How strong is "new evidence" for mandatory ECG screening of athletes?
Pelliccia and Corrado (1) have recently advanced what they claim to
be new support (2, 3) for the controversial practice (4-8) of mandatory
pre-participation ECG screening of athletes as a means of preventing
exercise-related sudden death. The same article (1) also created some
confusion by suggesting that both the American Heart Association (AHA) and
the European Society of Cardiology call for cardiovascular screening,
although in fact the AHA has firmly recommended against the ECG screening
of athletes (9).
How strong is the additional evidence presented by Pelliccia and
Corrado (1)? The first of the recent studies cited is by Baggish et al.
(2). They used what seems a rather small sample (510 unselected U.S.
college athletes, presumably male, although this is not stated) to
investigate a very rare problem They compared the diagnostic efficacy of
history and physical examination alone against a combination of such
information with the findings from a 12-lead resting ECG obtained on the
same subjects. The outcome of their comparison necessarily depends on the
skill used in making the respective evaluations. We read that an 8-minute
clinical examination was conducted by non-cardiologist clinicians from the
University Health Service, individuals who were not dedicated sports
physicians; further, the subsequent ECG evaluation was based on European
College of Cardiology standards, which do not take account of athlete-
specific criteria of normality. Moreover, the gold standard for a correct
diagnosis was not subsequent cardiac death as observed by a prospective
trial, but rather a cross-sectional comparison of the two data sets with
reports of suggestive or diagnostic abnormalities as seen during a limited
echocardiographic imaging. Thus, the methods adopted to compare the two
diagnostic approaches must be judged as relatively weak. Nevertheless,
this provides the basis for their claim that after considering the results
of ECG testing, 11 individuals with dangerous abnormalities were detected,
as against only five athletes who were identified by history and physical
examination alone. It is hard to believe that 11 of 510 unselected
college athletes were at imminent risk of exercise-induced sudden death;
most estimates put the annual risk at around 1 incident per 100,000
athletes. It thus seems significant that only three of the 11 athletes
identified were asked to restrict their sport participation; in my view,
even this number seems excessive. Furthermore, we have no information
whether the restriction of physical activity lengthened or shortened the
subsequent life span of the individuals concerned!
The second piece of evidence advanced by Pelliccia and Corrado (1) is
a paper by Wheeler et al. (3). This sought to estimate the cost-
effectiveness of adding ECG screening to clinical examination. Costs were
based on 2004 figures from the US National Center for Health Statistics,
but the risks of sudden exercise-induced death were drawn from a somewhat
puzzling non-randomized Italian data set (10); the Italian statistics
suggested a very high initial prevalence of sudden exercise-induced death,
and figures have remained above those in the U.S. despite an apparent
decrease of mortality among the Italian athletes following the
introduction of mandatory ECG screening. Theoretical calculations
suggested an added expense of US $42,900 per life-year saved. At first
inspection, this figure might seem comparable with the cost-effectiveness
of other accepted procedures such as renal dialysis. However, the Italian
recommendation has been for annual rather than once only screening of
athletes, and this would immediately boost expenditures by a factor of 10-
20. Moreover, the ECG screening of an athletic population inevitably
creates a large proportion of false positive diagnoses, and the accounting
of Wheeler et al. (3) did not examine either the worsening of health
imposed by unnecessary restrictions upon physical activity, or the impact
of essential further testing upon the well-being and productivity of the
next of kin and those individuals wrongly identified as at increased risk
on the basis of their ECG records.
The new evidence in the papers of Baggish et al. (2) and Wheeler et
al. (3) thus seems far from convincing. More importantly, the recent
paper of Pelliccia and Corrado (1) does not answer the fundamental
question. How can their approach satisfy the classical Wilson-Jungner
criteria for any useful screening procedure (11), including particularly a
substantial disease prevalence and an appropriate level of sensitivity and
specificity in the test procedure?
References
1. Pelliccia A, Corrado D. Can ECG screening prevent sudden death in
athletes? Yes. BMJ 2010; 341:c4923.
2. Baggish AL, Hutter AM, Wang F, Yared K, Weiner RB, Kupperman E,
Picard MH, Wood MJ. Cardiovascular Screening in College Athletes With and
Without Electrocardiography. A Cross-sectional Study. Ann Intern Med 2010;
152: 269-275.
3. Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Wheeler
EAA, Cost-Effectiveness of Preparticipation Screening for Prevention of
Sudden Cardiac Death in Young Athletes. Ann Intern Med 2010; 152: 276-286.
4. Shephard RJ. Mass ECG screening of young athletes Br J.Sports Med.
2008;42;707-708.
5. Shephard RJ. Preparticipation screening of young athletes: An
effective investment? In: Year Book of Sports Medicine, 2005, RJ Shephard,
MJL Alexander, RC Cantu et al., eds. Philadelphia, PA. Elsevier/Mosby,
2005; xix-xvi.
6. Chaitman R. An Electrocardiogram Should Not Be Included in Routine
Preparticipation Screening of Young Athletes. Circulation 2007;116;2610-
2615.
7. Myerburg RJ, Vetter VL. Electrocardiograms Should Be Included in
Preparticipation Screening of Athletes. Circulation 2007;116;2616-2626.
8. Bahr R. Can ECG screening prevent sudden death in athletes? No.
BMJ 2010; 341:c4914.
9. Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D,
Dimeff R, Douglas PS, Glover DW, Hutter AM, Krauss MD, Maron MS, Mitten
MJ, Roberts WO, Puffer JC. Recommendations and Considerations Related to
Preparticipation Screening for Cardiovascular Abnormalities in Competitive
Athletes: 2007 Update: A ScientificStatement From the American Heart
Association Council on Nutrition, Physical Activity, and Metabolism:
Endorsed by the American College of Cardiology Foundation. Circulation
2007;115;1643-1655.
10. Corrado D, Basso C, Pavei A, et al. Trends in sudden
cardiovascular death in young competitive athletes after implementation of
a preparticipation screening program. JAMA 2006;296:1593-1601.
11. Andermann A, Blancquaert I, Beauchamp S, Deryc V. Revisiting
Wilson and Jungner in the genomic age: a review of screening criteria over
the past 40 years. Bull World Health Organ. 2008; 86:317-319.
Rapid Response:
How strong is "new evidence" for mandatory ECG screening of athletes?
Pelliccia and Corrado (1) have recently advanced what they claim to
be new support (2, 3) for the controversial practice (4-8) of mandatory
pre-participation ECG screening of athletes as a means of preventing
exercise-related sudden death. The same article (1) also created some
confusion by suggesting that both the American Heart Association (AHA) and
the European Society of Cardiology call for cardiovascular screening,
although in fact the AHA has firmly recommended against the ECG screening
of athletes (9).
How strong is the additional evidence presented by Pelliccia and
Corrado (1)? The first of the recent studies cited is by Baggish et al.
(2). They used what seems a rather small sample (510 unselected U.S.
college athletes, presumably male, although this is not stated) to
investigate a very rare problem They compared the diagnostic efficacy of
history and physical examination alone against a combination of such
information with the findings from a 12-lead resting ECG obtained on the
same subjects. The outcome of their comparison necessarily depends on the
skill used in making the respective evaluations. We read that an 8-minute
clinical examination was conducted by non-cardiologist clinicians from the
University Health Service, individuals who were not dedicated sports
physicians; further, the subsequent ECG evaluation was based on European
College of Cardiology standards, which do not take account of athlete-
specific criteria of normality. Moreover, the gold standard for a correct
diagnosis was not subsequent cardiac death as observed by a prospective
trial, but rather a cross-sectional comparison of the two data sets with
reports of suggestive or diagnostic abnormalities as seen during a limited
echocardiographic imaging. Thus, the methods adopted to compare the two
diagnostic approaches must be judged as relatively weak. Nevertheless,
this provides the basis for their claim that after considering the results
of ECG testing, 11 individuals with dangerous abnormalities were detected,
as against only five athletes who were identified by history and physical
examination alone. It is hard to believe that 11 of 510 unselected
college athletes were at imminent risk of exercise-induced sudden death;
most estimates put the annual risk at around 1 incident per 100,000
athletes. It thus seems significant that only three of the 11 athletes
identified were asked to restrict their sport participation; in my view,
even this number seems excessive. Furthermore, we have no information
whether the restriction of physical activity lengthened or shortened the
subsequent life span of the individuals concerned!
The second piece of evidence advanced by Pelliccia and Corrado (1) is
a paper by Wheeler et al. (3). This sought to estimate the cost-
effectiveness of adding ECG screening to clinical examination. Costs were
based on 2004 figures from the US National Center for Health Statistics,
but the risks of sudden exercise-induced death were drawn from a somewhat
puzzling non-randomized Italian data set (10); the Italian statistics
suggested a very high initial prevalence of sudden exercise-induced death,
and figures have remained above those in the U.S. despite an apparent
decrease of mortality among the Italian athletes following the
introduction of mandatory ECG screening. Theoretical calculations
suggested an added expense of US $42,900 per life-year saved. At first
inspection, this figure might seem comparable with the cost-effectiveness
of other accepted procedures such as renal dialysis. However, the Italian
recommendation has been for annual rather than once only screening of
athletes, and this would immediately boost expenditures by a factor of 10-
20. Moreover, the ECG screening of an athletic population inevitably
creates a large proportion of false positive diagnoses, and the accounting
of Wheeler et al. (3) did not examine either the worsening of health
imposed by unnecessary restrictions upon physical activity, or the impact
of essential further testing upon the well-being and productivity of the
next of kin and those individuals wrongly identified as at increased risk
on the basis of their ECG records.
The new evidence in the papers of Baggish et al. (2) and Wheeler et
al. (3) thus seems far from convincing. More importantly, the recent
paper of Pelliccia and Corrado (1) does not answer the fundamental
question. How can their approach satisfy the classical Wilson-Jungner
criteria for any useful screening procedure (11), including particularly a
substantial disease prevalence and an appropriate level of sensitivity and
specificity in the test procedure?
References
1. Pelliccia A, Corrado D. Can ECG screening prevent sudden death in
athletes? Yes. BMJ 2010; 341:c4923.
2. Baggish AL, Hutter AM, Wang F, Yared K, Weiner RB, Kupperman E,
Picard MH, Wood MJ. Cardiovascular Screening in College Athletes With and
Without Electrocardiography. A Cross-sectional Study. Ann Intern Med 2010;
152: 269-275.
3. Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Wheeler
EAA, Cost-Effectiveness of Preparticipation Screening for Prevention of
Sudden Cardiac Death in Young Athletes. Ann Intern Med 2010; 152: 276-286.
4. Shephard RJ. Mass ECG screening of young athletes Br J.Sports Med.
2008;42;707-708.
5. Shephard RJ. Preparticipation screening of young athletes: An
effective investment? In: Year Book of Sports Medicine, 2005, RJ Shephard,
MJL Alexander, RC Cantu et al., eds. Philadelphia, PA. Elsevier/Mosby,
2005; xix-xvi.
6. Chaitman R. An Electrocardiogram Should Not Be Included in Routine
Preparticipation Screening of Young Athletes. Circulation 2007;116;2610-
2615.
7. Myerburg RJ, Vetter VL. Electrocardiograms Should Be Included in
Preparticipation Screening of Athletes. Circulation 2007;116;2616-2626.
8. Bahr R. Can ECG screening prevent sudden death in athletes? No.
BMJ 2010; 341:c4914.
9. Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D,
Dimeff R, Douglas PS, Glover DW, Hutter AM, Krauss MD, Maron MS, Mitten
MJ, Roberts WO, Puffer JC. Recommendations and Considerations Related to
Preparticipation Screening for Cardiovascular Abnormalities in Competitive
Athletes: 2007 Update: A ScientificStatement From the American Heart
Association Council on Nutrition, Physical Activity, and Metabolism:
Endorsed by the American College of Cardiology Foundation. Circulation
2007;115;1643-1655.
10. Corrado D, Basso C, Pavei A, et al. Trends in sudden
cardiovascular death in young competitive athletes after implementation of
a preparticipation screening program. JAMA 2006;296:1593-1601.
11. Andermann A, Blancquaert I, Beauchamp S, Deryc V. Revisiting
Wilson and Jungner in the genomic age: a review of screening criteria over
the past 40 years. Bull World Health Organ. 2008; 86:317-319.
Competing interests: No competing interests