Are ECGs an essential part of screening for athletes?

Jonathan Rogers, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP

Sudden cardiac death (SCD) has for some time been a worrying and highly emotive aspect of high-level sport, albeit a rare event. Thus, since 2007 the American Heart Association has advocated a programme of pre-participation physical examination for competitive athletes, but this screening has controversially not included an ECG as mandatory, despite evidence from a study in Italy showing its effectiveness in reducing rates of SCD. (1)

However, the approach of a new study published in this month’s Journal of Pediatrics has brought a serious challenge to the utility of ECGs in this process by examining how accurate they are at alerting professionals to a danger. (2) ECG interpretation can certainly be difficult for medical students and for many non-specialists, but the intriguing aspect of this study is that it examined responses from paediatric cardiologists, giving rather surprising results. 18 athlete’s ECGs were analysed by the participating doctors and compared with the conclusions of 2 expert paediatric electrophysiologists (with 100% concordance between them), finding that accuracy among the participants was a mere 69%. Perhaps of even greater concern is that in athletes with ECGs considered normal, 26% of respondents said they would restrict participation in sports. Of particular difficulty was the identification of ventricular hypertrophy or WPW, probably because of the similarities with the normal changes to athletes’ hearts.

Although this study was not a large one and it did only consider ECGs in isolation without history or examination, it does raise concerns regarding the use of ECGs in pre-participation programmes. There are already serious ethical issues in such screening (should you be barred from fulfilling your dream because you have an increased risk of a very rare event occurring?), and more false positives could be very unhelpful for Western society, where frequent exercise can be so helpful in tackling obesity.

References: 

1. Washington RL. Pre-Participation Screening Electrocardiograms – Still Not a Good Idea. Journal of Pediatrics 2011;159(5):712-713.
doi: 10.1016/j.jpeds.2011.06.042

2. Hill AC, Μiyake CY, Grady S, Dubin AM. Accuracy of Interpretation of Preparticipation Screening Electrocardiograms. Journal of Pediatrics 2011;159(5);783-788.
doi: 10.1016/j.jpeds.2011.06.042

Story image from Wikimedia Commons.