The effectiveness of screening history, physical exam, and ECG to detect potentially lethal cardiac disorders in athletes: A systematic review/meta-analysis
Introduction
The preparticipation examination (PPE) or periodic health examination (PHE) is the practice of regularly screening athletes prior to participation in sport. PPEs have been common place in the United States for over 50 years, in some countries such as Italy for decades, and in other countries like England PPEs are not required. Although there are many objectives to the PPE, it is widely agreed that the primary purpose of the PPE is to screen for potentially life-threatening disorders [1], [2], [3], [4], [5]. Cardiovascular pathology leading to sudden cardiac death (SCD) is the most common medical cause of death in athletes [6], [7], [8]. Therefore, a large portion of effort during the PPE is directed toward screening for cardiovascular disease. Screening has traditionally consisted of a history and physical examination although the utility of this approach has been questioned [9], [10]. More recently there has been interest in adding a resting 12-lead electrocardiogram (ECG) to the PPE to improve detection of conditions associated with SCD. ECG screening is supported by Italian data showing a 90% decrease in the rate of SCD with the inclusion of ECG as part of athlete screening [6], although other studies have questioned this result [11]. The debate regarding various screening strategies engenders passionate support on both sides. This paper examines the data related to preparticipation cardiovascular screening in athletes through a systematic review of existing studies. The sensitivity, specificity, and positive predictive value of history, physical exam and ECG in the individual studies are calculated and a meta-analysis of pooled data performed in an effort to better understand the value and limitations of these tests in order to guide rational evidence-based approaches for cardiovascular screening in athletes.
Section snippets
Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines were followed conducting and reporting this review.
Results
The literature search initially yielded 787 articles. 756 articles were immediately excluded. There were 31 articles that potentially met the inclusion criteria and these were downloaded for further review. Of those 31, 16 articles were excluded because the study screened only with ECG and did not screen with a cardiovascular history or physical exam [15], [16], [17], [18], [19], [20], [21], [22] the athletes were screened with ECG, history and physical exam but the statistics needed were not
Discussion
The data on cardiovascular screening in a diverse population of over 47,000 athletes around the world is summarized by this systematic review. Cardiovascular screening examinations prior to participation in sport have a long history with various countries, states, and sporting organizations recommending or requiring differing elements. Most notably, the European Society of Cardiology (ESC), International Olympic Committee (IOC), Federation Internationale de Football Association (FIFA), and
Strengths and limitations
The strengths of this review are that it combines data on the screening of 47,137 athletes with a measure of the quality of the studies and meta-analysis of pooled data. The findings reinforce the emerging body of literature supporting the effectiveness of ECG in screening for potentially lethal cardiac disease in athletes while also demonstrating the low relative of history and physical exam.
There were several limitations to this review. The meta-analysis did not have the level of data to
Conclusions
The purpose of this study was to perform a systematic review/meta-analysis of evidence comparing screening strategies. There were fifteen articles identified reporting on 47,137 athletes. The sensitivity of 12-lead ECG was much higher than both history and physical with similar sensitivity. In addition, the false positive rate of ECG (6%) was less than that of history (8%), or physical exam (10%). ECG had the highest positive likelihood ratios and lowest negative likelihood ratios. There were a
References (64)
- et al.
Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12–25 years of age): A scientific statement from the American Heart Association and the American College of Cardiology
J Am Coll Cardiol
(2014) - et al.
Reframing the debate: Screening athletes to prevent sudden cardiac death
Heart Rhythm
(2013) - et al.
Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death proven fact or wishful thinking?
J Am Coll Cardiol
(2011) - et al.
An empirical comparison of methods for meta-analysis of diagnostic accuracy showed hierarchical models are necessary
J Clin Epidemiol
(2008) - et al.
Significance of false negative electrocardiograms in preparticipation screening of athletes for hypertrophic cardiomyopathy
Am J Cardiol
(2012) - et al.
Usefulness of echocardiography in preparticipation screening of competitive athletes
Rev Esp Cardiol
(2014) - et al.
Feasibility and findings of large-scale electrocardiographic screening in young adults: Data from 32,561 subjects
Heart Rhythm
(2011) - et al.
Lessons learned from preparticipation cardiovascular screening in a state funded program
Am J Cardiol
(2012) - et al.
Usefulness of combined history, physical examination, electrocardiogram, and limited echocardiogram in screening adolescent athletes for risk for sudden cardiac death
Am J Cardiol
(2014) - et al.
Cardiovascular screening with electrocardiography and echocardiography in collegiate athletes
Am J Med
(2011)
Comparison of three ECG criteria for athlete pre-participation screening
J Electrocardiol
Innocent murmurs: A suspect diagnosis in non-pregnant adults
Am J Cardiol
Incidence and etiology of sports-related sudden cardiac death in Denmark — Implications for preparticipation screening
Heart Rhythm
Sudden death in the young
Heart Rhythm
Sudden death in young adults: An autopsy-based series of a population undergoing active surveillance
J Am Coll Cardiol
The standard electrocardiogram as a screening test for hypertrophic cardiomyopathy
Am J Cardiol
Does sports activity enhance the risk of sudden death in adolescents and young adults?
J Am Coll Cardiol
Pathology of sudden death during recreational sports in Spain
Forensic Sci Int
Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes
J Am Coll Cardiol
Preparticipation physical evaluation
Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: Proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology
Eur Heart J
The International Olympic Committee (IOC) Consensus Statement on periodic health evaluation of elite athletes March 2009
Br J Sports Med
Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: Endorsed by the American College of Cardiology Foundation
Circulation
Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program
JAMA
Incidence of sudden cardiac death in National Collegiate Athletic Association athletes
Circulation
Sudden deaths in young competitive athletes. Analysis of 1866 deaths in the United States, 1980–2006
Circulation
Contemporary approaches to the identification of athletes at risk for sudden cardiac death
Curr Opin Cardiol
Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association
Circulation
A unification of models for meta-analysis of diagnostic accuracy studies
Biostatistics
Prevalence of hypertrophic cardiomyopathy on an electrocardiogram-based pre-participation screening programme in a young male South-East Asian population: Results from the Singapore Armed Forces Electrocardiogram and Echocardiogram screening protocol
Europace
ECG and echocardiographic findings in 10–15-year-old elite athletes
Eur J Prev Cardiol
The health profile of football/soccer players in Northern Ireland — A review of the UEFA pre-participation medical screening procedure
BMC Sports Sci Med Rehabil
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