Is There a Role for 12-Lead ECG as a Screening Test for Detection of CVD in Healthy General Populations of Young People?
The sudden, unexpected death of a young person is a devastating event. Friends, family members, and the community have a difficult time coping with the death.1 The reliable identification of individuals at risk for sudden death (SD) has been a focus of the cardiovascular community to possibly reduce SD events through selective disqualification from sports2,3 and prevent SD with the implantable cardioverter-defibrillator in individuals with genetic heart diseases.4,7 The desire to screen populations theoretically at risk for cardiovascular disease to reduce morbidity and mortality is quite understandable but an important question is whether the conditions responsible for these events can be detected effectively by the available testing techniques. Most of the data concerning SD prevention has been limited to the screening of young populations of competitive athletes, and almost all of the available data specifically related to cardiovascular screening efficacy come from such populations composed of trained athletes. Although reports on cardiovascular screening efficacy have predominantly involved populations of adolescents and young adults participating in competitive athletics, the recently published Scientific Statement From the American Heart Association (AHA) and the American College of Cardiology (ACC) on Assessment of the 12-Lead Electrocardiogram (ECG) as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age) includes recommendations for screening large, young, and truly general populations (school-aged, 12–25 years old, of both sexes) with respect to relevant logistical, ethical, legal, and societal issues.8 It is important to place into proper perspective the absolute numbers of SDs, because the frequency of these events is a very important variable in the screening debate. Cardiovascular deaths in young athletes in the United States each year are much less frequent than virtually all other causes of death in the same age group (Figure 1).9,10
There is general consensus among clinicians that conducting a comprehensive screening of personal and family history and physical examination is useful; however, data supporting the efficacy of such a screening strategy alone are limited. The quality of the history-taking and physical examination process (including the expertise of examiners) may be significantly enhanced by using the specific 14-point recommendations of the AHA (Table 1). Although screening ECGs in young people have been used for the purpose of promoting cardiovascular safety, including but not limited to participation in competitive athletics, the value and limitations of screening populations with the 12-lead ECG remain controversial. The 12-lead ECG is widely used to diagnose cardiovascular disease, particularly acute myocardial infarction, in clinics and hospital-based practice. Recently, the ECG has been promoted as a screening test to detect or raise suspicion of predominantly genetic/congenital cardiac disease, such as hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, and long QT syndrome, specifically in large populations of young trained athletes, including consideration for programs even for entire nations. Designing the optimal and most practical strategy to screen young people for underlying cardiovascular disease is complicated, with no simple and definitive solution. Overall, the 12-lead ECG does not appear to qualify as a precise, validated, and suitable screening test known to reliably distinguish the affected from the nonaffected. Moreover, general agreement is lacking on the criteria for defining an abnormal ECG in screening such populations and evidence is lacking from randomized or prospective controlled trials showing that screening ECGs are effective in reducing morbidity and mortality. Furthermore, it is uncertain what proportion of the potential population to be screened, when fully informed with regard to the consequences of testing, would consent to actually participate. Population screening also raises the issue of false positives, particularly in athletes and African American males. The widespread ECG screening would lead to expensive downstream testing that could often be unnecessary and produce anxiety in patients and their families. Indeed, false positives could exceed true positives.
In the recently published document, the ACC/AHA scientific committee suggested that cardiovascular screening programs (independent of size, scope, or design) should be driven by sound scientific principles and policy and not by reaction to catastrophic events or political pressure from advocacy groups. The committee recommended (Table 2) that the AHA 14-point screening guidelines and those of other societies, such as the Preparticipation Physical Evaluation monograph, be used by examiners as part of a comprehensive history-taking and physical examination to detect or raise suspicion of genetic/congenital and other cardiovascular abnormalities and that standardization of the questionnaire forms used as guides for examiners of high school and college athletes in the United States be pursued. The committee felt that screening with 12-lead ECGs (or echocardiograms) in association with comprehensive history-taking and physical examination to identify or raise suspicion of genetic/congenital and other cardiovascular abnormalities may be considered in relatively small cohorts of young healthy people 12 to 25 years of age, not necessarily limited to athletes (e.g., in high schools, colleges/ universities, or local communities), provided that close physician involvement and sufficient quality control can be achieved. The committee felt that mandatory and universal mass screening with 12-lead ECGs in large general populations of young healthy people 12 to 25 years of age (including on a national basis in the United States) to identify genetic/congenital and other cardiovascular abnormalities is not recommended for either athletes or nonathletes. At this time consideration for large-scale, general population, and universal cardiovascular screening in the age group 12 to 25 years with history-taking and physical examination alone is not recommended including on a national basis in the United States.8
The scientific statement committee acknowledged the tragic nature of SDs in the young, but did not believe the available data support a significant public health benefit from using the 12-lead ECG as a universal screening tool. There is a need for more widespread dissemination of automated external defibrillators, which are effective in saving young lives on the athletic field and elsewhere.
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