Is ECG Detection of Cardiac Abnormalities Same For Black and White Athletes?

Over the past several years a growing debate has emerged among cardiologists regarding pre-participation screenings of young athletes to prevent the risk of sudden cardiac death (SCD). While evidence from Italy suggest that ECG-based screening is effective in detecting athletes with potentially serious cardiac disorders, and a growing number of sporting bodies and scientific organization worldwide advocate for its use, justifiable concerns remain in light of high false-positive rates (10-20 percent) occurring from an overlap of physiological ECG patterns and those reflecting cardiac pathology.

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Moving a step further in refining a firm scientific recommendation of the procedure, a new study—published in Circulation on March 11—has attempted to compare the ECG detection of cardiac abnormalities in both black and white elite athletes, filling an informational gap that exists in the predominantly white athlete criteria issued by the European Society of Cardiology (ESC).

Between 2000 and 2012, 4,297 white athletes and 1,208 elite black athletes aged 14-35 were evaluated with a health questionnaire, cardiovascular examination, and 12-lead ECG. The ECGs were retrospectively analyzed according to the ESC recommendations, a "Seattle criteria" recently collaborated on by international experts, and a proposed refined criteria by the authors, which excludes several specific ECG patterns when present in isolation. While ESC recommendations raised suspicion of a cardiac abnormality in 40.4 percent of black athletes and 16.2 of white athletes, the Seattle criteria reduced abnormal ECGs to 18.4 in black athletes and 7.1 percent in white athletes, and the refined criteria further reduced abnormal ECGs to 11.5 percent in black athletes and 5.3 percent in white athletes. In comparison to the ESC recommendations, the refined criteria improved specificity from 40.3 percent to 84.2 in black athletes and 73.8 percent to 94.1 percent in white athletes without compromising the sensitivity of the ECG in detecting cardiac pathology.

The authors conclude that "refinement of current ECG screening criteria has the potential to significantly reduce the burden of false-positive ECGs in athletes, particularly [in] black athletes." Given that black athletes comprise up to 70 percent of individuals participating in certain sports in the U.S., high false-positive rates observed by black athletes using current ECG screening criteria support many of the concerns raised by the American Heart Association. The authors note that the best alternative is to strive towards improved specificity through a better understanding of benign versus abnormal ECG patterns, as well as more appropriate training and education of physicians in the correct interpretation of an athlete’s ECG.

They add that moving forward "the results from this preliminary study require further evaluation and confirmation by other centres. It is our aspiration that the data will provide an important evidence base for revising existing guidelines in the future."

Clinical Topics: Arrhythmias and Clinical EP, Sports and Exercise Cardiology, SCD/Ventricular Arrhythmias

Keywords: Athletes, European Continental Ancestry Group, Sports, Electrocardiography, Questionnaires, African Continental Ancestry Group, Cost of Illness, Death, Sudden, Cardiac

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