Cardiovascular Screening With Electrocardiography and Echocardiography in Collegiate Athletes

Study Questions:

Is there incremental value of electrocardiography (ECG) and echocardiography added to a screening program consisting of history and physical examination in college athletes?

Methods:

Competitive collegiate athletes at a single university underwent prospective collection of medical history, physical examination, 12-lead ECG, and two-dimensional echocardiography. ECGs were classified as normal, mildly abnormal, or distinctly abnormal according to previously published criteria. Eligibility for competition was determined using criteria from the 36th Bethesda Conference on Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities.

Results:

In 964 consecutive athletes, ECGs were classified as abnormal in 334 (35%), of which 95 (10%) were distinctly abnormal. Distinct ECG abnormalities were more common in men than women (15% vs. 6%, p < 0.001) and in black compared with white athletes (18% vs. 8%, p < 0.001). Echocardiographic and ECG findings initially resulted in exclusion of nine athletes from competition, including one for long-QT syndrome and one for aortic root dilatation; seven athletes with Wolff-Parkinson-White patterns were ultimately cleared for participation (four received further evaluation and treatment, and three were determined to not need treatment). After multivariable adjustment, black race was a statistically significant predictor of distinctly abnormal ECGs (relative risk, 1.82; 95% confidence interval, 1.22-2.73; p = 0.01).

Conclusions:

Distinctly abnormal ECGs were found in 10% of athletes and were most common in black men. Noninvasive screening using both ECG and echocardiography resulted in identification of nine athletes with important cardiovascular conditions, two of whom were excluded from competition. The authors concluded that these findings offer a framework for performing preparticipation screening for competitive collegiate athletes.

Perspective:

All agents that lower cholesterol prevent heart attacks and save lives. Oh. Umm…no, actually, that’s not true. There are endpoints, and there are clinically important endpoints. Identification of an abnormal ECG, or of an abnormal echo––or even of a disease––isn’t the same as identification of a patient at risk; and disqualifying someone from athletic participation isn’t the same as preventing sudden cardiac death. There is no question that more tests performed will result in more ‘abnormalities’ discovered. However, this strategy leaves unanswered the questions of whether any of the screened patients were at risk of a morbid or mortal cardiac event, whether screening (and disqualification of athletes) reduced cardiac risk, and how many athletes were disqualified from participation who were never at risk.

Clinical Topics: Noninvasive Imaging, Sports and Exercise Cardiology, Echocardiography/Ultrasound, Sports & Exercise and Imaging

Keywords: Athletes, Dilatation, Sports, Electrocardiography, Universities, Physical Examination, Echocardiography


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