Tweet
Copyright 2005 The McGraw-Hill Companies, Inc. http://www.mcgrawhill.com
All Rights Reserved
Physician and Sportsmedicine
SECTION: News Briefs; Pg. 12 Vol. 33 No. 3
LENGTH: 1628 words
HEADLINE: Groups Endorse ECG Screening for Athletes
BYLINE: Lisa Schnirring.
Barry J. Maron, MD, an international expert on sudden cardiac death in
athletes, wrote that the Un
BODY:
Obstacles such as cost, staffing, and the likelihood of false-positives have
prevented cardiac diagnostic tests such as 12-lead electrocardiography (ECG)
from becoming a routine part of the preparticipation examination (PPE) in most
countries, including the United States. Two international medical groups,
however, have recently endorsed the inclusion of the 12-lead ECG in the PPE.
In December 2004, the International Olympic Committee (IOC) medical
commission released a consensus statement that outlines standards for the
cardiac PPE, which includes 12-lead ECG testing. (Reference)1 Soon after, in
February, study groups of the European Society of Cardiology published a
consensus statement proposing a European standard for cardiac evaluation of
athletes that includes the 12-lead ECG. (Reference)2
The Scope of the Problem
Estimates of sudden death in high school athletes range from 1 in 100,000 to
1 in 300,000, and sudden death is disproportionately higher in male athletes.
(Reference)3,4 An Italian study (Reference)5 projected that adolescents and
young adults who compete in sports are more than twice as likely to die as their
nonathletic peers.
In 1996, the American Heart Association (AHA) released guidelines for the
cardiac PPE that are still in use. (Reference)6 Since then, sports cardiologists
and PPE experts have pushed for the adoption of a national standardized cardiac
PPE, because the cardiac component of the PPE forms used by several states do
not conform to AHA recommendations. The recently updated PPE monograph
(Reference)7 incorporates the AHA guidelines and provides further guidance about
the cardiac component of the exam.
The AHA recommendations state that ECG testing is not cost-effective for
screening large numbers of athletes because of its low specificity. Italians,
however, have been doing ECG screening of athletes for 25 years as part of a
government-mandated PPE policy. High-profile sudden deaths in athletes combined
with high hopes that technologic advances will make noninvasive cardiac tests
more cost efficient still fuel discussions about adding the ECG to the PPE.
IOC Advances Care for its Athletes
The IOC statement, commonly referred to as the Lausanne recommendations,
advises that participants in competitive sports who are younger than age 35
undergo a preparticipation cardiovascular screening at least every other year
that includes:
-- A detailed personal history to rule out any potentially detectable
cardiovascular condition,
-- A detailed family history to detect inherited cardiomyopathies, heart
rhythm problems such as long QT syndrome, and connective tissue disorders such
as Marfan syndrome,
-- A physical examination, and
-- 12-lead resting ECG after the onset of puberty to detect rhythm,
conduction, or repolarization abnormalities.
The Lausanne recommendations also suggest that athletes who have a
positive personal history, have a family history of an inherited cardiac
disease, or have positive findings on the physical exam or ECG be refereed to an
age-appropriate cardiologist for further evaluation.
Joel I. Brenner, MD, director of pediatric cardiology at Johns Hopkins
University in Baltimore, was part of the group that drafted the consensus
statement. Brenner says the IOC's statement isn't intended to influence global
cardiac PPE policies. ``They're clearly making this recommendation for their own
constituents: the Olympic medical community and the sports federations,'' he
says. Brenner says the statement signals that the IOC medical commission is
shifting its focus back to its original mission of safeguarding the health and
safety of athletes. Doping responsibilities are now maintained by the World
Anti-Doping Agency.
The consensus group realizes that not all countries have the resources to
cover the cost of ECG testing their athletes. ``Some can't even buy shoes for
their athletes,'' he says.
Europeans Seek a Common Standard
Italy's 25-year history of ECG screening of athletes, and the contributions
to the medical literature that have followed, are a central theme in the
European recommendations that advocate inclusion of ECG testing to increase the
sensitivity for conditions that increase the risk of sudden cardiac death.
In advocating for the inclusion of the ECG in the PPE, the European group
states that, based on Italian findings, the 12-lead ECG may be as sensitive as
echocardiography in detecting hypertrophic cardiomopathy, the leading cause of
sudden death in young competitive athletes. The authors wrote: ``These findings
indicate that the Italian screening modality has 77 percent greater power for
detecting HCM and expected to result in a corresponding additional number of
lives saved.'' They estimated that the increased diagnostic power triples the
cost effectiveness of the Italian strategy as compared with the US screening
protocol.
The group proposes that a cardiac PPE that combines a thorough history,
physical exam, and ECG screening be adopted as a European standard for medical
evaluation of competitive athletes. It suggests that screening should start at
the beginning of an athlete's competitive career (at about ages 12 to 14) and be
repeated at least every 2 years.
Though the group recognizes that different socioeconomic and cultural
conditions across Europe may make standardizing the 12-lead ECG difficult, they
believe the increased cost is reasonable. They estimate that mass ECG screenings
would add 10 Euros ($13.25 US) to the cost of the cardiac PPE. They add that
costs are generally covered by the athlete or the sports team, and that national
health systems often cover the exam for athletes who are younger than 18.
Will Statements Influence North American Policies?
In an editorial (Reference)8 in the European Heart Journal that accompanied
the European group's consensus statement, Barry J. Maron, MD, an expert on
sudden cardiac death in athletes who directs the Hypertrophic Cardiomyopathy
Center at the Minneapolis Heart Institute Foundation in Minneapolis, lauded the
idea of a common European protocol and praised the group's efforts to increase
awareness and interest in sudden cardiac death across Europe. Maron writes:
``Extending this Italian programme to other European countries would certainly
be a laudable enterprise, for it has the potential to save young lives.
Nevertheless, the central challenge is one of practicality, feasibility, and
implementation--with the primary potential obstacle being adequate resources and
economic support.
Maron believes that it's highly unlikely that the US could adopt a cardiac
PPE policy that includes mass 12-lead ECG screening. With a population of 284
million people and 12 to 15 million widely dispersed sports participants,
``There are simply too many competing healthcare priorities and special
interests and anticipated difficulties in cost control, as well as heightened
concerns for medicolegal liability, to warrant serious consideration for such an
undertaking in the United States,'' Maron wrote.
Though Maron says the suggestions by the European group and the IOC would
be superior to the current US cardiac PPE strategies, adding ECG screening would
present serious problems. ``It could also be expected to be fraught with the
major limitation of many false-positive test results and reevaluations, which
would negatively impact available resources and increase the psychological
burden on the athletes, families, coaches, and institutions.''
In Canada, the obstacles are similar, despite the fact that Canadian
healthcare is partially nationalized, says Andrew Pipe, MD, chair of the
Canadian Centre for Ethics in Sport and a physician at the University of Ottawa
Heart Institute. He says the examinations by third parties such as insurance
companies or athletic organizations are not covered by provincial health
services. ``Thus, they would become the responsibility of the athlete or the
athletic organizations requesting the test. As a consequence, it is unlikely
that such testing will be formalized,'' Pipe says.
Pipe, like Maron, is concerned about the technical comfort levels of those
who would be interpreting ECGs if widespread screening for athletes were
instituted. ``Our experience in addressing the concerns raised by clinicians who
are unfamiliar with the ECG changes that commonly occur in athletes serves to
underscore Dr Maron's point, in this regard,'' he says. While the public might
perceive that adding an extra screening step to the cardiac PPE as a manageable
change, physicians who perform PPE exams know how complex the process really is,
Pipe says.
Public health would be better served if clinicians worried less about the
small minority of individuals for whom exercise may be hazardous and focus more
on the number of young people who are sedentary, Pipe says. ``A cynic might
suggest that they need a medical exam to determine whether they are able to
withstand the `rigors' and risks of a sedentary, obesogenic lifestyle!'' he
adds.
Brenner emphasizes that there is no perfect system for the cardiac PPE,
but that the current systems can always be improved, even for Olympic-level
athletes. Within the United States Olympic Committee (USOC), Brenner says he's
aware of two athlete deaths during training in the last two decades. ``One
clearly might have been avoided if a better history had been taken, because
there was evidence of syncope with activity,'' he says, ``So it's safe to say
that 50 percent of deaths could have been avoided.'' While mass ECG screening
might not be realistic, clinicians can still improve the process by taking a
thorough approach to the patient and family histories, Brenner says, adding that
the USOC has already adopted a more rigorous cardiac history form.
LOAD-DATE: March 28, 2005
All Rights Reserved
Physician and Sportsmedicine
SECTION: News Briefs; Pg. 12 Vol. 33 No. 3
LENGTH: 1628 words
HEADLINE: Groups Endorse ECG Screening for Athletes
BYLINE: Lisa Schnirring.
Barry J. Maron, MD, an international expert on sudden cardiac death in
athletes, wrote that the Un
BODY:
Obstacles such as cost, staffing, and the likelihood of false-positives have
prevented cardiac diagnostic tests such as 12-lead electrocardiography (ECG)
from becoming a routine part of the preparticipation examination (PPE) in most
countries, including the United States. Two international medical groups,
however, have recently endorsed the inclusion of the 12-lead ECG in the PPE.
In December 2004, the International Olympic Committee (IOC) medical
commission released a consensus statement that outlines standards for the
cardiac PPE, which includes 12-lead ECG testing. (Reference)1 Soon after, in
February, study groups of the European Society of Cardiology published a
consensus statement proposing a European standard for cardiac evaluation of
athletes that includes the 12-lead ECG. (Reference)2
The Scope of the Problem
Estimates of sudden death in high school athletes range from 1 in 100,000 to
1 in 300,000, and sudden death is disproportionately higher in male athletes.
(Reference)3,4 An Italian study (Reference)5 projected that adolescents and
young adults who compete in sports are more than twice as likely to die as their
nonathletic peers.
In 1996, the American Heart Association (AHA) released guidelines for the
cardiac PPE that are still in use. (Reference)6 Since then, sports cardiologists
and PPE experts have pushed for the adoption of a national standardized cardiac
PPE, because the cardiac component of the PPE forms used by several states do
not conform to AHA recommendations. The recently updated PPE monograph
(Reference)7 incorporates the AHA guidelines and provides further guidance about
the cardiac component of the exam.
The AHA recommendations state that ECG testing is not cost-effective for
screening large numbers of athletes because of its low specificity. Italians,
however, have been doing ECG screening of athletes for 25 years as part of a
government-mandated PPE policy. High-profile sudden deaths in athletes combined
with high hopes that technologic advances will make noninvasive cardiac tests
more cost efficient still fuel discussions about adding the ECG to the PPE.
IOC Advances Care for its Athletes
The IOC statement, commonly referred to as the Lausanne recommendations,
advises that participants in competitive sports who are younger than age 35
undergo a preparticipation cardiovascular screening at least every other year
that includes:
-- A detailed personal history to rule out any potentially detectable
cardiovascular condition,
-- A detailed family history to detect inherited cardiomyopathies, heart
rhythm problems such as long QT syndrome, and connective tissue disorders such
as Marfan syndrome,
-- A physical examination, and
-- 12-lead resting ECG after the onset of puberty to detect rhythm,
conduction, or repolarization abnormalities.
The Lausanne recommendations also suggest that athletes who have a
positive personal history, have a family history of an inherited cardiac
disease, or have positive findings on the physical exam or ECG be refereed to an
age-appropriate cardiologist for further evaluation.
Joel I. Brenner, MD, director of pediatric cardiology at Johns Hopkins
University in Baltimore, was part of the group that drafted the consensus
statement. Brenner says the IOC's statement isn't intended to influence global
cardiac PPE policies. ``They're clearly making this recommendation for their own
constituents: the Olympic medical community and the sports federations,'' he
says. Brenner says the statement signals that the IOC medical commission is
shifting its focus back to its original mission of safeguarding the health and
safety of athletes. Doping responsibilities are now maintained by the World
Anti-Doping Agency.
The consensus group realizes that not all countries have the resources to
cover the cost of ECG testing their athletes. ``Some can't even buy shoes for
their athletes,'' he says.
Europeans Seek a Common Standard
Italy's 25-year history of ECG screening of athletes, and the contributions
to the medical literature that have followed, are a central theme in the
European recommendations that advocate inclusion of ECG testing to increase the
sensitivity for conditions that increase the risk of sudden cardiac death.
In advocating for the inclusion of the ECG in the PPE, the European group
states that, based on Italian findings, the 12-lead ECG may be as sensitive as
echocardiography in detecting hypertrophic cardiomopathy, the leading cause of
sudden death in young competitive athletes. The authors wrote: ``These findings
indicate that the Italian screening modality has 77 percent greater power for
detecting HCM and expected to result in a corresponding additional number of
lives saved.'' They estimated that the increased diagnostic power triples the
cost effectiveness of the Italian strategy as compared with the US screening
protocol.
The group proposes that a cardiac PPE that combines a thorough history,
physical exam, and ECG screening be adopted as a European standard for medical
evaluation of competitive athletes. It suggests that screening should start at
the beginning of an athlete's competitive career (at about ages 12 to 14) and be
repeated at least every 2 years.
Though the group recognizes that different socioeconomic and cultural
conditions across Europe may make standardizing the 12-lead ECG difficult, they
believe the increased cost is reasonable. They estimate that mass ECG screenings
would add 10 Euros ($13.25 US) to the cost of the cardiac PPE. They add that
costs are generally covered by the athlete or the sports team, and that national
health systems often cover the exam for athletes who are younger than 18.
Will Statements Influence North American Policies?
In an editorial (Reference)8 in the European Heart Journal that accompanied
the European group's consensus statement, Barry J. Maron, MD, an expert on
sudden cardiac death in athletes who directs the Hypertrophic Cardiomyopathy
Center at the Minneapolis Heart Institute Foundation in Minneapolis, lauded the
idea of a common European protocol and praised the group's efforts to increase
awareness and interest in sudden cardiac death across Europe. Maron writes:
``Extending this Italian programme to other European countries would certainly
be a laudable enterprise, for it has the potential to save young lives.
Nevertheless, the central challenge is one of practicality, feasibility, and
implementation--with the primary potential obstacle being adequate resources and
economic support.
Maron believes that it's highly unlikely that the US could adopt a cardiac
PPE policy that includes mass 12-lead ECG screening. With a population of 284
million people and 12 to 15 million widely dispersed sports participants,
``There are simply too many competing healthcare priorities and special
interests and anticipated difficulties in cost control, as well as heightened
concerns for medicolegal liability, to warrant serious consideration for such an
undertaking in the United States,'' Maron wrote.
Though Maron says the suggestions by the European group and the IOC would
be superior to the current US cardiac PPE strategies, adding ECG screening would
present serious problems. ``It could also be expected to be fraught with the
major limitation of many false-positive test results and reevaluations, which
would negatively impact available resources and increase the psychological
burden on the athletes, families, coaches, and institutions.''
In Canada, the obstacles are similar, despite the fact that Canadian
healthcare is partially nationalized, says Andrew Pipe, MD, chair of the
Canadian Centre for Ethics in Sport and a physician at the University of Ottawa
Heart Institute. He says the examinations by third parties such as insurance
companies or athletic organizations are not covered by provincial health
services. ``Thus, they would become the responsibility of the athlete or the
athletic organizations requesting the test. As a consequence, it is unlikely
that such testing will be formalized,'' Pipe says.
Pipe, like Maron, is concerned about the technical comfort levels of those
who would be interpreting ECGs if widespread screening for athletes were
instituted. ``Our experience in addressing the concerns raised by clinicians who
are unfamiliar with the ECG changes that commonly occur in athletes serves to
underscore Dr Maron's point, in this regard,'' he says. While the public might
perceive that adding an extra screening step to the cardiac PPE as a manageable
change, physicians who perform PPE exams know how complex the process really is,
Pipe says.
Public health would be better served if clinicians worried less about the
small minority of individuals for whom exercise may be hazardous and focus more
on the number of young people who are sedentary, Pipe says. ``A cynic might
suggest that they need a medical exam to determine whether they are able to
withstand the `rigors' and risks of a sedentary, obesogenic lifestyle!'' he
adds.
Brenner emphasizes that there is no perfect system for the cardiac PPE,
but that the current systems can always be improved, even for Olympic-level
athletes. Within the United States Olympic Committee (USOC), Brenner says he's
aware of two athlete deaths during training in the last two decades. ``One
clearly might have been avoided if a better history had been taken, because
there was evidence of syncope with activity,'' he says, ``So it's safe to say
that 50 percent of deaths could have been avoided.'' While mass ECG screening
might not be realistic, clinicians can still improve the process by taking a
thorough approach to the patient and family histories, Brenner says, adding that
the USOC has already adopted a more rigorous cardiac history form.
LOAD-DATE: March 28, 2005
Comment