Elsevier

Heart Rhythm

Volume 8, Issue 5, May 2011, Pages 721-727
Heart Rhythm

Clinical
General
Cost and yield of adding electrocardiography to history and physical in screening Division I intercollegiate athletes: A 5-year experience

Presented in part at the Heart Rhythm Society Annual Meeting, Denver, Colorado, May 14, 2010.
https://doi.org/10.1016/j.hrthm.2010.12.024Get rights and content

Background

Electrocardiographic screening of intercollegiate athletes is controversial because the costs and yield are not well defined. Both the American Heart Association (AHA) and the European Society of Cardiology (ESC) have different criteria for screening, partly because the populations being screened are different.

Objective

The purpose of this study was to determine the cost and yield of a 5-year ECG screening program at a United States Division I college.

Methods

At the University of Virginia, all 1,473 competitive athletes over the course of 5 years were screened with history and physical and with ECGs using ESC guidelines with follow-up testing as dictated by clinical symptoms and ECG findings.

Results

History and physical alone uncovered five significant cardiac abnormalities. ECGs were abnormal in 275 (19%), resulting in 359 additional tests. Additional testing confirmed eight significant cardiac abnormalities that were not found by history and physical: 1 bicuspid aortic valve, 4 rapidly conducting accessory pathways, 1 long QT patient, 1 with frequent premature ventricular contractions and low ejection fraction, and 1 with frequent premature ventricular contractions but normal ejection fraction. No cases of hypertrophic cardiomyopathy were found. Total cost of the program was US $894,870. Cost of history and physical screening alone was $343,725 or $68,745 per finding. The marginal cost of adding ECG screening, including resulting tests and procedures. was US$551,145 or US$68,893 per additional finding.

Conclusion

ECG screening of U.S. college athletes can uncover significant cardiac pathology not discovered by history and physical alone. Although ECG screening also results in many false positives resulting in additional tests, the overall cost per diagnosis of adding ECG screening is similar to that of history and physical screening alone.

Introduction

Preparticipation athletic screening with electrocardiograms (ECGs) is controversial. Whereas European Society of Cardiology (ESC) guidelines1 recommend preparticipation ECGs in addition to history and physical in all competitive athletes younger than 35 years, the American Heart Association (AHA)2, 3 in the United States recommends only history and physical without ECG. The rationale for these two recommendations rests on disparate findings regarding cost and yield. One potential reason for this is that the United States is more ethnically diverse and thus may have a different prevalence of any given genetic condition. For example, in Italy, the incidence of arrhythmogenic right ventricular cardiomyopathy (ARVC) appears to be higher than in the United States.4 The U.S. population has grown more diverse, and few data from the modern era are available on the cost and yield of ECG screening in a U.S. college population. The few studies that exist include fewer than 600 patients.5 At the University of Virginia, we have performed ECG screening in all 1,473 competitive athletes since 2005. We report the yield and cost of an ECG screening program in addition to history and physical in a National Collegiate Athletic Association Division I college athlete population, the most elite of the U.S. college athlete divisions.

Section snippets

Methods

From 2005 to 2010, all 1,473 National Collegiate Athletic Association Division I athletes regardless of sport underwent screening with history and physical and with ECG. The screening was a requirement that was disclosed to athletes and their parents prior to the athletes accepting an athletic position at the University of Virginia. The history and physical was performed by a team of physicians, including two internists with input from a cardiologist. Tests including echocardiograms were

Athlete demographics

Demographic information of athletes screened is given in Table 1. Of the athletes, 741 (51%) were women. Racial distribution was white (71%), African-American (12.9%), Asian (2%), and Latino (2%.) Ninety percent had no prior medical conditions, and 978 (66%) were taking no prescription medicines. Thirty athletes were taking medications (including Adderall) for attention deficit hyperactivity disorder.

Two athletes had undergone ablation procedures in the past, both for symptomatic accessory

Discussion

In a 5-year experience, we demonstrated that adding ECGs to an athletic screening program discovers significant pathology in Division I college athletes at a cost per significant cardiac finding that is similar to that of history and physical alone. Although adding ECG to history and physical did increase the cost, the yield increased proportionately. Thus, the overall program cost per diagnosis was similar to the cost per diagnosis for history and physical or ECG screening alone. This

Conclusion

ECG screening of elite collegiate athletes increased the cost of screening due to false-positive ECGs but identified 8 cardiac abnormalities, 6 of which required intervention and 2 of which required discontinuation of athletic participation. The cost per diagnosis suggested by history and physical alone was similar to the cost per diagnosis identified by ECG.

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