Randomized Controlled Trial of ECG Screening in Young Athletes: Necessary, Yes – Feasible, Maybe

By Benjamin Levine, M.D., Director, Institute for Exercise and Environmental Medicine
Professor of Internal Medicine
and Karl Gordon Patti, M.D., Internal Medicine Resident 

The sudden death of a young athlete is a tragedy that affects families and communities across the country. Identifying who is at risk for sudden cardiac death is challenging, and the role of ECG in screening these athletes is hotly debated. Current AHA/ACC guidelines do not recom­mend routine ECG screening in young athletes, in contrast to some interna­tional guidelines. Despite this lack of scientific support, in 2013, 2015, and 2017 the Texas Legislature considered bills that would require high school students to undergo mandated ECG screening prior to participating in high school athletics.

Advocates of the ECG screening argue that it can help identify young athletes with high-risk conditions such as electrical or structural heart diseases that might not be detected in routine history and physical exams, the current standard of care. Opponents cite the low prevalence of these conditions, the challenges in accurate interpretation of the ECG, and the high risk of false positives requiring additional, possibly invasive testing, with consequent expense and potential life-threatening risk. Indeed, the only reason to add ECG to standard screening of athletes is if it can be demonstrated that including it actually saves lives; the exclusive way to test this objective is with a randomized, controlled trial.

This year’s AHA held a session titled “Rhythm is Relevant: Screening Tools for Arrhythmias.” As part of this session, we presented data from our recent pilot study to assess the feasibility of a randomized, controlled trial investigating ECG screening in Texas high school athletes. Our experience identified several challenges with ECG screening in this population, includ­ing low participation in “opt-in” enrollment, accurate diagnosis of abnor­mal ECGs using specialized software, and, most challengingly, difficulties in study follow-up for nonfatal cardiac events.