Whenever young athletes die from undetected heart problems, the deaths naturally generate considerable media attention and re-ignite the debate over the optimal approach to screening young competitive athletes for heart problems to minimize death from sudden cardiac arrest.

Current standard

To screen for possible heart conditions, the current recommendation of experts in the United States is for health care professionals to:

• conduct a physical exam (testing an athlete's blood pressure and listening for abnormal heart rhythms or murmurs); and 
• ask the athlete (and, for middle school and high school athletes, his parents) to complete a detailed health questionnaire, including questions tailored to detection of cardiac abnormalities through the taking of both (1) the athlete's medical history (chest pain, heaviness or tightness, palpitations, fainting or near fainting or dizziness with or without exercise, etc.); and (2) the athlete's family history (premature death before age 50 from heart disease of one or more relatives, specific knowledge of certain cardiac conditions in family members).

While numerous groups have conducted local screening of student-athletes for heart defects using a combination of electrocardiograms (ECG or EKG) and echocardiography (echocardiograms), often in response to a recent sudden death in the community, and such programs are often praised by local and national parent groups (10) and the media, the use of ECGs and echocardiograms is not currently a routine part of an athlete's pre-participation physical evaluation in the United States. (1,2,11,13)

In its most recent science advisory (11), the American Heart Association reaffirmed the soundness of the position it took in a 2007 Statement (2), which emphasized the importance of risk assessment with questionnaires and physical examination, but concluded that recommending the routine use of tests such as 12-lead ECG (EKG) or echocardiography in the context of mass, universal screening was neither "prudent nor practical."

Most recently, the National Athletic Trainers' Association in its 2014 position statement on preparticipation physicial exams (13) found that such noninvasive cardiac testing is not a routine aspect of the screening PPE unless warranted by findings from the personal and family history.  The NATA said such testing is not "cost-effective in a population at relatively low risk for cardiac abnormalities, and it cannot consistently identify athletes at actual risk." 

Arguments in favor of routine EKG screening

In athletes with underlying but undiscovered heart disease, the risk for sudden cardiac death may be more than 100-fold higher than that of unaffected peers. (3)

A cornerstone of the argument in favor of pre-participation EKGs is a 25-year study from a region in Italy, where EKG screenings of all athletes in officially sanctioned sports has been mandatory since 1982. (3)  A 2006 study (4) showed a nearly 90 percent drop in sudden cardiac deaths in Italy since the program began. No deaths were recorded from athletes disqualified from competition because of hypertrophic cardiomyopathy (HCM), a thickening of the heart muscle that makes it work harder to pump blood, which is a common cause of sudden cardiac death among youth athletes.  In its PPE position statement (13), the NATA listed several limitations of the study.

The cost of adding EKGs to the screening program has been a central argument against its use, but two 2010 studies (3,5) suggest that lives could be saved if the test was routinely performed in addition to the taking of a thorough personal and family history and physical examination.

In the first, researchers at Stanford University applied a theoretical model to project the costs and survival rates of U.S. high school and college athletes who had pre-participation screening, finding that adding ECG to history and physical examination could be expected to save about 2 years of life per 1,000 athletes at a cost of $89 per athlete. The authors found that the $42,000 per year of life saved was not prohibitive and a sum in line with other health care expenditures that society undertakes, such as kidney dialysis ($20,000-$80,000 per year of life saved) or public access to defibrillators ($55,000-$162,000).

They thus concluded that preparticipation screening of young athletes with EKG plus cardiovascular-focused history and physical examination, while "substantially more costly and [only] marginally more effective than no screening," is "reasonable in cost and effective at saving lives." (3)

In the second, researchers at Massachusetts General Hospital and Harvard University examined the effect of cardiovascular screening with and without ECG in 510 collegiate athletes, finding that including ECG in the screening increased the recognition of a group of heart conditions called cardiomyopathies, including HCM. (5)   [Wes Leonard, the 16-year-old who collapsed on the court on March 3, 2011, died of cardiac arrest brought on by dilated cardiomyopathy, a condition that often strikes suddenly and without warning.]

A 2007 British study of high school athletes (6) found that physical examination and screening using personal and family history questionnaires alone were inadequate in identifying individuals with diseases associated with sudden cardiac death and recommended use of EKG as "paramount when screening for cardiac pathology in the young."

Arguments against routine EKG screening

Those who argue against routine EKG screening suggest that it fails one of the most important criteria developed by the World Health Organization for appraising a screening program: that the condition being screened for is an important health problem, which depends not only on how serious the condition is but also how common it is.

They argue that although sudden cardiac death is tragic (more than 90 competitive young athletes dying suddenly and unexpectedly each year), it is also rare (7) affecting just 1 per 220,000 high school athletes in the United States each year. (8)

AHA supports more study before endorsing universal screening

While concluding that its 2007 statement (2) on athletic pre-participation, which did not endorse mandatory screening with ECG and other non-invasive tests remained "sound,"  the American Heart Association neverthless reaffirmed in its 2012 science advisory (11) its "strong support" for novel approaches to screening and the need for further studies to evaluate these strategies.  Assembling sound data and the support of other key stakeholders such as governmental agencies and the healthcare community will be required, the AHA concluded, before it can endorse universal screening programs.  

This is also the position of the National Athletic Trainers' Association which, in its 2011 position statement on preventing sudden death in sports (12) states that "further research is needed to understand whether additional tests such as electrocardiograms and echocardiograms improve sensitivity and can be performed with acceptable cost-effectiveness and an acceptable false-positive rate."

Advice for parents

In the absence of routine EKG screening, what, then, can parents do to minimize the chances of their child suffering sudden cardiac death from an undetected heart condition?

1. Know the warning signs and symptoms of a heart condition. If your child has one or more of these signs or symptoms, consult a doctor promptly:

• Fainting (syncope) or seizure during or after exercise
• Fainting (syncope) or seizure resulting from emotional excitement, emotional distress or startle
• Chest pain or discomfort
• Racing heartbeat (palpitations)
• Family history of heart disease
• Family history of sudden cardiac death during physical activity or during a seizure, or any other unexplained sudden death of an otherwise healthy family member under age 50
• Unusual shortness of breath
• Unusual fatigue/tiredness
• Dizziness/lightheadedness during or after exercise

2. Ask your child's doctor to use the latest pre-participation physical evaluation form (9) which includes not only a physical exam but the heart health questions about the athlete and his family;

3. Complete a Pediatric Sudden Cardiac Death Risk Assessment Form at periodic times during well child visits (neonatal, preschool, before/during middle school, and before/during high school);

4. Become certified in CPR and know the links in the Cardiac Chain-of-Survival; and

5. Work to make sure automated external defibrillators (AEDs) are available in schools and at school-sponsored athletic events.

Notes:

1. Maron BJ, Douglas PS, Graham TP, Nishimura RA, Thompson PD. Task Force 1: preparticipation screening and diagnosis of cardiovascular disease in athletes. J Am Coll Cardiol. 2005;45:1322-6.

2. 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(12):1643-1655.

3. Wheeler MT, Heidenreich PA, Froelicher V, Hlatky MA, Ashley EA. Cost-Effectiveness of Preparticipation Screening for Prevention of Sudden Cardiac Death in Young Athletes. Ann Intern Med. 2010;152:276-286.

4. Corrado D, Basso C, Pavel A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program.  2006;296:1593-1601.

5.  Baggsi AL, Hutter AM Jr, Wang F, Yared K, Weiner RB, Kupperman E, Picard MH, Wood MJ.  Cardiovascular Screening in College Atheltes With and Without Electrocardiography.  Ann Intern Med. 2010;152:269-275.

6. Wilson MG, Basavarajalah S, Whyte G, Cox S, Loosemore M, Sharma S. Efficacy of personal symptom and family history questionnaires when screening for inherited cardiac pathologies? The role of electrocardiography. Br J Sports Med. 2007

7. Bahr R. Can electrocardiographic screening prevent sudden death in athletes? No. BMJ 2010; 341:c4914.

8. Maron BJ, Hypertrophic cardiomyopathy and other causes of sudden cardiac death in young competitive athletes, with considerations for preparticipation screening and criteria for disqualification. Cardiol Clin 2007;25:399-414.

9.  American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

10. Parent Heart Watch (www.parentheartwatch.org).

11.  Mahle W, et. al. Key Concepts in the Evaluation of Screening Approaches for Heart Disease in Children and Adolescents. Circulation 2012;125:00-00. DOI: 10.1161/CIR.0b013e3182579f25 (accessed April 30, 2012).  

12.  Casa D, Guskiewicz K, et al. National Athletic Trainers' Association Position Statement: Preventing Sudden Death in Sports. J Athl Tr 2011;47(1):1-24.

13.  Conley KM, Bolin DJ, Carek PJ, Konin JG, Neal TL, Violette D. National Athletic Trainers' Association Position Statement: Preparticipation Physical Examination and Disqualifying Conditions. J Athl Tr. 2014;49(1):102-120. doi:10.4085/1062-6050-48.6.05.