An Electrocardiogram Should Not Be Included in Routine Preparticipation Screening of Young Athletes
2007; Lippincott Williams & Wilkins; Volume: 116; Issue: 22 Linguagem: Inglês
10.1161/circulationaha.107.711465
ISSN1524-4539
Autores Tópico(s)Sports injuries and prevention
ResumoHomeCirculationVol. 116, No. 22An Electrocardiogram Should Not Be Included in Routine Preparticipation Screening of Young Athletes Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBAn Electrocardiogram Should Not Be Included in Routine Preparticipation Screening of Young Athletes Bernard R. Chaitman, MD, FACC Bernard R. ChaitmanBernard R. Chaitman From the Department of Medicine, Division of Cardiology, St Louis University School of Medicine, St Louis, Mo. Originally published27 Nov 2007https://doi.org/10.1161/CIRCULATIONAHA.107.711465Circulation. 2007;116:2610–2615The sudden death of a young athlete during competition is a tragic yet rare occurrence that results in significant public and media attention. Increased catecholamine response to maximum stress in subjects with underlying structural heart disease is a well-known cause of lethal cardiac arrhythmias.1 In 1996, the American Heart Association issued a scientific statement advocating universal cardiovascular preparticipation screening for high school and college athletes in an attempt to identify those at increased risk of cardiovascular events.2 The recommendations included a 12-point complete history and physical examination (including brachial artery blood pressure measurement) before competitive sports (Table 1) and reserved noninvasive testing such as a 12-lead ECG, echocardiogram, exercise testing, and cardiovascular consultation for athletes in whom any abnormality was detected. TABLE 1. The 12-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive AthletesReprinted from Maron et al,5 with permission of the publisher. Copyright © 2007, the American Heart Association.*Parental verification is recommended for high school and middle school athletes.†Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion.‡Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.§Preferably taken in both arms.Medical history* Personal history 1. Exertional chest pain/discomfort 2. Unexplained syncope/near syncope† 3. Excessive exertional and unexplained dyspnea/fatigue associated with exercise 4. Prior recognition of a heart murmur 5. Elevated systemic blood pressure Family history 6. Premature death (sudden and unexpected or otherwise) before 50 y of age resulting from heart disease in ≥1 relative 7. Disability from heart disease in a close relative <50 y of age 8. Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmiasPhysical examination 9. Heart murmur‡ 10. Femoral pulses to exclude aortic coarctation 11. Physical stigmata of Marfan syndrome 12. Brachial artery blood pressure (sitting position)§Response by Myerburg and Vetter p 2615The recommendations include repeat cardiovascular screening every 2 years with an abbreviated examination in intervening years. Parental participation in gathering a proper history in younger athletes was encouraged. The committee recommended a national standard for preparticipation cardiovascular medical evaluation and education of all healthcare providers who screen athletes because of the marked heterogeneity in the design and content of preparticipation cardiovascular screening and variable experience of healthcare screeners at the time. Routine diagnostic tests (ie, a 12-lead ECG) as part of the screening procedure were excluded primarily for cost-efficacy considerations. In the 2007 update,3 recently published in Circulation, the 12-point recommendations listed in Table 1 remain unchanged and do not include universal 12-lead ECG recordings as part of every preparticipation history and physical examination, unless, of course, the athlete fails the 12-point examination.3 The European Society of Cardiology (ESC) and the International Olympic Committee (IOC) screening questionnaires serve a purpose similar to that of the 12-point AHA questionnaire, although they include more questions and the content is slightly different4 (Table 2). However, the prescreening strategy of the ESC and IOC differs significantly from the American approach in that universal 12-lead rest ECGs are recommended for athletes <35 years, leading to an important controversy between the American and European positions on the need for routine ECG recording.5 The IOC-ESC consensus document published in 2004 to 2005 relied heavily on the 25-year Italian experience of systematic preparticipation screening of competitive athletes.4–8TABLE 2. Sudden Cardiovascular Death in Sports for All Participants at the Beginning of Competitive Activities Until 35 Years of AgeFrom the ESC and the IOC Meeting on Sudden Cardiovascular Death in Sport, Lausanne, Switzerland, December 9 to 10, 2004; Lausanne recommendations adopted.4Medical History Personal History: Have you ever fainted or passed out when exercising? Do you ever have chest tightness? Does running ever cause chest tightness? Have you ever had chest tightness, cough, or wheezing that made it difficult for you to perform in sports? Have you ever been treated/hospitalized for asthma? Have you ever had a seizure? Have you ever been told you have epilepsy? Have you ever been told to give up sports because of health problems? Have you ever been told you have high blood pressure? Have you ever been told you have high cholesterol? Do you have trouble breathing or do you cough during or after activity? Have you ever been dizzy during or after exercise? Have you ever had chest pain during or after exercise? Do you have or have you ever had racing of your heart or skipped heartbeats? Do you get tired more quickly than your friends do during exercise? Have you ever been told you have a heart murmur? Have you ever been told you have a heart arrhythmia? Do you have any other history of heart problems? Have you had a severe viral infection (eg, myocarditis or mononucleosis) within the last month? Have you ever been told you had rheumatic fever? Do you have any allergies? Are you taking any medications at the present time? Have you routinely taken any medication in the past 2 y? Family history: Has anyone in your family 50% of the high school and college student athletic field deaths resulting from hypertrophic cardiomyopathy and have a relatively high prevalence of early repolarization changes and a relatively high maximal ventricular septal thickness on echocardiography that make it difficult to distinguish an athletic heart from mild anatomic expressions of nonobstructive hypertrophic cardiomyopathy.12–15Unsuspected cardiovascular disease is estimated to be present in 0.3% of the general athlete population in the United States. The detection of some types of cardiovascular disease does not mean that sudden death will occur with exercise. Although it is difficult to estimate the precise incidence rate of sudden death in young athletes, a Minnesota study of 1.4 million high school student-athlete participants in 27 sports over 12 years reported a rate of 1:200 000 per year (3 deaths).10 In other reports summarized in a recent AHA update, the sudden rates are even smaller, less than the postscreening rates published by Corrado et al.16 It would be very difficult for the 12-lead resting ECG to separate out low- and high-risk subjects at risk of sudden death during competitive activities with sufficient diagnostic accuracy, even if resources were sufficient to provide universal ECG recordings as part of preparticipation screening.Routine ECG Recordings in Young AthletesThe attraction of adding a rest 12-lead ECG to the screening process is the potential to detect conditions associated with exercise-induced cardiac arrhythmias and sudden death. In 1 retrospective analysis of 134 high school and collegiate athletes who died suddenly, only 3% of the examined athletes had abnormalities suspected by a standard history and physical.15 Abnormal ECGs are common in some conditions such as hypertrophic cardiomyopathy (in which as many as 90% of ECGs are abnormal) and in myocarditis, arrhythmogenic right ventricular dysplasia, long- and short-QT syndrome, congenital atrioventricular block, Brugada syndrome, and preexcitation syndrome. Other conditions associated with sudden death during exertion such as Marfan syndrome, coronary artery anomalies, or catecholamine-induced ventricular tachycardia might not be detected with a resting ECG. Table 3 lists the ECG criteria for an abnormal response proposed by the ESC.5 These criteria have not been tested prospectively to determine the incremental value in identifying athletes at increased risk of sudden death during competition, and some criteria are relatively common in a normal population such as increased voltage, T-wave flattening in 2 leads, or even a slightly prolonged QTc interval.17,18 ECG abnormalities are more common in athletes and may be due to cardiac remodeling from training effects.14 Maron and colleagues19 prospectively screened 501 intercollegiate competitive athletes at the University of Maryland using a process that included a baseline 12-lead ECG. Of the 501 subjects, 102 (20%) had at least 1 abnormality, and 13% had an abnormal ECG. Of 83 athletes with alterations on 1 study alone, 57 (69%) occurred because of the ECG, 16 (19%) were detected on the physical examination, and 10 (12%) had an abnormal history. The greater frequency of abnormal ECG responses compared with the history and physical has been reported by others.20 Thus, one would anticipate a high rate of false-positive results if routine ECGs were added to clinical screening as a preparticipation requirement for competitive athletics from bayesian principles. TABLE 3. Criteria for a Positive 12-Lead ECGReprinted from Corrado et al,5 with permission from the publisher. Copyright © 2005, 'on'Oxford University Press.*Increasing 0.44 s in males and >0.46 s in femalesRhythm and conduction abnormalities Premature ventricular beats or more severe ventricular arrhythmias Supraventricular tachycardias, atrial flutter, or atrial fibrillation Short PR interval ( 20 years but has not been implemented completely because of the magnitude of the medical screening requirements and the lack of adequate financial support.8 The United States comprises ≈25 000 000 competitive athletes involved in a network of sporting activities and 10 000 000 high school and college athletes. The strategy of adding a more detailed specific questionnaire to identify the extremely rare high school or college athlete in the United States at risk of exercise-related death is prudent but requires prospective testing. More research is needed into the type of questionnaire/physical examination needed for athletes of both genders and of different ethnic backgrounds and for different types and intensities of physical activity to optimize the detection of high-risk individuals. For example, the risk of exertional sudden death is greatest for sports like football and basketball and is uncommon in young female athletes of any race compared with men, occurring in a ratio of 1:9. The risk of exercise-related death in young women is 1 per 769 000 in 1 US series and includes all sports-related nontraumatic events, not just cardiovascular, far less than the event rates reported by Corrado et al6 and Van Camp et al10 with ECG screening. Adding universal 12-lead resting ECG screening to this large segment of the US population when the strategy has not been sufficiently tested does not make sense unless prospective studies demonstrate that doing so reduces exercise-related acute cardiovascular events in a cost-effective way. Trying to identify the extremely rare young athlete at risk of nontraumatic sudden death during sports activities removes resources from the healthcare system in the United States and abroad that could be allocated to other urgent healthcare needs that are present in a much greater percentage of high school and college age students, such as the escalating risks of obesity, diabetes mellitus, and other conditions that reduce long-term life expectancy in this age group.I am indebted to my good friend Victor Froelicher, MD, for reading this article and for providing meaningful insightful commentary.DisclosuresNone.FootnotesCorrespondence to Bernard R. Chaitman, MD, Professor of Medicine, Director of Cardiovascular Research, St. Louis University School of Medicine, Division of Cardiology, 1034 S Brentwood Blvd, Suite 1550, St. Louis, MO 63117. E-mail [email protected] References 1 Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman BR, Fromer M, Gregoratos G, Klein GJ, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy CM. ACC/AHA/ESC 2006 guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patient With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). 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Prospective screening of 5,615 high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc. 1997; 29: 1131–1138.CrossrefMedlineGoogle Scholar21 Fuller CM. Cost effectiveness analysis of screening of high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc. 2000; 32: 887–890.CrossrefMedlineGoogle ScholarcirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinsResponse to Chaitman27112007Robert J. Myerburg, MD, and Victoria L. Vetter, MDWillingness to reconsider and amend a course of action on the basis of evolving information and current circumstances is a reflection of wisdom and strength and leads to coherent policy recommendations. Applying this principle to the question of ECG screening of young athletes leads to the conclusion that a rational basis exists for the American Heart Association (AHA) to reconsider its position on this issue. In his analysis of the currently held position of the AHA, Dr Chaitman accurately summarizes the information relied on by the authors of the AHA 2007 Update to arrive at their position. He supports their conclusions but does not explore beyond the largely historical considerations. We believe the multiple factors cited in our article, based on current and forward-looking considerations, support our position that the AHA should amend its recommendation. Among the reasons for our conclusion are the following: It is undisputed that a high percentage of athletes at risk for sudden cardiac arrest (SCA) can be identified or suspected from a screening ECG.The differences in causes of SCA among athletes in Italy and the United States actually support the strategy of ECG screening in the United States because the most common cause in the United States, hypertrophic cardiomyopathy, is more reliably identified by an ECG than is the most common cause in the Italian study, and such deaths are unevenly distributed among specific segments of the heterogeneous US population.ECGs can often distinguish normal athletic heart from hypertrophic cardiomyopathy.It is agreed that better standards for "normal" are needed, but they will not emerge from a prohibitive posture, inhibiting large-scale use of this screening strategy.Although the ECG is not perfect, it is intended only as the first line in the screening process. It is not claimed to be absolutely "diagnostic." Moreover, conditions that the ECG cannot identify (coronary artery anomalies or catecholaminergic polymorphic ventricular tachycardia) cannot be
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