Electrocardiographic Screening in National Collegiate Athletic Association Athletes
Drezner JA, Owens DS, Prutkin JM, Salerno JC, Harmon KG, Prosise S, Clark A, Asif IM. Am J Cardiol. 2016 Sep 1;118(5):754-9. doi: 10.1016/j.amjcard.2016.06.004
Take Home Message: Electrocardiographic screening is more accurate than patient history or physical examination to screen for potentially fatal cardiac abnormalities among collegiate athletes.
Preparticipation cardiac screening is a vital strategy to minimize the risk of sudden cardiac death among college athletes. Electrocardiographic (ECG) screening is advised to detect cardiac abnormalities that may be missed with less sophisticated screening methods but can be cost prohibitive. Therefore, it is important to know if ECG screening is accurate and more effective in detecting cardiac abnormalities in college athletes compared to a standardized history or a physical examination. Drezner and colleagues prospectively collected data from 35 NCAA institutions over a two-year period to compare the accuracy of cardiovascular screening among collegiate athletes using a standardized history, physical exam, and ECG. 5,258 athletes from 17 sports in Division I, II, or III schools participated in the study, which included a 12-question history questionnaire, a cardiovascular examination (pulse, blood pressure, cardiac auscultation, and visual inspection), and a 12-lead ECG at rest using the Seattle criteria. Cardiologists read the ECG results at the University of Washington, while history and cardiovascular examination results were recorded by the athlete’s university. Athletes with detected abnormalities received secondary evaluations by cardiovascular specialists. The investigators calculated the number of detectable cardiovascular diseases and determined the diagnostic performance of ECG screening compared to patient history and physical exam. In the patient history questionnaire, 34% of athletes reported at least one positive cardiovascular symptom or family history response. This lead to patient history having the highest false positive rate at 33.3% and lowest sensitivity/specificity at 15% and 67% respectively (see definitions below). On physical exam, 2% had a detectable heart murmur and 0.3% of athletes had physical signs of Marfan's Syndrome. Hence, physical exam had a low false positive rate (2%) and specificity was 98%, but sensitivity was very low at 8%. The cardiologist found ECG abnormalities in 3.7% of athletes. Of the 13 athletes (0.25%) that ECG screening found serious abnormalities associated with sudden cardiac death, only two had abnormal histories and one had an abnormal physical exam. The ECG screening had a slightly higher false positive rate (3%) than physical exam but it is still low when you take into account ECG had a 100% sensitivity and 97% specificity for abnormalities.
Sports medicine departments primary concern is to keep athletes safe, but in reality budgets and finances play a role in what treatment and screening an athlete can receive. While this article did not address the complex cost analysis universities have to consider, it does give objective data from the largest study on cardiac screening methods in college athletes. Drezner and colleagues concluded that sports medicine departments may miss fatal cardiac abnormalities by just using patient history or physical examination. ECG screening detects potentially fatal cardiac abnormalities that are often missed in less sophisticated screening methods. However, the authors were not able to report from this data set how likely athletes with cardiac abnormalities are to have a cardiac emergency or how often athletes with normal ECG results have cardiac emergencies. Clinicians can use the information in this study to guide clinical recommendations, as well as to educate the public about the value of cardiac screening protocols in reducing the risk of sudden cardiac death or other cardiac incidents.
Questions for Discussion: How confident are you that your preseason health screening is effective at finding cardiac abnormalities? How do you think we can get more athletes to complete preseason ECG protocols?
Written by: Joshua Baracks
Reviewed by: Jeffrey Driban
Cardiovascular Screening Practices in College Athletics has Room for Improvement
Preparticipation Cardiovascular Screening among NCAA Division I Institutions
African-American/Minority Males are at High Risk of Sudden Death
Interassociation Consensus Statement on Cardiovascular Care of College Student-Athletes
"Sensitivity —The proportion of people with the disease who are correctly identified by a positive test result (“true positive rate”)
Specificity —The proportion of people free of the disease who are correctly identified by a negative test result (“true negative rate”)
Drezner, J., Owens, D., Prutkin, J., Salerno, J., Harmon, K., Prosise, S., Clark, A., & Asif, I. (2016). Electrocardiographic Screening in National Collegiate Athletic Association Athletes The American Journal of Cardiology, 118 (5), 754-759 DOI: 10.1016/j.amjcard.2016.06.004