ECG Screening of Youth: Letting Evidence and Reason Prevail

Sudden death (SCD) is most commonly due to underlying cardiovascular conditions that predispose to cardiac arrest in youth. The desire to screen youth to identify those with cardiovascular conditions and intervene to prevent these high profile tragic deaths is laudable. While routine screening with a history and physical examination has been endorsed previously by the American Heart Association (AHA), routine ECG screening has not been recommended in youth aged 12-25 years.¹ An effective ECG screening strategy for this population is intuitively appealing with the primary objective of detecting cardiovascular conditions likely to manifest with SCD. 1 This screening must be linked to an intervention that reduces the risk of SCD and improves outcomes.¹ Despite significant advancements, considerable knowledge gaps remain about the etiology of SCD and the frequency with which SCD occurs in youth. Reports of screening programs inclusive of an ECG from Italy that have reduced the incidence of SCD have limited relevance to the US, based on program design and the populations studied. Within the US, considerable gaps in knowledge exist related to the frequency of SCD in youth and to the incremental predictive value of an ECG when added to a standardized history and physical examination.¹ The strategy of ECG screening of young populations needs careful consideration based on principles of effective screening and evidence-based medicine. From a health policy perspective, additional data are needed from robust registries and carefully designed trials before advancing ECG screening in youth.

The recently released Scientific Statement from the American Heart Association (AHA) and the American College of Cardiology (ACC) addresses the complex and somewhat controversial issues related to use of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age).¹ The writing group, Chaired by Dr. Barry Maron, defined cardiovascular screening as an initiative intended to prospectively identify or raise suspicion of previously unrecognized and largely genetic/congenital cardiovascular diseases known to cause sudden cardiac arrest and SD in young people.¹ The writing group notes that this has become a highly visible and vigorously debated topic, since the SD risk associated with intense physical activity could potentially be modified by withdrawal from a competitive athletic lifestyle, and even preventable in high-risk patients by prophylactic treatment interventions such as an ICD.¹ The writing group has produced comprehensive and balanced recommendations related to this deceptively complex topic concerning population screening for cardiovascular disease.¹

The AHA has previously taken the position that screening to detect cardiovascular disease in athletes is desirable but has not recommended inclusion of an ECG.¹ A complete and targeted 12-point history and physical examination performed by qualified examiners were recommended in both 1996 and 2007. ¹ The AHA has not support national mandatory ECG screening of athletes because the logistics, manpower, and financial and resource considerations make such a substantial program inapplicable to the US healthcare system.¹ By contrast, individual quality-controlled local, community, or student-related initiatives were supported if conducted properly and with quality control and adequate resources.¹ The AHA also recommended screening ECGs (as Class IIa) for all children prior to administration of stimulant medications used to treat attention deficit/hyperactivity disorders to avoid the risk for heart rhythm disturbances that may occur with such drugs in children with structural heart disease.¹ This recommendation was subsequently repudiated by an opposing viewpoint from the American Academy of Pediatrics. ¹

The European Society of Cardiology (ESC) recommends systematic preparticipation screening for all young competitive athletes, including a family and personal history, physical examination, and 12-lead ECG based largely on the Italian screening model.¹ With the exception of Israel, this strategy has not been translated on a national basis in other countries. The International Olympic Committee (IOC) recommends a targeted personal and family history, physical examination, and 12-lead ECG for all sports participants at the beginning of competitive activity, to be repeated every 2 years thereafter.¹ The commitment of national Olympic teams to such programs throughout the world is unclear, but to date this recommendation has not been adopted in the US. Finally, a recent NIH (NHLBI) position paper did not support mass screening of young athletes (<40 years) with ECGs, concluding that insufficient data were currently available to resolve this controversy.¹ The Working Group recommended pilot ECG screening studies in target populations to test sensitivity and specificity of the ECG for cardiac diagnosis, but did not offer funding or resources for such ambitious projects.¹

With a systematic review of all of the best available evidence, the group of experts authoring the new paper affirmed that all cardiovascular screening programs should be driven by sound scientific principles and policy independent of size, scope, or design.¹ The document, entitled “Assessment of the 12-Lead Electrocardiogram as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12-25 Years of Age)” specifically notes that reaction to catastrophic events or political pressure from advocacy groups should not drive the screening program design.¹ Several specific recommendations were made in this Scientific Statement.¹

The Class I recommendations, those that should be performed in youth, include the use of the AHA 14-point screening guideline by examiners as part of a comprehensive history and physical examinations to detect or raise suspicion of genetic/congenital cardiovascular abnormalities.¹ In addition, it is recommended that forms used as guides to examiners for high school and college athletes in the US be standardized. Class IIb recommendations, those that would be reasonable, include screening with 12-lead ECGs (and/or echocardiograms) in association with comprehensive history and physical examination to identify or raise suspicion of genetic/congenital cardiovascular abnormalities in smaller cohorts of young healthy people 12-25 years of age.¹ Importantly, it is specified that this not necessarily be limited to athletes as long as close physician involvement and sufficient quality control can be achieved.¹ If undertaken, such initiatives should recognize the known and anticipated limitations of the 12-lead ECG as a population screening test, including the expected frequency of false-positive and false-negative test results, as well as the cost required to support these initiatives over time.¹ Class III recommendations, indicating those programs that should not be used, include mandatory and universal mass screening with 12-lead ECGs in large general populations of young healthy people 12-25 years of age (including on a national basis in the US) to identify genetic/congenital cardiovascular abnormalities for athletes and non-athletes alike. It is also noted that large scale general population universal cardiovascular screening in the age group 12-25 years with history and physical examination alone is not recommended. All of these recommendations are noted to be supported by level of evidence C.

The writing group notes that the preponderance of evidence indicates that SD in young athletes and non-athletes in the age range of 12-25 years is low. The authors encourage additional research to further clarify the cost-efficacy of screening initiatives, ECG sensitivity, and specificity as a screening tool. They acknowledge that to achieve a precise incidence of SD in youthful populations would require a national mandatory reporting process with centralized database and dedicated resources. They also note that a randomized trial of sufficient scale comparing mortality in ECG vs. non-ECG tested populations is impractical. Based on these considerations, they conclude that there is sufficient information available to support the view that universal ECG-based screening of asymptomatic youth is not appropriate or possible on a national basis for the US either in competitive athletes or in the general youthful population.¹ They also note that the future evolution of mass ECG screening programs to other countries ultimately depends on the particular socio-economic and cultural background and available resources within that particular healthcare system.¹

In essence, the panel has concluded that the extremely low rate of SD in youth due to cardiovascular conditions, the unproven efficacy, and unknown costs are sufficient to recommend against widespread ECG screening of youth in the US.¹ They also concluded that preferential focus on legislation for such large scale programs could divert attention, energy, and resources from other important healthcare initiatives, e.g., suicide prevention and control of illicit drug use, and dissemination of automatic external defibrillators, which are effective in saving young lives on the athletic field or elsewhere.¹ The writing group provides evidence-based recommendations that are balanced and identifies gaps in knowledge where additional research is needed. It is evident that this Scientific Statement will serve as an authoritative and practical guide for all healthcare professionals involved with screening for cardiovascular disease in youth.