Elsevier

Heart Rhythm

Volume 11, Issue 3, March 2014, Pages 442-449
Heart Rhythm

Electrocardiography-inclusive screening strategies for detection of cardiovascular abnormalities in high school athletes

https://doi.org/10.1016/j.hrthm.2013.12.002Get rights and content

Background

The best protocol for cardiovascular preparticipation screening (PPS) in young athletes is uncertain.

Objective

The purpose of this study was to determine the value of integrating electrocardiographic (ECG) testing with standard history and physical examination during PPS to identify potentially serious cardiovascular abnormalities in young athletes.

Methods

A total of 2017 high school athletes seeking clearance for competitive sports were prospectively evaluated using a standardized history and physical examination, 12-lead ECG, and two-dimensional echocardiogram (echo). Primary outcome measures included the identification of cardiac disorders associated with sudden cardiac death. Secondary outcome measures included identification of abnormal, but nonlethal, cardiac conditions that required medical follow-up.

Results

Of these athletes, 14.7% had an abnormal history or physical examination and 3.1% had an abnormal ECG based on modern ECG interpretation criteria. Five primary outcomes (1 hypertrophic cardiomyopathy, 4 Wolff-Parkinson-White syndrome) and four secondary outcomes were identified. History and physical examination detected 40% of primary and 50% of secondary abnormalities. ECG detected all five primary abnormalities but none of the secondary abnormalities. Echo was abnormal in 1.2% and detected one primary and four secondary abnormalities. The false-positive rates for primary and secondary outcomes for history and physical examination and ECG were 14.5% and 2.8%, respectively.

Conclusion

ECG adds value to PPS through increased detection of arrhythmogenic and structural cardiovascular conditions associated with sudden cardiac death. Use of modern ECG interpretation standards allows a low false-positive rate. Routine echo may detect other clinically important cardiac abnormalities, but its role in PPS remains uncertain.

Section snippets

Study design

This prospective study evaluated the prevalence of cardiac conditions in athletes at two large PPS events in June 2010 and June 2011. All athletes underwent a screening evaluation that included (1) a personal and family history with physical examination; (2) ECG; and (3) limited echo. Athletes with abnormal screening results were followed until a definitive diagnosis was made. The study was approved by the Institutional Review Board of Carolinas Healthcare System, and all participants provided

Demographics

A total of 2017 high school athletes (71% male) seeking medical clearance for competitive sports were screened. The ethnicity of the athletes was added to the registration form in 2011, so demographic data are available only for that year. The athletes were 34% Caucasian, 31% black/African American, 5% Hispanic, 1% Asian, and 25% other ethnicity (checked ≥2 ethnicities); 4% did not respond. The athletes represented 14 different sports.

Primary and secondary outcomes

In this cohort of 2017 screened athletes, five primary

Discussion

The American College of Cardiology states that the “ultimate objective of PPS of athletes is the detection of silent cardiovascular abnormalities that can lead to SCD.”33 Similar to previous research, this study demonstrates that history and physical examination alone has limited ability to detect potentially lethal cardiovascular abnormalities in a population of young athletes, and that the addition of ECG to PPS improves early detection of athletes with abnormalities associated with SCD.

Conclusion

Our findings suggest that an integrated PPS consisting of history, physical examination, and ECG provides improved detection of conditions associated with SCD in high school athletes. When modern interpretation standards are used, ECG has an acceptably low false-positive rate and high negative predictive value for the presence of cardiomyopathy. The use of echo has the potential to identify additional minor cardiac abnormalities, but the clinical significance requires further study. In order to

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