Barry J. Maron, MD
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-2799.
Requests for Single Reprints: Barry J. Maron, MD, Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, 920 East 28th Street, Suite 620, Minneapolis, MN 55407; e-mail, email@example.com.
Maron B.; National Electrocardiography Screening for Competitive Athletes: Feasible in the United States?. Ann Intern Med. 2010;152:324-326. doi: 10.7326/0003-4819-152-5-201003020-00012
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Published: Ann Intern Med. 2010;152(5):324-326.
Sudden death in young persons, associated with participation in competitive athletics, has generated considerable visibility and concern in both the general public and medical community (1–7). Such deaths, particularly when associated with unsuspected cardiovascular disease, have become a prominent public health debate focused on strategies to prevent these catastrophes (8–11). Two primary prevention initiatives have evolved in an effort to create a safer athletic environment: preparticipation screening in athlete populations to identify the culprit diseases (3, 5, 12–17), and eligibility and disqualification standards to prohibit athletes identified with cardiovascular abnormalities from engaging in competitive sports to reduce their risk (2, 4).
joseph c. marek
Midwest Heart Specialists
March 9, 2010
National ECG screening is feasible.
I read with interest the editorial by Dr. Maron, however I take issue with several of his assertions (1). I offer the following arguments based on my experience with screenings in a multi-county region in suburban Chicago. Since 2006 our program, Young Hearts for Life, has screened more than 45,000 high school students.
I believe Dr. Maron's efforts to relate the Italian system to the U.S. are flawed in fact and logic. He contends there is a dramatic disparity in physician resources between Italy and the U.S. Of course the absolute number of athletes in this country is larger but in terms of percentage of population, U.S. athletes number about half that of Italy, 5% in the U.S. vs.10% in Italy (1). Moreover, the number of primary care physicians per capita is similar at 1/1,000 in the U.S. vs. 0.9/1,000 in Italy. (2) Besides, current AHA recommendations already expect all young adult athletes to be seen by a physician (3).
Dr. Maron also exaggerates the magnitude of national ECG screening in the U.S. He cites 75 million as the number of Americans under the age of 18. In fact, testing is recommended for only those 12-25 yrs of age, which puts the total closer to 40 million, according to U.S. census data from 2005. Moreover, his estimate of SCD incidence is debatable. The less than 100 athlete deaths per year statistic he references is based not on a scientific registry like the Italian data but rather on a compilation of media reports (5).
Dr. Maron's concern with excessively high rates of abnormal results does not reflect more contemporary standards of ECG interpretation with rates reported at 5% or less (6). In our screening program, we have refined our testing by employing "stratified screening. "Our "abnormal" rate of 2.3% is certainly a number manageable by the medical community (7).
Moreover I do not understand the preoccupation with false positives when similar issues have not impeded testing in other areas of medicine (mammography, newborn PKU screening, etc). The medical community's approach has always been to pursue improvements that reduce the false positive rate through refinement in techniques and experience. It should be no different with ECG screening.
Our program strongly maintains that the focus on athletes-only screenings as defined in the AHA guidelines is too restrictive. Shouldn't we be concerned about SCD in all young adults and not just the deaths in a restrictively defined subgroup called athletes? Atkins' prospective study on the incidence of SCD in children reported a death rate that is much higher than that cited by Dr. Maron, specifically greater than 2,500 SCDs in U.S young adults annually in the U.S. (4).
Finally, we should not assume that our only choices are either mandated screening as in Italy or no screening at all. America is a nation with a tradition of ingenuity. Solutions to problems are not found by saying how we can't achieve a worthy goal but rather by asking how we can. Until we change this mindset we will continue to unnecessarily lose too many of our precious youth to potentially preventable causes of sudden death.
1. Maron; National Electrocardiography Screening for Competitive Athletes: Feasible in the United States? Ann Intern Med 2010 152:324-326.
2. OECD Health Data 2009; General practitioners and specialists in OECD countries 2007
3. Maron et al; Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007 Update. Circulation. 2007;115:1643-1655.
4. Atkins et al; Epidemiology and Outcomes From Out-of-Hospital Cardiac Arrest in Children. The Resuscitation Outcomes Consortium Epistry- Cardiac Arrest. Circulation. 2009;119:1484-1491.
5. Maron et al; Sudden Deaths in Young Competitive Athletes Analysis of 1866 Deaths in the United States, 1980-2006. Circulation. 2009;119:1085-1092.
6. Pelliccia et al; Prevalence of abnormal ECGs in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J. 28: 2006-2010, 2007.
7. Nora et al; Preliminary findings of ECG screening in 9,125 young adults [Abstract 3718]. Circulation. 2007;116:845.
Institute of Sport Medicine and Science
April 20, 2010
THE ECG AND THE PREPARTICIPATION SCREENING OF COMPETITIVE ATHLETES: TIME IS TO CHANGE THE CUSTOMARY CLINICAL PRACTICE
To the Editor: Two original investigations that recently appeared in the Annals [1,2] have interesting implications regarding the scientific debate about preparticipation cardiovascular screening for athletes. Baggish and colleagues  compared a screening protocol with or without 12-lead ECG in a cohort of US collegiate athletes and demonstrated that inclusion of the ECG improved sensitivity for detecting important cardiac abnormalities from 45.5% to 90.9% and altered the negative predictive value of screening from 98.7% to 99.8%. Wheeler  assessed the costs and survival rates in US athletes undergoing screening with or without 12-lead ECG, and estimated that inclusion of the ECG resulted in 2.1 life-years saved per 1,000 athletes screened. The incremental cost-effectiveness ratio of the screening with ECG was $ 42,000 per life-year saved. Based on these new investigations and the Italian experience [3,4]) scientific evidence supporting the efficacy and cost-effectiveness of a customary screening ECG for athletes is growing. Given this, we believe that the current AHA position  that recommends medical history and physical examination is inadequate and inconsistent with evolving scientific knowledge. We acknowledge that implementation of a national screening program for athletes that includes a customary ECG is a difficult task in a large and multiethnic society (such as the US), and that such a screening program may not be viewed as a top health care priority. We also acknowledge that this type of screening program should not be federally supported (is not in Italy as well). But, we believe that High Schools and Colleges share an ethical and legal obligation to ensure that their young affiliates avoid the cardiovascular risk related to sport participation. Young athletes and their families should be fully informed regarding the additional value of the ECG and should be offered the opportunity to be screened with an ECG. Denying athletes such opportunities may be viewed by some as denial of a potentially life-saving diagnostic test, as the test detects silent cardiomyopathy which is a potentially lethal condition. Moreover, it is perhaps only a matter of time before a malpractice lawsuit is brought in the case of a young athlete dying suddenly who had not been screened with an ECG.
1. Baggish AL, Hutter AM Jr, Wang F, Yared K, Weiner RB, Kupperman E, et al. Cardiovascular screening in college athletes with and without electrocardiography. A cross-sectional study. Ann Intern Med. 2010;152:269 -75.
2. Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA. Cost- effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med. 2010;152:276-86.
3. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006;296:1593-601.
4. Pelliccia A, Di Paolo FM, Corrado D, Buccolieri C, Quattrini FM, Pisicchio C, et al. Evidence for efficacy of the Italian national pre- participation screening programme for identification of hypertrophic cardiomyopathy in competitive athletes. Eur Heart J. 2006;27:2196-200.
5. Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, et al; American Heart Association Council on Nutrition, Physical Activity, and Metabolism. 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. 2007;115:1643-455.
Barry J. Maron
Minneapolis Heart Institue Foundation
June 2, 2010
Re:National ECG screening is feasible.
To the Editor:
I read with interest Dr. Marek's reaction to my editorial regarding preparticipation screening for cardiovascular disease in U.S. athletes (1). Unfortunately, my comments seem to have been largely misunderstood. First, the disparity cited between U.S. and Italian physicians performing screening examinations relates specifically to the unique cadre of sports medicine physicians solely dedicated to this program in Italy --- a crucial resource that simply does not exist in the U.S. making national mandatory ECG screening exceedingly difficult, if not impractical. Second, the sudden death of any young athlete is tragic, but these events occur at a low rate (2-4). Third, Dr. Marek's characterization of the Sudden Death in Athletes Registry as "only a compilation of media reports" is inaccurate (2). Of note, tabulation of athlete deaths in Italy is based on events limited to the Veneto region which comprises only 9% of the Italian population. Fourth, there is no evidence that mortality rates in athletes due to cardiovascular disease differ between the U.S. and Italy (4), despite dissimilar screening strategies (4,5). Fifth, Dr. Marek suggests that I cited obsolete data for false positive tests (i.e., 10-20%) and claims a rate of only 2% from his own program. I encourage Dr. Marek to publish his "stratified screening" data so that we may all learn from his substantial experience screening 45,000 high school students over the last 4 years. I believe that we should be "preoccupied" with false-positive ECG test results due to the potential for over-burdening the system, excessive subspecialty testing, over-diagnosis, unnecessary anxiety and confusion for patients and families, and unwarranted disqualification from sports.
Sixth, suggesting that the debate is about a choice between mandated ECG screening (Italian model) and "no screening at all" is a mischaracterization of the athlete screening process in the U.S. Screening of U.S. high school and college athletes (with history and physical examination) is practiced almost universally (6) and is of value (7). Seventh, it is an exaggeration to suggest our character as Americans is somehow dependent on adopting mandatory ECG screening for athletes. Preparticipation screening in large general populations is deceptively complex and requires measured consideration (8,9), for it is impacted by practical, societal, cultural and legal considerations relevant to the U.S. healthcare system (9). Perhaps most importantly, limiting mass screening to sports participants would undoubtedly be regarded as exclusionary, if not discriminatory, with respect to young non-athletes. Finally, while the 2007 American Heart Association (AHA) screening recommendations (10) do not endorse mandated national ECG screening for all competitive athletes, in no way do the recommendations discourage individual initiatives such as "Young Hearts for Life." Moreover, it is incorrect to characterize the many clinicians and experts who do not endorse ECG screening on a required national basis as complicit in past and future sudden deaths of young athletes because of their misguided "mindset."
Lastly, I appreciate the comments concerning strategies for cardiovascular screening in competitive athletes from Dr. Pelliccia. Some of the remarks, however, may reflect a naive zeal to export ECG screening to the United States. The comments about ethical and legal obligations and the language about "denial of a potentially life- saving diagnostic test" and it "being only a matter of time before a malpractice lawsuit is brought" were unsettling and could be interpreted by some as thinly veiled accusations of unethical behavior and dereliction of duty if ECG screening is not done. In the U.S., medical practice (e.g., preparticipation screening) must conform to accepted, customary and reasonable standards as formulated by the medical establishment, and not from governmental legal fiat as in Italy (5). Consensus guidelines such as the 2 AHA scientific statements on athlete preparticipation screening (10) contribute importantly to this customary and accepted framework of practice. Therefore, I underscore the following: There is no legal obligation on the part of U.S. practitioners, high schools and colleges to routinely incorporate ECGs into their screening practice.
1. Maron BJ. National electrocardiography screening for competitive athletes: feasible in the United States? Ann Intern Med 2010;152:324-326.
2. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the U.S., 1980- 2006. Circulation 2009;119:1085-1092.
3. Maron BJ, Gohman TE, Aeppli D. Prevalence of sudden cardiac death during competitive sports activities in Minnesota high school athletes. J Am Coll Cardiol 1998;32:1881-1884.
4. Maron BJ, Haas TS, Doerer JJ, Thompson PD, Hodges JS. Comparison of U.S. and Italian experiences with sudden cardiac deaths in young competitive athletes and implications for preparticipation screening strategies. Am J Cardiol 2009;104:276-280.
5. Corrado D, Basso C, Pavei A, Michieli, Schiavon M, Thiene G. Hypertrophic cardiomyopathy. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 2006;296:1593-1601.
6. Glover DW, Glover DW, Maron BJ. Evolution in the process of screening United States high school student-athletes for cardiovascular disease. Am J Cardiol 2007;100:1709-1712.
7. Adabag AS, Kuskowski MA, Maron BJ. Determinants for clinical diagnosis of hypertrophic cardiomyopathy. Am J Cardiol 2006;98:1507-1511.
8. Viskin S. Routine screening of all athletes prior to participation in competitive sports should be mandatory to prevent sudden cardiac death. Heart Rhythm 2007;4:525-528.
9. Thompson PD. Preparticipation screening of competitive athletes: seeking simple solutions to a complex problem. Circulation 2009;119:1072- 1074.
10. Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, Dimeff R, Douglas PS. Glover DW, Hutter AM Jr, Krauss MD, Maron MS, Mitten MJ, Roberts WO, Puffer JC. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: Update 2007. A Scientific Statement from the American Heart Association, Nutrition, Physical Activity, and Metabolism Council. Circulation 2007;115:1643-1655.
Chairperson of the American Heart Association position paper on guidelines for athlete screening and a member of the medical advisory board of the Hypertrophic Cardiomyopathy Association.
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