Author + information
- Jonathan A. Drezner, MD∗ (, )
- Jordan M. Prutkin, MD, MHS,
- Kimberly G. Harmon, MD,
- John W. O’Kane, MD,
- Hank F. Pelto, MD,
- Ashwin L. Rao, MD,
- Jeffrey D. Hassebrock, BS,
- Bradley J. Petek, BS,
- Colin Teteak, BA,
- Miranda Timonen, BA,
- Monica Zigman, MPH and
- David S. Owens, MD, MS
- ↵∗Department of Family Medicine, Sports Medicine Section, University of Washington, 3800 Montlake Boulevard NE, P.O. Box 354060, Seattle, Washington 98195-4060
Sudden cardiac death (SCD) is the leading cause of death in college athletes during sports (1). Pre-participation examinations are required in college athletes, although the best screening protocol to identify cardiovascular diseases known to cause SCD is debated. The purpose of this study was to examine results from a single National Collegiate Athletic Association (NCAA) Division I institution with extensive experience conducting electrocardiograms (ECGs) in the cardiovascular screening of athletes.
Routine 12-lead ECG screening of all intercollegiate athletes undergoing pre-participation evaluations at the University of Washington began in August 2010. The screening evaluation included a standardized history questionnaire from the Pre-Participation Physical Evaluation Monograph (4th edition), physical examination, and resting ECG. ECG interpretation was guided by modern standards, and screening abnormalities underwent additional evaluation in consultation with cardiovascular specialists.
Findings were compared among student athletes using the Fisher exact test, and statistical significance was defined as p < 0.05. The primary outcome measure was the identification of disorders associated with SCD. The Human Subjects Division at the University of Washington approved the study.
Data from 790 consecutive athletes screened between August 2010 and June 2014 were analyzed. Of the athletes, 56.2% were male, the mean age was 18 years (range, 17 to 25 years), 59.4% were Caucasian, 14.6% were African-American, 3% were Asian, 23.2% were of other/mixed race, and they participated in 19 different intercollegiate sports plus cheerleading.
At least 1 positive cardiovascular symptom or family history response was reported by 294 athletes (37.2%). Female athletes were more likely to report at least 1 positive symptom or family history response (43.3%) versus male athletes (32.4%) (p = 0.002). The most common history responses were syncope/near-syncope during or after exercise (7.4%), chest discomfort/pain/tightness/pressure during exercise (5.1%), and a family history of a heart problem, a pacemaker, or an implanted defibrillator (15.2%). Physical examination findings were abnormal in 28 athletes (3.5%), including 26 athletes (3.3%) with a heart murmur and 2 athletes (0.3%) with physical stigmata of Marfan syndrome.
ECG abnormalities were present in 22 athletes (2.8%). Male and female athletes (3.6% vs. 1.7%; p = 0.131), and African-American and Caucasian athletes (3.5% vs. 3.2%; p = 0.776) had similar rates of ECG abnormalities. The average time loss from sport to conduct secondary testing was 6.4 days (range, 0-33 days), and there were no adverse medical events from secondary testing or therapeutic procedures.
Five athletes (0.6%) were identified with cardiac conditions associated with SCD, including hypertrophic cardiomyopathy (n = 1), genetically confirmed long QT type I (n = 1), and Wolff-Parkinson-White syndrome (n = 3). All athletes with potentially lethal disorders were asymptomatic and had abnormal ECG findings (Table 1).
This analysis demonstrates that screening by history and physical examination alone has a low sensitivity to detect conditions associated with SCD in college athletes and that the addition of an ECG, when properly interpreted and with skilled cardiology resources, improves the detection of silent/congenital cardiac conditions associated with SCD. All 5 athletes in this cohort identified with a disorder associated with SCD were detected by an ECG and would have been missed by only a screening history and physical examination.
This analysis exhibits the rather vague nature and low yield of screening questionnaires. More than one-third of athletes reported at least 1 positive cardiac symptom or family history response. The American Heart Association recently expanded their primary recommendations for screening from a 12-point to a 14-point assessment (2). However, simply asking more questions is unlikely to improve detection of athletes at risk when the sensitivity and specificity of the tool itself have considerable limitations.
SCD in NCAA athletes is more frequent than initial estimates, with an overall incidence of 1:43,000, with male basketball players having the highest risk of SCD at 1:7,000 athletes per year (1). Strong consideration must be given to implementing improved models of prevention.
Accurate interpretation of an athlete’s ECG requires proper training and experience. The false-positive rate in this study was only 2.2%, and approximately 1 in 4 athletes with abnormal ECG findings were found to have a cardiac disorder associated with SCD. Physician expertise, cardiology, and institutional resources vary among NCAA institutions, which will affect both the capacity and ability to implement ECG screening. Thus, the findings of this study may not be applicable to institutions with less experience. If an ECG is included in the cardiovascular screening of athletes, it must be interpreted with modern standards that distinguish physiological cardiac remodeling from findings suggestive of underlying cardiac pathology and be conducted with adequate cardiology oversight and resources to assist with the secondary investigation of ECG abnormalities.
Screening history questionnaires have a high response rate, and their value in the detection of athletes at risk when used as the sole screening tool is uncertain. ECG screening increases the ability to identify athletes with disorders associated with SCD and thus meet the primary objective of pre-participation screening. An integrated cardiovascular screening that includes an ECG should be considered best practice for the pre-participation evaluation of college athletes.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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