Could Routine ECGs Reduce Sudden Cardiac Deaths in Young Athletes?

By Terry Zeigler, EdD, ATC 

According to a study published in the Journal of the American Medical Association (Maron, B.J., Shirani, J., Poliac, L.C., Mathenge, R., Roberts, W.C., & Mueller, F.O., 1996), routine electroencephalographs as part of a preparticipation physical exam could reduce sudden cardiac deaths in young athletes. The researchers analyzed sudden deaths in young athletes between 1985 and 1995, and determined that 85% of the sudden deaths were caused by some type of heart related abnormality.

Of those athletes who died from heart abnormalities, the most common structural cardiovascular disease was identified as hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy is a congenital heart disease that causes thickening in the wall of the left ventricle leading to electrical problems of the heart and possible arrhythmias.

Sudden death may occur when the electrical relay system of the heart is compromised and the heart “flutters” rather than beats. When the heart beats effectively, blood is transported through the chambers of the heart and carried throughout the body by the circulatory system. When the heart “flutters”, blood is trapped within the chambers of the heart with very little blood being transported to the vital organs.

The challenge that sports medicine professionals face is that many people with hypertrophic cardiomyopathy experience no symptoms prior to their sudden collapse. If quality emergency medical treatments are not provided immediately (CPR and administration of an AED), the athlete may not be able to recover.

So if the athlete has no history of shortness of breath, chest pain, or exertional cardiac symptoms associated with exercise, how can these types of sudden deaths be prevented?

This has been a controversial topic in the sports medicine community throughout the years as media attention of sudden deaths in young athletes has increased. However, this subject has been recently fueled by the results of a recent study done in Italy.

Approximately 27 years ago, the country of Italy mandated the nationwide use of a 12-lead ECGs as part of the preparticipation screening for all athletes and followed the results for a 25 year period. Their results showed an 89% reduction in the incidence of sudden cardiac death in young athletes.

So the question for sports medicine professionals to ask in the United States is “are the screening tools currently used for preparticipation exams effective enough or should more be done to protect young athletes from sudden death?”

Currently young athletes in this country are only required to pass a pre-participation physical exam (including a medical history questionnaire and medical screening) by a licensed medical doctor. The doctor needs to sign the paperwork stating that there are no pre-existing medical conditions preventing the athlete from safely competing in sports.

Young athletes competing in high school sports are required to complete an annual pre-participation physical exam and health history screening prior to participating and competing in their school sports. The requirements for pre-participation physical exams for college athletes are dependent on the level of competition as rules differ depending on if the athlete competes at the NCAA, NAIA, or at the community college level.

Many high schools and universities offer one or two dates for their athletes to participate in large group physical exam screenings. Depending on the resources of the schools involved, this might entail bringing one or two physicians on-campus to screen several hundred athletes within a two to four hour period.

If athletes miss the mass screening pre-participation physical exams, then they are required to have their personal physician complete the physical exam and sign the necessary paperwork.

If something comes up during the screening that may indicate that an athlete might have a cardiac abnormality, the athlete is held from participation and referred for further follow-up.

Specific signs and symptoms warranting referral might include:

• Family history of heart attack or sudden death before age 55
• Cigarette smoking
• Hypertension (high blood pressure)
• Fainting or dizziness with activity
• Undue fatigue or shortness of breath after exercise
• Chest pain during exertion
• Heart palpitations or tachycardia
• Abnormal heart rhythm

A more recent study published in the Annals of Internal Medicine concluded that screening young athletes with an electrocardiogram (ECG) test may be a cost-effective way to reduce these types of sudden death occurrences (Stein, J., 2010). Researchers from the Stanford University School of Medicine analyzed the sudden deaths of young athletes aged 14-22. They used various statistical analyses for different screening tools to determine if these tools may have an influence on the outcome of those athletes who died.

The researchers determined that adding an ECG test to the required preparticipation exam could identify at risk athletes and could be a cost effective way to reduce sudden deaths. Although this information is relevant and needs consideration in the sports medicine community, there are others who do not agree with their results.

One of the strongest arguments against mandatory ECG testing is the daunting task of trying to implement diagnostic ECGs on the thousands of athletes who compete in interscholastic sports. Other arguments (Stein, J., 2010) include:

• 7%-20% rate of false positive tests (tests that come back positive but that are actually negative)
• Difficulty of obtaining future health insurance
• Possible other solutions could save lives at less cost (i.e., providing automated external defibrillators on the sidelines)
• Possible lawsuits from disqualifying athletes due to a pre-existing condition

In a perfect world (without financial or personnel limitations), the addition of ECG tests as part of the pre-participation exam would ensure that at-risk athletes would be identified and referred for advanced cardiac tests. Theoretically, the addition of an ECG would reduce the rate of sudden death in young athletes.

However, reality brings in the all too real challenges including the financial limitations of the current health care insurance industry to cover ECGs on otherwise healthy young athletes, and the logistics of implementing ECG tests on thousands of young athletes with limited time, equipment, and personnel.

References

Anderson, M.K., Parr, G.P., & Hall, S.J. (2009). Foundations of Athletic Training: Prevention, Assessment, and Management. (4th Ed.). Lippincott Williams and Wilkins: Philadelphia, PA.

Maron, B. (March 2, 2010). National Electrocardiography Screening for Competitive Athletes: Feasibility in the United States? Annals of Internal Medicine, 152(5), 324-355.

Maron, B.J., Shirani, J., Poliac, L.C., Mathenge, R., Roberts, W.C., & Mueller, F.O. (July, 1996). Sudden Death in Young Competitive Athletes: Clinical, Demographic, and Pathological Profiles. Journal of the American Medical Association, 276: 199-204.

Stein, J. (March 2, 2010). Tests could identify at-risk youth athletes. Los Angeles Times: Los Angeles, CA.

Wheeler, M., Heidenreich, P., Froelicher, V., Hlatky, M., & Ashley, E. (March 2, 2010). Cost-Effectiveness of Preparticipation Screening for Prevention of Sudden Cardiac Death in Young Athletes. Annals of Internal Medicine, 152(5), 276-296.