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Cardiovascular Screening in College Athletes With and Without Electrocardiography: A Cross-sectional Study

Aaron L. Baggish, MD; Adolph M. Hutter Jr., MD; Francis Wang, MD; Kibar Yared, MD; Rory B. Weiner, MD; Eli Kupperman, BA; Michael H. Picard, MD; and Malissa J. Wood, MD
[+] Article and Author Information

From Massachusetts General Hospital, Boston, and Harvard University, Cambridge, Massachusetts.


Acknowledgment: The authors thank Jennifer Neary, RDCS; Carlene McClanahan, RDCS; and Trisha Eshelman, RDCS, for their assistance with echocardiographic image acquisition.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-1561.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Baggish (e-mail, abaggish@partners.org). Data set: Not available.

Requests for Single Reprints: Aaron L. Baggish, MD, Division of Cardiology, Massachusetts General Hospital, Yawkey 5B, 55 Fruit Street, Boston, MA 02114; e-mail, abaggish@partners.org.

Current Author Addresses: Drs. Baggish, Hutter, Yared, Weiner, Picard, and Wood: Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114.

Dr. Wang and Mr. Kupperman: Harvard University Health Services, 75 Mount Auburn Street, Cambridge, MA 02138.

Author Contributions: Conception and design: A.L. Baggish, A.M. Hutter, M.H. Picard, M.J. Wood.

Analysis and interpretation of the data: A.L. Baggish, A.M. Hutter, K. Yared, M.H. Picard, M.J. Wood.

Drafting of the article: A.L. Baggish, K. Yared, M.H. Picard.

Critical revision of the article for important intellectual content: A.L. Baggish, A.M. Hutter, K. Yared, M.H. Picard, M.J. Wood.

Final approval of the article: A.L. Baggish, A.M. Hutter, K. Yared, R.B. Weiner, M.H. Picard, M.J. Wood.

Provision of study materials or patients: A.L. Baggish, A.M. Hutter, F. Wang, M.J. Wood.

Statistical expertise: A.L. Baggish.

Obtaining of funding: A.L. Baggish, M.J. Wood.

Administrative, technical, or logistic support: A.L. Baggish, K. Yared, R.B. Weiner, M.H. Picard, M.J. Wood.

Collection and assembly of data: A.L. Baggish, F. Wang, K. Yared, R.B. Weiner, E. Kupperman, M.J. Wood.


Ann Intern Med. 2010;152(5):269-275. doi:10.7326/0003-4819-152-5-201003020-00004
Text Size: A A A

Background: Although cardiovascular screening is recommended for athletes before participating in sports, the role of 12-lead electrocardiography (ECG) remains uncertain. To date, no prospective data that compare screening with and without ECG have been available.

Objective: To compare the performance of preparticipation screening limited to medical history and physical examination with a strategy that integrates these with ECG.

Design: Cross-sectional comparison of screening strategies.

Setting: University Health Services, Harvard University, Cambridge, Massachusetts.

Participants: 510 collegiate athletes who received cardiovascular screening before athletic participation.

Measurements: Each participant had routine history and examination–limited screening and ECG. They received transthoracic echocardiography (TTE) to detect or exclude cardiac findings with relevance to sports participation. The performance of screening with history and examination only was compared with that of screening that integrated history, examination, and ECG.

Results: Cardiac abnormalities with relevance to sports participation risk were observed on TTE in 11 of 510 participants (prevalence, 2.2%). Screening with history and examination alone detected abnormalities in 5 of these 11 athletes (sensitivity, 45.5% [95% CI, 16.8% to 76.2%]; specificity, 94.4% [CI, 92.0% to 96.2%]). Electrocardiography detected 5 additional participants with cardiac abnormalities (for a total of 10 of 11 participants), thereby improving the overall sensitivity of screening to 90.9% (CI, 58.7% to 99.8%). However, including ECG reduced the specificity of screening to 82.7% (CI, 79.1% to 86.0%) and was associated with a false-positive rate of 16.9% (vs. 5.5% for screening with history and examination only).

Limitation: Definitive conclusions regarding the effect of ECG inclusion on sudden death rates cannot be made.

Conclusion: Adding ECG to medical history and physical examination improves the overall sensitivity of preparticipation cardiovascular screening in athletes. However, this strategy is associated with an increased rate of false-positive results when current ECG interpretation criteria are used.

Primary Funding Source: None.

Figures

Grahic Jump Location
Figure.
Study flow diagram.

LV = left ventricular; LVH = left ventricular hypertrophy; RV = right ventricular.

Grahic Jump Location

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Cardiovascular Screening of Young Athletes
Posted on March 16, 2010
Steven A. Yarows
IHA, Chelsea, MI
Conflict of Interest: None Declared

The recent articles indicating the additional value of electrocardiography (ECG) screening in detecting serious cardiovascular abnormalities and the cost-effectiveness of this addition are important to primary care physicians and parents of young athletes (1,2). The addition of ECG to the history and physical exam by non-specialized clinicians increased the overall sensitivity and negative predictive value to 99.8% and compared to cardiovascular screening by history and physical alone saved 2.1 life-years pr 1000 athletes at an incremental cost of $88 per athlete. Although the American Heart Association consensus panel, led by Dr. Maron, does not endorse this, what mandatory screening is actually currently performed in the United States and at what cost (3,4)? In Michigan student athletes in public schools are required to have yearly "Sports Physical" forms completed and on file in the school's athletic office to participate in activities. Some of these examinations are performed in mass screening centers such as auditoriums and others at individual physician offices. The fees range from $5 to routine "physical" charges of several hundred dollars. Most insurance copayments average approximately $20 making the average 4-year high school out of pocket fees approximately $80, with insurance costs much higher. There is no requirement for what is examined and many exams are very brief in noisy auditoriums.

Chelsea Community Hospital in conjunction with physician and staff volunteers have been performing athletic screening of appropriately 1,500 adolescents since 2003. The screening sessions are free and have been performed 1-2 per year. Approximately 1/4 of those screened receive limited echocardiograms. We also offer a screening of ECG and a limited echocardiogram on all weekdays for $55. This was initiated to help prevent sudden death in adolescents due to one of the author's children being involved in high school sports.

As a parent, wouldn't you want to pay $88 once in high school to screen effectively for a cardiovascular potential sudden death rather than yearly ineffective and unproven "Sports Physicals." This is less than a pair of athletic shoes. We would hope that the American Heart Association would review these articles and consider what is currently required to determine what should be recommended. We believe that at a minimum, all adolescent athletes should have a standard screening questionnaire for conditions related to sudden death in addition to blood pressure recording, auscultation in the supine and seated position, and now with this recent evidence an ECG. If there is a concern, a limited echocardiogram could be considered.

References

1. Baggish AL, Hutter AM, Wang F, Yared K, Weiner RB, Kupperman E, Picard MH, Wood MJ. Ann Intern Med. 2010;152:269-275.

2. Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA. Ann Intern Med. 2010,152:276-286.

3. Maron BJ, Thompson PD, Ackerman MJ, Balady G. Berger S, Cohen D, et al. Circulation. 2007;115:1643-455.

4. Maron BJ. Ann Intern Med. 2010l152:324-6.

Conflict of Interest:

None declared

Cardiovascular Screening in College Athletes With and Without Electrocardiography...
Posted on April 9, 2010
Aaron L. Baggish
Massachusetts General Hospital, Boston, MA
Conflict of Interest: None Declared

Dr. Yarows description of an ambitious community based athlete preparticipation screening service is welcomed. Similar programs run by competent, dedicated, and well intending clinicians exist in many regions of the US. The sharing of outcomes data from such efforts, particularly those describing diagnostic yield, financial cost, and local sudden death incidence, is welcomed and will continue to inform scientific opinion.

The recent study conducted by our group confirmed the hypothesis that the inclusion of 12-lead ECG improves the sensitivity of cardiovascular disease screening in athlete [1]. However, it does so at a cost that high and one that extends far beyond dollar figures. An ECG-based screening program that falsely identifies 16% (our experience) or 25% (limited echocardiography rate quoted in above correspondence) of athletes as having a cardiovascular issue is problematic. Until this short-coming of ECG based screening is addressed, widespread implementation may do more harm than good.

More study is needed before U.S. public health recommendations can be effectively revised. Two important areas of work hold promise. First, ECG- criteria for distinguishing athletic cardiac remodeling from true underlying pathology must be established. Although a relevant European consensus document has recently become available [2], this paper does not obviate the need for criteria that are based on data rather than opinion. Second, screening must be studied in a large, multicenter, multination, prospective fashion using a study design that is powered to determine how different screening options impact the incidence of sudden death.

While we await the necessary work, there is room for immediate action. First, there is important heterogeneity with respect to who performs screening, what constitutes adequate screening, and how the results of screening are managed. Individuals with the responsibility of overseeing student athlete health may wish to start, not by rushing to perform 12-lead ECG, but by making every effort to ensure that the current ACC/AHA recommendations are adhered to by competent providers. This will best be accomplished by more extensive education for clinicians, athletes, and families. Second, group efforts can and should replace the traditional practice of office-based individualized sport clearance exams. Group screening promotes resource concentration and will enable the best care, for the most people, at the lowest cost.

Conflict of Interest:

None

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Summary for Patients

Adding Electrocardiography to Medical History and Physical Examination for Evaluation Before Sports Participation in College Athletes

The summary below is from the full report titled “Cardiovascular Screening in College Athletes With and Without Electrocardiography. A Cross-sectional Study.” It is in the 2 March 2010 issue of Annals of Internal Medicine (volume 152, pages 269-275). The authors are A.L. Baggish, A.M. Hutter Jr., F. Wang, K. Yared, R.B. Weiner, E. Kupperman, M.H. Picard, and M.J. Wood.

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