Performance of the 2010 European Society of Cardiology criteria for ECG interpretation in athletes
Weiner RB, Hutter AM, Wang F, Kim JH, Wood MJ, Wang TJ, Picard MH, Baggish AL. Heart. 2011 Oct;97(19):1573-7.
SMR has summarized a few studies (see related posts below) regarding the debate about whether or not electrocardiograms (ECGs) should be included in preparticipation physical examinations. One concern is that universal ECG screening may lead to a high rate of false positive findings (summary of common diagnostic terms). To address this concern, the European Society of Cardiology (ESC), one of the organizations endorsing ECG screening, recently updated recommendations for ECG interpretation among athletes. However, the performance of these new recommendations has not been assessed in a large prospective cohort that also was assessed with echocardiograms. Therefore, Weiner et al assessed the performance of the 2010 ESC recommendations among 508 university athletes undergoing routine preparticipation cardiovascular disease screening (2006 to 2008). All of the athletes (68% Caucasian) underwent a standardized medical history/physical examination and12-lead ECG screening. ECG was performed and interpreted (with the 2005 and 2010 ESC recommendation) by study investigators that were unaware of the results of the medical history/physical examination. Transthoracic echocardiography, to assess structural abnormalities, was performed by investigators blinded to the results of the other evaluations. All participants were followed for a minimum of 2 years after enrollment. Echocardiographies were used to classify athletes as normal (375 [74%] athletes), mildly abnormal (benign findings of normal exercise-induced cardiac remodeling; 122 [45%] athletes), or abnormal (“findings suggestive of, or diagnostic for, cardiac disease relevant to sport participation risk”). Eleven athletes were defined as abnormal (6 had valvular heart disease, 5 had signs of excessive cardiac tissue remodeling) and referred for further evaluation. Three of these athletes were restricted from sport participation (overall 0.6% of screened athletes were restricted). In comparison, 29 athletes had abnormal ECG findings only (based on 2010 recommendations), 20 athletes had abnormal findings on medical history/physical exam and ECG, and 13 athletes had only abnormal medical history/physical exam. Of the 11 participants defined as abnormal on echocardiograms, the 6 with valvular heart disease did not have abnormal ECG abnormalities, and the five with structural concerns were identified by ECG abnormalities. Compared to the 2005 recommendations, the 2010 recommendations identified fewer athletes as abnormal (83 athletes vs 49 athletes). The new recommendations were associated with improved specificity (0.90 vs 0.83; reduction in false positive rate) and similar sensitivity (0.91 vs 0.91) compared to the 2005 recommendations. No athletes had an adverse cardiovascular event during follow-up.
This study is an important step forward for potential implementation of ECGs in preparticipation screenings. The authors previously showed that ECG increases the sensitivity of preparticipation screening but it also increased the false positive rate. Since that study, the new ESC recommendations were released and these guidelines reduce the false positive rate (0.17 vs 0.10). The improved performance is associated with reclassification of some exercise-induced cardiac tissue remodeling as normal but there is some evidence to suggest that these changes may have some pathological importance. The authors note that these recommendations may be beneficial to organizations already implementing ECG screening but we need to keep in mind that there is still a 10% false positive rate. This study will definitely not end the debate about the role ECG in preparticipation screening but it is a positive step forward to understanding the performance of the ESC recommendations. Do you use ECGs in your preparticipation screening and if so are you using the 2010 ESC recommendations?
Written by: Jeffrey Driban
Reviewed by: Stephen Thomas
Weiner RB, Hutter AM, Wang F, Kim JH, Wood MJ, Wang TJ, Picard MH, & Baggish AL (2011). Performance of the 2010 European Society of Cardiology criteria for ECG interpretation in athletes. Heart, 97 (19), 1573-7 PMID: 21602522
12 lead ECG screening is a relatively cheap source of information that could be extremely beneficial as an additional screening tool for assuring safe participation. The improved 10% false positive rate does not seem unreasonably high until one considers holding back a potential star athlete for an issue that does not exist. Continuously updating recommendations based on current research is critical in the process to implement pre-participation ECG screening. One issue not discussed here is the competence and experience of the interpreter. Specific training programs in various programs of study could potentially lend support to screening. As the science is updated, user error needs to be eliminated.
Justin: Great point. I think you also commented on a recent post by Hallie Labrador and Marc Harwood (https://sportsmedresearch.blogspot.com/2011/08/are-interpretations-of-preparticipation.html) that discussed the accuracy of ECG screenings.
Harmon et al suggested that the costs-benefit analyses could be more favorable if we screened primarily high risk populations. (https://sportsmedresearch.blogspot.com/2011/04/incidence-of-sudden-cardiac-death-among.html)
It is important for all of us to recognize the strengths and limitations of these screening tools as well as how to maximize the strengths (e.g., having well trained assessors).
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