This post was authored by James Beckerman, MD, FACC, member of the ACC’s Sports and Exercise Cardiology Section.

For the past several years, I have had the honor of volunteering with Play Smart Youth Heart Screenings in Portland, OR, providing free blood pressure and electrocardiogram screenings for nearly 5,000 young people ages 12 through 18 in our cardiology clinics and in their schools. We have identified nearly 200 with hypertension, and approximately one out of every 100 children screened is diagnosed with a cardiac condition, including structural abnormalities like hypertrophic cardiomyopathy, coarctation of the aorta, and bicuspid aortic valves, as well as electrical anomalies like long QT syndrome and Wolff-Parkinson-White syndrome. Along with over 50 screening programs nationwide, from family-run foundations like Simon's Fund and the Nick of Time Foundation to academic centers like Johns Hopkins, University of Washington and Stanford, we screen kids because we believe that there is value in identifying young people with cardiac conditions before they might become symptomatic or dangerous. We actively fundraise to support our efforts and provide our screenings for free.

As the medical director of a heart screening program, I have followed the ongoing electrocardiogram debate with interest and passion. As an active member of the ACC's Sports Cardiology Section and as an attendee of the yearly ACC Sports Cardiology Summit, I am thankful to have this opportunity to share my perspective as a cardiologist who provides electrocardiogram screenings – currently a Class IIb indication.

Many of us on both sides of the screening debate are concerned about the risk of false positives. That is why we have refined our electrocardiogram interpretations, thanks to the development of the Seattle Criteria. In our own program experience, this criteria has resulted in us performing echocardiograms in only 3 percent of our screening population. Given that we have identified cardiac conditions by echocardiography, our false positive rate is closer to 2 percent. We consider this acceptable in the context of the false-positives rates of other types of screening programs. An echocardiogram is thankfully painless and without significant risk, although it does add cost, but should also be considered in the context of needle and surgical biopsy rates for false-positive mammograms or the incidental diagnosis of benign colon polyps that are removed during colonoscopies.

Many of us who perform screenings also share the opinion that electrocardiogram screening should not be mandatory. This is consistent with our expectations regarding other forms of screening, including lipids, blood pressure, mammograms and colonoscopies. But we do believe that they should be available and accessible. It has been interesting to note that the electrocardiogram screening debate is sometimes framed as a choice between universal, mass screenings or no screenings at all. There is likely a reasonable middle ground to explore further.

We also believe that we should hold various types of heart screenings to a similar standard, including the AHA 14-point screening guidelines, currently a Class I indication. This questionnaire is known to have high false-positive rates (at least six times that of electrocardiograms), and if it is actually adopted in a wide-spread fashion, will result in a higher number of normal echocardiograms performed than an electrocardiogram strategy alone. The downstream costs would appear to be an important consideration, yet this is not generally addressed by its supporters. Another important feature of this screening strategy is that it has not been demonstrated to reduce the risk of sudden cardiac death. This is ironically a frequent criticism of the electrocardiogram screening strategy. Both strategies should be held to similar standards, regarding false-positives, efficacy and downstream costs.

This speaks to the purpose of screening. The debate would suggest that prevention of sudden death is the only possible value of electrocardiogram screening. Yet there are other outcomes to consider. As the Italian experience continues to be discussed, it will be difficult to prove in our own communities that we are preventing a death by identifying hypertrophic cardiomyopathy, long QT syndrome, coarctation of the aorta, Wolff-Parkinson-White syndrome, long QT syndrome, or other cardiac conditions, but we also have the potential to positively impact our young people and their families by raising awareness around their conditions, considering any future symptoms with higher alert and a more targeted differential diagnosis, and also providing parents, coaches and teachers with more insight to promote overall safety of our young people. There are also opportunities for treatment that should be considered on a case-by-case basis. Although it is assumed, we lack compelling evidence that identification of cardiac conditions as a result of heart screenings causes net negative clinical effects in real-world practice. The testimonials of young people and families who have been diagnosed are quite striking, yet do not have a prominent voice.

As we become more patient-centered and encourage our patients to track and own their health data and medical records, it is interesting to note that the screening debate has many cardiologists taking on more paternalistic tones. Some opponents of screening might argue that "what they don't know probably won't hurt them, and what they learn probably will." While this is a well-meaning point of view, families also have a right to informed consent about the screening process. Some families will choose to opt out of certain types of screening, and others will choose to participate.

Finally, it seems appropriate to seek greater consistency around our approaches to the outcomes of diagnosing young people with heart disease. It is confusing for us to argue against the possibility of identifying young people with heart disease by better screening, yet simultaneously encourage providers to adhere closely to the Bethesda Guidelines which limit sports participation for some young people with asymptomatic heart disease. I recently discussed screening with a colleague who does not support an electrocardiogram strategy, and was interested to learn that he referred his children to an electrocardiogram screening program. Just in case.

I agree with others that registries and more research may shed more light on this issue, as well as the experiences of our patients and their families. It is my opinion that screening may be best if done as part of local actions rather than global legislation. Therefore, Play Smart will continue to screen kids in our own community, and we will continue to identify kids with heart disease.

This post is part of a series of posts from the ACC’s Sports and Exercise Cardiology Section. For more information about the Section, click here. Follow the sports and exercise cardiology conversation on Twitter with the hashtag #SportsCardio.

Statements or opinions expressed on the Blog reflect the views of the contributor, and do not reflect the official views of the ACC, unless otherwise noted.

< Back to Listings