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Abstract
Purpose Determine the psychological impact of false-positive ECG screening in National Collegiate Athletic Association (NCAA) athletes.
Methods Athletes representing seven NCAA institutions received a standardised history, physical examination and ECG interpreted using the 2013 Seattle Criteria. Assessments of health attitudes, anxiety and impact of screening on sport were conducted using validated prescreen and postscreen measurements.
Results 1192 student-athletes participated (55.4% male, median age 19 years, 80.4% Caucasian). 96.8% of athletes had a normal cardiovascular screen, 2.9% had a false-positive ECG and 0.3% were diagnosed with a serious cardiac condition. Prior to screening, 4.5% worried about potentially harbouring cardiac disease and 70.1% preferred knowing about an underlying condition, rather than play sports without this knowledge. There was no difference in anxiety described by athletes with a normal versus false-positive screen (p=0.369). Reported anxiety levels during screening also did not differ when analysed by different gender, race, division of play or sport. Athletes with normal and false-positive screens had similar levels of satisfaction (p=0.714) and would recommend ECG screening to other athletes at similar rates (p=0.322). Compared with athletes with a normal screen, athletes with false-positive results also reported feeling safer during competition (p>0.01). In contrast, athletes with false-positive screens were more concerned about the possibility of sports disqualification (p<0.001) and the potential for developing a future cardiac condition (p<0.001).
Conclusions Athletes with a false-positive ECG do not experience more anxiety than athletes with a normal screen but do express increased concern regarding sports disqualification and the development of a cardiac disorder. These findings do not justify avoiding advanced cardiovascular screening protocols. Further understanding of athlete experiences could better prepare the practising physician to counsel athletes with an abnormal ECG.
- ECG
- sudden cardiac death
- prevention
- sport
- athlete
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Introduction
Sudden cardiac death (SCD) is the leading cause of death during exercise in young athletes, and preparticipation cardiovascular screening is widely supported.1–5 Consensus documents have outlined a need to understand the psychological impact of cardiovascular screening in young athletes prior to widespread implementation of new screening protocols.6 While never proven, increased anxiety has been cited as a reason against ECG screening in competitive athletes.4 5
Previously, we reported the psychological implications of preparticipation ECG screening in US high school athletes.7 8 No study to date has investigated the emotional impact of cardiovascular screening in collegiate athletes—an athletic population shown to be at higher risk of SCD.1 2 9 Indeed, the premium placed on athletic competition and performance at the collegiate level could alter athletes’ perceptions, experiences and preferences regarding precompetition cardiovascular screening.
The purpose of this study was to perform a large-scale investigation to better understand the psychological impact of cardiovascular screening among college athletes with false-positive results.
Methods
This was a multisite, cross-sectional investigation of athletes from seven National Collegiate Athletic Association (NCAA) institutions. Athletes 18 years of age or older without a previously diagnosed cardiac condition were eligible for the study. Informed consent was obtained for each athlete prior to the screening process. Athletes underwent preparticipation screening with a standardised medical history and physical (H&P) examination based on the American Heart Association recommendations, as well as a 12-lead resting ECG that was interpreted using the 2013 Seattle Criteria.10 If any element of the history, physical examination or ECG was determined to be abnormal, the athlete was referred for further evaluation.
All athletes completed validated prescreen and postscreen psychological survey assessments evaluating their experiences, health attitudes, anxiety and the impact of screening on sport.7 8 For each athlete, the prescreen assessment was given on-site just prior to the preparticipation screening examination, while the postscreen evaluation was administered after completion of all cardiac testing, including follow-up examinations. For athletes with a normal history, physical examination and ECG (normal screens), the postscreen assessment was administered after the screening evaluation. For athletes requiring additional testing for an abnormal screen, the postscreen assessment was administered after definitive diagnostic evaluations could be performed and the presence or absence of underlying cardiac pathology determined.
The prescreen psychological assessment consisted of questions evaluating baseline measures of anxiety, health attitudes, concern for cardiac pathology, attitudes regarding the potential for further testing and interest in cardiac screening prior to sports participation. Baseline screening for trait anxiety was assessed using a validated anxiety subsection of the Primary Care Evaluation of Medical Disorders (PRIME-MD).11
The postscreen psychological assessment was adapted from Solberg et al, 12 who investigated the implications of cardiac screening in Norwegian soccer players. It contained questions evaluating satisfaction with screening, feelings of anxiety during and immediately after screening, beliefs about whether other athletes should receive a cardiac screen prior to competition, and the impact of cardiac screening on the individual’s athletic activity. A 5-point Likert scale (−2 = strongly disagree, −1 = disagree, 0 = neutral, 1 = agree, 2 = strongly agree) was used to measure athlete preferences during the prescreen and postscreen psychological evaluations.
Student’s t-tests were performed to analyse differences among groups based on the screening result (normal vs false-positive). Analyses with a p value <0.05 were considered statistically significant. All analyses were performed using R.3.2.3 statistical software (R Foundation for Statistical Computing, Vienna, Austria).
The study was approved by the Human Subjects Division within the Greenville Health System.
Results
A total of 1192 athletes representing 18 different intercollegiate sports participated (table 1). Within this student athlete population, 96.8% were deemed to have a normal cardiovascular exam, 2.9% had false-positive results and 0.3% had a cardiac disorder in need of follow-up testing (two athletes with hypertrophic cardiomyopathy, one with Wolff-Parkinson-White pattern and one with multiple premature ventricular contractions).
Demographics
Overall, 1.4% of athletes reported having a family member or close friend die from cardiac disease <50 years old. A positive screen for baseline anxiety trait using the PRIME-MD was present in 13.3% of athletes. Prior to screening, only 4.5% of athletes were worried about having an underlying cardiac disorder, and 70.1% of athletes reported that they would rather know about a possible underlying cardiovascular disorder, rather than play sports without possessing this knowledge. Table 2 further delineates the psychological impact of ECG screening in this cohort.
Responses
Athletes screening normal and false-positive (FP) did not report measurable anxiety both during (normal=−0.774, FP=−0.594) and after (normal=−1.054, FP=−0.750) screening with no statistically significant differences between these two groups. Levels of anxiety during screening were reported by 13% of athletes with a normal cardiovascular screen and 21% of those with false-positive results. Reported anxiety during cardiovascular screening did not differ by gender (male=−0.788 vs female −0.727), race (Caucasian=−0.769 vs African–American), NCAA division (division I=−0.716 vs division II=−0.820, vs division III=−0.761) or sport (baseball=−0.576 vs basketball=−0.642, cross country/track=−0.813 vs football=−0.861 vs soccer=−0.721 vs swimming=−0.671 vs rowing=−0.855).
Athletes were additionally asked (1) whether they were scared if the screen would reveal a cardiac abnormality or (2) whether they were more likely to develop a cardiac condition in the future. Overall, data did not demonstrate that the group of false-positive athletes felt scared about having a heart condition (mean=−0.156; 32% of athletes with false-positive results vs 9% in those with a normal screen) or developing one in the future (mean=−0.500); there was a significant difference when compared with those who screened normal (p<0.001 and p<0.05, respectively; table 2). Athletes with false-positive results were also more concerned about the potential for sports disqualification (normal=−0.734 vs FP=0.241, p<0.001). Conversely, athletes with false-positive results were significantly more likely to feel that all athletes should receive an ECG prior to athletic competition (FP=1.156 vs normal=0.824, p<0.01) and to feel safer during athletics (FP=0.719 vs normal=0.185, p<0.01).
Discussion
SCD in young athletes is a tragic event and compels sports medicine professionals to develop and implement effective screening protocols.6 Unfortunately, the ideal preparticipation screening strategy has become a source of polarising debate worldwide.13 14 Among the reasons cited against advanced screening programmes inclusive of an ECG is the assumption that the ECG would cause undue anxiety.4 To date, however, no study has sought to understand collegiate athletes’ perspectives, attitudes or experiences during cardiovascular screening prior to athletic competition.
This investigation describes the psychological implications of ECG screening in collegiate athletes and helps to better delineate the impact of false-positive results. The majority of athletes with false-positive results (79%) do not report excessive anxiety during screening, with no significant differences compared with athletes with normal results. Follow-up questions that delve deeper into athlete emotions demonstrate that some individuals with false-positive results do feel scared about having an abnormal cardiac disorder and think that they are more likely to develop a cardiac condition in the future. While the low mean scores for those responses demonstrate that these reactions are not described by the majority of athletes, there are statistical differences when compared with athletes with normal screening results, signifying that clinicians should be aware of this potential consequence. These sentiments, however, do not appear to justify an argument against ECG screening as this did not seem to be the prevailing reaction, and athletes with false-positive results do not describe lingering anxiety that occurs after screening completion. Furthermore, there are several notable positive consequences found in athletes who screen false-positive. This includes feeling more safe during athletic competition and believing that all athletes should receive an ECG as part of their cardiac screen prior to participating in athletics.
This study highlights the need to appreciate an athlete’s perspective following an abnormal test result as some athletes may feel increased levels of concern. This may be true regardless of the screening modality (eg, abnormal result following medical history, physical examination, ECG or other). In fact, it may occur more often during the medical history portion of screening as studies have shown the rate of abnormal responses from the medical history is tenfold higher than an ECG when interpreted with athlete-specific criteria.15 Regardless, in those circumstances, it is critical to understand how best to counsel these athletes to minimise distress. Best practices in communication in these instances may be an area for future research.
While this investigation was not powered to delineate the psychological effects of cardiovascular screening in athletes diagnosed with cardiac disease, previous studies have demonstrated heightened levels of anxiety in this population.7 8 16 In fact, those studies have shown increased psychological morbidity in collegiate athletes when compared with those competing at the high school level. The four athletes diagnosed with cardiovascular diseases in this investigation did report anxiety both during and after screening completion, which supports findings from previous research. Given the risk for psychological injury in these athletes, it is important to provide emotional support to these individuals immediately following diagnosis, and in fact a vulnerable athlete emergency response plan is an essential part of each collegiate athletic programme such that triggering events (eg, the diagnosis of a potentially lethal cardiovascular condition) should elicit appropriate responses from key personnel, especially those with expertise in mental health.16
While this investigation provides insight into the psychological experiences of a large cohort of US collegiate athletes, several limitations are worth noting. First, this study did not compare anxiety levels in athletes who received an H&P versus those who received an H&P + ECG. However, prior studies in high school athletes have shown that anxiety levels are independent of the reason for additional testing.7 8 This means that one would not expect heightened anxiety in an individual with an abnormal ECG as compared with someone with an abnormal medical history or physical examination finding. This investigation is also limited to collegiate athletes and may not be applicable to other athletic populations. Our findings mirror those found in the high school setting, but to date there have not been investigations at the professional level, which warrants further study.7 8 Lastly, there is the potential for lack of standardisation in secondary testing after an abnormal finding since multiple sites were used in the investigation, including the length of time between additional investigations. However, the study does capture real-world screening practices and timing, which adds to the authenticity of the results. Additionally, the consistency between results from individuals with a variety of backgrounds further supports that the differences in protocols between institutions did not alter the findings.
Conclusion
The preferences, perspectives and experiences of athletes who undergo preparticipation cardiovascular screening should be considered when developing screening recommendations. This is the first study to investigate the psychological implications of cardiovascular screening in a large cohort of US collegiate athletes across all three NCAA divisions and sports. ECG screening does not cause undue anxiety in the vast majority of individuals in this population, including those with false-positive results. Additionally, any increase in anxiety found in athletes with false-positive findings diminished after receiving final results, which argues against any potential lingering impact. In fact, athletes with false-positive results felt safer during competitive and were more likely to support ECG screening in other athletes. As such, heightened anxiety does not appear to be a justifiable reason to oppose ECG screening. However, some athletes with false-positive results did describe short-term feelings of being scared about harbouring an underlying cardiac condition, developing a disorder in the future and concern about the potential for disqualification from athletic competition. These concerns are noteworthy and provide useful information to guide physicians during counselling of athletes with abnormal screening results or engage in conversations regarding shared decision-making or the risks/benefits of advanced cardiovascular screening.
What are the findings?
The majority of athletes with false-positive results do not report excessive anxiety during screening, with no significant differences compared with athletes with normal results.
However, athletes who screen false-positive are more concerned with the possibility of sports disqualification and the potential for developing a future cardiac condition.
Athletes with false-positive results from ECG screening still feel that all athletes should receive an ECG prior to competitive athletics and would recommend this testing to other athletes.
How might it impact on clinical practice in the future?
Undue anxiety should not be used as an argument against the implementation of ECG screening during the preparticipation exam for young athletes. Understanding the psychological implications of cardiovascular screening and the risk of sudden cardiac death during athletics may enhance conversations surrounding informed or shared decision-making and subsequent counselling for abnormal screening results.
References
Footnotes
Contributors IMA: contributed to the conception, design, data collection, analysis, manuscript preparation and manuscript review. SA: contributed to the design, data collection, analysis, manuscript preparation and manuscript review. JAE: contributed to the design, data collection, analysis, manuscript preparation and manuscript review. RA: contributed to the data collection, analysis and manuscript review. BS: contributed to the data collection, analysis and manuscript review. KC: contributed to the data collection, analysis and manuscript review. JR: contributed to the design, data collection, analysis, manuscript preparation and manuscript review. KGH: contributed to the conception, design, data collection, analysis, manuscript preparation and manuscript review. JAD: contributed to the conception, design, data collection, analysis, manuscript preparation and manuscript review.
Competing interests None declared.
Patient consent Obtained.
Ethics approval Greenville Health System.
Provenance and peer review Not commissioned; externally peer reviewed.