac death with ECG screening.

However, the reason ECG screening works well in Italy may be due to the relatively high prevalence of inherited cardiac disorders in the country. In other areas of the world, where inherited cardiac disorders are not as prevalent, the effect of the pre-participation ECG screening in reducing sudden cardiac arrest might not be as substantial.

We also need to realize that many cardiac disorders, inherited or not, may have a normal baseline ECG. Therefore, the diseases may not be identified by the screening.

2. Possible false alarms 

A pre-participation ECG screening may lead to false alarms. It will identify cardiac abnormalities: some of these findings are going to be serious and some are not going to have an important clinical impact. When an unusual finding is found on the screening ECG, this will result in additional testing along with a cardiologist consultation.

Even though additional testing results may be reassuring, there are significant additional healthcare costs that need to be addressed. Additionally, there may be findings “in the gray area” which could not be classified as reassuring, versus concerning. These typically require long-term follow-up with additional testing.

3. Not all student athlete cardiac arrests are sports related

Conditions like Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT), Long QT Syndrome (certain types) have clear associations between physical activity and triggered arrhythmias leading to cardiac arrest.

Also the disease process in conditions such as Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) may progress and worsen with continued strenuous physical activity. This may lead to decline in the heart function and lead to arrhythmias.

The link between physical activity and sudden cardiac arrest is not clearly defined for conditions like Brugada Syndrome and certain types of Long QT Syndrome, which may be picked up by the ECG screening.

4. The importance of resuscitation (Automatic External Defibrillator use and Cardiopulmonary Resuscitation)

Although it is under-emphasized, resuscitation training, (for everyone involved in athletic activities: coaches, trainers, athletes themselves,) will save lives. Even though pre-participation ECG screenings detect many known cardiac conditions in athletes, there will still be sudden deaths. Some we may identify the reason; some we may not. Appropriate and timely resuscitation is key to survival for a person who has suffered sudden cardiac arrest. It is invaluable for this reason.

Who should be screened?

• Family history of sudden or unexpected death, including infant deaths and miscarriages. 
• Personal or family history of heart disease.
• Symptoms that could be cardiac, such as, fainting/near-fainting (particularly during exercise), chest pain/discomfort during exercise, palpitations.

Any student athlete with this history or series of symptoms should be screened with an ECG.