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.