Optimal Screening Methods to Detect Cardiac Disorders in Athletes: An Evidence-Based Review

Abstract

Reference/Citation: Harmon KG, Zigman M, Drezner JA. The effectiveness of screening history, physical exam, and ECG to detect potentially lethal cardiac disorders in athletes: a systematic review/meta-analysis. J Electrocardiol. 2015;48(3):329-338.Clinical Question: Which screening method should be considered best practice to detect potentially lethal cardiac disorders during the preparticipation physical examination (PE) of athletes?Data Sources: The authors completed a comprehensive literature search of MEDLINE, CINAHL, Cochrane Library, Embase, Physiotherapy Evidence Database (PEDro), and SPORTDiscus from January 1996 to November 2014. The following key words were used individually and in combination: ECG, athlete, screening, pre-participation, history, and physical. A manual review of reference lists and key journals was performed to identify additional studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this review.Study Selection: Studies selected for this analysis involved (1) outcomes of cardiovascular screening in athletes using the history, PE, and electrocardiogram (ECG); (2) history questions and PE based on the American Heart Association recommendations and guidelines; and (3) ECGs interpreted following modern standards. The exclusion criteria were (1) articles not in English, (2) conference abstracts, and (3) clinical commentary articles. Study quality was assessed on a 7-point scale for risk of bias; a score of 7 indicated the highest quality. Articles with potential bias were excluded.Data Extraction: Data included number and sex of participants, number of true-and false-positives and negatives, type of ECG criteria used, number of cardiac abnormalities, and specific cardiac conditions. The sensitivity, specificity, falsepositive rate, and positive predictive value of each screening tool were calculated and summarized using a bivariate randomeffects meta-analysis model.Main Results: Fifteen articles reporting on 47 137 athletes were fully reviewed. The overall quality of the 15 articles ranged from 5 to 7 on the 7-item assessment scale (ie, participant selection criteria, representative sample, prospective data with at least 1 positive finding, modern ECG criteria used for screening, cardiovascular screening history and PE per American Heart Association guidelines, individual test outcomes reported, and abnormal screening findings evaluated by appropriate diagnostic testing). The athletes (66% males and 34% females) were ethnically and racially diverse, were from several countries, and ranged in age from 5 to 39 years. The sensitivity and specificity of the screening methods were, respectively, ECG, 94% and 93%; history, 20% and 94%; and PE, 9% and 97%. The overall false-positive rate for ECG (6%) was less than that for history (8%) or PE (10%). The positive likelihood ratios of each screening method were 14.8 for ECG, 3.22 for history, and 2.93 for PE. The negative likelihood ratios were 0.055 for ECG, 0.85 for history, and 0.93 f...

Athletic Trainers' Knowledge and Practice Application of Public Health Topics

“…Therefore, it is imperative that ATs have a better understanding of not only individual-level and population-level public health concepts, but also how these initiatives impact the cost of care and influence one another. From the population health dimension, measures of health/functional status, 57,58 assessing risk, 59,60 understanding the incidence and prevalence of diseases, 61,62 and appreciating the years of potential life lost 63,64 are all relevant standards for ATs to be competent in as they deliver patient care.…”

Implementing Cardiac Testing to Mitigate the Risk of Sudden Cardiac Death: An Evidence-to-Practice Review

“…1 Although there is a concern that ECGs produce a high number of false-positive results leading to unnecessary diagnostic testing, studies have shown that the adoption of modern, strict ECG criteria have lowered false-positive rates to 6% compared to history at 8% and physical examination at 10%. 1,3 The studies in this review highlight that the rate of false-positives are greater with a history and physical examination model. Another consideration is the cost component associated with the implementation of ECG to pre-participation screenings.…”

“…2 This position statement also indicated the need for continued research on cardiac screening methods to "improve the ability to identify at-risk individuals in a cost-effective manner" with an acceptable false-positive rate to be utilized as a screening method to reduce the rates of sudden cardiac death (SCD). 3 In the United States between 2014-2018, 50% of sudden cardiac arrest cases occurred in Caucasian competitive athletes with 55% (n=88/164) of those cases resulting in survival. 4 However, the survival rates for African American athletes was only 25% (n=39/109) with an accompanied incidence rate for a male, African American, National Collegiate Athletic Association (NCAA) Division 1 basketball player at 1:2087.…”

Primary Care Considerations for the Baseball Athlete

“…Cardiac pre-participation screening has been implemented among professional sports organizations for identification of athletes at risk for cardiac disorders to prevent sudden cardiac events. NATA and the American Heart Association (AHA) have recommended a complete history and physical exam, with an emphasis on family history, as 80% of individuals who experience sudden cardiac death are asymptomatic themselves prior to the event [30]. Electrocardiograms (EKG) are also completed as part of entrance physicals league wide; however, the use of EKG is controversial at other levels of sport.…”