Breaking Down the Mandatory Electrocardiogram Debate

With four seconds on the clock, the rumble of the crowd is deafening. The entire school is on their feet, doused in green and gold, anxiously waiting for the play that will lead them to victory or defeat. The quarterback takes the snap, reads the coverage, sets up to pass and suddenly falls to the ground. This is no blitz. This is sudden cardiac death and it’s the last time the young quarterback will ever be sacked.

The emotional impact of a young athlete’s death on the field is an event that reverberates throughout the youth’s entire community, causing the collective voice to ask – is there anything we could have done to prevent this? How do we stop this from happening again?

The answers to these questions are highly debated and exceedingly sensitive due to the tragic and jarring nature of sudden cardiac death. Many have pointed to mandatory electrocardiogram (ECG) screenings in all young athletes as a possible solution. But the question remains: will mandating these screenings save lives?

Many parents and affected communities think yes. In their eyes, it increases the chance that their children will be safe – another layer of assurance that their children will be unharmed on the field. It’s an emotional response to a chilling problem but an opinion that is not rooted in scientific fact. The medical community, however, is split.

Both the ACC and the American Heart Association agree that the mandatory screening of all young athletes with an ECG is not warranted based on cost (due to the large number of tests that would be required), the low incidence of sudden death among athletes in the U.S., as well as the concern for false positive results. Overseas, however, both the European Society of Cardiology and the International Olympic Committee recommend resting ECGs for all young athletes before they are allowed to compete.

The variance in these recommendations could have something to do with the significant decrease in athlete mortality in Italy after the country mandated screenings in all their athletes. Many at home and abroad have pointed to this success and think this approach should be implemented in the U.S.

An ECG is a non-invasive, easy-to-perform test that can be a helpful diagnostic tool in patients experiencing symptoms or risk factors. In theory, it would catch most cardiovascular conditions before they could become an issue and would be able to decrease occurrences of sudden death in children as they did in Italy. The problem with this method is the lack of evidence that this could be successful in the U.S.

“The issue with replicating Italy’s success in the U.S. is that the population there is much smaller,” says Silvana Molossi, MD, PhD, FACC, co-chair of ACC’s Sports and Exercise Section. “The incidences of sudden cardiac death found in the Italian studies are not necessarily representative of the sudden death risk in the U.S.’s youth-athlete population. Take data from Israel, for example. They implemented a similar mandate which resulted in no changes in the incidence of sudden death in the population.”

Molossi explains that although death on the field has a tremendous impact in the affected community, it is a rare occurrence. Requiring this test would not necessarily yield better outcomes in the population and in many cases would lead to an increase of false-positive readings. Unless tests are read by an expert – which are not readily available in many communities throughout the U.S. – these screenings are generally read by automated ECG machines with software containing outdated data that often produce a false-positive reading. These false-positive results lead to worry and great expense in subsequent testing. Moreover, the next question inevitably becomes, why would we screen just athletes? Sudden death occurs in athletes and non-athletes. This becomes an ethical dilemma in choosing to screen just a subset of the population.

“It’s a very emotional and shocking situation; losing a child, losing an athlete that represents the healthiest part of our population,” says Molossi. “We as cardiologists recognize that we need to put our heads together to figure out a process to help us avoid these events. In my opinion, the best approach for diagnosing cardiac conditions in young patients is by enforcing the use of a comprehensive patient and family history, increasing awareness of symptoms and using the ECG when those symptoms present themselves or supported by family history of pertinent cardiovascular conditions. Let’s better educate the population in the use of automated external defibrillators (AEDs) and CPR, and advocate for legislature that requires AEDs and an action plan for sudden cardiac arrest in all sporting events in every community.”

“It would be great if the mandatory ECG were the answer. It would make this simple. But unfortunately, that’s not the way it is,” she notes.

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias

Keywords: ACC Publications, Cardiology Magazine, Cardiopulmonary Resuscitation, Death, Sudden, Death, Sudden, Cardiac, Defibrillators, Electrocardiography, Risk Factors


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