Background The primary objective of pre-participation screening in athletes is the detection of potentially lethal cardiac conditions. The American Heart Association (AHA) recommends a directed history and physical examination. The added value of electrocardiogram (ECG) screening is debated⇓.

Objective To determine the effectiveness of different cardiac screening strategies in young competitive athletes.

Setting Heart screening events in U.S. high schools from October 2010 through June 2013.

Patients Competitive athletes ages 13-19.

Interventions Heart health questionnaire and physical examination based on AHA recommendations, resting 12-lead ECG, and echocardiogram if indicated.

Main outcome measurements Prevalence of potentially lethal cardiac conditions, false-positive results, and positive predictive value for testing procedures.

Results 4,812 athletes underwent cardiac screening (54% male, 46% female; 65% Caucasian, 10% Asian, 6% African-American, and 19% other). 23 athletes (0.5%, 1 in 209) were identified with a potentially lethal cardiac condition including 9 Wolff-Parkinson-White, 4 coronary artery anomaly, 3 dilated aortic root/aneurysm, 3 long QT syndrome, 2 hypertrophic cardiomyopathy, 1 ventricular arrhythmia, and 1 short QT syndrome. Abnormal history or physical findings led to the diagnosis in 14/23 (61%) disorders and an abnormal ECG led to the diagnosis in 16/23 (70%). The addition of ECG led to detection of 7/23 (30%) athletes not otherwise identified by the AHA protocol. One case was identified by echocardiography without a relevant abnormality on history, physical, or ECG.

Conclusions Standardized history and physical examination has a high false-positive rate in cardiac screening of young athletes. ECG screening using modern interpretation criteria provides a low false-positive rate and increases the likelihood of detecting disorders associated with sudden cardiac death. An integrated screening protocol using history, physical examination, and ECG is recommended for pre-participation screening in young athletes.