Tuesday, April 23, 2013
ECG Worthwhile for Pre-Sports Check-Up By Crystal Phend, Senior Staff Writer, MedPage Today Published: April 23, 2013 Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania Action Points Note that these studies were published as abstracts and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal. There is controversy concerning the most effective screening strategy for youngsters participating in sports. The European Society of Cardiology advocates the use of the 12-lead ECG, while the American Heart Association does not, placing emphasis on symptoms. In one study reported here, a pre-sports participation exam that included a 12-lead ECG turned up group 2 findings in less than 8% of young people, a small fraction of whom had pathology confirmed on further work-up. Another study found a larger percentage of electrocardiographic abnormalities in a population of apparently healthy young people. ROME -- Screening students before participation in sports with an electrocardiogram to pick up potentially deadly cardiac problems is worthwhile, two European studies argued. A pre-sports participation exam that included a 12-lead ECG turned up group 2 findings in 7.8% of young people, 0.44% of whom had pathology confirmed on further work-up, Jakir Ullah, MD, of St. George's University of London, and colleagues found. Self-reported symptoms weren't useful, as 40% reported them but none turned out related to cardiac pathology, the group reported here at the European Association for Cardiovascular Prevention and Rehabilitation's EuroPRevent meeting. "If you're going to do it for the reason of detecting cardiac pathology, then you really need to be exhaustive," Ullah told MedPage Today. "Not including the ECG, you on the one hand end up investigating too many people based on symptoms and possibly missing people who don't have symptoms but do have ECG changes." A separate study screening all Italian teens rather than just those going out for sports found a 21% rate of pathological ECG, Maria Chiara Gatto, MD, of "La Sapienza" University of Rome, and colleagues reported at the meeting as well. "It's important to perform an ECG not only in young competitive athletes but also in noncompetitive athletes and nonathletes as there is a high prevalence of ECG abnormalities in the young general population," Gatto's group concluded. The European Society of Cardiology advocates for use of a 12-lead ECG for pre-participation screening; whereas the American Heart Association recommends taking a history and physical examination without the ECG. Ullah's study included screening of 15,027 individuals ages 14 to 35 over a 5-year period, using a health questionnaire to collect symptoms and family history, a 12-lead ECG, and consultation with a cardiologist. The most common symptoms reported were chest pain and pre-syncope at around 16% each. Syncope, palpitations, and dyspnea were reported by 8% to 10%. However, 96% of these individuals with reported symptoms had a normal ECG. The rest were cleared either by the cardiologist at the initial session or after a referral for 0.6%. The overall false positive rate was 36% for symptoms but 7.4% with group 2 ECG findings on screening. The positive predictive value of symptoms was 0% and 4% for group 2 ECG findings. "If pre-participation screening is advocated, it must include a 12-lead ECG," Ullah argued. The individuals who did turn out to have pathology included four cases of Brugada syndrome, 29 cases of Wolf-Parkinson-White, one case of hypertrophic cardiomyopathy, three cases of arrhythmogenic right ventricular cardiomyopathy, eight cases of long QT interval, and other congenital defects in 22 cases. In Gatto's study, all high school students (ages 16 to 20) were screened with an ECG done by volunteer physicians and transmitted to a reading center. The 27% with "almost normal" ECGs included mostly right ventricular conduction delay, as well as some early repolarization, left or right axis deviation, sinus tachycardia, and sinus bradycardia. The pathological ECGs included: 2.09% suspected Brugada syndrome 3.25% supraventricular arrhythmias 1.08% ventricular arrhythmias 0.91% AV block 4.50% fascicular block 1.55% right or left complete bundle branch block 3.69% pre-excitation 0.98% atrial enlargement 0.61% long or short QT intervals 4.50% abnormal ventricular repolarization 0.47% left ventricular hypertrophy Less than 0.2% junctional rhythm Less than 0.3% coronary sinus rhythm Gatto suggested a national program of screening to reduce sudden cardiac deaths among young people and proposed that the volunteer physician program made it cost-effective. A national screening program in the U.S. has been projected to cost upwards of $10.6 million per life saved, with a tab of at least $52 billion over a 20-year period to save about 4,800 lives. Most groups have called it too expensive for the potential benefit, although some say it is getting less expensive as ECG machine prices drop. The cost of the screening itself isn't the only challenge, as the significant false positive rate contributes to anxiety and costs as well, Hugo Saner, MD, of the University of Bern, Switzerland, commented in an interview. One reason for the substantially high rate of pathology found in the Italian cohort may have been because of particular characteristics of the population there that would limit generalizability, added Sidney Smith, MD, a past president of the American Heart Association and the World Heart Federation. "Previous studies showing benefit [of a 12-lead screening] have been primarily from northern Italy where there is a high prevalence of genetic abnormalities that can lead to death," he cautioned.